Heather Gage graduated with a BA (Hons) Economics and an MSc in Urban and Regional Planning Studies from the University of Reading. Subsequently, she gained a PhD in Health Services Research from the University of Surrey and became Professor of Health Economics in 2012. As Director of Surrey Health Economics Centre, Heather oversees a varied portfolio of applied health and social care projects. She has held visiting positions at the Boston University School of Public Health and the Centre for Health Quality, Outcomes and Economic Research of the US Veterans Healthcare Administration.
Heather's research interests encompass many aspects of health service delivery, but particularly focus on evaluative studies and outcomes measurement. She is currently involved as economist in a variety of multidisciplinary projects funded by NHS, EU, industry and the voluntary sector. Recent work has been published in a range of health, clinical and medical journals.
Heather is a research adviser, and leads on health economics, for the NHS Research Design Service in Kent Surrey and Sussex.
People living with dementia often develop distressing behavioural and psychological symptoms (BPSD) that can affect their quality of life and the capacity of family carers and staff providing support at home. This systematic review of qualitative studies considers the views and experiences of people living with dementia and care providers about these symptoms and what helps to reduce their impact.
The two-stage review involved (a) An initial mapping of the literature to understand the range of BPSD, and how it is operationalised by different groups, to develop a search strategy; (b) A search of electronic databases from January 2000 to March 2015, updated in October 2016. Included studies focused on people living in their own homes. Data extraction and thematic analysis were structured to provide a narrative synthesis of the evidence.
We retrieved 17, 871 records and included relevant qualitative papers (n = 58) targeting community-dwelling people with dementia and family carers around the management of BPSD. Five key themes were identified: (1) Helpful interventions/support for BPSD management, (2) Barriers to support services for BPSD management, (3) Challenges around recognition/diagnosis of BPSD, (4) Difficulties in responding to aggression and other BPSD, and (5) Impact of BPSD on family carers and people living with dementia.
Family carers sometimes feel that their experiences of BPSD may not be evident to professionals until a crisis point is reached. Some helpful services exist but access to support, lack of knowledge and skills, and limited information are consistently identified as barriers to their uptake. The lack of common terminology to identify and monitor the range of BPSD that people with dementia living at home may experience means that closer attention should be paid to family carer accounts. Future research should include qualitative studies to evaluate the relevance of interventions.
Background: As more men survive a diagnosis of prostate cancer, alternative models of follow-up care that address men?s enduring unmet needs and are economical to deliver are needed. This paper describes the protocol for an ongoing evaluation of a nurse-led supported self-management and remote surveillance programme implemented within the secondary care setting.
Methods/design: The evaluation is taking place within a real clinical setting, comparing the outcomes of men enrolled in the Programme with the outcomes of a pre-service change cohort of men, using a repeated measures design. Men are followed up at four and eight months post recruitment on a number of outcomes, including quality of life, unmet need, psychological wellbeing and activation for self-management. An embedded health economic analysis and qualitative evaluation of implementation processes are being undertaken.
Discussion: The evaluation will provide important information regarding the effectiveness, cost effectiveness and implementation of an integrated supported self-management follow-up care pathway within secondary care.
physician assistants) are new to the NHS
and there is little evidence concerning their
contribution in general practice.
This study aimed to compare outcomes and
costs of same-day requested consultations by
PAs with those of GPs.
Older people living in care homes often have
limited life expectancy. Practitioners and
policymakers are increasingly questioning
the appropriateness of many acute hospital
admissions and the quality of end-of-life care
provided in care homes.Aim
To describe care home residents? trajectories
to death and care provision in their final weeks
of life.Design and setting
Prospective study of residents in six residential
care homes in three sociodemographically varied
English localities: Hertfordshire, Essex, and
Case note reviews and interviews with residents,
care home staff, and healthcare professionals.Results
Twenty-three out of 121 recruited residents
died during the study period. Four trajectories
to death were identified: ?anticipated dying?
with an identifiable end-of-life care period and
death in the care home (n = 9); ?unexpected
dying? with death in the care home that was not
anticipated and often sudden (n = 3); ?uncertain
dying? with a period of diagnostic uncertainty
or difficult symptom management leading to
hospital admission and inpatient death (n = 7);
and ?unpredictable dying? with an unexpected
event leading to hospital admission and
inpatient death (n = 4). End-of-life care tools
were rarely used. Most residents who had had
one or more acute hospital admission were still
alive at the end of the study.Conclusion
For some care home residents there was an
identifiable period when they were approaching
the end-of-life and planned care was put in
place. For others, death came unexpectedly
or during a period of considerable uncertainty,
with care largely unplanned and reactive to
M (2016) Understanding the impact of legislation on ?reduction of disease risk? claims on food and drinks: the REDICLAIM project, Agro Food Industry Hi-Tech 27 (3) pp. 30-32 Teknoscienze
Aim: To assess the impact of a rapid response hospice at home service (intervention) on people dying in their preferred place, and carer quality of life, compared to usual care (control).
Design: Quasi-experimental multi-centred controlled evaluation. Patient data were collected from hospice records; carers completed postal questionnaires to report quality of life, anxiety and depression.
Setting and participants: Community served by one hospice (three contiguous sites) in South East England; 953 patients who died with a preferred place of death recorded and 64 carers who completed questionnaires.
Results: There was no significant difference between control and intervention groups in proportions achieving preferred place of death (61.9% vs 63.0% (odds ratio: 0.949; 95% confidence interval: 0.788?1.142)). People living at home alone were less likely to die where they wanted (0.541; 95% confidence interval: 0.438?0.667). Carers in the intervention group reported worse mental health component summary scores (short form-12, p = 0.03) than those in the control group; there were no differences in other carer outcomes.
Conclusion: The addition of a rapid response hospice at home service did not have a significant impact on helping patients to die where they wanted in an area already well served by community palliative care. Recording preferences, and changes over time, is difficult and presented challenges for this study.
Background/Objectives: Several factors affect the mental performance of children. The importance that parents attribute to food-related determinants, compared with genetic, socio-economic and school environment, was investigated.
Subjects/Methods: Parents of school children (aged 4?11) were recruited through state primary schools in four European countries. Interviews were conducted in which participants were asked to sort 18 cards representing possible determinants of four elements of mental performance (attention, learning, mood and behaviour) according to perceived strength of effect. Determinants were identified from the literature and grouped in six categories: food-related, school environment, physical, social, psychological and biological. Effects were scored: 0=none; 1=moderate; and 2=strong. Views were compared between and within countries.
Results: Two hundred parents took part (England: 53; Germany: 45; Hungary: 52; Spain: 50). Differences existed between countries in the proportions reporting university education and being in employment. Taking all countries together, parents consider the food category (mean 1.33) to have a lower impact on a child?s mental performance than physical (activity and sleep, 1.77), psychological (mood and behaviour, 1.69) and school environment (1.57). Social (1.12) and biological (0.91) determinants were ranked lower than food. Of determinants in the food category, parents thought regularity of meals had more influence on mental performance (1.58) than what a child eats now (1.36), food at school (1.35), nutrition as a baby/infant (1.02).
Conclusion: Scope exists to improve parental awareness of the repercussions of their dietary choices for the mental performance of their children.
Physician associates [PAs] (also known as
physician assistants) are new to the NHS
and there is little evidence concerning their
contribution in general practice. Aim
This study aimed to compare outcomes and
costs of same-day requested consultations by
PAs with those of GPs. Design and setting
An observational study of 2086 patient records
presenting at same-day appointments in 12
general practices in England. Method
PA consultations were compared with those
of GPs. Primary outcome was re-consultation
within 14 days for the same or linked problem.
Secondary outcomes were processes of care. Results
There were no significant differences in
the rates of re-consultation (rate ratio 1.24,
95% confidence interval [CI] = 0.86 to 1.79,
P = 0.25). There were no differences in rates
of diagnostic tests ordered (1.08, 95% CI = 0.89
to 1.30, P = 0.44), referrals (0.95, 95% CI = 0.63
to 1.43, P = 0.80), prescriptions issued (1.16,
95% CI = 0.87 to 1.53, P = 0.31), or patient
satisfaction (1.00, 95% CI = 0.42 to 2.36,
P = 0.99). Records of initial consultations of
79.2% (n = 145) of PAs and 48.3% (n = 99) of
GPs were judged appropriate by independent
GPs (P consultation was 5.8 minutes longer than the
GP consultation (95% CI = 2.46 to 7.1; P cost per consultation was GBP £6.22, (US$
10.15) lower (95% CI = ?7.61 to ?2.46, P The processes and outcomes of PA and GP
consultations for same-day appointment
patients are similar at a lower consultation
cost. PAs offer a potentially acceptable and
efficient addition to the general practice
Background/Aims: Use of placebo is the ideal for comparison in clinical trials to reduce biases. With digital technology being used more frequently in healthcare interventions, how do we determine the placebo effect where interventions exploit technology? If placebo in medicine is traditionally defined by a lack of pharmacological agents, how might we begin to move towards controlling for effects of digital technology?
Method: This paper explores the traditional placebo effect and discusses its impact in healthcare contexts with digital technology with reference to a particular trial. Different meanings of placebo in the context of evaluating technology suggest new challenges and positive consequences.
Results: Methodological considerations are discussed, which enabled the development of a placebo-controlled evaluation of a digital technology in healthcare and rehabilitation.
Conclusion: Digital placebo was controlled in our trial by employing technology across all groups in the absence of evidence-based practice and shows how to control for unknown and hidden effects of technology.
To identify information available in six European countries (England, France, Germany, Netherlands, Portugal, Sweden) that addresses the specific needs of people with young onset dementia (YOD) and their carers, and identify gaps.
Search of websites of organisations with potential interest in dementia. Narrative synthesis and comparative analysis.
21 sources of information were identified (Netherlands 6, England 6, France 3, Germany 2, Portugal 2, Sweden 2); 11 were from voluntary sector organisations. Sources dedicated to YOD were limited (4 websites, 4 books); all other YOD information was sub-entries in generic dementia sources, difficult to locate and with limited coverage of relevant topics. Gaps related to implications of living with YOD in Germany, Portugal and Sweden.
Availability of information varies among countries, some having no dedicated source and incomplete coverage of issues of importance to YOD.
Information is an important means of supporting carers; their needs change as the condition progresses. A comprehensive resource collating key information is needed so that the issues that differentiate the specific needs of people living with YOD from those of people with dementia in older age are available and easily located.
Objective: This randomized controlled trial compared low-, habitual-, and high-fiber diets for the prevention of gastrointestinal toxicity in patients undergoing pelvic radiotherapy.
Design: Patients were randomly assigned to low-fiber [d10 g nonstarch polysaccharide (NSP)/d], habitual-fiber (control), or high-fiber (e18 g NSP/d) diets and received individualized counseling at the start of radiotherapy to achieve these targets. The primary endpoint was the difference between groups in the change in the Inflammatory Bowel Disease Questionnaire?Bowel Subset (IBDQ-B) score between the starting and nadir (worst) score during treatment. Other measures included macronutrient intake, stool diaries, and fecal short-chain fatty acid concentrations.
Results: Patients were randomly assigned to low-fiber (n = 55), habitual-fiber (n = 55), or high-fiber (n = 56) dietary advice. Fiber intakes were significantly different between groups (P
Conclusions: Dietary advice to follow a high-fiber diet during pelvic radiotherapy resulted in reduced gastrointestinal toxicity both acutely and at 1 y compared with habitual-fiber intake. Restrictive, non?evidence-based advice to reduce fiber intake in this setting should be abandoned. This trial was registered at clinicaltrials.gov as NCT 01170299.
To explore the impact of price manipulation and healthy eating information on intended food choices
Health information was provided to a random half of subjects (vs. information on Saudi agriculture). Each subject chose from the same lunch menu, containing two healthy and two unhealthy entrees, deserts and beverages, on five occasions. Reference case prices were 5, 3 and 2 Saudi Arabian Reals (SARs). Prices of healthy and unhealthy items were manipulated up (taxed) and down (subsidised) by 1 SAR in four menu variations (random order); subjects were given a budget enabling full choice within any menu. The number of healthy food choices were compared with different price combinations, and between information groups. Linear regression modelling explored the effect of relative prices of healthy / unhealthy options and information on number of healthy choices controlling for dietary behaviours and hunger levels.
University campus, Saudi Arabia, 2013
99 women students
In the reference case, 49.5% of choices were for healthy items. When the price of healthy items was reduced, 58.5% of selections were healthy; 57.2% when the price of unhealthy items rose. In regression modelling, reducing the price of healthy items and increasing the price of unhealthy items increased the number of healthy choices by 5% and 6% respectively. Students reporting a less healthy usual diet selected significantly fewer healthy items. Providing healthy eating information was not a significant influence.
Price manipulation offers potential for altering behaviours to combat rising youth obesity in Saudi Arabia.
care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use.
a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners.
context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which ?wraps around? care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites.
Conclusion activities generating opportunities and an interest in healthcare and care home staff working together are integral to optimal healthcare provision in care homes. Outcomes are likely to be better where: focus and activities legitimise ongoing contact between healthcare staff and care homes at an institutional level; link with a wider system of healthcare; and provide access to dementia-specific expertise.
There are limited case-mix classification systems for primary care settings which are applicable when considering the optimal clinical skill mix to provide services.
To develop a case-mix classification system (CMCS) and test its impact on analyses of patient outcomes by clinician type, using example data from physician associates? (PAs) and GPs' consultations with same-day appointment patients.
Design & setting
Secondary analysis of controlled observational data from six general practices employing PAs and six matched practices not employing PAs in England.
Routinely-collected patient consultation records (PA n = 932, GP n = 1154) were used to design the CMCS (combining problem codes, disease register data, and free text); to describe the case-mix; and to assess impact of statistical adjustment for the CMCS on comparison of outcomes of consultations with PAs and with GPs.
A CMCS was developed by extending a system that only classified 18.6% (213/1147) of the presenting problems in this study's data. The CMCS differentiated the presenting patient?s level of need or complexity as: acute, chronic, minor problem or symptom, prevention, or process of care, applied hierarchically. Combination of patient and consultation-level measures resulted in a higher classification of acuity and complexity for 639 (30.6%) of patient cases in this sample than if using consultation level alone. The CMCS was a key adjustment in modelling the study?s main outcome measure, that is rate of repeat consultation.
This CMCS assisted in classifying the differences in case-mix between professions, thereby allowing fairer assessment of the potential for role substitution and task shifting in primary care, but it requires further validation.
Hospice at home (HAH) services aim to enable patients to be cared for and die in their place of choice, if that is at home, and to achieve a ?good death?. There is a considerable range of HAH services operating in England. The published evidence focuses on evaluations of individual services which vary considerably, and there is a lack of consistency in terms of the outcome measures reported. The evidence, therefore, does not provide generalisable information, so the question ?What are the features of hospice at home service models that work, for whom, and under what circumstances?? remains unanswered. The study aims to answer this question.
Methods and analysis
This is a mixed-methods study in three phases informed by realist evaluation methodology. All HAH services in England will be invited to participate in a telephone survey to enable the development of a typology of services. In the second phase, case study sites representing the different service types will collect patient data and recruit carers, service managers and commissioners to gather quantitative and qualitative data about service provision and outcomes. A third phase will synthesise and refine the results through consensus workshops.
Ethics and dissemination
The first survey phase has university ethics approval and the second phase, Integrated Research Application System (IRAS) and Health Research Authority (HRA) approval (IRAS ID:205986, REC:17/LO/0880); the third phase does not require ethics approval. Dissemination will be facilitated by project coapplicants with established connections to national policy-making forums, in addition to publications, conference presentations and reports targeted to service providers and commissioners.
Two-thirds of people living with dementia live at home in the UK and many experience distressing behavioural and psychological symptoms. This systematic review evaluates the effectiveness of non-pharmacological interventions for behavioural and psychological symptoms among community-dwelling people living with dementia.
This two-stage review undertook an initial mapping of the literature followed by a systematic review of relevant randomised controlled trials. We searched electronic databases for pertinent studies reporting outcomes from interventions from January 2000 to March 2015 and updated searches in October 2016. We included studies that considered behavioural and psychological symptom management for older people living with dementia who live at home and excluded studies conducted in long-term care settings. This paper presents findings from a narrative synthesis of 48 randomised controlled trials evaluating interventions for people living with dementia alone, family carers alone and patient-carer dyads.
We retrieved 17,871 de-duplicated records and screened them for potential inclusion. Evidence from 48 randomised controlled trials suggests that family carer training and educational programmes that target problem behaviours and potential triggers can improve outcomes. Nurses and occupational therapists appear to help people with dementia with behavioural and psychological symptoms, but professional comparisons are lacking and there is no shared language about or understanding of behavioural and psychological symptoms amongst professionals, or between professionals and family carers.
Future research should focus on the effectiveness of components of multi-faceted programmes and their cost effectiveness and include qualitative data to better target interventions for behavioural and psychological symptoms. It is important to consider family carer readiness to use non-pharmacological strategies and to develop a shared language about the inherent needs and communications of behavioural and psychological symptoms.
To appraise and synthesise research on the impact of physician assistants/associates (PA) in secondary care, specifically acute internal medicine, care of the elderly, emergency medicine, trauma and orthopaedics, and mental health.
Electronic databases (Medline, Embase, ASSIA, CINAHL, SCOPUS, PsycINFO, Social Policy and Practice, EconLit and Cochrane), reference lists and related articles.
Peer-reviewed articles of any study design, published in English, 1995?2017.
Blinded parallel processes were used to screen abstracts and full text, data extractions and quality assessments against published guidelines. A narrative synthesis was undertaken.
Impact on: patients? experiences and outcomes, service organisation, working practices, other professional groups and costs.
5472 references were identified and 161 read in full; 16 were included?emergency medicine (7), trauma and orthopaedics (6), acute internal medicine (2), mental health (1) and care of the elderly (0). All studies were observational, with variable methodological quality. In emergency medicine and in trauma and orthopaedics, when PAs are added to teams, reduced waiting and process times, lower charges, equivalent readmission rate and good acceptability to staff and patients are reported. Analgesia prescribing, operative complications and mortality outcomes were variable. In internal medicine outcomes of care provided by PAs and doctors were equivalent.
PAs have been deployed to increase the capacity of a team, enabling gains in waiting time, throughput, continuity and medical cover. When PAs were compared with medical staff, reassuringly there was little or no negative effect on health outcomes or cost. The difficulty of attributing cause and effect in complex systems where work is organised in teams is highlighted. Further rigorous evaluation is required to address the complexity of the PA role, reporting on more than one setting, and including comparison between PAs and roles for which they are substituting.
Younger people with dementia face significant challenges in gaining access to age- and needs-appropriate support. In this paper, we tell the story so far, of the ANGELA
Research Project, which seeks to develop guidance to improve the ?dementia journey? for younger people with dementia and their families/supporters.
Our story is one of a research group aiming to conduct clinically relevant research to achieve positive changes for younger people with dementia. Our research journey will last 3 years and is now almost one year in. In this article, we aim to convey some of the decisions we have made to date, and what lies ahead for a successful implementation.
So far, we have been forming as a research group and turning our initial ideas into plans that will work in the real world. Our methods for ensuring all elements of the project work well have involved internal and external aspects and processes. These have included involvement with and feedback from experts-by-experience and an advisory panel.
To date we have generated a protocol for all the key elements and have launched the Improving Support and Service Use Survey; a national survey gathering evidence from younger people with dementia and their supporters. In this article, we present how we aim to move forward to bring positive real-life changes to the lives of those affected by young onset dementia.
There is a cautiously happy ending to this first phase, as we are now collecting data. However, the judgement of whether the Angela Project is a success overall will depend on whether it makes a difference at its conclusion to younger people with dementia and their supporters.
Multidisciplinary rehabilitation is recommended for Parkinson's disease, but evidence suggests that benefit is not sustained.
(1) Implement a specialist domiciliary rehabilitation service for people with Parkinson's and carers. (2) Provide continuing support from trained care assistants to half receiving the rehabilitation. (3) Evaluate the clinical effectiveness of the service, and the value added by the care assistants, compared with usual care. (4) Assess the costs of the interventions. (5) Investigate the acceptability of the service. (6) Deliver guidance for commissioners.
Pragmatic three-parallel group randomised controlled trial.
Community, county of Surrey, England, 2010?11.
People with Parkinson's, at all stages of the disease, and live-in carers.
Groups A and B received specialist rehabilitation from a multidisciplinary team (MDT) ? comprising Parkinson's nurse specialists, physiotherapists, occupational therapists, and speech and language therapists ? delivered at home, tailored to individual needs, over 6 weeks (about 9 hours? individual therapy per patient). In addition to the MDT, participants in group B received ongoing support for a further 4 months from a care assistant trained in Parkinson's (PCA), embedded in the MDT (1 hour per week per patient). Participants in control group (C) received care as usual (no co-ordinated MDT or ongoing support).
Main outcome measures
Follow-up assessments were conducted in participants? homes at 6, 24 and 36 weeks after baseline. Primary outcomes: Self-Assessment Parkinson's Disease Disability Scale (patients); the Modified Caregiver Strain Index (carers). Secondary outcomes included: for patients, disease-specific and generic health-related quality of life, psychological well-being, self-efficacy, mobility, falls and speech; for carers, strain, stress, health-related quality of life, psychological well-being and functioning.
A total of 306 people with Parkinson's (and 182 live-in carers) were randomised [group A, n = 102 (n = 61); group B, n = 101 (n = 60); group C, n = 103 (n = 61)], of whom 269 (155) were analysed at baseline, pilot cohort excluded. Attrition occurred at all stages. A per-protocol analysis [people with Parkinson's, n = 227 (live-in carers, n = 125)] [group A, n = 75 (n = 45); group B, n = 69 (n = 37); group C, n = 83 (n = 43)] showed that, at the end of the MDT intervention, people with Parkinson's in groups A and B, compared with group C, had reduced anxiety (p = 0.02); their carers had improved psychological well-being (p = 0.02). People with Parkinson's in groups A and B also had marginally reduced disability (primary outcome, p = 0.09), and improved non-motor symptoms (p = 0.06) and health-related quality of life (p = 0.07), compared with C. There were significant differences in change scores between week 6 (end of MDT) and week 24 (end of PCA for group B) in favour of group B, owing to worsening in group A (no PCA support) in posture (p = 0.001); non-motor symptoms (p = 0.05); health-related quality of life (p = 0.07); and self-efficacy (p = 0.09). Carers in group B (vs. group A) reported a tendency for reduced strain (p = 0.06). At 36 weeks post recruitment, 3 months after the end of PCA support for group B, there were few differences between the groups. Participants reported learning about Parkinson's, and valued individual attention. The MDT cost £833; PCA support was £600 extra, per patient (2011 Great British pounds).
Further research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.
Over 28,000 nurses in the UK can prescribe the same medicines as doctors provided that it is in their level of experience and competence. Over 30%, mostly in general practice, prescribe medicines for patients with diabetes.
A comparative case study.
Nurses managing care of people with Type 2 diabetes were recruited in twelve general practices in England; six could prescribe, six could not. Patients, recruited by nurses, were followed up for 6 months (2011?2012).
The patient sample comprised 131 in prescriber sites, 83 in non-prescriber sites. Patients of prescribers had been diagnosed and cared for by the nurse longer than those of non-prescribers. There were no differences in reported self-care activities or HbA1c test results between the patients of prescribers and non-prescribers. Mean HbA1c decreased significantly in both groups over 6 months. Patients of prescribers were more satisfied. Consultation duration was longer for prescribers (by average of 7·7 minutes). Non-prescribing nurses sought support from other healthcare professionals more frequently. Most prescribing nurses were on a higher salary band than non-prescribers.
Clinical outcomes of patients managed by prescribing and non-prescribing diabetes nurses are similar. Prescribing nurses had longer relationships with their patients and longer consultations, possibly contributing to higher satisfaction with care. Employment costs of prescribing nurses are potentially higher.
Physician associates are new to English general practice and set to expand
To investigate the patients? perspective on consulting with physician
associates in general practice.
A qualitative study, using semi-structured interviews, with thematic analysis.
Setting and participants:
Thirty volunteer patients of 430 who had consulted physician
associates for a same-day appointment and had returned a satisfaction survey, in six
general practices employing physician associates in England.
Some participants only consulted once with a physician associate and others
more frequently. The conditions consulted for ranged from minor illnesses to those
requiring immediate hospital admission. Understanding the role of the physician associate
varied from ?certain and correct? to ?uncertain?, to ?certain and incorrect?, where
the patient believed the physician associate to be a doctor. Most, but not all, reported
positive experiences and outcomes of their consultation, with some choosing to consult
the physician. Those with negative experiences described problems when the limits
of the role were reached, requiring additional GP consultations or prescription
delay. Trust and confidence in the physician associate was derived from trust in the
NHS, the general practice and the individual physician associate. Willingness to consult
a physician associate was contingent on the patient?s assessment of the severity
or complexity of the problem and the desire for provider continuity.
Patients saw physician associates as an appropriate general practitioner
substitute. Patients? experience could inform delivery redesign.
symptoms that have a serious adverse effect on quality of life. Management is problematic due to the variable and
fluctuating nature of symptoms, often hourly and daily. The PD_Manager mHealth platform aims to provide a
continuous feed of data on symptoms to improve clinical understanding of the status of any individual patient and
inform care planning. The objectives of this trial are to (1) assess patient (and family carer) perspectives of PD_
Manager regarding comfort, acceptability and ease of use; (2) assess clinician views about the utility of the data
generated by PD_Manager for clinical decision making and the acceptability of the system in clinical practice.
Methods/design: This trial is an unblinded, parallel, two-group, randomised controlled pilot study. A total of 200
persons with Parkinson?s disease (Hoehn and Yahr stage 3, experiencing motor fluctuations at least 2 h per day),
with primary family carers, in three countries (110 Rome, 50 Venice, Italy; 20 each in Ioannina, Greece and Surrey,
England) will be recruited. Following informed consent, baseline information will be gathered, including the
following: age, gender, education, attitudes to technology (patient and carer); time since Parkinson?s diagnosis,
symptom status and comorbidities (patient only). Randomisation will assign participants (1:1 in each country), to
PD_Manager vs control, stratifying by age (1 d 70 : 1 > 70) and gender (60% M: 40% F). The PD_Manager system
captures continuous data on motor symptoms, sleep, activity, speech quality and emotional state using wearable
devices (wristband, insoles) and a smartphone (with apps) for storing and transmitting the information. Control
group participants will be asked to keep a symptom diary covering the same elements as PD_Manager records.
After a minimum of two weeks, each participant will attend a consultation with a specialist doctor for review of the
data gathered (by either means), and changes to management will be initiated as indicated. Patients, carers and
clinicians will be asked for feedback on the acceptability and utility of the data collection methods. The PD_
Manager intervention, compared to a symptom diary, will be evaluated in a cost-consequences framework Discussion: Information gathered will inform further development of the PD_Manager system and a larger
Trial registration: ISRCTN Registry, ISRCTN17396879. Registered on 15 March 2017.
Saudi Arabia : an empirical investigation.,
Aim: To investigate factors influencing choice of healthy food items by students in a university cafeteria in Saudi Arabia.
Theoretical framework: Psychological theories of how individual factors affect behaviours and concepts from the emerging field of behavioural economics underpinned the studies.
Methods: Three empirical studies involving students at the University of Ha?il, central Saudi Arabia: 1. Questionnaire gathering background information about students? health-related behaviours and knowledge of behavioural risk factors for type 2 diabetes, 2. Investigation of student purchasing patterns and intentions through a) a questionnaire probing willingness-to-buy fruit (a healthier option) if available in the campus cafeteria, b) a controlled experiment manipulating menu choices, 3. Analysis of actual purchasing decisions when fruit was introduced to the campus cafeteria. Impacts of price variation and health messages were explored in Studies II and III.
Results: 1. Students report poor health-related behaviours (dietary and physical activity); knowledge of the link between lifestyle and type 2 diabetes is patchy. 2a. Over 50% of cafeteria users said they would buy fruit if available. 2b. Choice of healthy items was responsive to price manipulation. 3. When fruit was available, it was purchased by less than 10%. Health messages had no effect on healthy item choices.
Conclusions: Pricing strategies may be effective to stimulate healthier choices. Additional health education targeting individual psychological determinants of behaviour change may also be required.
UK deaths due to chronic liver diseases such as cirrhosis have quadrupled over the last 40 years, making this condition now the third most common cause of premature death. Most patients with advanced cirrhosis (end-stage liver disease [ESLD]) develop ascites. This is often managed with diuretics, but if refractory, then the fluid is drained from the peritoneal cavity every 10?14 days by large volume paracentesis (LVP), a procedure requiring hospital admissions. As the life expectancy of patients with ESLD and refractory ascites (if ineligible for liver transplantation) is on average d 6 months, frequent hospital visits are inappropriate from a palliative perspective. One alternative is long-term abdominal drains (LTADs), used successfully in patients whose ascites is due to malignancy. Although inserted in hospital, these drains allow ascites management outside of a hospital setting. LTADs have not been formally evaluated in patients with refractory ascites due to ESLD.
Due to uncertai/nty about appropriate outcome measures and whether patients with ESLD would wish or be able to participate in a study, a feasibility randomised controlled trial (RCT) was designed. Patients were consulted on trial design. We plan to recruit 48 patients with refractory ascites and randomise them (1:1) to either (1) LTAD or (2) current standard of care (LVP) for 12 weeks. Outcomes of interest include acceptability of the LTAD to patients, carers and healthcare professionals as well as recruitment and retention rates. The Integrated Palliative care Outcome Scale, the Short Form Liver Disease Quality of Life questionnaire, the EuroQol 5 dimensions instrument and carer-reported (Zarit Burden Interview) outcomes will also be assessed. Preliminary data on cost-effectiveness will be collected, and patients and healthcare professionals will be interviewed about their experience of the trial with a view to identifying barriers to recruitment.
LTADs could potentially improve end-of-life care in patients with refractory ascites due to ESLD by improving symptom control, reducing hospital visits and enabling some self-management. Our trial is designed to see if such patients can be recruited, as well as to inform the design of a subsequent definitive trial.
ISRCTN, ISRCTN30697116. Registered on 7 October 2015.
Care homes provide personal care and support for older people who can no longer be supported in the community. As part of a larger study of integrated working between the NHS and care homes we asked older people how they accessed health care services. Our aim was to understand how older people resident in care homes access health services using the Andersen model of health care access.
Case studies were conducted in six care homes with different socio-economic characteristics, size and ownership in three study sites. Residents in all care homes with capacity to participate were eligible for the study. Interviews explored how residents accessed NHS professionals. The Andersen model of health seeking behaviour was our analytic framework.
Thirty-five participants were interviewed with an average of 4 different conditions. Expectations of their health and the effectiveness of services to mitigate their problems were low. Enabling factors were the use of intermediaries (usually staff, but also relatives) to seek access. Residents expected that care home staff would monitor changes in their health and seek appropriate help unprompted.
Care home residents may normalise their health care needs and frame services as unable to remediate these which may combine to disincline older care home residents to seek care. Care access was enabled using intermediaries -either staff or relatives-and the expectation that staff would proactively seek care when they observed new/changed needs. Residents may over-estimate the health-related knowledge of care home staff and their ability to initiate referrals to NHS professionals.
Research into interventions to improve health and well-being for older people living in care homes is increasingly common. Health-related quality of life (HRQoL) is frequently used as an outcome measure, but collecting both self-reported and proxy HRQoL measures is challenging in this setting. This study will investigate the reliability of UK care home staff as proxy respondents for the EQ-5D-5L and HowRu measures.
Methods and analysis
This is a prospective cohort study of a subpopulation of care home residents recruited to the larger Proactive Healthcare for Older People in Care Homes (PEACH) study. It will recruit residents e60 years across 24 care homes and not receiving short stay or respite care. The sample size is 160 participants. Resident and care home staff proxy EQ-5D-5L and HowRu responses will be collected monthly for 3 months. Weighted kappa statistics and intraclass correlation adjusted for clustering at the care home level will be used to measure agreement between resident and proxy responses. The extent to which staff variables (gender, age group, length of time caring, role, how well they know the resident, length of time working in care homes and in specialist gerontological practice) influence the level of agreement between self-reported and proxy responses will be considered using a multilevel mixed-effect regression model.
Ethics and dissemination
The PEACH study protocol was reviewed by the UK Health Research Authority and University of Nottingham Research Ethics Committee and was determined to be a service development project. We will publish this study in a peer-reviewed journal with international readership and disseminate it through relevant national stakeholder networks and specialist societies.
Care home residents are often unable to complete health-related quality of life questionnaires for themselves because of prevalent cognitive impairment. This study compared care home resident and staff proxy responses for two measures, the EQ-5D-5L and HowRU.
A prospective cohort study recruited residents e60 years across 24 care homes who were not receiving short stay, respite or terminal care. Resident and staff proxy EQ-5D-5L and HowRu responses were collected monthly for 3 months. Weighted kappa statistics and intra-class correlation coefficients (ICCs) adjusted for clustering at the care home level were used to measure agreement between resident and proxies for each time point. The effect of staff and resident baseline variables on agreement was considered using a multilevel mixed effect regression model.
117, 109 and 104 matched pairs completed the questionnaires at 1, 2 and 3 months, respectively. When clustering was controlled for, agreement between resident and staff proxy EQ-5D-5L responses was fair for mobility (ICC: 0.29) and slight for all other domains (ICC d 0.20). EQ-5D Index and Quality-Adjusted Life Year scores (proxy scores higher than residents) showed better agreement than EQ-5D-VAS (residents scores higher than proxy). HowRU showed only slight agreement (ICC d 0.20) between residents and proxies. Staff and resident characteristics did not influence level of agreement for either index.
The levels of agreement for EQ-5D-5L and HowRU raise questions about their validity in this population.
Background: Care homes are the institutional providers of long-term care for older people. The OPTIMAL
study argued that it is probable that there are key activities within different models of health-care provision
that are important for residents? health care.
Objectives: To understand ?what works, for whom, why and in what circumstances??. Study questions
focused on how different mechanisms within the various models of service delivery act as the ?active
ingredients? associated with positive health-related outcomes for care home residents.
Methods: Using realist methods we focused on five outcomes: (1) medication use and review; (2) use of
out-of-hours services; (3) hospital admissions, including emergency department attendances and length of
hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed
the evidence to develop an explanatory theory of what supported good health-care provision for further
testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care
for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents.
The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care
provision to care homes was distinctive in each site.
Findings: Phase 1 found that health-care provision to care homes is reactive and inequitable. The realist
review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to
assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and
implement agreed approaches to health care. Phase 2 tested this further and found that, although there
were few differences between the sites in residents? use of resources, the differences in service integration
between the NHS and care homes did reflect how these institutions approached activities that supported
relational working. Key to this was how much time NHS staff and care home staff had had to learn how to
work together and if the work was seen as legitimate, requiring ongoing investment by commissioners
and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when
supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work.
Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care
home staff were equipped to provide appropriate care.
Limitations: Findings were constrained by the numbers of residents recruited and retained in phase 2 for
the 12 months of data collection.
Conclusions: NHS services work well with care homes when payments and role specification endorse the
importance of this work at an institutional level as well as with individual residents. GP involvement is
important but needs additional support from other services to be sustainable. A focus on strategies that
promote co-design-based approaches between the NHS and care homes has the potential to improve
residents? access to and experience of health care.
Funding: The National Institute for Health Research Health Services and Delivery Research programme.
Measuring service use and costs is an important aspect of service delivery evaluation. In end-of-life care, there is heavy reliance on care by family/friends (informal carers) and this should be reflected in the total cost of care alongside formal services. The Ambulatory and Home Care Record, developed in Canada, is both comprehensive in coverage and validated for collecting data on formal and informal caring. This study aimed to adapt and pilot the Ambulatory and Home Care Record questionnaire for use in the UK within a study evaluating a new palliative care service. The objectives were to test if family carers could be recruited and assess acceptability and usability of data gathered.
Single cohort pilot study using a structured telephone questionnaire carried out every other week. Family carers of patients newly added to the palliative care register or referred to hospice services in the South East of England were invited to participate by mail. Volunteers remained in the study for a maximum of six interviews or until the patient died.
In total, 194 carers were invited by mail to participate in the study, of which 23 (11.8%) completed at least one interview and 16 (8.2%) completed all possible interviews. Recruitment to the study was lower than anticipated, but most participants seemed to find the interviews acceptable. The modified questionnaire produced usable and relevant data for an economic evaluation of formal and informal caring costs.
Modifications are needed to the process of recruitment as a postal recruitment strategy did not have a high response rate. The Ambulatory and Home Care Record has proved a viable tool for use in the UK setting, with a few minor modifications, and will be used in a larger study comparing hospice models.
Early or timely recognition of dementia is a key policy goal of the National Dementia Strategy. However, older people who are homeless are not considered in this policy and practice imperative, despite their high risk of developing dementia.
Objectives and study design
This 24-month study was designed to (1) determine the prevalence of memory problems among hostel-dwelling homeless older people and the extent to which staff are aware of these problems; (2) identify help and support received, current care and support pathways; (3) explore quality of life among older homeless people with memory problems; (4) investigate service costs for older homeless people with memory problems, compared with services costs for those without; and (5) identify unmet needs or gaps in services.
Following two literature reviews to help study development, we recruited eight hostels ? four in London and four in North England. From these, we first interviewed 62 older homeless people, exploring current health, lifestyle and memory. Memory assessment was also conducted with these participants. Of these participants, 47 were included in the case study groups ? 23 had ?memory problems?, 17 had ?no memory problems? and 7 were ?borderline?. We interviewed 43 hostel staff who were participants? key workers. We went back 3 and 6 months later to ask further about residents? support, service costs and any unmet needs.
Overall, the general system of memory assessment for this group was found to be difficult to access and not patient-centred. Older people living in hostels are likely to have several long-term conditions including mental health needs, which remain largely unacknowledged. Participants frequently reported experiences of declining abilities and hostel staff were often undertaking substantial care for residents.
The hostels that were accessed were mainly in urban areas, and the needs of homeless people in rural areas were not specifically captured. For many residents, we were unable to access NHS data. Many hostel staff referred to this study as ?dementia? focused when introducing it to residents, which may have deterred recruitment.
To the best of our knowledge, no other study and no policy acknowledges hostels as ?dementia communities? or questions the appropriateness of hostel accommodation for people with dementia. Given the declining number of hostels in England, the limits of NHS engagement with this sector and growing homelessness, this group of people with dementia are under-recognised and excluded from other initiatives.
A longitudinal study could follow hostel dwellers and outcomes. Ways of improving clinical assessment, record-keeping and treatment could be investigated. A dementia diagnosis could trigger sustained care co-ordination for this vulnerable group.
Objectives To investigate the deployment of physician associates (PAs); the factors supporting and inhibiting their employment and their contribution and impact on patients? experience and outcomes and the organisation of services.
Design Mixed methods within a case study design, using interviews, observations, work diaries and documentary analysis.
Setting Six acute care hospitals in three regions of England in 2016?2017.
Participants 43 PAs, 77 other health professionals, 28 managers, 28 patients and relatives.
Results A key influencing factor supporting the employment of PAs in all settings was a shortage of doctors. PAs were found to be acceptable, appropriate and safe members of the medical/surgical teams by the majority of doctors, managers and nurses. They were mainly deployed to undertake inpatient ward work in the medical/surgical team during core weekday hours. They were reported to positively contribute to: continuity within their medical/surgical team, patient experience and flow, inducting new junior doctors, supporting the medical/surgical teams? workload, which released doctors for more complex patients and their training. The lack of regulation and attendant lack of authority to prescribe was seen as a problem in many but not all specialties. The contribution of PAs to productivity and patient outcomes was not quantifiable separately from other members of the team and wider service organisation. Patients and relatives described PAs positively but most did not understand who and what a PA was, often mistaking them for doctors.
Conclusions This study offers new insights concerning the deployment and contribution of PAs in medical and surgical specialties in English hospitals. PAs provided a flexible addition to the secondary care workforce without drawing from existing professions. Their utility in the hospital setting is unlikely to be completely realised without the appropriate level of regulation and authority to prescribe medicines and order ionising radiation within their scope of practice.
The European RHAPSODY project sought to develop and test an online information and support programme for caregivers of individuals diagnosed with young onset dementia. The objectives were to assess user acceptability and satisfaction with the programme and to test outcome measures for a larger effectiveness study.
A pilot randomised controlled trial in England, France, and Germany was conducted with 61 caregivers for adults with young onset Alzheimer's disease or frontotemporal degeneration. Evaluations at baseline, week 6, and week 12 assessed user acceptability and satisfaction. Use of the programme was measured from online back?end data. Qualitative feedback on user experiences was collected via semi?structured interviews. Measures of caregiver well?being (self?efficacy, stress, burden, frequency of patient symptoms, and caregiver reactions) were explored for use in a subsequent trial.
Participants logged in online on average once a week over a 6?week period, consulting approximately 31% of programme content. Seventy percent of participants described the programme as useful and easy to use. Eighty?five percent expressed intent to use the resource in the future. Reductions in reported levels of stress and caregivers' negative reactions to memory symptoms were observed following use of the programme.
Results indicated that the RHAPSODY programme was acceptable and useful to caregivers. The programme may be complementary to existing services in responding to the specific needs of families affected by young onset dementia. Distribution of the programme is underway in England, France, Germany, and Portugal.
Evidence is increasing for effective virtual reality therapy for motor rehabilitation for children
with Cerebral Palsy. We assessed the feasibility of a virtual reality therapy mode of intervention, appropriateness
of measures, and potential cost-effectiveness.
A 12-week, 2-group, parallel-feasibility trial (ISRCT 17624388) using Nintendo Wii FitTM at home.
Children aged 5?16, with ambulatory Cerebral Palsy, who were able to follow simple instructions were
randomised to two groups; one supported by physiotherapists (individualised activity programme), the
other unsupported with children having free choice (control). Children were assessed in clinic at baseline,
week 6, and week 12 by blinded assessors. Feasibility of the intervention was assessed via recruitment,
adherence, and usefulness of measurement tools.
Forty-four children were eligible (out of 48 approached): 31 consented, 30 were randomised, 21
completed the study; 10 in the supported group and 11 in the unsupported group. Nine children discontinued
from tiredness, after-school activities, homework, surgery, technical difficulties or negative system
feedback. The supported group completed 19 of 36 (IQR 5-35) possible sessions; the unsupported group
24 of 36 sessions (IQR 8-36). Gross Motor Function Measure scores varied by Cerebral Palsy severity after
the intervention. There were no adverse events.
Virtual reality therapy offers potential as a therapeutic adjunct for children with Cerebral
Palsy, warranting substantive confirmatory study. Gross Motor Function Measure, with modifications to
improve sensitivity, appeared appropriate as a primary measure, with Timed up and Go test secondary.
The intervention was inexpensive costing £20 per child. An explanatory trial to evaluate the clinical/cost effectiveness
of commercial system virtual reality therapy is feasible with minor methodological
Alternative models of cancer follow-up care are needed to ameliorate pressure on services and better
meet survivors? long-term needs. This paper reports an evaluation of a service improvement initiative for the followup
care of prostate cancer patients based on remote monitoring and supported self-management.
This multi-centred, historically controlled study compared patient reported outcomes of men
experiencing the new Programme with men experiencing a traditional clinic appointment model of follow-up care,
who were recruited in the period immediately prior to the introduction of the Programme. Data were collected by
self-completed questionnaires, with follow up measurement at four and eight months post-baseline. The primary
outcome was men?s unmet survivorship needs, measured by the Cancer Survivors? Unmet Needs Survey. Secondary
outcomes included cancer specific quality of life, psychological wellbeing and satisfaction with care. The analysis
was intention to treat. Regression analyses were conducted for outcomes at each time point separately, controlling
for pre-defined clinical and demographic variables. All outcome analyses are presented in the paper. Costs were
compared between the two groups.
Results: Six hundred and twenty-seven men (61%) were consented to take part in the study (293 in the
Programme and 334 in the comparator group.) Regarding the primary measure of unmet survivorship needs, 25 of
26 comparisons favoured the Programme, of which 4 were statistically significant. For the secondary measures of
activation for self-management, quality of life, psychological well-being and lifestyle, 20 of 32 comparisons favoured
the Programme and 3 were statistically significant. There were 22 items on the satisfaction with care questionnaire
and 13 were statistically significant. Per participant costs (British pounds, 2015) in the 8 month follow up period
were slightly lower in the programme than in the comparator group (£289 versus £327). The Programme was
acceptable to patients.
The Programme is shown to be broadly comparable to traditional follow-up care in all respects,
adding to evidence of the viability of such models.
Maintaining physical activity for older residents in care homes maximises their physical and mental health and wellbeing, independence, dignity and quality of life. Unfortunately, most residents do not participate in regular physical activity. Active Residents in Care Homes, ARCH, was designed to increase physical activity by facilitating whole-system change in a care home. We evaluated whether ARCH can be delivered, its effects on resident?s physical activity, wellbeing and costs.
Three residential care homes.
Care home residents and staff.
Occupational and physiotherapists implemented ARCH over 4 months with an 8-month follow-up.
Main outcome measures:
Assessment of Physical Activity, Pool Activity Level, EQ5D-5 L, Dementia Care Mapping, cost of implementing ARCH, health and social care utilisation.
After implementing ARCH, residents displayed more positive behaviours, better mood and engagement and higher physical activity levels, but these improvements were not sustained at 8-month follow-up. The cost (2016 prices) of implementing ARCH was £61,037, which equates to £1,650/resident. Healthcare utilisation was £295/resident (SD320) in the 4 months prior to ARCH, £308/resident (SD406) during the 4-month implementation and £676/resident (SD438) in the 8-month follow-up.
The ARCH programme can be delivered, it may have some short-term benefits and is affordable. Rather than have unrealistic increases in the health and longevity of older care home residents, ARCH may slow the decline in physical, mental and emotional well-being usually seen in older people in care homes, return some dignity and improve their quality of life in their last months or years.
Increasing demand for hospital services and staff shortages has led NHS organisations to
review workforce configurations. One solution has been to employ physician associates (PAs). PAs are
trained over 2 years at postgraduate level to work to a supervising doctor. Little is currently known about
the roles and impact of PAs working in hospitals in England.
(1) To investigate the factors influencing the adoption and deployment of PAs within medical
and surgical teams in secondary care and (2) to explore the contribution of PAs, including their impact on
patient experiences, organisation of services, working practices, professional relationships and service costs,
in acute hospital care.
This was a mixed-methods, multiphase study. It comprised a systematic review, a policy review,
national surveys of medical directors and PAs, case studies within six hospitals utilising PAs in England and
a pragmatic retrospective record review of patients in emergency departments (EDs) attended by PAs and
Foundation Year 2 (FY2) doctors.
The surveys found that a small but growing number of hospitals employed PAs. From the case
study element, it was found that medical and surgical teams mainly used PAs to provide continuity to the
inpatient wards. Their continuous presence contributed to smoothing patient flow, accessibility for patients
and nurses in communicating with doctors and releasing doctors? (of all grades) time for more complex
patients and for attending to patients in clinic and theatre settings. PAs undertook significant amounts of
ward-based clinical administration related to patients? care. The lack of authority to prescribe or order
ionising radiation restricted the extent to which PAs assisted with the doctors? workloads, although the
extent of limitation varied between teams. A few consultants in high-dependency specialties considered
that junior doctors fitted their team better. PAs were reported to be safe, as was also identified from the
review of ED patient records. A comparison of a random sample of patient records in the ED found no
difference in the rate of unplanned return for the same problem between those seen by PAs and those seen
by FY2 doctors (odds ratio 1.33, 95% confidence interval 0.69 to 2.57; p = 0.40). In the ED, PAs were also
valued for the continuity they brought and, as elsewhere, their input in inducting doctors in training into
local clinical and hospital processes. Patients were positive about the care PAs provided, although they were
not able to identify what or who a PA was; they simply saw them as part of the medical or surgical team
looking after them. Although the inclusion of PAs was thought to reduce the need for more expensive
locum junior doctors, the use of PAs was primarily discussed in terms of their contribution to patient safety
and patient experience in contrast to utilising temporary staff.
PAs work within medical and surgical teams, such that their specific impact cannot be
distinguished from that of the whole team.
PAs can provide a flexible advanced clinical practitioner addition to the secondary care
workforce without drawing from existing professions. However, their utility in the hospital setting is
unlikely to be fully realised without the appropriate level of regulation and attendant authority to prescribe
medicines and order ionising radiation within their scope of practice.
Comparative investigation is required of patient experience, outcomes and service costs
in single, secondary care specialties with and without PAs and in comparison with other types of advanced
The systematic review component of this study is registered as PROSPERO
The National Institute for Health Research Health Services and
Alcohol-related harm is currently estimated to cost the National Health Service (NHS) in England £3.5 bn a
year. Of the estimated 1.6 million people with some degree of alcohol dependence, some 600,000 are believed to be
moderately or severely dependent and may benefit from intensive treatment. Outcomes from medically assisted
withdrawal, also referred to as detoxification, are often poor, with poor engagement in relapse prevention interventions
and subsequent high relapse rates. Detoxification is costly both financially and to the individual. It has been found that
people who experience multiple detoxifications show more emotional and cognitive impairments. These changes may
confer upon them the inability to resolve conflict and increased sensitivity to stress thus contributing to increased
vulnerability risk of relapse. The study aims to test the feasibility of using a group intervention aiming to prepare
participants for long-term abstinence before, rather than after, they have medically assisted detoxification. The current
study will establish key parameters that influence trial design such as recruitment, compliance with the intervention,
retention, and sensitivity of alternative outcome measures, in preparation for a future randomised controlled trial (RCT).
This paper presents the protocol of the feasibility study.
The study corresponds to phase 2 of the Medical Research Council (MRC) complex interventions guidelines which
cover the development and feasibility testing of an intervention. The work is in three stages. The development, adaptation
and implementation of the Structured Preparation before Alcohol Detoxification (SPADe) intervention (stage 1), a randomised
feasibility study with economic evaluation (stage 2) and a qualitative study (stage 3). Fifty participants will be recruited from
two community alcohol treatment services in England. Participants will be randomised in two arms: the treatment as usual
arm (TAU), which includes planned medically assisted detoxification and aftercare and the intervention arm in which
participants will receive structured group preparation before detoxification in addition to TAU. The main outcomes are
duration of continuous abstinence with no incidents of lapse or relapse, percentage of days abstinent and time to relapse.
The socioeconomic harms associated with alcohol have been well-documented, yet existing treatment options
have not been able to reduce high relapse rates. This study will build on existing naturalistic studies underpinned by
psychological interventions offered early and before detoxification from alcohol, which aim to reverse automatised habitual
behaviours and thus may help us to understand how better to support people to remain abstinent and improve post
Objective: Complex cardiac devices including implantable cardioverter defibrillator (ICD) and cardiac resynchronisation therapy (CRT) devices can safely be implanted as a day case procedure as opposed to overnight stay. We assess how common day case complex device therapy is and the cost implications of more widespread adoption across the UK.
Methods: A freedom of information request was sent to all centres performing complex cardiac devices across the UK to assess the adoption of this technique. Cost implications were assessed using Department of Health National Schedule of Reference Costs 2016?2017.
Results: 100 UK centres were surveyed, 80% replied. Eighty per cent of UK centres already implant complex cardiac devices as a day case to some extent. 64.06% of centres have a protocol for this. 12.82% of centres do Â25% of complex devices as a day case. 15.38% do 25%?50% as day case. 17.95% do 50%?75% as day case and 33.33% do Ã75% as day case. There was no relationship between centre volume and the proportion of devices done as a day case as opposed to overnight stay. The cost saving of performing a complex device as a day case as opposed to overnight stay was £412 per ICD, £525 per CRT-pacemaker and £2169 per CRT-defibrillator.
Conclusions: Day case complex devices are already widespread across the UK, however, there is scope for increase. An increase in proportion of day case devices could translate to £5 583 265 in savings annually for the National Health Service if all centres performed 75% of devices as a day case.
Background and aims: Ascites develops in about 90% with advanced
cirrhosis; when refractory to medical therapy, standard of care is
repeated large volume paracentesis (LVP) with albumin support.
Refractory ascites (RA) confers a median life expectancy of six months
without liver transplantation (LT). LVP is not an optimal palliative
strategy. One alternative is long-term abdominal drains (LTAD), used
in advanced malignant ascites, also enabling community management. Our ultimate aim is to improve end of life care (EoLC) in
advanced cirrhosis and RA. This feasibility randomised controlled
trial (RCT) aimed to resolve uncertainties in designing a definitive
Method: Multicentre feasibility RCT with 1:1 randomisation between
standard of care (LVP) vs. LTAD (Rocket Medical) in adults with RA,
ineligible for LT. Both arms received prophylactic antibiotics. LTAD
were inserted under ultrasound guidance. Community nurses
undertook home visits to drain ascites dependent on symptoms;
(maximum 6L/week), without albumin support. Follow-up was 12
weeks with home visits every two weeks for the following
assessments: clinical, questionnaire based to include quality of life,
palliative care needs, carer burden and health economics (HE). Here
we report clinical and HE outcomes.
Results: Thirty six patients were randomised; 19 LVP (two withdrew,
wanting LTAD) and 17 LTAD (one withdrew-insufficient ascites). Mean
age (years) LTAD vs. LVP 66 + 10.4 vs. 68 ± 12; predominately male
(76% vs. 74%). Participants were well matched at baseline in liver tests
and prognostic scores: LTAD vs. LVP (serum bilirubin (¼mol/L) 26 ±
15.8 vs. 16 ±10, serum albumin (g/L) 33 ± 4.2 vs. 31 ± 3.3, serum
creatinine (mmol/L) 113 ± 46.7 vs.118 ± 53.1; MELD 14 ± 4.6 vs. 16 ±
7.2). One LTAD participant required hospitalisation for repeated LVP.
Serum albumin (g/L) in the LTAD arm declined to 29 ± 3.3 at week
two, subsequently remaining stable LTAD vs. LVP (29 ± 5.6 vs. 31 ±
5.5). Serum creatinine remained stable in both arms. There were no
LTAD related serious adverse reactions. LTAD related adverse reactions
included mild cellulitis (n = 4) and small volume leakage around LTAD
insertion site (n = 3), all resolving rapidly. Peritonitis was rare, LTAD
(possible) n = 1 and LVP n = 2. Overall mortality was 36% (12/33).
Mortality and median survival (days in those who died) were 7/16
(44%) vs. 5/17 (29%), 53 days (IQR 43) vs. 61 days (IQR 35) in LTAD vs.
LVP respectively. All but one death was liver related. Those in LTAD
arm spent H20% less time in hospital. All nine alive in the LTAD arm at
end of study elected to keep LTAD in. Detailed clinical and HE analysis
Conclusion: Preliminary data from the REDUCe study supports the
safety and efficacy of palliative LTAD in RA due to advanced cirrhosis.
LTAD allows successful management in the community with
reduction in health resource utilisation. Proceeding to a definitive
RCT is justified.
Methods: A suite of user needs studies was conducted in 4 European countries (Greece, Italy, Slovenia, the UK) prior to the development of PD_Manager, a mHealth-based CDSS designed for Parkinson?s Disease, using wireless technology. Study 1 undertook Hierarchical Task Analysis (HTA) including elicitation of user needs, cognitive demands and perceived risks/benefits (ethical considerations) associated with the proposed CDSS, through structured interviews of prescribing clinicians (N=47). Study 2 carried out computational modelling of prescribing clinicians? (N=12) decision strategies based on social judgment theory. Study 3 was a vignette study of prescribing clinicians? (N=18) willingness to change treatment based on either self-reported symptoms data, devices-generated symptoms data or combinations of both.
Results: Study 1 indicated that system development should move away from the traditional silos of ?motor? and ?non-motor? symptom evaluations and suggest that presenting data on symptoms according to goal-based domains would be the most beneficial approach, the most important being patients? overall Quality of Life (QoL). The computational modelling in Study 2 extrapolated different factor combinations when making judgements about different questions. Study 3 indicated that the clinicians were equally likely to change the care plan based on information about the change in the patient?s condition from the patient?s self-report and the wearable devices.
Conclusions: Based on our approach, we could formulate the following principles of mHealth design: 1) enabling shared decision making between the clinician, patient and the carer; 2) flexibility that accounts for diagnostic and treatment variation among clinicians; 3) monitoring of information integration from multiple sources. Our approach highlighted the central importance of the patient-clinician relationship in clinical decision making and the relevance of theoretical as opposed to algorithm (technology)-based modelling of human judgment.
Background: mhealth, predominantly wearable technology and mobile apps, have been considered in Parkinson?s Disease to provide valuable ecological data between face to face visits and improve monitoring of motor symptoms remotely.
Objective: In this study we explore the feasibility of using a technology based mhealth platform comprising a smartphone in combination with a smartwatch and a pair of smart insoles, described in the present study as the PD_manager system, to collect clinically meaningful data. We also explore outcomes and disease related factors which are important determinants to establish feasibility. Finally, we further validate a tremor evaluation method with data collected while patients perform their daily activities.
Methods: PD_manager trial was an open label parallel group randomized study. The mheath platform consists of a wristband, a pair of sensor insoles, a smartphone (with dedicated mobile Android apps and a knowledge platform) serving as the cloud backend. The compliance was assessed with statistical analysis and the factors affecting it using appropriate regression analysis. The correlation of the scores of our previous algorithm for tremor evaluation and the respective UPDRS estimations by clinicians were explored.
Results: There were 65 of the 75 study participants (87%) who completed the protocol. They used the PD_manager system for a median 11.57 days (Std. dev. 3.15). The regression analysis suggests that the main factor associated with high usage was caregivers? burden. Motor Aspects of Experiences of Daily Living and patients? self-rated health status also influence the system?s usage. Our algorithm provided clinically meaningful data for the detection and evaluation of tremor.
Conclusions: We found that PD patients, regardless of their demographics and disease characteristics, used the system for 11-14 days. The study further supports that mhealth can be an effective tool for the ecologically valid, passive, unobtrusive monitoring and evaluation of symptoms. Future studies will be required to demonstrate that an mhealth platform can improve disease management and care.
The National Institute for Health and Care Excellence (NICE) recommends that Cognitive Behaviour
Therapy for psychosis (CBTp) is offered to all patients with a psychosis diagnosis. However, only a minority of
psychosis patients in England and Wales are offered CBTp. This is attributable, in part, to the resource-intensive
nature of CBTp. One response to this problem has been the development of CBTp in brief formats that are targeted
at a single symptom and the mechanisms that maintain distress. We have developed a brief form of CBTp for
distressing voices and reported preliminary evidence for its effectiveness when delivered by highly trained
therapists (clinical psychologists). This study will investigate the delivery of this intervention by a cost-effective
workforce of assistant psychologists following a brief training and evaluate the acceptability and feasibility of
conducting a future, definitive, randomised controlled trial (RCT).
This is a feasibility study for a pragmatic, three-arm, parallel-group, superiority 1:1:1 RCT comparing a
Guided self-help CBT intervention for voices and treatment as usual (GiVE) to Supportive Counselling and treatment
as usual (SC) to treatment as usual alone (TAU), recruiting across two sites, with blinded post-treatment and followup
assessments. A process evaluation will quantitatively and qualitatively explore stakeholder experience.
Expected outcomes will include an assessment of the feasibility of conducting a definitive RCT, and
data to inform the calculation of its sample size. If evidence from a subsequent, fully powered RCT suggests that
GiVE is clinically and cost-effective when delivered by briefly trained assistant psychologists, CBTp offered in these less resource-intensive forms has the potential to generate benefits for individual patients (reduced distress,
enhanced recovery and enhanced quality of life), service-level patient benefit (increased access to evidence-based
psychological therapies) and economic benefits to the NHS (in terms of the reduced use of mental health inpatient
for a ?find-and-treat strategy.? We aimed to report real-world clinical, patient
reported and health economic outcomes of community-based hepatitis C virus (HCV)
screening/treatment in people who use drugs (PWUDs).
Methods: Project ITTREAT (2013-2021), established at a drug and alcohol treatment
centre, offered a comprehensive service. Generic (SF-12v2 and EQ-5D-5L) and liverspecific
(SFLDQoL) health-related quality of life (HRQoL) were assessed before and
after HCV treatment. Costs/case detected and cured were calculated. Primary outcome
measure was sustained virological response (SVR) (intention to treat).
Results: Till March 2018, 573 individuals recruited, 462 (81%) males, mean age
40.5 ± 10.0 years. Of the 125 treated, 115 (92%) had past/current history of injecting
drug use, 88 (70%) were receiving opioid agonist treatment and 50 (40%) were homeless.
Twenty-six per cent received interferon-based and 74% DAA-only regimens.
SVR (ITT) was 87% (90% with DAAs). Service uptake/HCV treatment completion
rates were >95%, HCV reinfection being 2.63/100 person years (95% CI 0.67-10.33).
HRQoL improved significantly at end of treatment (EOT) in those with SVR: SFLDQoL
(symptoms, memory, distress, loneliness, hopelessness, sleep and stigma) (P = .011);
SF-12 v2 physical and mental health domains (P score (P = .009) and visual analogue scale, P case detected was £171; mean cost per cure (excluding medication) was £702 ± 188.
Conclusions: Excellent real-world SVRs in PWUDs with significant improvement in
HRQoL can be achieved at modest costs. Project ITTREAT endorses communitybased
integrated services to help achieve HCV elimination.
M. Fader, A. Cottenden, H.Gage, P. Williams, K. Getliffe, S. Clarke-O'Neill, K. Jamieson, N. Green. Individual budgets for people with incontinence: results from a 'shopping' experiment within the British National Health Service, Health Expectations, doi: 10.1111/j.1369-7625.2011.00750.x
L. Axelrod, K. Bryan, H.Gage,J.Kaye, S.Ting, P. Williams, P. Trend, D.Wade, Disease - specific training in Parkinson's disease for care assistants: a comparison of interactive and self study methods. Clinical Rehabilitation, 26(6):545-57, 2012
H.Gage, E. Erdal, P. Saigal, Y. Qiao, P. Williams, J. Ogden, M. Raats. Recognition and management of overweight and obese children: a questionnaire survey of General Practitioners and parents in England. Journal of Pediatrics and Child Health, 48(2):146-52; 2012
B. Brands, B. Egan, E. Gyorei, J-C Lopez-Robles, H. Gage, C. Campoy, T. Decsi, M. Raats. A qualitative interview study on effects of diet on children's mental state and performance. Evaluation of perceptions, attitudes and beliefs of parents in four European countries. Appetite; 58: 739-746, 2012
C. Goodman, E. Mathie, M. Cowe, A. Mendoza, D. Westwood, D. Munday, P. Wilson P, C. Crang, K. Froggatt, S. Iliffe, J. Manthorpe, H. Gage, S. Barclay. Talking about living and dying with the oldest old: public involvement in a study on end of life care in care homes. BMC Palliative Care; 10:20, 2011
H. Gage, S. Ting, P. Williams, K. Bryan, B. Castleton, P. Trend, D.Wade. A comparison of specialist rehabilitation and care assistant support with specialist rehabilitation alone and usual care for people with Parkinson's living in the community: study protocol for a randomised controlled trial, Trials, 12: 250, 2011
S.L. Davies, C. Goodman, F.Bunn, C. Victor, A. Dickenson, S. Iliffe, H.Gage, W. Martin, K. Frogatt. A systematic review of integrated working between care homes and health care services. BMC Health Services Research, 11; 320, 2011
L. Poltawski, C. Goodman, S. Iliffe, J. Manthorpe, H.Gage, D.Shah, V. Drennan. Frailty scales - their potential in interprofessional working with older people: a discussion paper. Journal of Interprofessional Care, 25(4): 280-286; 2011
C. Goodman, V. Drennan, F. Schiebl, D. Shah, J. Manthorpe, H. Gage, S. Iliffe. Models of inter professional working for older people living at home: a survey and review of the local strategies of English health and social care statutory organisations. BMC Health Services Research, 11;337, 2011
S. Iliffe, V. Drennan, J. Manthorpe, H.Gage, S. Davies, H. Massey, C. Scott, S. Brearley, C. Goodman. Nurse case management and General Practice: implications for GP consortia. British Journal of General Practice, 61(591): 658-665; 2011
V. Drennan, C. Goodman, J. Manthorpe, S. Davies, C. Scott, H.Gage, S. Iliffe. Establishing new nursing roles: a case study of the English community matron initiative. Journal of Clinical Nursing, 20(19-20):2948-2957; 2011
H.Gage, M. Raats, P. Williams, B.Egan,V. Jakobik, K. Laitinen, E. Martin-Bautista, M. Schmid, J. von Rosen-von Hoewel, C. Campoy, T. Decsi, J.Morgan, B. Koletzko. Developmental origins of health and disease: the views of first time mothers in five European countries on the importance of nutritional influences in the first year of life. American Journal of Clinical Nutrition; 94(suppl):2018S-24S, 2011
H.Gage, J. Morgan, P. Williams, M. Schmid, K. Laitenen, J.von Rosen, B. Koletzko, T. Decsi, V. Jacobi, E. Martin-Bautista, C. Campoy, M.M. Raats. Infant feeding intentions of new mothers in five European countries. Proceedings of the Nutrition Society, 69 (OCE1), E69, 2010
B. Egan, H. Gage, M. Raats, B. Anton, B. Koletzko, E. Gyorie, T. Decsi, E. Martin-Bautista, J.C. Lopez-Roberts, C. Campoy. The effect of diet on children's mental performance: a study of the attitudes, knowledge and perceptions of UK parents. Proceedings of the Nutrition Society, 69 (OCE1), E72, 2010
C. Goodman, K. Froggatt, E. Mathie, C. Craig, J. Wright, M. Handley, H.Gage, S. Iliffe, et al. The experiences and expectations of older people resident in care homes, their carers and professionals: a prospective study. Report for NIHR Research for Patient Benefit Programme, Sept. 2010
H.Gage, J. Kaye, A. Kimber, L. Storey, M. Egan, Y. Qiao, P. Trend. Correlates of constipation in people with Parkinson's. Parkinsonism and Related Disorders, 17 (2):106-111; 2011
S. Iliffe, D. Kendrick, R. Morris, D. Skelton, H. Gage, S. Dinan, Z. Stevens, M. Pearl, T. Masud T. Multi-centre cluster randomised trial comparing a community group exercise programme with home based exercise with usual care for people aged 65 and over in primary care: protocol of the ProAct 65+ trial, Trials, 11:6,2010
E. Martin-Bautista, H. Gage, J. von Rosen-von Hoewel, V. Jakobik, K. Laitinen, M. Schmid2, J. Morgan, P. Williams, T. Decsi, C. Campoy, B. Koletzko, M. Raats. Lifetime health outcomes of breast-feeding: a comparison of the policy documents of five European countries. Public Health Nutrition, 13(10), 1653-1662, 2010
L. Axelrod, H. Gage, J, Kaye, K, Bryan, P. Trend, D. Wade. Workloads of Parkinson's specialist nurses: implications for implementing national service guidelines in England. Journal of Clinical Nursing, 19, 3575-3580, 2010
H. Gage, C Goodman, S.L. Davies, C. Norton, M. Fader, M. Wells, J. Morris, P. Williams. Laxative use in care homes, Journal of Advanced Nursing, 66 (6), 1266-72, 2010
H.Gage, J. Evans, W. Knibb, P. Williams, N. Rickman, K. Bryan. Nursing homes: more on quality of care. British Medical Journal, 339, b3526, 2009
C. Goodman, V. Drennan, S. Davies, H. Masey, H. Gage, C. Scott, J. Manthorpe, S. Brearley, S. Iliffe. The nursing contribution to chronic disease management: nursing case management. Report for the National Coordinating Centre, NHS Service Delivery and Organisation, June 2009
S. Kendall, P. Wilson, S. Proctor, E. McNeilly, F. Bunn, F. Brooks, H. Gage. The nursing, midwifery and health visitor contribution to chronic disease management: a whole system approach. Report for the National Coordinating Centre, NHS Service Delivery and Organisation, May 2009
H.Gage, J. Evans, W. Knibb, P. Williams, N. Rickman, K. Bryan. Why are some care homes better than others? An empirical study of the factors associated with the quality of care for older people in residential homes in Surrey. Health and Social Care in the Community, 17(6), 599-609, 2009