Heather Gage

Professor Heather Gage


Professor of Health Economics
+44 (0)1483 686948

Biography

Research

Research interests

My publications

Publications

Braun Andreas, Trivedi Daksha P, Dickinson Angela, Hamilton Laura, Goodman Claire, Gage Heather, Ashaye Kunle, Iliffe Steve, Manthorpe Jill (2018) Managing behavioural and psychological symptoms in community dwelling older people with dementia: 2. A systematic review of qualitative studies, Dementia pp. 1-21 SAGE Publications

Background

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.

Methods

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.

Results

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.

Conclusions

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.

Drennan Vari M, de Lusignan Simon, Gage Heather, Gabe Jon, Halter Mary (2018) Building an evidence base for the primary care workforce, BMJ 360 BMJ Publishing Group
Building an evidence base for the effects of different types of staff in general practice is challenging and takes time. McCartney is right to say that no evidence shows that physician associates make a difference to clinician stress and burnout. But more evidence is available than she suggests, which may be important at a time of considerable vacancies for general practitioners and practice nurses.
Trend P, Kaye J, Gage H, Owen C, Wade D (2002) Short-term effectiveness of intensive multidisciplinary rehabilitation for people with Parkinson's disease and their carers, Clinical Rehabilitation 16 (7) pp. 717-725
Objective: To evaluate the short-term effectiveness of an intensive multidisciplinary rehabilitation programme for people with Parkinson's disease and their carers. Design: Observational, with assessments before and after intervention. Setting: An elderly care day unit in a district general hospital in south-east England. Subjects: One hundred and eighteen people with Parkinson's disease and no cognitive impairment, and their carers. Intervention: Participants attended the day hospital in groups of six patients with their carers for one day per week over six consecutive weeks. After assessment, they received individual treatment from a specialist team. Weekly group activities included relaxation and talks from experts. Outcome measures: Patients and carers were assessed for: health-related quality of life, psychological well-being, social services need, perceptions of the programme. Patients were additionally assessed for mobility, gait and speech. Carers were assessed for strain. Results: After treatment significant improvements were recorded in patients' mobility and gait (p
Trivedi D, Goodman C, Gage H, Baron N, Scheibl F, Iliffe S, Manthorpe J, Bunn F, Drennan V (2013) The effectiveness of inter-professional working for older people living in the community: A systematic review, Health and Social Care in the Community 21 (2) pp. 113-128
Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people. © 2012 Blackwell Publishing Ltd.
Gage H, Kenward G, Hodgetts TJ, Castle N, Ineson N, Shaikh L (2002) Health system costs of in-hospital cardiac arrest, Resuscitation 54 (2) pp. 139-146
This paper reports on the health system resources used in the treatment of in-hospital cardiac arrests in a British district general hospital. The resources used in resuscitation attempts were recorded prospectively by observation of a convenience sample of 30 cardiac arrests. The post-resuscitation resource use by survivors was collected through a retrospective record review (n=37) and by following survivor members in the prospective sample (n=6). Financial data were used to translate resource use into costs (1999 prices). There was a non-significant trend for more resources to be used in daytime resuscitations than at night. Survivors had significantly fewer diagnostic tests during resuscitation than those who died (P=0.004). Length of resuscitation attempt was positively and significantly related to resource use (P
Iliffe S, Davies SL, Gordon AL, Schneider J, Dening T, Bowman C, Gage Heather, Martin FC, Gladman JRF, Victor C, Meyer J, Goodman C (2016) Provision of NHS generalist and specialist services to care homes in England: review of surveys, PRIMARY HEALTH CARE RESEARCH AND DEVELOPMENT 17 (2) pp. 122-137 CAMBRIDGE UNIV PRESS
Background The number of beds in care homes (with and without nurses) in the United Kingdom is three times greater than the number of beds in National Health Service (NHS) hospitals. Care homes are predominantly owned by a range of commercial, not-for-profit or charitable providers and their residents have high levels of disability, frailty and co-morbidity. NHS support for care home residents is very variable, and it is unclear what models of clinical support work and are cost-effective. Objectives To critically evaluate how the NHS works with care homes. Methods A review of surveys of NHS services provided to care homes that had been completed since 2008. It included published national surveys, local surveys commissioned by Primary Care organisations, studies from charities and academic centres, grey literature identified across the nine government regions, and information from care home, primary care and other research networks. Data extraction captured forms of NHS service provision for care homes in England in terms of frequency, location, focus and purpose. Results Five surveys focused primarily on general practitioner services, and 10 on specialist services to care home. Working relationships between the NHS and care homes lack structure and purpose and have generally evolved locally. There are wide variations in provision of both generalist and specialist healthcare services to care homes. Larger care home chains may take a systematic approach to both organising access to NHS generalist and specialist services, and to supplementing gaps with in-house provision. Access to dental care for care home residents appears to be particularly deficient. Conclusions Historical differences in innovation and provision of NHS services, the complexities of collaborating across different sectors (private and public, health and social care, general and mental health), and variable levels of organisation of care homes, all lead to persistent and embedded inequity in the distribution of NHS resources to this population. Clinical commissioners seeking to improve the quality of care of care home residents need to consider how best to provide fair access to health care for older people living in a care home, and to establish a specification for service delivery to this vulnerable population.
Trivedi D, Goodman C, Baron N, Scheibl F, Bunn F, Gage H, Iliffe S, Manthorpe J, Drennan V (2012) The effectiveness of inter-professional working for older people living in the community: A systematic review, Health and Social Care in the Community
Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people. © 2012 Blackwell Publishing Ltd.
Gage H, Hampson S, Skinner TC, Hart J, Storey L, Foxcroft D, Kimber A, Cradock S, McEvilly EA (2004) Educational and psychosocial programmes for adolescents with diabetes: approaches, outcomes and cost-effectiveness, Patient Education and Counseling 53 (3) pp. 333-346
Diabetes incurs heavy personal and health system costs. Self-management is required if complications are to be avoided. Adolescents face particular challenges as they learn to take responsibility for their diabetes. A systematic review of educational and psychosocial programmes for adolescents with diabetes was undertaken. This aimed to: identify and categorise the types of programmes that have been evaluated; assess the cost-effectiveness of interventions; identify areas where further research is required. Sixty-two papers were identified and Subjected to a narrative review. Generic programmes focus on knowledge/skills, psychosocial issues, and behaviour/self-management. They result in modest improvements across a range of outcomes but improvements are often not sustained, suggesting a need for continuous support, possibly integrated into normal care. In-hospital education at diagnosis confers few advantages over home treatment. The greatest returns may be obtained by targeting poorly controlled individuals. Few studies addressed resourcing issues and robust cost-effectiveness appraisals are required to identify interventions that generate the greatest returns on expenditure. (C) 2004 Elsevier Ireland Ltd. All rights reserved.
Brooke-Wavell K, Duckham R, Taylor R, Kendrick D, Carpenter H, Iliffe S, Morris R, Dinan S, Skelton D, Gage H, Masud T (2014) EFFECTIVENESS OF COMMUNITY GROUP AND HOME BASED FALLS PREVENTION EXERCISE PROGRAMMES ON BONE HEALTH IN OLDER PEOPLE: THE PROACT65+BONE STUDY, OSTEOPOROSIS INTERNATIONAL 25 pp. S676-S676 SPRINGER LONDON LTD
Metta V, Logishetty K, Martinez-Martin P, Gage HM, Schartau PES, Kaluarachchi TK, Martin A, Odin P, Barone P, Stocchi F, Antonini A, Chaudhuri KR (2011) The possible clinical predictors of fatigue in parkinson's disease: A study of 135 patients as part of international nonmotor scale validation project, Parkinson's Disease
Iliffe S, Haworth D, Stevens Z, Barlow C, Gawler S, Pearl M, Belcher C, Gage H, Carpenter H, Kendrick D, Dinan-Young S, Bowling A, Masud T, Skelton DA (2012) THE PROACT65+ EXERCISE TRIAL SYMPOSIUM: AN OVERVIEW, PRACTICAL IMPLICATIONS AND LESSONS LEARNED, JOURNAL OF AGING AND PHYSICAL ACTIVITY 20 pp. S115-S115 HUMAN KINETICS PUBL INC
Gage H, Cheynel J, Dickinson A, Davies SL, Goodman C, Victor C, Martin W, Williams P, Iliffe S, Froggatt K (2012) Integrated working between residential care homes and primary care: A survey of care homes in England, BMC Geriatrics 12
Background: Older people living in care homes in England have complex health needs due to a range of medical conditions, mental health needs and frailty. Despite an increasing policy expectation that professionals should operate in an integrated way across organisational boundaries, there is a lack of understanding between care homes and the National Health Service (NHS) about how the two sectors should work together, meaning that residents can experience a poor "fit" between their needs, and services they can access. This paper describes a survey to establish the current extent of integrated working that exists between care homes and primary and community health and social services. Methods. A self-completion, online questionnaire was designed by the research team. Items on the different dimensions of integration (funding, administrative, organisational, service delivery, clinical care) were included. The survey was sent to a random sample of residential care homes with more than 25 beds (n = 621) in England in 2009. Responses were analysed using quantitative and qualitative methods. Results: The survey achieved an overall response rate of 15.8%. Most care homes (78.7%) worked with more than one general practice. Respondents indicated that a mean of 14.1 professionals/ services (other than GPs) had visited the care homes in the last six months (SD 5.11, median 14); a mean of.39 (SD.163) professionals/services per bed. The most frequent services visiting were district nursing, chiropody and community psychiatric nurses. Many (60%) managers considered that they worked with the NHS in an integrated way, including sharing documents, engaging in integrated care planning and joint learning and training. However, some care home managers cited working practices dictated by NHS methods of service delivery and priorities for care, rather than those of the care home or residents, a lack of willingness by NHS professionals to share information, and low levels of respect for the experience and knowledge of care home staff. Conclusions: Care homes are a hub for a wide range of NHS activity, but this is ad hoc with no recognised way to support working together. Integration between care homes and local health services is only really evident at the level of individual working relationships and reflects patterns of collaborative working rather than integration. More integrated working between care homes and primary health services has the potential to improve quality of ca
Bryan K, Gage Heather, Gilbert K (2006) Delayed transfers of older people from hospital: Causes and policy implications, HEALTH POLICY 76 (2) pp. 194-201 ELSEVIER IRELAND LTD
Health and social care agencies in the UK. have been under pressure for some time to reduce delayed transfers of older people from hospital because they absorb scarce health service resources and incur a human cost through inappropriate placement. A local study based on an analysis of records and interviews with managers showed that delays reflect the complex needs of older people, and arise from financing and organisational problems at both the planning and implementation stages of a discharge. Family resistance may also be a factor. Budgetary constraints result in delays in confirming public support for some clients. Shortages of professional staff and care assistants limit the provision of domiciliary packages. The contraction of the residential sector has reduced the availability of beds and increased the cost of care home placements. Scope exists for expediting administrative aspects of transfers by coordinating health and social services. More recent legislation that imposes fines on social service departments for delayed transfers does not address underlying causes.
Egan B, Gage H, Williams P, Gyoerei E, Brands B, Lopez-Robles JC, Campoy C, Koletzko B, Desci T, Raats M (2013) ASSOCIATION BETWEEN DIET AND MENTAL PERFORMANCE OF CHILDREN: VIEWS OF PARENTS AND TEACHERS IN FOUR EUROPEAN COUNTRIES, ANNALS OF NUTRITION AND METABOLISM 63 pp. 1862-1862 KARGER
Gage H, Goodman C, Davies SL, Norton C, Fader M, Wells M, Morris J, Williams P (2010) Laxative use in care homes, JOURNAL OF ADVANCED NURSING 66 (6) pp. 1266-1272 WILEY-BLACKWELL
Kassianos A, Raats M, Rayman M, Gage H (2010) Information needs and information-seeking behaviour, PSYCHOLOGY & HEALTH 25 pp. 250-251 TAYLOR & FRANCIS LTD
Gage Heather, Avery M, Flannery C, Williams P, Fader M (2016) Community prevalence of long-term urinary catheters use in England., Neurourol Urodyn Wiley
OBJECTIVES: To calculate the prevalence of long term catheter use in the community in two areas in the south and west of England. SUBJECTS/PATIENTS (OR MATERIALS) AND METHODS: People in England register with general practices to access health care through a National Health Service. Catheters are provided by prescription free of charge. In 2008, patients using urinary catheters for over 3 months were identified, and demographic information collected, from databases of general practices, using catheter prescribing records. The age and sex distributions of people in each practice were obtained from capitation claims. Overall, and age and sex-specific prevalence were calculated separately for each area, and compared. RESULTS: A total of 583 long term catheter users (329 south, 254 west) were identified from 404,328 people registered with practices. The overall population prevalence is similar in both locations (0.146% southern, 0.141% western). Extrapolating for the United Kingdom, this is over 90,000 long term catheter users. Prevalence increases with age (0.732% in over 70 years, 1.224% over 80), especially amongst men. Overall, higher proportions have neurological (vs. non-neurological) reasons (62.9% vs. 37.1%) and use urethral (vs. suprapubic) catheters (59.7% vs. 40.3%). Compared to men, more women tend to use suprapubic (56.4% vs. 29.3%) and have a catheter for neurological reasons (71.8% vs. 56.2%, P = 0.053). CONCLUSIONS: Previous evidence on prevalence of long term catheter use is sparse, and of variable quality. The strength of this study is utilisation of a reliable source of data (catheter prescriptions) from a large population of patients. Neurourol. Urodynam. © 2016 Wiley Periodicals, Inc.
Andreyev HJN, Benton BE, Lalji A, Norton C, Mohammed K, Gage H, Pennert K, Lindsay JO (2013) Algorithm-based management of patients with gastrointestinal symptoms in patients after pelvic radiation treatment (ORBIT): a randomised controlled trial, LANCET 382 (9910) pp. 2084-2092 ELSEVIER SCIENCE INC
Frankland Jane, Brodie Hazel, Cooke Deborah, Foster Claire, Foster Rebecca, Gage Heather, Jordan Jake, Mesa-Eguiagaray Ines, Pickering Ruth, Richardson Alison (2017) Follow-up care after treatment for prostate cancer: protocol for an evaluation of a nurse-led supported self-management and remote surveillance programme, BMC Cancer 17 (656) BioMed Central

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.

Koskela SA, Jones F, Clarke N, Anderson L, Kennedy B, Grant R, Gage H, Hurley MV (2015) Active Residents in Care Homes (ARCH): study protocol to investigate the implementation and outcomes of a whole-systems activity programme in residential care homes for older people., Physiotherapy
To evaluate the effectiveness, acceptability and costs of Active Residents in Care Homes, ARCH - a programme aiming to increase opportunities for activity in older care home residents.Feasibility study.Residential care homes for older people.10-15 residents, staff and family members will be recruited in each of the three participating care homes.ARCH is a 12-month 'whole-systems' programme implemented by occupational therapists and physiotherapists. They will conduct a comprehensive assessment of each care home, considering the physical environment, working practices and organisation structure as well as residents' individual needs, and recommend ways to address barriers and increase residents' activity levels. The therapists will then work with staff to improve understanding of the issues, instigate training, environmental, organisational and working practice changes as necessary.Residents' activity levels, health and quality of life will be tested using several measures to see which are practicable and appropriate for this population in this context. This includes: Assessment of Physical Activity in Frail Older People; Pool Activity Level Checklist; Dementia Care Mapping observations; and EQ-5D-5L. Residents will be assessed prior to programme implementation then 4- and 12-months post-implementation. Semi-structured interviews will explore the experiences of residents, staff, family members and therapists.Providing evidence of effectiveness and acceptability of ARCH, and documenting factors that impede/facilitate implementation will help us identify ways to enhance the care and quality of life of older people in residential care, and our understanding of how to implement them.ISRCTN24000891.
Halimic A, Gage H, Vrikki M, Williams P (2013) Diabetes Awareness and Behavioural Risk Factors among University Students in Saudi Arabia, Middle East Journal of Family Medicine 11 (3)
Dowson HM, Ballard K, Gage H, Jackson D, Williams P, Rockall TA (2013) Quality of Life in the First 6 Weeks Following Laparoscopic and Open Colorectal Surgery, VALUE IN HEALTH 16 (2) pp. 367-372 ELSEVIER SCIENCE INC
Drennan V, Goodman C, Manthorpe J, Davies S, Scott C, Gage H, Iliffe S (2011) Establishing new nursing roles: a case study of the English community matron initiative, JOURNAL OF CLINICAL NURSING 20 (19-20) pp. 2948-2957 WILEY-BLACKWELL
Drennan VM, Halter M, Joly L, Gage Heather, Grant RL, Gabe J, Brearley S, Carneiro W, de Lusignan Simon (2015) Physician associates and GPs in primary care: a comparison, BRITISH JOURNAL OF GENERAL PRACTICE 65 (634) ROYAL COLL GENERAL PRACTITIONERS
Physician associates [PAs] (also known as
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.
Goodman C, Drennan V, Manthorpe J, Gage H, Trivedi D, Shah D, Scheibl F, Poltawski L, Handley M, Nash A, Iliffe S (2012) A study of the effectiveness of interprofessional working for community dwelling older people, In: Report for NIHR Service Delivery and Organisation
Hoewel J, Laitinen K, Schmid MA, Decsi T, Martin-Bautista E, Koletzko B, Jakobik V, Campoy C, Gage Heather, Morgan J, Raats MM (2007) Nutrition programming statements in materials on infant feeding aimed at parents: comparison among five European countries, Proceedings of the Nutrition Society 66 (Supp O) pp. 23A-23A
Bird A, Gage H, Owen C, Storey L (2005) Understanding of blood pressure and behavioural risk factors amongst British adolescents, Public Health 119 (12) pp. 1069-1079
Objectives: To survey students aged 16-18 years in secondary education establishments in one school district in the south of England in order to: Assess knowledge about the importance of blood pressure (BP) for health; investigate associations between knowledge and health-related behaviours; and explore home, school and health service influences on knowledge. Study design: Observational. Methods: Self-reported data from a structured questionnaire administered to convenience samples of students in schools were analysed by Chi-squared tests and multiple linear regression. The questionnaire assessed knowledge about BP risks, symptoms, consequences and measurement, and collected information on BP-related instruction, health behaviours (smoking, exercise, alcohol and nutrition) and family background. Results: A cross-section of 569 students completed questionnaires, representing 19.6% of the total age cohort. Most students recognized the major behavioural risks and consequences of high BP, but 104 (18.3%) could not describe how BP is measured, and 401 (88.1%) had no idea what a normal BP reading should be. In multivariate analysis, BP knowledge was associated with previous academic attainment, having received advice or instruction about BP, and having BP measured in the last 2 years. Family experience was not significant. Many students reported unhealthy behaviours: current smoker (n = 87, 15.3%); less than three exercise sessions per week (n = 172, 30.2%); and two portions or less of fruit/ vegetables per day (n = 223, 39.2%). BP knowledge was significantly associated with regular exercise but not with other health-promoting behaviours. One hundred and twenty-one (21.3%) students acknowledged having received instruction about BP, mainly from doctors/nurses (32%) and schools (28%). Conclusion: Gaps in adolescents' knowledge about BP were identified. Greater awareness was associated with having received formal advice and instruction, so health services and schools could play an important part in improving BP knowledge among adolescents. More understanding of cumulative risks may encourage fuller engagement in health-promoting activities. © 2005 The Royal Institute of Public Health. Published by Elsevier Ltd. All rights reserved.
Gage H, Kaye J, Owen C, Trend P, Wade D (2006) Evaluating rehabilitation using cost-consequences analysis: An example in Parkinson's disease, Clinical Rehabilitation 20 (3) pp. 232-238
Objective: To use cost-consequences analysis to evaluate rehabilitation, and to discuss some practical limitations. Design: Case study of a cost -consequences analysis. Setting: Day hospital. Subjects: People with Parkinson's disease witho ut major cognitive loss, and their carers. Intervention: A programme of multidisciplinary rehabilitation, delivered for one day per week over six weeks, and including 2 h of individual therapy (physical, occupational, speech and language, specialist nurse) and group activities on each occasion. Main measures: Costs: direct and overhead costs of treatment; participant travel. Consequences: patient outcomes (mobility, speech and language, disability, psychological well-being, health-related quality of life); carer outcomes (psychological well-being, health-related quality of life, strain); social service utilization; satisfaction. Results: In this example the main costs were facility's overheads and hospital-provided transport. The consequences of the intervention were improved immediate outcomes for patients that diminished over four months, discovery of unmet social services need, high satisfaction. No benefits for carers were observed. Conclusion: A cost-consequences analysis provides a clear descriptive summary for decision-makers that is easier to interpret than cost-effectiveness, cost-utility and cost-benefit analysis. It is a useful technique in rehabilitation research where multiple outcomes and several perspectives (health service, patient, carer) are relevant. However limitations remain: it is difficult to capture all consequences because of data deficiencies and long-term effects; evaluations of individual interventions are partial and do not guarantee economic rationality; local studies may not be generalizable; fixed protocols impede the evaluation of alternative service configurations. © 2006 Edward Arnold (Publishers) Ltd.
Barclay S, Froggatt K, Crang C, Mathie E, Handley M, Iliffe S, Manthorpe J, Gage Heather, Goodman C (2014) Living in uncertain times: trajectories to death in residential care homes, BRITISH JOURNAL OF GENERAL PRACTICE 64 (626) pp. E576-E583 ROYAL COLL GENERAL PRACTITIONERS
Background
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
Cambridgeshire. Method
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
events.
Mitra R, Gage H, Leatham EW (2005) Cost-effectiveness of transoesophageal echocardiography guided direct current cardioversion for acute atrial fibrillation, EUROPEAN HEART JOURNAL 26 pp. 370-371 OXFORD UNIV PRESS
Lopez Robles J, Egan B, Brands B, Gyoerei E, Gage Heather, Raats M, Koletzko B, Decsi T, Campoy C (2011) Teachers knowledge of the influence of nutrition on childrens mental performance in four European countries, ANNALS OF NUTRITION AND METABOLISM 58 pp. 409-409 KARGER
Introduction: Nutrition plays an important role in the development of children affecting them physically and mentally. Teachers are in a unique position to observe what factors influence a child?s cognitive development and performance hence it?s important to understand if they perceive diet to have an effect on mental performance. Objectives: Examine teachers? understanding of the effect of diet on children?s mental performance, using semi-structured interviews. Method/Design: The study was conducted in England, Germany, Hungary and Spain. Participants were teachers of children aged 4-10 years old recruited in state elementary schools. Semi-structured interviews were used to ask what they thought about the effects of diet on mental performance. Responses were recorded, coded and group analysed using the Nudist-Vivo 8.0 program. Reports on the national data from each country were analysed to make cross- country comparisons. Results: Preliminary analysis reveals that teachers highlight having a healthy diet affects mental aspects of children?s lives. The principal aspects of mental performance mentioned by them were attention and concentration. Most of the teachers expressed the opinion that hunger acts as a barrier to concentrating in class. Many teachers recognized an association between low levels of attention and students not having breakfast: it was highlighted as an important habit to avoid lethargy or becoming tired quickly throughout the school day. Teachers also noted unhealthy foods (sweets and junk foods) provide a quick burst of energy in a short period of time but also Irritability, nervousness or hyperactivity resulting in an inability to concentrate. Conclusions: Teachers perceive diet has a direct influence on the ability of children to concentrate, as well as on their mood and behavior. Their opinion of what a child eats affecting their health and development is closely linked to some specific foods which teachers label as ?unhealthy?. Study Supported by 7th Framework Programme (NUTRIMENTHE Grant-agreement: 212652)
Getliffe KA, Crouch R, Gage H, Lake F, Wilson SL (2000) Hypertension awareness, detection and treatment in a university community: Results of a worksite screening, Public Health 114 (5) pp. 361-366
This study aimed to assess knowledge levels, explore the extent of undiagnosed hypertension, record previous screening activity and monitor the outcomes of previous hypertension treatment. To this end, information was collected from volunteer members of a university community, by means of a self-report questionnaire, about their personal characteristics, knowledge and experience of hypertension and stroke, and previous blood pressure measurements. In addition, their current blood pressure was recorded. A total of 653 staff and students completed the questionnaire and had their blood pressure measured. Analysis revealed that 82% were normotensive (diastolic blood pressure 89 mmHg were previously unaware of a potential hypertension problem. Hypertension rates amongst the university volunteers are higher than those recently recorded from a population sample. Scope exists for increasing knowledge and awareness, and for raising both screening rates and treatment outcomes. Improvements in these areas are required if current public health targets for heart disease and stroke are to be achieved. Worksite screening programmes can contribute to this endeavour.
Fader M, Cottenden A, Getliffe K, Gage H, Clarke-O'Neill S, Jamieson K, Green N, Williams P, Brooks R, Malone-Lee J (2008) Absorbent products for urinary/faecal incontinence: A comparative evaluation of key product designs, Health Technology Assessment 12 (29) pp. iii-129
Brands B, Egan B, Györei E, López-Robles JC, Gage Heather, Campoy C, Decsi T, Koletzko B, Raats MM (2012) 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 (2) pp. 739-746 Elsevier
Nutrition is one of the many factors that influence a child?s cognitive development and performance. Understanding the relationship between nutrition and mental performance in children is important in terms of their attainment and productivity both in school and later life. Since parents are seen as nutritional gatekeepers for their children?s diets, their views and beliefs are of crucial importance. The present study aims to qualitatively examine parents? perceptions of the relationship between diet and mental performance of children. The study was conducted with a total of 124 parents in four European countries using a semi-structured interview schedule. Parents speak of the effects of diet at two levels; the nature of the effects of diet and the characteristics of the foods responsible for these effects. Mental outcomes are related to diet, with the effects perceived to be associated with attention and concentration, often mediated by effects on children?s mood and behaviour. Parents categorise foods as ?good? or ?bad? with positive effects related generally to a healthy balanced diet while negative effects are perceived to be associated with sugary and fatty foods. Understanding parental perceptions is important for many purposes including the targeting of dietary advice and prioritising of public health issues.
von Rosen-von Hoewel J, Martin-Bautista E, Campoy C, Jakobik V, Decsi T, Laitinen K, Schmid MA, Morgan J, Gage H, Koletzko B, Raats M (2007) Reflection of early nutrition programming in parental information of infant feeding: comparative analysis of five European countries, Early Human Development 83 pp. S126-S126
Raats MM, Malcolm RN, Lähteenmäki L, Pravst I, Gage Heather, Cleary A, Karatzia A, Kuaar A, Yang W, Jackson DL, Hodgkins CE, Klop
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(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
The Nutrition and Health Claims Regulation (EC No. 1924/2006) has established a common framework for the regulation of nutrition and health claims used on foods across the European Union. This regulation aims to provide the European food industry opportunities for product innovation whilst protecting consumer interests with respect to controlling misleading advertising and promoting public health. However, in order to satisfy the approval of new health claims procedure particularly for new ?reduction of disease risk? claims [Article 14(1)(a) claims] , significant research activity is required by industry to scientifically substantiate the claims they wish to make. There is a need to establish whether the implementation of this legislation is in fact driving product innovation and the development of healthy foods or whether it forms a barrier to such developments. The EU-funded REDICLAIM project is currently considering these issues. This article describes the project?s preliminary results and outlines the further programme of work.
Fader M, Cottenden A, Getliffe K, Gage H, Clarke-O'Neill S, Jamieson K, Green N, Williams P, Brooks R, Malone-Lee J (2008) Absorbent products for urinary/faecal incontinence: a comparative evaluation of key product designs - Introduction, Health Technology Assessment 12 (29) GRAY PUBLISHING
To compare the performance and cost-effectiveness of the key absorbent product designs to provide a more solid basis for guiding selection and purchase. Also to carry out the first stage in the development of a quality of life (QoL) instrument for measuring the impact of absorbent product use on users' lives.Design: Three clinical trials focused on the three biggest market sectors. Each trial had a similar crossover design in which each participant tested all products within their group in random order.Setting, participants and interventions: In Trial 1, 85 women with light urinary incontinence living in the community tested three products from each of the four design categories available (total of 12 test products): disposable inserts (pads); menstrual pads; washable pants with integral pad; and washable inserts. In Trial 2a, 85 moderate/ heavily incontinent adults (urinary or urinary/faecal) living in the community (49 men and 36 women) tested three (or two) products from each of the five design categories available (total of 14 test products): disposable inserts (with mesh pants); disposable diapers ( nappies); disposable pull-ups (similar to toddlers' trainer pants); disposable T-shaped diapers (nappies with waist-band); and washable diapers. All products were provided in a daytime and a (mostly more absorbent) night-time variant. In these first two trials, the test products were selected on the basis of data from pilot studies. In Trial 2b, 100 moderate/ heavily incontinent adults (urinary or urinary/faecal) living in 10 nursing homes (27 men and 73 women) evaluated one product from each of the four disposable design categories from Trial 2a. Products were selected on the basis of product performance in Trial 2a and, again, day time and night-time variants were provided. The first phase of developing a QoL tool for measuring the impact of using different pad designs was carried out by interviewing participants from Trials 1 and 2a.Main outcome measures: Product performance ( e. g. comfort, discreetness) was characterised using a weekly validated questionnaire. A daily pad change and leakage diary was used to record severity of leakage, numbers of laundry items and pads. Skin health changes were recorded weekly. At a final interview preferences were ranked, acceptability of each design recorded, and overall opinion marked on a visual analogue scale (VAS) of 0 - 100 points. This VAS score was used to estimate cost-effectiveness. In addition, a timed pad
Goodman C, Dening T, Gordon AL, Davies SL, Meyer J, Martin FC, Gladman JRF, Bowman C, Victor C, Handley M, Gage Heather, Iliffe S, Zubair M (2016) Effective health care for older people living and dying in care homes: a realist review, BMC Health Services Research 16 ARTN 269 BioMed Central
Abstract Background Care home residents in England have variable access to health care services. There is currently no coherent policy or consensus about the best arrangements to meet these needs. The purpose of this review was to explore the evidence for how different service delivery models for care home residents support and/or improve wellbeing and health-related outcomes in older people living and dying in care homes. Methods We conceptualised models of health care provision to care homes as complex interventions. We used a realist review approach to develop a preliminary understanding of what supported good health care provision to care homes. We completed a scoping of the literature and interviewed National Health Service and Local Authority commissioners, providers of services to care homes, representatives from the Regulator, care home managers, residents and their families. We used these data to develop theoretical propositions to be tested in the literature to explain why an intervention may be effective in some situations and not others. We searched electronic databases and related grey literature. Finally the findings were reviewed with an external advisory group. Results Strategies that support and sustain relational working between care home staff and visiting health care professionals explained the observed differences in how health care interventions were accepted and embedded into care home practice. Actions that encouraged visiting health care professionals and care home staff jointly to identify, plan and implement care home appropriate protocols for care, when supported by ongoing facilitation from visiting clinicians, were important. Contextual factors such as financial incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support relational working to occur, but of themselves appeared insufficient to achieve change. Conclusion How relational working is structured between health and care home staff is key to whether health service interventions achieve health related outcomes for residents and their respective organisations. The belief that either paying clinicians to do more in care homes and/or investing in training of care home staff is sufficient for better outcomes was not supported.
Waterman H, Ballinger C, Brundle C, Chastin S, Gage HM, Harper R, Henson D, Laventure B, McEvoy L, Pilling M, Olleveant N, Skelton D, Stanford P, Todd C (2016) A feasibility study to prevent falls in older people who are sight impaired: the VIP2UK randomised controlled trial, TRIALS 17 (464) ARTN 464 BIOMED CENTRAL LTD
Background: Published evaluations of successful interventions to prevent falls in people with sight impairment (SI) are limited. The aim of this feasibility study is to optimise the design and investigation of home safety (HS) and home exercise (HE) programmes to prevent falls in older people with SI. Methods: A community-based feasibility study in north-west England comprising a three-arm randomised controlled trial (RCT) allocated participants to (1) a control group receiving usual care and social visits, (2) an experimental group receiving the HS programme and (3) an experimental group receiving the HS + HE programme. Participants were community-dwelling, aged 65 years and older and sight impaired. Primary outcome data on falls were collected continuously over 6 months. Secondary outcomes on physical activity (self-report and instrumented) and adherence were collected at baseline and 3 and 6 months for HE and at 6 months for the HS programme. Costs for the HS and HS + HE groups were calculated from logs of time spent on home visits, telephone calls and travel. The research assistant and statistician were blinded to group allocation. Results: Altogether, 49 people were recruited over a 9-month period (randomised: 16 to control, 16 to HS, 17 to HS + HE). The interventions were implemented over 6 months by an occupational therapist at a cost per person (pounds sterling, 2011) of £249 (HS) and £674 (HS + HE). Eighty-eight percent (43/49) completed the trial and 6-month follow-up. At 6-month follow-up, 100 % reported partially or completely adhering to HS recommendations but evidence for adherence to HE was equivocal. Although self-reported physical activity increased, instrumented monitoring showed a decrease in walking activity. There were no statistically significant differences in falls between the groups; however, the study was not powered to detect a difference. Conclusion: It is feasible and acceptable for an occupational therapist to deliver HS and HE falls prevention programmes to people with SI living independently in the community. Future studies could access Local Authority Registers of people with SI to improve recruitment rates. Further research is required to identify how to improve adherence to HE and to measure changes in physical activity before conducting a definitive RCT. Trial registration: ISRCTN53433311, registered on 8 May 2014.
Fader MJ, Cottenden AM, Gage Heather, Williams P, Getliffe K, Clarke-O'Neill S, Jamieson KM, Green NJ (2014) Individual budgets for people with incontinence: Results from a 'shopping' experiment within the British National Health Service, Health Expectations 17 (2) pp. 186-196 Wiley
Background and context Most people with urinary incontinence are given limited choice when provided with absorbent products through the British National Health Service (NHS), even though the available range is large. Objective To investigate users' preferences for four disposable designs (inserts, all-in-ones, belted/T-shaped and pull-ups) and towelling washable/reusable products, day and night. Design Shopping experiment. Setting and participants Community-dwelling women and men in England with moderate-to-heavy urinary incontinence recruited to a larger trial. Intervention Participants tested each design and selected products they would prefer with a range of different budgets. Main outcome measures Design preferences (rankings); 'purchasing' decisions from designated budgets. Results Eighty-five participants (49 men) tested products, 75 completed the shopping experiment. Inserts, most frequently supplied by the NHS, were ranked second to pull-ups by women and lowest by men. When faced with budget constraints, up to 40% of participants opted to 'mix-and-match' designs. Over 15 different combinations of products were selected by participants in the shopping experiment. Most (91%) stated a willingness to 'top-up' assigned budgets from income to secure preferred designs. © 2012 John Wiley & Sons Ltd.
Sutton J, Family HE, Scott JA, Gage Heather, Taylor DA (2016) The influence of organisational climate on care of patients with schizophrenia: a qualitative analysis of health care professionals' views., International journal of clinical pharmacy 38 (2) pp. 344-352 Springer
Background Organizational climate relates to how employees perceive and describe the characteristics of their employing organization. It has been found to have an impact on healthcare professionals' and patients' experiences of healthcare (e.g. job satisfaction, patient satisfaction), as well as organizational outcomes (e.g. employee productivity). This research used organizational theory to explore dynamics between health care professionals (pharmacists, doctors and nurses) in mental health outpatients' services for patients taking clozapine, and the perceived influence on patient care. Setting Seven clozapine clinics (from one NHS mental health Trust in the UK) which provided care for people with treatment resistant schizophrenia. Methods This study used qualitative methods to identify organizational climate factors such as deep structures, micro-climates and climates of conflict that might inhibit change and affect patient care. Using Interpretative Phenomenological Analysis, semistructured interviews were conducted with 10 healthcare professionals working in the clinics to explore their experiences of working in these clinics and the NHS mental health Trust the clinics were part of. Main outcome measure Health Care Professionals' perceptions of the care of patients with treatment resistant schizophrenia. Results Three superordinate themes emerged from the data: philosophy of care, need for change and role ambiguity. Participants found it difficult to articulate what a philosophy of care was and in spite of expressing the need for change in the way the clinics were run, could not see how 'changing things would work'. There was considerable role ambiguity with some 'blurring of the boundaries between roles'. Factors associated with organizational climate (role conflict; job satisfaction) were inhibiting team working and preventing staff from identifying the patients' health requirements and care delivery through innovation in skill mix. There were mixed attitudes towards the pharmacist's inclusion as a team member. Conclusions Our findings suggest deficiencies within the clinics that may be manifestations of the wider culture of the NHS. The implications for mental health outpatient clinics are that local initiatives are crucial to the implementation of recovery models; clear guidance should be provided on the skill mix required in clozapine clinics and interprofessional learning should be encouraged to reduce role conflict.
Gage H, Knibb W, Evans J, Williams P, Rickman N, Bryan K (2009) Nursing homes More on quality of care, BRITISH MEDICAL JOURNAL 339 ARTN b3526 B M J PUBLISHING GROUP
Gage H, Ting S, Williams P, Drennan V, Goodman C, Iliffe S, Manthorpe J, Davies SL, Masey H (2013) Nurse-led case management for community dwelling older people: An explorative study of models and costs, Journal of Nursing Management 21 (1) pp. 191-201
Aim To compare community matrons with other nurses carrying out case management for impact on service use and costs. Background In England, nurses working in general practice, as district nurses and disease-specific nurses, undertake use case management. Community matrons were introduced to case management to reduce unplanned hospitalizations of people with complex conditions. Methods Managers in three Primary Care Trusts (PCTs) identified four nurses/matrons engaged in case management. Nurses/matrons recruited five community-dwelling patients referred to them for case management. Patients reported use of health/social services for 9months, 2008 to 2009. Nurses/matrons completed activity diaries. Results Service use data were available for 33 patients. Compared with other nurse case managers, community matrons had: smaller caseloads; more patient contact time (mean 364 vs. 80minutes per patient per month); and older patients (mean age 81 vs. 75years, P=0.03) taking more medications (mean 8.9 vs. 5.6, P=0.014). Monthly costs were significantly higher for patients managed by community matrons (add £861), and who lived alone (add £696). Hospitalizations were not associated with patient or service delivery factors. Conclusion Further research on cost-effectiveness of case management models is required. Implications for Nursing Management The case for continued investment in community matrons remains to be proven. © 2012 Blackwell Publishing Ltd.
Gage H, Hendricks A, Zhang S, Kazis L (2003) The relative health related quality of life of veterans with Parkinson's disease, Journal of Neurology Neurosurgery and Psychiatry 74 (2) pp. 163-169
Objectives: To use databases of the US Veterans Health Administration (VHA) to describe the impact of Parkinson's disease on health related quality of life (HRQoL) of veterans; to compare the HRQoL of veterans with Parkinson's disease with that of veterans reporting eight other neurological or chronic conditions; and to estimate the unique effect of Parkinson's disease on HRQoL. Methods: Respondents to the VHA 1999 large national health survey of veteran enrollees with a diagnosis of Parkinson's disease in VHA treatment files for the fiscal years 1997-1999 were identified by merging databases. The survey incorporated the Veterans SF-36, a well validated generic measure of HRQoL and functional status. This was used to compare patient groups. Mean physical (PCS) and mental (MCS) component summary scores were calculated for Parkinson's disease and eight other diseases by multivariable regressions that adjusted for age, sex, race, education, and 15 mental and physical co-morbid conditions that were self reported in the survey. Results: Of 887 775 survey respondents, 14 530 (1.64%) had a Parkinson's disease diagnosis. Controlling for sociodemographic factors and co-morbidities, veterans with Parkinson's disease had PCS and MCS below veterans with angina/coronary heart disease, arthritis, chronic low back pain, congestive heart failure, diabetes, and stroke. Veterans with spinal cord injury reported slightly lower PCS than veterans with Parkinson's disease (32.38 v 32.72; 0.03 of 1 SD). Veterans with depression reported markedly lower MCS than veterans with Parkinson's disease (35.94 v 41.48; 0.55 of 1 SD). The unique effect of having Parkinson's disease on HRQoL was to lower PCS and MCS by 4.10 and 3.42 points (0.41 and 0.34 of 1 SD), respectively. Conclusions: The analysis quantifies the negative impact of Parkinson's disease on HRQoL, after controlling for sociodemographic factors and co-morbidities. Compared with eight other chronic conditions, Parkinson's disease imposes a relatively heavy burden on US veterans in the VHA health care system.
Gage H, Egan B, Williams P, Lopez-Robles JC, Brands B, Gyoerei E, Campoy C, Desci T, Koletzko B, Raats M (2013) ASSOCIATION BETWEEN DIET AND PHYSICAL AND MENTAL DEVELOPMENT OF CHILDREN: VIEWS OF PARENTS AND TEACHERS IN FOUR EUROPEAN COUNTRIES, ANNALS OF NUTRITION AND METABOLISM 63 pp. 1863-1863 KARGER
Gage HM, Goodman C, Dickinson A, Davies S, Froggatt K, Morbey H, Victor C, Martin W, Masey H, Gage H, Iliffe S (2012) Approach: A study to develop integrated working between primary health care services and care homes, In: Report for NIHR Service Delivery and Organisation
Macaulay M, Broadbridge J, Gage Heather, Williams P, Birch B, Moore KN, Cottenden A, Fader MJ (2015) A trial of devices for urinary incontinence after treatment for prostate cancer, BJU INTERNATIONAL 116 (3) pp. 432-442 WILEY-BLACKWELL
Objective To compare the performance of three continence management devices and absorbent pads used by men with persistent urinary incontinence (>1 year) after treatment for prostate cancer. Patients and Methods Randomised, controlled trial of 56 men with 1-year follow-up. Three devices were tested for 3 weeks each: sheath drainage system, body-worn urinal (BWU) and penile clamp. Device and pad performance were assessed. Quality of life (QoL) was measured at baseline and follow-up with the King's Health Questionnaire. Stated (intended use) and revealed (actual use) preference for products were assessed. Value-for-money was gathered. Results Substantial and significant differences in performance were found. The sheath was rated as ?good? for extended use (e.g. golf and travel) when pad changing is difficult; for keeping skin dry, not leaking, not smelling and convenient for storage and travel. The BWU was generally rated worse than the sheath and was mainly used for similar activities but by men who could not use a sheath (e.g. retracted penis) and was not good for seated activities. The clamp was good for short vigorous activities like swimming/exercise; it was the most secure, least likely to leak, most discreet but almost all men described it as uncomfortable or painful. The pads were good for everyday activities and best for night-time use; most easy to use, comfortable when dry but most likely to leak and most uncomfortable when wet. There was a preference for having a mixture of products to meet daytime needs; around two-thirds of men were using a combination of pads and devices after testing compared with baseline. Conclusions This is the first trial to systematically compare different continence management devices for men. Pads and devices have different strengths, which make them particularly suited to certain circumstances and activities. Most men prefer to use pads at night but would choose a mixture of pads and devices during the day. Device limitations were important but may be overcome by better design.
Brooke-Wavell K, Duckham RL, Taylor R, Kendrick D, Carpenter H, Iliffe S, Morris R, Skelton DA, Dinan S, Gage H, Masud T (2015) DOES ADHERENCE TO FALLS PREVENTION EXERCISE PROGRAMMES BENEFIT BONE MINERAL DENSITY IN OLDER PEOPLE? THE PROACT65+BONE STUDY, AGE AND AGEING 44 pp. 13-13 OXFORD UNIV PRESS
Gage H, Ting S, Chorley C, Kaye J, Bryan K, Williams P, Axelrod L, Trend P, Wade D (2010) Disease-Specific Training for Care Assistants: A Randomized Controlled Trial Comparing Two Approaches for Improving Understanding of Parkinson's, MOVEMENT DISORDERS 25 pp. S700-S700 WILEY-LISS
Butler C, Holdsworth LM, Coulton S, Gage Heather (2012) Evaluation of a hospice rapid response community service: A controlled evaluation, BMC Palliative Care 11 BioMed Cental
Background: While most people faced with a terminal illness would prefer to die at home, less than a third in England are enabled to do so with many dying in National Health Service hospitals. Patients are more likely to die at home if their carers receive professional support. Hospice rapid response teams, which provide specialist palliative care at home on a 24/7 on-call basis, are proposed as an effective way to help terminally ill patients die in their preferred place, usually at home. However, the effectiveness of rapid response teams has not been rigorously evaluated in terms of patient, carer and cost outcomes. Methods/Design: The study is a pragmatic quasi-experimental controlled trial. The primary outcome for the quantitative evaluation for patients is dying in their preferred place of death. Carers quality of life will be evaluated using postal questionnaires sent at patient intake to the hospice service and eight months later. Carers perceptions of care received and the patients death will be assessed in one to one interviews at 6 to 8 months post bereavement. Service utilisation costs including the rapid response intervention will be compared to those of usual care. Discussion: The study will contribute to the development of the evidence base on outcomes for patients and carers and costs of hospice rapid response teams operating in the community. Trial registration: Current controlled trials ISRCTN32119670. © 2012 Butler et al.; licensee BioMed Central Ltd.
Sheehan BD, Lall R, Stinton C, Mitchell K, Gage H, Holland C, Katz J (2012) Patient and proxy measurement of quality of life among general hospital in-patients with dementia, Aging and Mental Health 16 (5) pp. 603-607
Background: We aimed to investigate quality of life ratings among people with varying severity of dementia and their carers, recruited in general hospital. Method: We recruited 109 people with dementia, and their proxies (carers), from psychiatric referrals of inpatients in two general hospitals in England. From patients, we gathered data on quality of life (QoL-AD and EQ5-D) and depressive symptoms, and from proxies we gathered data on patient quality of life (Proxy QoL-AD and EQ5-D), severity of dementia, activities of daily living, physical illness and depressive symptoms, and on carer stress. Results: Completion rates for both measures were progressively lower with increasing dementia severity. Patients rated their quality of life more highly than proxies on Qol-AD (patients=32.2, CI=30.7-33.7, proxies=24.7, CI=23.8-26.0, p
Gage Heather, Williams P, Von Rosen-Von Hoewel J, Laitinen K, Jakobik V, Martin-Bautista E, Schmid M, Egan B, Morgan J, Decsi T, Campoy C, Koletzko B, Raats MM (2012) Influences on infant feeding decisions of first-time mothers in five European countries, European Journal of Clinical Nutrition 66 (8) pp. 914-919 Nature Publishing Group
BACKGROUND/OBJECTIVES: Infant feeding decisions made by new parents have significant health implications. The study aimed to investigate: influences on infant feeding decisions; characteristics of mothers reporting reliance on alternative information sources; associations between reliance on different sources and intentions to exclusively breastfeed and introduce complementary foods later; and subsequent breastfeeding and weaning behaviours. SUBJECTS/METHODS: First-time mothers in five European countries (England, Finland, Germany, Hungary, Spain) completed questionnaires about the importance of 17 influences on infant feeding choices at birth and 8 months later, during 2007?2008. Use of individual sources and reliance on four categories (family and friends, health professionals, written materials, audio-visual media) were compared between countries. Associations between information sources used and mother characteristics, feeding intentions and behaviours were investigated using appropriate statistical tests. RESULTS: In all, 2071 first-time mothers provided baseline data; 78% at 8 months. Variation exists between countries in the influence of different sources on feeding decisions of first-time mothers. Across all countries, the most important influences at both time points were books, partner and antenatal midwife. Mothers in higher income quintiles and remaining at school beyond age 16 years reported greater reliance on written sources (P
Jones F, Gage Heather, Drummond A, Bhalla A, Grant R, Lennon S, McKevitt C, Riazi A, Liston M (2016) Feasibility study of an integrated stroke self-management programme: a cluster-randomised controlled trial, BMJ OPEN 6 (1) ARTN e0089 BMJ PUBLISHING GROUP
Objectives To test the feasibility of conducting a controlled trial into the effectiveness of a self-management programme integrated into stroke rehabilitation. Design A feasibility cluster-randomised design was utilised with stroke rehabilitation teams as units of randomisation. Setting Community-based stroke rehabilitation teams in London. Participants 78 patients with a diagnosis of stroke requiring community based rehabilitation. Intervention The intervention consisted of an individualised approach to self-management based on self-efficacy. Clinicians were trained to integrate defined self-management principles into scheduled rehabilitation sessions, supported by a patient-held workbook. Main outcomes measures Patient measures of quality of life, mood, self-efficacy and functional capacity, and health and social care utilisation, were carried out by blinded assessors at baseline, 6?weeks and 12?weeks. Fidelity and acceptability of the delivery were evaluated by observation and interviews. Results 4 community stroke rehabilitation teams were recruited, and received a total of 317 stroke referrals over 14?months. Of these, 138 met trial eligibility criteria and 78 participants were finally recruited (56.5%). Demographic and baseline outcome measures were similar between intervention and control arms, with the exception of age. All outcome measures were feasible to use and clinical data at 12?weeks were completed for 66/78 participants (85%; 95% CI 75% to 92%). There was no significant difference in any of the outcomes between the arms of the trial, but measures of functional capacity and self-efficacy showed responsiveness to the intervention. Observation and interview data confirmed acceptability and fidelity of delivery according to predetermined criteria. Costs varied by site. Conclusions It was feasible to integrate a stroke self-management programme into community rehabilitation, using key principles. Some data were lost to follow-up, but overall results support the need for conducting further research in this area and provide data to support the design of a definitive trial.
Fader M, Clarke-O'Neill S, Green N, Jamieson K, Gage H, Getliffe K, Brooks R, Malone-Lee J, Cottenden A (2007) Gender differences in performance of and preferences for absorbent products for men and women with moderate-heavy urinary incontinence: A randomized cross-over clinical trial, NEUROUROLOGY AND URODYNAMICS 26 (5) pp. 635-636 WILEY-BLACKWELL
Gage H, Cheynel J, Williams P, Mitchell K, Stinton C, Katz J, Holland C, Sheehan B (2014) Service utilisation and family support of people with dementia: a cohort study in England, INTERNATIONAL JOURNAL OF GERIATRIC PSYCHIATRY 30 (2) pp. 166-177 WILEY-BLACKWELL
Goodman C, Froggatt K, Mathie E, Craig C, Wright J, Handley M, Gage H, Iliffe S (2010) The experiences and expectations of older people resident in care homes, their carers and professionals: a prospective study, In: Report for NIHR Research for Patient Benefit
Poltawski L, Goodman C, Iliffe S, Manthorpe J, Gage H, Shah D, Drennan V (2011) Frailty scales - Their potential in interprofessional working with older people: A discussion paper, Journal of Interprofessional Care 25 (4) pp. 280-286
Hampson SE, Skinner TC, Hart J, Storey L, Gage H, Foxcroft D, Kimber A, Shaw K, Walker J (2001) Effects of educational and psychosocial interventions for adolescents with diabetes mellitus: A systematic review, Health Technology Assessment 5 (10)
Goodman C, Scheibl F, Drennan V, Shah D, Manthorpe J, Gage H, Iliffe S (2011) 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
Background: Most services provided by health and social care organisations for older people living at home rely on interprofessional working (IPW). Although there is research investigating what supports and inhibits how professionals work together, less is known about how different service models deliver care to older people and how effectiveness is measured. The aim of this study was to describe how IPW for older people living at home is delivered, enacted and evaluated in England. Method. An online survey of health and social care managers across England directly involved in providing services to older people, and a review of local strategies for older people services produced by primary care organisations and local government adult services organisations in England. Results: The online survey achieved a 31% response rate and search strategies identified 50 local strategies that addressed IPW for older people living at home across health and social care organisations. IPW definitions varied, but there was an internal consistency of language informed by budgeting and organisation specific definitions of IPW. Community Services for Older People, Intermediate Care and Re-enablement (rehabilitation) Teams were the services most frequently identified as involving IPW. Other IPW services identified were problem or disease specific and reflected issues highlighted in local strategies. There was limited agreement about what interventions or strategies supported the process of IPW. Older people and their carers were not reported to be involved in the evaluation of the services they received and it was unclear how organisations and managers judged the effectiveness of IPW, particularly for services that had an open-ended commitment to the care of older people. Conclusion: Health and social care organisations and their managers recognise the value and importance of IPW. There is a theoretical literature on what supports IPW and what it can achieve. The need for precision may not be so necessary for the terms used to describe IPW. However, there is a need for shared identification of both user/patient outcomes that arise from IPW and greater understanding of what kind of model of IPW achieves what kind of outcomes for older people living at home. © 2011 Goodman et al; licensee BioMed Central Ltd.
Gage Heather, Holdsworth LM, Flannery C, Williams P, Butler C (2015) Impact of a hospice rapid response service on preferred place of death, and costs, BMC PALLIATIVE CARE 14 ARTN 75 BIOMED CENTRAL LTD
Background Many people with a terminal illness would prefer to die at home. A new palliative rapid response service (RRS) provided by a large hospice provider in South East England was evaluated (2010) to provide evidence of impact on achieving preferred place of death and costs. The RRS was delivered by a team of trained health care assistants and available 24/7. The purpose of this study was to (i) compare the characteristics of RRS users and non-users, (ii) explore differences in the proportions of users and non-users dying in the place of their choice, (iii) monitor the whole system service utilisation of users and non-users, and compare costs. Methods All hospice patients who died with a preferred place of death recorded during an 18 month period were included. Data (demographic, preferences for place of death) were obtained from hospice records. Dying in preferred place was modelled using stepwise logistic regression analysis. Service use data (period between referral to hospice and death) were obtained from general practitioners, community providers, hospitals, social services, hospice, and costs calculated using validated national tariffs. Results Of 688 patients referred to the hospice when the RRS was operational, 247 (35.9 %) used it. Higher proportions of RRS users than non-users lived in their own homes with a co-resident carer (40.3 % vs. 23.7 %); more non-users lived alone or in residential care (58.8 % vs. 76.3 %). Chances of dying in the preferred place were enhanced 2.1 times by being a RRS user, compared to a non-user, and 1.5 times by having a co-resident carer, compared to living at home alone or in a care home. Total service costs did not differ between users and non-users, except when referred to hospice very close to death (users had higher costs). Conclusions Use of the RRS was associated with increased likelihood of dying in the preferred place. The RRS is cost neutral.
Gage Heather, Cheynel J, Williams P, Mitchell K, Stinton C, Katz J, Holland C, Sheehan B (2015) Service utilisation and family support of people with dementia: A cohort study in England, International Journal of Geriatric Psychiatry 30 (2) pp. 166-177 John Wiley & Sons, Ltd.
Copyright © 2014 John Wiley & Sons, Ltd.Objectives: This study aimed to compare costs of caring for people with dementia in domiciliary and residential settings, central England. Methods: A cohort of people with dementia was recruited during a hospital stay 2008-2010. Data were collected by interview at baseline, and 6- and 12-month follow-up, covering living situation (own home with or without co-resident carer, care home); cognition, health status and functioning of person with dementia; carer stress; utilisation of health and social services; and informal (unpaid) caring input. Costs of formal services and informal caring (replacement cost method) were calculated. Costs of residential and domiciliary care packages were compared. Results: Data for 109 people with dementia were collected at baseline; 95 (87.2%) entered hospital from their own homes. By 12 months, 40 (36.7%) had died and 85% of the survivors were living in care homes. Over one-half of people with dementia reported social care packages at baseline; those living alone had larger packages than those living with others. Median caring time for co-resident carers was 400 min/day and 10 h/week for non co-resident carers. Residential care was more costly than domiciliary social care for most people. When the value of informal caring was included, the total cost of domiciliary care was higher than residential care, but not significantly so. Carer stress reduced significantly after the person with dementia entered a care home. Conclusions: Caring for people with dementia at home may be more expensive, and more stressful for carers, than care in residential settings.
Davies SL, Goodman C, Bunn F, Dickinson A, Victor C, Martin W, Iliffe S, Gage H, Froggatt K (2011) A systematic review of integrated working between care homes and health care services, BMC Health Services Research 11
Background: In the UK there are almost three times as many beds in care homes as in National Health Service (NHS) hospitals. Care homes rely on primary health care for access to medical care and specialist services. Repeated policy documents and government reviews register concern about how health care works with independent providers, and the need to increase the equity, continuity and quality of medical care for care homes. Despite multiple initiatives, it is not known if some approaches to service delivery are more effective in promoting integrated working between the NHS and care homes. This study aims to evaluate the different integrated approaches to health care services supporting older people in care homes, and identify barriers and facilitators to integrated working. Methods. A systematic review was conducted using Medline (PubMed), CINAHL, BNI, EMBASE, PsycInfo, DH Data, Kings Fund, Web of Science (WoS incl. SCI, SSCI, HCI) and the Cochrane Library incl. DARE. Studies were included if they evaluated the effectiveness of integrated working between primary health care professionals and care homes, or identified barriers and facilitators to integrated working. Studies were quality assessed; data was extracted on health, service use, cost and process related outcomes. A modified narrative synthesis approach was used to compare and contrast integration using the principles of framework analysis. Results: Seventeen studies were included; 10 quantitative studies, two process evaluations, one mixed methods study and four qualitative. The majority were carried out in nursing homes. They were characterised by heterogeneity of topic, interventions, methodology and outcomes. Most quantitative studies reported limited effects of the intervention; there was insufficient information to evaluate cost. Facilitators to integrated working included care home managers' support and protected time for staff training. Studies with the potential for integrated working were longer in duration. Conclusions: Despite evidence about what inhibits and facilitates integrated working there was limited evidence about what the outcomes of different approaches to integrated care between health service and care homes might be. The majority of studies only achieved integrated working at the patient level of care and the focus on health service defined problems and outcome measures did not incorporate the priorities of residents or acknowledge the skills of care home staff. There is a
Goodman C, Drennan V, Davies S, Masey H, Gage H, Scott C, Manthorpe G, Brearley S, Iliffe S (2009) The nursing contribution to chronic disease management: nursing case management, In: Report for NIHR Service Delivery and Organisation
Iliffe S, Kendrick D, Morris R, Griffin M, Haworth D, Carpenter H, Masud T, Skelton DA, Dinan-Young S, Bowling A, Gage Heather (2015) Promoting physical activity in older people in general practice: ProAct65+cluster randomised controlled trial, BRITISH JOURNAL OF GENERAL PRACTICE 65 (640) pp. E731-E738 ROYAL COLL GENERAL PRACTITIONERS
Background Regular physical activity reduces falls, hip fractures, and all-cause mortality, but physical activity levels are low in older age groups. Aim To evaluate two exercise programmes promoting physical activity among older people. Design and setting Pragmatic three-arm, parallel-design cluster randomised controlled trial involving 1256 people aged e65 years (of 20 507 invited) recruited from 43 general practices in London, Nottingham, and Derby. Method Practices were randomised to the class-based Falls Management Exercise programme (FaME), the home-based Otago Exercise Program (OEP), or usual care. The primary outcome was the proportion reaching the recommended physical activity target 12 months post-intervention. Secondary outcomes included falls, quality of life, balance confidence, and costs. Results In total, 49% of FaME participants reached the physical activity target compared with 38% for usual care (adjusted odds ratio 1.78, 95% confidence interval [CI] =1.11 to 2.87, P = 0.02). Differences between FaME and usual care persisted 24 months after intervention. There was no significant difference comparing those in the OEP (43% reaching target at 12 months) and usual-care arms. Participants in the FaME arm added around 15 minutes of moderate-to-vigorous physical activity per day to their baseline level; this group also had a significantly lower rate of falls (incident rate ratio 0.74, 95% CI = 0.55 to 0.99, P = 0.042). Balance confidence was significantly improved in both intervention arms. The mean cost per extra person achieving the physical activity target was £1740. Attrition and rates of adverse reactions were similar. Conclusion The FaME programme increases self-reported physical activity for at least 12 months post-intervention and reduces falls in people aged e65 years, but uptake is low. There was no statistically significant difference in reaching the target, or in falls, between the OEP and usual-care arms.
Wade DT, Gage H, Owen C, Trend P, Grossmith C, Kaye J (2003) Multidisciplinary rehabilitation for people with Parkinson's disease: A randomised controlled study, Journal of Neurology Neurosurgery and Psychiatry 74 (2) pp. 158-162
Objective: To determine whether a programme of multidisciplinary rehabilitation and group support achieves sustained benefit for people with Parkinson's disease or their carers. Methods: The study was a randomised controlled crossover trial comparing patients and carers who had received rehabilitation four months before assessment with those who had not. Patients were recruited from a neurology clinic, attended a day hospital from home weekly for six weeks using private car or hospital transport, and received group educational activities and individual rehabilitation from a multidisciplinary team. Patients were assessed at entry and at six months using a 25 item self assessment Parkinson's disease disability questionnaire, Euroqol-5d, SF-36, PDQ-39, hospital anxiety and depression scale, and timed stand-walk-sit test. Carers were assessed using the carer strain index and Euroqol-5d. Results: 144 people with Parkinson's disease without severe cognitive losses and able to travel to hospital were registered (seven were duplicate registrations); 94 had assessments at baseline and six months. Repeated measures analysis of variance comparing patients at the 24 week crossover point showed that those receiving rehabilitation had a trend towards better stand-walk-sit score (p = 0.093) and worse general and mental health (p = 0.002, p = 0.019). Carers of treated patients had a trend towards more strain (p = 0.086). Analysis comparing patients before and six months after treatment showed worsening in disability, quality of life, and carer strain. Conclusions: Patients with Parkinson's disease decline significantly over six months, but a short spell of multidisciplinary rehabilitation may improve mobility. Follow up treatments may be needed to maintain any benefit.
Gage H (2001) Keeping nurses nursing: a quantitative analysis., Nursing times 97 (7) pp. 35-37
Decsi T, Bokor SZ, Martin-Bautista E, Campoy C, Laitinen K, Hoewel J, Schmid MA, Gage Heather, Koletzko B, Morgan J, Raats MM (2007) Representation of early nutritional programming in policy documents on infant nutrition: comparison of five European countries, Proceedings of the Nutrition Society 66 pp. 16A-16A
Kendall S, Wilson P, Proctor S, McNeilly E, Bunn F, Brooks F, Gage H (2009) The nursing, midwifery and health visitor contribution to chronic disease management: a whole system approach, In: Report for NIHR Service Delivery and Organisation
Kassianos AP, Raats MM, Gage Heather, Peacock M (2015) Quality of life and dietary changes among cancer patients: a systematic review, QUALITY OF LIFE RESEARCH 24 (3) pp. 705-719 SPRINGER
Purpose: To review the literature focusing on the effects of dietary behavioural changes on cancer patients? health-related quality of life (HRQOL). Methods: Relevant databases were searched for studies that report the relationship between dietary changes and HRQOL of people with cancer and synthesized and systematically reviewed the available evidence. Papers were assessed for methodological quality and the themes identified were summarized. Results: The selected studies included only randomized-controlled trials, which target changes in diet. Twelve studies were identified which focus on the association between lifestyle changes which included changes in diet and HRQOL among cancer patients. Results have been mixed and dietary changes have been shown to partly affect HRQOL, but other factors seem to be important as well in defining that relationship. Moreover cancer groups with higher survival rates (prostate, breast, colorectal) seem to benefit more from dietary changes while different HRQOL constructs are affected with no clear indication of directional benefits on physical or mental health. Conclusions: Even though there are some indications of a direct relationship between dietary changes and HRQOL further research should establish which areas of HRQOL are directly affected. Perhaps nutritional changes in future interventions can be isolated in order to identify a potential direct relationship with HRQOL.
Gage H, Ting S, Williams P, Drennan V, Goodman C, Iliffe S, Manthorpe J, Davies SL, Masey H (2012) Nurse-led case management for community dwelling older people: An explorative study of models and costs, Journal of Nursing Management
Aim To compare community matrons with other nurses carrying out case management for impact on service use and costs. Background In England, nurses working in general practice, as district nurses and disease-specific nurses, undertake use case management. Community matrons were introduced to case management to reduce unplanned hospitalizations of people with complex conditions. Methods Managers in three Primary Care Trusts (PCTs) identified four nurses/matrons engaged in case management. Nurses/matrons recruited five community-dwelling patients referred to them for case management. Patients reported use of health/social services for 9months, 2008 to 2009. Nurses/matrons completed activity diaries. Results Service use data were available for 33 patients. Compared with other nurse case managers, community matrons had: smaller caseloads; more patient contact time (mean 364 vs. 80minutes per patient per month); and older patients (mean age 81 vs. 75years, P=0.03) taking more medications (mean 8.9 vs. 5.6, P=0.014). Monthly costs were significantly higher for patients managed by community matrons (add £861), and who lived alone (add £696). Hospitalizations were not associated with patient or service delivery factors. Conclusion Further research on cost-effectiveness of case management models is required. Implications for Nursing Management The case for continued investment in community matrons remains to be proven. © 2012 Blackwell Publishing Ltd.
Fader M, Cottenden A, Getliffe K, Gage H, Clarke-O'Neill S, Jamieson K, Green N, Williams P, Brooks R, Malone-Lee J (2008) Absorbent products for urinary/faecal incontinence: A comparative evaluation of key product designs, Health Technology Assessment 12 (29) pp. iii-129
To compare the performance and cost-effectiveness of the key absorbent product designs to provide a more solid basis for guiding selection and purchase. Also to carry out the first stage in the development of a quality of life (QoL) instrument for measuring the impact of absorbent product use on users' lives. Three clinical trials focused on the three biggest market sectors. Each trial had a similar crossover design in which each participant tested all products within their group in random order. SETTING, PARTICIPANTS AND INTERVENTIONS: In Trial 1, 85 women with light urinary incontinence living in the community tested three products from each of the four design categories available (total of 12 test products): disposable inserts (pads); menstrual pads; washable pants with integral pad; and washable inserts. In Trial 2a, 85 moderate/heavily incontinent adults (urinary or urinary/faecal) living in the community (49 men and 36 women) tested three (or two) products from each of the five design categories available (total of 14 test products): disposable inserts (with mesh pants); disposable diapers (nappies); disposable pull-ups (similar to toddlers' trainer pants); disposable T-shaped diapers (nappies with waist-band); and washable diapers. All products were provided in a daytime and a (mostly more absorbent) night-time variant. In these first two trials, the test products were selected on the basis of data from pilot studies. In Trial 2b, 100 moderate/heavily incontinent adults (urinary or urinary/faecal) living in 10 nursing homes (27 men and 73 women) evaluated one product from each of the four disposable design categories from Trial 2a. Products were selected on the basis of product performance in Trial 2a and, again, day time and night-time variants were provided. The first phase of developing a QoL tool for measuring the impact of using different pad designs was carried out by interviewing participants from Trials 1 and 2a. Product performance (e.g. comfort, discreetness) was characterised using a weekly validated questionnaire. A daily pad change and leakage diary was used to record severity of leakage, numbers of laundry items and pads. Skin health changes were recorded weekly. At a final interview preferences were ranked, acceptability of each design recorded, and overall opinion marked on a visual analogue scale (VAS) of 0-100 points. This VAS score was used to estimate cost-effectiveness. In addition, a timed pad changing exercise was conducted wi
Dowson H, Huang A, Soon Y, Gage H, Lovell D, Rockall T (2007) Systematic review of the costs of laparoscopic colorectal surgery, Diseases of the Colon and Rectum 50 (6) pp. 908-919
Gage HM, Pope R, Lake F (2002) Retaining nurses in the NHS - Nurses' loyalty may be underestimated, BRITISH MEDICAL JOURNAL 325 (7376) pp. 1362-1362 BRITISH MED JOURNAL PUBL GROUP
Gage H, Storey L, McDowell C, Maguire G, Williams P, Faithfull S, Thomas H, Poole K (2009) Integrated care: Utilisation of complementary and alternative medicine within a conventional cancer treatment centre, Complementary Therapies in Medicine 17 (2) pp. 84-91
Objectives: To estimate the proportion of cancer outpatients who visit a Complementary and Alternative Medicine (CAM) unit that is located within a conventional cancer treatment centre; to compare the characteristics of CAM unit visitors with those of all outpatients; to monitor the demand for 20 CAM therapies delivered by professionals, and the use of the CAM unit for waiting, gathering information and informal support from volunteer staff. Design: Prospective, observational, over a six month period. Setting: CAM unit within a NHS cancer treatment centre. Main outcome measures: Utilisation of the CAM unit for 20 complementary therapies, and for waiting, gathering information, informal support; characteristics of CAM users compared with those of all cancer outpatients attending the cancer centre; predictors of CAM therapy use and frequent use. Results: 761 (95% of those approached) people were recruited, 498 (65.4%) cancer patients, 202 (26.5%) relatives, 37 (4.8%) friends/carers, 24 (3.2%) staff. Women predominated (n = 560, 73.6%). Of all outpatients attending the cancer centre, 498 (15.8%) visited the CAM unit, 290 (9.2%) accessed therapies. Compared to all outpatients, those visiting the CAM unit were: younger (mean 63.7 vs. 58.4 years), more likely to be female (57.9% vs. 78.7%), have breast (14.8% vs. 51.9%), gynaecotogical (5.0% vs. 9.1%) cancer, live in local postal district (57.3% vs. 61.6%). Significant predictors of therapy use and frequent visits were being a patient, female, higher education, living closer to the cancer centre. Conclusions: Despite easy access to CAM therapies, a relatively small number of people regularly used them, whilst a larger number selectively tried a few. The integrated CAM unit meets a demand for information and informal support. The findings inform emerging policy on integrating CAM and conventional cancer treatment to address psychosocial needs of people with cancer. More research is needed on why people do not use integrated CAM services and how charges affect demand. (C) 2008 Published by Elsevier Ltd.
Gage Heather, Knibb W, Evans J, Williams P, Rickman N, Bryan K (2009) Why are some care homes better than others? An empirical study of the factors associated with quality of care for older people in residential homes in Surrey, England, HEALTH & SOCIAL CARE IN THE COMMUNITY 17 (6) pp. 599-609 WILEY-BLACKWELL PUBLISHING, INC
Drennan V, Goodman C, Manthorpe J, Davies S, Scott C, Gage H, Iliffe S (2011) Establishing new nursing roles: A case study of the English community matron initiative, Journal of Clinical Nursing 20 (19-20) pp. 2948-2957
Holdsworth LM, Gage Heather, Coulton S, King A, Butler C (2015) A quasi-experimental controlled evaluation of the impact of a hospice rapid response community service for end-of-life care on achievement of preferred place of death, PALLIATIVE MEDICINE 29 (9) pp. 817-825 SAGE PUBLICATIONS LTD
Background: Rapid response services operating 24 h a day have been advocated in UK health policy to support dying patients at home, though there is limited evidence of their effectiveness.
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.
Katz J, Holland C, Mitchell K, Gage H, Thein N, Sheehan B (2013) Carers' perspectives on choosing a care home for a relative with dementia, FAMILIES RELATIONSHIPS AND SOCIETIES 2 (2) pp. 211-228 POLICY PRESS
Andreyev HJ, Benton B, Lalji A, Pennert K, Lindsay JO, Gage H, Norton C (2013) ALGORITHMIC MANAGEMENT OF RADIATION-INDUCED GI SYMPTOMS IS HIGHLY EFFECTIVE: THE ORBIT RANDOMISED CONTROLLED TRIAL, GUT 62 pp. A29-A30 BMJ PUBLISHING GROUP
Handley M, Goodman C, Froggatt K, Mathie E, Gage Heather, Manthorpe J, Barclay S, Crang C, Iliffe S (2014) Living and dying: responsibility for end-of-life care in care homes without on-site nursing provision - a prospective study, HEALTH & SOCIAL CARE IN THE COMMUNITY 22 (1) pp. 22-29 WILEY-BLACKWELL
The aim of the study was to describe the expectations and experiences of end-of-life care of older people resident in care homes, and how care home staff and the healthcare practitioners who visited the care home interpreted their role. A mixed-method design was used. The everyday experience of 121 residents from six care homes in the East of England were tracked; 63 residents, 30 care home staff with assorted roles and 19 National Health Service staff from different disciplines were interviewed. The review of care home notes demonstrated that residents had a wide range of healthcare problems. Length of time in the care homes, functional ability or episodes of ill-health were not necessarily meaningful indicators to staff that a resident was about to die. General Practitioner and district nursing services provided a frequent but episodic service to individual residents. There were two recurring themes that affected how staff engaged with the process of advance care planning with residents; ?talking about dying? and ?integrating living and dying?. All participants stated that they were committed to providing end-of-life care and supporting residents to die in the care home, if wanted. However, the process was complicated by an ongoing lack of clarity about roles and responsibilities in providing end-of-life care, doubts from care home and primary healthcare staff about their capacity to work together when residents? trajectories to death were unclear. The findings suggest that to support this population, there is a need for a pattern of working between health and care staff that can encourage review and discussion between multiple participants over sustained periods of time.
Gage Heather, Erdal E, Saigal P, Qiao Y, Williams P, Raats MM (2012) Recognition and management of overweight and obese children: A questionnaire survey of general practitioners and parents in England., Journal of Paediatrics and Child Health 48 (2) pp. 146-152 Wiley-Blackwell
Aims:? To (i) compare the views of general practitioners (GPs) and parents about the causes, consequences and management of childhood overweight/obesity; and (ii) explore the extent to which they can identify overweight/obesity in children. Methods:? A questionnaire was mailed to all GPs in one Primary Care Trust and all parents in one primary school in southern England, 2008. Information was gathered on socio-demographic background, views about causes, consequences and management of childhood overweight/obesity; judgements about the weight status of 14 images of children (seven boys, seven girls) in the Children's Body Image Scale (CBIS). Comparisons were made between GP and parents' responses using unpaired bivariate tests. Results:? The response rate was 33%. Differences exist between the views of GPs and parents about childhood weight management: 86.4% of parents felt GPs should be involved, compared to 73.3% of GPs (P
Andreyev HJ, Thomas K, Benton B, Lalji A, Lindsay JO, Gage H, Norton C (2012) OPTIMISING RADIATION BOWEL INJURY THERAPY, THE ORBIT STUDY, A RANDOMISED CONTROLLED TRIAL, GUT 61 pp. A36-A36 B M J PUBLISHING GROUP
Gage H, Egan B, Williams P, Gyoerei E, Brands B, Lopez-Robles J, Campoy C, Koletzko B, Decsi T, Raats M (2014) Views of parents in four European countries about the effect of food on the mental performance of primary school children, European Journal of Clinical Nutrition 68 (1) pp. 32-37 Nature Publishing Group

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.

Meyers AR, Gage H, Hendricks A (2000) Health-related quality of life in neurology, Archives of Neurology 57 (8) pp. 1224-1227
Context: In a climate of growing concern about costs of health care, professional accountability, and the effectiveness and efficiency of treatment, neurologists should understand measures of health-related quality of life (HRQoL) and appreciate both their values and their limits. Objective: To provide a critical review of current concepts in the measurement of HRQoL, with particular emphasis on those pertaining to neurologic conditions. Design: A selective overview of measurement strategies and specific instruments. Setting: Clinical and research settings. Participants: Special attention to people with such conditions as multiple sclerosis and Parkinson disease. Main Outcome Measures: The utility and relevance to neurologists of available measures of HRQoL. Results: There are both generic and condition- or disease- specific measures of HRQoL. Though many measures do not elicit response or are even offensive to people with such conditions as multiple sclerosis and Parkinson disease, other measures pertain directly to their circumstances and needs. Conclusions: Measures of HRQoL are both meaningful and relevant to neurologists. However, they must be refined - enabled - and used in combinations to address the clinical and existential realities of many neurologic conditions.
Kaye J, Gage H, Kimber A, Storey L, Trend P (2006) Excess burden of constipation in Parkinson's disease: A pilot study, Movement Disorders 21 (8) pp. 1270-1273
An analysis was undertaken of clinic-based questionnaires that asked people with Parkinson's disease and a control group of older people without a known neurological condition about their experiences of constipation. People with Parkinson's disease report higher constipation on a validated objective measure, the Rome criterion (59% vs. 20.9%); a behavioral indicator, laxative-taking (38.4% vs. 14.2%); and subjective self-report of being always or often concerned by it (33.4% vs. 6.1%). Many people with Parkinson's disease experience constipation problems but they may not bring these to the attention of their healthcare providers. More research is required to understand the causes and management options. © 2006 Movement Disorder Society.
Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L, Thomas H (2002) The measurement of satisfaction with healthcare: implications for practice from a systematic review of the literature., Health technology assessment (Winchester, England) 6 (32) pp. 1-244
Gage H, Kaye J, Kimber A, Storey L, Egan M, Qiao Y, Trend P (2010) Correlates of constipation in people with Parkinson's, PARKINSONISM & RELATED DISORDERS 17 (2) pp. 106-111 ELSEVIER SCI LTD
Gage H, Ting S, Williams P, Bryan K, Kaye J, Castleton B, Trend P, Wade D (2011) 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 BioMed Central
Parkinson's Disease is a degenerative neurological condition that causes movement problems and other distressing symptoms. People with Parkinson's disease gradually lose their independence and strain is placed on family members. A multidisciplinary approach to rehabilitation for people with Parkinson's is recommended but has not been widely researched. Studies are needed that investigate cost-effective community-based service delivery models to reduce disability and dependency and admission to long term care, and improve quality of life.
Fader M, Clarke-O'Neill S, Green N, Jamieson K, Gage H, Getliffe K, Brooks R, Malone-Lee J, Cottenden A (2007) Gender differences in performance of and preferences for absorbent products for men and women with moderate-heavy urinary incontinence: A randomized cross-over clinical trial, Wiley-Liss
Gage H, Storey L (2004) Rehabilitation for Parkinson's disease: A systematic review of available evidence, Clinical Rehabilitation 18 (5) pp. 463-482
Objective: To systematically review the available evidence on the effectiveness of nonpharmacological rehabilitation interventions for people with Parkinson's disease, and identify future research needs. Design: Electronic searches of four databases (CINAHL, Cochrane Library, MEDLINE, PsychLIT) 1980-2002; examination of reference lists of relevant papers. Controlled trials and observational studies were included. Data extraction and quality assessment of papers by two independent reviewers. A narrative review. Setting: Rehabilitation interventions delivered either in subjects' own homes, or in clinical settings as outpatients. Subjects: Community-living adults with Parkinson's disease. Interventions: Physiotherapy, occupational therapy, speech and language therapy, psychological counselling and support, and education. Main measures: A range of outcomes: mobility, functional status, speech, swallowing, psychological well-being, as determined by the studies included in the review. Results: Forty-four different studies (reported in 51 papers) were included (25 physiotherapy, 4 occupational therapy, 10 speech and language therapy, 3 psychological counselling, 1 educational, 1 multidisciplinary). All studies, except one, reported improvements on at least one outcome measure. Conclusions: Findings may reflect publication bias, but suggest interventions can affect patients' lives for the better in a variety of ways. It is difficult to interpret the clinical importance of statistically significant improvements reported in most studies. There is a need for methodologically more robust research with meaningful follow-up periods, designed in a manner that separates specific and nonspecific effects. Cost-effectiveness evidence is required to provide clear guidance on service extensions. © Arnold 2004.
Hampson SE, Skinner TC, Hart J, Storey L, Gage H, Foxcroft D, Kimber A, Cradock S, McEvilly EA (2000) Behavioral interventions for adolescents with type 1 diabetes: How effective are they?, Diabetes Care 23 (9) pp. 1416-1422
OBJECTIVE - To evaluate the effectiveness of behavioral interventions for adolescents with type 1 diabetes based on a systematic review of the literature. RESEARCH DESIGN AND METHODS - The literature was identified by searching 11 electronic databases, hand-searching 3 journals from their start dates, and contacting individual researchers. Only articles that reported evaluations of behavioral (including educational and psychosocial) interventions for adolescents (age range 9-21 years) with type 1 diabetes that included a control group were included in the present review. Data summarizing the key features of the interventions and their effects were extracted from each article. Where possible, effect sizes for the randomized control trials (RCTs) were calculated. RESULTS - The search process identified 64 reports of empirical studies. Of these, 35 studies included a control group, and 24 were RCTs. Effect sizes could be calculated for 18 interventions. The overall mean effect size calculated across all outcomes was 0.33 (median 0.21), indicating that these interventions have a small- to medium-sized beneficial effect on diabetes management. Interventions that were theoretically based were significantly more effective than those that were not (P
Axelrod L, Gage Heather, Kaye J, Bryan K, Trend P, Wade D (2010) Workloads of Parkinson's specialist nurses: implications for implementing national service guidelines in England, J CLIN NURS 19 (23-24) pp. 3575-3580 WILEY-BLACKWELL PUBLISHING, INC
Drennan VM, Halter M, Joly L, Gage HM, Grant RL, Gabe J, Brearley S, Carneiro W, de Lusignan S (2015) Physician associates and GPs in primary care: a comparison., British Journal of General Practice pp. e344-e350
Background
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
workforce.
Poole K, Gage H, Storey L, Egan B, Thomas H (2007) Home Chemotherapy: should patients have a choice?, British Journal of Home Healthcare 2 (2) pp. 12-14
Gage H, Egan B, Williams P, Brands B, Györei E, López-Robles J, Campoy C, Decsi T, Koletzko B, Raats M (2016) Importance of mental performance in parental choice of food for children aged 4 ? 10 years: a study in four European countries, Public Health Nutrition 20 (6) pp. 992-1000 Cambridge University Press
Objective: Typically, attention focuses on how nutrition affects physical health. The present study investigated the importance that parents attach to the impact of diet on mental performance when choosing food for their child. Design: Questionnaire. Setting: Four European countries. Subjects: Parents of children aged 4?10 years (n 1574): England (n 397), Germany (n 389), Hungary (n 398) and Spain (n 390). Results: Most parents (80?85 %) considered the effect of food on four elements of mental performance (child?s ability to learn, attention, behaviour, mood) to be moderately, very, extremely (v. slightly, not at all) important in food choices; over 90% considered healthiness of food and making food appealing to their child important; 79·8% cost; 76·8% convenience. Belief that food affects mental performance was 57·4% (ability to learn), 60·5% (attention); less than 40% of parents agreed they were aware which foods had an effect. Parents with lower general interest in healthy eating were less likely to consider the effect of food on mental performance elements as important. Respondents from Germany were more likely to rate mental performance as important (except behaviour); those in Hungary less likely. The most important influence on parents? decisions about feeding their child was their own experience, except Spain, where family/friends/ health professionals were more important. Conclusions: Nutrition affects brain development and cognitive functioning. Low prioritisation of the effect of food on mental performance indicates potential for educating parents.
Goodman C, Davies SL, Norton C, Fader M, Morris J, Wells M, Gage H (2013) Can district nurses and care home staff improve bowel care for older people using a clinical benchmarking tool?, British Journal of Community Nursing 18 (12) pp. 580-587
A quasi-experimental study tested a clinical benchmarking tool (Essence of Care) to improve bowel-related care for older people living in six care homes. In the intervention care homes, district nurses and care home staff used the clinical benchmarking tool to discuss and plan how to improve bowel care for residents. In the control care homes, staff were provided with detailed information about the residents and continence services contact details. The intervention was acceptable to care home and district nursing staff, and possible to incorporate into existing working patterns. The study did not demonstrate a significant reduction in bowel-related problems, although there was evidence in one care home of reduction in episodes of avoidable faecal incontinence. At an individual level of care, there were observable benefits, and examples of person-centred care were prompted through participating in the intervention and improved staff awareness. Clinical benchmarking tools can be used to structure discussion between district nurses and care home staff to review and plan care for residents. However, it takes time to achieve change and embedding this kind of approach requires either robust pre-existing working relationships or the involvement of a facilitator. © 2013 MA Healthcare Ltd.
Iliffe S, Kendrick D, Morris R, Skelton D, Gage H, Dinan S, Stevens Z, Pearl M, Masud T (2010) 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
Egan B, Gage H, Williams P, Brands B, Gyoerei E, Lopez-Robles JC, Koletzko B, Campoy C, Desci T, Raats M (2013) FACTORS AFFECTING FOOD CHOICES OF PARENTS OF CHILDREN AGED 4-10 YEARS IN FOUR EUROPEAN COUNTRIES, ANNALS OF NUTRITION AND METABOLISM 63 pp. 1862-1862 KARGER
Gage Heather, Raats MM, Williams P, Egan B, Jakobik V, Laitinen K, Martin-Bautista E, Schmid M, von Rosen-von Hoewel J, Campoy C, Decsi T, Morgan J, Koletzko B (2011) Developmental origins of health and disease: the views of first-time mothers in 5 European countries on the importance of nutritional influences in the first year of life., American Journal of Clinical Nutrition 94 (6S) pp. 2018S-2024S American Society for Nutrition
Background: The programming concept suggests that poor early nutrition causes an array of medical problems later in life. Public health messages about the implications of programming may not be reaching parents and influencing infant feeding behaviors. Objective: The views of new mothers were sought about the extent to which lifelong health is influenced by diet as an infant, rather than by genetic predispositions or lifestyles and behaviors. Design: A questionnaire survey of first-time mothers was undertaken in 5 European countries. Results: A convenience sample of 2071 mothers from England (438), Finland (426), Germany (414), Hungary (389), and Spain (404) self-completed the questionnaire. High proportions of mothers agreed that how an infant is fed affects his or her health over the first year (95.8%) and in subsequent years (88.5%), but the effect of infant feeding decisions on the development of long-term conditions was the least-cited underlying reason. Diet as an infant was rated an extremely/very important influence on adult health by 64% of mothers, equivalent to environmental pollution (63%), but by fewer mothers than were diet and physical activity in childhood/adolescence (79%, 84%) and adulthood (81%, 83%), genetics/inheritance (70%), and exposure to cigarette smoke (81%). Inter- and intracountry differences were observed. Conclusions: Mothers in this study consider diet as an infant to be a less important influence on lifelong health than many lifestyle, behavioral, and environmental factors and genetics. Further dissemination of the implications of programming to consumers may be warranted.
Gage Heather, Family H, Murphy F, Williams P, Sutton J, Taylor D (2015) Comparison of sole nurse and team-delivered community clozapine services for people with treatment-resistant schizophrenia, JOURNAL OF ADVANCED NURSING 71 (3) pp. 547-558 WILEY-BLACKWELL
Aim To compare sole nurse and doctor-led multidisciplinary team delivery of community clozapine services for people with treatment-resistant schizophrenia. Background Around 20% of people with schizophrenia are treatment resistant and fail to respond to front line medications. Clozapine, a second-line treatment, has potentially serious side effects requiring regular monitoring. Different models of community clozapine services are emerging in the British National Health Service, but there is little evidence about which is best. Design Questionnaire survey of service users. Methods All patients on the lists of seven clozapine clinics (four sole nurse, three multidisciplinary team) in one trust were invited to participate, 2009?2010. Forward stepwise regression was used to investigate associations between patient well-being, functioning, self-efficacy and satisfaction, and clinic model attended, controlling for socio-demographic and health characteristics and processes of care. Use (and costs) of other health and social services accessed was compared between models. Results Sixty-six service users (35% participation rate) responded. Well-being and functioning were associated with patient characteristics and processes of care, not clinic model. Patients managed by sole nurses reported, over 3 months: more community psychiatric nurse visits and hospital psychiatrist appointments. Clinic list size affects costs per patient. Conclusions Multidisciplinary team delivery may reduce use of other services. Although multidisciplinary team delivery is regarded as best practice, sole nurses can effectively provide clozapine services and may be warranted in areas of low population density.
Halter M, Drennan V, Chattopadhyay K, Carneiro W, Yiallouros J, de Lusignan Simon, Gage Heather, Gabe J, Grant R (2013) The contribution of Physician Assistants in primary care: a systematic review., BMC Health Serv Res 13 ARTN 223 BioMed Central
Primary care provision is important in the delivery of health care but many countries face primary care workforce challenges. Increasing demand, enlarged workloads, and current and anticipated physician shortages in many countries have led to the introduction of mid-level professionals, such as Physician Assistants (PAs). Objective: This systematic review aimed to appraise the evidence of the contribution of PAs within primary care, defined for this study as general practice, relevant to the UK or similar systems.
OBJECTIVE: Current plans in the English National Health Service are to replace block contracts for mental health providers with a single tariff for each 'cluster' of conditions. A single tariff will not take into account the potential additional complexity and costs inherent in caring for older people. To examine the basis for a uniform tariff, differences in service utilisation and costs between working age adults and older adults in two populous clusters (non-psychotic, psychotic) were investigated across five mental health healthcare providers in and around London. METHODS: Retrospective review of records over 3 months assessing service utilisation and costs using the Client Services Receipt Inventory. RESULTS: Records of 362 patients were reviewed, 179 older adults (90 non-psychotic, 89 psychotic) and 183 adults of working age (83 non-psychotic, 100 psychotic). Older adults in both clusters had more tests, assessments and home visits. Overall costs of care of older adults were significantly higher in the non-psychotic cluster (£5634, vs £4405 psychotic, p = 0.044). CONCLUSIONS: An appropriate age-related tariff is required for each cluster. Copyright © 2016 John Wiley & Sons, Ltd.
Kassianos AP, Raats Monique, Gage Heather (2016) An exploratory study on the information needs of prostate cancer patients and their partners, Health Psychology Research 4 (1) 4786 PAGEPress Publications
The aim of this study is to explore the information needs of men with prostate cancer and their partners retrospectively at various points in the treatment process. An online questionnaire was used to collect information from men with prostate cancer and their partners about information needs, and when these developed. Readers of a Prostate Care Cookbook and members of a Prostate Cancer Charity were invited to participate: 73 men with prostate cancer and 25 partners completed the questionnaire. Responses showed that participants develop their information needs close to diagnosis. Less educated men with prostate cancer and partners developed their needs closer to the time after diagnosis than those with higher education. Partners develop an interest on information related to treatment and interaction earlier than patients. Patients prioritised treatment and disease-specific information. Patients and partners differ in how their information needs develop. Medical information is prioritized by patients as opposed to practical information by partners. Health care provision can be tailored to meet the different needs of prostate cancer patients and their partners at different times in the treatment process.
Halter M, Drennan V, Joly L, Gabe J, Gage H, de Lusignan S (2017) The patients? perspective of physician associates in primary care in England: a qualitative study, Health Expectations 20 (5) pp. 1011-1019 Wiley
Background: Physician Associates are new to English general practice and set to expand in numbers. Objective: To investigate the patients? perspective on consulting with PAs in general practice. Design: A qualitative study, using semi structured interviews, with thematic analysis. Setting and participants: Thirty volunteer patients of 430 who had consulted PAs for a same day appointment and had returned a satisfaction survey, in six general practices employing physician associates in England. Findings: 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 was 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. Conclusion: Patients saw PAs as an appropriate general practitioner substitute. Patients? experience could inform delivery redesign.
Fader MJ, Cottenden AM, Gage HM, Williams P, Getliffe K, Clarke-O'Neill S, Jamieson KM, Green NJ (2012) Individual budgets for people with incontinence: Results from a 'shopping' experiment within the British National Health Service, Health Expectations
Background and context Most people with urinary incontinence are given limited choice when provided with absorbent products through the British National Health Service (NHS), even though the available range is large. Objective To investigate users' preferences for four disposable designs (inserts, all-in-ones, belted/T-shaped and pull-ups) and towelling washable/reusable products, day and night. Design Shopping experiment. Setting and participants Community-dwelling women and men in England with moderate-to-heavy urinary incontinence recruited to a larger trial. Intervention Participants tested each design and selected products they would prefer with a range of different budgets. Main outcome measures Design preferences (rankings); 'purchasing' decisions from designated budgets. Results Eighty-five participants (49 men) tested products, 75 completed the shopping experiment. Inserts, most frequently supplied by the NHS, were ranked second to pull-ups by women and lowest by men. When faced with budget constraints, up to 40% of participants opted to 'mix-and-match' designs. Over 15 different combinations of products were selected by participants in the shopping experiment. Most (91%) stated a willingness to 'top-up' assigned budgets from income to secure preferred designs. Discussion Participants displayed diverse preferences. Enabling user choice of absorbent product design through individual budgets could improve satisfaction of consumers and efficiency of allocation of limited NHS resources. Conclusion Recent policy for the NHS seeks to provide consumers with more control in their care. Extension of the concept of individual budgets to continence supplies could be feasible and beneficial for patients and provide better value-for-money within the NHS. Further research is warranted. © 2012 Blackwell Publishing Ltd.
Goodman C, Mathie E, Cowe M, Mendoza A, Westwood D, Munday D, Wilson PM, Crang C, Froggatt K, Iliffe S, Manthorpe J, Gage H, Barclay S (2011) 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
Paul S, Kokossis A, Gage H, Storey L, Lawrenson R, Trend P, Walmsley K, Morrison S, Kaye J, Gradwell E, Baker M (2006) A semantically enabled formalism for the knowledge management of Parkinson's disease., Med Inform Internet Med 31 (2) pp. 101-120
Bio-ontology is a formal representation of biological concepts that is used in the interchange of communication between computers and humans alike. They can then be used in the formulation and retrieval of knowledge. In developing a knowledge-based system for Parkinson's Disease, a procedure of knowledge map was used to capture and harness the intellectual resources of an organization, and new paradigms for knowledge mapping were also formulated. Knowledge bases for symptoms and drugs, physiotherapy, speech and language therapy, and dieting that affect patient care were developed. Finally, the knowledge bases were merged to form a single central repository of knowledge base.
Gage Heather, Kaye J, Kimber A, Storey L, Egan M, Qiao Y, Trend P (2011) Correlates of constipation in people with Parkinson's, Parkinsonism and Related Disorders 17 (2) pp. 106-111 Elsevier
Purpose To investigate clinical, demographic and dietary factors associated with constipation in a sample of community dwelling people with Parkinson?s disease, recruited through a specialist outpatient clinic. Partners/carers provided a convenience control group. Scope Participants completed a baseline questionnaire (background information, diet and exercise, activities of daily living: mobility and manual dexterity, health-related quality of life (SF-12), stool frequency and characteristics, extent of concern due to constipation, laxative taking), and a four-week stool diary. The Rome criterion was used to determine constipation status. Multiple regression methods were used to explore the correlates of constipation. Baseline data were provided by 121 people with Parkinson?s, (54 controls), of whom 73% (25%) met the Rome criterion. Prospective diary data from 106 people with Parkinson?s (43 controls) showed lower proportions: 35% (7%) meeting the Rome criterion. Among all study subjects, i.e. Parkinson?s patients and controls taken together, the presence of constipation is predicted by having Parkinson?s disease (p = .003; odds ratio 4.80, 95% CI 1.64?14.04) and mobility score (p = .04; odds ratio 1.15, 95% CI 1.01?1.31), but not by dietary factors. Amongst people with Parkinson?s constipation is predicted by number of medications (p = .027). Laxative taking masks constipation, and is significantly associated with wearing protection against bowel incontinence (p = .009; odds ratio 4.80, 95% CI: 1.48?15.52). Conclusions Constipation is disease-related, not a lifestyle factor. More research is needed on optimal management and laxative use.
Egan B, Gage H, Hood J, Poole K, McDowell C, Maguire G, Storey L (2012) Availability of complementary and alternative medicine for people with cancer in the British National Health Service: Results of a national survey, Complementary Therapies in Clinical Practice 18 (2) pp. 75-80 Elsevier
This study assessed access to Complementary and Alternative Medicine (CAM) therapies for people with cancer within the British National Health Service. CAM units were identified through an internet search in 2009. A total of 142 units, providing 62 different therapies, were identified: 105 (74.0%) England; 23 (16.2%) Scotland; 7 (4.9%) each in Wales and Northern Ireland. Most units provide a small number of therapies (median 4, range 1?20), and focus on complementary, rather than alternative approaches. Counselling is the most widely provided therapy (available at 82.4% of identified units), followed by reflexology (62.0%), aromatherapy (59.1%), reiki (43.0%), massage (42.2%). CAM units per million of the population varied between countries (England: 2.2; Wales: 2.3; Scotland: 4.8; Northern Ireland: 5.0), and within countries. Better publicity for CAM units, greater integration of units in conventional cancer treatment centres may help improve access to CAMs.
Dowson HM, Cowie AS, Ballard K, Gage H, Rockall TA (2008) Systematic review of quality of life following laparoscopic and open colorectal surgery, Colorectal Disease 10 (8) pp. 757-768
Objective To compare the health-related quality of life (HRQoL) of patients following laparoscopic and open colorectal surgery. Method A systematic review was performed according to Quorum guidelines. Prospective studies comparing the HRQoL of patients after laparoscopic and open colorectal surgery were identified. The primary outcome measure was postoperative quality of life; performance status and cosmesis were secondary outcome measures. Results Twenty-three studies were identified that satisfied the inclusion criteria; 18 assessed HRQoL, four performance status, and three cosmesis. It was not possible to perform a meta-analysis due to study heterogeneity. The studies reported outcomes for 2946 patients. The most frequent HRQoL instruments employed were Short Form 36, European Organization for Research and Treatment of Cancer, and gastrointestinal quality of life index. Six studies, using a total of 12 separate measures, evaluated QoL during the first three postoperative months: 10 of these measures showed no significant difference, and two showed an improved HRQoL with laparoscopy. Twelve further studies evaluated HRQoL up to 5 years postoperatively: nine showed no difference between the two groups, and three demonstrated a benefit for laparoscopy. Three of four studies assessing performance status on discharge, and all three studies assessing cosmesis, reported benefits with the laparoscopic approach. Conclusions The current evidence suggests there is no significant difference in HRQoL following laparoscopic and open colorectal surgery, although there is a lack of good quality data. There is a trend towards improved quality of life outcomes and performance status with laparoscopy in the early postoperative period. There is a need for further research, particularly assessing quality of life in the early postoperative period.
Duckham R, Brooke-Wavell K, Masud T, Taylor R, Kendrick D, Carpenter H, Skelton D, Dinan S, Gage H, Morris R, Iliffe S (2014) Effectiveness of Community Group and Home Based Falls Prevention Exercise Programmes on Bone Health in Older People: the ProAct65+Bone Study., JOURNAL OF BONE AND MINERAL RESEARCH 29 pp. S224-S224 WILEY-BLACKWELL
Fader M, Cottenden A, Getliffe K, Gage H, Clarke-O'Neill S, Jamieson K, Green N, Williams P, Brooks R, Malone-Lee J (2008) Absorbent products for urinary/faecal incontinence: a comparative evaluation of key product designs - Introduction, Health Technology Assessment 12 (29) pp. 1-+
Objectives: To compare the performance and cost-effectiveness of the key absorbent product designs to provide a more solid basis for guiding selection and purchase. Also to carry out the first stage in the development of a quality of life (QoL) instrument for measuring the impact of absorbent product use on users' lives. Design: Three clinical trials focused on the three biggest market sectors. Each trial had a similar crossover design in which each participant tested all products within their group in random order. Setting, participants and interventions: In Trial 1, 85 women with light urinary incontinence living in the community tested three products from each of the four design categories available (total of 12 test products): disposable inserts (pads); menstrual pads; washable pants with integral pad; and washable inserts. In Trial 2a, 85 moderate/ heavily incontinent adults (urinary or urinary/faecal) living in the community (49 men and 36 women) tested three (or two) products from each of the five design categories available (total of 14 test products): disposable inserts (with mesh pants); disposable diapers ( nappies); disposable pull-ups (similar to toddlers' trainer pants); disposable T-shaped diapers (nappies with waist-band); and washable diapers. All products were provided in a daytime and a (mostly more absorbent) night-time variant. In these first two trials, the test products were selected on the basis of data from pilot studies. In Trial 2b, 100 moderate/ heavily incontinent adults (urinary or urinary/faecal) living in 10 nursing homes (27 men and 73 women) evaluated one product from each of the four disposable design categories from Trial 2a. Products were selected on the basis of product performance in Trial 2a and, again, day time and night-time variants were provided. The first phase of developing a QoL tool for measuring the impact of using different pad designs was carried out by interviewing participants from Trials 1 and 2a. Main outcome measures: Product performance ( e. g. comfort, discreetness) was characterised using a weekly validated questionnaire. A daily pad change and leakage diary was used to record severity of leakage, numbers of laundry items and pads. Skin health changes were recorded weekly. At a final interview preferences were ranked, acceptability of each design recorded, and overall opinion marked on a visual analogue scale (VAS) of 0 - 100 points. This VAS score was used to estimate cost-effectiveness. In additi
Gage Heather, Erdal E, Saigal P, Raats MM, Williams P, Qiao Y (2012) Recognition and management of overweight and obese children: A questionnaire survey of general practitioners and parents in England, Journal of Paediatrics and Child Health 48 (2) pp. 146-152
Aims: To (i) compare the views of general practitioners (GPs) and parents about the causes, consequences and management of childhood overweight/obesity; and (ii) explore the extent to which they can identify overweight/obesity in children. Methods: A questionnaire was mailed to all GPs in one Primary Care Trust and all parents in one primary school in southern England, 2008. Information was gathered on socio-demographic background, views about causes, consequences and management of childhood overweight/obesity; judgements about the weight status of 14 images of children (seven boys, seven girls) in the Children's Body Image Scale (CBIS). Comparisons were made between GP and parents' responses using unpaired bivariate tests. Results: The response rate was 33%. Differences exist between the views of GPs and parents about childhood weight management: 86.4% of parents felt GPs should be involved, compared to 73.3% of GPs (P
Jakobik V, Martin-Bautista E, Gage Heather, Von Rosen-Von Hoewel J, Laitinen K, Schmid M, Morgan J, Williams P, Campoy C, Koletzko B, Raats MM, Decsi T (2011) Programming effect of breast-feeding in infant nutrition policy documents in Hungary | Az anyatejes táplálás hosszú távú hatásainak megjelenése a csecsemotáplálási irányelvekben Magyarországon, Orvosi Hetilap 152 (41) pp. 1641-1647 Akadémiai Kiadó
Aims: To identify and describe infant feeding policy documents in Hungary and compare them to the documents of other four European countries (England, Finland, Germany and Spain). The question was also addressed how the phenomenon of nutritional programming was represented in the documents. Subjects: Policy documents on infant feeding were identified and analyzed in the five European countries by using uniform methods for searching and coding. Results: Twenty-six documents were identified: 4 in England, 2 in Finland, 9 in Germany, 6 in Hungary and 5 in Spain. Altogether 203 statements linked to references were identified: benefits of breast-feeding in general (24%), protection against infections (32%), long-term advantages like the prevention of diabetes (31%) or allergy (12%). Considerable variations were found within and between countries in the evaluation of the duration and character of the positive effects. The majority of the statements in the Hungarian documents referred either to the role of breast-feeding in infection protection (n = 8), or to long-term protective effects (n = 13). Conclusion: Policy documents in the study countries varied both in their extent and in the description of the long-term effects of infant nutrition. Majority of the documents failed to contain evidence based discussion of the phenomenon of early nutritional programming.
Paul S, Kokossis A, Gage H, Storey L, Lawrenson R, Trend P, Walmsley K, Morrison S, Kaye J, Gradwell E, Baker M (2006) A semantically enabled formalism for the knowledge management of Parkinson's disease, Informatics for Health and Social Care 31 (2) pp. 101-120
Bio-ontology is a formal representation of biological concepts that is used in the interchange of communication between computers and humans alike. They can then be used in the formulation and retrieval of knowledge. In developing a knowledge-based system for Parkinson's Disease, a procedure of knowledge map was used to capture and harness the intellectual resources of an organization, and new paradigms for knowledge mapping were also formulated. Knowledge bases for symptoms and drugs, physiotherapy, speech and language therapy, and dieting that affect patient care were developed. Finally, the knowledge bases were merged to form a single central repository of knowledge base. © 2006 Informa UK Ltd All rights reserved.
Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L, Thomas H (2002) The measurement of satisfaction with healthcare: implications for practice from a systematic review of the literature., Health technology assessment (Winchester, England) 6 (32) pp. 1-244
Gage H (2001) NHS malaise: Diagnosis and treatment options, Economic Affairs 21 (4) pp. 9-13
The paper questions whether the recent reform package of the NHS will solve its ongoing problems, or whether a more fundamental reappraisal of the system is required.
Mitra R, Gage H, Leatham EW (2005) Cost-effectiveness of transoesophageal echocardiography guided direct current cardioversion for acute atrial fibrillation, Oxford Univ Press
Dowson HM, Gage H, Jackson D, Qiao Y, Williams P, Rockall TA (2012) Laparoscopic and open colorectal surgery: A prospective cost analysis, Colorectal Disease 14 (11) pp. 1424-1430
Aim Cost has been perceived to be a factor limiting the development of laparoscopic colorectal surgery. This study aimed to compare the costs of laparoscopic and open colorectal surgery. Method Patients undergoing laparoscopic or open elective colorectal surgery were recruited into a prospective study to evaluate the healthcare costs of each operative procedure in a district general hospital in England. All healthcare resources used (operation, hospital and community) were recorded and converted to costs in British pounds, 2006-2007. Costs of laparoscopic and open surgery were compared. Results In all, 201 consecutive patients consented and were recruited (131 laparoscopic, 70 open). Operative costs were greater in the laparoscopic group (£2049 vs£1263, P
Goodman C, Davies S, Norton C, Leyshon S, Gage H, Fader M, Morris J, See Tai S, Wells M (2007) Can clinical benchmarking improve bowel care in care homes for older people?, Report for Nursing Quality Research Initiative, Dept of Health
Sheehan B, Lall R, Gage H, Holland C, Katz J, Mitchell K (2013) A 12-month follow-up study of people with dementia referred to general hospital liaison psychiatry services, AGE AND AGEING 42 (6) pp. 786-790 OXFORD UNIV PRESS
Martin-Bautista E, Gage Heather, Von Rosen-Von Hoewel J, Jakobik V, Laitinen K, Schmid M, Morgan J, Williams P, Decsi T, Campoy C, Koletzko B, Raats MM (2010) Lifetime health outcomes of breast-feeding: A comparison of the policy documents of five European countries, Public Health Nutrition 13 (10) pp. 1653-1662
Objective To (i) identify and describe prevailing infant feeding policy documents in five diverse European countries; (ii) analyse types of health outcomes for the infant that are associated with feeding breast milk rather than formula milk in the documents of different countries; and (iii) assess the extent to which documents reflect the WHO global recommendation of exclusive breast-feeding for 6 months.Design Documentary review and analysis.Setting Five geographically dispersed countries of Europe (England, Finland, Germany, Hungary and Spain).Subjects Policy documents on infant feeding were identified; statements that linked choice between breast- and formula-feeding to a health outcome for the infant were extracted.Results Twenty-six documents (varied authorships, dates, length and character) were identified: four from England; two from Finland; nine from Germany; six from Hungary; and five from Spain. There was no consistency in the way in which health outcomes were cited as factors in the recommendations for breast- rather than formula-feeding. Seven documents contained no reference to the health implications of infant feeding choice. Of 203 statements in remaining documents citing health outcomes, 241 % mentioned general health effects, 325 % protection against infections, 315 % long-term conditions (e.g. diabetes, CVD) and 118 % mentioned allergy. Health outcomes were linked to exclusive breast-feeding in only 25 % of statements.Conclusions Policy documents in the study countries varied in the extent to which they reflect the health outcomes for the baby of breast-feeding, and this may limit effective promotion by health professionals. There is scope to improve the process of bringing evidence and recommendations into policy documents. © 2010 The Authors.
Goodman C, Davies S, Leyshon S, Fader M, Norton C, Morris J, Gage H, Wells M, See Tai S (2007) Collaborating with primary care: promoting shared working between district nurses and care home staff., In: K.Froggatt, J.Meyer, S.Davies (eds.), Understanding Care Homes: a Research and Development Perspective Jessica Kingsley
Jones F, Lennon S, Gage H, Bhalla A, Drummond A, Grant R, McKevitt C, Riazi A, Liston M (2015) A feasibility study of an integrated stroke self-management program: A cluster randomized controlled trial, INTERNATIONAL JOURNAL OF STROKE 10 pp. 91-91 WILEY-BLACKWELL
Dowson H, Huang A, Soon Y, Gage H, Lovell D, Rockall T (2006) Systematic review of the costs of laparoscopic colorectal surgery, pp. 908-919 Springer
PURPOSE: Recent studies have confirmed the clinical efficacy of laparoscopic colorectal surgery; however, its use has not become widespread. One reason for this is perceived economic implications. A systematic review was undertaken examining the costs of laparoscopic colorectal surgery. METHODS: Electronic databases were searched for articles comparing laparoscopic colorectal surgery and open surgery. Primary outcome measures were operating room, direct hospital, and indirect costs. Secondary outcomes were conversion rates and length of hospital stay. The percentage difference in costs was used for comparisons between studies. RESULTS: Twenty-nine articles were identified in which cost data were presented (total number of patients 3,681); the economic data in most studies was limited. Operating room costs were greater for laparoscopic colorectal surgery than open surgery in all studies (median difference, 50 percent; interquartile range, 27-78 percent; P
Gage H (1998) Objective and subjective evidence of success with WinEcon, Computers in Higher Education Economics Review 12 (2) pp. 14-16
Kurz A, Bakker C, Böhm M, Diehl-Schmid J, Dubois B, Ferreira C, Gage Heather, Graff C, Hergueta T, Jansen T, Jones B, Komar A, de Mendonça A, Metcalfe A, Milecka K, Millenaar J, Orrung Wallin A, Oyebode J, Schneider-Schelte H, Saxl S, de Vugt M (2016) RHAPSODY ? Internet-Based Support For Caregivers of People with Young Onset Dementia: Program Design and Methods of a Pilot Study, International Psychogeriatrics
Background: Young Onset Dementia (YOD), defined by first symptoms of cognitive or behavioral decline occurring before the age of 65 years, is relatively rare compared to dementia of later onset, but it is associated with diagnostic difficulty and heavy burden on affected individuals and their informal carers. Existing health and social care structures rarely meet the needs of YOD patients. Internet-based interventions are a novel format of delivering health-related education, counseling and support to this vulnerable yet underserved group. Methods: The RHAPSODY (Research to Assess Policies and Strategies for Dementia in the Young) project is a European initiative to improve care for people with YOD by providing an internet-based information and skill-building program for family carers. The e-learning program focuses on managing problem behaviors, dealing with role change, obtaining support and looking after oneself. It will be evaluated in a pilot study in three countries using a randomized unblinded design with a wait-list control group. Participants will be informal carers of people with dementia in Alzheimer?s disease or behavioral-variant Frontotemporal degeneration with an onset before the age of 65 years. The primary outcome will be caregiving self-efficacy after 6 weeks of program use. As secondary outcomes caregivers? stress and burden, carer health-related quality of life, caring-related knowledge, patient problem behaviors and user satisfaction will be assessed. Program utilization will be monitored and a health-economic evaluation will also be performed. Conclusions: The RHAPSODY project will add to the evidence on the potential and limitations of a conveniently accessible, user-friendly and comprehensive internet-based intervention as an alternative for traditional forms of counseling and support in healthcare, aiming to optimize care and support for people with YOD and their informal caregivers.
Jordan J, Dowson H, Gage Heather, Jackson Daniel, Rockall T (2014) Laparoscopic versus open colorectal resection for cancer and polyps: a cost-effectiveness study., Clinicoecon Outcomes Res 6 pp. 415-422 Dove Medical Press
BACKGROUND: Available evidence that compares outcomes from laparoscopic and open surgery for colorectal cancer shows no difference in disease free or survival time, or in health-related quality of life outcomes, but does not capture the short term benefits of laparoscopic methods in the early postoperative period. AIM: To explore the cost-effectiveness of laparoscopic colorectal surgery, compared to open methods, using quality of life data gathered in the first 6 weeks after surgery. METHODS: Participants were recruited in 2006-2007 in a district general hospital in the south of England; those with a diagnosis of cancer or polyps were included in the analysis. Quality of life data were collected using EQ-5D, on alternate days after surgery for 4 weeks. Costs per patient, from a National Health Service perspective (in British pounds, 2006) comprised the sum of operative, hospital, and community costs. Missing data were filled using multiple imputation methods. The difference in mean quality adjusted life years and costs between surgery groups were estimated simultaneously using a multivariate regression model applied to 20 imputed datasets. The probability that laparoscopic surgery is cost-effective compared to open surgery for a given societal willingness-to-pay threshold is illustrated using a cost-effectiveness acceptability curve. RESULTS: The sample comprised 68 laparoscopic and 27 open surgery patients. At 28 days, the incremental cost per quality adjusted life year gained from laparoscopic surgery was £12,375. At a societal willingness-to-pay of £30,000, the probability that laparoscopic surgery is cost-effective, exceeds 65% (at £20,000 H60%). In sensitivity analyses, laparoscopic surgery remained cost-effective compared to open surgery, provided it results in a saving e£699 in hospital bed days and takes no more than 8 minutes longer to perform. CONCLUSION: The study provides formal evidence of the cost-effectiveness of laparoscopic approaches and supports current guidelines that promote use of laparoscopy where suitably trained surgeons are available.
Iliffe S, Drennan V, Manthorpe J, Gage H, Davies SL, Massey H, Scott C, Brearley S, Goodman C (2011) Nurse case management and general practice: Implications for GP consortia, British Journal of General Practice 61 (591) pp. e658-e665
Axelrod L, Bryan K, Gage Heather, Kaye J, Ting S, Williams P, Trend P, Wade D (2012) Disease-specific training in Parkinson's disease for care assistants: a comparison of interactive and self-study methods, CLINICAL REHABILITATION 26 (6) pp. 545-557 SAGE PUBLICATIONS LTD
Objective: To compare two approaches to providing training to care assistants in Parkinson's disease.Design: Pragmatic parallel arm controlled trial.Setting: Training either by an interactive training day at a local medical education establishment or self study.Subjects: Care assistants recruited from local health and social care providers.Interventions: The content of both interventions was similar, covering causes, symptoms, diagnosis of Parkinson's disease, multidisciplinary management, mobility, communication, swallowing, and involving 5 hours of study time.Main measures: Knowledge about Parkinson's (assessed by true/false quizzes and identifying 'four facts' about Parkinson's) immediately post training and six weeks later; views on training methods of care assistants and employers/managers.Results: Thirty-seven employers nominated 100 care staff who were allocated to interactive training (49) and self study (51). Training completion rates (retained to six-week follow-up) were lower for self study (42.1% vs. 83.7% training day). There were no significant differences between groups on quiz or 'four facts' scores at baseline or six-week follow-up. Immediately post training, the self-study group (with access to written materials) had significantly higher quiz scores than the training day group (no access to materials at test). Within-group comparisons showed improvements post training. Although interactive training may be preferred, obtaining release from duties can be problematic.Conclusions: Both approaches have similar effects on knowledge of care assistants without prior specific training. Providing a variety of approaches will cater for all preferences. The findings may be generalizable to training the care workforce for other specific roles. © The Author(s) 2011.
Kumar A, Carpenter H, Cook J, Skelton DA, Stevens Z, Haworth D, Belcher CM, Gawler SJ, Gage H, Masud T, Bowling A, Pearl M, Morris RW, Iliffe S, Zijlstra GAR, Delbaere K, Kendrick D (2014) EXERCISE FOR REDUCING FEAR OF FALLING IN OLDER PEOPLE LIVING IN THE COMMUNITY: A COCHRANE SYSTEMATIC REVIEW, AGE AND AGEING 43 OXFORD UNIV PRESS
Background Fear of falling is common in older people and associated with serious physical and psychosocial consequences. Exercise (planned,structured, repetitive and purposive physical activity aimed at improving physical ?tness) may reduce f ear of falling by improving strength, gait, balance and mood, and reducing the occurrence of falls. Objectives To assess the effects (bene?ts, harms and costs) of exercise interventions for reducing fear of falling in older people living in the community. Search methods We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2013), the Central Register of ControlledTrials (CENTRAL 2013, Issue 7), MEDLINE (1946 to July Wee k 3 2013), EMBASE (1980 to 2013 Week 30), CINAHL (1982 toJuly 2013), PsycINFO (1967 to August 2013), AMED (1985 to August 2013), the World Health Or ganization International Clinical Trials Registry Platform (accessed 7 August 2013) and Current Controlled Trials (accessed 7 August 2013). We applied no language restrictions. We handsearched reference lists and consulted experts
Martin-Bautista E, Campoy C, Decsi T, Bokor S, von Rosen-von Hoewel J, Laitinen K, Schmid MA, Morgan J, Gage Heather, Koletzko B, Raats M (2009) Obesity Related Programming Statements in Infant Feeding Policies in Five European Countries, pp. 169-173 Springer
The aim of this Study was to know how the early nutrition programming concept and its relation with long-term diseases such as obesity is reflected in policy recommendations on infant nutrition in five European countries (Finland, Germany. Hungary, Spain and England). After collating and evaluating infant nutrition policy documents, statements about early nutrition programming, as the origin of diseases such as obesity, were analysed. The number of policy documents analysed were 38 (England: 10, Finland: 2, Germany: 11, Hungary: 8, Spain: 7) with a total of 455 statements identified and categorized into 53 different health outcomes. Obesity was mentioned in 5.5% (n = 25) of the statements, the third most frequent outcome after allergy (14.1%, n = 64) and health in general (5.7%, n = 26). Twenty six percent (it = 6) of the obesity related statements referred to short-term duration of the effects, 48% (n = 12) to medium-term, 24% (n = 6) to long-term effects and the rest were not identified. Only 22% of the obesity statements were evidence based. The link between infant feeding and obesity is integrated into policy documents, but most of the statements did not fully specify the short, medium and long term health implications. Action may be required to keep documents up to date as new evidence emerges and to ensure the evidence base is properly recorded.
Gage H, Schmid M, Egan B, Morgan J, Raats M, Williams P, Von Rosen-Von Hoewel J, Koletzko B, Laitinen K, Jakobik V, Martin-Bautista E, Decsi T, Campoy C (2012) Influences on infant feeding decisions of first-time mothers in five European countries, European Journal of Clinical Nutrition
BACKGROUND/OBJECTIVES:Infant feeding decisions made by new parents have significant health implications. The study aimed to investigate: influences on infant feeding decisions; characteristics of mothers reporting reliance on alternative information sources; associations between reliance on different sources and intentions to exclusively breastfeed and introduce complementary foods later; and subsequent breastfeeding and weaning behaviours.SUBJECTS/METHODS:First-time mothers in five European countries (England, Finland, Germany, Hungary, Spain) completed questionnaires about the importance of 17 influences on infant feeding choices at birth and 8 months later, during 2007-2008. Use of individual sources and reliance on four categories (family and friends, health professionals, written materials, audio-visual media) were compared between countries. Associations between information sources used and mother characteristics, feeding intentions and behaviours were investigated using appropriate statistical tests.RESULTS:In all, 2071 first-time mothers provided baseline data; 78% at 8 months. Variation exists between countries in the influence of different sources on feeding decisions of first-time mothers. Across all countries, the most important influences at both time points were books, partner and antenatal midwife. Mothers in higher income quintiles and remaining at school beyond age 16 years reported greater reliance on written sources (P
Gordon AL, Goodman C, Dening T, Davies S, Gladman JRF, Bell BG, Zubair M, Handley MJ, Meyer J, Bowman C, Gage H, Iliffe SR, Martin FC, Schneider J, Victor C (2014) The optimal study: Describing the key components of optimal health care delivery to UK care home residents: A research protocol, Journal of the American Medical Directors Association 15 (9) pp. 681-686
Long-term institutional care in the United Kingdom is provided by care homes. Residents have prevalent cognitive impairment and disability, have multiple diagnoses, and are subject to polypharmacy. Prevailing models of health care provision (ad hoc, reactive, and coordinated by general practitioners) result in unacceptable variability of care. A number of innovative responses to improve health care for care homes have been commissioned. The organization of health and social care in the United Kingdom is such that it is unlikely that a single solution to the problem of providing quality health care for care homes will be identified that can be used nationwide. Realist evaluation is a methodology that uses both qualitative and quantitative data to establish an in-depth understanding of what works, for whom, and in what settings. In this article we describe a protocol for using realist evaluation to understand the context, mechanisms, and outcomes that shape effective health care delivery to care home residents in the United Kingdom. By describing this novel approach, we hope to inform international discourse about research methodologies in long-term care settings internationally. © 2014 AMDA - The Society for Post-Acute and Long-Term Care Medicine.
Egan B, Gage Heather, Williams P, Brands B, Györei E, López-Robles JC, Campoy C, Decsi T, Koletzko B, Raats M (2016) The effect of diet on the physical and mental development of children: views of parents and teachers in four European countries., The British journal of nutrition pp. 1-9 Cambridge University Press
Although the impact of diet on physical health is an important public health issue, less attention has been devoted to the relationship between nutrition and children's mental development. The views of parents and teachers about the extent to which diet affects physical and mental development of children were compared in four European countries. An online questionnaire (developed in English and translated) was circulated through a market research agency. Participants were parents or teachers of children aged 4-10 years without learning or behavioural issues. Questionnaires were returned by 1606 parents (401 in England, Germany and Hungary; 403 in Spain) and 403 teachers (100 in each country, except for 103 in Hungary). Teachers were older than parents (35·3 % v. 18·3 % over 45 years; P
Flannery C, Burke LA, Grainger L, Williams P, Gage Heather (2015) Risky sun tanning behaviours amongst Irish University students: a quantitative analysis., Irish journal of medical science Springer
Despite Ireland's temperate maritime climate, it has the third highest rate of malignant melanoma in the European Union, indicating the need to recognise tanning practices as a risky behaviour, especially amongst those most at risk (the younger population).To explore the factors associated with deliberate sun tanning amongst university students in Cork, Ireland.Self-reported sun exposure, attitudes to tanning and sun protection practices were investigated using an online questionnaire in April 2010.There were 833 responses (8.33 %), mean age 22 years, 75 % female. Reporting deliberate tanning in the previous summer (n = 389, 46.7 %) was positively correlated (r = 0.622, p 
Drennan VM, Chattopadhyay K, Halter M, Brearley S, de Lusignan Simon, Gabe J, Gage Heather (2012) Physician assistants in English primary care teams: A survey., J Interprof Care
Ensuring that healthcare teams have a mix of skilled professionals to meet patient needs and deliver safe and cost-effective services is a major imperative in all health services. The health services in the UK, like a number of other countries, have been exploring the contribution that physician assistants (PAs) can make to healthcare teams including primary care. PAs are well established in the USA, where they have a recognized qualification and undertake physical examinations, investigations, diagnosis, treatment and prescribing within their scope of practice as agreed with their supervising doctor. The first UK-trained PAs graduated in 2009 from post-graduate courses, which are modeled closely on those in the USA to a UK agreed set of competencies and curriculum. There is evidence of the substantive employment of PAs in primary care teams in England. The UK has a well-developed primary care system, with most care delivered via general practice teams which generally include a mix of medical, nursing and support staff. The extent of the employment of PAs in primary care in the England and their contribution within the team to patient care is unknown. This paper reports on a survey that investigated these questions.
Gage H, Egan B, Williams P, Gyoerei E, Brands B, Lopez-Robles J, Brown K, Campoy C, Koletzko B, Decsi T, Raats M (2013) VIEWS OF PARENTS IN FOUR EUROPEAN COUNTRIES ABOUT THE EFFECT OF FOOD ON THE MENTAL PERFORMANCE OF PRIMARY SCHOOL CHILDREN, ANNALS OF NUTRITION AND METABOLISM 63 pp. 1132-1132 KARGER
Crow R, Gage H, Hampson S, Hart J, Kimber A, Storey L, Thomas H (2002) The measurement of satisfaction with healthcare: Implications for practice from a systematic review of the literature, Health Technology Assessment 6 (32)
Egan B, Gage H, Hood J, Poole K, McDowell C, Maguire G, Storey L (2012) Availability of complementary and alternative medicine for people with cancer in the British National Health Service: Results of a national survey, Complementary Therapies in Clinical Practice 18 (2) pp. 75-80
This study assessed access to Complementary and Alternative Medicine (CAM) therapies for people with cancer within the British National Health Service. CAM units were identified through an internet search in 2009. A total of 142 units, providing 62 different therapies, were identified: 105 (74.0%) England; 23 (16.2%) Scotland; 7 (4.9%) each in Wales and Northern Ireland. Most units provide a small number of therapies (median 4, range 1-20), and focus on complementary, rather than alternative approaches. Counselling is the most widely provided therapy (available at 82.4% of identified units), followed by reflexology (62.0%), aromatherapy (59.1%), reiki (43.0%), massage (42.2%). CAM units per million of the population varied between countries (England: 2.2; Wales: 2.3; Scotland: 4.8; Northern Ireland: 5.0), and within countries. Better publicity for CAM units, greater integration of units in conventional cancer treatment centres may help improve access to CAMs. © 2011 Elsevier Ltd.
Batehup L, Porter K, Gage H, Williams P, Simmonds P, Lowson E, Dodson L, Davies N, Wagland R, Winter J, Richardson A, Turner A, Corner J (2017) Follow-up after curative treatment for colorectal cancer: longitudinal evaluation of patient initiated follow-up in the first 12 months., Supportive Care in Cancer 25 (7) pp. 2063-2073 Springer Verlag
Purpose: To compare patient-triggered follow-up (PTFU) for curatively treated colorectal cancer against traditional outpatient follow-up (OPFU). Methods: Questionnaires were mailed at four time points over one-year post-treatment to two prospectively-recruited cohorts: A, patients entering follow-up and receiving OPFU pre-implementation of PTFU; B, patients entering follow-up (FU) and receiving either OPFU (B1) or PTFU (B2) post-implementation of PTFU. Bi-variate tests were used to compare patient characteristics and outcomes eight months after entering follow-up (generic and cancer-specific quality of life (QoL), satisfaction). Regression analysis explored associations between follow-up model and outcomes. Resource implications and costs of models were compared. Results: Patients in Cohort B1 were significantly more likely to have received chemotherapy (p
Sandsund C, Towers R, Thomas K, Tigue R, Lalji A, Doyle N, Jordan J, Gage H, Shaw C (2017) Holistic needs assessment and care plans for women with gynaecological cancer: do they improve cancer-specific health-related quality of life? A randomised controlled trial using mixed methods, BMJ Supportive & Palliative Care 72 (1) pp. S175-S175 BMJ Publishing Group
Holistic needs assessment (HNA) and care planning is proposed to address unmet needs of people treated for cancer. We tested whether HNA and care planning by an allied health professional improved cancer-specific quality of life for women following curative treatment for stage I-III gynaecological cancer. Methods Consecutive women were invited to participate in a randomised controlled study (HNA and care planning vs. usual care) at a UK cancer centre. Data were collected by questionnaire at baseline, three and six months. The outcomes were six month change in EORTC-QLQ-C30 global score (primary), and in EORTC sub-scales, generic quality of life, self-efficacy (secondary). The study was blinded for data management and analysis. Differences in outcomes were compared between groups. Health service utilisation and Quality Adjusted Life Years (from SF-6) were gathered for a cost-effectiveness analysis. Thematic analysis was used to interpret data from an exit interview. Results 150 women consented (75 per group), ten undertook interviews. For 124 participants (61 intervention, 63 controls) with complete data, no statistically significant differences were seen between groups in the primary end-point. The majority of those interviewed reported important personal gains they attributed to the intervention which reflected trends to improvement seen in EORTC functional and symptom scales. Economic analysis suggests a 62% probability of cost-effectiveness at a £30,000/QALY threshold. Conclusion: Care plan development with an allied health professional is cost-effective, acceptable and useful for some women treated for stage 1-111 gynaecological cancer. We recommend its introduction early in the pathway to support person-centred care.
Halter M, Wheeler C, Drennan V, de Lusignan S, Grant R, Gabe J, Gage H, Ennis J, Parle J (2017) Physician associates in England's hospitals: a survey of medical directors exploring current usage and factors affecting recruitment, Clinical Medicine 17 (2) pp. 126-131 Royal College of Physicians
In the UK secondary care setting, the case for physician associates is based on the cover and stability they might offer to medical teams. We assessed the extent of their adoption and deployment - that is, their current usage and the factors supporting or inhibiting their inclusion in medical teams - using an electronic, self-report survey of medical directors of acute and mental health NHS trusts in England. Physician associates - employed in small numbers, in a range of specialties, in 20 of the responding trusts - were reported to have been employed to fill gaps in medical staffing and support medical specialty trainees. Inhibiting factors were commonly a shortage of physician associates to recruit and lack of authority to prescribe, as well as a lack of evidence and colleague resistance. Our data suggest there is an appetite for employment of physician associates while practical and attitudinal barriers are yet to be fully overcome.
Farr W, Male I, Green D, Morris C, Gage H, Bailey S, Speller S, Colville V, Jackson M, Bremner S, Memon A (2017) Methodological Issues of using Placebos in Interventions Based on Digital Technology, Journal of Mobile Technology in Medicine 6 (2) pp. 56-63 Journal of Mobile Technology in Medicine (jMTM)

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.

Farr W, Green D, Male I, Morris C, Bailey S, Gage HM, Speller S, Colville V, Jackson M, Bremner S, Memon A (2017) Therapeutic potential and ownership of commercially available consoles in children with cerebral palsy, British Journal of Occupational Therapy 80 (2) pp. 108-116 Sage
Introduction: We conducted a survey amongst families of children with cerebral palsy to ascertain the ownership and therapeutic use and potential of commercial games consoles to improve motor function. Method: Three hundred families in South East England were identified through clinical records, and were requested to complete an anonymised questionnaire. Results: A total of 61 families (20% response) returned a completed questionnaire with 41 (68%) identified males and 19 (32%) identified females with cerebral palsy, with a mean age of 11 years 5 months (SD 3Y 7M). The large majority of families, 59 (97%), owned a commercial console and the child used this for 50?300 minutes a week. Returns by severity of motor impairment were: Gross Motor Function Classification System I (22%), II (32%), III (13%), IV (15%), V (18%). Consoles were used regularly for play across all Gross Motor Function Classification System categories. Conclusion: The potential of games consoles, as home-based virtual reality therapy, in improving the motor function of children with cerebral palsy should be appropriately tested in a randomised controlled trial. Wide ownership, and the relative ease with which children engage in the use of commercially-based virtual reality therapy systems, suggests potential as a means of augmenting therapy protocols, taking advantage of interest and participation patterns of families.
Jordan J, Gage HM, Benton B, Lalji A, Norton C, Andreyev H (2017) Gastroenterologist and nurse management of symptoms after pelvic radiotherapy for cancer: an economic evaluation of a clinical Randomized Controlled Trial (the ORBIT study)., ClinicoEconomics and Outcomes Research 9 pp. 241-249 Dove Medical Press
Background: Over 20 distressing gastrointestinal symptoms affect many patients after pelvic radiotherapy, but in the United Kingdom few are referred for assessment. Algorithmic-based treatment delivered by either a consultant gastroenterologist or clinical nurse specialist has been shown in a randomised trial to be statistically and clinically more effective than provision of a self-help booklet. In this study we assessed cost-effectiveness. Methods: Outcomes were measured at baseline (pre randomisation) and six months. Change in quality adjusted life years (QALY) was the primary outcome for the economic evaluation; a secondary analysis used change in the bowel subset score of the modified Inflammatory Bowel Disease Questionnaire (IBDQ-B). Intervention costs, British pounds 2013, covered visits with the gastroenterologist or nurse, investigations, medications and treatments. Incremental outcomes and incremental costs were estimated simultaneously using multivariate linear regression. Uncertainty was handled non-parametrically using bootstrap with replacement. Results: The mean (SD) cost of treatment was £895 (499) for the nurse, £1101 (567) for the consultant. The nurse was dominated by usual care which was cheaper and achieved better outcomes. The mean cost per QALY gained from the consultant, compared to usual care, was £250,455; comparing the consultant to the nurse, it was £25,875. Algorithmic care produced better outcomes compared to the booklet only, as reflected in the IBDQ-B results, at a cost of approximately £1,000. Conclusion: Algorithmic treatment of radiation bowel injury by consultant or nurse results in significant symptom relief for patients, but was not found to be cost-effective according to the NICE criteria.
Parker Wendy, Gage Heather, Sterr Annette, Williams Peter (2017) Holiday play for disabled children in England: access, choice and parents? views about integration, International Journal of Disability, Development and Education 64 (6) pp. 573-595 Taylor & Francis
Families with children with disabilities can feel isolated during school holidays and concerns exist that they face greater difficulties than families of children without disabilities in finding enriching activities for their child. In the context of national policies that encourage integrated play, local service commissioners in England require evidence on what sort of short breaks parents and children prefer. The parents of 99 children with disabilities and 43 children without disabilities attending various holiday play schemes in summer 2010 completed mailed questionnaires. Parents of children with disabilities reported more difficulty getting information, less choice of schemes and further distances to travel than parents of children without disabilities. Although 72% of parents of children without disabilities and 55.5% of parents of children with disabilities stated integrated schemes would be suitable for their child, open text comments provided weaker support. Variety of provision is required to meet all needs and preferences.
Kassianos A, Raats MM, Gage HM (2016) Post-diagnostic dietary changes in prostate cancer: associations with patients? wellbeing and the perceptions of GPs, European Journal of Cancer Care 26 (4) e12599 Wiley
This article aims to investigate associations between perceived control and health-related quality of life (HRQOL) with dietary changes after prostate cancer diagnosis and to explore General Practitioners? (GPs) perceptions on the role of diet in prostate cancer post-diagnosis. Ninety-five prostate cancer patients completed measures of dietary change, one for after diagnosis and another for after therapy. They also scored their HRQOL and perceived control. There were discrepancies in dietary changes reported between a general question (28.4% no dietary changes) and a specific (42.1%? 51.5% range of no change for various food items). Most patients initiated healthy changes. Patients who changed their diet after diagnosis had lower cognitive functioning and external locus of control (doctors). Patients who changed their diet after therapy had lower cognitive and emotional functioning, quality of life and external locus of control (doctors). Then, fourty-four GPs responded to an online survey. Their open-ended responses were analysed using Content Analysis. They reported interest in the role of diet in cancer but also lack of relevant knowledge. They were skeptical on providing information. Clinical interventions should consider patients? cognitive ability, their relationship with their health professional and their wellbeing. Also, GPs? confidence to provide dietary advice needs to be addressed.
Ebru E, Saigal P, Gage HM, Raats MM, Ogden JE, Qiao Y, Williams P (2010) Overweight and obesity in children: a comparison of the views of general practitioners and parents, Proceedings of the Nutrition Society 69 Cambridge University Press
Jones Bridget, Gage Heather, Bakker Christian, Barrios Helena, Boucault Sarah, Mayer Johannes, Metcalfe Anna, Millenaar Joany, Parker Wendy, Orrung Wallin Anneli (2017) Availability of information on young onset dementia for patients and carers in six European countries, Patient Education and Counseling 101 (1) pp. 159-165 Elsevier
Objectives

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.

Methods

Search of websites of organisations with potential interest in dementia. Narrative synthesis and comparative analysis.

Results

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.

Conclusion

Availability of information varies among countries, some having no dedicated source and incomplete coverage of issues of importance to YOD.

Practical implications

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.

Wedlake L, Shaw C, McNair H, Lalji A, Mohammed K, Klopper T, Allan L, Tait D, Hawkins M, Somaiah N, Lalondrelle S, Taylor A, VanAs N, Stewart A, Essapen S, Gage H, Whelan K, Andreyev H (2017) Randomized controlled trial of dietary fiber for the prevention of radiation-induced gastrointestinal toxicity during pelvic radiotherapy, The American Journal of Clinical Nutrition 106 (3) pp. 849-857 American Society for Nutrition
Background: Therapeutic radiotherapy is an important treatment of pelvic cancers. Historically, low-fiber diets have been recommended despite a lack of evidence and potentially beneficial mechanisms of fiber.

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.

Wheeler C, Halter M, Drennan V, de Lusignan S, Grant R, Gabe J, Gage H, Begg P, Ennis J, Parle J (2017) Physician associates working in secondary care teams in England: Interprofessional implications from a national survey, Journal of Interprofessional Care 31 (6) pp. 774-776 Taylor & Francis:
Physician associates (PAs) are a new type of healthcare professional to the United Kingdom; however, they are well established in the United States (where they are known as physician assistants). PAs are viewed as one potential solution to the current medical workforce doctor shortage. This study investigated the deployment of PAs within secondary care teams in England, through the use of a cross-sectional electronic, self-report survey. The findings from 14 questions are presented. Sixty-three PAs working in a range of specialties responded. A variety of work settings were reported, most frequently inpatient wards, with work generally taking place during weekdays. Both direct and non-direct patient care activities were reported, with the type of work undertaken varying at times, depending on the presence or absence of other healthcare professionals. PAs reported working within a variety of secondary care team staffing permutations, with the majority of these being interprofessional. Line management was largely provided by consultants; however day-to-day supervision varied, often relating to different work settings. A wide variation in ongoing supervision was also reported. Further research is required to understand the nature of PAs? contribution to collaborative care within secondary care teams in England.
Goodman C, Davies S, Gordon A, Dening T, Gage HM, Meyer J, Schneider J, Bell B, Jordan J, Martin F, Iliffe S, Bowman C, Gladman J, Victor C, Mayrhofer A, Handley M, Zubair M (2017) Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings, Health Services and Delivery Research 5 (29) pp. 1-204 NIHR Journals Library

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 wa

This study appraises the effectiveness and cost-effectiveness of consumption of plant sterol-enriched margarine-type spreads for the prevention of cardiovascular disease (CVD) in people with hypercholesterolemia in England, compared to a normal diet. A nested Markov model was employed using the perspective of the British National Health Service (NHS). Effectiveness outcomes were the 10-year CVD risk of individuals with mild (4?6 mmol/l) and high (above 6 mmol/l) cholesterol by gender and age groups (45?54, 55?64, 65?74, 75?85 years); CVD events avoided and QALY gains over 20 years. This study found that daily consumption of enriched spread reduces CVD risks more for men and older age groups. Assuming 50% compliance, 69 CVD events per 10,000 men and 40 CVD events per 10,000 women would be saved over 20 years. If the NHS pays the excess cost of enriched spreads, for the high-cholesterol group, the probability of enriched spreads being cost-effective is 100% for men aged over 64 years and women over 74, at £20,000/QALY threshold. Probabilities of cost-effectiveness are lower at younger ages, with mildly elevated cholesterol and over a 10-year time horizon. If consumers bear the full cost of enriched spreads, NHS savings arise from reduced CVD events.
Halimic Aida, Gage Heather, Raats Monique, Williams Peter (2017) Effect of price and information on the food choices of women university students in Saudi Arabia: an experimental study, Appetite 123 pp. 175-182 Elsevier
Objective:

To explore the impact of price manipulation and healthy eating information on intended food choices

Design:

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.

Setting:

University campus, Saudi Arabia, 2013

Subjects:

99 women students

Results:

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.

Conclusion:

Price manipulation offers potential for altering behaviours to combat rising youth obesity in Saudi Arabia.

Gordon Adam L, Goodman Claire, Davies Sue L, Dening Tom, Gage Heather, Meyer Julienne, Schneider Justine, Bell Brian, Jordan Jake, Martin Finbarr C, Iliffe Steve, Bowman Clive, Gladman John R F, Victor Christina, Mayrhofer Andrea, Handley Melanie, Zubair Maria (2018) Optimal healthcare delivery to care homes in the UK: a realist evaluation of what supports effective working to improve healthcare outcomes, Age and Ageing 47 (4) pp. 595-603 Oxford University Press
Introduction
care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use.

Methods
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.

Results
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.

Halter M, Joly L, de Lusignan S, Grant R, Gage H, Drennan V (2018) Capturing complexity in clinician case-mix: classification system development using GP and physician associate data, BJGP Open Royal College of General Practitioners
Background

There are limited case-mix classification systems for primary care settings which are applicable when considering the optimal clinical skill mix to provide services.

Aim

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.

Method

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.

Results

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.

Conclusion

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.

Egan M, Gage H, Hood J, Poole K, McDowell C, Maguire G, Storey L (2012) Availability of CAM for people with cancer in the British NHS: the results of a national survey, Complementary Therapies in Clinical Practice 18 (2) pp. 75-80 Elsevier
This study assessed access to Complementary and Alternative Medicine (CAM) therapies for people with cancer within the British National Health Service. CAM units were identified through an internet search in 2009. A total of 142 units, providing 62 different therapies, were identified: 105 (74.0%) England; 23 (16.2%) Scotland; 7 (4.9%) each in Wales and Northern Ireland. Most units provide a small number of therapies (median 4, range 1?20), and focus on complementary, rather than alternative approaches. Counselling is the most widely provided therapy (available at 82.4% of identified units), followed by reflexology (62.0%), aromatherapy (59.1%), reiki (43.0%), massage (42.2%). CAM units per million of the population varied between countries (England: 2.2; Wales: 2.3; Scotland: 4.8; Northern Ireland: 5.0), and within countries. Better publicity for CAM units, greater integration of units in conventional cancer treatment centres may help improve access to CAMs.
Butler Claire, Brigden Charlotte, Gage Heather, Williams Peter, Holdsworth Laura, Greene Kay, Wee Bee, Barclay Stephen, Wilson Patricia (2018) Optimum hospice at home services for end-of-life care: protocol of a mixed-methods study employing realist evaluation, BMJ Open 8 (5) e021192 pp. e021192-1 - e021192-8 BMJ Publishing Group

Introduction

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.

Trivedi Daksha P, Braun Andreas, Dickinson Angela, Gage Heather, Hamilton Laura, Goodman Claire, Ashaye Kunle, Iliffe Steve, Manthorpe Jill (2018) Managing behavioural and psychological symptoms in community dwelling older people with dementia: 1. A systematic review of the effectiveness of interventions, Dementia pp. 1-25 SAGE Publications

Background

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.

Methods

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.

Results

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.

Conclusions

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.

Halter Mary, Wheeler Carly, Pelone Ferruccio, Gage Heather, de Lusignan Simon, Parle Jim, Grant Robert, Gabe Jonathan, Nice Laura, Drennan Vari M (2018) Contribution of physician assistants/associates to secondary care: a systematic review, BMJ Open 8 (6) e019573 pp. e019573-1 BMJ Publishing Group

Objective

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.

Design

Systematic review.

Setting

Electronic databases (Medline, Embase, ASSIA, CINAHL, SCOPUS, PsycINFO, Social Policy and Practice, EconLit and Cochrane), reference lists and related articles.

Included articles

Peer-reviewed articles of any study design, published in English, 1995?2017.

Interventions

Blinded parallel processes were used to screen abstracts and full text, data extractions and quality assessments against published guidelines. A narrative synthesis was undertaken.

Outcome measures

Impact on: patients? experiences and outcomes, service organisation, working practices, other professional groups and costs.

Results

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.

Conclusions

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.

Gage Heather, Morgan J, Williams P, Schmid M, Laitenen K, von Rosen J, Koletzko B, Decsi T, Jacobi V, Martin-Bautista E, Campoy C, Raats Monique Infant feeding intentions of new mothers in five European countries, Proceedings of the Nutrition Society 69
Stamou Vasileios, La Fontaine Jenny, Oyebode Jan, Jones Bridget, Gage Heather, O?Malley Mary, Parkes Jacqueline (2018) The ANGELA Project: Improving diagnosis and post-diagnostic support for younger people with dementia and their families/supporters, FPOP Bulletin 142 pp. 26-31 The British Psychological Society

Objectives:

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.

Design:

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.

Methods:

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.

Results:

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.

Conclusions:

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.

Duckham RL, Masud T, Taylor R, Kendrick D, Carpenter H, Iliffe S, Morris R, Gage Heather, Skelton DA, Dinan-Young S, Brooke-Wavell K (2015) Randomised controlled trial of the effectiveness of community group and home-based falls prevention exercise programmes on bone health in older people: the ProAct65+bone study, AGE AND AGEING 44 (4) pp. 573-579 OXFORD UNIV PRESS
Background: exercise can reduce osteoporotic fracture risk by strengthening bone or reducing fall risk. Falls prevention exercise programmes can reduce fall incidence, and also include strengthening exercises suggested to load bone, but there is little information as to whether these programmes influence bone mineral density (BMD) and strength. Objective: to evaluate the skeletal effects of home (Otago Exercise Programme, OEP) and group (Falls Exercise Management, FaME) falls prevention exercise programmes relative to usual care in older people. Methods: men and women aged over 65 years were recruited through primary care. They were randomised by practice to OEP, FaME or usual care. BMD, bone mineral content (BMC) and structural properties were measured in Nottingham site participants before and after the 24-week intervention. Results: participants were 319 men and women, aged mean(SD) 72(5) years. Ninety-two percentage of participants completed the trial. The OEP group completed 58(43) min/week of home exercise, while the FaME group completed 39(16) and 30(24) min/week of group and home exercise, respectively. Femoral neck BMD changes did not differ between treatment arms: mean (95% CI) effect sizes in OEP and FaME relative to usual care arm were ?0.003(?0.011,0.005) and ?0.002(?0.010,0.005) g cm?2, respectively; P = 0.44 and 0.53. There were no significant changes in BMD or BMC at other skeletal sites, or in structural parameters. Conclusions: falls prevention exercise programmes did not influence BMD in older people. To increase bone strength, programmes may require exercise that exerts higher strains on bone or longer duration.
Drennan VM, Halter M, Brearley S, Carneiro W, Gabe J, Gage Heather, Grant R, Joly L, de Lusignan Simon (2014) Investigating the contribution of physician assistants to primary care in England: a mixed-methods study, Health Services and Delivery Research 2 (16) NIHR Journals Library
Background: Primary health care is changing as it responds to demographic shifts, technological changes and fiscal constraints. This, and predicted pressures on medical and nursing workforces, raises questions about staffing configurations. Physician assistants (PAs) are mid-level practitioners, trained in a medical model over 2 years at postgraduate level to work under a supervising doctor. A small number of general practices in England have employed PAs. Objective: To investigate the contribution of PAs to the delivery of patient care in primary care services in England. Design: A mixed-methods study conducted at macro, meso and micro organisational levels in two phases: (1) a rapid review, a scoping survey of key national and regional informants, a policy review, and a survey of PAs and (2) comparative case studies in 12 general practices (six employing PAs). The latter incorporated clinical record reviews, a patient satisfaction survey, video observations of consultations and interviews with patients and professionals. Results: The rapid review found 49 published studies, mainly from the USA, which showed increased numbers of PAs in general practice settings but weak evidence for impact on processes and patient outcomes. The scoping survey found mainly positive or neutral views about PAs, but there was no mention of their role in workforce policy and planning documents. The survey of PAs in primary care (n = 16) found that they were mainly deployed to provide same-day appointments. The comparative case studies found that physician assistants were consulted by a wide range of patients, but these patients tended to be younger, with less medically acute or complex problems than those consulting general practitioners (GPs). Patients reported high levels of satisfaction with both PAs and GPs. The majority were willing or very willing to consult a PA again but wanted choice in which type of professional they consulted. There was no significant difference between PAs and GPs in the primary outcome of patient reconsultation for the same problem within 2 weeks, investigations/tests ordered, referrals to secondary care or prescriptions issued. GPs, blinded to the type of clinician, judged the documented activities in the initial consultation of patients who reconsulted for the same problem to be appropriate in 80% (n = 223) PA and 50% (n = 252) GP records. PAs were judged to be competent and safe from observed consultations. The average consultation with a physician assistant is significantly longer than that with a GP: 5.8 minutes for patients of average age for this sample (38 years). Costs per consultation were £34.36 for GPs and £28.14 for PAs. Costs could not be apportioned to GPs for interruptions, supervision or training of PAs.Conclusions: PAs were found to be acceptable, effective and efficient in complementing the work of GPs. PAs can provide a flexible addition to the primary care workforce. They offer another labour pool to consider in health professional workforce and education planning at local, regional and national levels. However, in order to maximise the contribution of PAs in primary care settings, consideration needs to be given to the appropriate level of regulation and the potential for authority to prescribe medicines. Future research is required to investigate the contribution of PAs to other first contact services as well as secondary services; the contribution and impact of all types of mid-level practitioners (including nurse practitioners) in first contact services; the factors and influences on general practitioner and practice manager decision-making as to staffing and skill mix; and the reliability and validity of classification systems for both primary care patients and their presenting condition and their consequences for health resource utilisation.
Gage Heather, Grainger L, Ting S, Williams P, Chorley, C, Carey G, Borg N, Bryan K, Castleton B, Trend P, Kaye J, Jordan J, Wade D (2014) Specialist rehabilitation for people with Parkinson?s disease in the community: a randomized controlled trial, Health Services and Delivery Research 2 (51) NIHR Journals Library
Background: Multidisciplinary rehabilitation is recommended for Parkinson?s disease, but evidence suggests that benefit is not sustained. Objectives: (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. Design: Pragmatic three-parallel group randomised controlled trial. Setting: Community, county of Surrey, England, 2010?11. Participants: People with Parkinson?s, at all stages of the disease, and live-in carers. Interventions: 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. Results: 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). Conclusions: Further research is needed into ways of sustaining benefits from rehabilitation including the use of care assistants.
Stenner KL, Courtenay M, Carey N, Gage Heather, Williams P (2015) Comparison of Prescribing and non-prescribing nurses in the management of people with diabetes in English General Practice, Journal of Advanced Nursing 71 (12) pp. 2950-2964 Wiley
The aim of this study were to compare nurse prescribers and non-prescribers managing people with diabetes in general practice regarding: (a) patient characteristics; (b) activities and processes of care; (c) patient outcomes (self-management, clinical indicators, satisfaction) and (d) resource implications and costs.
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.
Iliffe S, Kendrick D, Morris R, Masud T, Gage Heather, Skelton D, Dinan S, Bowling A, Griffin M, Haworth D, Swanwick G, Carpenter H, Kumar A, Stevens Z, Gawler S, Barlow C, Cook J, Belcher C (2014) Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care, HEALTH TECHNOLOGY ASSESSMENT 18 (49) pp. 1-+ NIHR JOURNALS LIBRARY
Background: Regular physical activity (PA) reduces the risk of falls and hip fractures, and mortality from all causes. However, PA levels are low in the older population and previous intervention studies have demonstrated only modest, short-term improvements. Objective: To evaluate the impact of two exercise promotion programmes on PA in people aged e65 years. Design: The ProAct65+ study was a pragmatic, three-arm parallel design, cluster randomised controlled trial of class-based exercise [Falls Management Exercise (FaME) programme], home-based exercise [Otago Exercise Programme (OEP)] and usual care among older people (aged e65 years) in primary care. Setting: Forty-three UK-based general practices in London and Nottingham/Derby. Participants: A total of 1256 people e65 years were recruited through their general practices to take part in the trial. Interventions: The FaME programme and OEP. FaME included weekly classes plus home exercises for 24 weeks and encouraged walking. OEP included home exercises supported by peer mentors (PMs) for 24 weeks, and encouraged walking. Main outcome measures: The primary outcome was the proportion that reported reaching the recommended PA target of 150 minutes of moderate to vigorous physical activity (MVPA) per week, 12 months after cessation of the intervention. Secondary outcomes included functional assessments of balance and falls risk, the incidence of falls, fear of falling, quality of life, social networks and self-efficacy. An economic evaluation including participant and NHS costs was embedded in the clinical trial. Results: In total, 20,507 patients from 43 general practices were invited to participate. Expressions of interest were received from 2752 (13%) and 1256 (6%) consented to join the trial; 387 were allocated to the FaME arm, 411 to the OEP arm and 458 to usual care. Primary outcome data were available at 12 months after the end of the intervention period for 830 (66%) of the study participants.The proportions reporting at least 150 minutes of MVPA per week rose between baseline and 12 months after the intervention from 40% to 49% in the FaME arm, from 41% to 43% in the OEP arm and from 37.5% to 38.0% in the usual-care arm. A significantly higher proportion in the FaME arm than in the usual-care arm reported at least 150 minutes of MVPA per week at 12 months after the intervention [adjusted odds ratio (AOR) 1.78, 95% confidence interval (CI) 1.11 to 2.87; p=0.02]. There was no significant difference in MVPA between OEP and usual care (AOR 1.17, 95% CI 0.72 to 1.92; p=0.52). Participants in the FaME arm added around 15 minutes of MVPA per day to their baseline physical activity level. In the 12 months after the close of the intervention phase, there was a statistically significant reduction in falls rate in the FaME arm compared with the usual-care arm (incidence rate ratio 0.74, 95% CI 0.55 to 0.99; p=0.042). Scores on the Physical Activity Scale for the Elderly showed a small but statistically significant benefit for FaME compared with usual care, as did perceptions of benefits from exercise. Balance confidence was significantly improved at 12 months post intervention in both arms compared with the usual-care arm. There were no statistically significant differences between intervention arms and the usual-care arm in other secondary outcomes, including quality-adjusted life-years. FaME is more expensive than OEP delivered with PMs (£269 vs. £88 per participant in London; £218 vs. £117 in Nottingham). The cost per extra person exercising at, or above, target was £1919.64 in London and £1560.21 in Nottingham (mean £1739.93).Conclusion: The FaME intervention increased self-reported PA levels among community-dwelling older adults 12 months after the intervention, and significantly reduced falls. Both the FaME and OEP interventions appeared to be safe, with no significant differences in adverse reactions between study arms.
Halter M, Drennan VM, Joly LM, Gabe J, Gage Heather, de Lusignan Simon (2017) Patients? experiences of consultations with physician associates in primary care in England: A qualitative study, Health Expectations 20 pp. 1011-1019 Wiley Open Access
Background:

Physician associates are new to English general practice and set to expand
in numbers.

Objective:

To investigate the patients? perspective on consulting with physician
associates in general practice.

Design:

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.

Findings:

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.

Conclusion:

Patients saw physician associates as an appropriate general practitioner
substitute. Patients? experience could inform delivery redesign.

Kendrick D, Kumar A, Carpenter H, Zijlstra GAR, Skelton DA, Cook JR, Stevens Z, Belcher CM, Haworth D, Gawler SJ, Gage Heather, Masud T, Bowling A, Pearl M, Morris RW, Iliffe S, Delbaere K (2014) Exercise for reducing fear of falling in older people living in the community, COCHRANE DATABASE OF SYSTEMATIC REVIEWS (11) ARTN CD009 WILEY-BLACKWELL
BACKGROUND: Fear of falling is common in older people and associated with serious physical and psychosocial consequences. Exercise (planned, structured, repetitive and purposive physical activity aimed at improving physical fitness) may reduce fear of falling by improving strength, gait, balance and mood, and reducing the occurrence of falls. OBJECTIVES: To assess the effects (benefits, harms and costs) of exercise interventions for reducing fear of falling in older people living in the community. SEARCH METHODS: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (July 2013), the Central Register of Controlled Trials (CENTRAL 2013, Issue 7), MEDLINE (1946 to July Week 3 2013), EMBASE (1980 to 2013 Week 30), CINAHL (1982 to July 2013), PsycINFO (1967 to August 2013), AMED (1985 to August 2013), the World Health Organization International Clinical Trials Registry Platform (accessed 7 August 2013) and Current Controlled Trials (accessed 7 August 2013). We applied no language restrictions. We handsearched reference lists and consulted experts. SELECTION CRITERIA: We included randomised and quasi-randomised trials that recruited community-dwelling people (where the majority were aged 65 and over) and were not restricted to specific medical conditions (e.g. stroke, hip fracture). We included trials that evaluated exercise interventions compared with no intervention or a non-exercise intervention (e.g. social visits), and that measured fear of falling. Exercise interventions were varied; for example, they could be 'prescriptions' or recommendations, group-based or individual, supervised or unsupervised. DATA COLLECTION AND ANALYSIS: Pairs of review authors independently assessed studies for inclusion, assessed the risk of bias in the studies and extracted data. We combined effect sizes across studies using the fixed-effect model, with the random-effect model used where significant statistical heterogeneity was present. We estimated risk ratios (RR) for dichotomous outcomes and incidence rate ratios (IRR) for rate outcomes. We estimated mean differences (MD) where studies used the same continuous measures and standardised mean differences (SMD) where different measures or different formats of the same measure were used. Where possible, we performed various, usually prespecified, sensitivity and subgroup analyses. MAIN RESULTS: We included 30 studies, which evaluated 3D exercise (Tai Chi and yoga), balance training or strength and resistance training. Two of these were cluster-randomised trials, two were cross-over trials and one was quasi-randomised. The studies included a total of 2878 participants with a mean age ranging from 68 to 85 years. Most studies included more women than men, with four studies recruiting women only. Twelve studies recruited participants at increased risk of falls; three of these recruited participants who also had fear of falling.Poor reporting of the allocation methods in the trials made it difficult to assess the risk of selection bias in most studies. All of the studies were at high risk of performance and detection biases as there was no blinding of participants and outcome assessors and the outcomes were self reported. Twelve studies were at high risk of attrition bias. Using GRADE criteria, we judged the quality of evidence to be 'low' for fear of falling immediately post intervention and 'very low' for fear of falling at short or long-term follow-up and all other outcomes.Exercise interventions were associated with a small to moderate reduction in fear of falling immediately post intervention (SMD 0.37 favouring exercise, 95% confidence interval (CI) 0.18 to 0.56; 24 studies; 1692 participants, low quality evidence). Pooled effect sizes did not differ significantly between the different scales used to measure fear of falling. Although none of the sensitivity analyses changed the direction of effect, the greatest reduction in the size of the effect was on removal of an ex
Gyoerei E, Egan B, Gage Heather, Williams P, Raats M, Brands B, Lopez-Robles J, Campoy C, Koletzko B, Decsi T (2011) Effect of food on learning: views of parents in four European countries, Annals of Nutrition and Metabolism: European journal of nutrition, metabolic diseases and dietetics 58 pp. 137-138 KARGER
Introduction: Nutrition is one of many factors influencing a child?s learning abilitiy. Objectives: This study aims to assess parents? views on the effect of food on children?s ability to learn in four European countries (England, Germany, Hungary, Spain). Method. Design: Parents of children aged 4 to 10 years were recruited through state elementary schools. Participants were asked to sort 18 cards representing possible determinants of learning (in 6 categories: 4 food related, 3 educational, 2 physical, 4 social, 2 psychological, 3 biological) according to their views about strength of effect. Determinants were identified from the literature. Effects were scored: 0=none; 1=moderate; 2=strong. Results: 201 parents took part. There were no significant differences among countries in age, gender, number of children of participants. Higher proportions of parents in England and Germany had received university education than in the other countries (p=0.015); significantly fewer parents in Spain were in employment (p
Schmid MA, von Rosen-von Hoewel J, Martin-Bautista E, Szabó E, Campoy C, Decsi T, Morgan J, Gage Heather, Koletzko B, Raats Monique (2009) Infant feeding and the concept of early nutrition programming: a comparison of qualitative data from four European countries., In: Koletzko B, Decsi T, Molnár D, Hunty de la A (eds.), Early Nutrition Programming and Health Outcomes in Later Life. Obesity and Beyond 646 (21) pp. 183-187 Springer Link (Netherlands)
The concept of early nutrition programming is appearing in policy documents, leaflets and magazine articles with different types of statements. However, the level of representation and influence of this concept is unknown in the area of infant nutrition. We established the degree of reflection and the impact of the concept of nutrition programming among the different government stakeholders of infant nutrition in four European countries. In each country, a list of stakeholders in the area of infant feeding was established and key persons responsible for the remit of infant nutrition were identified. We conducted standardised face-to-face or phone interviews from January 2006 to January 2007. The interview guide included questions about the concept of nutrition programming. All interviews were digitally recorded and qualitative data analysis was done using QRS NVivo V2. In total, we analyzed 17 interviews from government organizations in England (5 interviews), Germany (4 interviews), Hungary (3 interviews) and Spain (5 interviews). The concept of nutrition programming was recognized from 4/5 English and 3/4 German interviewees, whereby one organisation reflected the concept in their documents in both countries. In Hungary, 1/3 interviewees recognised the concept and reflected it in their documents. All interviewed Spanish governmental bodies (5/5) recognised the concept of nutrition programming and three of them reflected the concept in their documents. The concept of early nutrition programming was widely recognized among the key persons of government bodies in all four European countries. However, the concept was not necessarily represented in the produced documents.
Schmid MA, von Rosen-von Hoewel J, Martin-Bautista E, Szabo E, Campoy C, Decsi T, Morgan J, Gage Heather, Koletzko B, Raats Monique (2009) Infant Feeding and the Concept of Early Nutrition Programming: A Comparison of Qualitative Data from Four European Countries, pp. 183-187
The concept of early nutrition programming is appearing in policy documents, leaflets and magazine articles with different types of statements. However, the level of representation and influence of this concept is unknown in the area of infant nutrition. We established the degree of reflection and the impact of the concept of nutrition programming among the different government stakeholders of infant nutrition in four European countries. In each country, a list of stakeholders in the area of infant feeding was established and key persons responsible for the remit of infant nutrition were identified. We conducted standardised face-to-face or phone interviews from January 2006 to January 2007. The interview guide included questions about the concept of nutrition programming. All interviews were digitally recorded and qualitative data analysis was done using QRS NVivo V2. In total, we analyzed 17 interviews from government organizations in England (5 interviews), Germany (4 interviews), Hungary (3 interviews) and Spain (5 interviews). The concept of nutrition programming was recognized from 4/5 English and 3/4 German interviewees, whereby one organisation reflected the concept in their documents in both countries. In Hungary, 1/3 interviewees recognised the concept and reflected it in their documents. All interviewed Spanish governmental bodies (5/5) recognised the concept of nutrition programming and three of them reflected the concept in their documents. The concept of early nutrition programming was widely recognized among the key persons of government bodies in all four European countries. However, the concept was not necessarily represented in the produced documents.
Lopez-Robles JC, Egan B, Gage Heather, Gyorei E, Brands B, Raats M, Martin-Bautista E, Tamas D, Koletzko B, Campoy C (2010) QUANTITATIVE STUDY OF SPANISH PARENTS BELIEFS OF WHAT EFFECTS CHILDREN'S MENTAL PERFORMANCE, JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION 50 pp. E191-E191 LIPPINCOTT WILLIAMS & WILKINS
Objectives and Study: Parents have a direct influence on the food choices presented to children in the home. Thinking of what parents consider when choosing foood for their children it is important to know what factors they perceive to influence a child?s cognitive development and mental performance. Parents play a very important role in the development of children food choices and eating habits which may in turn influence children?s future health positively or negatively. The present study aims to quantitatively examine parents? understanding of the factors influencing children?s mental performance. Methods: The study was conducted in Spain and participants were parents of children aged 4?10 years recruited through state elementary schools. A card sorting task was developed and used to conduct interviews with a total of 50 parents. Parents were asked about five different group of influencing factors: Biological, Educational, Social, Environmental and Psychological (18 factors in total), factors were based on evidence from scientific literature. Mental performance was defined in terms of Attention, Learning, Mood and Behavior Parents were asked to rate the effect of each factor as strong, moderate or no effects on child?s mental development in relation to each of the chosen aspects of mental performance. Responses were recorded manually, coded and group analysed using Friedman test and Cronbach Alpha test with the SPSS version 15.0. Results: The Friedman test for the general analysis show that factors that have a strong effect on mental performance for the participant were ??School discipline??, ??Parents education level??, ??Class size??, ??Regularity of meals?? and ??Nutrition as a baby?? for the four groups of cards colors sorting. Although Mood is considered lower than Attention, Learning and Behavior, all were taking from the strong effects answers groups. The card sorting colors game was tested in the study. Using the Cronbach Alpha test the questions? homogenity, averaging all correlations between all items, were measured giving a mean value of 95,26/100. Conclusion: Spanish data reveal that parents perceive the Environmental, Social and Educational group of factors as having most influence on children?s mental performance. Mood is valued by the Spanish parents with less responses regarding the strengths compared with Attention, Learning and Behavior, which appear more homogeneous in relation to wich factors have an influence in mental performance. Disclosure of Interest: This study is part of the FP7 Project NUTRIMENTHE Grant agreement n8: 212652.
Egan B, Gage Heather, Williams P, Raats M, Brands B, Gyoerei E, Lopez-Robles J, Campoy C, Koletzko B, Decsi T (2011) Diet and mental performance of children: A questionnaire survey of parents in four European countries., Annals of Nutrition and Metabolism: European journal of nutrition, metabolic diseases and dietetics 58 pp. 29-29 KARGER
Introduction: Diet is one of many factors influencing a child?s mental performance. but little is known about the beliefs. attitudes and knowledge of parents. and how these affect food choices. A survey of parents of children aged 4-10 years was conducted in four European countries (England. Germany. Hungary. Spain) to explore their views about the effect of diet on children?s attention and ability to learn. Objectives: Diet is one of many factors influencing a child?s mental performance. but little is known about the beliefs. attitudes and knowledge of parents. and how these affect food choices. A survey of parents of children aged 4-10 years was conducted in four European countries (England. Germany. Hungary. Spain) to explore their views about the effect of diet on children?s attention and ability to learn. Method/Design: A questionnaire was designed. translated and piloted in the four countries. Parents of children in mainstream education and without diagnosed pathologies such as Attention Deficit Hyperactivity Disorder were recruited through online panels accessed by a market research company. Background information was collected on respondents? personal characteristics (household composition and demography. socioeconomic status. education. ethnicity). The questionnaire explored views on the relationship between diet and physical and mental development. attention and ability to learn. and how such considerations affected food choices. Results: 1604 parents completed the questionnaire (401 in England. Germany and Hungary. 403 in Spain); 61% female (range 54% Spain ? 68% England). Most respondents had completed higher education (range 66% England ? 39% Hungary). Almost one half were current smokers (range 42% England ? 52% Germany). Many parents thought that a child?s ability to learn was very much . extremely dependent on diet (71% overall. range 64% Spain ? 78% Hungary). but smaller proportions reported that they considered this (very much. extremely) when providing food for their child (51% overall. range 47% England and Hungary ? 55 % Germany). Differences between views and reported behaviours of parents were smaller for other aspects of mental performance. Conclusions: Parents may belief that diet affects mental performance but other factors. such as providing variety and overall healthiness of diet. may be more important in the food choices they make for their children.
Dowson H, Gage Heather, Jackson DL, Qiao Y, Williams P, Rockall T (2012) Laparoscopic and Open Colorectal Surgery: A Prospective Cost Analysis, Colorectal Disease
H. Dowson, H. Gage, D. Jackson Y. Qiao, P. Williams, T. Rockall
Egan B, Gage Heather, Raats M, Anton B, Koletzko B, Györei E, Desci T, Martin-Bautista E, Lopez-Roberts JC, Campoy C (2010) 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) pp. E72-?
Nutrition is one of many factors that affect development of the brain and hence the mental performance of children; the latter term being used to describe a great variety of different brain-mediated functions and processes. The brain develops throughout childhood and an adequate diet is required for its optimal functioning and development(1). Consequently undernutrition has been associated with problems of cognition and behaviour, both on a short-term and long-term basis(2). To remain metabolically active the brain requires a constant supply of glucose as well as a range of other nutrients and both the nature of children?s diets and pattern of meal consumption may influence mental performance. Parents are responsible for the provision of food within the home and as such play a key role in the development of children?s food choices and eating behaviours(3,4). There is little published research on parent?s perceptions of the relationship between a child?s diet and their mental performance. The aim of the present qualitative study was to explore the attitudes, knowledge and perceptions of parents of the effect of diet on children?s development. Parents were recruited through a number of primary schools in the Guildford area. A semistructured interview schedule was used; topics included the effect of food on children?s wellbeing and development, the physical and mental effects of food and the short- and long-term effects of children?s diets. Further questions were asked about possible effects of specific foods, meals and supplements as well as the impact of what children eat in school on their performance. Analysis of the interviews identified a number of themes including the overarching relationship between diet and health. Parents spoke of the effects of diet in terms of physical, mental and behavioural outcomes, clearly distinguishing between what they perceived as positive and negative foods: ?I?ve seen children?s behaviour different when they?ve eaten certain foods, like they get hyper when they have sweet stuff and drink sugary stuff and eat sweets and cakes?. Concentration was the aspect of mental performance most discussed by parents, being affected both by particular foods and by feelings of hunger: ?I would imagine that if they?re hungry they will be tired, they?re not going to concentrate, they?re not going to do as well as they could do?. Parents attested to the importance of establishing good eating habits in childhood, as these habits would continue into adult life with implications for future health. The present study provides evidence of parents? views on the effects of food on children?s performance. Further research is needed to examine the views of others with insights in relation to children?s development (e.g. teachers). This research is funded by the European Community?s 7th Framework Programme (FP7/2008?2013) under grant agreement no. 212652 (NUTRIMENTHE Project ?The effect of diet on the mental performance of children?).
Brands B, Egan B, Gage Heather, Lopez-Robles JC, Gyoerei E, Raats M, Martin-Bautista E, Decsi T, Campoy C, Koletzko B (2010) THE EFFECT OF DIET ON CHILDREN'S MENTAL PERFORMANCE - A QUALITATIVE STUDY OF PERCEPTIONS, ATTITUDES AND BELIEFS OF PARENTS IN FOUR EUROPEAN COUNTRIES, JOURNAL OF PEDIATRIC GASTROENTEROLOGY AND NUTRITION 50 pp. E189-E189 LIPPINCOTT WILLIAMS & WILKINS
Objectives and Study: Nutrition is one of the many factors that influence a child?s cognitive development and mental performance. Understanding the relationship between nutrition and mental performance in children is important in terms of their attainment and productivity both in school and later life. Parents play a key role in the development of children?s food choices and dietary habits. To date, there is little published research on parent?s perceptions of the relationship between diet and mental performance of children. The present study aims to qualitatively examine parents? perceptions and beliefs about this relationship. Methods: The study was conducted in four European countries, England, Germany, Hungary and Spain. Participants were parents of children aged 4?10 years recruited through state elementary schools. A semi-structured interview schedule was used to conduct interviews with a total of 127 parents; it included questions on the effect of food on a child?s physical.and mental wellbeing and development. Further questions were asked about short or long term effects of diet, the effects of specific foods, meals and supplements. All interviews were transcribed and thematically analysed using NVIVO8. Results: Four main themes emerged from the interviews with a number of subthemes: ??physical effects of diet??, ??mental effects of diet??, ??healthiness of diet?? and ??parenting (responsibility, food preferences, dietary habits)??. The mental effects of diet are perceived by parents to be on attention and concentration as well as on children?s mood and behaviour. Negative effects are associated with sugary and fatty foods while positive effects are associated more generally with a healthy balanced diet. Conclusion: In all countries parents perceive attention and concentration to be negatively affected by sugary and fatty foods while a healthy balanced diet is believed to have a positive effect on mental outcomes. Based on the exploratory findings of this study, subsequent quantitative studies will need to further examine the prevalence of these perceptions in relation to socioeconomic factors. A detailed understanding of parents? perceptions of the relationship between diet and mental performance can provide valuable input for better targeted and formulated communication with parents, including intervention programmes as well as claims related to specific food products. Disclosure of Interest: None declared.
von Rosen-von Hoewel J, Laitinen K, Martin-Bautista E, Campoy C, Jakobik V, Decsi T, Schmid MA, Morgan J, Gage Heather, Koletzko B, Raats M (2009) Obesity Related Programming Statements in Materials on Infant Feeding Aimed at Parents in Five European Countries, EARLY NUTRITION PROGRAMMING AND HEALTH OUTCOMES IN LATER LIFE: OBESITY AND BEYOND 646 pp. 175-181 SPRINGER
Early nutrition programming as an origin of obesity is well acknowledged, but to what extent is this concept communicated to parents? In five European countries, UK, Finland (FI), Germany (DE), Hungary (HU) and Spain (ES), a total of 130 stand alone leaflets and 161 articles from parenting magazines providing information on feeding of healthy infants aged 0-12 months were identified and screened for nutrition programming statements. Obesity was mentioned in 8.5% (54/638) of the statements, and was the fourth most frequent outcome after allergy (20.7%), risk of infections (15.5%) and growth and development (11.4%). A temporal prognosis was given in 39% of obesity related statements, 6% referring to short- ( 15 years) duration of effects. So advice on obesity focuses oil the intrinsic long-term perspective of programming in contrary to other surveyed health-outcomes where only 8% considered a lifelong approach. The major programming related behaviour concerned breast-feeding compared to formula and complementary feeding with meaningful differences concerning the recommended duration: for ES and HU the predominant advice was for exclusive breast-feeding for 6 months, for DE exclusive breast-feeding for 4-6 months and for UK and FI breast-feeding without further specification. In summary, statements relating to the programming of later obesity have been partially integrated into feeding information in five European countries. These Countries have slightly different breastfeeding recommendations, but consistently refer to the preventive potential of breastfeeding in general. This is important as obesity and its resulting morbidity are of increasing public health concern in developed countries.
Gage Heather, Von Rosen-Von Hoewel J, Laitinen K, Jakobik V, Martin-Bautista E, Schmid M, Egan B, Morgan J, Williams P, Decsi T, Campoy C, Koletzko B, Raats MM (2013) Health effects of infant feeding: Information for parents in leaflets and magazines in five European countries, Public Understanding of Science 22 (3) pp. 365-379 Sage
Parents? decisions about whether to breastfeed their infant, and when to introduce complementary foods, are important public health issues. Breastfeeding has beneficial health effects and is widely promoted. Leaflets and magazine articles on infant feeding were collected in 2005, in five European countries (England, Finland, Germany, Hungary, Spain), and screened for statements that link feeding behaviours to infant health outcomes. A total of 127 leaflets contained 512 statements (0.38 / published page). Magazines contained approximately 1 article / month. Health outcomes were more intensively covered in England and Germany. Most statements referred to short term health implications. Lack of scientific agreement may underlie lack of cover of longer term health effects. Scope may exist to promote improved infant feeding practices by increasing the quantity and specificity of messages about health effects. Further research is required to evaluate the impact of alternative means of providing information on infant feeding practices.
Touray Morro, Antonini A, Gentile G, Giglio M, Marcante A, Gage Heather, Fotiadis D, Gatsios D, Konitsiotis S, Timotijevic Lada, Egan B, Hodgkins Charo, Biundo R, Pellicano C (2018) Acceptability to patients, carers and clinicians of a mHealth platform for the management of Parkinson's disease (PD_Manager): study protocol for a pilot randomised controlled trial, Trials 19 (492) BioMed Central
Background: Parkinson?s disease is a degenerative neurological condition causing multiple motor and non-motor
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
effectiveness trial.
Trial registration: ISRCTN Registry, ISRCTN17396879. Registered on 15 March 2017.
Background: One of the major health, social and economic problems in the Kingdom of Saudi Arabia is the rising prevalence of overweight and obesity amongst young people and the implications this has for the future burden of chronic diseases, such as type 2 diabetes. Nearly 10% of the Saudi population are now diagnosed with diabetes at a cost to the nation in 2010 estimated at $0.9 billion.
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.
Macken Lucia, Mason Louise, Evans Catherine, Gage Heather, Jordan Jake, Austin Mark, Parnell Nick, Cooper Max, Steer Shani, Boles Justine, Bremner Stephen, Lambert Debbie, Crook David, Earl Gemma, Timeyin Jean, Verma Sumita (2018) Palliative long-term abdominal drains versus repeated drainage in individuals with untreatable ascites due to advanced cirrhosis: study protocol for a feasibility randomised controlled trial, Trials 19 (401) BMC

Background

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.

Methods/design

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.

Discussion

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.

Trial registration

ISRCTN, ISRCTN30697116. Registered on 7 October 2015.

Victor Christina, Davies Susan, Dickinson Angela, Morbey Hazel, Masey Helen, Gage Heather, Froggatt Katherine, Iliffe Steve, Goodman Claire (2018) ?It just happens?. Care home residents? experiences and expectations of accessing GP care, Archives of Gerontology and Geriatrics 79 pp. 97-103 Elsevier

Background

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.

Methods

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.

Findings

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.

Conclusions

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.

Usman Adeela, Lewis Sarah, Hinsliff-Smith Kathryn, Long Annabelle, Housley Gemma, Jordan Jake, Gage Heather, Dening Tom, Gladman John R F, Gordon Adam L (2018) Measuring health-related quality of life of care home residents, comparison of self-report with staff proxy responses for EQ-5D-5L and HowRu: protocol for assessing proxy reliability in care home outcome testing, BMJ Open 8 (8) e022127 pp. 1-6 BMJ Publishing Group

Introduction

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.

Additional publications