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.
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.
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.
Jordan J, Dowson H, Gage H, Jackson D, Rockall T (2014) Laparoscopic versus open colorectal resection for cancer and polyps: a cost-effectiveness study., Clinicoecon Outcomes Res 6 pp. 415-422
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.
Sharples L, Glover M, Clutterbuck-James A, Bennett M, Jordan J, Chadwick R, Pittman M, East C, Cameron M, Davies M, Oscroft N, Smith I, Morrell M, F (2014) Clinical effectiveness and cost-effectiveness results from the randomised controlled Trial of Oral Mandibular Advancement Devices for Obstructive sleep apnoea?hypopnoea (TOMADO) and long-term economic analysis of oral devices and continuous positive airway pressure, Health Technol Assess 18 (67)
Gage HM, 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 group
Quinnell TG, Bennett M, Jordan J, Clutterbuck-James AL, Davies MG, Smith IE, Oscroft N, Pittman MA, Cameron M, Chadwick R, Morrell MJ, Glover MJ, Fox-Rushby JA, Sharples LD (2014) A crossover randomised controlled trial of oral mandibular advancement devices for obstructive sleep apnoea-hypopnoea (TOMADO), THORAX 69 (10) pp. 938-945 BMJ PUBLISHING GROUP
Quinnell TG, Clutterbuck-James AL, Bennett M, Jordan J, Chadwick R, Davies MG, Oscroft N, Smith IE, East CL, Pittman MA, Cameron M, Morrell MJ, Glover M, Fox-Rushby JA, Sharples LD (2014) Randomised controlled trial of mandibular advancement devices for obstructive sleep apnoea (TOMADO): one year follow-up, JOURNAL OF SLEEP RESEARCH 23 pp. 116-116 WILEY-BLACKWELL
Drobniewski F, Cooke M, Jordan J, Casali N, Mugwagwa T, Broda A, Townsend C, Sivaramakrishnan A, Green N, Jit M, Lipman M, Lord J, White PJ, Abubakar I (2015) Systematic review, meta-analysis and economic modelling of molecular diagnostic tests for antibiotic resistance in tuberculosis, HEALTH TECHNOLOGY ASSESSMENT 19 (34) pp. 1-+ NIHR JOURNALS LIBRARY
Quinnell TG, Pittman MA, Bennett M, Jordan J, Clutterbuck-James AL, East CL, Davies MG, Oscroft N, Cameron M, Chadwick R, Smith IE, Morrell M, Glover M, Fox-Rushby JA, Sharples LD (2013) TOMADO: A CROSSOVER RANDOMISED CONTROLLED TRIAL OF ORAL MANDIBULAR ADVANCEMENT DEVICES FOR OBSTRUCTIVE SLEEP APNOEA-HYPOPNOEA, THORAX 68 pp. A4-A4 BMJ PUBLISHING GROUP
Patel S, Hee S, Mistry D, Jordan J, Brown S, Dritsaki M, Ellard D, Friede T, Lamb S, Lord J, Madan J, Morris T, Stallard N, Tysall C, Willis A, Underwood M (2016) Identifying back pain subgroups: developing and applying approaches using individual patient data collected within clinical trials, Programme Grants Appl Res 4 (10) NIHR Health Technology Assessment Programme
There is good evidence that therapist delivered interventions have modest beneficial effects for people with low back pain (LBP). Identification of subgroups of people with LBP who may benefit from these different treatment approaches is an important research priority.
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
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
care home residents have high healthcare needs not fully met by prevailing healthcare models. This study explored how healthcare configuration influences resource use.
a realist evaluation using qualitative and quantitative data from case studies of three UK health and social care economies selected for differing patterns of healthcare delivery to care homes. Four homes per area (12 in total) were recruited. A total of 239 residents were followed for 12 months to record resource-use. Overall, 181 participants completed 116 interviews and 13 focus groups including residents, relatives, care home staff, community nurses, allied health professionals and General Practitioners.
context-mechanism-outcome configurations were identified explaining what supported effective working between healthcare services and care home staff: (i) investment in care home-specific work that legitimises and values work with care homes; (ii) relational working which over time builds trust between practitioners; (iii) care which ?wraps around? care homes; and (iv) access to specialist care for older people with dementia. Resource use was similar between sites despite differing approaches to healthcare. There was greater utilisation of GP resource where this was specifically commissioned but no difference in costs between sites.
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.