Two-year follow-up of the 'Families for Health' programme for the treatment of childhood obesity

Background The high prevalence of obesity in children in the UK warrants continuing public health attention. ‘Families for Health’ is a family‐based group programme for the treatment of childhood obesity. Significant improvements in body mass index (BMI) z‐score (?0.21, 95% CI: ?0.35 to ?0.07, P= 0.007) and other health outcomes were seen in children at a 9‐month follow‐up. Aim To undertake a 2‐year follow‐up of families who attended ‘Families for Health’ in Coventry, to assess long‐term outcomes and costs. Methods ‘Families for Health’ is a 12‐week programme with parallel groups for parents and children, addressing parenting skills, healthy lifestyles and emotional well‐being. The intervention was delivered at a leisure centre in Coventry, England, with 27 overweight or obese children aged 7–13 years (18 girls, 9 boys) and their parents, from 21 families. A ‘before‐and‐after’ evaluation was completed with 19 (70%) children followed up at 2 years. The primary outcome was change in BMI z‐score from baseline; secondary outcomes were children's quality of life, parent–child relationships, eating/activity habits and parents' mental health. Costs to deliver the intervention and to families were recorded. Results Mean change in BMI z‐score from baseline was ?0.23 (95% CI: ?0.42 to ?0.03, P= 0.027) at the 2‐year follow‐up and eight (42%) children had a clinically significant reduction in BMI z‐score. Significant improvements were seen in children's quality of life and eating habits in the home, while there were sustained reductions in unhealthy foods and sedentary behaviour. Fruit and vegetable consumption and parent's mental health were not significantly different at 2 years. Costs of the programme were £517 per family (£402 per child), equivalent to £2543 per unit reduction in BMI z‐score. Conclusions Improvements in BMI z‐score and certain other outcomes associated with the ‘Families for Health’ programme were sustained at the 2‐year follow‐up. ‘Families for Health’ is a promising new childhood obesity intervention, and a randomized controlled trial is now indicated.     

Patterns of mortality among Bangladeshis in England and Wales

Objectives. To investigate the patterns of mortality among Bangladeshis living in England and Wales.

Methods. An analysis of national mortality data, classified by country of birth, for the latest period (1988–1992), using the method of indirect standardization for deriving standardized mortality ratios (SMRs) with the age‐ and sex‐specific rates for England and Wales as the standard ( = 100). The SMRs were derived for Bangladeshi‐born men and women aged 20–69 years for major disease entities.

Results. The mortality among Bangladeshi men was significantly higher (SMR 118 and 95% CI 111–126) than the levels prevalent in England and Wales. In contrast, the mortality among Bangladeshi women was significantly lower (SMR 71 and 95% CI 61–82). The cancer mortality overall was lower than expected in both sexes, with the exception of cancer of the liver and gall bladder. The mortality from breast cancer (SMR 16 and 95% CI 6–34) and cervical cancer (SMR 51 and 95% CI 14–131) was lower than expected. Bangladeshi men experienced high mortality from diabetes (SMR 685 and 95% CI 529–874), coronary heart disease (SMR 148 and 95% CI 134–163) and cerebrovascular disease (SMR 267 and 95% CI 222–319); they also experienced excess deaths from cirrhosis of the liver (SMR 254 and 95% CI 175–357).

Conclusions. The findings establish significant variations in the recent health experiences of Bangladeshi men living in England and Wales, posing a major challenge for purchasers of care. If the Health of the Nation strategy is to ensure that equity in health and health care is to apply to all those living in this country, the Bangladeshi population needs special targeting.     

Use of paracetamol for suicide and non-fatal poisoning in the UK and France: are restrictions on availability justified?

OBJECTIVE: To investigate the relationship between the availability of paracetamol and its use for overdose and suicide. DESIGN: Analysis of routinely collected information on time trends for paracetamol suicides, non-fatal overdoses, and sales. SETTING: England and Wales and France. RESULTS: There were strong correlations between trends in paracetamol sales in the UK and trends in non-fatal paracetamol overdose in Oxford between 1976 and 1993 (Spearman's r = 0.86; 95% confidence interval (CI) 0.54, 0.96) and between paracetamol sales and non-fatal overdoses in France between 1974 and 1990 (r = 0.99; 95% CI 0.97, 1.00). Sales figures were also correlated with paracetamol related suicides in both England and Wales, 1983-91 (r = 0.72; 95% CI 0.11, 0.94) and France, 1974-90 (r = 0.79; 95% CI 0.50, 0.92). Similarly strong relationships were observed between trends in non-fatal overdoses and suicide by paracetamol poisoning in England and Wales (r = 0.85; 95% CI 0.61, 0.95) and France (r = 0.79; 95% CI 0.50, 0.92). It is estimated that approximately 32,000 overdoses involving paracetamol occur annually in England and Wales. Fatality rates from paracetamol overdose were four times as high in England and Wales (0.4%, 95% CI 0.38, 0.46) as in France (0.1%, 95% CI 0.06, 0.17). CONCLUSION: Trends towards greater availability of paracetamol are paralleled by increases in its use for both non-fatal overdose and suicide. Paracetamol related morbidity and mortality seem to be less frequent in France where the quantity of paracetamol in a single purchase is limited. Although not conclusive, these data add to a body of evidence which suggests that restrictions in the quantity of paracetamol available as a single purchase in the UK may reduce suicide and liver failure related to paracetamol.     

THE COST‐EFFECTIVENESS OF USING FINANCIAL INCENTIVES TO IMPROVE PROVIDER QUALITY: A FRAMEWORK AND APPLICATION

Despite growing adoption of pay‐for‐performance (P4P) programmes in health care, there is remarkably little evidence on the cost‐effectiveness of such schemes. We review the limited number of previous studies and critique the frameworks adopted and the narrow range of costs and outcomes considered, before proposing a new more comprehensive framework, which we apply to the first P4P scheme introduced for hospitals in England. We emphasise that evaluations of cost‐effectiveness need to consider who the residual claimant is on any cost savings, the possibility of positive and negative spillovers, and whether performance improvement is a transitory or investment activity. Our application to the Advancing Quality initiative demonstrates that the incentive payments represented less than half of the £13m total programme costs. By generating approximately 5200 quality‐adjusted life years and £4.4m of savings in reduced length of stay, we find that the programme was a cost‐effective use of resources in its first 18 months. Copyright © 2013 John Wiley & Sons, Ltd.     

Trends in access to complementary or alternative medicines via primary care in England: 1995-2001 results from a follow-up national survey

A prior national survey of one in eight randomly selected general practices in England estimated that 39% of general practices [95% confidence interval (CI) 35-43%] provided some access to complementary or alternative medicine (CAM) therapies in 1995. A repeat survey, conducted in 2001, estimated that one in two practices in England now offer their patients some access to CAMs (95% CI 46-52%). The change was due to increased provision in-house; the proportion of practices making NHS referrals remained unchanged. The proportion of services supported by patient payments rose from 26 to 42%.     

A Cross-Sectional Study on Socioeconomic Systems Supporting Outpatients With Parkinson’s Disease in Japan

Objectives

We conducted a cross-sectional study to evaluate the socioeconomic systems supporting outpatients with Parkinson’s disease (PD) in Japan.

Methods

The study was performed in 2013 at two private hospitals and one clinic in Hokkaido Prefecture, Japan. A survey was conducted with 248 consecutive PD patients, and the data from 237 PD outpatients were analyzed after excluding 11 patients who did not meet inclusion criteria. Monthly medical and transportation payments as a PD outpatient were selected as outcome variables, and their association with various explanatory variables, such as utilization of support systems for PD outpatients, were evaluated using logistic regression model analysis.

Results

After controlling for potential confounding variables, the utilization of the system providing financial aid for treatment for patients with intractable disease was significantly inversely associated with monthly medical payment among PD outpatients (OR 0.46; 95% CI, 0.22–0.95). Experience of hospital admission for PD treatment was significantly positively associated with monthly transportation payment (OR 4.74; 95% CI, 2.18–10.32). Monthly medical payment was also significantly positively associated with monthly transportation payment (OR 4.01; 95% CI, 2.23–7.51).

Conclusions

Use of Japanese public financial support systems may be associated with reductions in medical payments for PD outpatients. However, those systems may not have supported transportation payments, and higher transportation payments may be associated with an increased risk of hospitalization.Key words: Parkinson’s disease, medical payment, cross-sectional study     

Cost‐minimisation analysis of home care reablement for older people in England: A modelling study

Many governments have introduced or encouraged home‐care reablement schemes for older people at home with the aim of improving outcomes and reducing costs. We examined if such schemes have the potential to reduce costs from the perspective of the National Health Service (NHS) and Personal Social Services (PSS) in England. Our study was carried out to inform recommendations of a national guideline. Cost‐minimisation analysis was carried out using decision‐analytic Markov modelling. Home‐care reablement was compared with standard home care. Costs included those of the intervention, home care and hospital admission. Uncertainty was explored using univariate and probabilistic sensitivity analysis. Mean costs per person were £56,499 (95% confidence interval 55,690 to 57,307) in the reablement group, and £58,560 (95% confidence interval 57,800 to 59,319) in the standard care group. The mean difference was ‐£2,061 (95% confidence interval 1,933 to 2,129). The probability that home‐care reablement costs less than standard home care was 94.5% (95% confidence interval 93.1 to 95.9). In sensitivity analyses, this probability remained above 85% in all scenarios. Home‐care reablement can be a successful cost‐minimisation strategy for supporting some older people. More research is needed about the impact of home‐care reablement on health outcomes for different groups of older people; and the effects of different durations of reablement on outcomes and costs for different subpopulations.     

Morbidity profiles of patients consulting during influenza and respiratory syncytial virus active periods

We compared the burden of illness due to a spectrum of respiratory diagnostic categories among persons presenting in a sentinel general practice network in England and Wales during periods of influenza and of respiratory syncytial virus (RSV) activity. During all periods of viral activity, incidence rates of influenza-like illness, bronchitis and common cold were elevated compared to those in baseline periods. Excess rates per 100,000 of acute bronchitis were greater in children aged <1 year (median difference 2702, 95% CI 929-4867) and in children aged 1-4 years (994, 95% CI 338-1747) during RSV active periods rather than influenza; estimates for the two viruses were similar in other age groups. Excess rates of influenza-like illness in all age groups were clearly associated with influenza virus activity. For common cold the estimates of median excess rates were significantly higher in RSV active periods for the age groups <1 year (3728, 95% CI 632-5867) and 5-14 years (339, 95% CI 59-768); estimates were similar in other age groups for the two viruses. The clinical burden of disease associated with RSV is as great if not greater than influenza in patients of all ages presenting to general practitioners.     

Meta‐analysis of absolute mean differences from randomised trials with treatment‐related clustering associated with care providers

Nesting of patients within care providers in trials of physical and talking therapies creates an additional level within the design. The statistical implications of this are analogous to those of cluster randomised trials, except that the clustering effect may interact with treatment and can be restricted to one or more of the arms. The statistical model that is recommended at the trial level includes a random effect for the care provider but allows the provider and patient level variances to differ across arms. Evidence suggests that, while potentially important, such within‐trial clustering effects have rarely been taken into account in trials and do not appear to have been considered in meta‐analyses of these trials. This paper describes summary measures and individual‐patient‐data methods for meta‐analysing absolute mean differences from randomised trials with two‐level nested clustering effects, contrasting fixed and random effects meta‐analysis models. It extends methods for incorporating trials with unequal variances and homogeneous clustering to allow for between‐arm and between‐trial heterogeneity in intra‐class correlation coefficient estimates. The work is motivated by a meta‐analysis of trials of counselling in primary care, where the control is no counselling and the outcome is the Beck Depression Inventory. Assuming equal counsellor intra‐class correlation coefficients across trials, the recommended random‐effects heteroscedastic model gave a pooled absolute mean difference of ?2.53 (95% CI ?5.33 to 0.27) using summary measures and ?2.51 (95% CI ?5.35 to 0.33) with the individual‐patient‐data. Pooled estimates were consistently below a minimally important clinical difference of four to five points on the Beck Depression Inventory. Copyright © 2014 John Wiley & Sons, Ltd.     

Predicting the likelihood of emergency admission to hospital of older people: development and validation of the Emergency Admission Risk Likelihood Index (EARLI)

OBJECTIVE: To develop and evaluate an evidence-based tool for predicting the likelihood of emergency admission to hospital of older people aged 75 years and over in the UK. METHODS: Prospective cohort study of older people registered with 17 general practices within Halton Primary Care Trust in the north-west of England. A questionnaire with 20 items was sent to older people aged>or=75 years. Items for inclusion in the questionnaire were selected from information gleaned from published literature and a pilot study. The primary outcome measurement was an emergency admission to hospital within 12 months of completing the questionnaire. A logistic regression analysis was carried out to identify those items which predicted emergency admission to hospital. A scoring system was devised to identify those at low, moderate, high and very high risk of admission, using the items identified in the predictive modelling process. RESULTS: In total, 83% (3032) returned the questionnaire. A simple, six-item tool was developed and validated-the Emergency Admission Risk Likelihood Index (EARLI). The items included in the tool are as follows: do you have heart problems? [odds ratio (OR) 1.40, 95% confidence interval (CI) 1.15-1.72]; do you have leg ulcers? (OR 1.46, 95% CI 1.04-2.04); can you go out of the house without help? (OR 0.60, 95% CI 0.47-0.75); do you have problems with your memory and get confused? (OR 1.46, 95% CI 1.19-1.81); have you been admitted to hospital as an emergency in the last 12 months? (OR 2.16, CI 1.72-2.72); and would you say the general state of your health is good? (OR 0.66, 95% CI 0.53-0.82). The tool had high negative predictive value (>79%) and identified over 50% of those at high or very high risk of emergency admission. A very high score (>20) identified 6% of older people, 55% of whom had an emergency admission in the following 12 months. A low score (相似文献   

Cost-Utility Analysis Comparing Heavy-Weight and Light-Weight Mesh in Laparoscopic Surgery for Unilateral Inguinal Hernias

Background

Hernioplasty is one of the most frequent surgeries in the UK. Light-weight mesh (LWM) has the potential to reduce chronic groin pain but its cost-effectiveness compared with heavy-weight mesh (HWM) is unknown.

Objective

Our objective was to conduct a cost-utility analysis between laparoscopic hernioplasty with HWM and LWM for unilateral inguinal hernias.

Methods

A Markov model simulated costs and health outcomes over a period of 1 year (2012) from the societal and National Health Service (NHS) perspective (England). The main outcome was cost per quality-adjusted life-year (QALY) gained. Surgery results were gleaned from the randomized control trial by Bittner et al. Other input parameters were drawn from the literature and public sources of the NHS.

Results

From the societal perspective, LWM induces lower incremental costs (?£88.85) than HWM but yields a slightly smaller incremental effect (?0.00094 QALYs). The deterministic incremental cost-effectiveness ratio (ICER) for HWM compared with LWM amounts to £94,899 per QALY, while the probabilistic ICER is £118,750 (95 % confidence interval [CI] £57,603–180,920). Owing to the withdrawal of productivity losses from the NHS perspective, LWM causes higher incremental costs (£13.09) and an inferior incremental effect (?0.00093), resulting in a dominance of HWM over LWM (ICER 95 % CI ?£12,382 to ?£21,590).

Conclusions

There is no support for the adoption of LWM as standard treatment from an NHS perspective. However, given the small differences between HWM and LWM, LWM has at least the potential of improving patient outcomes and reducing expenditure from the societal perspective.     

Optimal Respiratory Syncytial Virus intervention programmes using Nirsevimab in England and Wales

IntroductionRespiratory Syncytial Virus (RSV) is a major cause of acute lower respiratory tract infections (ALRI) in infants. There are no licensed vaccines and only one monoclonal antibody available to protect infants from disease. A new and potentially longer-lasting monoclonal antibody, Nirsevimab, showed promising results in phase IIb/III trials. We evaluate the cost-effectiveness of Nirsevimab intervention programmes in England and Wales.MethodsWe used a dynamic model for RSV transmission, calibrated to data from England and Wales. We considered a suite of potential Nirsevimab programmes, including administration to all neonates (year-round); only neonates born during the RSV season (seasonal); or neonates born during the RSV season plus infants less than six months old before the start of the RSV season (seasonal + catch-up).ResultsIf administered seasonally to all infants at birth, we found that Nirsevimab would have to be priced at £63 or less per dose for at least 50% certainty that it could cost-effectively replace the current Palivizumab programme, using an ICER threshold of £20,000/QALY. An extended seasonal programme which includes a pre-season catch-up becomes the optimal strategy at a purchasing price of £32/dose or less for at least 50% certainty. At a purchasing price per dose of £5-32, the annual implementation costs of a seasonal programme could be as high as £2 million before a switch to a year-round strategy would be optimal.DiscussionNirsevimab has the potential to be cost-effective in England and Wales not only for use in high-risk infants.     

An assessment of the economic and heart health benefits of replacing saturated fat in the diet with monounsaturates in the form of rapeseed (canola) oil

There is a well‐established requirement for the UK population to reduce the saturates content of its diet from around 13.3% energy (E) intake to 10% E intake (including alcohol) and to improve fat quality by increasing monounsaturated fatty acid (MUFA) intake. Canola (rapeseed) oil is one of the richest sources of dietary MUFAs and is a good source of the omega‐3 polyunsaturated fatty acid (PUFA) alpha‐linolenic acid. Recent advances using conventional plant breeding have led to the development of high‐oleic canola, which has an increased level of MUFA and greater oxidative stability, making it suitable for a wide range of culinary purposes including frying. Around 7% of dietary saturated fatty acid (SFA) intake in adults derives from potatoes (fried potatoes and chips) and savoury snacks, with the value increasing to 13%–15% SFA in 4–18‐year‐olds. Traditionally, frying oils have been high in saturates content and their replacement with lower SFA alternatives provides the opportunity for food manufactures to lower SFA content of food with minimal consumer intervention. It has been estimated that at least half of the SFA in this category of foods can be replaced. In this review of literature, ten intervention studies were identified, where SFAs and/or carbohydrates were replaced by rapeseed oil, and the effect on blood lipids were reported. Results from these studies were pooled using standard meta‐analysis methods. The standard mean differences in total cholesterol (Total‐C) and low‐density lipoprotein cholesterol (LDL‐C) were 0.86 mmol/l [95% confidence interval (CI): ?1.05 to ?0.66] (ten studies) and 0.87 mmol/l (95% CI: ?1.07 to ?0.66) (nine studies), respectively, both significant (P < 0.0001) and non‐heterogeneous (P > 0.1). Using the pooled data, it can be calculated that each gram of SFA intake reduction was associated with reductions in both Total‐C and LDL‐C of 0.03 mmol/l, while each gram increase in either MUFA or PUFA reduced Total‐C by 0.05 and 0.09, respectively, and LDL‐C by 0.04 mmol/l and 0.08 mmol/l, respectively. It was also calculated that each 10 g increase in MUFA or rapeseed oil intake was associated with a reduction in Total‐C of 9.8% and 5.8%, respectively. In 2006, annual direct healthcare costs associated with coronary heart disease were estimated at £3.2 billion and the overall cost to the UK economy was nearly £9.0 billion. Assuming 3.5 g total fat (typically 30% E SFA) is replaced by 3.5 g rapeseed oil, then it can be predicted that Total‐C will be reduced by 1.9%, equivalent to an annual reduction of £61 million direct health costs and £171 million total costs.     

Mendelian Randomization analysis of the causal effect of adiposity on hospital costs

Estimates of the marginal effect of measures of adiposity such as body mass index (BMI) on healthcare costs are important for the formulation and evaluation of policies targeting adverse weight profiles. Most estimates of this association are affected by endogeneity bias. We use a novel identification strategy exploiting Mendelian Randomization – random germline genetic variation modelled using instrumental variables – to identify the causal effect of BMI on inpatient hospital costs. Using data on over 300,000 individuals, the effect size per person per marginal unit of BMI per year varied according to specification, including £21.22 (95% confidence interval (CI): £14.35-£28.07) for conventional inverse variance weighted models to £18.85 (95% CI: £9.05-£28.65) for penalized weighted median models. Effect sizes from Mendelian Randomization models were larger in most cases than non-instrumental variable multivariable adjusted estimates (£13.47, 95% CI: £12.51-£14.43). There was little evidence of non-linearity. Within-family estimates, intended to address dynastic biases, were imprecise.     

Cost-effectiveness of roflumilast as an add-on treatment to long-acting bronchodilators in the treatment of COPD associated with chronic bronchitis in the United Kingdom

Objective

To estimate the cost-effectiveness of adding a selective phosphodiesterase-4 inhibitor, roflumilast, to a long-acting bronchodilator therapy (LABA) for the treatment of patients with severe-to-very severe chronic obstructive pulmonary disease (COPD) associated with chronic bronchitis with a history of frequent exacerbations from the UK payer perspective.

Methods

A Markov model was developed to predict the lifetime cost and outcomes [exacerbations rates, life expectancy, and quality-adjusted life years (QALY)] in patients treated with roflumilast, which showed a reduction in the exacerbation rates and lung function improvement in a pooled analysis from two clinical trials, M2-124 and M2-125. Sensitivity analyses were conducted to explore the impact of uncertainties on the cost-effectiveness.

Results

The addition of roflumilast to concomitant LABA reduced the number of exacerbations from 15.6 to 12.7 [2.9 (95 % CI 0.88–4.92) exacerbations avoided] and increased QALYs from 5.45 to 5.61 [0.16 (95 % CI 0.02–0.31) QALYs gained], at an incremental cost of £3,197 (95 % CI £2,135–£4,253). Cost in LABA alone and LABA + roflumilast were £16,161 and £19,358 respectively. The incremental cost-effectiveness ratios in the base case were £19,505 (95 % CI £364–£38,646) per quality-adjusted life-year gained and 18,219 (95 % CI £12,697–£49,135) per life-year gained. Sensitivity analyses suggest that among the main determinants of cost-effectiveness are the reduction of exacerbations and the case fatality rate due to hospital-treated exacerbations. Probabilistic sensitivity analysis suggests that the probability of roflumilast being cost-effective is 82 % at willingness-to-pay £30,000 per QALY.

Conclusions

The addition of roflumilast to LABA in the treatment of patients with severe-to-very severe COPD reduces the rate of exacerbations and can be cost-effective in the UK setting.     

Funding community pharmacy dispensing: A qualitative exploration of current and alternate models leading to the development of quality focused funding principles

BackgroundPerformance-linked remuneration for pharmacists’ dispensing in which payment may be adjusted based on an outcome of the service, has been introduced by some funders in the US. However, in most countries, pharmacists’ dispending is still remunerated on a set fee-for-service (sFFS) basis.ObjectiveTo assess sFFS and performance-linked payment concepts and identify quality-focused funding principles for dispensing within an Australian context.MethodsWithin an adaptation framework, the study used thematic analysis of interviews with Australian community pharmacy stakeholders to evaluate the existing sFFS dispensing payment model, determine the fit of key elements of a performance-linked payment model, and evaluate acceptance of a simple performance-linked model. We induced quality-focused dispensing payment principles from the data.ResultssFFS funding is not ideal for either patients or the profession as it encourages pharmacists to dispense quickly rather than commit time and expertise in accordance with each patient's requirements. However, the lack of specificity and correlation between pharmacists’ services and patient outcomes is an impediment to using performance-linked payment in Australia.ConclusionsQuality-focused principles within a fee-for-service model should separate payment for commercial aspects of dispensing from professional aspects, which should include a schedule of time-based payments linked to patient and medication risk factors.