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Background: The MODEM project (A comprehensive approach to MODelling outcome and costs impacts of interventions for DEMentia) explores how changes in arrangements for the future treatment and care of people living with dementia, and support for family and other unpaid carers, could result in better outcomes and more efficient use of resources.Methods: MODEM starts with a systematic mapping of the literature on effective and (potentially) cost-effective interventions in dementia care. Those findings, as well as data from a cohort, will then be used to model the quality of life and cost impacts of making these evidence-based interventions more widely available in England over the period from now to 2040. Modelling will use a suite of models, combining microsimulation and macrosimulation methods, modelling the costs and outcomes of care, both for an individual over the life-course from the point of dementia diagnosis, and for individuals and England as a whole in a particular year. Project outputs will include an online Dementia Evidence Toolkit, making evidence summaries and a literature database available free to anyone, papers in academic journals and other written outputs, and a MODEM Legacy Model, which will enable local commissioners of services to apply the model to their own populations.Discussion: Modelling the effects of evidence-based cost-effective interventions and making this information widely available has the potential to improve the health and quality of life both of people with dementia and their carers, while ensuring that resources are used efficiently. [ABSTRACT FROM AUTHOR]

Background: Mental health acute crisis episodes are associated with high inpatient costs. Self-management interventions may reduce readmission by enabling individuals to manage their condition. Delivery of such interventions by Peer Support Workers (PSWs) may be cost-effective. CORE, a randomized control trial of a PSW self-management intervention compared to usual care, found a significant reduction in admissions to acute mental healthcare for participants receiving the intervention. This paper aims to evaluate the cost-effectiveness of the intervention over 12 months from a mental health service perspective. Analysis methods of increasing complexity were used to account for data missingness and distribution. Methods: Participants were recruited from six crisis resolution teams in England from 12 March 2014 to 3 July 2015 (trial registration ISRCTN: 01027104). Resource use was collected from patient records at baseline and 12 months. The EQ-5D-3L was collected at baseline and 4 and 18 months, and linear interpolation was used to calculate 12-month values for quality-adjusted life-years (QALYs). The primary analysis of adjusted mean incremental costs and QALYs for complete cases are calculated separately using OLS regression. Secondly, a complete-case non-parametric two-stage bootstrap (TSB) was performed. The impacts of missing data and skewed cost data were explored using multiple imputation using chained equations and general linear models, respectively. Results: Four hundred and forty-one participants were recruited to CORE; 221 randomized to the PSW intervention and 220 to usual care plus workbook. The probability that the PSW intervention was cost-effective compared with the workbook plus usual care control at 12 months varied with the method used, and ranged from 57% to 96% at a cost-effectiveness threshold of £20,000 per QALY gained. Discussion: There was a minimum 57% chance that the intervention was cost-effective compared to the control using 12-month costs and QALYs. The probability varied by 40% when methods were employed to account for the relationship between costs and QALYs, but which restricted the sample to those who provided both complete cost and utility data. Caution should therefore be applied when selecting methods for the evaluation of healthcare interventions that aim to increase precision but may introduce bias if missing data are heavily unbalanced between costs and outcomes. [ABSTRACT FROM AUTHOR]

Background: Telephone therapist delivered CBT (TCBT) and web-based CBT (WCBT) have been shown to be significantly more clinically effective than treatment as usual (TAU) at reducing IBS symptom severity and impact at 12 months in adults with refractory IBS. In this paper we assess the cost-effectiveness of the interventions.Methods: Participants were recruited from 74 general practices and three gastroenterology centres in England. Interventions costs were calculated, and other service use and lost employment measured and costed for one-year post randomisation. Quality-adjusted life years (QALYs) were combined with costs to determine cost-effectiveness of TCBT and WCBT compared to TAU.Results: TCBT cost £956 more than TAU (95% CI, £601-£1435) and generated 0.0429 more QALYs. WCBT cost £224 more than TAU (95% CI, - £11 to £448) and produced 0.029 more QALYs. Compared to TAU, TCBT had an incremental cost per QALY of £22,284 while the figure for WCBT was £7724. After multiple imputation these ratios increased to £27,436 and £17,388 respectively. Including lost employment and informal care, TCBT had costs that were on average £866 lower than TAU (95% CI, - £1133 to £2957), and WCBT had costs that were £1028 lower than TAU (95% CI, - £448 to £2580).Conclusions: TCBT and WCBT resulted in more QALYs and higher costs than TAU. Complete case analysis suggests both therapies are cost-effective from a healthcare perspective. Imputation for missing data reduces cost-effectiveness but WCTB remained cost-effective. If the reduced societal costs are included both interventions are likely to be more cost-effective. Trial registration ISRCTN44427879 (registered 18.11.13). [ABSTRACT FROM AUTHOR]

Background The evidence on public health interventions has traditionally focussed on a limited number of costs and benefits, adopted inconsistent methods and is not always relevant to the UK context. This paper develops a multi-criteria decision analysis (MCDA) approach to overcome these challenges. Methods A document review and stakeholder consultation was used to identify interventions and the criteria against which they should be assessed. The interventions were measured against these criteria using literature reviews and decision models. Criteria weights were generated using a discrete choice experiment. Results Fourteen interventions were included in the final ranking. Taxation was ranked as the highest priority. Mass-media campaigns and brief interventions ranked in the top half of interventions. School-based educational interventions, statins and interventions to address mental health problems ranked in the bottom half of interventions. Conclusions This paper demonstrates that it is possible to incorporate criteria other than cost-effectiveness in the prioritization of public health investment using an MCDA approach. There are numerous approaches available that adopt the MCDA framework. Further research is required to determine the most appropriate approach in different settings. [ABSTRACT FROM AUTHOR]

Background: This paper describes the design and development of a complex multifactorial falls prevention (MFFP) intervention for implementation and testing within the framework of a large UK-based falls prevention randomised controlled trial (RCT).Methods: A complex intervention was developed for inclusion within the Prevention of Falls Injury Trial (PreFIT), a multicentre pragmatic RCT. PreFIT aims to compare the clinical and cost-effectiveness of three alternative primary care falls prevention interventions (advice, exercise and MFFP), on outcomes of fractures and falls. Community-dwelling adults, aged 70 years and older, were recruited from primary care in the National Health Service (NHS), England.Results: Development of the PreFIT MFFP intervention was informed by the existing evidence base and clinical guidelines for the assessment and management of falls in older adults. After piloting and modification, the final MFFP intervention includes seven falls risk factors: a detailed falls history interview with consideration of 'red flags'; assessment of balance and gait; vision; medication screen; cardiac screen; feet and footwear screen and home environment assessment. This complex intervention has been fully manualised with clear, documented assessment and treatment pathways for each risk factor. Each risk factor is assessed in every trial participant referred for MFFP. Referral for assessment is based upon a screening survey to identify those with a history of falling or balance problems. Intervention delivery can be adapted to the local setting.Conclusion: This complex falls prevention intervention is currently being tested within the framework of a large clinical trial. This paper adheres to TIDieR and CONSORT recommendations for the comprehensive and explicit reporting of trial interventions. Results from the PreFIT study will be published in due course. The effectiveness and cost-effectiveness of the PreFIT MFFP intervention, compared to advice and exercise, on the prevention of falls and fractures, will be reported at the conclusion of the trial. [ABSTRACT FROM AUTHOR]

Background: Most water fluoridation studies were conducted on children before the widespread introduction of fluoride toothpastes. There is a lack of evidence that can be applied to contemporary populations, particularly adolescents and adults. Objective: To pragmatically assess the clinical and cost effectiveness of water fluoridation for preventing dental treatment and improving oral health in a contemporary population of adults, using a natural experiment design. Design: Retrospective cohort study using routinely collected National Health Service dental claims (FP17) data. Setting: National Health Service primary dental care: general dental practices, prisons, community dental services, domiciliary settings, urgent/out-of-hours and specialised referral-only services. Participants: Dental patients aged 12 years and over living in England (n = 6,370,280). Intervention and comparison: Individuals exposed to drinking water with a fluoride concentration ≥ 0.7 mg F/l between 2010 and 2020 were matched to non-exposed individuals on key characteristics using propensity scores. Outcome measures: Primary: number of National Health Service invasive dental treatments (restorations/'fillings' and extractions) received per person between 2010 and 2020. Secondary: decayed, missing and filled teeth, missing teeth, inequalities, cost effectiveness and return on investment. Data sources: National Health Service Business Services Authority dental claims data. Water quality monitoring data. Primary outcome: Predicted mean number of invasive dental treatments was 3% lower in the optimally fluoridated group than in the sub/non-optimally fluoridated group (incidence rate ratio 0.969, 95% CI 0.967 to 0.971), a difference of −0.173 invasive dental treatments (95% CI −0.185 to −0.161). This magnitude of effect is smaller than what most stakeholders we engaged with (n = 50/54) considered meaningful. Secondary outcomes: Mean decayed, missing and filled teeth were 2% lower in the optimally fluoridated group, with a difference of −0.212 decayed, missing and filled teeth (95% CI −0.229 to −0.194). There was no statistically significant difference in the mean number of missing teeth per person (0.006, 95% CI −0.008 to 0.021). There was no compelling evidence that water fluoridation reduced social inequalities in treatments received or missing teeth; however, decayed, missing and filled teeth data did not demonstrate a typical inequalities gradient. Optimal water fluoridation in England in 2010–20 was estimated to cost £10.30 per person (excluding original setup costs). Mean National Health Service treatment costs for fluoridated patients 2010–20 were 5.5% lower per person, by £22.26 (95% CI −£23.09 to −£21.43), and patients paid £7.64 less in National Health Service dental charges per person (2020 prices). Limitations: Pragmatic, observational study with potential for non-differential errors of misclassification in fluoridation assignment and outcome measurement and residual and/or unmeasured confounding. Decayed, missing and filled teeth data have not been validated. Water fluoridation cost estimates are based on existing programmes between 2010 and 2020, and therefore do not include the potentially significant capital investment required for new programmes. Conclusions: Receipt of optimal water fluoridation between 2010 and 2020 resulted in very small health effects, which may not be meaningful for individuals, and we could find no evidence of a reduction in social inequalities. Existing water fluoridation programmes in England produced a positive return on investment between 2010 and 2020 due to slightly lower National Health Service treatment costs. These relatively small savings should be evaluated against the projected costs and lifespan of any proposed capital investment in water fluoridation, including new programmes. Future work: National Health Service dental data are a valuable resource for research. Further validation and measures to improve quality and completeness are warranted. Trial registrations: This trial is registered as ISRCTN96479279, CAG: 20/CAG/0072, IRAS: 20/NE/0144. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128533) and is published in full in Public Health Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information. Plain language summary: Fluoride is a natural mineral that prevents tooth decay. It is added to some drinking water and toothpastes to improve dental health. Water with fluoride added is known as 'optimally fluoridated'. Most research on water fluoridation was carried out before fluoride was added to toothpastes in the 1970s and only included children. We wanted to know if water fluoridation still produced large reductions in tooth decay, now that decay levels are much lower because of fluoride in toothpaste. We also wanted to look at its effect on adults and teenagers. Dental patients we spoke to told us they worried about needing treatment with the 'drill', or 'injection', losing their teeth and paying for their dental care. To see if water fluoridation helped with these concerns, we compared the National Health Service dental records of 6.4 million adults and teenagers who received optimally fluoridated or non-optimally fluoridated water in England between 2010 and 2020. We found water fluoridation made a very small difference to each person. Between 2010 and 2020, the number of NHS fillings and extractions was 3% lower per person for those who received optimally fluoridated water. We found no difference in the number of teeth lost per person and no strong sign that fluoridation reduced differences in dental health between rich and poor areas. Between 2010 and 2020, the cost of optimal water fluoridation was £10.30 per person (not including setup costs). National Health Service dental patients who received optimally fluoridated water cost the National Health Service £22.26 (5.5%) less and paid £7.64 (2%) less per person in National Health Service dental charges over the 10 years. The benefits we found are much smaller than in the past, when toothpastes did not contain fluoride. The cost to set up a new water fluoridation programme can be high. Communities may need to consider if these smaller benefits would still outweigh the costs. Scientific summary: Background: There is a lack of contemporary evidence on the effectiveness and cost effectiveness of water fluoridation in populations who are also using fluoride toothpastes and have significantly lower levels of decay than when most of the research on water fluoridation was carried out. In their 2002 review of water fluoridation, the UK Medical Research Council identified several priority areas for future research, in particular: the effect of water fluoridation on the dental health of adults the effects of fluoridation on health and well-being beyond the usual measures of decayed, missing or filled teeth the economic impacts of water fluoridation how the effects of water fluoridation vary with social class. Conducting research on the effects of water fluoridation in adults involves significant methodological challenges. This has resulted in a paucity of evidence and recommendations for research that have not been addressed in 20 years. The present study has been designed to contribute to the evidence base in a pragmatic and cost-efficient way, using routinely collected NHS dental claims data. During our initial public engagement work, patients and the public told us that preventing dental treatment, particularly 'the drill' or 'injection', was a key impact that they would hope water fluoridation would produce. Other impacts were not losing teeth to extraction and avoiding costly dental charges. This feedback is reflected in our choice of primary and secondary outcome measures. Aim: To pragmatically assess the clinical and cost effectiveness of water fluoridation for preventing dental treatment and improving oral health. Primary objective: Impact of water fluoridation on NHS invasive dental treatments (fillings, extractions). Secondary objectives: Impact on oral health [number of teeth and caries experience, missing and filled teeth (DMFT)]. Impact on social inequalities. Cost effectiveness and return on investment (ROI). Study inclusion criteria: Adults and adolescents aged 12 years and over who had attended an NHS dental practice in England within the last 10 years. Adolescents were included in the study cohort because they are likely to have all of their permanent, adult teeth. Patient confirmed as a unique individual using the combination of NHS Business Service Authority (BSA) identifier (initial, surname, gender, date of birth) and NHS number. Study exclusion criteria: Individuals who did not have at least two episodes of dental attendance within the 10-year observation period. The reason for this was to provide at least two data points on location of residence (to assign fluoridation exposure). Cohort setting: The study population data set was supplied by NHS BSA , which processes payment claims for NHS for dentists. The NHS BSA data retention period is 10 years. National Health Service primary dental care is delivered in a range of settings and types of services, including: general dental practices (high street practices) prison dental services community dental services (special care referral service, which treats patients with additional needs, including medical conditions, disabilities, homelessness or drug use) domiciliary settings (home visits for housebound patients) urgent/out-of-hours services for patients without a regular dentist specialised referral-only services such as sedation or oral surgery. Data on care delivered in all of the above services are collected by NHS BSA. Selection of the study population: Selection of the study population was carried out on 21 October 2020, by NHS BSA. Individual dental treatment claim entries for England and Wales were screened for linkage and selection by NHS BSA in the following order: Identifiable data: Withdrawn or 'no information' claims (FP17s) were dropped. Claims with no 1 : 1 match between NHS number and NHS BSA ID were dropped. Claims containing only orthodontic care were dropped. Patients whose NHS number was on 'NHS national data opt-out list' were dropped. Anonymised data: Patients who had attended only once were dropped. Patients aged under 12 years were dropped. Patients whose first recorded address was not in England were dropped. Patients whose first course of treatment was prior to 22 November 2010 were dropped. The study population data set, securely transferred to the University of Manchester, included anonymised data on 17,855,239 unique individuals. Exposure assignment: Water fluoride sample data (mg F/l) were obtained from water suppliers in England under the Environmental Information Regulations (2004) and converted from water supply zones to lower super output areas (LSOAs) using mapping in statistical software 'R'. This resulted in a record of annual mean water fluoride concentrations by LSOA for every year between 2010 and 2020. Individuals within the study population data set were then assigned an individual water fluoride exposure (mg F/l) by combining their residential history (recorded in the NHS BSA dental claims data set) with the annual concentration of fluoride in the drinking water of the LSOAs they lived in between 2010 and 2020. Individuals exposed to drinking water with a grand mean fluoride concentration ≥ 0.7 mg F/l between 2010 and 2020 were assigned to the 'optimally fluoridated' group, and those with a grand mean of < 0.7 mg F/l were assigned to the 'sub/non-optimally fluoridated' group. Propensity score matching: Individuals in the optimally fluoridated group were matched to individuals in the sub/non-optimally fluoridated group using propensity scores. The baseline characteristics used to create the propensity scores were selected using subject matter knowledge and theory to include all hypothesised confounders and important outcome predictors. To inform the selection of these variables, causal assumptions were made explicit using directed acyclic graphs. Baseline characteristics for propensity score estimation and matching were based on data recorded at the patient's first course of treatment: sex age ethnicity deprivation decile NHS exemption status rural–urban classification number of units of dental activities (UDAs) commissioned per person with the patient's local authority of residence dental practice contract type dental practice deprivation decile. Propensity scores were estimated using logistic regression, and matching was carried out using three specifications of nearest neighbour matching (one-to-one, variable ratio and variable ratio with a 0.25 calliper). The resulting matched data set which best met our pre-specified criteria regarding overall sample size, balance on baseline characteristics and ability to estimate the average treatment effect in the treated group was taken forwards for further analysis. Analysis of health effects: The effect of optimal water fluoridation on primary and secondary clinical outcomes was estimated using negative binomial regression models, including matching weights and using cluster-robust standard errors. Incidence rate ratios (IRRs) and 95% confidence intervals (CIs) were calculated for the mean number of invasive dental treatments received, the mean number of DMFTs and the mean number of missing teeth by fluoridation group. To determine whether there was a differential effect of water fluoridation according to deprivation, we included patient deprivation decile [Index of Multiple Deprivation (IMD) 2015] as an interaction term. 'Clinical' relevance of primary outcome: We engaged with 54 public and professional stakeholders from across the UK through 3 online workshops to explore views on what might be considered a relevant/practically significant effect of optimal water fluoridation on our primary outcome. We identified a wide range of views and some suggestions that dentists felt smaller reductions were meaningful, compared to non-dentists, but most contributors felt a reduction of at least one invasive NHS dental treatment per person over 10 years would be needed to be considered meaningful (a 16% relative reduction in the workshop scenario). Health economic evaluation: The health economic evaluation involved a cost-effectiveness and a ROI analysis. The time horizon was 2010–20, and the perspective was public sector payors [NHS, Public Health England (PHE) and local authorities]. Operating and capital costs of water fluoridation for England were supplied by PHE for the financial years 2013–9, with mean annual costs used for 2010–2. All costs are reported in 2020 prices. National Health Service dental care utilisation and patient charges were contained within the study population data set provided by NHS BSA , and an average UDA price for England supplied by NHS BSA [under the Freedom of Information Act (2000)] was used to calculate NHS costs. Differences in costs between patients from optimally fluoridated and sub/non-optimally fluoridated groups were estimated using a generalised linear model (GLM) with a log-link and a gamma distribution to account for right-skewed cost data. Cost effectiveness was based on the primary study outcome, assessed as the additional cost per avoided episode of invasive dental treatment [incremental cost-effectiveness ratio (ICER)]. We also calculated total NHS dental charges paid by patients in the optimally fluoridated and sub/non-optimally fluoridated groups. Water fluoridation cannot be provided on an individual basis, therefore per-patient cost effectiveness and ROI estimates were extrapolated from our sample to the estimated population of regular users of NHS dental services using a range of scenarios. Results: The study population data set (the full cohort) supplied by NHS BSA included records relating to 17,855,239 unique individuals. After propensity score matching (using nearest neighbour, one-to-three variable ratio), the matched cohort contained data on 6,370,280 individuals: 4,777,710 in the sub/non-optimally fluoridated group and 1,592,570 in the optimally fluoridated group. Primary objective: The rate of invasive dental treatments in the optimally fluoridated group was 3% lower than that of the sub/non-optimally fluoridated group (IRR 0.969, 95% CI 0.967 to 0.971). There was a predicted mean difference of 0.173 fewer invasive dental treatments per person (95% CI 0.185 to 0.161) in the optimally fluoridated group compared to the sub/non-optimally fluoridated group. During our stakeholder engagement work, only 4 of 54 contributors considered this magnitude of reduction to be meaningful. Secondary objectives: Oral health: Mean DMFT in the optimally fluoridated group was 2% lower than in the sub/non-optimally fluoridated group (IRR 0.984, 95% CI 0.983 to 0.985). There was a predicted mean difference of 0.212 fewer DMFTs (95% CI 0.229 fewer to 0.194 fewer) in the optimally fluoridated group compared to the sub/non-optimally fluoridated group. We found no significant difference in the mean number of missing teeth between the optimally fluoridated group and the sub/non-optimally fluoridated group (IRR 1.001, 95% CI 0.999 to 1.003). The negative binomial model predicted a mean difference of 0.006 more missing teeth in the fluoridated group, but the 95% CI includes the possibility of no effect (95% CI 0.008 fewer to 0.021 more). Effect of water fluoridation on social inequalities: In all deciles, the predicted number of invasive treatments was lower in the optimally fluoridated group than the sub/non-optimally fluoridated group, but the size of the reductions was very small. The largest predicted reduction of 0.337 fewer invasive dental treatments per person (95% CI 0.371 fewer to 0.302 fewer) was in the most deprived decile (IMD 1), a relative reduction of 5.3%. The relationship between patient deprivation and DMFT was unclear and did not demonstrate a social inequality gradient in the expected direction. Therefore, we are unable to conclude whether water fluoridation reduced social inequalities in DMFT. Small differences were evident in each decile, but the direction of effect was not consistent. Small differences in the number of missing teeth per person in the optimally fluoridated and sub/non-optimally fluoridated groups were evident in each decile of deprivation, but the direction of effect was not consistent. Overall, we could find no compelling evidence that water fluoridation reduced socioeconomic disparities in oral health in adult and adolescent users of NHS dental services. Health economic results: Water fluoridation costs: Total expenditure on water fluoridation between 2010 and 2019 was estimated to be £46,791,388. The cost of optimal water fluoridation per person over 10 years was estimated to be £10.30. No new water fluoridation programmes were commissioned between 2010 and 2020; therefore, our cost estimates for water fluoridation do not include setup costs, which are highly site-specific and can be significant. National Health Service dental treatment and patient charges: In the GLM , the marginal effects estimate revealed a saving in NHS treatment costs for optimally fluoridated patients over the study period of £22.26 per person (95% CI £21.43 to £23.09). This represents a relative reduction in costs to the NHS of 5.5% per person between 2010 and 2020. Patients in the optimally fluoridated group paid £7.64 less (2%) in total NHS dental charges than patients in the non-optimally fluoridated group between 2010 and 2020. Population-level cost effectiveness and return on investment: Water fluoridation is a whole-population intervention, which cannot be implemented on a per-person basis. In terms of cost effectiveness and ROI, it is important to consider the potential size of the population to whom our within-sample (per person) findings may apply. In the scenario thought to be most likely by our steering committee (that 62.9% of the population aged 12 years can be expected to use NHS dental services at least twice in 10 years), we estimate that: The cost to avoid one invasive dental treatment (the ICER) was £94.55. The predicted ROI for water fluoridation in England between November 2010 and October 2020 was estimated to be £16,884,595 (a 36% return on the investment). Conclusions: Receipt of optimal water fluoridation between 2010 and 2020 resulted in very small health effects which may not be meaningful for individuals, and we could find no evidence that water fluoridation reduced social inequalities in dental health. Slightly lower dental service utilisation produced a positive ROI during the period of observation, but it must be remembered that the cost estimates for water fluoridation did not include the initial set-up of the programmes. Where new capital investment in water fluoridation is required, the estimated project costs should be evaluated against the estimated savings contained within this report and the projected lifespan of the infrastructure. Whether the case for water fluoridation programmes can be based solely on a predicted ROI rather than meaningful health improvements may need to be considered by stakeholders. Recommendations for research: NHS primary care dental data are a potentially valuable resource for research, surveillance and epidemiology. Consideration should be given as to how to develop this resource further. Suggestions include: commissioning enhanced data collection through a network of dental providers (similar to medical G.P. Clinical Practice Research Datalink network); mandatory use of NHS numbers, recording the reason for treatment (caries, periodontal disease, trauma, repair of old restoration); steps to increase the completeness of patient ethnicity data and validation of the DMFT data. Routinely collected water quality monitoring data should be made publicly available. A central, annually updated database of water fluoride concentrations (mg F/l) at a small area level is required to support future research and monitoring of water fluoridation. To broaden the evidence base for triangulation, the effect of water fluoridation on the dental health of adults should be investigated in any future national dental epidemiology surveys. To determine if the estimated cost to avoid one invasive dental treatment (the ICER) represents good value for money, further work is required to identify a threshold level for 'good value' for this outcome. Trial registrations: This trial is registered as ISRCTN96479279, CAG: 20/CAG/0072, IRAS: 20/NE/0144. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Public Health Research programme (NIHR award ref: NIHR128533) and is published in full in Public Health Research; Vol. 12, No. 5. See the NIHR Funding and Awards website for further award information. [ABSTRACT FROM AUTHOR]

Background: The National Institute for Health and Care Excellence (NICE) recommends evidence-based parenting programmes as a first-line intervention for conduct disorders (CD) in children aged 5-11 years. As these are not effective in 25-33% of cases, NICE has requested research into second-line interventions. Child and Adolescent Psychotherapists (CAPTs) address highly complex problems where first-line treatments have failed and there have been small-scale studies of Psychoanalytic Child Psychotherapy (PCP) for CD. A feasibility trial is needed to determine whether a confirmatory trial of manualised PCP (mPCP) versus Treatment as Usual (TaU) for CD is practicable or needs refinement. The aim of this paper is to publish the abridged protocol of this feasibility trial.Methods and Design: TIGA-CUB (Trial on improving Inter-Generational Attachment for Children Undergoing Behaviour problems) is a two-arm, pragmatic, parallel-group, multicentre, individually randomised (1:1) controlled feasibility trial (target n = 60) with blinded outcome assessment (at 4 and 8 months), which aims to develop an optimum practicable protocol for a confirmatory, pragmatic, randomised controlled trial (RCT) (primary outcome: child's behaviour; secondary outcomes: parental reflective functioning and mental health, child and parent quality of life), comparing mPCP and TaU as second-line treatments for children aged 5-11 years with treatment-resistant CD and inter-generational attachment difficulties, and for their primary carers. Child-primary carer dyads will be recruited following a referral to, or re-referral within, National Health Service (NHS) Child and Adolescent Mental Health Services (CAMHS) after an unsuccessful first-line parenting intervention. PCP will be delivered by qualified CAPTs working in routine NHS clinical practice, using a trial-specific PCP manual (a brief version of established PCP clinical practice). Outcomes are: (1) feasibility of recruitment methods, (2) uptake and follow-up rates, (3) therapeutic delivery, treatment retention and attendance, intervention adherence rates, (4) follow-up data collection, and (5) statistical, health economics, process evaluation, and qualitative outcomes.Discussion: TIGA-CUB will provide important information on the feasibility and potential challenges of undertaking a confirmatory RCT to evaluate the effectiveness and cost-effectiveness of mPCP.Trial Registration: Current Controlled Trials, ID: ISRCTN86725795 . Registered on 31 May 2016. [ABSTRACT FROM AUTHOR]

Background: Mental health rehabilitation services provide specialist treatment to people with particularly severe and complex problems. In 2018, the Care Quality Commission reported that over half the 4,400 mental health inpatient rehabilitation beds in England were provided by the independent sector. They raised concerns that the length of stay and cost of independent sector care was double that of the NHS and that their services tended to be provided much further from people's homes. However, there has been no research comparing the two sectors and we therefore do not know if these concerns are justified. The ACER Study (Assessing the Clinical and cost-Effectiveness of inpatient mental health Rehabilitation services provided by the NHS and independent sector) is a national programme of research in England, funded from 2021 to 2026, that aims to investigate differences in inpatient mental health rehabilitation provided by the NHS and independent sector in terms of: patient characteristics; service quality; patient, carer and staff experiences; clinical and cost effectiveness. Methods: ACER comprises a:1) detailed survey of NHS and independent sector inpatient mental health rehabilitation services across England; 2) qualitative investigation of patient, family, staff and commissioners' experiences of the two sectors; 3) cohort study comparing clinical outcomes in the two sectors over 18 months; 4) comprehensive national comparison of inpatient service use in the two sectors, using instrumental variable analysis of routinely collected healthcare data over 18 months; 5) health economic evaluation of the relative cost-effectiveness of the two sectors. In Components 3 and 4, our primary outcome is 'successful rehabilitation' defined as a) being discharged from the inpatient rehabilitation unit without readmission and b) inpatient service use over the 18 months. Discussion: The ACER study will deliver the first empirical comparison of the clinical and cost-effectiveness of NHS and independent sector inpatient mental health rehabilitation services. Trial registration: ISRCTN17381762 retrospectively registered. [ABSTRACT FROM AUTHOR]

Background Adolescent mental health (AMH) needs in England have increased dramatically and needs exceed treatment availability. This study undertook a comparative assessment of the health and economic return on investment (ROI) of interventions to prevent and treat mental disorders among adolescents (10–19 years) and examined intervention affordability and readiness. Methods Interventions were identified following a review of published and grey literature. A Markov model followed a simulated adolescent cohort to estimate implementation costs and health, education, and economic benefits. Intervention affordability was assessed, comparing annual cost per adolescent with NHS England per capita spending, and an expert panel assessed intervention readiness using a validated framework. Results Over 10- and 80-year horizons, interventions to treat mild anxiety and mild depression were most cost-effective, with the highest individual lifetime ROI (GBP 5822 GBP 1 and GBP 257: GBP 1). Preventing anxiety and depression was most affordable and 'implementation ready' and offered the highest health and economic benefits. A priority package (anxiety and depression prevention; mild anxiety and mild depression treatment) would avert 5 million disability-adjusted life-years (DALYS) and achieve an ROI of GBP 15: GBP 1 over 10 years or 11.5 million DALYs (ROI of GBP 55: GBP 1) over 80 years. Conclusion The economic benefits from preventing and treating common adolescent mental disorders equivalent to 25% of NHS England's annual spending in 2021 over 10 years and 91% over 80 years. Preventing and early treatment for anxiety and depression had the highest ROIs and strong implementation readiness. [ABSTRACT FROM AUTHOR]

To present an approach to involving people with communication disorders in research. Background Patient and public involvement (PPI) is promoted at all stages of research, with everyone having a right to be involved. However, the high level of communication skills often required precludes the involvement of people with communication disorders. As people from several healthcare groups have communication difficulties, it is important to establish approaches that can help to involve them. Data source A study involving people with communication difficulties using computerised aphasia treatment. Review methods The paper describes techniques used to help an advisory group comprising people with aphasia and their carers to collaborate. Reflections on participating in a research group were elicited through videoed interviews. A thematic analysis of the video transcripts identified issues important to the group's members. Discussion The approach to patient and public involvement in research enabled collaboration with people with aphasia at all stages of research, including contributing to recruitment, refinement of protocols, new research methods and dissemination of project outcomes. Allowing time for careful preparation of group meetings, facilitation techniques and activities is crucial to achieve this level of involvement. Conclusion The group experienced increased confidence in communicating, stimulation and feelings of empowerment and being able to influence the future treatment of people with aphasia. Implications for practice/research People with communication difficulties need not be excluded from PPI activities designed to inform clinical practice or health research. Inclusion of this group can be made possible by using creative methods of exchanging ideas, reducing reliance on rapid, complex spoken interaction. [ABSTRACT FROM AUTHOR]

Background The need to make best use of limited resources in the English National Health Service is now greater than ever. This paper contributes to this endeavour by synthesizing data from cost-effectiveness evidence produced to support the development of public health guidance at the National Institute of Health and Clinical Excellence (NICE). No comprehensive list of cost-effectiveness estimates for public health interventions has previously been published in England. Methods Cost-effectiveness estimates using English cost data were collected and analysed from 21 (of 26) economic analyses underpinning public health guidance published by NICE between 2006 and 2010. Results Two hundred base-case cost-effectiveness estimates were analysed, 15% were cost saving (i.e. the intervention was more effective and cheaper than comparator). Eighty-five per cent were cost-effective at a threshold of £20 000 per quality-adjusted life year and 89% at the higher threshold of £30 000. A further 5.5% were above £30 000 and 5.5% of the interventions were dominated (i.e. the intervention was more costly and less effective than comparator). Conclusions The majority of public health interventions assessed are highly cost-effective. The next challenge is to provide commissioners with a framework that allows information from economic analyses to be combined with other criteria that supports making better investment decisions at a local level. [ABSTRACT FROM AUTHOR]

Background: Screening with the guaiac faecal occult blood test (gFOBt) is associated with improved colorectal cancer (CRC) survival, and is offered biennially to men and women aged 60-74 years in England's national Bowel Cancer Screening Programme (BCSP). Uptake of the gFOBt is low, with only 54 % of the eligible population completing the test. Text-message reminders could improve uptake of gFOBt.Methods/design: This paper describes the protocol for a randomised controlled trial, which will examine the effectiveness of a text-message reminder to promote uptake of gFOBt screening in the BCSP. Individual mobile telephone data from 180 general practices in London with existing mobile-health services will be linked to the national BCSP information system via a secure on-line network. All screening-eligible adults registered with a participating practice will be randomised, to receive either usual care (N = 1600) or usual care plus a text-message reminder to self-complete and return their kit eight weeks after their initial invitation (N = 1600). The primary outcome will be the proportion of individuals who return an adequately completed gFOBt kit within 18 weeks of the initial invitation. Differences in uptake between groups will be evaluated using a logistic regression analysis, adjusting for individual-level and area-level socio-demographic variables.Discussion: This will be the first large-scale randomised trial of a text-message reminder in a national screening programme for CRC. If effective, this study provides a cost-effective means to promote uptake of CRC screening in an organised programme.Trial Registration: Current Controlled Trials ISRCTN70904476 (18/09/2015). [ABSTRACT FROM AUTHOR]

Background: In contrast to evidence for interventions supporting victim/survivors of domestic violence and abuse (DVA), the effectiveness of perpetrator programmes for reduction of abuse is uncertain. This study aims to estimate the effectiveness and cost-effectiveness of a perpetrator programme for men. Methods: Pragmatic two-group individually randomised controlled trial (RCT) with embedded process and economic evaluation. Five centres in southwest England and South Wales aim to recruit 316 (reduced from original target of 366) male domestic abuse perpetrators. These will be randomised 2:1 to a community-based domestic abuse perpetrator programme (DAPP) or usual care comparator with 12-month follow-up. Female partners/ex-partners will be invited to join the study. The intervention for men comprises 23 weekly sessions of a group programme delivered in voluntary sector domestic abuse services. The intervention for female partners/ex-partners is one-to-one support from a safety worker. Men allocated to usual care receive no intervention; however, they are free to access other services. Their partners/ex-partners will be signposted to support services. Data is collected at baseline, and 4, 8 and 12 months' follow-up. The primary outcome is men's self-reported abusive behaviour measured by the Abusive Behaviour Inventory (ABI-29) at 12 months. Secondary measures include physical and mental health status and resource use alongside the abuse measure ABI (ABI-R) for partners/ex-partners and criminal justice contact for men. A mixed methods process evaluation and qualitative study will explore mechanisms of effectiveness, judge fidelity to the intervention model using interviews and group observations. The economic evaluation, over a 1-year time horizon from three perspectives (health and social care, public sector and society), will employ a cost-consequences framework reporting costs alongside economic outcomes (Quality-Adjusted Life Years derived from EQ-5D-5L, SF-12 and CHU-9D, and ICECAP-A) as well as the primary and other secondary outcomes. Discussion: This trial will provide evidence of the (cost)effectiveness of a DAPP. The embedded process evaluation will further insights in the experiences and contexts of participants and their journey through a perpetrator programme, and the study will seek to address the omission in other studies of economic evaluations. Trial registration: ISRCTN15804282, April 1, 2019 [ABSTRACT FROM AUTHOR]

Background: Systematic reviews suggest that multi-component interventions are effective in reducing bullying victimisation and perpetration. We are undertaking a phase III randomised trial of the INCLUSIVE multi-component intervention. This trial aims to assess the effectiveness and cost-effectiveness of the INCLUSIVE intervention in reducing aggression and bullying victimisation in English secondary schools. This paper updates the original trial protocol published in 2014 (Trials 15:381, 2014) and presents the changes in the process evaluation protocol and the secondary outcome data collection.Methods: The methods are summarised as follows.Design: cluster randomised trial.Participants: 40 state secondary schools. Outcomes assessed among the cohort of students at the end of year 7 (n = 6667) at baseline.Intervention: INCLUSIVE is a multi-component school intervention including a social and emotional learning curriculum, changes to school environment (an action group comprising staff and students reviews local data on needs to review rules and policies and determine other local actions) and staff training in restorative practice. The intervention will be delivered by schools supported in the first two years by educational facilitators independent of the research team, with a third intervention year involving no external facilitation but all other elements. Comparator: normal practice.Outcomes: Primary: Two primary outcomes at student level assessed at baseline and at 36 months: 1. Aggressive behaviours in school: Edinburgh Study of Youth Transitions and Crime school misbehaviour subscale (ESYTC) 2. Bullying and victimisation: Gatehouse Bullying Scale (GBS) Secondary outcomes assessed at baseline, 24 and 36 months will include measures relating to the economic evaluation, psychosocial outcomes in students and staff and school-level truancy and exclusion rates.Sample Size: 20 schools per arm will provide 90% power to identify an effect size of 0.25 SD with a 5% significance level. Randomisation: eligible consenting schools were randomised stratified for single-sex versus mixed-sex schools, school-level deprivation and measures of school attainment.Discussion: The trial involves independent research and intervention teams and is supervised by a Trial Steering Committee and a Data Monitoring Committee.Trial Registration: Current Controlled Trials, ISRCTN10751359 . Registered on 11 March 2014. [ABSTRACT FROM AUTHOR]

A case study was conducted in 2016 to evaluate the effectiveness of an innovation to enable people with "complex" care requirements to be discharged from hospital to an appropriate service for their care, without using the NHS England Continuing Health Care (CHC) assessment. The setting was a rural district general hospital in England, where the quality outcomes and cost‐effectiveness of the CHC assessment being conducted in hospital were giving cause for concern. The NHS CHC Framework advocates conducting these assessments in the community where a more accurate indication of long‐term care can be determined. The "5Q Care Test" was collaboratively developed with health and social care partners, care providers, and CHC interest groups, including users of the services. It was implemented as a tool to support moving the CHC assessment into the community, as it enabled practitioners to swiftly determine patients' appropriate initial care pathway out of hospital. A full economic impact analysis was conducted 7 months after the tool was introduced. The results showed significant improvement in the quality and cost‐effectiveness of the "5Q Care Test," with a reduction in the hospital length of stay, which is known to be associated with improved outcomes for patients and financial savings. [ABSTRACT FROM AUTHOR]

In this paper we look at the connection between police resources and crime by focussing on a large-scale policy intervention-the Street Crime Initiative-that was introduced in England and Wales in 2002. This allocated additional resources to some police force areas to specifically target street crime, whereas other forces did not receive any additional funding. Estimates derived from several empirical strategies show that robberies fell significantly in SCI police forces relative to non-SCI forces after the initiative was introduced. Moreover, the policy seems to have been a cost effective one, even after extensively testing for possible displacement or diffusion effects onto other crimes and into adjacent areas. Overall, we reach the conclusion that increased police resources can be used to generate falls in crime, at least in the context of the SCI program we study. (JEL: H00, H5, K42) [ABSTRACT FROM AUTHOR]

As social services councils face a more constrained economic environment and as eligibility criteria tighten, the issue of targeting becomes increasingly relevant. This paper presents findings from a pilot project in one local authority that aimed to target access to assessment for older people with low-level needs who would normally have fallen under eligibility thresholds. Self-assessment was used as a tool whereby these older people could identify, with assistance, their preferences for a range of preventative services. Via a randomised design, the study evaluated the costs and benefits, in terms of reported satisfaction, of the approach compared with the usual care management assessment. Although self-assessed cases were offered more advice as to a wider range of preventative services, which generated greater costs, total costs were lower for this group. This cost saving arose from the use of staff with a lower unit cost who also spent less time on administrative duties and gathering information. Satisfaction with self-assessment was comparable to a professional assessment, therefore representing a cost-effective approach. The project offers evidence of how councils can target resources through assessment and how self-assessment approaches may be appropriately configured to offer value for these users whilst also generating resource savings. [ABSTRACT FROM PUBLISHER]

Road pricing LESSONS FROM LONDON This paper assesses the original London Congestion Charging Scheme (LCCS) and its impacts, and it simulates the proposed extension which will include most of Kensington and Chelsea. It also touches upon the political economy of the congestion charge and the increase of the charge from £5 to £8 per day. The possibility of transferring the experience to Paris, Rome and New York is also discussed. The LCCS has had positive impacts. This was despite the considerable political influences on the charge level and location. It is difficult to assess the impacts of the increase of the charge from £5 to £8, which took place in July 2005, because no data have yet been released by Transport for London. The proposed extension of the charging zone does not seem to be an efficient change on economic grounds, at least for the specific boundaries, method of charging and level of charging that is currently planned. Our benefit cost ratios computed under different assumptions of costs and benefits are all below unity. Overall, the experience shows that simple methods of congestion charging, though in no way resembling first-best Pigouvian taxes, can do a remarkably good job of creating benefits from the reduction of congestion. Nevertheless, the magnitude of these benefits can be highly sensitive to the details of the scheme, which therefore need to be developed with great care. [ABSTRACT FROM AUTHOR]

Background: Child maltreatment is a significant public health problem. Group Family Nurse Partnership (gFNP) is a new intervention for young, expectant mothers implemented successfully in pilot studies. This study was designed to determine the effectiveness and cost-effectiveness of gFNP in reducing risk factors for maltreatment with a potentially vulnerable population.Methods: A multi-site, randomized controlled, parallel-arm trial and prospective economic evaluation was conducted, with allocation via remote randomization (minimization by site, maternal age group) to gFNP or usual care. Participants were expectant mothers aged below 20 years with at least one live birth, or aged 20-24 years with no live births and with low educational qualifications. Data from maternal interviews at baseline and when infants were 2, 6 and 12 months, and video-recording at 12 months, were collected by researchers blind to allocation. Cost information came from weekly logs completed by gFNP family nurses and other service delivery data reported by participants. Primary outcomes measured at 12 months were parenting attitudes (Adult-Adolescent Parenting Index, AAPI-2) and maternal sensitivity (CARE Index). The economic evaluation was conducted from a UK NHS and personal social services perspective with cost-effectiveness expressed in terms of incremental cost per quality-adjusted life year (QALY) gained. The main analyses were intention-to-treat with additional complier average causal effects (CACE) analyses.Results: Between August 2013 and September 2014, 492 names of potential participants were received of whom 319 were eligible and 166 agreed to take part, 99 randomly assigned to receive gFNP and 67 to usual care. There were no between-arm differences in AAPI-2 total (7 · 5/10 in both, SE 0.1), difference adjusted for baseline, site and maternal age group 0 · 06 (95% CI - 0 · 15 to 0 · 28, p = 0 · 59) or CARE Index (intervention 4 · 0 (SE 0 · 3); control 4 · 7 (SE 0 · 4); difference adjusted for site and maternal age group - 0 · 68 (95% CI - 1 · 62 to 0 · 16, p = 0 · 25) scores. The probability that gFNP is cost-effective based on the QALY measure did not exceed 3%.Conclusions: The trial did not support gFNP as a means of reducing the risk of child maltreatment in this population but slow recruitment adversely affected group size and consequently delivery of the intervention.Trial Registration: ISRCTN78814904 . Registered on 17 May 2013. [ABSTRACT FROM AUTHOR]

The care home staff influenza vaccination rate in England is significantly lower than the 75% World Health Organisation recommendation. This represents a substantial potential for resident harm. Barriers to staff vaccination stem from individual and organisational levels. Existing interventions address some but not all barriers and are not underpinned by behavioural science theory. This study aims to estimate the effectiveness and cost-effectiveness of a theory-informed intervention to improve care home staff vaccination rates compared to routine practice. Set in care homes with both nursing and residential focus, and a range of ownership status, only homes providing long stay care to older people with a staff vaccination rate below 40% are eligible to participate. Participation expressions of interest will be sought using a variety of approaches prior to seeking consent. The primary outcome measure is the proportion of staff vaccinated at 6 months, with secondary outcome measures being proportion vaccinated at 3 months, numbers of staff sick days, general practitioner and nurse visits to care home, care home resident hospitalisations and mortality. Based on the assumptions that the mean cluster (care home) size is 54 staff, a coefficient of variation of 0.48, control vaccination rate is 55%, intervention 75%, intra-cluster correlation coefficient of 0.2 and with 90% power, and 20% attrition, we require 39 care homes per arm. Blocked randomisation will be at the level of care home, stratified by the proportion of non-white care home staff, and implemented by Norwich Clinical Trials Unit. The intervention comprises co-designed information videos and posters, provision of in-house staff vaccination clinics, and incentive scheme and monthly data collection on trial outcomes. Beyond usual practice, the control arm will additionally contribute monthly data. Data will be collected at the start, monthly and at 6 months, and analysis will be blind to allocation. Statistical analysis will use the intention-to-treat principle with the difference in vaccination rates between groups compared using a random effect logistic regression model at the staff-level. This will be the first study to use a theory-informed intervention designed to comprehensively address identified barriers to care home staff influenza vaccination. Trial registration: ISRCTN ISRCTN22729870. Registered on 24 August 22. Secondary identifiers: R209939, IRAS 316820, CPMS 53812. [ABSTRACT FROM AUTHOR]

There are long‐standing concerns that people experiencing homelessness may not recover well if left unsupported after a hospital stay. This study reports on a study investigating the cost‐effectiveness of three different 'in patient care coordination and discharge planning' configurations for adults experiencing homelessness who are discharged from hospitals in England. The first configuration provided a clinical and housing in‐reach service during acute care and discharge coordination but with no 'step‐down' care. The second configuration provided clinical and housing in‐reach, discharge coordination and 'step‐down' intermediate care. The third configuration consisted of housing support workers providing in‐reach and discharge coordination as well as step‐down care. These three configurations were each compared with 'standard care' (control, defined as one visit by the homelessness health nurse before discharge during which patients received an information leaflet on local services). Multiple sources of data and multi‐outcome measures were adopted to assess the cost utility of hospital discharge service delivery for the NHS and broader public perspective. Details of 354 participants were collated on service delivery costs (salary, on‐costs, capital, overheads and 'hotel' costs, advertising and other indirect costs), the economic consequences for different public services (e.g. NHS, social care, criminal justice, housing, etc.) and health utilities (quality‐adjusted‐life‐years, QALYs). Findings were complex across the configurations, but, on the whole, there was promising evidence suggesting that, with delivery costs similar to those reported for bed‐based intermediate care, step‐down care secured better health outcomes and improved cost‐effectiveness (compared with usual care) within NICE cost‐effectiveness recommendations. [ABSTRACT FROM AUTHOR]

Background: Empirical estimates of health system opportunity costs have been suggested as a basis for the cost-effectiveness threshold to use in Health Technology Assessment. Econometric methods have been used to estimate these in several countries based on data on spending and mortality. This study examines empirical evidence on four issues: non-linearity of the relationship between spending and mortality; the inclusion of outcomes other than mortality; variation in the efficiency with which expenditures generate health outcomes; and the relationship among efficiency, mortality rates and outcome elasticities. Methods: Quantile Regression is used to examine non-linearities in the relationship between mortality and health expenditures along the mortality distribution. Data Envelopment Analysis extends the approach, using multiple measures of health outcomes to measure efficiency. These are applied to health expenditure data from 151 geographical units (Primary Care Trusts) of the National Health Service in England, across eight different clinical areas (Programme Budget Categories), for 3 fiscal years from 2010/11 to 2012/13. Results: The results suggest differences in efficiency levels across geographical units and clinical areas as to how health resources generate outcomes, which indicates the capacity to adjust to a decrease in health expenditure without affecting health outcomes. Moreover, efficient units have lower absolute levels of mortality elasticity to health expenditure than inefficient ones. Conclusions: The policy of adopting thresholds based on estimates of a single system-wide cost-effectiveness threshold assumes a relationship between expenditure and health outcomes that generates an opportunity cost estimate which applies to the whole system. Our evidence of variations in that relationship and therefore in opportunity costs suggests that adopting a single threshold may exacerbate the efficiency and equity concerns that such thresholds are designed to counter. In most health care systems, many decisions about provision are not made centrally. Our analytical approach to understanding variability in opportunity cost can help policy makers target efficiency improvements and set realistic targets for local and clinical area health improvements from increased expenditure. [ABSTRACT FROM AUTHOR]

Background: Psychiatric mother and baby units (MBUs) are recommended for severe perinatal mental illness, but effectiveness compared with other forms of acute care remains unknown.Aims: We hypothesised that women admitted to MBUs would be less likely to be readmitted to acute care in the 12 months following discharge, compared with women admitted to non-MBU acute care (generic psychiatric wards or crisis resolution teams (CRTs)).Method: Quasi-experimental cohort study of women accessing acute psychiatric care up to 1 year postpartum in 42 healthcare organisations across England and Wales. Primary outcome was readmission within 12 months post-discharge. Propensity scores were used to account for systematic differences between MBU and non-MBU participants. Secondary outcomes included assessment of cost-effectiveness, experience of services, unmet needs, perceived bonding, observed mother-infant interaction quality and safeguarding outcome.Results: Of 279 women, 108 (39%) received MBU care, 62 (22%) generic ward care and 109 (39%) CRT care only. The MBU group (n = 105) had similar readmission rates to the non-MBU group (n = 158) (aOR = 0.95, 95% CI 0.86-1.04, P = 0.29; an absolute difference of -5%, 95% CI -14 to 4%). Service satisfaction was significantly higher among women accessing MBUs compared with non-MBUs; no significant differences were observed for any other secondary outcomes.Conclusions: We found no significant differences in rates of readmission, but MBU advantage might have been masked by residual confounders; readmission will also depend on quality of care after discharge and type of illness. Future studies should attempt to identify the effective ingredients of specialist perinatal in-patient and community care to improve outcomes. [ABSTRACT FROM AUTHOR]

The article presents the discussion on Chief Medical Officer for England recommending that young people remaining alcohol free until 18 years of age. Topics include highest levels of drinking among adolescents and the North East England being one of the highest levels of adolescent alcohol consumption in the UK; and exploring the relationship between alcohol use during adolescence and negative consequences in adulthood.

Background: Identifying and supporting young children who are at risk of developing anxiety disorders would benefit children, families, and wider society. Elevated anxiety symptoms, inhibited temperament, and high parental anxiety are established risk factors for later anxiety disorders, but it remains unclear who is most likely to benefit from prevention and early intervention programmes. Delivering an online intervention through schools to parents of young children who have one or more of these risks could maximise reach. The primary aim of this trial is to evaluate the effectiveness and cost-effectiveness of delivering an online parent-led intervention, compared with usual school provision only, for children (aged 4-7) identified as at risk for anxiety disorders on the basis of at least one risk factor. We also aim to identify the characteristics of children who do and do not benefit from intervention and mechanisms of change from the intervention.Methods: The design will be a parallel group, superiority cluster randomised controlled trial, with schools (clusters) randomised to intervention or usual school practice arms in a 1:1 ratio stratified according to level of deprivation within the school. The study will recruit and randomise at least 60 primary/infant schools in England, and on the basis of recruiting 60 schools, we will recruit 1080 trial participants (540 per arm). Parents of all children (aged 4-7) in sampled Reception, Year 1, and Year 2 classes will be invited to complete screening questionnaires. Children who screen positive on the basis of anxiety symptoms, and/or behavioural inhibition, and/or parent anxiety symptoms will be eligible for the trial. Parents/carers of children in schools allocated to the intervention arm will be offered a brief online intervention; schools in both arms will continue to provide any usual support for children and parents throughout the trial. Assessments will be completed at screening, baseline (before randomisation), 6 weeks, 12 weeks, and 12 months post-randomisation. The primary outcome will be the absence/presence of an anxiety disorder diagnosis at 12 months.Discussion: The trial will determine if delivering an online intervention for parents of young children at risk of anxiety disorders identified through screening in schools is effective and cost-effective.Trial Registration: ISRCTN 82398107 . Prospectively registered on Jan. 14, 2021. [ABSTRACT FROM AUTHOR]

Abstract: In the UK, excessive levels of radon gas have been detected in domestic housing. Areas where 1% of existing homes were found to be over the Action Level of 200Bq·m−3 were declared to be Radon Affected Areas. Building Regulations have been introduced which require that, for areas where between 3% and 10% of existing houses are above the Action Level, new homes should be built with basic radon protection using a membrane, and that, where 10% or more of existing homes exceed this level, new homes should be built with full radon protection. Initially these affected areas followed administrative boundaries, known as Counties. However, with increasing numbers of measurements of radon levels in domestic homes recorded in the national database, these areas have been successively refined into smaller units – 5km grid squares in 1999, down to 1km grid squares in 2007. One result is the identification of small areas with raised radon levels within regions where previously no problem had been identified. In addition, some parts of areas that were previously considered radon affected are now considered low, or no, risk. Our analysis suggests that the net result of improved mapping is to increase the number of affected houses. Further, the process is more complex for local builders, and inspectors, who need to work out whether radon protection in new homes is appropriate. Our group has assessed the cost-effectiveness of radon remediation programmes, and has applied this analysis to consider the cost-effectiveness of providing radon protection in both new and existing homes. This includes modelling the potential failure rate of membranes, and whether testing radon levels in new homes is appropriate. The analysis concludes that it is more cost effective to provide targeted radon protection in high radon areas, although this introduces more complexity. The paper also considers the trend in housing to a greater proportion of apartments, the regional variations in types of housing and the decreasing average number of occupants in each dwelling, and concludes that data and methods are now available to respond to the health risks of radon at a local level, in keeping with a general initiative to prioritise responses to health and social welfare issues at a more local level. [Copyright &y& Elsevier]

Background: The novel coronavirus disease in 2019 (COVID-19) has placed unprecedented strain on healthcare providers, in particular, primary care services. General practitioners (GP) have to effectively manage patients remotely preserving social distancing. We aim to assess an app-based remote patient monitoring solution in reducing the workload of a clinician and reflect this as time-saved in an economic context. Primary care COVID patients in West London deemed medium risk were recruited into the virtual ward. Patients were monitored for 14 days by telephone or by both the Huma app and telephone. Information on number of phone calls, duration of phone calls and duration of time spent reviewing the app data was recorded. Results: The amount of time spent reviewing one patient in the telephone only arm of the study was 490 min, compared with 280 min spent reviewing one patient who was monitored via both the Huma app and telephone. Based on employed clinicians monitoring patients, this equates to a 0.04 reduction of full-time equivalent staffing I.e. for every 100 patients, it would require 4 less personnel to remotely monitor them. There was no difference in mortality or adverse events between the two groups. Conclusion: App-based remote patient monitoring potentially holds large economic benefit to COVID-19 patients. In wake of further waves or future pandemics, and even in routine care, app-based remote monitoring patients could free up vital resources in terms of clinical team's time, allowing a better reallocation of services. [ABSTRACT FROM AUTHOR]

Two studies examined whether rapport-based interviewing with child sexual abuse (CSA) suspects provides greater interview yield that could result in overall cost-savings to the investigation. First, multi-level modelling was applied to 35 naturalistic CSA suspect interviews to establish whether rapport-based interviewing techniques increase "yield" – defined as information of investigative value. The Observing Rapport Based Interviewing Technique (ORBIT coding manual was used to code interviews; it includes an assessment of both interpersonal adaptive and maladaptive rapport-based interviewer engagement as well as motivational interviewing (MI) strategies. The impact of these two strands (interpersonal and MI) on extracting information of investigative value (including strengthening a case for court and safeguarding) were examined. Adaptive interpersonal strategies increased case strengthening and safeguarding yield, with motivational interviewing having the largest impact on safeguarding yield. Both strategies increase the likelihood of gaining additional types of economic yield. Maladaptive interviewer strategies reduced case strengthening and different types of economic yield. In study two, literature-based economic estimates were applied to establish the potential cost benefits from following national ORBIT rapport training. Further training in adaptive and motivational interviewing could contribute cost savings between £19 and £78 million (annual unit costs) increasing to £238–£972 million (lifetime costs) for online CSA across England and Wales; and £157–£639 million (annual unit costs) increasing to £2–£8 billion (lifetime costs) for all CSA. Failure to commit training resource to this, or an alternative strategy, could mean the cost burden attributable to maladaptive interviewing (between £1 and £6 million for online CSA and £12 and £48 million for all CSA) is not successfully averted. [ABSTRACT FROM AUTHOR]

ObjectiveTo estimate the costs per relevant unit (pupils and meals) associated with improvements to school food and the potential economic and health gains that may result.DesignCalculation of costs per relevant unit (pupils and meals) based on (i) Department for Education expenditure to support improvements in school food, 2005–2011 and (ii) measures of the changes in the number of pupils taking school lunch and the number of meals served over the same time period; plus examples of the use of linked data to predict longer-term economic and health outcomes of healthier eating at school.SettingEngland.SubjectsLocal authorities, government departments and non-departmental public bodies.ResultsAnalysis of investment over a 6-year period indicates that costs of setting up and maintaining a change organization such as the School Food Trust were low in relation to short-term benefits in nutrition and behaviour. Models that predict long-terms gains to the exchequer and to quality-adjusted life years need further elaboration.ConclusionsModest levels of government investment in the delivery and promotion of healthier school food is likely to yield both short-term and long-term benefits in relation to nutrition, learning, economics and health. [ABSTRACT FROM PUBLISHER]

Background: With increased governmental interest in value assessment of technologies and where medical device manufacturers are finding it increasingly necessary to become more familiar with economic evaluation methods, the study sought to explore the levels of health economics knowledge within small and medium-sized enterprises (SMEs) and to scope strategies they employ to demonstrate the value of their products to purchasers. Methods: A short questionnaire was completed by participants attending one of five workshops on product development in the medical device sector that took place in England between 2007 and 2011. From all responses obtained, a large proportion of participants were based in SMEs (N = 43), and these responses were used for the analysis. Statistical analysis using non-parametric tests was performed on questions with approximately interval scales. Qualitative data from participant responses were analysed to reveal emerging themes. Results: The questionnaire results revealed that 60% of SME participants (mostly company directors or managers, including product or project managers) rated themselves as having low or no knowledge of health economics prior to the workshops but the rest professed at least medium knowledge. Clinical trials and cost analyses or cost-effectiveness studies were the most highly cited means by which SMEs aim to demonstrate value of products to purchasers. Purchasers were perceived to place most importance on factors of safety, expert opinion, cost-effectiveness and price. However many companies did not utilise formal decision-making tools to prioritise these factors. There was no significant dependence of the use of decision-making tools in general with respect to professed knowledge of health economics methods. SMEs did not state a preference for any particular aspect of potential value when deciding whether to develop a product. A majority of SMEs stated they would use a health economics tool. Research and development teams or marketing and sales departments would most likely use one. Conclusion: This study points to the need for further research into the education requirements of SMEs in the area of Health Technology Assessment (HTA) and also for investigation into how SMEs engage with existing HTA processes as required by assessors such as NICE. [ABSTRACT FROM AUTHOR]

This paper explores whether expert judgements can be taken as a proxy for citizen preferences for determining investment strategies for public goods. As an illustration, we focus on the provision of Public Rights Of Way (PROW) by Local Government Authorities in England. These provide rights of passage over property to those other than the owners, and little information is available on the welfare effects of changes in the provision and use of PROW. Given limited funds, reliance on expert judgement could be a cost effective alternative for decision-making compared with stated preference surveys of citizens. Two methods are compared. The Analytic Hierarchy Process (AHP) is used to elicit expert judgement to proxy citizen preferences for different attributes of PROW. The Choice Experiment (CE) technique is then used to derive preferences directly through personal interviews with citizens. Overall it was found that judicious use of AHP by experts can, in this instance, be used to represent citizen views. However, this result may not be easily generalisable to other settings. [Copyright &y& Elsevier]

We consider the activity-based costing situation, in which for each of several comparable operational units, multiple cost drivers generate a single cost pool. Our study focuses on published data from a set of property tax collection offices, called rates departments, for the London metropolitan area. We define what may be called benchmark or most efficient costs per unit of driver. A principle of maximum performance efficiency is proposed, and an approach to estimating the benchmark unit costs is derived from this principle. A validation approach for this estimation method is developed in terms of what we call normal-like-or-better performance effectiveness. Application to longitudinal data on a single unit is briefly discussed. We also consider some implications for the more routine case when costs are disaggregated to subpools associated with individual cost drivers. [ABSTRACT FROM AUTHOR]

River infrastructure can cause adverse impacts on fish populations, which, in turn, compromises the ability of river ecosystems to provide a range of ecosystem services. In this paper, we present a methodological approach to assess the potential economics costs and benefits of river connectivity enhancement achieved through removal and mitigation of fish dispersal barriers. Our approach combines the results of a stated preference study for nonuse values of rivers and statistical models of fish population responses to barrier mitigation actions within an integrated bioeconomic optimization framework. We demonstrate the utility of our methodology using a case study of the River Wey catchment in southeast England, which contains over 650 artificial barriers. Our results reveal the presence of benefit-cost trade-offs which can form the basis for river barrier mitigation policy development. In particular, we find that benefits exceed costs in the River Wey for all levels of investment in barrier mitigation considered (£2.5 to 53.4 M). Furthermore, from an economic efficiency standpoint, a total budget of approximately £22.5M allocated to barrier mitigation would maximize net societal benefits derived from anticipated increases fish species richness and abundance. • We present an integrated approach to examine costs & benefits of river restoration. • We develop and employ a novel mixed integer linear program to integrate all data. • We derive optimal economic solutions for river barrier mitigation actions. • Our integrated framework enables practical application of cost benefit analysis. [ABSTRACT FROM AUTHOR]

Objective: To assess implementation of the Saving Babies Lives (SBL) Care Bundle, a collection of practice recommendations in four key areas, to reduce stillbirth in England. Design: A retrospective cohort study of 463,630 births in 19 NHS Trusts in England using routinely collected electronic data supplemented with case note audit (n = 1,658), and surveys of service users (n = 2,085) and health care professionals (n = 1,064). The primary outcome was stillbirth rate. Outcome rates two years before and after the nominal SBL implementation date were derived as a measure of change over the implementation period. Data were collected on secondary outcomes and process outcomes which reflected implementation of the SBL care bundle. Results: The total stillbirth rate, declined from 4.2 to 3.4 per 1,000 births between the two time points (adjusted Relative Risk (aRR) 0.80, 95% Confidence Interval (95% CI) 0.70 to 0.91, P<0.001). There was a contemporaneous increase in induction of labour (aRR 1.20 (95%CI 1.18–1.21), p<0.001) and emergency Caesarean section (aRR 1.10 (95%CI 1.07–1.12), p<0.001). The number of ultrasound scans performed (aRR 1.25 (95%CI 1.21–1.28), p<0.001) and the proportion of small for gestational age infants detected (aRR 1.59 (95%CI 1.32–1.92), p<0.001) also increased. Organisations reporting higher levels of implementation had improvements in process measures in all elements of the care bundle. An economic analysis estimated the cost of implementing the care bundle at ~£140 per birth. However, neither the costs nor changes in outcomes could be definitively attributed to implementation of the SBL care bundle. Conclusions: Implementation of the SBL care bundle increased over time in the majority of sites. Implementation was associated with improvements in process outcomes. The reduction in stillbirth rates in participating sites exceeded that reported nationally in the same timeframe. The intervention should be refined to identify women who are most likely to benefit and minimise unwarranted intervention. Trial registration: The study was registered on (NCT03231007); www.clinicaltrials.gov. [ABSTRACT FROM AUTHOR]

Objective: To determine the cost-utility of a multi-professional simulation training programme for obstetric emergencies–Practical Obstetric Multi-Professional Training (PROMPT)–with a particular focus on its impact on permanent obstetric brachial plexus injuries (OBPIs). Design: A model-based cost-utility analysis. Setting: Maternity units in England. Population: Simulated cohorts of individuals affected by permanent OBPIs. Methods: A decision tree model was developed to estimate the cost-utility of adopting annual, PROMPT training (scenario 1a) or standalone shoulder dystocia training (scenario 1b) in all maternity units in England compared to current practice, where only a proportion of English units use the training programme (scenario 2). The time horizon was 30 years and the analysis was conducted from an English National Health Service (NHS) and Personal Social Services perspective. A probabilistic sensitivity analysis was performed to account for uncertainties in the model parameters. Main outcome measures: Outcomes for the entire simulated period included the following: total costs for PROMPT or shoulder dystocia training (including costs of OBPIs), number of OBPIs averted, number of affected adult/parental/dyadic quality adjusted life years (QALYs) gained and the incremental cost per QALY gained. Results: Nationwide PROMPT or shoulder dystocia training conferred significant savings (in excess of £1 billion ($1.5 billion)) compared to current practice, resulting in cost-savings of at least £1 million ($1.5 million) per any type of QALY gained. The probabilistic sensitivity analysis demonstrated similar findings. Conclusion: In this model, national implementation of multi-professional simulation training for obstetric emergencies (or standalone shoulder dystocia training) in England appeared to both be cost-saving when evaluating their impact on permanent OBPIs. [ABSTRACT FROM AUTHOR]

The paper develops a cost frontier model of electricity distribution and estimates it on data for the 12 regional electricity companies of England and Wales. It is found that some significant cost drivers in cross-section estimation are insignificant when the model is estimated on panel data, highlighting the well-known drawbacks of cross-section estimation. Panel data estimation suggests that the main determinants of distribution operating costs are the number of customers in the area and simultaneous maximum demand. These results and the efficiency rankings of the companies are not sensitive to changes in error distribution assumptions and sample size. There is also significant evidence of economies of scale. There is a small but significant effect on cost efficiency from privatization, but this is as likely to be due to the changes in accounting policies at the time of privatization as any real effect. [ABSTRACT FROM AUTHOR]

Background: The NHS Health Check Programme is a risk-reduction programme offered to all adults in England aged 40-74 years. Previous studies mainly focused on patient perspectives and programme delivery; however, delivery varies, and costs are substantial. We were therefore working with key stakeholders to develop and co-produce an NHS Health Check Programme modelling tool (workHORSE) for commissioners to quantify local effectiveness, cost-effectiveness, and equity. Here we report on Workshop 1, which specifically aimed to facilitate engagement with stakeholders; develop a shared understanding of current Health Check implementation; identify what is working well, less well, and future hopes; and explore features to include in the tool.Methods: This qualitative study identified key stakeholders across the UK via networking and snowball techniques. The stakeholders spanned local organisations (NHS commissioners, GPs, and academics), third sector and national organisations (Public Health England and The National Institute for Health and Care Excellence). We used the validated Hovmand "group model building" approach to engage stakeholders in a series of pre-piloted, structured, small group exercises. We then used Framework Analysis to analyse responses.Results: Fifteen stakeholders participated in workshop 1. Stakeholders identified continued financial and political support for the NHS Health Check Programme. However, many stakeholders highlighted issues concerning lack of data on processes and outcomes, variability in quality of delivery, and suboptimal public engagement. Stakeholders' hopes included maximising coverage, uptake, and referrals, and producing additional evidence on population health, equity, and economic impacts. Key model suggestions focused on developing good-practice template scenarios, analysis of broader prevention activities at local level, accessible local data, broader economic perspectives, and fit-for-purpose outputs.Conclusions: A shared understanding of current implementations of the NHS Health Check Programme was developed. Stakeholders demonstrated their commitment to the NHS Health Check Programme whilst highlighting the perceived requirements for enhancing the service and discussed how the modelling tool could be instrumental in this process. These suggestions for improvement informed subsequent workshops and model development. [ABSTRACT FROM AUTHOR]

Background: Post-traumatic stress disorder (PTSD) is a severe and disabling condition that may lead to functional impairment and reduced productivity. Psychological interventions have been shown to be effective in its management. The objective of this study was to assess the cost-effectiveness of a range of interventions for adults with PTSD. Methods: A decision-analytic model was constructed to compare costs and quality-adjusted life-years (QALYs) of 10 interventions and no treatment for adults with PTSD, from the perspective of the National Health Service and personal social services in England. Effectiveness data were derived from a systematic review and network meta-analysis. Other model input parameters were based on published sources, supplemented by expert opinion. Results: Eye movement desensitisation and reprocessing (EMDR) appeared to be the most cost-effective intervention for adults with PTSD (with a probability of 0.34 amongst the 11 evaluated options at a cost-effectiveness threshold of £20,000/QALY), followed by combined somatic/cognitive therapies, self-help with support, psychoeducation, selective serotonin reuptake inhibitors (SSRIs), trauma-focused cognitive behavioural therapy (TF-CBT), self-help without support, non-TF-CBT and combined TF-CBT/SSRIs. Counselling appeared to be less cost-effective than no treatment. TF-CBT had the largest evidence base. Conclusions: A number of interventions appear to be cost-effective for the management of PTSD in adults. EMDR appears to be the most cost-effective amongst them. TF-CBT has the largest evidence base. There remains a need for well-conducted studies that examine the long-term clinical and cost-effectiveness of a range of treatments for adults with PTSD. [ABSTRACT FROM AUTHOR]

Background: Although Positive Behaviour Support (PBS) is a widely used intervention for ameliorating challenging behaviour (CB), evidence for its use in adults with intellectual disability (ID) and comorbid autism (ASD) is lacking. We report a planned subsidiary analysis of adults with both ASD and ID who participated in a randomised trial of PBS delivered by health professionals. Methods: The study was a multicentre, cluster randomised trial conducted in 23 community ID services in England, participants were randomly allocated to either the delivery of PBS (n = 11 clusters) or to treatment as usual (TAU; n = 12). One-hundred and thirteen participants (46% of all participants in the trial) had a diagnosis of ID, autism spectrum disorder and CB (ASD+); (47 allocated to the intervention arm, and 66 to the control). CB (primary outcome) was measured with the Aberrant Behaviour Checklist total score (ABC-CT). Secondary outcomes included mental health status, psychotropic medication use, health and social care costs and quality adjusted life years (QALYs) over 12 months. Results: There were no statistically significant differences in ABC-CT between ASD+ groups randomised to the two arms over 12 months (adjusted mean difference = − 2.10, 95% CI: − 11.3 7.13, p = 0.655) or other measures. The mean incremental cost of the intervention per participant was £628 (95% CI -£1004 to £2013). There was a difference of 0.039 (95% CI − 0.028 to 0.103) for QALYs and a cost per QALY gained of £16,080. Conclusions: Results suggest lack of clinical effectiveness for PBS delivered by specialist ID clinical teams. Further evidence is needed from larger trials, and development of improved interventions. Trial registration: ClinicalTrials.gov: NCT01680276. [ABSTRACT FROM AUTHOR]

Background: Human papillomavirus (HPV) infection is a pre-requisite for cervical cancer, which represents the third most common cancer among women worldwide. A causal relationship also exists between HPV and cancer in other areas of the female reproductive system including the vagina and vulva. Whilst the incidence of vaginal cancer in the UK has remained relatively stable over the past 25 years, vulval cancer rates are increasing. A body of literature exists on the epidemiology and aetiology of vaginal and vulval cancer, but little is known about the economic burden. The objective of this study was to quantify the costs of treating these cancers on the National Health Service (NHS) in England.Methods: Inpatient and outpatient episodes were derived from Hospital Episode Statistics (HES). Health Resource Group (HRG) tariffs and National Reference Costs were used to estimate the cost of treating pre-cancerous and invasive vaginal and vulval lesions in England.Results: The study showed that for the 5 years from 2009/2010 to 2014/2015 the total cost associated with pre-cancerous and invasive vaginal and vulval lesions was over £14 million per year on average (95% of which was attributed to inpatient costs). Vulval cancer accounted for the largest proportion; an estimated 60% of the total cost (£8.82 million). On average 4316 patients per year in England were admitted to hospital and 912 patients attended outpatient settings for pre-cancerous and invasive disease of the vagina and vulva.Conclusion: The results indicate that vaginal and vulval cancer cost the English health care system over £14 million per year. Given the causal role of HPV in a proportion of these cancers, preventative measures such as the national HPV immunisation programme have the potential to reduce the economic burden. To ensure optimal use of NHS resources, it is important that future economic evaluations of such preventative measures consider the full burden of HPV related disease. [ABSTRACT FROM AUTHOR]

Background: Children with intellectual disabilities are likely to present with challenging behaviour. Parent mediated interventions have shown utility in influencing child behaviour, although there is a paucity of UK research into challenging behaviour interventions in this population. NICE guidelines favour Stepping Stones Triple P (SSTP) as a challenging behaviour intervention and this trial aims to evaluate its clinical and cost effectiveness in preschool children with moderate to severe intellectual disabilities. Methods: This trial launched in 2017 at four sites across England, with the aim of recruiting 258 participants (aged 30–59 months). The Intervention Group receive nine weeks of SSTP parenting therapy (six group sessions and three individualised face to face or telephone sessions) in addition to Treatment as Usual, whilst the Treatment as Usual only group receive other available services in each location. Both study groups undergo the study measurements at baseline and at four and twelve months. Outcome measures include parent reports and structured observations of behaviour. Service use and health related quality of life data will also be collected to carry out a cost effectiveness and utility evaluation. Discussion: Findings from this study will inform policy regarding interventions for challenging behaviour in young children with moderate to severe intellectual disabilities. Trial registration number: Clinicaltrials.gov, NCT03086876. Registered 22nd March 2017, https://clinicaltrials.gov/ct2/show/NCT03086876. [ABSTRACT FROM AUTHOR]

Background: We have previously modelled that the optimal number of comprehensive stroke centres (CSC) providing endovascular thrombectomy (EVT) in England would be 30 (net 6 new centres). We now estimate the relative effectiveness and cost-effectiveness of increasing the number of centres from 24 to 30.Methods: We constructed a discrete event simulation (DES) to estimate the effectiveness and lifetime cost-effectiveness (from a payer perspective) using 1 year's incidence of stroke in England. 2000 iterations of the simulation were performed comparing baseline 24 centres to 30.Results: Of 80,800 patients admitted to hospital with acute stroke/year, 21,740 would be affected by the service reconfiguration. The median time to treatment for eligible early presenters (< 270 min since onset) would reduce from 195 (IQR 155-249) to 165 (IQR 105-224) minutes. Our model predicts reconfiguration would mean an additional 33 independent patients (modified Rankin scale [mRS] 0-1) and 30 fewer dependent/dead patients (mRS 3-6) per year. The net addition of 6 centres generates 190 QALYs (95%CI - 6 to 399) and results in net savings to the healthcare system of £1,864,000/year (95% CI -1,204,000 to £5,017,000). The estimated budget impact was a saving of £980,000 in year 1 and £7.07 million in years 2 to 5.Conclusion: Changes in acute stroke service configuration will produce clinical and cost benefits when the time taken for patients to receive treatment is reduced. Benefits are highly likely to be cost saving over 5 years before any capital investment above £8 million is required. [ABSTRACT FROM AUTHOR]

Background Depressed patients often focus on negative life events. Effective antidepressant therapy reverses this negative emotional bias (NEB) within 1 week. Clinical therapeutic effect usually requires 4-6 weeks. The value of implementing NEB monitoring for the personalisation of antidepressant therapy is unknown. Objective To estimate the likely outcome and cost consequences of adopting the P1vital Oxford Emotional Test Battery (ETB) for this purpose in routine primary care in England. Methods A hybrid decision analytic model (decision tree plus Markov model) was developed to estimate the cost-effectiveness of ETB monitoring versus no ETB over 52 weeks using quality-adjusted life years (QALYs). Differences in depression severity, episode type and analytical perspectives were considered. Input data were derived from relevant guidelines, literature, national databases, expert opinion and the developers for the year 2013. Multiple sensitivity analyses addressed uncertainty. Findings The mean number of ETB tests is 2.162 per newly diagnosed patient and 2.166 per patient with recurrent depression. The incremental cost-effectiveness of ETB versus 'no ETB' is £4355/QALY from the healthcare perspective. From the broader societal perspective, ETB is more effective and cost saving. Conclusions Monitoring negative emotional bias in primary care in England for personalised antidepressant treatment using ETB seems as an effective and cost-effective option under all considered scenarios (including worst case). Its main economic value seems to lie in reduced productivity loss as opposed to healthcare savings. Clinical implications The test supports accelerated application of evidence-based depression care. Further optimisation and implementation in the ongoing European PReDicT trial is ongoing. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

The article discusses a study question of what is the cost effectiveness of vaccinating people with high risk conditions for invasive pneumococcal disease with the 13 valent pneumococcal conjugate vaccine. If the vaccine does not offer protection against nonbacteraemic pneumococcal pneumonia then it is unlikely to be considered cost effective. The results show that the timing of such a programme in relation to the introduction of infant immunisation with this vaccine is important.

Background: Despite the relative ease with which breech presentation can be identified through ultrasound screening, the assessment of foetal presentation at term is often based on clinical examination only. Due to limitations in this approach, many women present in labour with an undiagnosed breech presentation, with increased risk of foetal morbidity and mortality. This study sought to determine the cost effectiveness of universal ultrasound scanning for breech presentation near term (36 weeks of gestational age [wkGA]) in nulliparous women.Methods and Findings: The Pregnancy Outcome Prediction (POP) study was a prospective cohort study between January 14, 2008 and July 31, 2012, including 3,879 nulliparous women who attended for a research screening ultrasound examination at 36 wkGA. Foetal presentation was assessed and compared for the groups with and without a clinically indicated ultrasound. Where breech presentation was detected, an external cephalic version (ECV) was routinely offered. If the ECV was unsuccessful or not performed, the women were offered either planned cesarean section at 39 weeks or attempted vaginal breech delivery. To compare the likelihood of different mode of deliveries and associated long-term health outcomes for universal ultrasound to current practice, a probabilistic economic simulation model was constructed. Parameter values were obtained from the POP study, and costs were mainly obtained from the English National Health Service (NHS). One hundred seventy-nine out of 3,879 women (4.6%) were diagnosed with breech presentation at 36 weeks. For most women (96), there had been no prior suspicion of noncephalic presentation. ECV was attempted for 84 (46.9%) women and was successful in 12 (success rate: 14.3%). Overall, 19 of the 179 women delivered vaginally (10.6%), 110 delivered by elective cesarean section (ELCS) (61.5%) and 50 delivered by emergency cesarean section (EMCS) (27.9%). There were no women with undiagnosed breech presentation in labour in the entire cohort. On average, 40 scans were needed per detection of a previously undiagnosed breech presentation. The economic analysis indicated that, compared to current practice, universal late-pregnancy ultrasound would identify around 14,826 otherwise undiagnosed breech presentations across England annually. It would also reduce EMCS and vaginal breech deliveries by 0.7 and 1.0 percentage points, respectively: around 4,196 and 6,061 deliveries across England annually. Universal ultrasound would also prevent 7.89 neonatal mortalities annually. The strategy would be cost effective if foetal presentation could be assessed for £19.80 or less per woman. Limitations to this study included that foetal presentation was revealed to all women and that the health economic analysis may be altered by parity.Conclusions: According to our estimates, universal late pregnancy ultrasound in nulliparous women (1) would virtually eliminate undiagnosed breech presentation, (2) would be expected to reduce foetal mortality in breech presentation, and (3) would be cost effective if foetal presentation could be assessed for less than £19.80 per woman. [ABSTRACT FROM AUTHOR]

Aim and Background: In the absence of data providing an overview on the state of the assistant practitioner (AP) workforce, this study surveys trusts in NHS England with the aim of establishing how the role is viewed, used and managed. Methods: Based on an earlier survey undertaken around a decade ago, an online questionnaire was sent to members of an assistant practitioner network, generating a response from over fifty different trusts, drawn from different regions and health care settings. Results: The survey results highlight the increased use of assistant practitioners by trusts and in a more diverse range of clinical settings. This increase has been driven more by the apparent value of the APs in addressing issues of service design and quality, than by attempts to reduce costs through substitution and skill mix dilution. Conclusions: The AP role has retained value to nurse managers in developing and designing services, and indeed in establishing a career pathway for health care assistants. Most striking are future intentions to continue using APs, particularly within the context of the emerging nursing associate (NA) role. This suggests that the AP and NA are likely to be complementary rather than alternative roles. Implications for Nursing Managers: Nurse managers might note the continuing use and value of the AP role, although as a means of improving design and quality as well as providing career opportunities for health care assistants, rather than as a way of saving labour costs. Clearly, the AP role has a future although there is scope to review its position in relation to the newly emerging nursing associate role. [ABSTRACT FROM AUTHOR]

Objective To assess the cost-effectiveness of strategies to increase cervical cancer screening uptake at first invitation (STRATEGIC trial). Methods We performed an economic analysis alongside the STRATEGIC trial, comparing each of seven novel interventions for improving cervical screening uptake with control general practices in Greater Manchester and Grampian (United Kingdom). A template was developed to measure the intervention costs. Trial estimates of screening uptake were combined with data from the literature to estimate healthcare costs of each intervention. The added lifetime costs and quality adjusted life years (QALYs) of attending cervical screening were estimated by a systematic literature review, with relevant results pooled and weighted by study quality. Trial results and estimated lifetime costs and benefits of screening were then combined in a decision analytic model, giving an incremental cost per QALY gained for each intervention. Uncertainty was addressed in probabilistic and univariate sensitivity analyses. Results Intervention costs per screening round per woman attending varied from about £1.20 (2014 UK) for the nurse navigator intervention to £62 for the unrequested HPV self-sampler kit. The meta-analysis revealed a lifetime discounted benefit from screening of 0.043 QALYs per woman attending, at an additional lifetime discounted cost of £234. The incremental cost per QALY gained in all interventions was below £13,000. Probabilistic sensitivity analyses suggested that only unrequested self-sampling and timed appointments have a high probability of being cost-effective. Conclusions Unrequested self-sampling and timed appointments are likely to be cost-effective interventions. Further research is required on the duration of effects and on implementing combinations of interventions. [ABSTRACT FROM AUTHOR]

Introduction Coronary heart disease (CHD) remains a leading cause of UK mortality. Dietary trans fats (TFA) represent a powerful CHD risk factor. However, UK efforts to reduce intake have been less successful than other nations. We modelled the potential health and economic effects of eliminating industrial and all TFA up to 2020. Methods We extended the previously validated IMPACTsec model, to estimate the potential effects on health and economic outcomes of mandatory reformulation or a complete ban on dietary TFA in England and Wales from 2011 to 2020. We modelled two policy scenarios: 1) Elimination of industrial TFA consumption, from 0.8% to 0.4% daily energy 2) Elimination of all TFA consumption, from 0.8% to 0% Results Elimination of industrial TFA across the England and Wales population could result in approximately 1600 fewer deaths per year, with some 4000 fewer hospital admissions; gaining approximately 14 000 additional life years. Health inequalities would be substantially reduced in both scenarios. Elimination of industrial TFA would be cost saving. This would include approximately £100m saved in direct healthcare costs. Elimination of all TFA would double the health and economic gains. Conclusions Eliminating industrial or all UK dietary intake of TFA could substantially reduce CHD mortality and inequalities, while resulting in substantial annual savings. [ABSTRACT FROM AUTHOR]