Protocol for a pragmatic feasibility randomised controlled trial of peer coaching for adults with long-term conditions: PEER CONNECT.

INTRODUCTION: Patients with low levels of knowledge, skills and confidence to manage their health and well-being (activation) are more likely to have unmet health needs, delay seeking healthcare and need emergency care. National Health Service England estimates that this may be applicable to 25%-40% of patients with long-term health conditions. Volunteer peer coaching may support people to increase their level of activation. This form of intervention may be particularly effective for people with low levels of activation. METHODS AND ANALYSIS: This single site, two-arm randomised controlled trial has been designed to assess the feasibility of conducting a definitive trial of volunteer peer health and well-being coaching for people with long-term health conditions (multiple sclerosis, rheumatic diseases or chronic pain) and low activation. Feasibility outcomes include recruitment and retention rates, and intervention adherence. We will measure patient activation, mental health and well-being as potential outcomes for a definitive trial. These outcomes will be summarised descriptively for each time point by allocated group and help to inform sample size calculation for the definitive trial. Criteria for progression to a full trial will be used. ETHICS AND DISSEMINATION: Ethical approval has been granted by the London - Surrey Research Ethics Committee, reference 21/LO/0715. Results from this feasibility trial will be shared directly with participants, presented at local, regional and national conferences and published in an open-access journal. TRIAL REGISTRATION NUMBER: ISRCTN12623577.

Effectiveness of a targeted telephone-based case management service on activity in an Emergency Department in the UK: a pragmatic difference-in-differences evaluation.

BACKGROUND: This study evaluates the effectiveness of a targeted telephone-based case management service that aimed to reduce ED attendance amongst frequent attenders, known to disproportionately contribute to demand. Evidence on the effectiveness of these services varies. METHODS: A 24-month controlled before-and-after study, following 808 patients (128 cases and 680 controls (41 were non-compliant)) who were offered the service in the first four months of operation within a UK ED department. Patients stratified as high-risk of reattending ED within 6 months by a predictive model were manually screened. Those positively reviewed were offered a non-clinical, nurse-led, telephone-based health coaching, consisting of care planning, coordination and goal setting for up to 9 months. Service effectiveness was estimated using a difference-in-differences (DiD) analysis. Incident rate of ED and Minor Injury Unit (MIU) attendances and average length of stay in intervention recipients and controls over 12 months after receiving their service offer following ED attendance were compared, adjusting for the prior 12-month period, sex and age, to give an incidence rate ratio (IRR). RESULTS: Intervention recipients were more likely to be female (63.3% versus 55.4%), younger (mean of 69 years versus 76 years), and have higher levels of ED activity (except for MIU) than controls. Mean rates fell between periods for all outcomes (except for MIU attendance). The Intention-to-Treat analysis indicated non-statistically significant effect of the intervention in reducing all outcomes, except for MIU attendances, with IRRs: ED attendances, 0.856 (95% CI: 0.631, 1.160); ED admissions, 0.871 (95% CI: 0.628, 1.208); length of stay for emergency and elective admissions: 0.844 (95% CI: 0.619, 1.151) and 0.781 (95% CI: 0.420, 1.454). MIU attendance increased with an IRR: 2.638 (95% CI: 1.041, 6.680). CONCLUSIONS: Telephone-based health coaching appears to be effective in reducing ED attendances and admissions, with shorter lengths of stay, in intervention recipients over controls. Future studies need to capture outcomes beyond acute activity, and better understand how services like this provide added value.

Impact of COVID-19 on social prescribing across an Integrated Care System: A Researcher in Residence study.

Emerging evidence suggests that connecting people to non-medical activities in the community (social prescribing) may relieve pressure on services by promoting autonomy and resilience, thereby improving well-being and self-management of health. This way of working has a long history in the voluntary and community sector but has only recently been widely funded by the National Health Service (NHS) in England and implemented in Primary Care Networks (PCNs). The COVID-19 global pandemic coincided with this new service. There is wide variation in how social prescribing is implemented and scant evidence comparing different delivery models. As embedded researchers within an Integrated Care System in the Southwest of England, we examined the impact of COVID on the implementation of social prescribing in different employing organisations during the period March 2020 to April 2021. Data were collected from observations and field notes recorded during virtual interactions with over 80 social prescribing practitioners and an online survey of 52 social prescribing practitioners and middle managers. We conceptualise social prescribing as a pathway comprising access, engagement and activities, facilitated by workforce and community assets and strategic partnerships. We found that these elements were all impacted by the pandemic, but to different degrees according to the way the service was contracted, whether referrals (access) and approach (engagement) were universal ('open') or targeted ('boundaried') and the extent to which practitioners' roles were protected or shifted towards immediate COVID-specific work. Social prescribers contracted in PCNs were more likely to operate an 'open' model, although boundaries were developing over time. We suggest the presence of an explicit, agreed delivery model (whether 'open' or 'boundaried') might create a more coherent approach less likely to result in practitioner role drift, whilst allowing flexibility to adjust to the pandemic and enhancing practitioner satisfaction and well-being. The potential consequences of different models are examined.

Impact of 'Enhanced' Intermediate Care Integrating Acute, Primary and Community Care and the Voluntary Sector in Torbay and South Devon, UK.

Introduction: Intermediate care (IC) was redesigned to manage more complex, older patients in the community, avoid admissions and facilitate earlier hospital discharge. The service was 'enhanced' by employing GPs, pharmacists and the voluntary sector to be part of a daily interdisciplinary team meeting, working alongside social workers and community staff (the traditional model). Methods: A controlled before-and-after study, using mixed methods and a nested case study. Enhanced IC in one locality (Coastal) is compared with four other localities where IC was not enhanced until the following year (controls), using system-wide performance data (N = 4,048) together with ad hoc data collected on referral-type, staff inputs and patient experience (N = 72). Results: Coastal showed statistically significant increase in EIC referrals to 11.6% (95%CI: 10.8%-12.4%), with a growing proportion from GPs (2.9%, 95%CI: 2.5%-3.3%); more people being cared for at home (10.5%, 95%CI: 9.8%-11.2%), shorter episode lengths (9.0 days, CI 95%: 7.6-10.4 days) and lower bed-day rates in ≥70 year-olds (0.17, 95%CI: 0.179-0.161). The nested case study showed medical, pharmacist and voluntary sector input into cases, a more holistic, coordinated service focused on patient priorities and reduced acute hospital admissions (5.5%). Discussion and conclusion: Enhancing IC through greater acute, primary care and voluntary sector integration can lead to more complex, older patients being managed in the community, with modest impacts on service efficiency, system activity, and notional costs off-set by perceived benefits.

Capturing the Role of Context in Complex System Change: An Application of the Canadian Context and Capabilities for Integrating Care (CCIC) Framework to an Integrated Care Organisation in the UK.

INTRODUCTION: If integrated care approaches are to be properly adapted to local contexts, a better understanding is required of key determinants of implementation and how these might be appropriately supported. PURPOSE: This study applied the Canadian Context and Capabilities for Integrating Care (CCIC) Framework to investigate factors influencing the implementation and outcomes of a complex integrated care change programme in Torbay and South Devon (TSD) and, more specifically, in one of five sub-localities, Coastal. METHODS: A case study method using embedded 'Researchers in Residence' to conduct action-based participatory research and deploying mixed qualitative methods. RESULTS: The relative importance of some domains differ between the English and Canadian studies. In this case study, physical features (structural and geographic) were found to be very pertinent to the relative success of the Coastal Locality, as were empowered clinical leadership, with readiness for change being expressed through processes and cultures that were risk-enabling, strengths-based, person-/outcome-focused. CONCLUSIONS: The CCIC Framework provided a useful tool capturing key elements of complex system change with key domains being transferable across settings, while also finding local variation in the UK. This would encourage its wider application so that further comparisons can be made of the ways in which different contextual and implementation properties impact upon delivery and outcomes.

Does a social prescribing 'holistic' link-worker for older people with complex, multimorbidity improve well-being and frailty and reduce health and social care use and costs? A 12-month before-and-after evaluation.

AIM: To evaluate the impact of 'holistic' link-workers on service users' well-being, activation and frailty, and their use of health and social care services and the associated costs. BACKGROUND: UK policy is encouraging social prescribing (SP) as a means to improve well-being, self-care and reduce demand on the NHS and social services. However, the evidence to support this policy is generally weak and poorly conceptualised, particularly in relation to frail, older people and patient activation. Torbay and South Devon NHS Foundation Trust, an integrated care organisation, commissioned a Well-being Co-ordinator service to support older adults (≥50 years) with complex health needs (≥2 long-term conditions), as part of its service redesign. METHODS: A before-and-after study measuring health and social well-being, activation and frailty at 12 weeks and primary, community and secondary care service use and cost at 12 months prior and after intervention. FINDINGS: Most of the 86 participants achieved their goals (85%). On average health and well-being, patient activation and frailty showed a statistically significant improvement in mean score. Mean activity increased for all services (some changes were statistically significant). Forty-four per cent of participants saw a decrease in service use or no change. Thirteen high-cost users (>£5000 change in costs) accounted for 59% of the overall cost increase. This was largely due to significant, rapid escalation in morbidity and frailty. Co-ordinators played a valuable key-worker role, improving the continuity of care, reducing isolation and supporting carers. No entry-level participant characteristic was associated with change in well-being or service use. Larger, better conceptualised, controlled studies are needed to strengthen claims of causality and develop national policy in this area.

Transforming Urgent and Emergency Care and the Vanguard Initiative: Learning from Evaluation of the Southern Cluster.

Urgent and Emergency Care (UEC) vanguards aim to improve the quality, efficiency and effectiveness of UEC services so that patients receive the most appropriate care at the right time and in the right place, and so that unnecessary admissions to accident and emergency (A&E) and hospitals are reduced. The Southern Cluster comprises three such UEC vanguards. RAND Europe's evaluation examined the impacts of the vanguards, the processes underpinning delivery (and associated enablers and challenges), and implications for future policy and practice. The evaluation used a multi-method approach, including theories of change, document review, workshops, interviews, surveys and data dashboards. The Southern Cluster UEC vanguards have made progress across core activities. Clinical hubs are operational across the sites. Direct booking capacity into primary care is progressing more with out-of-hours than with in-hours services. Gradual but variable progress has been made towards joint planning and governance of UEC services. Efforts to ensure seamless data sharing between providers, and interoperable IT infrastructure are progressing somewhat slower than originally hoped. Vanguard funding, committed leadership and practical mechanisms to support joint working helped drive progress. Public engagement, workforce-capacity and data interoperability will need to be addressed for longer-term impact at scale. The study makes recommendations concerning: (i) UEC health and care workforce capacity-building, (ii) local-national coordination around UEC transformation, (iii) collaboration across localities and professions, (iv) support for an end-to-end UEC pathway with mutually reinforcing activities, (v) cost and outcome data, (vi) an interoperable data infrastructure, and (vii) capacity for evaluation and learning.

Public health implications of establishing a national programme to screen young athletes in the UK.

OBJECTIVES: To assess how much competitive sport contributes to sudden cardiac death (SCD) in young athletes and the impact on population health if this group were to be screened in the UK. METHODS: Using reported and imputed incidence rates of SCD in athletes and non-athletes and false-negative and false-positive test rates reported in three key Italian screening studies, the authors calculated the population and attributable risk fractions of SCD in young athletes and the total population (athletes and non-athletes) aged 12-35 years before and after screening; the number of athletes needed to screen (NNS) to prevent one SCD and the sensitivity and the specificity of screening with electrocardiogram. Using these parameters, the authors developed a decision tree model based on the UK population aged 12-35 years to estimate the annual number of SCDs, the expected number of screening and diagnostic tests and the number of athletes disqualified from competitive sport per SCD prevented. RESULTS: Participation in competitive athletics contributes to 81.9% (62.4% to 91.6%) of SCD in athletes but only 26.6% (-20.3% to 55.8%) in the total population. After screening, the contribution in the total population falls to 7.2% (-10.7% to 22.4%). The NNS is 38 151 (20 534 to 267 380). A UK screening programme would result in 1 520 021 young athletes being screened, with 140 361 referred for diagnosis. Of an expected 196 SCDs per year, 40 (6 to 74) would be prevented. For every life saved, 791 athletes would be disqualified. CONCLUSIONS: The impact of screening on reducing SCD in young athletes is only modest and would be achieved with significant harms to population health.

Do metronomes improve the quality of life in people with Parkinson's disease? A pragmatic, single-blind, randomized cross-over trial.

OBJECTIVE: To evaluate the effect of acoustic cueing using metronomes on the quality of life of people with moderate to severe Parkinson's disease. STUDY DESIGN: Pragmatic, single-blind, randomized cross-over trial. PARTICIPANTS: Forty-two people aged 50-85 years, in Hoehn and Yahr stage II-IV and on stable medication. Eight were lost to follow-up. INTERVENTION: Participants were randomized using concealed allocation to either an early group (n = 21) to receive an electronic metronome without therapy but limited support (5-10 minutes instruction and on-demand telephone assistance) for four weeks, or a late group (n = 21) to receive the same intervention at 10 weeks. In both groups the beat frequency was initially set to be comfortable for walking. OUTCOMES MEASURES: Primary and secondary outcomes were measured at baseline, 4, 10 and 14 weeks using the Parkinson's Disease Questionnaire 39 (PDQ-39), the Short Form 36 version 2 (SF-36 version 2) and a falls diary. RESULTS: There were positive effects in six domains of the SF-36 version 2 and eight domains of the PDQ-39, although only one mean difference was clinically important: the role limitation (emotional) domain of SF-36 version 2 (a mean difference of 3.77, 95% confidence interval (CI), -2.68 to 10.22), a secondary outcome. None of these changes were statistically significant. There were no statistically significant differences in falls rates over the study period. Ten participants (24%) wanted to continue with their metronomes at the end of the study. CONCLUSION: To demonstrate metronomes are beneficial on the role limitation domain of the SF-36 version 2 in people with moderate to severe Parkinson's disease a sample size of 600 would be required.

Use of surrogate outcomes in cost-effectiveness models: a review of United Kingdom health technology assessment reports.

OBJECTIVES: The aim of this study was to explore the use of surrogate outcomes--a substitute outcome that predicts final patient-related outcomes--in cost-effectiveness models (CEM) within health technology assessment (HTA) reports and provide guidance for their future use. METHODS: Our sampling frame was all UK HTA Program monograph series reports published in 2005 and 2006. Reports were included if they addressed a treatment effectiveness/efficacy question and included a CEM based on a surrogate outcome. The two authors independently applied inclusion and exclusion criteria, and the following data was extracted from included reports: source of surrogate outcome, level of evidence for validation of the surrogate outcomes, methods used in report to quantify link between surrogate outcome and final outcome, and consideration of the uncertainty associated with using surrogate outcomes in the results or conclusions of report. RESULTS: Of 100 HTA reports, 35 complied with the inclusion criteria. Of these, four (11 percent) reports included a CEM based on a surrogate outcome. All four reports sourced treatment-related changes in surrogate outcome through a systematic review of the literature. One provided Level 1 surrogate evidence (randomized controlled trial data showing a strong association between the change in surrogate outcome and change final outcome); two reported Level 2 evidence (observational study data); and one provided Level 3 evidence (disease natural/ history data). The transparency of quantification and exploration of uncertainty of the surrogate and final outcome relationship varied considerably across all four reports. CONCLUSIONS: Recommendations are made for the use of surrogate outcomes in future HTA reports.

A rapid needs assessment of the provision of Health Technology Assessment in the south-west peninsula.

BACKGROUND: Key to delivering UK policies on clinical governance, evidence-based practice and value for money is Health Technology Assessment (HTA). Despite the provision of HTAs through the National Institute for Health and Clinical Excellence (NICE), local health organizations still undertake HTA and make decisions based on them. In some regions, capacity is provided by centralized arrangements, but in others provision is ad hoc. This rapid needs assessment evaluates the provision of HTA in the south-west peninsula, and its scope, content and quality. METHODS: We used semi-structured interviews and documentary analysis to assess the need for HTA. RESULTS: HTAs are most commonly used by drug and therapeutics committees and joint formulary committees. The scope of technologies assessed was predominantly drugs. The quality of literature review in HTAs was variable and virtually none considered value for money. Informants felt there was insufficient provision of local HTAs. Local focus and clinical engagement were seen as key to the implementation of appraisal decisions, but this was threatened by weak links with commissioning and processes to prioritize decisions across primary care trusts. CONCLUSIONS: The quality of some HTAs poses a risk to clinical and corporate governance.