The impact of the COVID-19 pandemic on antimicrobial prescribing at a specialist paediatric hospital: an observational study.

BACKGROUND: The COVID-19 pandemic has severely impacted healthcare delivery and there are growing concerns that the pandemic will accelerate antimicrobial resistance. OBJECTIVES: To evaluate the impact of the COVID-19 pandemic on antibiotic prescribing in a tertiary paediatric hospital in London, UK. METHODS: Data on patient characteristics and antimicrobial administration for inpatients treated between 29 April 2019 and Sunday 28 March 2021 were extracted from the electronic health record (EHR). Interrupted time series analysis was used to evaluate antibiotic days of therapy (DOT) and the proportion of prescribed antibiotics from the WHO 'Access' class. RESULTS: A total of 23 292 inpatient admissions were included. Prior to the pandemic there were an average 262 admissions per week compared with 212 during the pandemic period. Patient demographics were similar in the two periods but there was a shift in the specialities that patients had been admitted to. During the pandemic, there was a crude increase in antibiotic DOTs, from 801 weekly DOT before the pandemic to 846. The proportion of Access antibiotics decreased from 44% to 42%. However, after controlling for changes in patient characteristics, there was no evidence for the pandemic having an impact on antibiotic prescribing. CONCLUSIONS: The patient population in a specialist children's hospital was affected by the COVID-19 pandemic, but after adjusting for these changes there was no evidence that antibiotic prescribing was significantly affected by the pandemic. This highlights both the value of routine, high-quality EHR data and importance of appropriate statistical methods that can adjust for underlying changes to populations when evaluating impacts of the pandemic on healthcare.

The association between living alone and health care utilisation in older adults: a retrospective cohort study of electronic health records from a London general practice.

BACKGROUND: In 2016, one in three older people in the UK were living alone. These patients often have complex health needs and require additional clinical and non-clinical support. This study aimed to analyse the association between living alone and health care utilisation in older patients. METHODS: We conducted a retrospective cohort study of 1447 patients over the age of 64, living in 1275 households who were registered at a large general practice in South East London. The utilisation of four different types of health care provision were examined in order to explore the impact of older patients living alone on health care utilisation. RESULTS: After adjusting for patient demographics and clinical characteristics, living alone was significantly associated with a higher probability of utilising emergency department and general practitioner services, with odds ratios of 1.50 (95% confidence interval [CI] 1.16 to 1.93) and 1.40 (95% CI 1.04 to 1.88) respectively. CONCLUSIONS: Living alone has an impact on health care service utilisation for older patients. We show that general practice data can be used to identify older patients who are living alone, and general practitioners are in a unique position to identify those who could benefit from additional clinical and non-clinical support. Further research is needed to understand the mechanism driving higher utilisation for those patients who live alone.

Weekend admissions may be associated with poorer recording of long-term comorbidities: a prospective study of emergency admissions using administrative data.

BACKGROUND: Many studies have investigated the presence of a 'weekend effect' in mortality following hospital admission, and these frequently use diagnostic codes from administrative data for information on comorbidities for risk adjustment. However, it is possible that coding practice differs between week and weekend. We assess patients with a confirmed history of certain long-term health conditions and investigate how well these are recorded in subsequent week and weekend admissions. METHODS: We selected six long-term conditions that are commonly assessed when risk-adjusting mortality rates, via the Charlson and Elixhauser indices. Using Hospital Episode Statistics data from England for the period April 2009 to March 2011, we identified patients with the condition recorded at least twice, on separate emergency admissions. Then we assessed how often each condition was recorded on subsequent emergency admissions between April 2011 and March 2013. We then compared coding between week and weekend admissions using the Cochran-Mantel-Haenszel test, stratifying by hospital. RESULTS: We studied 111,457 patients with chronic pulmonary disease, 106,432 with diabetes, 36,447 with congestive heart failure, 30,996 with dementia, 7808 with hemiplegia or paraplegia and 5877 with metastatic cancer. Across the entire week, between April 2011 and March 2013, coding completeness ranged from 89% for diabetes to 43% for hemiplegia/paraplegia. Compared with weekday admissions, congestive heart failure was less likely to be recorded as a secondary diagnosis at the weekend (odds ratio 0.92, 95% CI, 0.88 to 0.97), with smaller but statistically significant differences also detected for chronic pulmonary disease (odds ratio 0.96, 95% CI, 0.93 to 0.99) and diabetes (odds ratio 0.95, 95% CI 0.91 to 0.99). There was no statistically significant difference in recording between week and weekend admissions for dementia (odds ratio 1.04, 95% CI 0.97 to 1.11), hemiplegia/paraplegia (odds ratio 0.99, 95% CI 0.89 to 1.10) or metastatic cancer (odds ratio 1.04, 95% CI 0.90 to 1.20). CONCLUSIONS: Long-term conditions are often not recorded on administrative data and the lack of recording may be worse for weekend admissions. Studies of the weekend effect that rely on administrative data might have underestimated the health burden of patients, particularly if admitted at the weekend.

Reductions in Readmission Rates Are Associated With Modest Improvements in Patient-reported Health Gains Following Hip and Knee Replacement in England.

BACKGROUND: Although many hospital readmission reduction initiatives have been introduced globally, health care systems ultimately aim to improve patients' health and well-being. We examined whether the hospitals that report greater success in reducing readmissions also see greater improvements in patient-reported outcomes. RESEARCH DESIGN: We examined hospital groups (Trusts) that provided hip replacement or knee replacement surgery in England between April 2010 and February 2013. For each Trust, we calculated risk-adjusted 30-day readmission rates from administrative datasets. We also obtained changes in patient-reported health between presurgical assessment and 6-month follow-up, using general health EuroQuol five dimensions questionaire (EQ-5D) and EuroQuol visual analogue scales (EQ-VAS) and procedure-specific (Oxford Hip and Knee Scores) measures. Panel models were used to assess whether changes over time in risk-adjusted readmission rates were associated with changes over time in risk-adjusted health gains. RESULTS: Each percentage point reduction in the risk-adjusted readmission rate for hip replacement was associated with an additional health gain of 0.004 for EQ-5D [95% confidence interval (CI), 0.002-0.006], 0.39 for EQ-VAS (95% CI, 0.26-0.52), and 0.32 for Oxford Hip Score (95% CI, 0.15-0.27). Corresponding figures for knee replacement were 0.003 for EQ-5D (95% CI, 0.001-0.004), 0.21 for EQ-VAS (95% CI, 0.12-0.30), and 0.14 in the Oxford Knee Score (95% CI, 0.09-0.20). CONCLUSIONS: Reductions in readmission rates were associated with modest improvements in patients' sense of their health and well-being at the hospital group level. In particular, fears that efforts to reduce readmission rates have had unintended consequences for patients appear to be unfounded.

Assessing the reliability of self-reported weight for the management of heart failure: application of fraud detection methods to a randomised trial of telemonitoring.

BACKGROUND: Since clinical management of heart failure relies on weights that are self-reported by the patient, errors in reporting will negatively impact the ability of health care professionals to offer timely and effective preventive care. Errors might often result from rounding, or more generally from individual preferences for numbers ending in certain digits, such as 0 or 5. We apply fraud detection methods to assess preferences for numbers ending in these digits in order to inform medical decision making. METHODS: The Telemonitoring to Improve Heart Failure Outcomes trial tested an approach to telemonitoring that used existing technology; intervention patients (n = 826) were asked to measure their weight daily using a digital scale and to relay measurements using their telephone keypads. First, we estimated the number of weights subject to end-digit preference by dividing the weights by five and comparing the resultant distribution with the uniform distribution. Then, we assessed the characteristics of patients reporting an excess number of weights ending in 0 or 5, adjusting for chance reporting of these values. RESULTS: Of the 114,867 weight readings reported during the trial, 18.6% were affected by end-digit preference, and the likelihood of these errors occurring increased with the number of days that had elapsed since trial enrolment (odds ratio per day: 1.002, p < 0.001). At least 105 patients demonstrated end-digit preference (14.9% of those who submitted data); although statistical significance was limited, a pattern emerged that, compared with other patients, they tended to be younger, male, high school graduates and on more medications. Patients with end-digit preference reported greater variability in weight, and they generated an average 2.9 alerts to the telemonitoring system over the six-month trial period (95% CI, 2.3 to 3.5), compared with 2.3 for other patients (95% CI, 2.2 to 2.5). CONCLUSIONS: As well as overshadowing clinically meaningful changes in weight, end-digit preference can lead to false alerts to telemonitoring systems, which may be associated with unnecessary treatment and alert fatigue. In this trial, end-digit preference was common and became increasingly so over time. By applying fraud detection methods to electronic medical data, it is possible to produce clinically significant information that can inform the design of initiatives to improve the accuracy of reporting. TRIAL REGISTRATION: ClinicalTrials.gov registration number NCT00303212 March 2006.

Estimating Lifetime Costs of Social Care: A Bayesian Approach Using Linked Administrative Datasets from Three Geographical Areas.

We estimated lifetime costs of publicly funded social care, covering services such as residential and nursing care homes, domiciliary care and meals. Like previous studies, we constructed microsimulation models. However, our transition probabilities were estimated from longitudinal, linked administrative health and social care datasets, rather than from survey data. Administrative data were obtained from three geographical areas of England, and we estimated transition probabilities in each of these sites flexibly using Bayesian methods. This allowed us to quantify regional variation as well as the impact of structural and parameter uncertainty regarding the transition probabilities. Expected lifetime costs at age 65 were £20,200-27,000 for men and £38,700-49,000 for women, depending on which of the three areas was used to calibrate the model. Thus, patterns of social care spending differed markedly between areas, with mean costs varying by almost £10,000 (25%) across the lifetime for people of the same age and gender. Allowing for structural and parameter uncertainty had little impact on expected lifetime costs, but slightly increased the risk of very high costs, which will have implications for insurance products for social care through increasing requirements for capital reserves.

Effect of a telephonic alert system (Healthy outlook) for patients with chronic obstructive pulmonary disease: a cohort study with matched controls.

BACKGROUND: Healthy Outlook was a telephonic alert system for patients with chronic obstructive pulmonary disease (COPD) in the UK. It used routine meteorological and communicable disease reports to identify times of increased risk to health. We tested its effect on hospital use and mortality. METHODS: Enrolees with a history of hospital admissions were linked to hospital administrative data. They were compared with control patients from local general practices, matched for demographic characteristics, health conditions, previous hospital use and predictive risk scores. We compared unplanned hospital admissions, admissions for COPD, outpatient attendances, planned admissions and mortality, over 12 months following enrolment. RESULTS: Intervention and matched control groups appeared similar at baseline (n = 1413 in each group). Over the 12 months following enrolment, Healthy Outlook enrolees experienced more COPD admissions than matched controls (adjusted rate ratio 1.26, 95% confidence interval (CI), 1.05-1.52) and more outpatient attendances (adjusted rate ratio 1.08, 95% CI, 1.03-1.12). Enrolees also had lower mortality rates over 12 months (adjusted odds ratio 0.61, 95% CI, 0.45-0.84). CONCLUSION: Healthy Outlook did not reduce admission rates, though mortality rates were lower. Findings for hospital utilization were unlikely to have been affected by confounding.

The effect of telecare on the quality of life and psychological well-being of elderly recipients of social care over a 12-month period: the Whole Systems Demonstrator cluster randomised trial.

BACKGROUND: home-based telecare (TC) is utilised to manage risks of independent living and provide prompt emergency responses. This study examined the effect of TC on health-related quality of life (HRQoL), anxiety and depressive symptoms over 12 months in patients receiving social care. DESIGN: a study of participant-reported outcomes [the Whole Systems Demonstrator (WSD) Telecare Questionnaire Study; baseline n = 1,189] was nested in a pragmatic cluster-randomised trial of TC (the WSD Telecare trial), held across three English Local Authorities. General practice (GP) was the unit of randomisation and TC was compared with usual care (UC). METHODS: participant-reported outcome measures were collected at baseline, short-term (4 months) and long-term (12 months) follow-up, assessing generic HRQoL, anxiety and depressive symptoms. Primary intention-to-treat analyses tested treatment effectiveness and were conducted using multilevel models to control for GP clustering and covariates for participants who completed questionnaire measures at baseline assessment plus at least one other assessment (n = 873). RESULTS: analyses found significant differences between TC and UC on Short Form-12 mental component scores (P < 0.05), with parameter estimates indicating being a member of the TC trial-arm increases mental component scores (UC-adjusted mean = 40.52; TC-adjusted mean = 43.69). Additional significant analyses revealed, time effects on EQ5D (decreasing over time) and depressive symptoms (increasing over time). CONCLUSIONS: TC potentially contributes to the amelioration in the decline in users' mental HRQoL over a 12-month period. TC may not transform the lives of its users, but it may afford small relative benefits on some psychological and HRQOL outcomes relative to users who only receive UC. International Standard Randomised Controlled Trial Number Register: ISRCTN 43002091.

Cost-effectiveness of telecare for people with social care needs: the Whole Systems Demonstrator cluster randomised trial.

PURPOSE OF THE STUDY: to examine the costs and cost-effectiveness of 'second-generation' telecare, in addition to standard support and care that could include 'first-generation' forms of telecare, compared with standard support and care that could include 'first-generation' forms of telecare. DESIGN AND METHODS: a pragmatic cluster-randomised controlled trial with nested economic evaluation. A total of 2,600 people with social care needs participated in a trial of community-based telecare in three English local authority areas. In the Whole Systems Demonstrator Telecare Questionnaire Study, 550 participants were randomised to intervention and 639 to control. Participants who were offered the telecare intervention received a package of equipment and monitoring services for 12 months, additional to their standard health and social care services. The control group received usual health and social care. PRIMARY OUTCOME MEASURE: incremental cost per quality-adjusted life year (QALY) gained. The analyses took a health and social care perspective. RESULTS: cost per additional QALY was £297,000. Cost-effectiveness acceptability curves indicated that the probability of cost-effectiveness at a willingness-to-pay of £30,000 per QALY gained was only 16%. Sensitivity analyses combining variations in equipment price and support cost parameters yielded a cost-effectiveness ratio of £161,000 per QALY. IMPLICATIONS: while QALY gain in the intervention group was similar to that for controls, social and health services costs were higher. Second-generation telecare did not appear to be a cost-effective addition to usual care, assuming a commonly accepted willingness to pay for QALYs. TRIAL REGISTRATION NUMBER: ISRCTN 43002091.

Effect of telehealth on glycaemic control: analysis of patients with type 2 diabetes in the Whole Systems Demonstrator cluster randomised trial.

BACKGROUND: The Whole Systems Demonstrator was a large, pragmatic, cluster randomised trial that compared telehealth with usual care among 3,230 patients with long-term conditions in three areas of England. Telehealth involved the regular transmission of physiological information such as blood glucose to health professionals working remotely. We examined whether telehealth led to changes in glycosylated haemoglobin (HbA1c) among the subset of patients with type 2 diabetes. METHODS: The general practice electronic medical record was used as the source of information on HbA1c. Effects on HbA1c were assessed using a repeated measures model that included all HbA1c readings recorded during the 12-month trial period, and adjusted for differences in HbA1c readings recorded before recruitment. Secondary analysis averaged multiple HbA1c readings recorded for each individual during the trial period. RESULTS: 513 of the 3,230 participants were identified as having type 2 diabetes and thus were included in the study. Telehealth was associated with lower HbA1c than usual care during the trial period (difference 0.21% or 2.3 mmol/mol, 95% CI, 0.04% to 0.38%, p = 0.013). Among the 457 patients in the secondary analysis, mean HbA1c showed little change for controls following recruitment, but fell for intervention patients from 8.38% to 8.15% (68 to 66 mmol/mol). A higher proportion of intervention patients than controls had HbA1c below the 7.5% (58 mmol/mol) threshold that was targeted by general practices (30.4% vs. 38.0%). This difference, however, did not quite reach statistical significance (adjusted odds ratio 1.63, 95% CI, 0.99 to 2.68, p = 0.053). CONCLUSIONS: Telehealth modestly improved glycaemic control in patients with type 2 diabetes over 12 months. The scale of the improvements is consistent with previous meta-analyses, but was relatively modest and seems unlikely to produce significant patient benefit. TRIAL REGISTRATION NUMBER: International Standard Randomized Controlled Trial Number Register ISRCTN43002091.

Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial.

OBJECTIVE: to assess the impact of telecare on the use of social and health care. Part of the evaluation of the Whole Systems Demonstrator trial. PARTICIPANTS AND SETTING: a total of 2,600 people with social care needs were recruited from 217 general practices in three areas in England. DESIGN: a cluster randomised trial comparing telecare with usual care, general practice being the unit of randomisation. Participants were followed up for 12 months and analyses were conducted as intention-to-treat. DATA SOURCES: trial data were linked at the person level to administrative data sets on care funded at least in part by local authorities or the National Health Service. MAIN OUTCOME MEASURES: the proportion of people admitted to hospital within 12 months. Secondary endpoints included mortality, rates of secondary care use (seven different metrics), contacts with general practitioners and practice nurses, proportion of people admitted to permanent residential or nursing care, weeks in domiciliary social care and notional costs. RESULTS: 46.8% of intervention participants were admitted to hospital, compared with 49.2% of controls. Unadjusted differences were not statistically significant (odds ratio: 0.90, 95% CI: 0.75-1.07, P = 0.211). They reached statistical significance after adjusting for baseline covariates, but this was not replicated when adjusting for the predictive risk score. Secondary metrics including impacts on social care use were not statistically significant. CONCLUSIONS: telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use, at least in terms of results assessed over 12 months.

Impact of telehealth on general practice contacts: findings from the whole systems demonstrator cluster randomised trial.

BACKGROUND: Telehealth is increasingly used in the care of people with long term conditions. Whilst many studies look at the impacts of the technology on hospital use, few look at how it changes contacts with primary care professionals. The aim of this paper was to assess the impacts of home-based telehealth interventions on general practice contacts. METHOD: Secondary analysis of data from a Department of Health funded cluster-randomised trial with 179 general practices in three areas of England randomly assigned to offer telehealth or usual care to eligible patients. Telehealth included remote exchange of vitals signs and symptoms data between patients and healthcare professionals as part of the continuing management of patients. Usual care reflected the range of services otherwise available in the sites, excluding telehealth. Anonymised data from GP systems were used to construct person level histories for control and intervention patients. We tested for differences in numbers of general practitioner and practice nurse contacts over twelve months and in the number of clinical readings recorded on general practice systems over twelve months. RESULTS: 3,230 people with diabetes, chronic obstructive pulmonary disease or heart failure were recruited in 2008 and 2009. 1219 intervention and 1098 control cases were available for analysis. No statistically significant differences were detected in the numbers of general practitioner or practice nurse contacts between intervention and control groups during the trial, or in the numbers of clinical readings recorded on the general practice systems. CONCLUSIONS: Telehealth did not appear associated with different levels of contact with general practitioners and practice nurses. We note that the way that telehealth impacts on primary care roles may be influenced by a number of other features in the health system. The challenge is to ensure that these systems lead to better integration of care than fragmentation. TRIAL REGISTRATION NUMBER: International Standard Randomised Controlled Trial Number Register ISRCTN43002091.

A comparison of synthetic control approaches for the evaluation of policy interventions using observational data: Evaluating the impact of redesigning urgent and emergency care in Northumberland.

OBJECTIVE: To compare the original synthetic control (OSC) method with alternative approaches (Generalized [GSC], Micro [MSC], and Bayesian [BSC] synthetic control methods) and re-evaluate the impact of a significant restructuring of urgent and emergency care in Northeast England, which included the opening of the UK's first purpose-built specialist emergency care hospital. DATA SOURCES: Simulations and data from Secondary Uses Service data, a single comprehensive repository for patient-level health care data in England. STUDY DESIGN: Hospital use of individuals exposed and unexposed to the restructuring is compared. We estimate the impact using OSC, MSC, BSC, and GSC applied at the general practice level. We contrast the estimation methods' performance in a Monte Carlo simulation study. DATA COLLECTION/EXTRACTION METHODS: Hospital activity data from Secondary Uses Service for patients aged over 18 years registered at a general practice in England from April 2011 to March 2019. PRINCIPAL FINDINGS: None of the methods dominated all simulation scenarios. GSC was generally preferred. In contrast to an earlier evaluation that used OSC, GSC reported a smaller impact of the opening of the hospital on Accident and Emergency (A&E) department (also known as emergency department or casualty) visits and no evidence for any impact on the proportion of A&E patients seen within 4 h. CONCLUSIONS: The simulation study highlights cases where the considered methods may lead to biased estimates in health policy evaluations. GSC was found to be the most reliable method of those considered. Considering more disaggregated data over a longer time span and applying GSC indicates that the specialist emergency care hospitals in Northumbria had less impact on A&E visits and waiting times than suggested by the original evaluation which applied OSC to more aggregated data.

Estimating length of stay in publicly-funded residential and nursing care homes: a retrospective analysis using linked administrative data sets.

BACKGROUND: Information about how long people stay in care homes is needed to plan services, as length of stay is a determinant of future demand for care. As length of stay is proportional to cost, estimates are also needed to inform analysis of the long-term cost effectiveness of interventions aimed at preventing admissions to care homes. But estimates are rarely available due to the cost of repeatedly surveying individuals. METHODS: We used administrative data from three local authorities in England to estimate the length of publicly-funded care homes stays beginning in 2005 and 2006. Stays were classified into nursing home, permanent residential and temporary residential. We aggregated successive placements in different care home providers and, by linking to health data, across periods in hospital. RESULTS: The largest group of stays (38.9%) were those intended to be temporary, such as for rehabilitation, and typically lasted 4 weeks. For people admitted to permanent residential care, median length of stay was 17.9 months. Women stayed longer than men, while stays were shorter if preceded by other forms of social care. There was significant variation in length of stay between the three local authorities. The typical person admitted to a permanent residential care home will cost a local authority over £38,000, less payments due from individuals under the means test. CONCLUSIONS: These figures are not apparent from existing data sets. The large cost of care home placements suggests significant scope for preventive approaches. The administrative data revealed complexity in patterns of service use, which should be further explored as it may challenge the assumptions that are often made.

Ethical funding for trustworthy AI: proposals to address the responsibilities of funders to ensure that projects adhere to trustworthy AI practice.

AI systems that demonstrate significant bias or lower than claimed accuracy, and resulting in individual and societal harms, continue to be reported. Such reports beg the question as to why such systems continue to be funded, developed and deployed despite the many published ethical AI principles. This paper focusses on the funding processes for AI research grants which we have identified as a gap in the current range of ethical AI solutions such as AI procurement guidelines, AI impact assessments and AI audit frameworks. We highlight the responsibilities of funding bodies to ensure investment is channelled towards trustworthy and safe AI systems and provides case studies as to how other ethical funding principles are managed. We offer a first sight of two proposals for funding bodies to consider regarding procedures they can employ. The first proposal is for the inclusion of a Trustworthy AI Statement' section in the grant application form and offers an example of the associated guidance. The second proposal outlines the wider management requirements of a funding body for the ethical review and monitoring of funded projects to ensure adherence to the proposed ethical strategies in the applicants Trustworthy AI Statement. The anticipated outcome for such proposals being employed would be to create a 'stop and think' section during the project planning and application procedure requiring applicants to implement the methods for the ethically aligned design of AI. In essence it asks funders to send the message "if you want the money, then build trustworthy AI!".

Predicting who will use intensive social care: case finding tools based on linked health and social care data.

BACKGROUND: the costs of delivering health and social care services are rising as the population ages and more people live with chronic diseases. OBJECTIVES: to determine whether predictive risk models can be built that use routine health and social care data to predict which older people will begin receiving intensive social care. DESIGN: analysis of pseudonymous, person-level, data extracted from the administrative data systems of local health and social care organisations. SETTING: five primary care trust areas in England and their associated councils with social services responsibilities. SUBJECTS: people aged 75 or older registered continuously with a general practitioner in five selected areas of England (n = 155,905). METHODS: multivariate statistical analysis using a split sample of data. RESULTS: it was possible to construct models that predicted which people would begin receiving intensive social care in the coming 12 months. The performance of the models was improved by selecting a dependent variable based on a lower cost threshold as one of the definitions of commencing intensive social care. CONCLUSIONS: predictive models can be constructed that use linked, routine health and social care data for case finding in social care settings.

A comprehensive evaluation of the impact of telemonitoring in patients with long-term conditions and social care needs: protocol for the whole systems demonstrator cluster randomised trial.

BACKGROUND: It is expected that increased demands on services will result from expanding numbers of older people with long-term conditions and social care needs. There is significant interest in the potential for technology to reduce utilisation of health services in these patient populations, including telecare (the remote, automatic and passive monitoring of changes in an individual's condition or lifestyle) and telehealth (the remote exchange of data between a patient and health care professional). The potential of telehealth and telecare technology to improve care and reduce costs is limited by a lack of rigorous evidence of actual impact. METHODS/DESIGN: We are conducting a large scale, multi-site study of the implementation, impact and acceptability of these new technologies. A major part of the evaluation is a cluster-randomised controlled trial of telehealth and telecare versus usual care in patients with long-term conditions or social care needs. The trial involves a number of outcomes, including health care utilisation and quality of life. We describe the broad evaluation and the methods of the cluster randomised trial DISCUSSION: If telehealth and telecare technology proves effective, it will provide additional options for health services worldwide to deliver care for populations with high levels of need. TRIAL REGISTRATION: Current Controlled Trials ISRCTN43002091.

Healthcare utilization among migrants to the UK: cross-sectional analysis of two national surveys.

OBJECTIVE: To contribute objective evidence on health care utilization among migrants to the UK to inform policy and service planning. METHODS: We analysed data from Understanding Society, a household survey with fieldwork from 2015 to 2017, and the European Health Interview Survey with data collected between 2013 and 2014. We explored health service utilization among migrants to the UK across primary care, inpatient admissions and maternity care, outpatient care, mental health, dental care and physiotherapy. We adjusted for age, sex, long-term health conditions and time since moving to the UK. RESULTS: Health care utilization among migrants to the UK was lower than utilization among the UK-born population for all health care dimensions except inpatient admissions for childbirth; odds ratio (95%CI) range 0.58 (0.50-0.68) for dental care to 0.88 (0.78-0.98) for primary care). After adjusting for differences in age and self-reported health, these differences were no longer observed, except for dental care (odds ratio 0.57, 95%CI 0.49-0.66, P < 0.001). Across primary care, outpatient and inpatient care, utilization was lower among those who had recently migrated, increasing to the levels of the nonmigrant population after 10 years or more since migrating to the UK. CONCLUSIONS: This study finds that newly arrived migrants tend to utilize less health care than the UK population and that this pattern was at least partly explained by better health, and younger age. Our findings contribute nationally representative evidence to inform public debate and decision-making on migration and health.

Effect of an integrated care pathway on use of primary and secondary healthcare by patients at high risk of emergency inpatient admission: a matched control cohort study in Tower Hamlets.

OBJECTIVES: To assess the effects of an integrated care pathway on the use of primary and secondary healthcare by patients at high risk of emergency inpatient admission. DESIGN: Observational study of a real-life deployment of integrated care, using patient-level administrative data. Regression analysis was used to compare integrated care patients with matched controls. SETTING: A deprived, inner city London borough (Tower Hamlets). PARTICIPANTS: 1720 patients aged 50+ years registered with a general practitioner in Tower Hamlets and at high risk of emergency inpatient admission enrolled onto integrated care during 2014. These patients were matched to control patients, also selected from Tower Hamlets, with respect to demographics, diagnoses of health conditions, previous hospital use and risk score. INTERVENTIONS: Enrolled patients were eligible for a range of interventions, such as case management, support with self-care and enhanced care coordination. Control patients received usual care. PRIMARY AND SECONDARY ENDPOINTS: Number of emergency inpatient admissions in the year after enrolment onto integrated care. Secondary endpoints included numbers of elective inpatient admissions, inpatient bed days, accident and emergency attendances, outpatient attendances and general practitioner contacts in the year after enrolment. RESULTS: There was no evidence that the integrated care pathway reduced patients' healthcare utilisation in the first year post-enrolment. Matched controls and integrated care patients were similar at baseline. Following enrolment, integrated care patients were more likely than matched controls to experience elective inpatient admissions (adjusted incidence rate ratio (IRR)=1.27, 95% CI 1.08 to 1.49, p=0.004). They were also more likely to experience general practitioner contacts (adjusted IRR=1.11, 95% CI 1.06 to 1.16, p<0.001), but other endpoints were not significantly different between the groups. CONCLUSIONS: The integrated care pathway was not associated with a reduction in healthcare utilisation in the first year, but appeared to have increased elective inpatient admissions and general practitioner workload.