Effects of implementation of a care bundle on rates of necrotising enterocolitis and own mother's milk feeding in the East Midlands: protocol for a mixed methods impact and process evaluation study.

INTRODUCTION: Prevention of necrotising enterocolitis (NEC) is vital for improving neonatal outcomes. Feeding own mother's milk helps prevent NEC. Rates of own mother's milk feeding in the East Midlands are lower than the national average and the incidence of NEC is higher. The East Midlands Neonatal Operational Delivery Network (EMNODN) has created a care bundle to improve these in babies born at <32 weeks' gestation, the group at the highest risk of NEC. The bundle was introduced in September 2022 and embedded by December 2022. We will evaluate its effectiveness and conduct a process evaluation to understand barriers and facilitators to implementation. METHODS AND ANALYSIS: We will conduct a retrospective cohort study (workstream 1) using data from the National Neonatal Research Database (NNRD). We will identify infants receiving any own mother's milk on day 14 and at discharge, and cases of severe NEC. We will aggregate outcomes by birth month and use interrupted time series analysis to estimate an incidence rate ratio for changes after the care bundle was embedded, relative to pre-implementation. We will model data from all other NNRD units and assess whether there are any concurrent changes to exclude confounding due to other events.We will apply the RE-AIM framework (workstream 2), supplemented by the Consolidated Framework for Implementation Research and Framework for Implementation Fidelity, to conduct a mixed methods evaluation in EMNODN units. We will triangulate data from several sources, including questionnaires and semistructured interviews with parents and healthcare professionals, and data from patient records. ETHICS AND DISSEMINATION: The study has approval from the South East Scotland Research Ethics Committee 01 and the Health Research Authority and Health and Care Research Wales (IRAS 323099). Results will be disseminated via scientific journals and conferences, to neonatal service commissioners and through public-facing infographics. TRIAL REGISTRATION NUMBER: NCT05934123.

Factors influencing the commissioning and implementation of health and social care interventions for people with dementia: commissioner and stakeholder perspectives.

BACKGROUND: Despite several interventions demonstrating benefit to people living with dementia and their caregivers, few have been translated and implemented in routine clinical practice. There is limited evidence of the barriers and facilitators for commissioning and implementing health and social care interventions for people living with dementia. The aim of the current study was to explore the barriers and facilitators to commissioning and implementing health and social care interventions for people with dementia, using a dementia friendly exercise and physical activity-based intervention (PrAISED [Promoting Activity, Stability and Independence in Early Dementia and Mild Cognitive Impairment]) as a case study. METHODS: Qualitative semi-structured interviews were conducted with stakeholders from a range of backgrounds including individuals from health and social care, local government, the voluntary and community sector, universities, and research centres in England. The Consolidated Framework for Intervention Research (CFIR) was used to guide the design and analysis. RESULTS: Fourteen participants took part, including commissioning managers, service managers, partnership managers, charity representatives, commercial research specialists, academics/researchers, and healthcare professionals. Data were represented in 33 constructs across the five CFIR domains. Participants identified a need for greater support for people diagnosed with dementia and their caregivers immediately post dementia diagnosis. Key barriers included cost/financing, the culture of commissioning, and available resources. Key facilitators included the adaptability of the intervention, cosmopolitanism/partnerships and connections, external policy and incentives, and the use of already existing (and untapped) workforces. CONCLUSION: Several barriers and facilitators for commissioning and implementing health and social care interventions for people with dementia were identified which need to be addressed. Recommended actions to facilitate the commissioning and implementation of dementia friendly services are: 1) map out local needs, 2) evidence the intervention including effectiveness and cost-effectiveness, 3) create/utilise networks with stakeholders, and 4) plan required resources.

Patterns and trends of medicinal poisoning substances: a population-based cohort study of injuries in 0-11 year old children from 1998-2018.

BACKGROUND: There have been sharp increases in antidepressant and opioid prescriptions over the last 10 years, as well as increased over-the-counter medicine availability. However, the impact on childhood medicinal poisonings rates, particularly by socioeconomic deprivation is unclear. This study reports population level medicinal poisoning substance patterns in England among children aged 0-11 years, helping inform safety advice and poisoning prevention interventions. METHODS: An open cohort study of 1,489,620 0-11 year olds was conducted from 1998 to 2018, using the Clinical Practice Research Datalink, to examine inpatient hospital admissions for poisoning. Incidence rates and adjusted incidence rate ratios (aIRR) were calculated for poisoning substance groups by age, sex, socio-economic deprivation and year. RESULTS: 3,685 medicinal poisoning hospital admissions were identified. The most common substances were paracetamol (33.2%), dependence/withdrawal risk drugs (DWRD - antidepressants, opioids, gabapentinoids, benzodiazepines) (13.5%) and other over-the-counter (OTC) analgesics/anti-common cold drugs (13.0%). Over the study period DWRD poisonings decreased 33% (aIRR 0.67, 95%CI 0.50-0.90 comparing 2013/14-2017/18 to 1998/99-2002/03), while paracetamol poisonings increased 43% (aIRR 1.43, 95%CI 1.20-1.70 for the same periods), with no change in incidence rates for other OTC drugs (aIRR 0.82, 95% CI 0.60-1.12) or all medications combined (aIRR 0.97, 95%CI 0.88-1.07). A gradient in poisonings by area-level socioeconomic deprivation was shown for all medications (aIRR 1.32, 95%CI 1.18-1.47 for most deprived compared to least deprived quintile), and DWRDs (aIRR 2.03, 95%CI 1.42-2.88 for 4th most deprived quintile and aIRR 1.88, 95%CI 1.32-2.66 for 5th most deprived quintile, compared to least deprived quintile), but not for paracetamol or other OTC drug poisonings. CONCLUSIONS: Poisonings from DWRDs decreased by 33%, while paracetamol poisonings increased by 43% during the study period. There was a gradient by area-level socioeconomic deprivation in prescribed medication poisonings, including drugs with withdrawal/dependence risk, but not OTC medication poisonings. Households in more socioeconomically deprived areas have the potential to benefit most from measures to improve safe storage of medicines and are likely to require targeted interventions providing education and safety equipment. In addition, universal promotion of the safe storage of OTC and prescribed medicines must be provided by prescribers, community pharmacies and other outlets of such medication.

Implementation fidelity of the 'Stay One Step Ahead' home safety intervention: a mixed-methods analysis.

OBJECTIVE: To assess implementation fidelity of the Stay One Step Ahead (SOSA), a complex intervention which was delivered by health visiting teams, children's centres, and family mentors and was aimed at preventing unintentional home injuries in children under 5 in disadvantaged communities. STUDY DESIGN: A mixed-methods evaluation of the implementation fidelity of the SOSA intervention. METHODS: A conceptual framework for implementation fidelity was used to triangulate data from questionnaires and semistructured interviews with parents and practitioners, observations of parent and practitioner contacts, and meeting documents. Quantitative data were analysed using logistic regression and descriptive statistics. Thematic analysis was used for qualitative data. RESULTS: Parents in intervention wards were more likely to receive home safety advice from a practitioner than those living in matched control wards. Monthly safety messages and family mentor home safety activities were delivered with greater fidelity than other intervention components. Content most frequently adapted included the home safety checklist used by health visiting teams, and safety weeks delivered at children's centres. CONCLUSION: Consistent with similarly complex interventions, SOSA was delivered with variable fidelity in a challenging environment. The findings add to the body of evidence on implementation fidelity of home injury prevention programmes, providing important information for future intervention development and delivery.

Cost-effectiveness of England's national 'Safe At Home' scheme for reducing hospital admissions for unintentional injury in children aged under 5.

BACKGROUND: Injuries in children aged under 5 years most commonly occur in the home and disproportionately affect those living in the most disadvantaged communities. The 'Safe at Home' (SAH) national home safety equipment scheme, which ran in England between 2009 and 2011, has been shown to reduce injury-related hospital admissions, but there is little evidence of cost-effectiveness. MATERIALS AND METHODS: Cost-effectiveness analysis from a health and local government perspective. Measures were the incremental cost-effectiveness ratio per hospital admission averted (ICER) and cost-offset ratio (COR), comparing SAH expenditure to savings in admission expenditure. The study period was split into three periods: T1 (years 0-2, implementation); T2 (years 3-4) and T3 (years 5-6). Analyses were conducted for T2 versus T1 and T3 versus T1. RESULTS: Total cost of SAH was £9 518 066. 202 223 hospital admissions in the children occurred during T1-3, costing £3 320 000. Comparing T3 to T1 SAH reduced admission expenditure by £924 per month per local authority and monthly admission rates by 0.5 per local authority per month compared with control areas. ICER per admission averted was £4209 for T3 versus T1, with a COR of £0.29, suggesting that 29p was returned in savings on admission expenditure for every pound spent on SAH. CONCLUSION: SAH was effective at reducing hospital admissions due to injury and did result in some cost recovery when taking into admissions only. Further analysis of its cost-effectiveness, including emergency healthcare, primary care attendances and wider societal costs, is likely to improve the return on investment further.

Effectiveness of systematically delivered evidence-based home safety promotion to improve child home safety practices: a controlled before-and-after study.

OBJECTIVE: Evaluate the effectiveness of systematically delivered evidence-based home safety promotion for improving child home safety practices. DESIGN: Controlled before-and-after study. SETTING: Nine electoral wards in Nottingham, UK. PARTICIPANTS: 361 families with children aged 2-7 months at recruitment living in four intervention wards with high health, education and social need; and 401 in five matched control wards. INTERVENTION: Evidence-based home safety promotion delivered by health visiting teams, family mentors and children's centres including 24 monthly safety messages; home safety activity sessions; quarterly 'safety weeks'; home safety checklists. OUTCOMES: Primary: composite measure comprising having a working smoke alarm, storing poisons out of reach and having a stairgate. Secondary: other home safety practices; medically attended injuries. Parents completed questionnaires at 12 and 24 months after recruitment plus optional three monthly injury questionnaires. RESULTS: At 24 months there was no significant difference between groups in the primary outcome (55.8% vs 48.8%; OR 1.58, 95% CI 0.98 to 2.55) or medically attended injury rates (incidence rate ratio 0.89, 95% CI 0.51 to 1.56), but intervention families were more likely to store poisons safely (OR 1.81, 95% CI 1.06 to 3.07), have a fire escape plan (OR 1.81, 95% CI 1.06 to 3.08), use a fireguard or have no fire (OR 3.17, 95% CI 1.63 to 6.16) and perform more safety practices (ß 0.46, 95% CI 0.13 to 0.79). CONCLUSIONS: Systematic evidence-based home safety promotion in areas with substantial need increases adoption of some safety practices. Funders should consider commissioning evidence-based multicomponent child home safety interventions. TRIAL REGISTRATION NUMBER: ISRCTN31210493.

A Contouring Strategy and Reference Atlases for the Full Abdominopelvic Bowel Bag on Treatment Planning and Cone Beam Computed Tomography Images.

Purpose: To establish a practical contouring strategy with reference atlases for the abdominopelvic bowel bag on treatment planning computed tomography (TPCT) and cone beam computed tomography (CBCT) images. Methods and Materials: A scoping literature review was done to evaluate the existing definitions and contouring guidelines for bowel bag and small bowel planning-at-risk volume-like structures. A comprehensive definition was proposed for the abdominopelvic bowel bag that expanded the Radiation Therapy Oncology Group Pelvic Normal Tissue Consensus definition. Seven patients with TPCT and first-treatment-day CBCT images were selected from an institutional database to represent a range of normal anatomy and CBCT image quality. The TPCT and CBCT images were contoured using the proposed definition. During contouring, the Radiation Therapy Oncology Group definition's list of inclusion and exclusion structures was expanded. For areas with limited visibility of the bowel bag on either TPCT or CBCT, a set of operational definitions was developed based on consistently visible reference structures. Results: A literature review showed that previously existing bowel bag definitions predominantly focused on the pelvic region and did not provide a complete and practical description of the full abdominopelvic contour relative to structures consistently visible in all radiation therapy images. The proposed contouring strategy had 4 components: a definition, a list of inclusion and exclusion structures, 15 tabulated operational definitions, and a set of atlases. The bowel bag was defined as the peritoneal cavity and retroperitoneal duodenum and ascending and descending colon, as visualized at the time of image acquisition. The operational definitions formalized the location of the peritoneal fascial planes through a simple look-up table. The proposed contouring strategy and reference atlases were successfully used on both TPCT and CBCT images. Conclusions: This study produced a practical contouring strategy and reference atlases to enable reproducible delineation of the full bowel bag on TPCT and CBCT images. The strategy is a necessary first step toward consensus contouring with reduced observer variability, which is a prerequisite for evaluation of cumulative dose and its correlation with toxic effects, adaptive planning strategies, and automated contouring potential.

'It is designed for everybody to find their own level and to improve themselves'; views of older people and instructors of the Falls Management Exercise (FaME) programme.

BACKGROUND: Older adults are at increased risk of falls due to ageing, decreased muscle strength and impaired balance. Clinical trials have demonstrated the efficacy and effectiveness of the Falls Management Exercise (FaME) programme in improving functioning and preventing falls. However, programme completion is often low, impacting the potential benefits of FaME. OBJECTIVE: To explore the barriers and facilitators for participation and completion of the FaME programme from an instructor and participant perspective. METHODS: Semi-structured interviews were conducted with 20 FaME users and seven Postural Stability Instructors from the East Midlands region of England, UK. Interviews were conducted using a topic guide and explored their views of the programme, intended benefits, reasons for participating, instructor's approach and venue facilities. Data were transcribed verbatim and analysed using thematic analysis. Written informed consent was obtained from all participants and instructors. RESULTS: Common themes identified by participants and instructors for adherence related to perceived health benefits, psychological well-being, intervention characteristics, cost, instructors' qualities, opportunity to socialise, venue accessibility and facilities. Further factors such as maintaining independence, discipline, relationship with peers and caring responsibilities influenced participants' engagement with the programme. Instructor factors such as progression were also reported as important predictors. CONCLUSIONS: Instructor and participant factors influence uptake, attendance and adherence of FaME. The findings from this study can inform the development and improvement of additional falls-prevention programmes. It can also guide marketing strategies to promote uptake of exercise-based falls-prevention programmes among older adults.

Impact of the national home safety equipment scheme 'Safe At Home' on hospital admissions for unintentional injury in children under 5: a controlled interrupted time series analysis.

BACKGROUND: Unintentional home injuries are a leading cause of preventable death in young children. Safety education and equipment provision improve home safety practices, but their impact on injuries is less clear. Between 2009 and 2011, a national home safety equipment scheme was implemented in England (Safe At Home), targeting high-injury-rate areas and socioeconomically disadvantaged families with children under 5. This provided a 'natural experiment' for evaluating the scheme's impact on hospital admissions for unintentional injuries. METHODS: Controlled interrupted time series analysis of unintentional injury hospital admission rates in small areas (Lower Layer Super Output Areas (LSOAs)) in England where the scheme was implemented (intervention areas, n=9466) and matched with LSOAs in England and Wales where it was not implemented (control areas, n=9466), with subgroup analyses by density of equipment provision. RESULTS: 57 656 homes receiving safety equipment were included in the analysis. In the 2 years after the scheme ended, monthly admission rates declined in intervention areas (-0.33% (-0.47% to -0.18%)) but did not decline in control areas (0.04% (-0.11%-0.19%), p value for difference in trend=0.001). Greater reductions in admission rates were seen as equipment provision density increased. Effects were not maintained beyond 2 years after the scheme ended. CONCLUSIONS: A national home safety equipment scheme was associated with a reduction in injury-related hospital admissions in children under 5 in the 2 years after the scheme ended. Providing a higher number of items of safety equipment appears to be more effective in reducing injury rates than providing fewer items.

Aeciospore ejection in the rust pathogen Puccinia graminis is driven by moisture ingress.

Fungi have evolved an array of spore discharge and dispersal processes. Here, we developed a theoretical model that explains the ejection mechanics of aeciospore liberation in the stem rust pathogen Puccinia graminis. Aeciospores are released from cluster cups formed on its Berberis host, spreading early-season inoculum into neighboring small-grain crops. Our model illustrates that during dew or rainfall, changes in aeciospore turgidity exerts substantial force on neighboring aeciospores in cluster cups whilst gaps between spores become perfused with water. This perfusion coats aeciospores with a lubrication film that facilitates expulsion, with single aeciospores reaching speeds of 0.053 to 0.754 m·s-1. We also used aeciospore source strength estimates to simulate the aeciospore dispersal gradient and incorporated this into a publicly available web interface. This aids farmers and legislators to assess current local risk of dispersal and facilitates development of sophisticated epidemiological models to potentially curtail stem rust epidemics originating on Berberis.

Keeping adults physically active after Falls Management Exercise (FaME) programmes end: development of a physical activity maintenance intervention.

BACKGROUND: Falls prevention exercise programmes help to improve muscle strength, balance and physical function, and reduce falling rates in older adults. Improvements in muscle strength, balance and physical function are reversed if older adults do not continue to be physically active after falls prevention exercise programmes end. This paper describes the design process of an intervention that aimed to maintain physical activity in older adults exiting falls prevention exercise programmes. METHODS: The development of the Keeping Adults Physically Active (KAPA) intervention and its implementation plan was guided by Bartholomew's Intervention Mapping approach. The intervention mapping approach involved (1) performing a needs assessment and developing intervention objectives using previous literature; (2) identifying theory-based intervention strategies from a systematic review and the National Institute of Clinical Excellence guidelines; and (3) designing the KAPA intervention and its implementation plan with the guidance from an expert steering group. RESULTS: The KAPA intervention comprised of six group sessions of motivational interviewing, delivered monthly by trained and mentor-supported falls prevention practitioners. Intervention sessions lasted up to 90 min and were delivered in community settings over a 6-month duration. Participant manuals, illustrated exercise books, physical activity diaries and pedometers supported the KAPA intervention. CONCLUSIONS: The intervention development process, consisting of Bartholomew's Intervention Mapping approach and the input from an expert steering group, was successful in creating the evidence-based KAPA intervention ready to be evaluated in a feasibility trial.

Is proactive frailty identification a good idea? A qualitative interview study.

BACKGROUND: In England, GPs are independent contractors working to a national contract. Since 2017, the contract requires GPs to use electronic tools to proactively identify moderate and severe frailty in people aged ≥65 years, and offer interventions to help those identified to stay well and maintain independent living. Little is currently known about GPs' views of this contractual requirement. AIM: To explore GPs' views of identifying frailty and offering interventions for those living with moderate or severe frailty. DESIGN AND SETTING: A sequential mixed-methods study of GPs in the East Midlands region of England - namely Derbyshire, Leicestershire, Lincolnshire, Nottinghamshire, and Northamptonshire - undertaken between January and May 2019. METHOD: GPs were made aware of the study via professional organisations' newsletters and bulletins, GP email lists, and social media, and were invited to complete an online questionnaire. Responses were analysed using descriptive statistics and, based on those survey responses, GPs with a range of GP and practice characteristics, as well as views on identifying frailty, were selected to participate in a semi-structured telephone interview. Interview transcripts were analysed using framework analysis. RESULTS: In total, 188 out of 3058 (6.1%) GPs responded to the survey and 18 GPs were interviewed. GPs were broadly supportive of identifying frailty, but felt risk-stratification tools lacked sensitivity and specificity, and wanted evidence showing clinical benefit. Frailty identification increased workload and was under-resourced, with limited time for, and access to, necessary interventions. GPs felt they lacked knowledge about frailty and more education was required to better understand it. CONCLUSION: Proactively identifying and responding to frailty in primary care requires GP education, highly sensitive and specific risk-stratification tools, better access to interventions to lessen the impact of frailty, and adequate resourcing to achieve potential clinical impact.

'Real world' effectiveness of the Falls Management Exercise (FaME) programme: an implementation study.

BACKGROUND: Falls incidence increases with age alongside declines in strength and balance. Clinical trials show that the Falls Management Exercise (FaME) programme improves strength and balance, which can reduce falls and improve physical functioning. OBJECTIVE: To determine if the clinical trial efficacy of FaME translates into effectiveness in non-research settings. DESIGN AND SETTING: An implementation study of FaME in 10 local authorities across the East Midlands region of England. SUBJECTS: Adults aged 65 and over enrolled on a FaME programme. METHOD: Anonymised outcome data collected by the FaME providers were compared at baseline, end of programme and 6 months follow-up using univariate and multivariate analyses. RESULTS: For 348 adults enrolled in programmes and analysed, the mean age was 76.8, 73% were female and 143 (41%) completed ≥75% of classes. Overall confidence in balance, fear of falling, functional reach and timed-up-and-go (all P < 0.001), and turn 180° (P = 0.008) improved significantly at programme completion versus baseline, but improvements were not maintained 6 months later. Falls risk (FRAT score) and total minutes of physical activity did not change significantly though minutes of strength and balance activity increased by 55% at programme completion and was maintained at 6 months. The falls incidence rate ratio (IRR) was non-significantly lower at programme completion (IRR 0.76, 95% Confidence Interval (CI) 0.48,1.21) and follow-up (IRR 0.82 95% CI 0.48,1.39) versus baseline. CONCLUSIONS: There is modest translation of FaME efficacy into effectiveness, but not all effects persist after completion. Strategies to aid adherence and exercise maintenance are important to maximise benefits.

Trauma-Informed Pediatric Primary Care: Facilitators and Challenges to the Implementation Process.

This article describes the process of integrating trauma-informed behavioral health practices into a pediatric primary care clinic serving low-income and minority families while facing barriers of financial, staffing, and time limitations common to many community healthcare clinics. By using an iterative approach to evaluate each step of the implementation process, the goal was to establish a feasible system in which primary care providers take the lead in addressing traumatic stress. This article describes (1) the process of implementing trauma-informed care into a pediatric primary care clinic, (2) the facilitators and challenges of implementation, and (3) the impact of this implementation process at patient, provider, and community levels. Given the importance of trauma-informed care, especially for families who lack access to quality care, the authors conceptualize this paper as a guide for others attempting to integrate best behavioral health practices into pediatric clinics while working with limited resources.

Incident Type 2 Diabetes and Risk of Fracture: A Comparative Cohort Analysis Using U.K. Primary Care Records.

OBJECTIVE: To estimate risk of fracture in men and women with recent diagnosis of type 2 diabetes compared with individuals without diabetes. RESEARCH DESIGN AND METHODS: In this cohort study, we used routinely collected U.K. primary care data from The Health Improvement Network. In adults (>35 years) diagnosed with type 2 diabetes between 2004 and 2013, fractures sustained until 2019 were identified and compared with fractures sustained in individuals without diabetes. Multivariable models estimated time to first fracture following diagnosis of diabetes. Annual prevalence rates included at least one fracture in a given year. RESULTS: Among 174,244 individuals with incident type 2 diabetes and 747,290 without diabetes, there was no increased risk of fracture among males with diabetes (adjusted hazard ratio [aHR] 0.97 [95% CI 0.94, 1.00]) and a small reduced risk among females (aHR 0.94 [95% CI 0.92, 0.96]). In those aged ≥85 years, those in the diabetes cohort were at significantly lower risk of incident fracture (males: aHR 0.85 [95% CI 0.71, 1.00]; females: aHR 0.85 [95% CI 0.78, 0.94]). For those in the most deprived areas, aHRs were 0.90 (95% CI 0.83, 0.98) for males and 0.91 (95% CI 0.85, 0.97) for females. Annual fracture prevalence rates, by sex, were similar for those with and without type 2 diabetes. CONCLUSIONS: We found no evidence to suggest a higher risk of fracture following diagnosis of type 2 diabetes. After a diagnosis of type 2 diabetes, individuals should be encouraged to make positive lifestyle changes, including undertaking weight-bearing physical activities that improve bone health.

Evaluation of the effectiveness, implementation and cost-effectiveness of the Stay One Step Ahead home safety promotion intervention for pre-school children: a study protocol.

BACKGROUND: Unintentional injuries in children under the age of 5 years commonly occur in the home and disproportionately affect those living in disadvantaged circumstances. Targeted home safety promotion should be offered to families most at risk but there is a paucity of standardised evidence-based resources available for use across family-support practitioners. OBJECTIVE: To assess the effectiveness, implementation and cost-effectiveness of a 2-year home safety programme (Stay One Step Ahead) developed by parents, practitioners and researchers, and delivered by a range of family support providers in inner-city localities, compared with usual care in matched control localities. METHODS: Parents of children aged 0 to 7 months will be recruited to a controlled before and after observational study. The primary outcome is home safety assessed by the proportion of families with a fitted and working smoke alarm, safety gate on stairs (where applicable) and poisons stored out of reach, assessed using parent-administered questionnaires at baseline, 12 and 24 months.Secondary outcomes include: the impact on other parent-reported safety behaviours, medically-attended injuries, self-efficacy for home safety and knowledge of child development and injury risk using questionnaires and emergency department attendance data; implementation (reach, acceptability, barriers, facilitators) of home safety promotion assessed through interviews and observations; and cost-effectiveness using medically-attended injury costs ascertained from healthcare records. CONCLUSION: If shown to be effective and cost-effective this study will provide a practical resource to underpin national guidance. The study could inform public health prevention strategies to reduce home injury in children most at risk, while delivering cost savings to health and care services. TRIAL REGISTRATION NUMBER: ISRCTN31210493; Pre result.

GP views on the routine identification of older people living with frailty in primary care.

BACKGROUND: To meet the challenges of an ageing population, the updated 2017/18 NHS GP contract requires primary care providers to use evidence-based frailty identification tools to risk-stratify all patients aged >65 years. Those patients flagged as moderately or severely frail should be clinically reviewed and if severe frailty is confirmed, providers have been asked to consider offering relevant interventions, with the overall aim of enabling these patients to live well for longer. However, there is limited knowledge about how this frailty contractual requirement is being operationalised in primary care. AIM: To improve understanding of the barriers and facilitators GPs encounter when routinely identifying, risk-stratifying and providing interventions for people living with frailty in primary care. METHOD: This was a two-part study: an initial survey via online questionnaire, with participants selected by maximum variation sampling to be followed up with a semi-structured telephone interview. All GPs working in the East Midlands region (Derbyshire, Leicestershire, Lincolnshire, Nottinghamshire, and Northamptonshire) were eligible to take part. The online questionnaire was analysed using descriptive statistics. Interview transcripts were analysed using framework analysis to identify key themes. RESULTS: In total, 188 GPs responded to the survey. Eighteen GPs were interviewed. Four themes were identified: 1) beliefs about stratification and pro-active identification of frailty; 2) frailty stratification tools; 3) managing complexity, resources and models of care; and 4) drivers of GP behaviour. CONCLUSION: The study findings will inform the further development of NHS England policy on the frailty contractual requirement for primary care providers.

A randomised feasibility study assessing an intervention to keep adults physically active after falls management exercise programmes end.

BACKGROUND: Physical inactivity contributes to disability and falls in older adults. Falls prevention exercise (FaME) programmes improve physical activity and physical function and reduce falling rates. Improvements in physical function are reduced, and falls rates increase, if physical activity is not maintained. This research investigated the feasibility and acceptability of an intervention that aimed to maintain physical activity in older adults exiting FaME. METHODS: The Keeping Adults Physically Active (KAPA) intervention comprised of six group sessions of motivational interviewing, delivered monthly by trained and mentor-supported postural stability instructor's after the FaME programme ceased. The KAPA intervention included participant manuals, illustrated exercise books, physical activity diaries and pedometers. A feasibility study was conducted in 8 FaME classes. The study design was a two-arm, cluster randomised, multi-site feasibility study comparing the KAPA intervention with usual care. A sample of 50 community-dwelling adults aged 65 years old or older were recruited. Recruitment, retention and attendance rates, self-reported physical activity and participant interviews were used to examine the feasibility and acceptability of the KAPA intervention. RESULTS: Fifty of the sixty-seven (74.6%) participants invited into the study agreed to take part, 94.2% of the available KAPA sessions were attended and 92.3% of the recruited participants provided outcome data. The KAPA participants expressed positive views about the venues and postural stability instructors and reported enjoying the group interactions. Intervention participants discussed increasing their physical activity in response to the peer-support, illustrated home exercise booklet, physical activity diaries and pedometers. Most discussed the written tasks to be the least enjoyable element of the KAPA intervention. The proportion of participants reporting at least 150 minutes of moderate to vigorous physical activity per week rose from 56.3 to 62.5% in the intervention arm and from 41.4 to 52.0% in the usual care arm. CONCLUSIONS: The participants found the KAPA intervention acceptable. Participants reported the exercise booklet, peer support and the physical activity monitoring tools encouraged them to keep active. A full-scale trial is needed to assess whether physical activity can be significantly maintained in response to the KAPA intervention. TRIAL REGISTRATION: Retrospectively registered on ClinicalTrials.gov (NCT03824015).

Economic evaluation of the OSAC randomised controlled trial: oral corticosteroids for non-asthmatic adults with acute lower respiratory tract infection in primary care.

OBJECTIVE: To estimate the costs and outcomes associated with treating non-asthmatic adults (nor suffering from other lung-disease) presenting to primary care with acute lower respiratory tract infection (ALRTI) with oral corticosteroids compared with placebo. DESIGN: Cost-consequence analysis alongside a randomised controlled trial. Perspectives included the healthcare provider, patients and productivity losses associated with time off work. SETTING: Fifty-four National Health Service (NHS) general practices in England. PARTICIPANTS: 398 adults attending NHS primary practices with ALRTI but no asthma or other chronic lung disease, followed up for 28 days. INTERVENTIONS: 2× 20 mg oral prednisolone per day for 5 days versus matching placebo tablets. OUTCOME MEASURES: Quality-adjusted life years using the 5-level EuroQol-5D version measured weekly; duration and severity of symptom. Direct and indirect resources related to the disease and its treatment were also collected. Outcomes were measured for the 28-day follow-up. RESULTS: 198 (50%) patients received the intervention (prednisolone) and 200 (50%) received placebo. NHS costs were dominated by primary care contacts, higher with placebo than with prednisolone (£13.11 vs £10.38) but without evidence of a difference (95% CI £3.05 to £8.52). The trial medication cost of £1.96 per patient would have been recouped in prescription charges of £4.30 per patient overall (55% participants would have paid £7.85), giving an overall mean 'profit' to the NHS of £7.00 (95% CI £0.50 to £17.08) per patient. There was a quality adjusted life years gain of 0.03 (95% CI 0.01 to 0.05) equating to half a day of perfect health favouring the prednisolone patients; there was no difference in duration of cough or severity of symptoms. CONCLUSIONS: The use of prednisolone for non-asthmatic adults with ALRTI, provided small gains in quality of life and cost savings driven by prescription charges. Considering the results of the economic evaluation and possible side effects of corticosteroids, the short-term benefits may not outweigh the long-term harms. TRIAL REGISTRATION NUMBERS: EudraCT 2012-000851-15 and ISRCTN57309858; Pre-results.