Systematic review of international evidence on the effectiveness and costs of paediatric home care for children and young people who are ill.

Promoting 'care closer to home' for ill children is a policy and practice objective internationally. Progress towards this goal is hampered by a perceived lack of evidence on effectiveness and costs. The aim of the work reported here was to establish the strength of current international evidence on the effectiveness and costs of paediatric home care by updating and extending an earlier systematic review. A systematic review following Centre for Reviews and Dissemination guidelines involved updating electronic searches, and extending them to cover paediatric home care for short-term acute conditions. Twenty-one databases were searched from 1990 to April 2007. Hand searching was also carried out. Pairs of team members, guided by an algorithm, selected randomized controlled trials (RCTs), other comparative studies and studies including health economics data. A third reviewer resolved any disagreements. The quality of RCTs was assessed, but a 'best-evidence' approach was taken overall. Data were extracted into specifically designed spreadsheets and a second team member checked all data. Narrative synthesis was used throughout. This paper reports findings from RCTs and studies with health economics data. In total, 16 570 publications were identified after de-duplication. Eleven new RCTs (reported in 17 papers) and 20 papers with health economics data were included and reviewed. Evidence on costs and effectiveness of paediatric home care has not grown substantially since the previous review, but this updated review adds weight to the conclusion that it can deliver equivalent clinical outcomes for children and not impose a greater burden on families. Indeed, in some cases, there is evidence of reduced burden and costs for families compared with hospital care. There is also growing evidence, albeit based on weaker evidence, that paediatric home care may reduce costs for health services, particularly for children with complex and long-term needs.

A qualitative study of patient perspectives of health-related quality of life in colorectal cancer: comparison with disease-specific evaluation tools.

AIM: Little is known about the factors that patients with colorectal cancer (CRC) consider as important in shaping their health-related quality of life (HrQoL) and whether these are adequately represented by currently used HrQoL instruments. The aim of this study was to determine which areas of HrQoL are important to patients with CRC and to establish whether these areas are represented by validated questionnaires. METHOD: Semi-structured interviews were conducted with 20 patients who were undergoing treatment or follow up for potentially curable CRC. The areas of HrQoL that were important to the patients were identified from the interview data using a qualitative thematic framework analysis. These themes were then compared with the item content of two CRC-specific HrQoL questionnaires, FACT-C and QLQ-C30/CR38. RESULTS: The interviews identified 10 themes considered by patients to be important determinants of their HrQoL. These comprised control, normality, fatigue, uncertainty, information, emotional support, self-image, coping, symptoms and emotionally challenging events. Both HrQoL instruments contained questions that concerned some of the themes identified, but none of the FACT-C scales and only three from QLQ-C30/CR38 produced scores from which clinicians could identify problems in these areas. CONCLUSION: Identifying and addressing areas of concern for patients may assist clinicians in improving HrQoL outcomes. However, validated instruments currently used in CRC provide little information with regard to these areas.

Estimation of the impact of genital warts on health-related quality of life.

OBJECTIVES: One of the two new human papillomavirus (HPV) vaccines protects against HPV types 6 and 11, which cause over 95% of genital warts, in addition to protecting against HPV types 16 and 18. In anticipation of HPV vaccine implementation, the impact of genital warts on health-related quality of life (HRQoL) was measured to assess the potential benefits of the quadrivalent over the bivalent vaccine. METHODS: Genitourinary medicine clinic patients aged 18 years and older with a current diagnosis of genital warts were eligible; 81 consented and were interviewed by a member of the research team. A generic HRQoL questionnaire, the EQ-5D (comprising EQ-5D index and EQ visual analogue scale (VAS) scores) and a disease-specific HRQoL instrument, the CECA10, were administered. Previously established UK population norms were used as a control group for EQ-5D comparisons. RESULTS: Cases (with genital warts) had lower EQ VAS and EQ-5D index scores than controls. After adjusting for age a mean difference between cases and controls 30 years of age and under (n = 70) of 13.9 points (95% CI 9.9 to 17.6, p<0.001) for the EQ VAS and 0.039 points (95% CI 0.005 to 0.068, p = 0.02) on the EQ-5D index (also adjusted for sex) was observed. The difference between cases and controls for the EQ VAS was especially notable in young women. CONCLUSIONS: Genital warts are associated with a significant detriment to HRQoL. The potential added benefit of preventing most cases of genital warts by HPV vaccination should be considered in decisions about which HPV vaccine to implement in the United Kingdom.

Risk factors for fracture in a UK population: a prospective cohort study.

BACKGROUND: Common clinical risk factors for fracture in older women have been identified. To date, most of these risk factors have not been confirmed in a UK population. AIM: To confirm the important risk factors for fracture in older women. DESIGN: Comprehensive cohort study (CCS) with a nested randomized controlled trial. METHODS: The CCS included 4292 women aged >70 years. We assessed potential risk factors for fracture, and followed-up participants for 24 months for incidence of non-vertebral fractures. RESULTS: Odds ratios (ORs) for predicting any non-vertebral fracture were: previous fracture, 2.67 (95%CI 2.10-3.40); a fall in the last 12 months, 2.06 (95%CI 1.63-2.59); and age (per year increase), 1.03 (95%CI 1.01-1.05). ORs for predicting hip fracture were: previous fracture, 2.31 (95%CI 1.31-4.08); low body weight (<58 kg), 2.20 (95%CI 1.28-3.77); maternal history of hip fracture, 1.68 (95%CI 0.85-3.31); a fall in the last 12 months, 2.92 (95%CI 1.70-5.01); and age (per year increase), 1.09 (95%CI 1.04-1.13). ORs for predicting wrist fracture were: previous fracture, 2.29 (95%CI 1.56-3.34); and a fall in the last 12 months, 1.60 (95%CI 1.10-2.31). Being a current smoker was not associated with an increase in risk, and was consistent across all fracture types. DISCUSSION: Older women with the clinical risk factors identified in this study should be investigated for osteoporosis or offered preventive treatment.

Improving the measurement of quality of life in older people: the York SF-12.

To assess whether changing the layout of the SF-12 affected item response rates, we tested two SF-12 formats in a quasi-randomized trial of women aged >or=70 years in two general practices in North Yorkshire. The modified version of the SF-12 ('York SF-12') converted the 'stem and leaf' format of some questions to individual items. We assessed the effect of the two types of questionnaires on item response rates. The difference in overall response rates to the two questionnaires (York SF-12 26.8%; SF-12 29.5%) was not statistically significant (95%CI -1.88% to 7.22%). However, the modified SF-12 had a statistically significantly lower item non-response rate of 8.5%, compared with the 26.6% of the SF-12 (95%CI 11.1%-25.1%). Chronbach's alpha reliability scores for the York SF-12 were also slightly better than for the older version. The York version of the SF-12 is an improvement on the original questionnaire. We recommend that the York SF-12 be used in preference to the SF-12 when surveying an older population.