Factors that shape recurrent miscarriage care experiences: findings from a national survey.

BACKGROUND: Learning what matters to women/couples with recurrent miscarriage (RM) is essential to inform service improvement efforts and future RM care practices. Previous national and international surveys have examined inpatient stays, maternity care, and care experiences around pregnancy loss, but there is little focus on RM care. We aimed to explore the experiences of women and men who have received RM care and identify patient-centred care items linked to overall RM care experience. METHODS: Between September and November 2021, we invited people who had experienced two or more consecutive first trimester miscarriages and received care for RM in Ireland in the ten-year period prior to participate in a cross-sectional web-based national survey. The survey was purposefully designed and administered via Qualtrics. It included questions on sociodemographics, pregnancy and pregnancy loss history, investigation and treatment for RM, overall RM care experience, and patient-centred care items at various stages of the RM care pathway such as respect for patients' preferences, information and support, the environment, and involvement of partners/family. We analysed data using Stata. RESULTS: We included 139 participants (97% women, n = 135) in our analysis. Of the 135 women, 79% were aged 35-44 years (n = 106), 24% rated their overall RM care experience as poor (n = 32), 36% said the care they received was much worse than expected (n = 48), and 60% stated health care professionals in different places did not work well together (n = 81). Women were more likely to rate a good care experience if they had a healthcare professional to talk to about their worries/fears for RM investigations (RRR 6.11 [95% CI: 1.41-26.41]), received a treatment plan (n = 70) (RRR 3.71 [95% CI: 1.28-10.71]), and received answers they could understand in a subsequent pregnancy (n = 97) (RRR 8 [95% CI: 0.95-67.13]). CONCLUSIONS: While overall experience of RM care was poor, we identified areas that could potentially improve people's RM care experiences - which have international relevance - such as information provision, supportive care, communication between healthcare professionals and people with RM, and care coordination between healthcare professionals across care settings.

Effects of maternal stress and/or anxiety interventions in the first 1000 days:Systematic review of reviews.

OBJECTIVE: Effective interventions are needed to mitigate effects of stress and anxiety from conception and up to two years postpartum (the first 1000 days), but it is unclear what works, for what populations and at what time points. This review aimed to synthesise evidence from existing reviews of the effects of stress and anxiety interventions. METHODS: A systematic review of systematic reviews was conducted. PsycINFO, CINAHL, MEDLINE and the Cochrane databases were searched (inception to January 2020). Reviews were eligible if they examined effects of interventions during the first 1000 days on women's stress and/or anxiety. Extracted data were narratively synthesised. Review quality was assessed using existing recommendations including the AMSTAR tool . RESULTS: Thirty-four reviews were eligible for inclusion; 21 demonstrated high methodological quality. Cognitive behavioural therapy demonstrates some beneficial effects for anxiety across the first 1000 days for general and at-risk populations. Support-based interventions demonstrate effects for stress and anxiety for at-risk mothers in the postpartum. Music, yoga and relaxation demonstrate some effects for stress and anxiety, but studies are limited by high risk of bias. CONCLUSION: Existing evidence is inconsistent. Cognitive behavioural therapy and support-based interventions demonstrate some benefits. Further methodologically and conceptually robust research is needed.

Enhancing referral processes within an integrated fall prevention pathway for older people: a mixed-methods study.

OBJECTIVES: Multifactorial interventions, which involve assessing an individual's risk of falling and providing treatment or onward referral, require coordination across settings. Using a mixed-methods design, we aimed to develop a process map to examine onward referral pathways following falls risk assessment in primary care. SETTING: Primary care fall risk assessment clinics in the South of Ireland. PARTICIPANTS: Focus groups using participatory mapping techniques with primary care staff (public health nurses (PHNs), physiotherapists (PT),and occupational therapists (OT)) were conducted to plot the processes and onward referral pathways at each clinic (n=5). METHODS: Focus groups were analysed in NVivo V.12 using inductive thematic analysis. Routine administrative data from January to March 2018 included details of client referrals, assessments and demographics sourced from referral and assessment forms. Data were analysed in Stata V.12 to estimate the number, origin and focus of onward referrals and whether older adults received follow-up interventions. Quantitative and qualitative data were analysed separately and integrated to produce a map of the service. RESULTS: Nine staff participated in three focus groups and one interview (PHN n=2; OT n=4; PT n=3). 85 assessments were completed at five clinics (female n=69, 81.2%, average age 77). The average number of risk factors was 5.4 out of a maximum of 10. Following assessment, clients received an average of three onward referrals. Only one-third of referrals (n=135/201, 33%) had data available on intervention receipt. Primary care staff identified variations in how formally onward referrals were managed and barriers, including a lack of client information, inappropriate referral and a lack of data management support. CONCLUSION: Challenges to onward referral manifest early in an integrated care pathway, such as clients with multiple risk factors sent for initial assessment and the lack of an integrated IT system to share information across settings.

Investigating group-based classes ('weaning workshops') to support complementary infant feeding in Irish primary care settings: a cross-sectional survey.

OBJECTIVE: This study aims to (1) investigate current practice regarding 'weaning workshops' to support complementary infant feeding delivered within Irish primary care, (2) explore the experiences and opinions of community dietitians regarding optimal content and modes of delivery of weaning workshops and (3) identify the key factors to be considered in the development and implementation of weaning workshops delivered within primary care. DESIGN: Cross-sectional survey. SETTING: Irish primary care. PARTICIPANTS: Forty-seven community-based dietitians. RESULTS: Sixteen dietitians reported that workshops were run in their area with variable frequency, with ten reporting that workshops were never run in their area. Participants reported that mostly mothers of medium socio-economic status (SES) attended weaning workshops when infants were aged between 4 and 7 months, and that feedback from workshop attendees was predominantly positive. Dietitians identified that key factors to be considered in future development and delivery of weaning workshops are (1) workshop characteristics such as content, timing and venue, (2) organisational characteristics such as availability of resources and multidisciplinary involvement and (3) attendee characteristics such as SES. CONCLUSIONS: This study highlights substantial variability regarding provision of weaning workshops in Ireland, and a lack of standardisation regarding the provider, content and frequency of workshops where workshops are being delivered. The study also provides unique insights into the experiences and opinions of primary care community dietitians regarding the development and delivery of weaning workshops in terms of optimal content and delivery options. These perspectives will make a valuable contribution given the dearth of evidence in this area internationally.

Exploring healthcare professionals' views of the acceptability of delivering interventions to promote healthy infant feeding practices within primary care: a qualitative interview study.

OBJECTIVE: Early-life nutrition plays a key role in establishing healthy lifestyles and preventing chronic disease. This study aimed to (1) explore healthcare professionals' (HCP) opinions on the acceptability of and factors influencing the delivery of interventions to promote healthy infant feeding behaviours within primary care and (2) identify proposed barriers/enablers to delivering such interventions during vaccination visits, to inform the development of a childhood obesity prevention intervention. DESIGN: A qualitative study design was employed using semi-structured telephone interviews. Data were analysed using qualitative content analysis; findings were also mapped to the Theoretical Framework of Acceptability (TFA). SETTING: Primary care in Ireland. PARTICIPANTS: Twenty-one primary care-based HCP: five practice nurses, seven general practitioners, three public health nurses, three community dietitians and three community medical officers. RESULTS: The acceptability of delivering interventions to promote healthy infant feeding within primary care is influenced by the availability of resources, HCP's roles and priorities, and factors relating to communication and relationships between HCP and parents. Proposed barriers and enablers to delivering interventions within vaccination visits include time constraints v. opportunistic access, existing relationships and trust between parents and practice nurses, and potential communication issues. Barriers/enablers mapped to TFA constructs of Affective Attitude, Perceived Effectiveness and Self-Efficacy. CONCLUSIONS: This study provides a valuable insight into HCP perspectives of delivering prevention-focused infant feeding interventions within primary care settings. While promising, factors such as coordination and clarity of HCP roles and resource allocation need to be addressed to ensure acceptability of interventions to HCP involved in delivery.

Fidelity of Interventions to Reduce or Prevent Stress and/or Anxiety from Pregnancy up to Two Years Postpartum: A Systematic Review.

INTRODUCTION: Intervention fidelity refers to whether an intervention is delivered as intended and can enhance interpretation of trial outcomes. Fidelity of interventions to reduce or prevent stress and anxiety during pregnancy and postpartum has yet to be examined despite inconsistent findings for intervention effects. This study systematically reviews use and/or reporting of intervention fidelity strategies in trials of interventions, delivered to (expectant) parents during pregnancy and postpartum, to reduce or prevent stress and/or anxiety. METHODS: MEDLINE, Embase, CINAHL, PsychINFO, and Maternity and Infant Care were searched from inception to March 2019. Studies were included if they were randomised controlled trials including pregnant women, expectant fathers and/or partners during pregnancy, and/ or parents within the first two years postpartum. The National Institutes of Health Behavior Change Consortium checklist was used to assess fidelity across five domains (study design, provider training, delivery, receipt, enactment). RESULTS: Sixteen papers (14 interventions) were identified. Average reported use of fidelity strategies was 'low' (45%), ranging from 17.5 to 76%. Fidelity ratings ranged from 22% for provider training to 54% for study design. CONCLUSIONS: Low levels of intervention fidelity may explain previous inconsistent effects of stress and anxiety reduction interventions. Important methodological areas for improvement include intervention provider training, fidelity of comparator conditions, and consideration of non-specific treatment effects. Increased methodological rigour in fidelity enhancement and assessment will improve intervention implementation and enhance examination of stress and anxiety reduction and prevention interventions delivered during pregnancy and the postpartum.

Effects of interventions for women and their partners to reduce or prevent stress and anxiety: A systematic review.

BACKGROUND: The period from conception to two years postpartum (the first 1000 days) represents a normative transitional period, which can be potentially stressful for some parents. Parental stress and anxiety adversely impacts psychological and physical health for parents and children. AIM: The aim of this review is to systematically examine effects of interventions for women and their partners to reduce or prevent stress and/or anxiety during the first 1000 days. METHODS: MEDLINE, Embase, CINAHL, PsychINFO, and Maternity and Infant Care were searched from inception to March 2019. Randomised controlled trials examining intervention effects on parental stress and/or anxiety during first 1000 days were eligible for inclusion. Data were independently extracted by two reviewers and narratively synthesised. FINDINGS: Fifteen interventions, reported in 16 studies, met inclusion criteria (n=1911 participants). Overall, findings were inconsistent and the majority of trials demonstrated high risk of bias. Interventions were predominantly delivered to women during pregnancy and only two studies included fathers. There was some evidence that adapting interventions to the pre and postnatal periods provided benefits for stress and anxiety reduction, however there was limited evidence for individual intervention types or approaches. CONCLUSIONS: There is currently inconsistent evidence of what interventions are most effective for women during the first 1000 days and there is insufficient evidence for any interventions for male partners during this period. There is a clear need for rigorous development and examination of interventions developed specifically to reduce or prevent stress and/or anxiety across the first 1000 days.

Maternal stress in the first 1000 days and risk of childhood obesity: a systematic review.

Objective: Maternal stress is associated with adverse child outcomes. Conception to 2-years postpartum (the first 1000 days) is a developmentally sensitive period for stress exposure. The role of maternal stress in the first 1000 days on child obesity risk is unclear. This review systematically examines the relationship between maternal stress across the first 1000 days and child obesity risk. Methods: The Cochrane Library, MEDLINE, PsycINFO, EMBASE, CINAHL, and Maternity and Infant Care were searched from inception to June 2018. Eligible studies included women who experienced maternal stress in the first 1000 days; an included a measure of maternal stress and of child anthropometrics. Results: Sixteen studies met inclusion criteria, the majority of these examined prenatal stress exposure. Inconsistent effects were observed for psychological and physiological stress responses, on child weight outcomes. Environmental stress exposures, including natural disaster and bereavement, were more consistently associated with increased obesity risk. Conclusion: This review does not provide support for the effects of psychological or physiological maternal stress on child weight outcomes; there is some evidence of associations between environmental stress exposures and greater childhood adiposity. Variation in conceptualisation and measurement of stress, timing of stress exposure, and limited examination of stress-related behaviours were noted.

Dietary behaviours and weight management: A thematic analysis of pregnant women's perceptions.

Maternal obesity is associated with increased risk of gestational diabetes and other complications. Although antenatal interventions to help prevent these complications are ongoing, an understanding of overweight and obese pregnant women's opinions and attitudes is lacking. Therefore, this study aims to explore these women's experiences and perceptions of dietary behaviours and weight management during pregnancy. Secondary analysis of qualitative data originally collected to examine lifestyle behaviours in pregnant women was conducted. The data were from a purposive sample of overweight and obese pregnant women attending a public antenatal clinic in Cork, Ireland. The data were explored using thematic analysis. Interviews with 30 overweight and obese pregnant women were analysed. Three themes were developed relating to overweight and obese women's dietary behaviours and weight management perceptions including 'pregnancy's influence on dietary behaviours', 'external influences on dietary behaviours' and 'perception of and preferences for weight related advice and resources'. Together these themes reveal women's experiences of diet and how pregnancy factors (physiological changes) and external factors (family and friends) can influence dietary behaviours. Furthermore, perceptions of weight management advice and lack thereof were highlighted with women drawing attention to potential resources for future use during pregnancy. This study provides important insights into overweight and obese pregnant women's dietary behaviours and perceptions of weight management. According to these findings, there is a need for clear and unambiguous information about weight management, acceptable weight gain, food safety and how to achieve a balanced diet.

Effectiveness of physical activity interventions for overweight and obesity during pregnancy: a systematic review of the content of behaviour change interventions.

BACKGROUND: Behaviour change techniques (BCTs) employed within PA intervention for pregnant women with a healthy body mass index (BMI) have been previously identified, however, these BCTS may differ for other weight profiles during pregnancy. The aim of this current review was to identify and summarise the evidence for effectiveness of PA interventions on PA levels for pregnant women with overweight and obesity, with an emphasis on the BCTs employed. METHODS: A systematic review and meta-analysis of PA intervention studies using the PRISMA statement was conducted. Searches were conducted of eight databases in January 2019. Strict inclusion/exclusion criteria were employed. The validity of each included study was assessed using the Cochrane Collaboration's tool for assessing risk of bias. The primary outcome measure was change in PA levels, subjectively or objectively measured, with physical fitness as a secondary outcome. All intervention descriptions were double coded by two authors using Michie's et al's BCT taxonomy V1. Meta-analyses using random effect models assessed the intervention effects on PA. Other PA outcomes were summarised in a narrative synthesis. RESULTS: From 8389 studies, 19 met the inclusion criteria 13 of which were suitable for inclusion in a meta-analysis. The remaining 6 studies were described narratively due to insufficient data and different outcome measures reported. In the meta-analysis, comparing interventions to a control group, significant increases were found in the intervention group for metabolic equivalent (SMD 0.39 [0.14, 0.64], Z = 3.08 P = 0.002) and physical fitness (VO2 max) (SMD 0.55 [0.34, 0.75], Z = 5.20 P = < 0.001). Of the other six, five studies reported an increase in PA for the intervention group versus the control with the other study reporting a significant decrease for women in their 3rd trimester (p = 0.002). 'Self-monitoring of behaviour' was the most frequently used BCTs (76.5%), with 'social support' being newly identified for this pregnant population with overweight or obesity. CONCLUSIONS: This review identified a slight increase in PA for pregnant women with overweight and obesity participating in interventions. However, due to the high risk of bias of the included studies, the results should be interpreted with caution. PA measures should be carefully selected so that studies can be meaningfully compared and standardised taxonomies should be used so that BCTs can be accurately assessed.

Choosing Healthy Eating for Infant Health (CHErIsH) study: protocol for a feasibility study.

INTRODUCTION: Childhood obesity is a public health challenge. There is evidence for associations between parents' feeding behaviours and childhood obesity risk. Primary care provides a unique opportunity for delivery of infant feeding interventions for childhood obesity prevention. Implementation strategies are needed to support infant feeding intervention delivery. The Choosing Healthy Eating for Infant Health (CHErIsH) intervention is a complex infant feeding intervention delivered at infant vaccination visits, alongside a healthcare professional (HCP)-level implementation strategy to support delivery. METHODS AND ANALYSIS: This protocol provides a description of a non-randomised feasibility study of an infant feeding intervention and implementation strategy, with an embedded process evaluation and economic evaluation. Intervention participants will be parents of infants aged ≤6 weeks at recruitment, attending a participating HCP in a primary care practice. The intervention will be delivered at the infant's 2, 4, 6, 12 and 13 month vaccination visits and involves brief verbal infant feeding messages and additional resources, including a leaflet, magnet, infant bib and sign-posting to an information website. The implementation strategy encompasses a local opinion leader, HCP training delivered prior to intervention delivery, electronic delivery prompts and additional resources, including a training manual, poster and support from the research team. An embedded mixed-methods process evaluation will examine the acceptability and feasibility of the intervention, the implementation strategy and study processes including data collection. Qualitative interviews will explore parent and HCP experiences and perspectives of delivery and receipt of the intervention and implementation strategy. Self-report surveys will examine fidelity of delivery and receipt, and acceptability, suitability and comprehensiveness of the intervention, implementation strategy and study processes. Data from electronic delivery prompts will also be collected to examine implementation of the intervention. A cost-outcome description will be conducted to measure costs of the intervention and the implementation strategy. ETHICS AND DISSEMINATION: This study received approval from the Clinical Research Ethics Committee of the Cork Teaching Hospitals. Study findings will be disseminated via peer-reviewed publications and conference presentations.

Social, biological, behavioural and psychological factors related to physical activity during early pregnancy in the Screening for Pregnancy Endpoints (Cork, Ireland) cohort study.

OBJECTIVE: The aim of this study was to identify the social, biological, behavioural and psychological factors related to physical activity (PA) in early pregnancy. DESIGN: This is a secondary analysis of data from a prospective cohort study. SETTING: The study was conducted in Cork, Ireland. PARTICIPANTS: Nulliparous women with singleton pregnancies were recruited and then interviewed at 15±1 weeks' gestation. PRIMARY AND SECONDARY OUTCOMES: The biopsychosocial model identified factors including social (age), biological (body mass index), behavioural (diet) and psychological (anxiety) at 15±1 weeks' gestation. PA subgroups were identified based on a latent class analysis of their responses to a set of questions about the amount and intensity of activity they were engaging in during the pregnancy. Associations were estimated with multivariable multinomial logistic regression models. RESULTS: From a total of 2579, 1774 (69%) women were recruited; ages ranged from 17 to 45 years. Based on a combination of model fit, theoretical interpretability and classification quality, the latent class analyses identified three PA subgroups: low PA (n=393), moderate PA (n=960) and high PA (n=413). The fully adjusted model suggests non-smokers, and consumers of fruit and vegetables were more likely to be in the high PA subgroup (vs low). Women with more than 12 years of schooling and a higher socioeconomic status were more likely to be in the moderate PA subgroup (vs low). CONCLUSION: The findings highlight potential links between PA, a low education level and a low socioeconomic background. These factors should be considered for future interventions to improve low PA levels during pregnancy. TRIAL REGISTRATION NUMBER: ACTRN 12607000551493.

Behaviour change techniques and theory use in healthcare professional-delivered infant feeding interventions to prevent childhood obesity: a systematic review.

The conceptual basis of early childhood feeding interventions for obesity prevention is poorly understood. The aim of this systematic review is to characterise these interventions' use of behaviour change techniques (BCTs) and psychological theory, focusing on interventions delivered by healthcare professionals for children ≤ 2 years. We searched seven electronic databases from inception to January 2019 and identified 12 trials. BCTs and theory use were identified using the Behaviour Change Technique Taxonomy v1 and the Theory Coding Scheme respectively. Interventions used 19 BCTs, most commonly 'Instruction on how to perform the behaviour' (12 of 12 studies) and 'Social support (unspecified)' (8 of 12 studies). The mean number of BCTs used was 5.1. Six trials explicitly stated basing interventions on theory, most commonly social cognitive theory and responsive feeding (4 of 6 studies each). Links between theory use and BCTs were poor. Early childhood feeding interventions have insufficiently integrated psychological theories into their development and evaluation. We recommend greater consideration of psychological theory incorporating family and systems approaches and responsive feeding in future intervention development. Moreover, these theories should explicitly link with BCTs. These theories and BCTs should also be included in the evaluation phase.

Exploring obstetricians', midwives' and general practitioners' approach to weight management in pregnant women with a BMI ≥25 kg/m2: a qualitative study.

OBJECTIVE: The aim of this study was to explore healthcare professionals' (HCPs) beliefs and attitudes towards weight management for pregnant women with a body mass index (BMI) ≥25 kg/m2. DESIGN: Qualitative study. SETTING: A public antenatal clinic in a large academic maternity hospital in Cork, Ireland, and general practice clinics in the same region. PARTICIPANTS: HCPs such as hospital-based midwives and consultant obstetricians and general practitioners (GPs). METHOD: Semistructured interviews were conducted with a purposive sample of hospital-based HCPs and a sample of GPs working in the same region. Interviews were recorded, transcribed and thematically analysed using NVivo software. RESULTS: Seventeen HCPs were interviewed (hospital based=10; GPs=7). Four themes identified the complexity of weight management in pregnancy and the challenges HCPs faced when trying to balance the medical and psychosocial needs of the women. HCPs acknowledged weight as a sensitive conversation topic, leading to a 'softly-softly approach' to weight management. HCPs tried to strike a balance between being woman centred and empathetic and medicalising the conversation. HCPs described 'doing what you can with what you have' and shifting the focus to managing obstetric complications. Furthermore, there were unclear roles and responsibilities in terms of weight management. CONCLUSION: HCPs need to have standardised approaches and evidence-based guidelines that support the consistent monitoring and management of weight during pregnancy.

Goal-setting in diabetes self-management: A systematic review and meta-analysis examining content and effectiveness of goal-setting interventions.

BACKGROUND: Goal-setting is recommended and widely used within diabetes self-management programmes. However, empirical evidence around its effectiveness lacks clarity. This review aims to evaluate the effectiveness of goal-setting interventions on diabetes outcomes and to determine which behaviour change techniques (BCTs) are frequently used within these interventions. METHODS: A systematic search identified 14 studies, describing 12 interventions targeting diabetic-control which incorporated goal-setting as the main intervention strategy. Study characteristics, outcome measures and effect sizes of the included studies were extracted and checked by two authors. The BCT taxonomy v1 was used to identify intervention content. Meta-analyses were conducted to assess intervention effects on the primary outcome of average blood glucose levels (HbA1c) and on body-weight. Psycho-social and behavioural outcomes were summarised in narrative syntheses. RESULTS: Significant post-intervention improvements in HbA1C were found (-.22, 95% CI, -.40, -.04) across studies. No other main effects were identified. The BCT 'goal-setting (behaviour)' was most frequently implemented and was identified in 84% of the interventions. CONCLUSIONS: Goal-setting interventions appear to be associated with reduced HbA1C levels. However, the low numbers of studies identified and the risk biases across studies suggest more research is needed to further explore goal-setting BCTs in diabetes self-management.

Community prevalence of long-term urinary catheters use in England.

OBJECTIVES: To calculate the prevalence of long term catheter use in the community in two areas in the south and west of England. SUBJECTS/PATIENTS (OR MATERIALS) AND METHODS: People in England register with general practices to access health care through a National Health Service. Catheters are provided by prescription free of charge. In 2008, patients using urinary catheters for over 3 months were identified, and demographic information collected, from databases of general practices, using catheter prescribing records. The age and sex distributions of people in each practice were obtained from capitation claims. Overall, and age and sex-specific prevalence were calculated separately for each area, and compared. RESULTS: A total of 583 long term catheter users (329 south, 254 west) were identified from 404,328 people registered with practices. The overall population prevalence is similar in both locations (0.146% southern, 0.141% western). Extrapolating for the United Kingdom, this is over 90,000 long term catheter users. Prevalence increases with age (0.732% in over 70 years, 1.224% over 80), especially amongst men. Overall, higher proportions have neurological (vs. non-neurological) reasons (62.9% vs. 37.1%) and use urethral (vs. suprapubic) catheters (59.7% vs. 40.3%). Compared to men, more women tend to use suprapubic (56.4% vs. 29.3%) and have a catheter for neurological reasons (71.8% vs. 56.2%, P = 0.053). CONCLUSIONS: Previous evidence on prevalence of long term catheter use is sparse, and of variable quality. The strength of this study is utilisation of a reliable source of data (catheter prescriptions) from a large population of patients. Neurourol. Urodynam. 36:293-296, 2017. © 2016 Wiley Periodicals, Inc.

Impact of a hospice rapid response service on preferred place of death, and costs.

BACKGROUND: Many people with a terminal illness would prefer to die at home. A new palliative rapid response service (RRS) provided by a large hospice provider in South East England was evaluated (2010) to provide evidence of impact on achieving preferred place of death and costs. The RRS was delivered by a team of trained health care assistants and available 24/7. The purpose of this study was to (i) compare the characteristics of RRS users and non-users, (ii) explore differences in the proportions of users and non-users dying in the place of their choice, (iii) monitor the whole system service utilisation of users and non-users, and compare costs. METHODS: All hospice patients who died with a preferred place of death recorded during an 18 month period were included. Data (demographic, preferences for place of death) were obtained from hospice records. Dying in preferred place was modelled using stepwise logistic regression analysis. Service use data (period between referral to hospice and death) were obtained from general practitioners, community providers, hospitals, social services, hospice, and costs calculated using validated national tariffs. RESULTS: Of 688 patients referred to the hospice when the RRS was operational, 247 (35.9%) used it. Higher proportions of RRS users than non-users lived in their own homes with a co-resident carer (40.3% vs. 23.7%); more non-users lived alone or in residential care (58.8% vs. 76.3%). Chances of dying in the preferred place were enhanced 2.1 times by being a RRS user, compared to a non-user, and 1.5 times by having a co-resident carer, compared to living at home alone or in a care home. Total service costs did not differ between users and non-users, except when referred to hospice very close to death (users had higher costs). CONCLUSIONS: Use of the RRS was associated with increased likelihood of dying in the preferred place. The RRS is cost neutral. TRIAL REGISTRATION: Current controlled trials ISRCTN32119670, 22 June 2012.