Tonsillectomy: a cost-effective option for childhood sore throat? Further analysis of a randomized controlled trial.

OBJECTIVE: To compare the estimated cost-effectiveness of childhood (adeno)tonsillectomy vs medical therapy for recurrent sore throats from the intention-to-treat (ITT) analysis of a randomized controlled trial (RCT) with that modeled on the recorded timing of surgical interventions as observed in all participants irrespective of their original group allocation. STUDY DESIGN: A pragmatic RCT (trial) with a parallel nonrandomized patient preference group (cohort) of (adeno)tonsillectomy vs medical therapy. SETTING: Five secondary care UK otolaryngology departments. SUBJECTS AND METHODS: Eligible children, aged 4 to 15 years, were enrolled to the trial (268) or cohort (461) groups. Outcomes included sore throat diaries, quality of life, and general practice consultations. The RCT protocol ITT analysis was compared with an as-treated analysis incorporating the cohort group, modeled to reflect the timing of tonsillectomy and the differential switch rates among the original groups. RESULTS: In the RCT ITT analysis, tonsillectomy saved 3.5 sore throats, whereas the as-treated model suggested an average reduction of more than 8 sore throats in 2 years for surgery within 10 weeks of consultation, falling to only 3.5 twelve months later due to the spontaneous improvement in the medical therapy group. CONCLUSION: In eligible UK school-age children, tonsillectomy can save up to 8 sore throats at a reasonable cost, if performed promptly. Further prospective data collection, accounting for baseline and per-trial preferences and choice, is urgently needed.

Intervention against excessive alcohol consumption in primary health care: a survey of GPs' attitudes and practices in England 10 years on.

AIMS: To ascertain the views of general practitioners (GPs) regarding the prevention and management of alcohol-related problems in practice, together with perceived barriers and incentives for this work; to compare our findings with a comparable survey conducted 10 years earlier. METHODS: In total, 282 (73%) of 419 GPs surveyed in East Midlands, UK, completed a postal questionnaire, measuring practices and attitudes, including the Shortened Alcohol and Alcohol Problems Perception Questionnaire (SAAPPQ). RESULTS: GPs reported lower levels of post-graduate education or training on alcohol-related issues (<4 h for the majority) than in 1999 but not significantly so (P = 0.031). In the last year, GPs had most commonly requested more than 12 blood tests and managed 1-6 patients for alcohol. Reports of these preventive practices were significantly increased from 1999 (P < 0.001). Most felt that problem or dependent drinkers' alcohol issues could be legitimately (88%, 87%) and adequately (78%, 69%) addressed by GPs. However, they had low levels of motivation (42%, 35%), task-related self-esteem (53%, 49%) and job satisfaction (15%, 12%) for this. Busyness (63%) and lack of training (57%) or contractual incentives (48%) were key barriers. Endorsement for government policies on alcohol was very low. CONCLUSION: Among GPs, there still appears to be a gap between actual practice and potential for preventive work relating to alcohol problems; they report little specific training and a lack of support. Translational work on understanding the evidence-base supporting screening and brief intervention could incentivize intervention against excessive drinking and embedding it into everyday primary care practice.

'I've just taken you to see the man with the CD on his head': the experience and management of recurrent sore throat in children.

Tonsillectomies for children with recurrent sore throat are common. There is a perception amongst medical professionals that parents are eager for surgical intervention but the parent/child perspective is overlooked in the literature. This study aimed to identify parent/child experience of recurrent sore throat. The study was qualitative, using grounded theory approach to data collection/analysis. Semi-structured, in-depth, interviews were conducted with 12 dyads of children (aged 4-16) and their parents, attending two Ear, Nose and Throat outpatient clinics held at a hospital in North East England, referred by their General Practitioner for recurrent sore throats. Analysis revealed recurrent sore throats significantly affected the families' quality of life. Families felt the need for antibiotics and tonsillectomies although parent and child were not always in agreement over their choice of treatment. Families felt empowered when the health care system showed some flexibility, such as allowing self re-referral, giving families greater choice in the way they managed the condition. Policy makers need to be aware of the consequences of recurrent sore throats in children and the needs of families in managing this chronic condition. More flexible approaches to health care, such as self re-referral and use of waiting list to review symptoms, may be needed if the number of tonsillectomies is to be reduced.

Childhood tonsillectomy: who is referred and what treatment choices are made? Baseline findings from the North of England and Scotland Study of Tonsillectomy and Adenotonsillectomy in Children (NESSTAC).

BACKGROUND: Tonsillectomies are frequently performed, yet variations exist in tonsillectomy rates. Clinicians use guidelines, but complex psychosocial influences on childhood tonsillectomy include anecdotal evidence of parental enthusiasm. Studies indicate that undergoing preferred treatment improves outcome. Despite the enthusiasm with which tonsillectomy is offered and sought, there is little evidence of efficacy. This resulted in a randomised controlled trial to evaluate the cost-effectiveness of (adeno)tonsillectomy in children with recurrent sore throats. OBJECTIVE: To compare characteristics of children entering the randomised trial with those recruited to a parallel, non-randomised study, to establish trends in referral and patient preferences for treatment. DESIGN: Baseline data from a randomised controlled trial with parallel non-randomised preference study, comparing surgical intervention with medical treatment in children aged 4-15 years with recurrent sore throat referred to five secondary care otolaryngology departments located in the north of England or west central Scotland. RESULTS: Centres assessed 1546 children; 21% were not eligible for tonsillectomy. Among older children (8-15 years), girls were significantly more likely to be referred to secondary care. Of 1015 eligible children, 268 (28.2%) agreed to be randomised, while 461 (45.4%) agreed to the parallel, non-randomised preference study, with a strong preference for tonsillectomy. Participants reporting that progress at school had been impeded or with more experience of persistent sore throat were more likely to seek tonsillectomy. Referred boys were more likely than girls to opt for medical treatment. Socio-economic data showed no effect. CONCLUSION: Preference for tonsillectomy reflects educational impact and recent experience, rather than age or socio-economic status.

Protocol for north of England and Scotland study of tonsillectomy and adeno-tonsillectomy in children (NESSTAC). A pragmatic randomised controlled trial comparing surgical intervention with conventional medical treatment in children with recurrent sore throats.

BACKGROUND: Uncertainties surrounding the effectiveness and cost-effectiveness of childhood tonsillectomy for recurrent sore throat led the NHS Health Technology Assessment Programme to commission this research to evaluate the effectiveness and cost-effectiveness of tonsillectomy and adeno-tonsillectomy in comparison with standard non-surgical management in children aged under 16 with recurrent throat infections. The aim is to evaluate if tonsillectomy and adeno-tonsillectomy reduces the number of episodes of sore throats among children to a clinically significant extent. METHODS/DESIGN: A simple prospective pragmatic randomised controlled trial with economic analysis and prospective cohort study of non-trial participants comparing surgical intervention with conventional medical treatment. The treatment arm will receive tonsillectomy and adeno-tonsillectomy while in the control arm non-surgical conventional medical treatment only will be used. The primary outcome measure will be reported number of episodes of sore throat over two years with secondary outcomes measures of reported number of episodes of sore throat, otitis media and upper respiratory tract infection which invoke a GP consultation; reported number of symptom-free days; reported severity of sore throats and surgical and anaesthetic morbidity. The study will take place in five hospitals in the UK. The trial population will be 406 children aged 4-15 on their last birthday with recurrent sore throat referred by primary care to the 5 otolaryngology departments. The duration of the study is seven years (July 2001-July 2008). DISCUSSION: As with all pragmatic randomised controlled trials it is impossible to control the external environment in which the research is taking place. Since this trial began a number of factors have arisen which could affect the outcome including; a reduction in the incidence of respiratory tract infections, marked socio-economic differences in consultation rates, the results from the National Prospective Tonsillectomy Audit and the Government's waiting list initiatives.

Effectiveness of nurse-led brief alcohol intervention: a cluster randomized controlled trial.

AIM: This paper reports an evaluation of the effectiveness and cost-effectiveness of nurse-led screening and brief intervention in reducing excessive alcohol consumption among patients in primary health care. BACKGROUND: Excessive alcohol consumption is a major source of social, economic and health problems. However, such consumption is responsive to brief alcohol intervention. To date, brief intervention research in primary health care has focused on general practitioner-led interventions, and there is only circumstantial evidence of effectiveness in nurse-led interventions. However, nurses are increasingly taking a lead in health promotion work in primary care. METHODS: A pragmatic cluster-randomized controlled trial was carried out between August 2000 and June 2003 to evaluate the effects of a brief intervention compared with standard advice (control condition). A total of 40 general practice clusters (intervention = 21 and control = 19) recruited 127 patients (intervention = 67 and control = 60) to the trial. Excessive consumption was identified opportunistically via the Alcohol Use Disorders Identification Test. After baseline assessment, patients received either a 5-10 minutes brief intervention using the 'Drink-Less' protocol or standard advice (control condition). Follow-up occurred at 6 and 12 months postintervention. RESULTS: Analysis of variance weighted for cluster size revealed no statistically significant differences between intervention and control patients at follow up. A majority of patients in both conditions reduced their alcohol consumption between assessment and subsequent measurement. Economic analysis suggested that the brief intervention led to no statistically significant changes in subsequent health service resource use relative to standard treatment. CONCLUSION: The brief intervention evaluated in this trial had no effect over standard advice delivered by nurses in primary health care. However, there was a reduction in excessive drinking across both arms of the trial over time. Due to nurse drop-out, this trial was significantly underpowered. Future research should explore barriers to nurses' involvement in research trials, particularly with an alcohol focus. A larger trial is required to evaluate the effectiveness of nurse-led screening and brief alcohol intervention in primary care.

Lifestyle interventions to prevent osteoporotic fractures: a systematic review.

The purpose of this study was to evaluate the clinical effectiveness of lifestyle interventions for preventing osteoporotic fractures in people at high risk. Data sources were electronic bibliographic databases, reference lists of systematic reviews, meta-analyses and included trials, registers of trials and conference databases. There was no language restriction. Study selection comprised randomized controlled trials (RCTs), with appropriate comparator groups and at least 8 weeks of follow-up, reporting a fracture endpoint. Two reviewers independently abstracted data on the population, interventions evaluated, trial quality and outcomes of interest: fractures at any site, spinal, hip and wrist fractures. Six RCTs, enrolling over 1,656 participants, met the inclusion criteria. Overall, trials were of uncertain quality. We categorized trials by type of intervention: exercise (n=3), multifactorial interventions (environmental modifications, exercise programs and review of medical conditions, medication and aids) (n=2) and exposure to sunlight (n=1), and used random effects meta-analyses to combine data within these categories. Exercise was associated with a non-significantly lower risk of spinal fractures (RR=0.52, 95% CI=0.17 to 1.60). Multifactorial interventions were associated with a lower risk of hip fracture, which was of borderline statistical significance (RR=0.37, 95% CI=0.13 to 1.03). Exposure to sunlight was associated with a non-significantly lower risk of hip fracture (RR=0.17, 95% CI=0.02 to 1.35). While withdrawals from treatment were poorly reported, there was no indication of adverse effects of treatment. Multifactorial interventions may reduce the risk of hip fractures when delivered by residential care staff and health visitors. More RCTs of higher quality, recording fractures at all sites susceptible to osteoporotic fractures, are necessary to evaluate exercise interventions, exposure to sunlight and the place of lifestyle alongside pharmacological interventions.

Implementation of brief alcohol interventions by nurses in primary care: do non-clinical factors influence practice?

BACKGROUND: In the UK, GPs and practice nurses selectively provide brief alcohol interventions to risk drinkers. GPs' provision of a brief alcohol intervention can be predicted by patient characteristics, practitioner characteristics and structural factors such as the features of the practice and how it is organized. However, much less is known about possible modifiers of nurse practice. OBJECTIVE: Our aim was to investigate if patient characteristics, nurse characteristics and practice factors influence provision of a brief alcohol intervention by practice nurses in primary health care. METHODS: One hundred and twenty-eight practice nurses who had implemented a brief alcohol intervention programme in a previous trial based in the North of England were requested to screen adults presenting to their surgery and follow a structured protocol to give a brief intervention (5 min of advice plus an information booklet) to all 'risk' drinkers. Anonymized carbon copies of 5541 completed Alcohol Use Disorders Identification Test (AUDIT) screening questionnaires were collected after a 3-month implementation period and analysed by logistic regression analysis. RESULTS: Although AUDIT identified 1500 'risk' drinkers, only 926 (62%) received a brief intervention. Logistic regression modelling showed that patients' risk status as measured by AUDIT score was the most influential predictor of a brief intervention by practice nurses. However, risk drinkers who were most likely to receive a brief intervention were male. Patients' age or social class did not independently predict a brief intervention. The multilevel model was unable to identify any independent nurse characteristics that could predict a brief intervention, but indicated significant variation between nurses in their tendency to offer the intervention to patients. No structural factors were found to be positively associated with selective provision. CONCLUSIONS: Patient and nurse factors contributed to the selective provision of a brief intervention in primary care. If patients are to experience the beneficial effects of a brief alcohol intervention, then there is a need to improve the accuracy of delivery.

Promoting brief alcohol intervention by nurses in primary care: a cluster randomised controlled trial.

This trial evaluated the clinical impact and cost-effectiveness of strategies promoting screening and brief alcohol intervention (SBI) by nurses in primary care. Randomisation was at the level of the practice and the interventions were: written guidelines (controls, n=76); outreach training (n=68); and training plus telephone-based support (n=68). After 3 months, just 39% of controls implemented the SBI programme compared to 74% of nurses in trained practices and 71% in trained and supported practices. Controls also screened fewer patients and delivered fewer brief interventions to risk drinkers than other colleagues. However, there was a trade-off between the extent and the appropriateness of brief intervention delivery with controls displaying the least errors in overall patient management. Thus cost-effectiveness ratios (cost per patient appropriately treated) were similar between the three strategies. Given the potential for anxiety due to misdirected advice about alcohol-related risk, the balance of evidence favoured the use of written guidelines to promote SBI by nurses in primary care.

A qualitative study of nurses' attitudes and practices regarding brief alcohol intervention in primary health care.

BACKGROUND: Excessive alcohol consumption causes significant mortality, morbidity, economic and social problems in the United Kingdom (UK). Despite strong evidence for the effectiveness of brief intervention to reduce excessive drinking in primary health care, there is little indication that such intervention routinely occurs. AIMS: This study aimed to explore primary health care nurses' attitudes and practices regarding brief alcohol intervention in order to understand why it is underexploited. METHODS: The study design was qualitative, using a grounded theory approach to data collection and analysis. Semi-structured in-depth interviews were conducted with 24 nurses from practices that had previously been involved in a General Practitioner (GP) led brief alcohol intervention trial in the North-east of England. A combination of convenience and purposive sampling was used to recruit subjects and gain a broad range of perspectives on issues emerging from ongoing data-analysis until data saturation occurred. RESULTS: It was clear that although primary health care nurses have many opportunities to engage in alcohol intervention, most have received little or no preparation for this work. This has left nurses at a disadvantage as alcohol consumption is a confusing and emotive area for both health professionals and patients. An analysis of factors influencing nurse involvement in alcohol intervention outlined a requirement for clear health messages about alcohol, training in intervention skills, facilitation to enhance confidence regarding intervention and support to help deal with negative patient reactions. CONCLUSIONS: As current health policy is to encourage, sustain and extend the health promotion and public health role of primary care nurses, more attention should be given to providing them with better preparation and support to carry out such work.