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[How has social status been measured in health research? A review of the international literature].
Social status (SS) is a multidimensional variable that is used widely in health research. There is no single optimal method for estimating social status. Rather, in each case the measurement may vary depending on the research subject, the base theory considered, the population of interest, the event of interest and, in some cases, the available information. This literature review develops the following topics related to SS measurement, based on the international scientific sources available electronically: i) identification of the role of SS in the context of social epidemiology research, ii) description of the principal indicators and methodological approaches used to measure SS in health research, and iii) analysis of the distinct difficulties of SS measurement in specific populations such as ethnic groups, women, children, the elderly, and in rural vs. urban contexts. The review finally makes it possible to describe some of the implications of SS measurement in Latin American countries.
Mapping the Oxford hip score onto the EQ-5D utility index.
PURPOSE: To assess different mapping methods for the estimation of a group's mean EQ-5D score based on responses to the Oxford hip score (OHS) questionnaire. METHODS: Four models were considered: a) linear regression using total OHS as a continuous regressor; b) linear regression employing responses to the twelve OHS questions as categorical predictors; c) two-part approach combining logistic and linear regression; and d) response mapping. The models were internally validated on the estimation data set, which included OHS and EQ-5D scores for total hip replacements, both before and six months after procedure for 1,759 operations. An external validation was also performed. RESULTS: All models estimated the mean EQ-5D score within 0.005 of an observed health-state utility estimate, ordinary least squares (OLS) continuous being the most accurate and OLS categorical the most consistent. Age, gender and deprivation did not improve the models. More accurate estimations at the individual level were achieved for higher scores of observed OHS and EQ-5D. CONCLUSION: Based on these results, when EQ-5D scores are not available, answers to the OHS questionnaire can be used to estimate a group's mean EQ-5D with a high degree of accuracy.
PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study.
BACKGROUND: Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. OBJECTIVE: This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. DESIGN: The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. SETTING: The setting was UK primary care general practices. PARTICIPANTS: Participants were patients aged ≥ 3 years with acute sore throat. INTERVENTIONS: An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. MAIN OUTCOME MEASURES: The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2-4 days). RESULTS: The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (-0.33; 95% confidence interval -0.64 to -0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (-0.30; -0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals' concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. CONCLUSIONS: Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals' concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians' perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed. TRIAL REGISTRATION: Current Controlled Trials ISRCTN32027234. SOURCE OF FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 6. See the NIHR Journals Library website for further project information.
Expected Benefits and Budget Impact From a Microsimulation Model Support the Prioritization and Implementation of Fracture Liaison Services.
Osteoporotic-related fractures cause significant patient disability, leading to a growing burden on health care systems. Effective secondary fracture prevention can be delivered by fracture liaison services (FLSs), but these are not available in most countries. A major barrier is insufficient policy prioritization, helped by the lack of economic assessments using national data and providing estimates of patient outcomes alongside health care resource use and cost impacts. The aim of this study was to develop an economic model to estimate the benefits and budget impact of FLSs and support their wider international implementation. Five interconnected stages were undertaken: establishment of a generic patient pathway; model design; identification of model inputs; internal validation and output generation; and scenario analyses. A generic patient pathway including FLS activities was built to underpin the economic model. A state-based microsimulation model was developed to estimate the impact of FLSs compared with current practice for men and women aged 50 years or older with a fragility fracture. The model provides estimates for health outcomes (subsequent fractures avoided and quality-adjusted life years [QALYs]), resource use, and health and social care costs, including those necessary for FLSs to operate, over 5 years. The model was run for an exemplar country the size of the United Kingdom. FLSs were estimated to lead to a reduction of 13,149 subsequent fractures and a gain of 11,709 QALYs. Hospital-bed days would be reduced by 120,989 and surgeries by 6455, while 3556 person-years of institutional social care would be avoided. Expected costs per QALY gained placed FLSs as highly cost-effective at £8258 per QALY gained over the first 5 years. Ten different scenarios were modeled using different configurations of FLSs. Further work to develop country-specific models is underway to delivery crucial national level data to inform the prioritization of FLSs by policy makers. © 2023 The Authors. Journal of Bone and Mineral Research published by Wiley Periodicals LLC on behalf of American Society for Bone and Mineral Research (ASBMR).
Mid- to late-term follow-up of primary hip and knee arthroplasty: the UK SAFE evidence-based recommendations.
To review the evidence and reach consensus on recommendations for follow-up after total hip and knee arthroplasty. A programme of work was conducted, including: a systematic review of the clinical and cost-effectiveness literature; analysis of routine national datasets to identify pre-, peri-, and postoperative predictors of mid-to-late term revision; prospective data analyses from 560 patients to understand how patients present for revision surgery; qualitative interviews with NHS managers and orthopaedic surgeons; and health economic modelling. Finally, a consensus meeting considered all the work and agreed the final recommendations and research areas. The UK poSt Arthroplasty Follow-up rEcommendations (UK SAFE) recommendations apply to post-primary hip and knee arthroplasty follow-up. The ten-year time point is based on a lack of robust evidence beyond ten years. The term 'complex cases' refers to individual patient and surgical factors that may increase the risk for arthroplasty failure. For Orthopaedic Data Evaluation Panel (ODEP) 10A* minimum implants, it is safe to disinvest in routine follow-up from one to ten years post-non-complex hip and knee arthroplasty provided there is rapid access to orthopaedic review. For ODEP 10A* minimum implants in complex cases, or non-ODEP 10A* minimum implants, periodic follow-up post-hip and knee arthroplasty may be required from one to ten years. At ten years post-hip and knee arthroplasty, clinical and radiological evaluation is recommended. After ten years post-hip and knee arthroplasty, frequency of further follow-up should be based on the ten-year assessment; ongoing rapid access to orthopaedic review is still required. Complex cases, implants not meeting the ODEP 10A* criteria, and follow-up after revision surgery are not covered by this recommendation.
Utilization and costs of formal and informal care, home adaptations, and physiotherapy among older patients with hip fracture.
AIMS: This feasibility study investigates the utilization and cost of health resources related to formal and informal care, home adaptations, and physiotherapy among patients aged 60 years and above after hip fracture from a multicentre cohort study (World Hip Trauma Evaluation (WHiTE)) in the UK. METHODS: A questionnaire containing health resource use was completed at baseline and four months post-injury by patients or their carer. Completion rate and mean cost of each health resource item were assessed and sensitivity analysis was performed to derive a conservative estimate of the informal care cost. All costs are presented in 2017/18 pound sterling. RESULTS: A total of 4,183 patients from the WHiTE cohort completed the baseline questionnaire between May 2017 and April 2018, of whom 3,524 (84.2%) completed the four-month health resource section. Estimated mean costs of formal and informal care, home adaptations, and physiotherapy during the four months following injury were £2,843 (SD 5,467), £6,613 (SD 15,146), £706 (SD 1,706) and £9 (SD 33), respectively. Mean cost of informal care decreased to £660 (SD £1,040) in the sensitivity analysis when informal care was capped at 17.2 hours per day. CONCLUSION: Informal care is a significant source of costs after hip fracture and should therefore be included in future economical analyses of this patient group. Our results show that there is considerable variation in the interpretation of time-use of informal care among patients and further work is needed to improve how data regarding informal care are collected in order to obtain a more accurate cost estimate.Cite this article: Bone Joint Res. 2020;9(5):250-257.
Individualised Placement and Support (IPS) for people unemployed with chronic pain: a feasibility study
BACKGROUND: Chronic pain is a common cause of health-related incapacity for work in the UK. Individualised Placement and Support (IPS) is a systematic approach to rehabilitation with emphasis on early funded work placement. It is effective in helping people with severe mental illness to gain employment but has not been tested for chronic pain. OBJECTIVE: To inform the design of a definitive randomised controlled trial to assess the effectiveness of IPS for people unemployed due to chronic pain. METHODS: A mixed methods feasibility study comprising qualitative interviews and focus groups with key stakeholders, alongside a pilot trial. STUDY PARTICIPANTS: Health care professionals from primary care (PCPs), Employment Support Workers (ESWs), employers, clients who participated in an IPS programme, individuals aged 18-64 years with chronic pain unemployed for at least three months. INTERVENTION: An IPS programme integrated with a personalised, responsive pain management plan, backed up by communication with the GP and rapid access to community-based pain services. OUTCOME(S): Stakeholder views about a trial and methods of recruitment. The feasibility and acceptability of the IPS intervention, study processes (including methods to recruit participants from primary care, training and support needs of the ESWs to integrate with pain services, acceptability of randomisation, Treatment As Usual (TAU) comparator) and scoping of outcome measures for a definitive trial. RESULTS: All stakeholders viewed a trial as feasible and important and saw the relevance of employment interventions in this group. Using all suggested methods, recruitment was feasible through primary care but slow and resource-intensive. Recruitment through pain services was more efficient. Fifty people with chronic pain were recruited (37 from primary care and 13 from pain services). Randomisation was acceptable: 22 were allocated to IPS and 28 to TAU. TAU was found acceptable. Retention of TAU participants was acceptable throughout 12-months. However, follow-up of IPS recipients using postal questionnaires proved challenging, especially when the participant started paid work, and new approaches would be needed for a trial. Clients, ESWs, PCPs and employers contributed to manualisation of the intervention. HARMS: No adverse events were reported. CONCLUSION: A definitive trial is not feasible if recruitment is through primary care until employment status is collected systematically or linkage of employment and healthcare databases is possible. The trial may be possible through pain services but clients may differ. Retention of participants proved challenging and methods for achieving this would need to be developed. The intervention has been manualised.
Physical function in UK adults with osteogenesis imperfecta: a cross-sectional analysis of the RUDY study.
UNLABELLED: We describe the physical function in adults with osteogenesis imperfecta (OI) and explored clinical and non-clinical factors related to its impairment. Our data showed that physical dysfunction is a common feature of adults with OI, varying by OI severity, and mediated by the presence and quality of pain and fatigue symptoms. INTRODUCTION: There is a paucity of data describing physical function in adults with osteogenesis imperfecta (OI). We investigated the effects of OI and its severity on physical function and explored the relationship between physical function and number of fractures and symptomatology. METHODS: Adults with OI of different types were recruited from the RUDY study, an ongoing UK-based prospective cohort study. Participants completed demographic and clinical questions and questionnaires. These assessed physical function (SF-36), mobility (EQ-5D-5L and NEADL), fatigue (FACIT-F), and pain (SF-MQ-2). Scores were compared using parametric or non-parametric statistical analyses, whereas correlations between outcomes were examined using univariate and multivariate regression analysis. RESULTS: Seventy-eight adults with OI aged 43.5 ± 14.5 years were enrolled (type I, 32; type III, 11; type IV, 10; unknown type, 26). Physical function (PCS, SF-36) was significantly lower in all participants than normative values (p
Unplanned admissions for patients with myeloma in the UK: Low frequency but high costs.
BACKGROUND: Multiple myeloma (MM) is associated with high healthcare resource utilisation and increasing hospitalisation rates. The aim of this study was to characterise the hospital use by patients with MM in the English National Health Service (NHS). METHODS: Routinely-collected aggregate data about all NHS-funded hospital admissions of patients with MM were analysed. Data were obtained from the English Hospital Episodes Statistics on admissions between 1 April 2014 and 31 March 2018. RESULTS: A total of 754,345 admissions were reported over four years, equivalent to a mean of 188,586 admissions per year. Of the 41,845 patients admitted during this period, 42% were women and 58% men. From the total admissions, 90% were elective and 10% unplanned. Mean annual estimated costs over the period were £46 million for elective and £56 million for unplanned admissions. The number of elective admissions increased by 4.5% with costs increasing 1.5% per year; for unplanned admissions, these figures were 4.1% and 9.0%, respectively. CONCLUSIONS: MM is associated with a significant number of hospital admissions and NHS costs. The majority of the hospital admissions are elective, but the highest burden in terms of costs relates to unplanned admissions, with numbers increasing over time.
Risk of serious adverse events after primary shoulder replacement: development and external validation of a prediction model using linked national data from England and Denmark.
BACKGROUND: Despite a rising rate of serious medical complications after shoulder replacement surgery, there are no prediction models in widespread use to guide surgeons in identifying patients at high risk and to provide patients with personalised risk estimates to support shared decision making. Our aim was to develop and externally validate a prediction model for serious adverse events within 90 days of primary shoulder replacement surgery. METHODS: Linked data from the National Joint Registry, National Health Service Hospital Episode Statistics Admitted Patient Care of England, and Civil Registration Mortality databases and Danish Shoulder Arthroplasty Registry and National Patient Register were used for our modelling study. Patients aged 18-100 years who had a primary shoulder replacement between April 1, 2012, and Oct 2, 2020, in England, and April 1, 2012, and Oct 2, 2018, in Denmark, were included. We developed a multivariable logistic regression model using the English dataset to predict the risk of 90-day serious adverse events, which were defined as medical complications requiring admission to hospital and all-cause death. We undertook internal validation using bootstrapping, and internal-external cross-validation across different geographical regions of England. The English model was externally validated on the Danish dataset. FINDINGS: Data for 40 631 patients undergoing primary shoulder replacement (mean age 72·5 years [SD 9·9]; 28 709 [70·7%] women and 11 922 [29·3%] men) were used for model development, of whom 2270 (5·6%) had a 90-day serious adverse event. On internal validation, the model had a C-statistic of 0·717 (95% CI 0·707-0·728) and was well calibrated. Internal-external cross-validation showed consistent model performance across all regions in England. Upon external validation on the Danish dataset (n=6653; mean age 70·5 years [SD 10·3]; 4503 [67·7%] women and 2150 [32·3%] men), the model had a C-statistic of 0·750 (95% CI 0·723-0·776). Decision curve analysis showed clinical utility, with net benefit across all risk thresholds. INTERPRETATION: This externally validated prediction model uses commonly available clinical variables to accurately predict the risk of serious medical complications after primary shoulder replacement surgery. The model is generalisable and applicable to most patients in need of a shoulder replacement. Its use offers support to clinicians and could inform and empower patients in the shared decision-making process. FUNDING: National Institute for Health and Care Research and the Department of Orthopaedic Surgery, Herlev and Gentofte Hospital, Denmark.
Modelled cost-effectiveness analysis of the Support and Treatment After Replacement (STAR) care pathway for chronic pain after total knee replacement compared with usual care.
BACKGROUND: The aim of the study was to estimate the long-term cost-effectiveness of the Support and Treatment After Replacement (STAR) care pathway for chronic pain after total knee replacement compared with usual postoperative care. METHODS: Study design: A decision-analytic (cohort Markov) model was used for the simulation with time dependent annual transition probabilities and a time horizon of five years. SETTING: Patients treated by National Health Service (NHS) hospitals in England and Wales. STUDY POPULATION: Adults classified as having chronic pain three months after undergoing a total knee replacement. INTERVENTION: The STAR care pathway following a total knee replacement. COMPARATOR: Usual postoperative care following a total knee replacement. PERSPECTIVE: The study was undertaken from the perspective of the NHS. OUTCOME MEASURES: Quality-adjusted life years and healthcare costs. Discounting: A rate of 3.5% for both costs and health utility. RESULTS: Model results indicate that the STAR intervention would dominate current practice by providing a gain in quality-adjusted life years (QALYs) of 0.086 and a reduction of £375 (per person) in costs over the first five years. The incremental net monetary benefit of the STAR intervention was estimated at £2,086 (at a threshold of £20,000 per QALY). Probabilistic sensitivity analysis suggests the STAR intervention is likely to be cost-effective with a probability of 0.62. The results remain robust to changes in model assumptions on comparator utility and the timing of the start of the intervention. If hospital admission costs are assumed not to be reduced by the STAR intervention, it would no longer be cost saving, but it would likely be cost-effective based on probabilistic sensitivity analysis (0.59). CONCLUSION: Evidence from the economic model suggests that the STAR care pathway is likely to be cost-effective and potentially dominant from an NHS perspective. TRIAL REGISTRATION: The STAR trial is registered with ISRCTN, ISRCTN92545361.