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Objective To compare the clinical effectiveness and cost benefit of different frequencies of scale and polish (S&P) treatments in combination with different types of oral hygiene advice (OHA). Design Multi-centre, multi-level cluster randomised factorial open trial with blinded outcome evaluation. UK dental practices were cluster randomised to deliver OHA as usual or personalised. In a separate randomisation, patients were allocated to receive S&P 6-monthly, 12-monthly or never. Setting UK primary dental care. Participants Practices providing NHS care and adults who had received regular dental check-ups. Main outcome measures The percent of sites with bleeding on probing, patient confidence in self-care, incremental net benefits (INB) over three years. Results Sixty-three practices and 1,877 adult patients were randomised and 1,327 analysed (clinical outcome). There was no statistically significant or clinically important difference in gingival bleeding between the three S&P groups (for example, six-monthly versus none: difference 0.87% sites, 95% CI: 1.6 to 3.3, p = 0.48) or between personalised or usual OHA groups (difference -2.5% sites, -95%CI: -8.3 to 3.3, p = 0.39), or oral hygiene self-efficacy (cognitive impact) between either group (for example, six-monthly versus none: difference -0.028, 95% CI -0.119 to 0.063, p = 0.543). The general population place a high value on, and are willing to pay for, S&P services. However, from a dental health perspective, none of the interventions were cost-effective. Conclusion Results suggest S&P treatments and delivering brief personalised OHA provide no clinical benefit and are therefore an inefficient approach to improving dental health (38% of sites were bleeding whatever intervention was received). However, the general population value both interventions. Zusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-021-2662-3 für autorisierte Leser zusätzliche Dateien abrufbar., Key points Describes the process of successfully delivering a multi-centre, cluster randomised factorial open trial in general dental practice in the NHS, for the most frequently provided dental treatment, scale and polish (S&P), and oral hygiene advice.Highlights the clinical, economic and patient-centred outcomes from providing S&P at different time intervals alongside personalised or routine oral hygiene advice to over 2,000 participants for three years.Evidence from IQuaD concludes that there was no difference in gingival bleeding across trial arms at three years; however, the general population are willing to pay for and place a high value on both S&P and personalised oral hygiene advice. Zusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-021-2662-3 für autorisierte Leser zusätzliche Dateien abrufbar.

Objective To compare the clinical effectiveness of different frequencies of dental recall over a four-year period. Design A multi-centre, parallel-group, randomised controlled trial with blinded clinical outcome assessment. Participants were randomised to receive a dental check-up at six-monthly, 24-monthly or risk-based recall intervals. A two-strata trial design was used, with participants randomised within the 24-month stratum if the recruiting dentist considered them clinically suitable. Participants ineligible for 24-month recall were randomised to a risk-based or six-month recall interval. Setting UK primary dental care. Participants Practices providing NHS care and adults who had received regular dental check-ups. Main outcome measures The percentage of sites with gingival bleeding on probing, oral health-related quality of life (OHRQoL), cost-effectiveness. Results In total, 2,372 participants were recruited from 51 dental practices. Of those, 648 were eligible for the 24-month recall stratum and 1,724 participants were ineligible. There was no evidence of a significant difference in the mean percentage of sites with gingival bleeding on probing between intervention arms in any comparison. For those eligible for 24-month recall stratum: the 24-month versus six-month group had an adjusted mean difference of -0.91%, 95% CI (-5.02%, 3.20%); the 24-month group versus risk-based group had an adjusted mean difference of 0.07%, 95% CI (-3.99%, 4.12%). For the overall sample, the risk-based versus six-month adjusted mean difference was 0.78%, 95% CI (-1.17%, 2.72%). There was no evidence of a difference in OHRQoL (0-56 scale, higher score for poorer OHRQoL) between intervention arms in any comparison. For the overall sample, the risk-based versus six-month effect size was -0.35, 95% CI (-1.02, 0.32). There was no evidence of a clinically meaningful difference between the groups in any comparison in either eligibility stratum for any of the secondary clinical or patient-reported outcomes. Conclusion Over a four-year period, we found no evidence of a difference in oral health for participants allocated to a six-month or a risk-based recall interval, nor between a 24-month, six-month or risk-based recall interval for participants eligible for a 24-month recall. However, patients greatly value and are willing to pay for frequent dental check-ups. Zusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-021-2612-0 für autorisierte Leser zusätzliche Dateien abrufbar., Key points This is the first national, multi-centre, pragmatic RCT in a primary care setting to evaluate the clinical, patient-centred and cost benefit of different recall intervals.Traditional practice of scheduling six-monthly recall appointments for patients, regardless of their risk of developing dental disease, does not improve oral health. A variable risk-based recall interval is appropriate, is not detrimental to oral health, and is acceptable to patients and dentists.Considering the impact of the COVID-19 pandemic limiting access to dental care, this study provides reassurance that, for appropriate patients, intervals between check-ups can be extended, based on an individual's risk, without detriment to oral health. Zusatzmaterial online: Zu diesem Beitrag sind unter 10.1038/s41415-021-2612-0 für autorisierte Leser zusätzliche Dateien abrufbar.

Background Progression of dental caries can result in irreversible pulpal damage. Partial irreversible pulpitis is the initial stage of this damage, confined to the coronal pulp whilst the radicular pulp shows little or no sign of infection. Preserving the pulp with sustained vitality and developing minimally invasive biologically based therapies are key themes within contemporary clinical practice. However, root canal treatment involving complete removal of the pulp is often the only option (other than extraction) given to patients with irreversible pulpitis, with substantial NHS and patient incurred costs. The European Society of Endodontology’s (ESE 2019) recent consensus statement recommends full pulpotomy, where the inflamed coronal pulp is removed with the goal of keeping the radicular pulp vital, as a more minimally invasive technique, potentially avoiding complex root canal treatment. Although this technique may be provided in secondary care, it has not been routinely implemented or evaluated in UK General Dental Practice. Method This feasibility study aims to identify and assess in a primary care setting the training needs of general dental practitioners and clinical fidelity of the full pulpotomy intervention, estimate likely eligible patient pool and develop recruitment materials ahead of the main randomised controlled trial comparing the clinical and cost-effectiveness of full pulpotomy compared to root canal treatment in pre/molar teeth of adults 16 years and older showing signs indicative of irreversible pulpitis. The feasibility study will recruit and train 10 primary care dentists in the full pulpotomy technique. Dentists will recruit and provide full pulpotomy to 40 participants (four per practice) with indications of partial irreversible pulpitis. Discussion The Pulpotomy for the Management of Irreversible Pulpitis in Mature Teeth (PIP) study will address the lack of high-quality evidence in the treatment of irreversible pulpitis, to aid dental practitioners, patients and policymakers in their decision-making. The PIP feasibility study will inform the main study on the practicality of providing both training and provision of the full pulpotomy technique in general dental practice. Trial registration ISRCTN Registry, ISRCTN17973604. Registered on 28 January 2021. Protocol version Protocol version: 1; date: 03.02.2021

Background Ascertaining the acceptability of healthcare provision to service users is an important factor in promoting service uptake, especially for populations who are reluctant to access care. This study identified the attributes of a Hepatitis C (HCV) testing service for people prescribed Opioid Substitution Therapy (OST) and used their expressed preferences to guide design of a service, using an applied health economics approach. Materials and methods Preferences of OST users were elicited using a discrete choice experiment. Important attributes for HCV testing were partly pre-determined by the research question and also identified using literature review and focus groups. Predetermined attributes included choice of provider and financial incentives. Other important attributes were place of testing; travel distance; attitudes and staff undertaking testing; waiting time for test results and incentive payment. The relative importance of defined attributes was assessed in 103 OST users attending 6 pharmacies from Dundee. Results OST users preferred testing at their “own pharmacy”, by their drug worker, followed by their general practitioner (GP). Use of another pharmacy was the least preferred option. Being treated with dignity and respect was valued most highly, with waiting time for test results and travel distance also important. Financial incentives were not considered important. Conclusions This study provides evidence that OST users prefer testing at their own pharmacy. The addition of a pharmacy to the providers offering HCV testing may increase uptake and support policies to eliminate HCV from our communities. Being treated with dignity and respect was highly valued and this suggests that testing uptake can be increased by developing positive relationships between OST users and test providers. Financial incentives were not found to be important.

Objectives Understanding the value the general population place on dentistry services is important for policymakers to aide service planning. Willingness to pay (WTP) is an economic method used to elicit the value of a good or service. The aim of this study is to estimate United Kingdom (UK) general population WTP for commonly provided scale and polish, and detailed and personalized oral hygiene advice (OHA), and to investigate what factors influence WTP. Methods Participants completed an online hypothetical WTP survey for scale and polish and detailed and personalized oral hygiene advice. The estimation sample consisted of 1405 participants, nationally representative of the UK general population in terms of age and sex. Regression analysis was used to estimate WTP and determine what factors are associated with WTP. Analyses were conducted including and excluding protest answers. Results The mean (SD) WTP for a scale and polish is £26.77 (£21.91) excluding protest answers and £24.80 (£22.71) for the full sample. The mean (SD) WTP for detailed and personalized OHA is £16.56 (£19.75) excluding protest answers and £12.77 (£22.28) for the full sample. Participants on higher incomes, private attenders and those who stated that maintaining clean and healthy gums was important had higher WTP for both services. Participants in Scotland and Northern Ireland were WTP less than their English counterparts, reflecting the different regional specific payment systems. Conclusion The general UK population value scale and polish, and detailed and personalized OHA. This study provides estimates of WTP for these services which can be used to inform resource allocation decisions.

BackgroundIn 2016, 26% of UK men were estimated to be obese. Systematic reviews suggest that few men engage in formal weight loss interventions that support weight reduction and improve health.ObjectiveTo co-produce, with patient and public involvement, an acceptable and feasible randomised controlled trial design to test a men-only weight management intervention.DesignThis was a two-phase feasibility study. Phase 1 was the development of intervention components, study procedures and materials including a discrete choice experiment with survey questions. Phase 2 was an individually randomised three-arm feasibility trial over 12 months. Qualitative interviews were conducted at 3 and 12 months.SettingThe setting was two sites in Scotland that had disadvantaged urban and rural areas and differed in employment levels and ethnic groups.ParticipantsIn phase 1, 1045 men with obesity were recruited by Ipsos MORI (London, UK;www.ipsos.com/ipsos-mori/en-uk) to represent the UK population. In phase 2, 105 men with obesity were recruited in the community or through general practice obesity registers. Qualitative interviews were conducted with 50 men at 3 months and with 33 men at 12 months.InterventionsThe trial arms were narrative short message service (SMS) for 12 months (SMS only), financial endowment incentive informed by loss aversion and linked to achievement of weight loss targets plus narrative SMS for 12 months (SMS + I), and waiting list control group for 12 months followed by 3 months of an alternative SMS style developed based on feedback from men who had received the narrative SMS (control).Main outcome measuresThe main outcome measures were acceptability and feasibility of recruitment, retention, engagement, intervention components and trial procedures. Outcomes were assessed by examining procedural, quantitative and qualitative data at 3, 6 and 12 months.ResultsThe most acceptable incentive strategy, based on the discrete choice experiment results, was to verify weight loss of 5% at 3 months, verify weight loss of 10% at 6 months and maintain weight loss of 10% at 12 months. Overall, 105 men with obesity from across the socioeconomic spectrum were successfully recruited to target, 59% of whom lived in more disadvantaged areas. Retention at 12 months was acceptable (74%) and was higher among individuals from disadvantaged areas. Narrative SMS were acceptable to many men, with a minority reporting negative reactions. Incentives were acceptable but were not the primary motivation for behaviour change. Twelve men in the incentive arm (33%) secured at least some money and three (8%) secured the full amount. Both intervention arms lost some weight, with greater weight loss in the arm that received SMS and incentives. The alternative SMS based on men’s feedback received no strong negative reactions.LimitationsFewer participants from the SMS + I arm (64%) completed the study at 12 months than did those in the SMS-only (79%) and control (83%) arms. The reasons for this difference were complex.ConclusionsThe men-only weight management intervention consisting of narrative SMS and financial incentives was acceptable and feasible, meeting the progression criteria for a full trial. Tailoring of SMS may improve acceptability and retention.Future workMinor refinements to the intervention components based on the study findings will be made prior to testing in a multisite definitive randomised controlled trial.Trial registrationClinicalTrials.gov NCT03040518.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 8, No. 11. See the NIHR Journals Library website for further project information.

ObjectivesTo examine the acceptability and feasibility of narrative text messages with or without financial incentives to support weight loss for men.DesignIndividually randomised three-arm feasibility trial with 12 months’ follow-up.SettingTwo sites in Scotland with high levels of disadvantage according to Scottish Index for Multiple Deprivation (SIMD).ParticipantsMen with obesity (n=105) recruited through community outreach and general practitioner registers.InterventionsParticipants randomised to: (A) narrative text messages plus financial incentive for 12 months (short message service (SMS)+I), (B) narrative text messages for 12 months (SMS only), or (C) waiting list control.OutcomesAcceptability and feasibility of recruitment, retention, intervention components and trial procedures assessed by analysing quantitative and qualitative data at 3, 6 and 12 months.Results105 men were recruited, 60% from more disadvantaged areas (SIMD quintiles 1 or 2). Retention at 12 months was 74%. Fewer SMS+I participants (64%) completed 12-month assessments compared with SMS only (79%) and control (83%). Narrative texts were acceptable to many men, but some reported negative reactions. No evidence emerged that level of disadvantage was related to acceptability of narrative texts. Eleven SMS+I participants (31%) successfully met or partially met weight loss targets. The cost of the incentive per participant was £81.94 (95% CI £34.59 to £129.30). Incentives were acceptable, but improving health was reported as the key motivator for weight loss. All groups lost weight (SMS+I: −2.51 kg (SD=4.94); SMS only: −1.29 kg (SD=5.03); control: −0.86 kg (SD=5.64) at 12 months).ConclusionsThis three-arm weight management feasibility trial recruited and retained men from across the socioeconomic spectrum, with the majority from areas of disadvantage, was broadly acceptable to most participants and feasible to deliver.Trial registration numberNCT03040518.

Background Periodontal disease is preventable but remains the most common oral disease worldwide, with major health and economic implications. Stakeholders lack reliable evidence of the relative clinical effectiveness and cost-effectiveness of different types of oral hygiene advice (OHA) and the optimal frequency of periodontal instrumentation (PI). Objectives To test clinical effectiveness and assess the economic value of the following strategies: personalised OHA versus routine OHA, 12-monthly PI (scale and polish) compared with 6-monthly PI, and no PI compared with 6-monthly PI. Design Multicentre, pragmatic split-plot, randomised open trial with a cluster factorial design and blinded outcome evaluation with 3 years’ follow-up and a within-trial cost–benefit analysis. NHS and participant costs were combined with benefits [willingness to pay (WTP)] estimated from a discrete choice experiment (DCE). Setting UK dental practices. Participants Adult dentate NHS patients, regular attenders, with Basic Periodontal Examination (BPE) scores of 0, 1, 2 or 3. Intervention Practices were randomised to provide routine or personalised OHA. Within each practice, participants were randomised to the following groups: no PI, 12-monthly PI or 6-monthly PI (current practice). Main outcome measures Clinical – gingival inflammation/bleeding on probing at the gingival margin (3 years). Patient – oral hygiene self-efficacy (3 years). Economic – net benefits (mean WTP minus mean costs). Results A total of 63 dental practices and 1877 participants were recruited. The mean number of teeth and percentage of bleeding sites was 24 and 33%, respectively. Two-thirds of participants had BPE scores of ≤ 2. Under intention-to-treat analysis, there was no evidence of a difference in gingival inflammation/bleeding between the 6-monthly PI group and the no-PI group [difference 0.87%, 95% confidence interval (CI) –1.6% to 3.3%; p = 0.481] or between the 6-monthly PI group and the 12-monthly PI group (difference 0.11%, 95% CI –2.3% to 2.5%; p = 0.929). There was also no evidence of a difference between personalised and routine OHA (difference –2.5%, 95% CI –8.3% to 3.3%; p = 0.393). There was no evidence of a difference in self-efficacy between the 6-monthly PI group and the no-PI group (difference –0.028, 95% CI –0.119 to 0.063; p = 0.543) and no evidence of a clinically important difference between the 6-monthly PI group and the 12-monthly PI group (difference –0.097, 95% CI –0.188 to –0.006; p = 0.037). Compared with standard care, no PI with personalised OHA had the greatest cost savings: NHS perspective –£15 (95% CI –£34 to £4) and participant perspective –£64 (95% CI –£112 to –£16). The DCE shows that the general population value these services greatly. Personalised OHA with 6-monthly PI had the greatest incremental net benefit [£48 (95% CI £22 to £74)]. Sensitivity analyses did not change conclusions. Limitations Being a pragmatic trial, we did not deny PIs to the no-PI group; there was clear separation in the mean number of PIs between groups. Conclusions There was no additional benefit from scheduling 6-monthly or 12-monthly PIs over not providing this treatment unless desired or recommended, and no difference between OHA delivery for gingival inflammation/bleeding and patient-centred outcomes. However, participants valued, and were willing to pay for, both interventions, with greater financial value placed on PI than on OHA. Future work Assess the clinical effectiveness and cost-effectiveness of providing multifaceted periodontal care packages in primary dental care for those with periodontitis. Trial registration Current Controlled Trials ISRCTN56465715. Funding This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 38. See the NIHR Journals Library website for further project information.

Background Hospital admissions for Ambulatory Care Sensitive Conditions (ACSC) are those that could potentially be prevented by timely and effective disease management within primary care. ACSC admissions are increasingly used as performance indicators. However, key questions remain about the validity of these measures. The evidence to date has been inconclusive and limited to specific conditions. The aim of this study was to test the robustness of ACSC admissions as indicators of the quality of primary care. It is the first study to examine a wide range of ACSCs using longitudinal data which enables us to control for unmeasured characteristics which differ by practice but which are constant over time. Methods Using longitudinal data at the practice level, from 907 Scottish practices for the time period 1/4/2005 to 31/32012, we explored the relationships between the quality of primary care, and hospital admissions for multiple ACSCs controlling for a wide range of covariates including characteristics of GP practices, characteristics of the practice population, hospital effects and year effects. We examined the impact of two dimensions of quality of care: clinical quality of and access to daytime general practice. Generalised Estimating Equations taking the form of Negative Binomial regression models with the practice population included as the exposure term were estimated. Results We found that higher achievement on some clinical quality measures of primary care was associated with reduced ACSC emergency admissions. We also show that access to primary care was associated with ACSC emergency admissions. However, the effects were small and inconsistent and ACSC emergency admissions were associated with several confounding factors such as deprivation, rurality and distance to the hospital. Conclusions The results suggest caution in the use of crude ACSC admission rates as a performance indicator of quality of primary care. Electronic supplementary material The online version of this article (10.1186/s12875-019-0921-z) contains supplementary material, which is available to authorized users.

Changing physical activity and dietary behavior in chronic disease patients is associated with significant health benefits but is difficult to achieve. An often-used strategy is for the physician or other health professional to encourage behavior changes by providing advice on the health consequences of such behaviors. However, adherence to advice on health behavior change varies across individuals. This paper uses data from a population-based cross-sectional survey of 1849 individuals with chronic disease to explore whether differences in individuals' time and risk preferences can help explain differences in adherence. Health behaviors are viewed as investments in health capital within the Grossman model. Physician advice plays a role in the model in that it improves the understanding of the future health consequences of investments. It can be hypothesized that the effect of advice on health behavior will depend on an individuals' time and risk preference. Within the survey, which measured a variety of health-related behaviors and outcomes, including receipt and compliance with advice on dietary and physical activity changes, time preferences were measured using financial planning horizon, and risk preferences were measured through a commonly used question which asked respondents to indicate their willingness to take risks on a ten-point scale. Results suggest that time preferences play a role in adherence to physical activity advice. While time preferences also play a role in adherence to dietary advice, this effect is only apparent for males. Risk preferences do not seem to be associated with adherence. The results suggest that increasing the salience of more immediate benefits of health behavior change may improve adherence.

Time and risk preferences are known to vary considerably across individuals but less is known about the determinants of these individual differences. This paper examines whether preferences vary by geographical location. The motivation for examining geographic heterogeneity is the higher level of mortality experienced in Glasgow over and above that explained by deprivation, sometimes referred to as the 'Glasgow effect'. Data were collected from 3702 individuals across Glasgow, Manchester and Liverpool between July and November 2011. The results show evidence of geographic preference heterogeneity. Contrary to our hypothesis, individuals in Glasgow have a lower rather than higher time preference rate. Individuals in Glasgow are on average more risk seeking compared to Liverpool and more likely to be at the tail end of the distribution (very risk seeking) compared to Manchester. Differences in risk preferences may help explain some of the differences in mortality associated with risky health behaviours such as drug and alcohol use. However, individuals in Glasgow were also more future oriented suggesting that they are less likely to engage in risky healthy behaviours. As the differences in time and risk preferences work in opposite directions in terms of health investments it less likely that these differences can help explain excess mortality in Glasgow.

We compared the costs and cost-effectiveness of telemonitoring vs usual care for patients with chronic obstructive pulmonary disease (COPD). A total of 256 patients were randomised to either telemonitoring or usual care. In the telemonitoring arm, the touch-screen telemonitoring equipment transmitted data to clinical teams monitoring the patients. Total healthcare costs were estimated over a 12-month period from a National Health Service perspective and quality adjusted life year (QALYs) were estimated by the EQ-5D tool. Telemonitoring was not significantly more costly than usual care (mean difference per patient £2065.90 ( P

Background Despite being a core component of self-management, goal setting is rarely used in routine care. We piloted a primary care, nurse-led intervention called Achieving Good Outcomes for Asthma Living (GOAL) for adults with asthma. Patients were invited to identify and prioritise their goals in preparation for discussing and negotiating an action/coping plan with the nurse at a routine asthma review. Methods The 18-month mixed methods feasibility cluster pilot trial stratified and then randomised practices to deliver usual care (UC) or a goal-setting intervention (GOAL). Practice asthma nurses and adult patients with active asthma were invited to participate. The primary outcome was asthma-specific quality of life. Semi-structured interviews with a purposive patient sample (n = 14) and 10 participating nurses explored GOAL perception. The constructs of normalisation process theory (NPT) were used to analyse and interpret data. Results Ten practices participated (five in each arm), exceeding our target of eight. However, only 48 patients (target 80) were recruited (18 in GOAL practices). At 6 months post-intervention, the difference in mean asthma-related quality of life (mAQLQ) between intervention and control was 0.1 (GOAL 6.20: SD 0.76 (CI 5.76–6.65) versus UC 6.1: SD 0.81 (CI 5.63–6.57)), less than the minimal clinically important difference (MCID) of 0.5. However, change from baseline was stronger in the intervention group: at 6 months the change in the emotions sub-score was 0.8 for intervention versus 0.2 for control. Costs were higher in the intervention group by £22.17. Routine review with goal setting was considered more holistic, enhancing rapport and enabling patients to become active rather than passive participants in healthcare. However, time was a major barrier for nurses, who admitted to screening out patient goals they believed were unrelated to asthma. Conclusions The difference in AQLQ score from baseline is larger in the intervention arm than the control, indicating the intervention may have impact if appropriately strengthened. The GOAL intervention changed the review dynamic and was well received by patients, but necessitated additional time, which was problematic in the confines of the traditional nurse appointment. Modification to recruitment methods and further development of the intervention are needed before proceeding to a definitive cluster randomised controlled trial. Trial registration ISRCTN18912042. Registered on 26 June 2012. Electronic supplementary material The online version of this article (doi:10.1186/s13063-016-1684-7) contains supplementary material, which is available to authorized users.

Objective To demonstrate how a discrete choice experiment (DCE) can be used to elicit individuals’ preferences for health care and how these preferences can be incorporated into a cost–benefit analysis. Methods A DCE which elicited preferences for three perinatal services: specialist nurse appointments; home visits from a trained lay visitor; and home-help. Cost was included to obtain a monetary measure of the value that individuals place on the services. In total, 292 women who had previously participated in a randomized trial of alternative forms of pre-natal care were interviewed. Results The most preferred service configuration consisted of three nurse appointments and two home visits before birth and 4 h of home-help per week for the first 4 weeks after birth. On average, women are willing to pay $371 for this package. A package that excluded home-help was valued at $122 whilst provision of three nurse appointments only was valued at $97. The predicted uptake of the services ranged from 37% to 93% depending on the woman’s experience with the service, whether or not it was her first child and her level of education. Conclusion The willingness to pay values were much higher than the costs for nurse appointments, suggesting this service produces a net social benefit. The willingness to pay for the package including both the nurse appointments and home visits only just exceeded the costs of the package, suggesting there is a relatively high chance that this package produces a net social loss.

We have conducted a feasibility study to establish whether ENT tele-endoscopy would be a suitable method of service delivery for patients who live in the Shetland Islands. Ten clinics were conducted over a period of 17 months using ISDN-based videoconferencing at a bandwidth of 384 kbit/s. A total of 42 patients were seen in Aberdeen via videoconferencing for a head and neck cancer assessment. Feasibility was confirmed after the first 20 patients, following positive feedback from all concerned and the absence of any significant clinical or technical problems. A total of 42 journeys was avoided, each journey saving 123 kg CO2 per person. A preliminary cost analysis showed that the threshold at which tele-ENT became cheaper than travel was a workload of 35 patients/year. The actual workload during the pilot study was 29 patients/year. A national telemedicine service for the initial assessment of potential malignancy has the potential to reduce unnecessary transfers to specialist centres, with accompanying reductions in carbon emissions.

Many theories have been proposed to explain the high levels of 'excess' mortality (i.e. higher mortality over and above that explained by differences in socio-economic circumstances) shown in Scotland-and, especially, in its largest city, Glasgow-compared with elsewhere in the UK. One such proposal relates to differences in optimism, given previously reported evidence of the health benefits of an optimistic outlook.A representative survey of Glasgow, Liverpool and Manchester was undertaken in 2011. Optimism was measured by the Life Orientation Test (Revised) (LOT-R), and compared between the cities by means of multiple linear regression models, adjusting for any differences in sample characteristics.Unadjusted analyses showed LOT-R scores to be similar in Glasgow and Liverpool (mean score (SD): 14.7 (4.0) for both), but lower in Manchester (13.9 (3.8)). This was consistent in analyses by age, gender and social class. Multiple regression confirmed the city results: compared with Glasgow, optimism was either similar (Liverpool: adjusted difference in mean score: -0.16 (95% CI -0.45 to 0.13)) or lower (Manchester: -0.85 (-1.14 to -0.56)).The reasons for high levels of Scottish 'excess' mortality remain unclear. However, differences in psychological outlook such as optimism appear to be an unlikely explanation.

We conduct a framed field experiment among patients and doctors to test whether the two groups have similar risk and time preferences. We elicit risk and time preferences using multiple price list tests and their adaptations to the healthcare context. Risk and time preferences are compared in terms of switching points in the tests and the structurally estimated behavioural parameters. We find that doctors and patients significantly differ in their time preferences: doctors discount future outcomes less heavily than patients. We find no evidence that doctors and patients systematically differ in their risk preferences in the healthcare domain.

The aim of this paper is to predict attendance if the age range for routine invitation to breast screening were to be extended. The response to the most recent screening invitation is modelled for women eligible for screening if the age range were extended. The independent variables include (i) the woman's characteristics: her screening history; the deprivation score of the area she lives in and (ii) the characteristics of the screening: whether the screening took place in a mobile van or at a static site; and time of the year. The predictive ability of the regression model is tested by goodness of fit measures and by predicting attendance for a holdout sample of the data and for women who participated in a demonstration project. The modelling of attendance is quite successful in that most hypothesised variables have the expected sign. Moreover, the predictive ability of the model is satisfactory in terms of goodness of fit statistics and in terms of accuracy of predictions for a holdout sample. The model predicts less well for the demonstration project possibly because it is less representative of usual screening practice.

BACKGROUND: Getting lost outside is stressful for people with dementia and their caregivers and a leading cause of long-term institutionalisation. Although Global Positional Satellite (GPS) location has been promoted to facilitate safe walking, reduce caregivers' anxiety and enable people with dementia to remain at home, there is little high quality evidence about its acceptability, effectiveness or cost-effectiveness. This observational study explored the feasibility of recruiting and retaining participants, and the acceptability of outcome measures, to inform decisions about the feasibility of a randomised controlled trial (RCT).METHODS: People with dementia who had been provided with GPS devices by local social-care services and their caregivers were invited to participate in this study. We undertook interviews with people with dementia, caregivers and professionals to explore the perceived utility and challenges of GPS location, and assessed quality of life (QoL) and mental health. We piloted three methods of calculating resource use: caregiver diary; bi-monthly telephone questionnaires; and interrogation of health and social care records. We asked caregivers to estimate the time spent searching if participants became lost before and whilst using GPS.RESULTS: Twenty people were offered GPS locations services by social-care services during the 8-month recruitment period. Of these, 14 agreed to be referred to the research team, 12 of these participated and provided data. Eight people with dementia and 12 caregivers were interviewed. Most participants and professionals were very positive about using GPS. Only one person completed a diary. Resource use, anxiety and depression and QoL questionnaires were considered difficult and were therefore declined by some on follow-up. Social care records were time consuming to search and contained many omissions. Caregivers estimated that GPS reduced searching time although the accuracy of this was not objectively verified.CONCLUSIONS: Our data suggest that a RCT will face challenges not least that widespread enthusiasm for GPS among social-care staff may challenge recruitment and its ready availability may risk contamination of controls. Potential primary outcomes of a RCT should not rely on caregivers' recall or questionnaire completion. Time spent searching (if this could be accurately captured) and days until long-term admission are potentially suitable outcomes.

In the Netherlands children up to the age of 4 years are regularly monitored. Several demographic and economic developments have led to the idea of using mobile child monitoring centres. Mobile units are expected to be flexible, effective and efficient but little information is available about the implications for the organization, the clients and other third parties involved. This paper outlines an approach for assessing the feasibility of mobile child monitoring centres. The focus is on the area Midden-Gelderland in the Netherlands and the implications of alternative options are compared on the basis of feasibility criteria or performance measures. The implementation of mobile units for child monitoring appears to be feasible with respect to most performance measures but there are also disadvantages. The approach taken proved to be a valuable exercise since it provided detailed information on all implications. It was decided that the mobile units would not be purchased but that some child monitoring centres could be closed without replacing them.

We compared conventional palliative homecare visits and a combination of conventional and home telehealth ‘video-visits’ with respect to symptom management and quality of life. Participants were recruited from 11 rural communities in Alberta and randomized to the treatment or control groups, remaining in the study for 8 weeks. Although we planned to recruit 200 clients over two years, only 44 clients participated. Factors contributing to low recruitment included the introduction of new service delivery models and changes in the home care environment. No significant differences were found between the groups in measures of symptom management and quality of life. Compared to the home care nurses, clients generally indicated a higher level of readiness to use the technology. The study suggested that videophone technology would probably not be adopted for palliative home care in the population that was studied although it might be considered for other applications in the management of chronic illnesses.

To test the effectiveness of telemonitoring integrated into existing clinical services such that intervention and control groups have access to the same clinical care.Researcher blind, multicentre, randomised controlled trial.UK primary care (Lothian, Scotland).Adults with at least one admission for chronic obstructive pulmonary disease (COPD) in the year before randomisation. We excluded people who had other significant lung disease, who were unable to provide informed consent or complete the study, or who had other significant social or clinical problems.Participants were recruited between 21 May 2009 and 28 March 2011, and centrally randomised to receive telemonitoring or conventional self monitoring. Using a touch screen, telemonitoring participants recorded a daily questionnaire about symptoms and treatment use, and monitored oxygen saturation using linked instruments. Algorithms, based on the symptom score, generated alerts if readings were omitted or breached thresholds. Both groups received similar care from existing clinical services.The primary outcome was time to hospital admission due to COPD exacerbation up to one year after randomisation. Other outcomes included number and duration of admissions, and validated questionnaire assessments of health related quality of life (using St George's respiratory questionnaire (SGRQ)), anxiety or depression (or both), self efficacy, knowledge, and adherence to treatment. Analysis was intention to treat.Of 256 patients completing the study, 128 patients were randomised to telemonitoring and 128 to usual care; baseline characteristics of each group were similar. The number of days to admission did not differ significantly between groups (adjusted hazard ratio 0.98, 95% confidence interval 0.66 to 1.44). Over one year, the mean number of COPD admissions was similar in both groups (telemonitoring 1.2 admissions per person (standard deviation 1.9) v control 1.1 (1.6); P=0.59). Mean duration of COPD admissions over one year was also similar between groups (9.5 days per person (standard deviation 19.1) v 8.8 days (15.9); P=0.88). The intervention had no significant effect on SGRQ scores between groups (68.2 (standard deviation 16.3) v 67.3 (17.3); adjusted mean difference 1.39 (95% confidence interval -1.57 to 4.35)), or on other questionnaire outcomes. Conclusions In participants with a history of admission for exacerbations of COPD, telemonitoring was not effective in postponing admissions and did not improve quality of life. The positive effect of telemonitoring seen in previous trials could be due to enhancement of the underpinning clinical service rather than the telemonitoring communication.ISRCTN96634935.The trial was funded by an NHS applied research programme grant from the Chief Scientist Office of the Scottish government (ARPG/07/03). The funder had no role in study design and the collection, analysis, and interpretation of data and the writing of the article and the decision to submit it for publication. NHS Lothian supported the telemonitoring service and the clinical services.

Background: Supporting self-management behaviours is recommended guidance for people with asthma. Preliminary work suggests that a brief, intensive, patient-centred intervention may be successful in supporting people with asthma to participate in life roles and activities they value. We seek to assess the feasibility of undertaking a cluster-randomised controlled trial (cRCT) of a brief, goal-setting intervention delivered in the context of an asthma review consultation.Methods/design: A two armed, single-blinded, multi-centre, cluster-randomised controlled feasibility trial will be conducted in UK primary care. Randomisation will take place at the practice level. We aim to recruit a total of 80 primary care patients with active asthma from at least eight practices across two health boards in Scotland (10 patients per practice resulting in similar to 40 in each arm). Patients in the intervention arm will be asked to complete a novel goal-setting tool immediately prior to an asthma review consultation. This will be used to underpin a focussed discussion about their goals during the asthma review. A tailored management plan will then be negotiated to facilitate achieving their prioritised goals. Patients in the control arm will receive a usual care guideline-based review of asthma. Data on quality of life, asthma control and patient confidence will be collected from both arms at baseline and 3 and 6 months post-intervention. Data on health services resource use will be collected from all patient records 6 months pre- and post-intervention. Semi-structured interviews will be carried out with healthcare staff and a purposive sample of patients to elicit their views and experiences of the trial. The outcomes of interest in this feasibility trial are the ability to recruit patients and healthcare staff, the optimal method of delivering the intervention within routine clinical practice, and acceptability and perceived utility of the intervention among patients and staff.Trial registration: ISRCTN18912042

Background Periodontal disease is the most common oral disease affecting adults, and although it is largely preventable it remains the major cause of poor oral health worldwide. Accumulation of microbial dental plaque is the primary aetiological factor for both periodontal disease and caries. Effective self-care (tooth brushing and interdental aids) for plaque control and removal of risk factors such as calculus, which can only be removed by periodontal instrumentation (PI), are considered necessary to prevent and treat periodontal disease thereby maintaining periodontal health. Despite evidence of an association between sustained, good oral hygiene and a low incidence of periodontal disease and caries in adults there is a lack of strong and reliable evidence to inform clinicians of the relative effectiveness (if any) of different types of Oral Hygiene Advice (OHA). The evidence to inform clinicians of the effectiveness and optimal frequency of PI is also mixed. There is therefore an urgent need to assess the relative effectiveness of OHA and PI in a robust, sufficiently powered randomised controlled trial (RCT) in primary dental care. Methods/Design This is a 5 year multi-centre, randomised, open trial with blinded outcome evaluation based in dental primary care in Scotland and the North East of England. Practitioners will recruit 1860 adult patients, with periodontal health, gingivitis or moderate periodontitis (Basic Periodontal Examination Score 0–3). Dental practices will be cluster randomised to provide routine OHA or Personalised OHA. To test the effects of PI each individual patient participant will be randomised to one of three groups: no PI, 6 monthly PI (current practice), or 12 monthly PI. Baseline measures and outcome data (during a three year follow-up) will be assessed through clinical examination, patient questionnaires and NHS databases. The primary outcome measures at 3 year follow up are gingival inflammation/bleeding on probing at the gingival margin; oral hygiene self-efficacy and net benefits. Discussion IQuaD will provide evidence for the most clinically-effective and cost-effective approach to managing periodontal disease in dentate adults in Primary Care. This will support general dental practitioners and patients in treatment decision making. Trial registration Protocol ID: ISRCTN56465715

Background— Little is known about the optimum way to deliver exercise to older, functionally impaired patients with heart failure. We tested whether an exercise program tailored to the needs of these patients could improve exercise capacity and quality of life or reduce costs to the National Health Service. Methods and Results— The study design was a parallel-group, single-blind, randomized controlled trial. Patients aged ≥70 years with symptomatic heart failure and left ventricular systolic dysfunction were randomized to either 24 weeks of exercise training or usual care. Six-minute walk distance was the primary outcome; markers of physical function, quality of life, health status, and daily activity were measured at baseline and 8 and 24 weeks. Carer strain and healthcare costs were also recorded. A total of 107 participants were randomized (mean age, 80 years; men, 72 [67%]). Six-minute walk distance did not improve compared to that of the control group at 8 weeks (−16.9 m; 95% CI, −41.8 to 7.9 m; P =0.18) or at 24 weeks (−5.3 m; 95% CI, −32.6 to 22.0 m; P =0.70). For secondary outcomes, only the sit-to-stand test improved significantly at 24 weeks (−6.4 s; 95% CI, −12.2 to 0.6 s; P =0.03); there was no difference in change for the Minnesota Living With Heart Failure score (0.1 points; 95% CI, −0.9 to 1.1 points; P =0.83) at 24 weeks. Carer strain did not decrease at 24 weeks (difference, −0.5 points; 95% CI, −8.3 to 7.3 points; P =0.80), and there was no difference in overall healthcare costs. Conclusions— This exercise intervention did not improve exercise capacity or quality of life in older patients with heart failure and was not cost saving to the National Health Service. Clinical Trial Registration— URL: http://www.controlled-trials.com . Unique identifier: ISRCTN51615566.

While everyone knows that we should eat healthily, translating such information into practice is a major challenge for many of us when it comes to eating well. So despite a huge increase in awareness of the implications of food-choices, obesity levels in the UK continue to increase. In this paper, we present a novel application designed to deliver psychological 'Approach Avoidance' training in a serious games format. Developed for tablet computers, gameplay requires players to repeatedly push unhealthy food icons away, and pull healthy food icons towards themselves. The hypothesis for the overall project is that repeated push away gestures will produce an implicit avoidance bias towards unhealthy foods, reducing players' tendency to consume them. Previous research using a joystick controlled PC training regime has shown success with alcohol choices, however the current project offers the potential for a pervasive game based intervention using a tablet and gestures making such training more readily accessible.

We assessed the cost and benefits of tele-endoscopy clinics in a remote location in Scotland. Before the introduction of a tele-endoscopy service, patients whose symptoms suggested possible cancer of the airways had to travel to the mainland (to Aberdeen) to receive an endoscopy. The costs of staff, capital, disposables and travel were estimated for the tele-endoscopy clinic and for the conventional, mainland clinic. The benefits of the two types of clinic were estimated from a sample of the general public using a survey method called the discrete choice experiment. The average cost per patient was lower for the tele-endoscopy clinic (pounds sterling 353) than for the mainland clinic (pounds sterling 381). This was true if more than 27 patients were seen per year. Assuming equal waiting times, individuals preferred the tele-endoscopy clinic to the mainland clinic. The net benefits were larger for tele-endoscopy clinics as long as the additional waiting time was not longer than four weeks. Tele-endoscopy clinics in Shetland are an efficient alternative to conventional practice. The results are sensitive to both economies of scale and scope. The model can readily be applied to mainland communities outside the main population centres in Scotland.

a Senior Clinical Research Fellow, Allergy & Respiratory Research Group, Centre for Population Health Sciences: GP Section, University of Edinburgh, Scotland, UK b Research Fellow, Centre for Integrated HealthCare Research, Napier University c Senior Research Fellow, Edinburgh Clinical Trials Unit, University of Edinburgh d Professor of Respiratory and Environmental Medicine, Edinburgh Lung and the Environment Group Initiative, University of Edinburgh e Senior Lecturer, E-Health Research Group, Centre for Population Health Sciences: GP Section, University of Edinburgh f Senior Research Fellow, Health Economics Research Unit, University of Aberdeen g Professor of Primary Care Research & Development, Allergy & Respiratory Research Group, Centre for Population Health Sciences: GP Section, University of Edinburgh h Reader in Primary Care Research, Centre for Population Health Sciences: GP Section, University of Edinburgh.

Objectives The aim of this article is to map the European Organization for Research and Treatment of Cancer (EORTC) QLQ C-30 onto the EQ-5D measure to enable the estimation of health state values based on the EORTC QLQ C-30 data. The EORTC QLQ C-30 is of interest because it is the most commonly used instrument to measure the quality of life of cancer patients. Methods Regression analysis is used to establish the relationship between the two instruments. The performance of the model is assessed in terms of how well the responses to the EORTC QLQ C-30 predict the EQ-5D responses for a separate data set. Results The results showed that the model explaining EQ-5D values predicted well. All of the actual values were within the 95% confidence intervals of the predicted values. More importantly, predicted difference in quality-adjusted life-years (QALYs) between the arms of the trial was almost identical to the actual difference. Conclusion There is potential to estimate EQ-5D values using responses to the disease-specific EORTC QLQ C-30 measure of quality of life. Such potential implies that in studies that do not include disease-specific measures, it might still be possible to estimate QALYs.

Aim. This paper reports the costs of a programme of supplementary prenatal care, including healthcare costs, in the year following childbirth. Background. Publicly funded healthcare systems have provided pregnant women with adequate medical care, but access to resources to address their non-medical needs is still an issue. To improve women's access to pregnancy-related resources, a community-based, prenatal programme involving consultations with a specialist nurse, or nurse plus a home visitor was evaluated. Method. A sample of 284 women who had participated in a randomized controlled trial of the prenatal care programme participated in this partial economic analysis. Women had been randomized to one of three trial arms: (1) standard care, (2) standard care plus consultations with a specialist prenatal care nurse, or (3) standard care plus nurse consultations and a home visitor. For the economic study, each woman was asked about her and her baby's use of healthcare services in the 12 months after the baby's birth. Health service utilization was multiplied by the unit cost of each service and summed to arrive at the total cost of services used. The study was undertaken in 2004. Results. Supplementary prenatal care neither increased the use of health services nor resulted in savings in health spending. Compared with standard care, women in the two intervention groups made more use of family physicians and less use of paediatricians, but no significant differences in the overall costs of health care were noted. Conclusion. While supplementary prenatal care had no impact on costs, some benefits occurred for those at greatest risk of not accessing services. However, it would be premature to draw widespread recommendations for policy from the results of a single study. Further investment in prenatal care should continue to be accompanied by rigorous evaluation of its costs and the value that women place on the service provided.

Objective: To review the methods and findings of studies that assess the costs and consequences of interventions to reduce mother-to-child HIV transmission in sub-Saharan Africa. Design: Systematic literature review Methods: A literature search was conducted to identify studies that assessed the costs and consequences of interventions aimed at reducing mother-to-child HIV transmission in African populations. The methodological quality of included studies was appraised using the British Medical Journal Economic Evaluation Working Party checklist and data were extracted for comparison using a data extraction template. Results: Nine studies, all of which used modelling techniques to predict the cost-effectiveness of anti-retroviral interventions, were identified for inclusion in the review. The quality of reporting was found to be lacking in several key areas. In particular a lack of detail was given regarding quantities of resources required for interventions, and the methods for valuing health outcomes and unit costs. In general, the more recent evaluations report more favourable cost-effectiveness ratios than earlier studies due to lower drug costs and in some cases the use of shorter drug regimens. Conclusions: Comparisons between studies were hampered by variations in the values attached to model parameters and by differences in the structure and design of models. The most encouraging findings have been reported for the CDC short zidovudine regimen and the HIVNET012 single dose nevirapine regimen. The generalizability of these findings is limited by the use of incremental costing, combined with uncertainty surrounding the level of infrastructure required to implement the interventions. In low-income sub-Saharan countries, the costs of strengthening the infrastructure to levels capable of providing such interventions, needs to be assessed before an optimal policy for the prevention of mother-to-child HIV transmission in sub-Saharan Africa can be established.

Objective: To develop a method of determining the relative importance of waiting time and location of care for patients with haematological disorders requiring red cell transfusion. Such information is particularly relevant when evaluating interventions that affect patient well-being (e.g. by changing waiting time and location) but do not affect health outcomes. Methods: Conjoint analysis is used to assess the relative importance of waiting time and location with respect to pre-transfusion testing and red cell transfusion. Compensation is also included as an attribute in order to estimate the monetary value of changes in waiting time and location. Results: Waiting time and location are important attributes in the provision of pre-transfusion testing and red cell transfusion. Compensation is not an important attribute. On average patients are willing to wait an additional 45 minutes in order to have pre-transfusion testing in their own home and an additional 35 minutes in order to receive red cell transfusions in their preferred location. Conclusion: The relative importance of waiting time and location of care was established. However, it was not possible to assign monetary values since compensation was not an important attribute for these respondents. The paper highlights the scope for using conjoint analysis to analyse the non-health benefits that may result from changes in the delivery of care.