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Background Alcohol consumption and related harm increase steeply from the ages of 12–20 years. Adolescents in the UK are among the heaviest drinkers in Europe. Excessive drinking in adolescents is associated with increased risk of accidents, injuries, self-harm, unprotected or regretted sex, violence and disorder, poisoning and accidental death. However, there is lack of clear evidence for the most clinically effective and cost-effective screening and brief interventions for reducing or preventing alcohol consumption in adolescents attending emergency departments (EDs). Objectives To estimate the distribution of alcohol consumption, alcohol-related problems and alcohol use disorders in adolescents attending EDs; to develop age-appropriate alcohol screening and brief intervention tools; and to evaluate the clinical effectiveness and cost-effectiveness of these interventions. Design The research has been conducted in three linked stages: (1) a prevalence study, (2) intervention development and (3) two linked randomised controlled trials (RCTs). Setting Twelve EDs in England (London, North East, and Yorkshire and The Humber). Participants A total of 5376 participants in the prevalence study [mean age 13.0 years, standard deviation (SD) 2.0 years; 46.2% female] and 1640 participants in the two linked RCTs (mean age 15.6 years, SD 1.0 years; 50.7% female). Interventions Personalised feedback and brief advice (PFBA) and personalised feedback plus electronic brief intervention (eBI), compared with alcohol screening alone. These age-appropriate alcohol interventions were developed in collaboration with the target audience through a series of focus groups and evaluations during stage 2 of the research programme and following two literature reviews. Main outcome measures Total alcohol consumed in standard UK units (1 unit = 8 g of ethanol) over the previous 3 months at 12-month follow-up, assessed using the Alcohol Use Disorders Identification Test, Consumption (3 items) (AUDIT-C). Results In the prevalence study, 2112 participants (39.5%) reported having had a drink of alcohol that was more than a sip in their lifetime, with prevalence increasing steadily with age and reaching 89.5% at the age of 17 years. The prevalence of at-risk alcohol consumption was 15% [95% confidence interval (CI) 14% to 16%] and the optimum cut-off point of the AUDIT-C in identifying at-risk drinking was ≥ 3. Associations of alcohol consumption and early onset of drinking with poorer health and social functioning were also found. In the RCT, the analysis of the primary outcome (average weekly alcohol consumption at month 12) identified no significant differences in effect between the three groups in both trials. In the high-risk drinking trial, the mean difference compared with control was 0.57 (95% CI –0.36 to 1.70) for PFBA and 0.19 (95% CI –0.71 to 1.30) for eBI. In the low-risk drinking trial, the mean difference compared with control was 0.03 (95% CI –0.07 to 0.13) for PFBA and 0.01 (95% CI –0.10 to 0.11) for eBI. The health economic analysis showed that eBI and PFBA were not more cost-effective than screening alone. Conclusions The ED can offer an opportunity for the identification of at-risk alcohol use in adolescents. A simple, short, self-completed screening instrument, the AUDIT-C, is an effective tool for identifying adolescents who are at risk of alcohol-related problems. Associations of alcohol consumption and earlier onset of drinking with poorer health and social functioning were observed in the prevalence study. The trials were feasible to implement and exceeded the recruitment target and minimum follow-up rates. However, PFBA and eBI were not found to be more effective than screening alone in reducing or preventing alcohol consumption in 14- to 17-year-olds attending EDs. Limitations and future work Only one-third of participants engaged with the application program; this is likely to have limited the effect of the intervention. We recommend that future research should focus on methods to maximise engagement with digital interventions and evaluate the effect of such engagement on clinical outcomes. Trial registration Current Controlled Trials ISRCTN45300218. Funding This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 8, No. 2. See the NIHR Journals Library website for further project information.

Objectives The effects of acute coronary syndrome (ACS) events on health-related quality-of-life (HRQoL) and the time dependency of these effects are unknown. This study aimed to characterize health utilities in ACS patients to aid development of future economic models estimating the cost per quality-adjusted life-year impact of ACS events and potential treatments. Methods Multi-center, non-interventional, longitudinal evaluation of health utility in patients experiencing ACS or stroke events. EuroQol-5 dimension 3 level (EQ-5D-3L) surveys were sent to patients (≥18 years) from three UK centers, 1 month after hospital discharge for myocardial infarction (MI), unstable angina (UA), or stroke. Patient demographics, lifestyle, and baseline utility score were collected in the first survey. Follow-up surveys were sent at 6, 12, 18, and 24 months to prospectively capture utility and subsequent health events. Two methods of patient identification were adopted-prospective, where the patient's qualifying events occurred after the study index date, and retrospective, where the patient's qualifying event occurred prior to the study index date. General healthy population utility values were assumed for pre-event HRQoL. Results Between January 2011 and March 2014, 2,103 prospectively (n = 1,350)/retrospectively (n = 753) identified patients (mean age = 68.3 years; 67.9% male) responded: MI = 55.9% (n = 1,176), UA = 42.7% (n = 898), stroke = 1.4% (n = 29); 24% had type 2 diabetes. Post-event utility values were lower than general healthy population values, although significant differences in utility between subsequent 6 (n = 1,031, change = -0.002), 12 (n = 1,096, change = -0.008), 18 (n = 1,246, change = -0.007), and 24 (n = 1,277, change = -0.004) month timepoints were not detected. Through multivariate regression analyses, wheelchair use, current smoking, and secondary mental and joint health events were associated with the greatest statistically significant utility decrements. Conclusions This study indicates that health utility decreases following a cardiovascular event and, although some improvement occurs over the subsequent 24 months, general healthy population utility is not necessarily attained.

Secondary hyperparathyroidism (SHPT) is a major complication of end stage renal disease (ESRD). For the National Health Service (NHS) to make appropriate choices between medical and surgical management, it needs to understand the cost implications of each. A recent pilot study suggested that the current NHS healthcare resource group tariff for parathyroidectomy (PTX) (£2071 and £1859 in patients with and without complications, respectively) is not representative of the true costs of surgery in patients with SHPT.This study aims to provide an estimate of healthcare resources used to manage patients and estimate the cost of PTX in a UK tertiary care centre.Resource use was identified by combining data from the Proton renal database and routine hospital data for adults undergoing PTX for SHPT at the University Hospital of Wales, Cardiff, from 2000-2008. Data were supplemented by a questionnaire, completed by clinicians in six centres across the UK. Costs were obtained from NHS reference costs, British National Formulary and published literature. Costs were applied for the pre-surgical, surgical, peri-surgical, and post-surgical periods so as to calculate the total cost associated with PTX.One hundred and twenty-four patients (mean age=51.0 years) were identified in the database and 79 from the questionnaires. The main costs identified in the database were the surgical stay (mean=£4066, SD=£,130), the first month post-discharge (£465, SD=£176), and 3 months prior to surgery (£399, SD=£188); the average total cost was £4932 (SD=£4129). From the questionnaires the total cost was £5459 (SD=£943). It is possible that the study was limited due to missing data within the database, as well as the possibility of recall bias associated with the clinicians completing the questionnaires.This analysis suggests that the costs associated with PTX in SHPT exceed the current NHS tariffs for PTX. The cost implications associated with PTX need to be considered in the context of clinical assessment and decision-making, but healthcare policy and planning may warrant review in the light of these results.

Infectious intestinal diseases cause substantial morbidity and economic loss in the UK. Rotavirus gastroenteritis (RVGE), a form of gastroenteritis, is the primary cause of severe diarrhoea in children. The primary objective of this study was to examine whether hospitalisation for gastroenteritis, and particularly RVGE, is linked to social deprivation.A retrospective study relating to hospital admissions in England with rotavirus, gastroenteritis, or type 1 diabetes mellitus (T1DM) was conducted in children aged under 5 years between 1st April 2009 and 31st March 2010 using the CHKS database. Admissions with selected diagnoses were extracted based on ICD-10 coding. Deprivation data were obtained from the Index of Multiple Deprivation (IMD) 2007 for England.A total of 20,571 unique hospital admissions were made by children, in England, with RVGE (n = 1334; 6.5%) together with a diagnosis of infectious gastroenteritis of all causes (n = 19,237; 93.5%), giving an overall hospital admission rate, for those aged under 5 years, of 65.7 per 10,000 population. With 'rank of average score' and the 'rank of average rank' as measures of deprivation, the rate of hospital admissions with gastroenteritis of all causes decreased by 0.346 and 0.287 per 10,000 (p 0.001) respectively for every unit increase in deprivation rank (decreasing deprivation), though this trend was not observed in patients admitted with RVGE specifically.Hospital admissions with gastroenteritis of all causes increased as deprivation increased. The implementation of a rotavirus vaccination programme would help to reduce the burden of RVGE and gastroenteritis of all causes, and in the context of gastroenteritis, some elements of health and social inequality may be vaccine preventable.It is possible that the study is limited by the accuracy and completeness of deprivation indices, and coding within CHKS; the existence of the 'ecological fallacy' must also be considered.

Metastatic bone disease (MBD) is the most common cause of cancer pain and of serious skeletal-related events (SREs) reducing quality of life. Management of MBD involves a multimodal approach aimed at delaying the first SRE and reducing subsequent SREs. The objective of the study was to characterise the hospital burden of disease associated with MBD and SREs following breast, lung and prostate cancer in Spain. Patients admitted into a participating hospital, between 1 January 2003 and 31 December 2003, with one of the required cancers were identified and selected for inclusion into the study. The index admission to hospital, incidence of patients admitted and hospital length of stay were analysed. There were 28,162 patients identified with breast, lung and prostate cancer. The 3 year incidence rates of hospital admission due to MBD were 95 per 1000 for breast cancer, 156 per 1000 for lung cancer and 163 per 1000 for prostate cancer. For patients admitted following an SRE, the incidence rates were 211 per 1000 for breast cancer, 260 per 1000 for lung cancer and 150 per 1000 for prostate cancer. This study has shown that cancer patients consume progressively more hospital resources as MBD and subsequent SREs develop.

To quantify the differences in hospital length of stay (LOS) and cost between healthy and vulnerable children with cystic fibrosis (CF), insulin-dependent diabetes mellitus (IDDM), cancer, and epilepsy who contract rotavirus (RVGE) or respiratory syncytial virus (RSV).Hospital Episode Statistics (HES) data were collected for England, for children5 years old, admitted between April 2001 and March 2008, using ICD-10 codes for RVGE and RSV. Cases were identified as having RVGE and/or RSV plus CF, IDDM, cancer, or epilepsy. Healthy controls had RVGE and/or RSV only, additional controls had eczema only. Cost, hospital LOS, and demographics were collected.Four hundred and eighty-six (0.5%) cases and 101,784 (99.5%) healthy controls were admitted with RVGE or RSV, with 17,420 eczema controls. RVGE was present in 153 (31.5%) cases and 7532 (7.4%) healthy controls, and RSV in 333 (68.5%) cases and 94,252 (92.6%) healthy controls. Cases were older (1.1 years, SD = 1.3 years), had greater LOS (9.9 days, SD = 19.9), and cost more (£3477, SD = £7765) than healthy controls (age = 0.2, SD = 0.5, p 0.001; LOS = 1.9 days, SD = 3.1, p 0.001; cost = £595, SD = £727, p 0.001). Cost for cases was 6-times greater than healthy controls (p 0.001). Controls had a 0.3 day greater LOS (p 0.001) with RSV, but a £17 (p = 0.085) lower mean cost than RVGE.RVGE and RSV are more serious diseases in vulnerable children, requiring more intense resource use. The importance of preventing infection in vulnerable children is underlined by hygiene and appropriate isolation and vaccination strategies. When universal vaccination is under consideration, as for rotavirus vaccines, evaluation of a vaccination programme should consider the potentially positive impact on vulnerable children.Limitations of the study include a dependency on accurate coding, an expectation that patients are identified through laboratory testing, and the possibility of unidentified underlying conditions affecting the burden.