Search

Background Irritable bowel syndrome (IBS) is a common functional bowel disorder that has a considerable impact on patient quality of life and substantial societal and health care resource costs. Current treatments are often ineffective. Tricyclic antidepressants have shown promise in secondary care populations but their effectiveness in a primary care setting remains unclear. Methods ATLANTIS is a randomised, multi-centre, parallel-group, two-arm, double-blind, placebo-controlled trial of low-dose amitriptyline as a second-line treatment for IBS in primary care. Participants will be invited by letter, or recruited opportunistically, from general practices in three regions of England (West Yorkshire, Wessex, and West of England) and screened for eligibility. A total of 518 adult patients with IBS, who are symptomatic despite first-line therapies, will be randomised 1:1 to amitriptyline or identical placebo for 6 months. Treatment will commence at a dose of 10 mg (or one placebo tablet) daily at night, with dose titration up to a maximum of 30 mg at night, depending on side effects and response to treatment. Participant-reported assessments will be conducted at baseline and 3, 6, and 12 months post-randomisation. The primary objective is to determine the effectiveness of amitriptyline, compared with placebo, in improving participant-reported global symptoms of IBS at 6 months (using the IBS Severity Scoring System). Secondary outcomes include relief of IBS symptoms, effect on IBS-associated somatic symptoms (Patient Health Questionnaire-12), anxiety and depression (Hospital Anxiety and Depression Scale), ability to work and participate in other activities (Work and Social Adjustment Scale), acceptability and tolerability of treatment, self-reported health care use, health-related quality of life (EQ-5D-3L), and cost-effectiveness. A nested, qualitative study will explore patient and general practitioner experiences of treatments and trial participation, including acceptability, adherence, unanticipated effects, and implications for wider use of amitriptyline for IBS in primary care. Discussion Determining the clinical and cost-effectiveness of low-dose amitriptyline as a second-line treatment for IBS in primary care will provide robust evidence to inform management decisions. Trial registration ISRCTN ISRCTN48075063 . Registered on 7th June 2019.

Background: The Refining and Optimising a behavioural intervention to Support Endocrine Therapy Adherence (ROSETA) programme has developed four intervention components aiming to improve medication adherence in women with early-stage breast cancer. These are (a) text messages, (b) information leaflet, (c) Acceptance and Commitment Therapy-based guided self-help (ACT), (d) side-effect management website. Guided by the Multiphase Optimisation Strategy, our pilot trial will use a fractional factorial design to evaluate the feasibility of undertaking a larger optimisation trial. The pilot will include a process evaluation to maximise learning regarding the fidelity and acceptability of the intervention components before proceeding with a larger trial. The trial process evaluation has three aims: to assess the (1) fidelity and (2) acceptability of the intervention components; and (3) to understand participant’s trial experience, and barriers and facilitators to recruitment and retention. Methods: The process evaluation will use multiple methods. Fidelity of the intervention components will be assessed using self-reported questionnaire data, trial data on intervention component adherence, and observations of the ACT sessions. Acceptability of the intervention components and trial experience will be explored using an acceptability questionnaire and interviews with patients and trial therapists. Trial experience will be assessed using a questionnaire and interviews with participants, while barriers and facilitators to recruitment and retention will be assessed using a questionnaire completed by research nurses and participant interviews. The pilot trial opened for recruitment on 20th May 2022 and was open at the time of submission. Conclusions: This process evaluation will provide information regarding whether the intervention components can be delivered with fidelity within a national healthcare setting and are acceptable to participants. We will also better understand participant experience in a pilot trial with a fractional factorial design, and any barriers and facilitators to recruitment and retention. Registration: ISRCTN registry (ISRCTN10487576, 16/12/2021).

Frailty is a risk factor for adverse health outcomes. There is a paucity of literature on frailty progression defined by a cumulative deficit model among community dwelling older people. The objective of this review was to synthesise evidence on these changes in health and mortality among community-dwelling older people.Six databases (Medline, Embase, CINAHL, Cochrane, PsycInfo, Web of Science) and a clinical trials registry were searched in July 2021. The inclusion criteria were studies using a frailty index and providing information on transition between frailty states or to death in community-dwelling older people aged ≥ 50. Exclusion criteria were studies examining specific health conditions, conference abstracts and non-English studies. To standardise the follow-up period and facilitate comparison, we converted the transition probabilities to annual transition rates.Two reviewers independently screened 5078 studies and 61 studies were included for analysis. Of these, only three used the same frailty state cut-points to facilitate cross-cohort comparison. This review found that frailty tends to increase with time, people who are frail at baseline have greater likelihood to progress in frailty and die, and the main factor that accelerates frailty progression is age. Other risk factors for progression are having chronic disease, smoking, obesity, low-income or/and low-education levels. A frailty index is an accurate predictor of adverse outcomes and death.This systematic review demonstrated that worsening in frailty was a common frailty transition, and older people who are frail at baseline are more likely to die. A frailty index has significant power to predict adverse health outcomes. It is a useful tool for within-cohort comparison but there are challenges comparing different cohorts due to dependence of frailty progression on age and differences in how frailty index is defined and measured.

BackgroundSince COVID-19 was declared a pandemic, attempts have been made to monitor trends over time and to compare countries and regions. Insufficient testing for COVID-19 underestimates the incidence and inflates the case-fatality proportion. Given the age- and sex- distribution of morbidity and mortality from COVID-19, the underlying sex- and age-distribution of a population needs to be accounted for. The aim of this paper is to present a method for monitoring trends of COVID-19 using adjusted mortality trend ratios (AMTR).MethodsAge- and sex-mortality distribution of a reference population composed of the first 14,086 fatalities which occurred before the end of March and were reported in Europe by some countries were used to calculate age- and sex-specific mortality rates per 1,000,000 population. These were applied to each country population to calculate the expected deaths. Adjusted Mortality Trend Ratios (AMTRs) with 95% confidence intervals (C.I.) were calculated for selected European countries from 17/03/2020 to 22/06/2020 by dividing observed cumulative mortality, by expected mortality times the crude mortality of the reference population. These estimated the sex- and age-adjusted mortality for COVID-19 per million population in each country.ResultsThe cumulative mortality from COVID-19, the crude mortality rates, and the AMTRs were calculated for each country and compared. United Kingdom, Italy, France and Spain registered the highest mortality in Europe. On 22/06/2020 in Europe the total mortality rate from COVID-19 was 352 per 1,000,000 inhabitants; and it was highest in Belgium (850 per 1,000,000 inhabitants) followed by Spain, UK, Italy, Sweden and France. When accounting for the underlying age and sex structure of each country, Belgium remained the single country experiencing the highest AMTR of 929 per million inhabitants on 22/06/2020; however Ireland – which had a CMR in line with the total European population – emerged as having experienced a much more important impact of COVID-19 mortality with an AMTR of 550/million on 22/06/2020, higher than Sweden and Italy.ConclusionsIn understanding and managing the pandemic of COVID-19, comparable international data is a priority. Our methods allow a fair comparison of mortality in space and over time. The authors urge the WHO, given the absence of age and sex-specific mortality data for direct standardisation, to adopt this method to estimate the comparative mortality from COVID-19 pandemic worldwide.Key messageComparing trends of the COVID-19 pandemic over time and in space is essential to monitor the disease and compare different local policiesUsing the concept of indirect standardisation we propose a method to effectively compare age- and sex-adjusted mortality rates trends interpretable as deaths for COVID-19 per million inhabitantsApplying this methods, interesting features of the infection in Europe emerged; e.g. by 22/06/2020 Belgium is the most severely affected country with an AMTR of 929 per million inhabitants, followed by the UK; Ireland and Sweden rank fourth and fifth most affected country in EuropeThe WHO should consider using this method for monitoring the spread of COVID-19, which only requires recording the total number of death from COVID-19 from each country/region

BACKGROUND Aims of the study were to: Implement supported self-management for chronic primary oro-facial pain in a clinical setting. Evaluate its impact on consultation rates, pain severity, interference with life and patient experience. METHODS Sixty-six patients with chronic primary oro-facial pain received the intervention at a facial pain clinic at Leeds Dental Institute, UK. Brief Pain Inventory (BPI) scores measured pain severity and interference with life before and after the intervention. Process mining outlined patient care pathways. Monthly consultation rates measured 12 months before and after the intervention were used to evaluate burden on healthcare services and economic impact. Patient feedback was assessed via Patient and Public involvement discussion groups. RESULTS Mean BPI scores significantly improved after intervention-from 5.70 (SD 1.89) to 3.78 (SD 2.34) (p

Objectives A growing literature acknowledges the association between childhood socioeconomic status (SES) and health in late adulthood (i.e., 50+). Less, however, is known about the association with mental health outcomes, such as depression. We use the Survey on Health, Ageing, and Retirement in Europe (SHARE) to analyze overall and gender-specific associations between childhood SES and late-adulthood depression. Methods Using life history and contemporaneous data from 21,989 SHARE respondents in combination with principal component analysis we construct indices of childhood SES. We measure late-adulthood depression using the EURO-D scale. Contemporaneous SES is operationalized as the logarithm of household equivalized income. We estimate associations using linear regression models. Results We document a positive association between childhood SES and the late-adulthood EURO-D score. The association persists even when allowing for contemporaneous SES. Zooming in on gender-specific associations reveals that the association for mental health is particularly pronounced for women. Discussion Our findings reveal the long-term association between childhood socioeconomic conditions and depression later in life, which persists even after taking into account current socioeconomic conditions and are stronger for women than for men. These results imply that boosting childhood socioeconomic conditions can potentially have effects lasting well beyond the childhood phase.

Despite reported increases in referral numbers, a large proportion of those with prediabetes still decline participation in the NHS England Diabetes Prevention Programme (NDPP). The aim of this study was to explore whether investment in interventions to improve uptake of the programme has the potential to be cost-effective. An early cost-utility analysis was conducted using a Markov model parameterized based on secondary data sources. We explored different uptake scenarios and the impact that this had on the maximum allowable intervention price based on cost-effectiveness at the UK NICE willingness to pay threshold of £20,000 (US$ 25,913). Value of information analyses were conducted to explore the potential value of further research to resolve uncertainty at each uptake level. As uptake levels increase, the maximum allowable intervention price and overall expected value of removing decision uncertainty increases. For 5 percentage and 50 percentage points increase in uptake levels, the maximum allowable intervention price is £41.86 (US$ 54.23) and £418.59 (US$ 542.34) per person, and the overall expected value of removing decision uncertainty are £361,818,839 (US$ 468,786,625) and £1,468,712,316 (US$ 1,902,921,063) respectively. There is headroom for investment in interventions that improve uptake to the NDPP, thereby allowing the programme itself to be delivered in a manner that remains cost-effective.

PurposeThis study aimed to determine the survival outcome and prognostic factors of patients with nasopharyngeal cancer accessing treatment in Yogyakarta, Indonesia.MethodsData on 759 patients with NPC diagnosed from 2007 to 2016 at Dr Sardjito General Hospital were included. Potential prognostic variables included sociodemographic, clinicopathology and treatment parameters. Multivariable analyses were implemented using semi-parametric Cox proportional hazards modelling and fully parametric survival analysis.ResultsThe median time of observation was 14.39 months. In the whole cohort the median observed survival was 31.08 months. In the univariable analysis, age, education status, insurance type, BMI, ECOG index, stage and treatment strategy had an impact on overall survival (OS) (p values ConclusionsMedian OS for the cohort was low compared to those reported in both endemic and non-endemic regions. By combining the findings of multivariable analyses, we showed that age, education status, ECOG index, stage and first treatment modality were independent predictors for the OS.

ObjectivesWe aimed to study the association of childhood urbanicity with depressive symptoms in late adulthood.Design, setting and participantsWe used linear and logistic regressions to analyse data drawn from 20 400 respondents from the Survey of Health, Ageing and Retirement in Europe, a panel dataset incorporating a representative sample of the 50+ population in 13 European countries.Outcomes and analysisChildhood urbanicity was determined using self-reports of the respondents’ circumstances at age 10, and late-adulthood depression using the EURO-D scale. We conditioned on circumstances early in life as well as later in life, most importantly late-adulthood urbanicity. We estimated the associations using linear regression models and limited dependent variable models.ResultsA pooled regression of both men and women suggested that childhood urbanicity is associated non-monotonically with depression in late adulthood and is particularly apparent for those spending their childhoods in suburban settings. We found that individuals who spend the longest time in their childhood in a suburban home exhibit an average increase in probability of 3.4 (CI 1.1 to 5.7) percentage points in reporting four or more depressive symptoms. The association was robust to the inclusion of a host of household characteristics associated with childhood urbanicity and was independent of current urbanicity and current income. When broken down by gender, we found some evidence of associations between depressive outcomes and urban living for men, and stronger evidence of such associations with urban and suburban living for women who exhibit an increase of 5.6 (CI 2.2 to 9.0) percentage points in reporting four or more depressive symptoms.ConclusionsOur analysis reveals a relationship between childhood urbanicity and depression in late adulthood. The evidence presented on the nature of this relationship is not straightforward but is broadly suggestive of a link, differing by gender, between greater urbanicity and higher levels of depressive symptoms. The life-long nature of this association may potentially inform policy agendas aimed at improving urban and suburban living conditions.

Objectives This paper introduces a framework with which to conceptualize the decision-making process in health technology assessment for new interventions with high budgetary impacts. In such circumstances, the use of a single threshold based on the marginal productivity of the healthcare system is inappropriate. The implications of this for potential partial implementation, horizontal equity, and pharmaceutical pricing are illustrated using this framework. Results Under the condition of perfect divisibility and given an objective of maximizing health, a large budgetary impact of a new treatment may imply that optimal implementation is partial rather than full, even at a given incremental cost-effectiveness ratio that would nevertheless mean the decision to accept the treatment in full would not lead to a net reduction in health. In a one-shot price-setting game, this seems to give rise to potential horizontal equity concerns. When the assumption of fixity of the incremental cost-effectiveness ratio (arising from the assumed exogeneity of the manufacturer’s price) is relaxed, it can be shown that the threat of partial implementation may be sufficient to give rise to an incremental cost-effectiveness ratio at which cost the entire potential population is treated, maximizing health at an increased level, and with no contravention of the horizontal equity principle.

ObjectivesTo analyse healthcare utilisation and costs in the last year of life in England, and to study variation by cause of death, region of patient residence and socioeconomic status.MethodsThis is a retrospective cohort study. Individuals aged 60 years and over (N=108 510) who died in England between 2010 and 2017 were included in the study.ResultsHealthcare utilisation and costs in the last year of life increased with proximity to death, particularly in the last month of life. The mean total costs were higher among males (£8089) compared with females (£6898) and declined with age at death (£9164 at age 60–69 to £5228 at age 90+) with inpatient care accounting for over 60% of total costs. Costs decline with age at death (0.92, 95% CI 0.88 to 0.95, pConclusionsHealthcare utilisation and costs in the last year of life increase with proximity to death, particularly in the last month of life. Finer geographical data and information on healthcare supply would allow further investigating whether people receiving more planned care by primary care and or specialist palliative care towards the end of life require less acute care.

Background The survival of patients with nasopharyngeal cancer (NPC) have been reported in endemic and non-endemic regions. However, this has never been analyzed in Indonesian cases although this malignancy is endemic. This study aimed to perform survival analysis of the local cases and determine the prognostic factors. Methods A total of 767 patients with NPC diagnosed from January 2007 to December 2016 at Dr Sardjito General Hospital were included. Potential prognostic variables included sociodemographic parameters, clinicopathology features and treatment strategy. Kaplan-Meier method and the log-rank test estimated the rates of overall survival (OS). Multivariate analyses were done by a Cox proportional hazards model. Results The median OS was 14.38 months for the whole cohort. Patients with education ≥9 years, government insurance for civil servants, advanced stage and combination of chemo-radiation treatment had a significantly better OS than their counterparts (p Conclusions Median OS of our cohort was low compared to those reported in international publications, emphasizing the importance to improve the local cancer management. Age, clinical stage and treatment modality were independent favourable predictos for the patients’ OS. Legal entity responsible for the study Ethics committee, Faculty of Medicine, Public Health and Nursing Universitas Gadjah Mada/Dr Sardjito Hospital. Funding Indonesian Society for Hematology and Medical Oncology Yogyakarta Branch; Dutch Cancer Society. Disclosure All authors have declared no conflicts of interest.

This paper uses Hospital Episode Statistics, English administrative data, to investigate the growth in admitted patient health care expenditures and the implications of an ageing population. We use two samples of around 40,000 individuals who (a) used inpatient health care in the financial year 2005/06 and died by the end of 2011/12 and (b) died in 2011/12 and had some hospital utilisation since 2005/06. We use a panel structure to follow individuals over seven years of this administrative data, containing estimates of inpatient health care expenditures (HCE), information regarding individuals' age, time-to-death (TTD), morbidities at the time of an admission, as well as the hospital provider, year and season of admission. We show that HCE is principally determined by proximity to death rather than age, and that proximity to death is itself a proxy for morbidity.

This chapter introduces the political focus on the productivity of the NHS. Productivity is a conceptually simple construct, relating the amount of output produced to the amount of inputs used in the production process. Productivity growth can also be calculated by comparing the change in outputs produced to the change in inputs utilised from one period to the next. Political interest is focused primarily on productivity growth. However, assessing productivity or efficiency is somewhat problematic in the context of a free-at-the-point-of-use health system service such as the NHS. The authors discuss some of the issues they face in attempting such an evaluation. With these issues in mind, the authors describe the growth in outputs, inputs and productivity between 2004/05 and 2013/14. The chapter concludes by discussing whether or not the key political measures highlighted in the first section appear to have had an influence on NHS productivity growth.

This paper investigates the relationship between smoking and ill-health, with a focus on the onset of cancer. A discrete latent factor model for smoking and health outcomes, allowing for these to be commonly affected by unobserved factors, is jointly estimated, using the British Health and Lifestyle Survey (HALS) dataset. Post-estimation predictions suggest the reduction in time-to-cancer to be 5.7 years for those with an exposure of 30 pack-years, compared to never-smokers. Estimation of posterior probabilities for class membership shows that individuals in certain classes exhibit similar observables but highly divergent health outcomes, suggesting that unobserved factors influence outcomes. The use of a joint model changes the results substantially. The results show that failure to account for unobserved heterogeneity leads to differences in survival times between those with different smoking exposures to be overestimated by more than 50% (males, with 30 pack-years of exposure).

Best-practice economic evaluation methods for health-related decision making at a national level in England are well established, and as a first principle generally involve attempting to maximise the amount of health generated from the health system’s budget. Such methods are applied in ways that are broadly transparent and accountable, often at arm’s length from explicit political pressures. At local levels of decision making, however, decision making is arguably less likely to be applied according to established overarching principles, is less transparent and is more subject to political pressures. This may be owing to a multiplicity of reasons, for example, undesirability/inappropriateness of such methods, or a failure to make the methods clear to local decision makers. We outline principles for economic evaluations and break down these methods into their component parts, considering their relevance in the English local context. These include taxonomies of decision-making frameworks, budgets, costs, outcome, and characterisations of cost effectiveness. We also explore the role of broader factors, including the relevance of assuming a single fixed budget, pressures resulting from political and budgetary cycles and affordability. We consider the data requirements to inform such deliberations. By setting out principles for economic evaluation methods in a clear language aimed at local decision making, a potential role for such methods can be established, which to date has failed to emerge. While the extent to which these methods can and should be applied are a matter for continued debate, the establishment of such a mutual understanding may assist in the improvement of methods for such decision making and the outcomes resulting from their application.