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ObjectiveTo assess the cost-utility and cost-effectiveness of a group-based outpatient physical therapy intervention delivered 6 weeks after primary total knee replacement (TKR) compared with usual care, alongside the Activity-Orientated Rehabilitation Following Knee Arthroplasty (ARENA) multicenter, randomized, controlled trial.MethodsThe economic analyses were performed from the perspective of the health and social care payer. We collected resource use for health and social care and productivity losses and patient outcomes for 12 months after surgery to derive costs and quality-adjusted life years (QALYs). Results were expressed in incremental cost-effectiveness ratios (ICERs), and incremental net monetary benefit statistics (INMBs) for a society willingness-to-pay (WTP) threshold of £20,000 per QALY gained, with sensitivity analyses to model specification and perspective.ResultsThe cost of the ARENA physical therapy classes was mean ± SD £179 ± 39 per patient. Treatment in the year following surgery cost was, on average, £1,739 (95% confidence interval [95% CI] –£742, £4,221) per patient in the intervention group (n = 89), which was an additional £346 (95% CI £38, £653) per patient compared with usual care (n = 91) (£1,393 [95% CI –£780, £3,568]). QALY benefits were 0.0506 higher (95% CI 0.009, 0.09) in the intervention group, corresponding to an additional 19 days in “perfect health.” The ICER for the intervention group was £6,842 per QALY gained, and the INMB was £665 (95% CI £139, £1,191), with a 92% probability of being cost-effective, and no less than 73% in all sensitivity analysis scenarios.ConclusionThe addition of group-based outpatient physical therapy classes to usual care improves quality of life and is a cost-effective treatment option following TKR for a society WTP threshold of £20,000 per QALY gained.

Meals on Wheels (MoWs) provide daily meals and social contact to adults who need support to live in the community. Many adults in England need help with shopping for food and preparing meals. MoWs could be essential for these individuals. In addition, MoWs could potentially lead to considerable savings for adult social care services and the NHS. However, many councils in England have stopped providing MoWs because of cuts in social care budgets. This leaves many individuals unable to access this essential service. To complicate matters further, there is no single model of MoWs provision. This makes it difficult to establish an evidence base to inform discussions about the role MoWs services have in contemporary social care. The proposed scoping review will explore the number and types of existing MoWs provision models that operate in England, which will help offer a comprehensive picture of provision of meals services for adults with care and support needs.

Background: UK schools increasingly have to respond to anxiety, depression, and conduct disorder as key causes of morbidity in children and young people (CYP).Objective: To assess the comparative effectiveness of educational setting-based interventions for the prevention of anxiety, depression, and conduct disorder in CYP.Design: Systematic review, network meta-analysis (NMA), economic evaluation.Data sources: MEDLINE, EMBASE, PsycINFO and CENTRAL searches to 4 April 2018 and NHS EED on 22 May 2019 for economic evaluations. No language or date filters applied.Main Outcomes: Post-intervention self-reported anxiety, depression or conduct disorder symptoms.Review methods: We included randomised/quasi-randomised trials of universal or targeted interventions for prevention of anxiety, depression or conduct disorder in CYP aged 4–18 years. Interventions were based on Cognitive Behavioural Therapy (CBT), mindfulness/relaxation, CBT+Interpersonal Therapy (IPT), third-wave, exercise, biofeedback, behavioural, IPT, bias modification and occupational therapy. Screening was conducted independently by two reviewers. Data extraction was conducted by one reviewer and checked by a second. Intervention and component-level NMA were conducted in OpenBUGS. A review of the economic literature and a cost-consequence analysis were conducted.Results: 142 studies were included in the review, and 109 contributed to the NMA. 57/109 were at unclear risk of bias for random sequence generation and allocation concealment. Heterogeneity was moderate. In universal secondary school settings, mindfulness/relaxation interventions (Standardised Mean Difference (SMD) -0.65, [95%CrI -1.14 to -0.19]) and CBT (SMD -0.15 [95%CrI -0.34 to 0.04]) may be effective for anxiety. CBT interventions containing a psychoeducation component may be effective (SMD -0.30, [-0.59 to -0.01]) at preventing anxiety post-intervention. For anxiety in targeted secondary settings there was evidence exercise was effective (SMD -0.47, [95%CrI -0.86 to -0.09]). There was weak evidence in universal (SMD -0.07, [95%CrI -0.23 to 0.05]) and targeted (SMD -0.38, [95%CrI -0.84 to 0.07]) primary settings, that CBT may prevent anxiety. For preventing depression in universal secondary settings, there was weak evidence that CBT (SMD -0.04, [-0.16 to 0.07]) and CBT+IPT (SMD -0.18, [-0.46 to 0.08]) may be effective. Third wave (SMD -0.35, [-0.70 to 0.00]) and CBT interventions (SMD -0.11, [-0.28 to 0.05]) containing a psychoeducation component may be effective at preventing depression post-intervention. There was no evidence of intervention effectiveness in targeted secondary, targeted primary, or universal primary settings post-intervention. Results for university settings were unreliable due to inconsistency in the NMA. A narrative summary was reported for five conduct disorder prevention studies, all in primary school settings. None reported the primary outcome at post-intervention. The economic evidence review reported heterogeneous findings from six studies. Taking the perspective of a single school budget and based on CBT intervention costs in universal secondary settings, the cost-consequence analysis estimated an intervention cost of £43 per student.Limitations: The emphasis on disorder-specific prevention excluded broader mental health interventions and restricted the number of eligible conduct disorder prevention studies. Restricting to interventions based in the educational setting limited the number of eligible university-level interventions.Conclusions: There was weak evidence of the effectiveness of school-based, disorder-specific prevention interventions, although effects were modest and the evidence not robust. CBT-based interventions may be more effective if they include a psychoeducation component.Future work: Future trials for prevention of anxiety and depression should evaluate CBT with and without a psychoeducation component, and include mindfulness/relaxation or exercise comparators, with sufficient follow-up. Cost implications must be adequately measured.

Additional file 1.

Objectives To evaluate the accuracy of routine data for costing inpatient resource use in a large clinical trial and to investigate costing methodologies. Design Final-year inpatient cost profiles were derived using (1) data extracted from medical records mapped to the National Health Service (NHS) reference costs via service codes and (2) Hospital Episode Statistics (HES) data using NHS reference costs. Trust finance departments were consulted to obtain costs for comparison purposes. Setting 7 UK secondary care centres. Population A subsample of 292 men identified as having died at least a year after being diagnosed with prostate cancer in Cluster randomised triAl of PSA testing for Prostate cancer (CAP), a long-running trial to evaluate the effectiveness and cost-effectiveness of prostate-specific antigen (PSA) testing. Results Both inpatient cost profiles showed a rise in costs in the months leading up to death, and were broadly similar. The difference in mean inpatient costs was £899, with HES data yielding ∼8% lower costs than medical record data (differences compatible with chance, p=0.3). Events were missing from both data sets. 11 men (3.8%) had events identified in HES that were all missing from medical record review, while 7 men (2.4%) had events identified in medical record review that were all missing from HES. The response from finance departments to requests for cost data was poor: only 3 of 7 departments returned adequate data sets within 6 months. Conclusions Using HES routine data coupled with NHS reference costs resulted in mean annual inpatient costs that were very similar to those derived via medical record review; therefore, routinely available data can be used as the primary method of costing resource use in large clinical trials. Neither HES nor medical record review represent gold standards of data collection. Requesting cost data from finance departments is impractical for large clinical trials. Trial registration number ISRCTN92187251; Pre-results.

BackgroundSocio-demographic characteristics are associated with participating in cancer screening and trials. We compared the characteristics of those responding with those not responding to a single invitation for PSA testing for prostate cancer as part of the Cluster randomised triAl of PSA testing for Prostate cancer (CAP).MethodsAge, rurality and deprivation among 197,763 men from 271 cluster-randomised primary care centres in the UK were compared between those responding (n=90,300) and not responding (n=100,953) to a prostate cancer testing invitation.Results There was little difference in age between responders and non-responders. Responders were slightly more likely to come from urban rather than rural areas and were slightly less deprived than those who did not respond. ConclusionThese data indicate similarities in age and only minor differences in deprivation and urban location between responders and non-responders. These differences were smaller, but in the same direction as observed in other screening trials.

Introduction: An increasing number of people are living with multimorbidity. The evidence base for how best to manage these patients is weak. Current clinical guidelines generally focus on single conditions, which may not reflect the needs of patients with multimorbidity. The aim of the 3D study is to develop, implement and evaluate an intervention to improve the management of patients with multimorbidity in general practice. Methods and analysis: This is a pragmatic two-arm cluster randomised controlled trial. 32 general practices around Bristol, Greater Manchester and Glasgow will be randomised to receive either the '3D intervention' or usual care. 3D is a complex intervention including components affecting practice organisation, the conduct of patient reviews, integration with secondary care and measures to promote change in practice organisation. Changes include improving continuity of care and replacing reviews of each disease with patient-centred reviews with a focus on patients' quality of life, mental health and polypharmacy. We aim to recruit 1383 patients who have 3 or more chronic conditions. This provides 90% power at 5% significance level to detect an effect size of 0.27 SDs in the primary outcome, which is health-related quality of life at 15 months using the EQ-5D-5L. Secondary outcome measures assess patient centredness, illness burden and treatment burden. The primary analysis will be a multilevel regression model adjusted for baseline, stratification/ minimisation, clustering and important co-variables. Nested process evaluation will assess implementation, mechanisms of effectiveness and interaction of the intervention with local context. Economic analysis of cost-consequences and cost-effectiveness will be based on quality-adjusted life years. Ethics and dissemination: This study has approval from South-West (Frenchay) National Health Service (NHS) Research Ethics Committee (14/SW/0011). Findings will be disseminated via final report, peerreviewed publications and guidance to healthcare professionals, commissioners and policymakers. Trial registration number: ISRCTN06180958; Preresults.