Self-care support for children and adolescents with long-term conditions : the REfOCUS evidence synthesis

Background: Self-care support (e.g. education, training, peer/professional support) is intended to enhance the self-care capacities of children and young people, while simultaneously reducing the financial burden facing health-care systems. Objectives: To determine which models of self-care support for long-term conditions (LTCs) are associated with significant reductions in health utilisation and costs without compromising outcomes for children and young people. Design: Systematic review with meta-analysis. Population: Children and young people aged 0–18 years with a long-term physical or mental health condition (e.g. asthma, depression). Intervention: Self-care support in health, social care, educational or community settings. Comparator: Usual care. Outcomes: Generic/health-related quality of life (QoL)/subjective health symptoms and health service utilisation/costs. Design: Randomised/non-randomised trials, controlled before-and-after studies, and interrupted time series designs. Data sources: MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, ISI Web of Science, NHS Economic Evaluation Database, The Cochrane Library, Health Technology Assessment database, Paediatric Economic Database Evaluation, IDEAS, reference scanning, targeted author searches and forward citation searching. All databases were searched from inception to March 2015. Methods: We conducted meta-analyses, simultaneously plotting QoL and health utilisation effects. We conducted subgroup analyses for evidence quality, age, LTC and intervention (setting, target, delivery format, intensity). Results: Ninety-seven studies reporting 114 interventions were included. Thirty-seven studies reported adequate allocation concealment. Fourteen were UK studies. The vast majority of included studies recruited children and young people with asthma (n = 66, 68%). Four per cent of studies evaluated ‘pure’ self-care support (delivered through health technology without additional contact), 23% evaluated facilitated self-care support (≤ 2 hours’/four sessions’ contact), 65% were intensively facilitated (≥ 2 hours’/four sessions’ contact) and 8% were case management (≥ 2 hours’ support with multidisciplinary input). Self-care support was associated with statistically significant, minimal benefits for QoL [effect size (ES) –0.17, 95% confidence interval (CI) –0.23 to –0.11], but lacked clear benefit for hospital admissions (ES –0.05, 95% CI –0.12 to 0.03). This finding endured across intervention intensities and LTCs. Statistically significant, minimal reductions in emergency use were observed (ES –0.11, 95% CI –0.17 to –0.04). The total cost analysis was limited by the small number of data. Subgroup analyses revealed statistically significant, minimal reductions in emergency use for children aged ≤ 13 years (ES –0.10, 95% CI –0.17 to –0.04), children and young people with asthma (ES –0.12, 95% CI –0.18 to –0.06) and children and young people receiving ≥ 2 hours per four sessions of support (ES –0.10, 95% CI –0.17 to –0.03). Preliminary evidence suggested that interventions that include the child or young person, and deliver some content individually, may optimise QoL effects. Face-to-face delivery may help to maximise emergency department effects. Caution is required in interpreting these findings. Limitations: Identification of optimal models of self-care support is challenged by the size and nature of evidence available. The emphasis on meta-analysis meant that a minority of studies with incomplete but potentially relevant data were excluded. Conclusions: Self-care support is associated with positive but minimal effects on children and young people’s QoL, and minimal, but potentially important, reductions in emergency use. On current evidence, we cannot reliably conclude that self-care support significantly reduces health-care costs. Future work: Research is needed to explore the short- and longer-term effects of self-care support across a wider range of LTCs. Study registration: This study is registered as PROSPERO CRD42014015452. Funding: The National Institute for Health Research Health Services and Delivery Research programme

Operational Modeling with Health Economics to Support Decision Making for COPD Patients

© Health Research and Educational Trust. This is the accepted manuscript version of an article which has been published in final form at https://doi.org/10.1111/1475-6773.13652Objective: To assess the impact of interventions for improving the management of chronic obstructive pulmonary disease (COPD), specifically increased use of pulmonary rehabilitation (PR) on patient outcomes and cost-benefit analysis. Data sources: We used the national Hospital Episode Statistics (HES) datasets in England, local data and experts from the hospital setting, National Prices and National Tariffs, reports and the literature around the effectiveness of PR programmes. Study Design: The COPD pathway was modelled using discrete event simulation (DES) to capture the patient pathway to an adequate level of detail as well as randomness in the real world. DES was further enhanced by the integration of a health economic model to calculate the net benefit and cost of treating COPD patients based on key sets of interventions. Data Collection/Extraction methods: A total of 150 input parameters and 75 distributions were established to power the model using the HES dataset, outpatient activity data from the hospital and community services, and the literature. Principal Findings: The simulation model showed that increasing referral to PR (by 10%, 20%, or 30%) would be cost-effective (with a benefit-cost ratio of 5.81, 5.95, 5.91, respectively) by having a positive impact on patient outcomes and operational metrics. Number of deaths, admissions and bed days decreased (i.e. by 3.56 patients, 4.90 admissions, 137.31 bed days for a 30% increase in PR referrals) as well as quality of life increased (i.e. by 5.53 QALY among 1540 patients for the 30% increase). Conclusions: No operational model, either statistical or simulation, has previously been developed to capture the COPD patient pathway within a hospital setting. To date, no model has investigated the impact of PR on COPD services, such as operations, key performance, patient outcomes and cost-benefit analysis. The study will support policies around extending availability of PR as a major intervention.Peer reviewedFinal Accepted Versio

The threat nets approach to information system security risk analysis

The growing demand for healthcare services is motivating hospitals to strengthen outpatient case management using information systems in order to serve more patients using the available resources. Though the use of information systems in outpatient case management raises patient data security concerns, it was established that the current approaches to information systems risk analysis do not provide logical recipes for quantifying threat impact and determining the cost-effectiveness of risk mitigation controls. Quantifying the likelihood of the threat and determining its potential impact is key in deciding whether to adopt a given information system or not. Therefore, this thesis proposes the Threat Nets Approach organized into 4 service recipes, namely: threat likelihood assessment service, threat impact evaluation service, return on investment assessment service and coordination management. The threat likelihood assessment service offers recipes for determining the likelihood of a threat. The threat impact evaluation service offers techniques of computing the impact of the threat on the organization. The return on investment assessment service offers recipes of determining the cost-effectiveness of threat mitigation controls. To support the application of the approach, a ThreNet tool was developed. The approach was evaluated by experts to ascertain its usability and usefulness. Evaluation of the Threat Nets Approach by the experts shows that it provides complete, usable and useful recipes for the assessment of; threat likelihood, threat impact and cost-effectiveness of threat mitigation controls. The results suggest that the application of Threat Nets approach is effective in quantifying risks to information system

The threat nets approach to information system security risk analysis

The growing demand for healthcare services is motivating hospitals to strengthen outpatient case management using information systems in order to serve more patients using the available resources. Though the use of information systems in outpatient case management raises patient data security concerns, it was established that the current approaches to information systems risk analysis do not provide logical recipes for quantifying threat impact and determining the cost-effectiveness of risk mitigation controls. Quantifying the likelihood of the threat and determining its potential impact is key in deciding whether to adopt a given information system or not. Therefore, this thesis proposes the Threat Nets Approach organized into 4 service recipes, namely: threat likelihood assessment service, threat impact evaluation service, return on investment assessment service and coordination management. The threat likelihood assessment service offers recipes for determining the likelihood of a threat. The threat impact evaluation service offers techniques of computing the impact of the threat on the organization. The return on investment assessment service offers recipes of determining the cost-effectiveness of threat mitigation controls. To support the application of the approach, a ThreNet tool was developed. The approach was evaluated by experts to ascertain its usability and usefulness. Evaluation of the Threat Nets Approach by the experts shows that it provides complete, usable and useful recipes for the assessment of; threat likelihood, threat impact and cost-effectiveness of threat mitigation controls. The results suggest that the application of Threat Nets approach is effective in quantifying risks to information system

Enabling better management of patients: discrete event simulation combined with the STAR approach

This is an Accepted Manuscript of an article published by Taylor & Francis Group in Journal of the Operational Research Society, on 1 May 2017, available online at: https://www.tandfonline.com/doi/full/10.1057/s41274-016-0029-y.Squeezed budgets and funding cuts are expected to become a feature of the healthcare landscape in the future, forcing decision makers such as service managers, clinicians and commissioners to find effective ways of allocating scarce resources. This paper discusses the development of a decision support toolkit (DST) that facilitates the improvement of services by identifying cost savings and efficiencies within the pathway of care. With the help of National Health Service and commercial experts, we developed a discrete event simulation model for Deep Vein Thrombosis (DVT) patients and adapted the socio technical allocation of resources (STAR) approach to answer crucial questions like: what sort of interventions should we spend our money on? Where will we get the most value for our investment? How will we explain the choices we have made? The DST enables users to model their own services by working with the DST interface allowing users to specify local DVT services. They can input local estimates, or data of service demands and capacities, thus creating a baseline discrete event simulation model. The user can then compare the baseline with potential changes in the patient pathway in the safety of a virtual environment. By making such changes key decision makers can easily understand the impact on activity, cost, staffing levels, skill-mix, utilisation of resources and, more importantly, it allows them to find the interventions that have the highest benefit to patients and provide best value for money.Peer reviewe

A Taxonomy of Case Management: Development, Dissemination and Impact

Background Case management is a widely-accepted care coordination strategy, although complex and variable due to the interaction of its components: model (theory); context (service); population and health condition; case manager's actions. This complexity impedes practice, quality analysis, policy and planning. The aim was to develop a case management taxonomy for a common understanding and language and assess the impact of international dissemination. Method The mixed methods used to develop the case management taxonomy included: scoping and mapping review to examine key components described in the literature; critical review of international frames for conceptual and technical frameworks; a nominal group of experts and feasibility analysis. After development, there was extensive international dissemination and impact assessment of dissemination to diverse groups. Results The taxonomy identifies the components and their relationship (two taxonomy trees), provides a glossary. The service tree comprises acute, mobility and intensity characteristics. The intervention tree comprises the main actions, actions and related actions of case manager interventions. There were 51 personalised taxonomy presentations to audiences across 11 countries and numerous non-personalised presentations. After dissemination data was collected from two questionnaires and opportunistic information. The taxonomy was perceived as highly acceptable and practical. Impact ratings (n=43) showed the taxonomy was: translated into meso organisation policy and international frameworks; embedded in tertiary education; used in practice with emerging uses in research. Conclusion The taxonomy provides a framework to manage case management complexity. It identifies and defines the components and their relationships. Impact ratings show the case management taxonomy is a useful tool in different sectors and fit for purpose across different health conditions, hereafter called the ‘case management taxonomy’