The relationship between social care resources and healthcare utilisation by older people in England : an exploratory investigation

Background Since 2010, adult social care spending has fallen significantly in real terms whilst demand has risen. Reductions in local authority (LA) budgets are expected to have had spill over effects on the demand for healthcare in the English NHS. Motivation If older people, including those with dementia, have unmet needs for social care, their use of healthcare may increase. Methods We assembled a panel dataset of 150 LAs, aggregating individual-level data where appropriate. We tested the impact of changes in LA social care resources, which was measured in two ways: expenditure and workforce. The effects on people aged 65+ were assessed on five outcomes. 1. Rates of emergency hospital admissions for falls in people with dementia aged 65 and over. 2. Rates of emergency hospital admissions for fractured neck of femur in people 65 and over. 3. Extended length of stay in people with dementia, 7 days and over 4. Extended length of stay in people with dementia, 21 days and over 5. Rates of NHS Continuing Healthcare (NHS CHC) Outcomes (utilisation) data were derived from the Hospital Episode Statistics (1, 2, 3 and 4), the Public Health Outcomes Framework (2), and publicly available datasets from NHS Digital (5). Datasets varied in the timeframes available for analysis. Planned analysis of the effects of social care cuts on delayed transfers of care in mental health trusts, and on deprivation of liberty safeguards were not undertaken because of data quality concerns. We tested the effect of two separate explanatory variables: adult social care gross current expenditure (per capita 65 and over) adjusted by area cost; and adult social care workforce staff (per capita 18 and over). Workforce measures distinguished LA and independent sector employees and included professional and non-professional staff providing direct social care. We ran negative binomial models and linear models, and controlled for a range of confounding factors, including deprivation, ethnicity, age, unpaid care, LA class and year effects. To account for potential endogeneity (‘reverse causality’), we also tested the Area Cost Adjustment (ACA) as an instrumental variable and ran dynamic panel models. Sensitivity analysis explored the effects of the additional effects of the Better Care Fund. Results The level of social care expenditure on older people was not significantly related to emergency admission rates for falls in people with dementia or for fractured neck of femur. Extended stays of 7 days or longer were significantly and positively related to the level of social care spend, but this association was no longer significant when additional spend from the Better Care Fund was taken into account. There was no significant relationship between the level of social care spend and hospital stays of 21 days or longer or between spend and uptake of NHS CHC. We also tested the effect of four social care workforce measures. LAs employing higher rates of social care staff (especially professional staff) had significantly higher levels of NHS CHC, but there was no significant relationship between LA staffing levels and the remaining four outcomes. LAs with higher levels of independent social care staffing had significantly lower rates of extended stays, but there was no association with either emergency admissions or on NHS CHC. The effect of ‘full time’ ii CHE Research Paper 174 unpaid care on outcomes was mixed, with tentative evidence of a protective effect on admissions for falls, and on extended stays of 21 days or longer. When the Area Cost Adjustment was used as an instrument in place of expenditure, results were largely consistent with the main analysis: there were negative effects on NHS CHC but no effect on any other outcome. The dynamic panel models found a positive relationship between spend and emergency admissions for falls, but the effect on other outcomes was statistically insignificant. Conclusions The study found no consistent evidence that reductions in social care budgets led to the expected rises in hospital admissions, hospital stays or uptake of NHS CHC. However, findings suggest that public sector staff providing direct social care, particularly professional staff, may be instrumental in facilitating access to NHS CHC. In addition, the study found tentative evidence that extended hospital stays are partially offset by social care provision by the independent sector and by unpaid carers providing intensive care. To test the validity and robustness of these findings, future research using linked individual-level health and social care data is needed

Prosthetic Joint Infection in Mega-Arthroplasty Following Shoulder, Hip and Knee Malignancy—A Prospective Follow-Up Study

Introduction: The risk of prosthetic joint infection (PJI) in mega-prosthesis for malignancy is increased compared with non-tumor cases. While several studies describe PJI in tumor-related arthroplasty, prospective studies comparing infection characteristics among different joints are limited. The present study analyzes mega-arthroplasty for hip, knee, and shoulder malignancy and compares the epidemiology, diagnosis, microbe spectrum, treatments, and outcomes between the different entities. Methods: The retrospective inclusion criteria were as follows: (1) mega-arthroplasty (2) in the hip, knee, or shoulder joint and a total femur arthroplasty (3) following a malignant bone tumor or metastasis (4) between 1996 and 2019. All included patients were prospectively followed and invited for a renewed hospital examination, and their PJI characteristics (if identified) were analyzed using both retrospective as well as newly gained prospective data. A PJI was defined according to the Infectious Disease Society of America (IDSA) and re-infection was defined according to the modified Delphi Consensus criteria. Results: In total, 83 cases of tumor mega-arthroplasty at a mean follow-up of 3.9 years could be included (32 knee, 30 hip, and 19 shoulder cases and 2 cases of total femur arthroplasty). In total, 14 PJIs were identified, with chondrosarcoma in 6 and osteosarcoma in 3 being the leading tumor entities. Knee arthroplasty demonstrated a significantly higher rate of PJI (p = 0.027) compared with hips (28.1% vs. 6.7%), while no significant difference could be found between the knee and shoulder (10.5%) (p = 0.134) or among shoulder and hip cases (p = 0.631). The average time of PJI following primary implantation was 141.4 months in knee patients, 64.6 in hip patients, and 8.2 months in shoulder patients. Age at the time of the primary PJI, as well as the time of the first PJI, did not show significant differences among the groups. Thirteen of the fourteen patients with PJI had a primary bone tumor. Statistical analysis showed a significant difference in the disadvantage of primary bone tumors (p = 0.11). While the overall cancer-related mortality in the knee PJI group (10%) was low, it was 50% in the hip and 100% in the shoulder group. Conclusion: The risk of PJI in knee tumor arthroplasty is significantly increased compared with hips, while cancer-related mortality is significantly higher in hip PJI cases. At the same time, mega-prostheses appear to be associated with a higher risk of infection due to a primary bone tumor compared with metastases. The study confirms existing knowledge concerning PJI in tumor arthroplasty, while, being one of the few studies to compare three different joints concerning PJI characteristics

Surgical Margins in Soft Tissue Sarcoma Management and Corresponding Local and Systemic Recurrence Rates: A Retrospective Study Covering 11 Years and 169 Patients in a Single Institution

Soft tissue sarcomas (STSs) are a diverse group of rare malignant soft tissue tumors with a high disease burden. Treatment protocols are complex and, to this day, a precise recommendation for the surgical margin width is lacking. The present study aims to analyze the width of the surgical margins in STS resection specimens and analyze them for local and systemic disease-free survival as well as for most frequent histologic STS subtypes. A total of 169 consecutive patients diagnosed and treated in curative intent in our institution following a primary and localized STS of the extremities or trunk from January 2010 to December 2020 were included in this study regardless of age. Our data reveal that low-grade STSs are best controlled locally by a surgical margin >= 2 mm and in this way also preventing distant metastases effectively. Local recurrence-free survival and metastasis-free survival in high-grade STS were improved by intact muscle fascia or periosteum at the margin when compared only to soft tissue. However, the outcome was independent of the surgical margin width, suggesting a close but negative margin may be safe in high-grade STS subtypes with less invasive growth patterns when combined with adjunct radiochemotherapy

The pregnant man: race, difference and subjectivity in Alan Paton’s Kalahari writing

In South African imaginative writing and scholarly research, there is currently an extensive and wide-ranging interest in the ‘Bushman’, either as a tragic figure of colonial history, as a contested site of misrepresentation, or even as an exemplary model of environmental consciousness. Writing and research about ‘Bushmen’ has not only become pervasive in the academy, but also a site of controversy and theoretical contestation. It is in this context that this paper investigates the meaning and significance of ‘Bushmen’ for Alan Paton, one of South Africa’s most well-known writers. Paton’s writing is not usually associated with ‘Bushman’ studies, yet this article shows that the ‘Bushman’ became a highly charged and ambivalent figure in his imagination. Paton’s problematic ideas are contextualised more carefully by looking at the broader context of South African letters. The article initially analyses Paton’s representation of ‘Bushmen’ in his Lost City of the Kalahari travel narrative (1956, published in 2005. Pietermaritzburg: KZN Press), and also discusses unpublished archival photographs. A study of the figure of the ‘Bushman’ throughout the entire corpus of his writing, ranging from early journalism to late autobiography, allows us to trace the shift of his views, enabling us to reflect not only on Paton’s thinking about racial otherness, but also gauge the extent to which his encounter with the Kalahari Bushmen destabilised his sense of self, finally also preventing the publication of the travelogueDepartment of HE and Training approved lis

The impact of primary care incentive schemes on care home placements for people with dementia

Objectives: the interface between primary care and long-term care is complex. In the case of dementia, this interface may be influenced by incentives offered to GPs as part of the Quality and Outcomes Framework (QOF) to provide an annual review for patients with dementia. The hypothesis is that the annual reviews reduce the likelihood of admission to a care home by supporting the patient to live independently and by addressing carers’ needs for support. Study period: 2006/07 to 2015/16. Outcomes: admissions to a care home

Drivers of Health Care Expenditure

Since the NHS was established in 1948, growth in health care expenditure (HCE) has outpaced the rise in both GDP and in total public expenditure. Known drivers of HCE growth include demographic factors, income and wealth effects, technology and cost pressures. To identify the challenges and opportunities for developing a model of healthcare demand, this report addressed two research questions: 1.What are the drivers of past trends in health care expenditure and how much has each of the drivers contributed to past increases in expenditure? 2.How much has each type of service contributed to past trends in health care expenditure and why have there been different trends for different types of care? We set out a conceptual framework for understanding drivers of HCE, placing it in the broader context of underlying drivers of demand and macroeconomic trends. We reviewed studies from higher-income countries published over the last decade, and analysed datasets compiled in-house of cost and volume of care by different settings. We linked data on HCE trends to relevant, setting-specific evidence from the literature review. We identified 52 studies using aggregate data and 54 individual-level studies. The relative contribution of different drivers could not be quantified due to heterogeneity in study methodologies. Aggregate studies using longer panels of data show that the relationship between HCE and its drivers is non-linear, varies over time and varies cross countries. These studies mostly find a strong, positive relationship between HCE and technological progress. Individual-level studies usually rely on observational, non-experimental data from administrative databases, such as claims data or registers, or on survey data or cohort studies. Trends in HCE from 2008/9 to 2016/17 reveal that the largest rises were in high cost drugs (231%), chemotherapy (113%) and attendances at A&E (60%) or outpatient departments (57%). Most evidence on the drivers of HCE related to hospital care, but we found no studies explaining the factors behind the rise in expenditure on chemotherapy or high cost drugs. We conclude by presenting four lessons that could inform decisions on building a projections model of health care expenditure

Identifying amyloid pathology–related cerebrospinal fluid biomarkers for Alzheimer\u27s disease in a multicohort study

Introduction: The dynamic range of cerebrospinal fluid (CSF) amyloid β (Aβ1–42) measurement does not parallel to cognitive changes in Alzheimer\u27s disease (AD) and cognitively normal (CN) subjects across different studies. Therefore, identifying novel proteins to characterize symptomatic AD samples is important. Methods: Proteins were profiled using a multianalyte platform by Rules Based Medicine (MAP-RBM). Due to underlying heterogeneity and unbalanced sample size, we combined subjects (344 AD and 325 CN) from three cohorts: Alzheimer\u27s Disease Neuroimaging Initiative, Penn Center for Neurodegenerative Disease Research of the University of Pennsylvania, and Knight Alzheimer\u27s Disease Research Center at Washington University in St. Louis. We focused on samples whose cognitive and amyloid status was consistent. We performed linear regression (accounted for age, gender, number of apolipoprotein E (APOE) e4 alleles, and cohort variable) to identify amyloid-related proteins for symptomatic AD subjects in this largest ever CSF–based MAP-RBM study. ANOVA and Tukey\u27s test were used to evaluate if these proteins were related to cognitive impairment changes as measured by mini-mental state examination (MMSE). Results: Seven proteins were significantly associated with Aβ1–42 levels in the combined cohort (false discovery rate adjusted P \u3c .05), of which lipoprotein a (Lp(a)), prolactin (PRL), resistin, and vascular endothelial growth factor (VEGF) have consistent direction of associations across every individual cohort. VEGF was strongly associated with MMSE scores, followed by pancreatic polypeptide and immunoglobulin A (IgA), suggesting they may be related to staging of AD. Discussion: Lp(a), PRL, IgA, and tissue factor/thromboplastin have never been reported for AD diagnosis in previous individual CSF–based MAP-RBM studies. Although some of our reported analytes are related to AD pathophysiology, other\u27s roles in symptomatic AD samples worth further explorations

Preventing Establishment: An Inventory of Introduced Plants in Puerto Villamil, Isabela Island, Galapagos

As part of an island-wide project to identify and eradicate potentially invasive plant species before they become established, a program of inventories is being carried out in the urban and agricultural zones of the four inhabited islands in Galapagos. This study reports the results of the inventory from Puerto Villamil, a coastal village representing the urban zone of Isabela Island. We visited all 1193 village properties to record the presence of the introduced plants. In addition, information was collected from half of the properties to determine evidence for potential invasiveness of the plant species. We recorded 261 vascular taxa, 13 of which were new records for Galapagos. Most of the species were intentionally grown (cultivated) (73.3%) and used principally as ornamentals. The most frequent taxa we encountered were Cocos nucifera (coconut tree) (22.1%) as a cultivated plant and Paspalum vaginatum (salt water couch) (13.2%) as a non cultivated plant. In addition 39 taxa were naturalized. On the basis of the invasiveness study, we recommend five species for eradication (Abutilon dianthum, Datura inoxia, Datura metel, Senna alata and Solanum capsicoides), one species for hybridization studies (Opuntia ficus-indica) and three species for control (Furcraea hexapetala, Leucaena leucocephala and Paspalum vaginatum)

Cost-effectiveness of telecare for people with social care needs: the Whole Systems Demonstrator cluster randomised trial

Purpose of the study: to examine the costs and cost-effectiveness of ‘second-generation’ telecare, in addition to standard support and care that could include ‘first-generation’ forms of telecare, compared with standard support and care that could include ‘first-generation’ forms of telecare. Design and methods: a pragmatic cluster-randomised controlled trial with nested economic evaluation. A total of 2,600 people with social care needs participated in a trial of community-based telecare in three English local authority areas. In the Whole Systems Demonstrator Telecare Questionnaire Study, 550 participants were randomised to intervention and 639 to control. Participants who were offered the telecare intervention received a package of equipment and monitoring services for 12 months, additional to their standard health and social care services. The control group received usual health and social care. Primary outcome measure: incremental cost per quality-adjusted life year (QALY) gained. The analyses took a health and social care perspective. Results: cost per additional QALY was £297,000. Cost-effectiveness acceptability curves indicated that the probability of costeffectiveness at a willingness-to-pay of £30,000 per QALY gained was only 16%. Sensitivity analyses combining variations in equipment price and support cost parameters yielded a cost-effectiveness ratio of £161,000 per QALY. Implications: while QALY gain in the intervention group was similar to that for controls, social and health services costs were higher. Second-generation telecare did not appear to be a cost-effective addition to usual care, assuming a commonly accepted willingness to pay for QALYs