Modelled cost-effectiveness analysis of the Support and Treatment After Replacement (STAR) care pathway for chronic pain after total knee replacement compared with usual care

Background The aim of the study was to estimate the long-term cost-effectiveness of the Support and Treatment After Replacement (STAR) care pathway for chronic pain after total knee replacement compared with usual postoperative care. Methods Study design: A decision-analytic (cohort Markov) model was used for the simulation with time dependent annual transition probabilities and a time horizon of five years. Setting: Patients treated by National Health Service (NHS) hospitals in England and Wales. Study population: Adults classified as having chronic pain three months after undergoing a total knee replacement. Intervention: The STAR care pathway following a total knee replacement. Comparator: Usual postoperative care following a total knee replacement. Perspective: The study was undertaken from the perspective of the NHS. Outcome measures: Quality-adjusted life years and healthcare costs. Discounting: A rate of 3.5% for both costs and health utility. Results Model results indicate that the STAR intervention would dominate current practice by providing a gain in quality-adjusted life years (QALYs) of 0.086 and a reduction of £375 (per person) in costs over the first five years. The incremental net monetary benefit of the STAR intervention was estimated at £2,086 (at a threshold of £20,000 per QALY). Probabilistic sensitivity analysis suggests the STAR intervention is likely to be cost-effective with a probability of 0.62. The results remain robust to changes in model assumptions on comparator utility and the timing of the start of the intervention. If hospital admission costs are assumed not to be reduced by the STAR intervention, it would no longer be cost saving, but it would likely be cost-effective based on probabilistic sensitivity analysis (0.59). Conclusion Evidence from the economic model suggests that the STAR care pathway is likely to be cost-effective and potentially dominant from an NHS perspective. Trial registration The STAR trial is registered with ISRCTN, ISRCTN92545361

Breaking the silence: Insights into the lived experiences of WA Aboriginal/LGBTIQ+ people: Community summary report 2021

The ‘Breaking the Silence’ research project is one of the first to focus on the unique experiences of Aboriginal and/or Torres Strait Islander LGBTIQ+ people living in Western Australia. Research focusing on the intersection of Indigeneity and gender/sexual diversity is severely lacking in Australia. This is the first survey to comprehensively capture the experiences of Aboriginal and Torres Strait Islander LGBTIQ+ Western Australians. Previously, major research pertaining to LGBTIQ+ Australians rarely just focused on Aboriginal and Torres Strait Islander same sex attracted or gender variant individuals (Bonson, 2017; Dudgeon, et. al., 2017; Growing Up Queer, 2014; Hill, et. al., 2021; Uink, et. al., 2020; Whitton, et. al, 2015). This summary report presents the key findings of a state-wide survey completed by Aboriginal and/or Torres Strait Islander people, living in Western Australia and identifying as LGBTIQ+. Findings about discrimination, homophobia and the ways in which participants are included and accepted within their own families and the wider community are presented. The report also provides a focus on the positive aspects of participants’ lives; including how they experience pride and inclusion and a sense of belonging to their Aboriginal and/or Torres Strait Islander and/or LGBTIQ+ communities. This summary report has important information for organisations that provide health and social support services to Aboriginal and Torres Strait Islander people who identify as LGBTIQ+, including the extent to which diverse health, social and emotional wellbeing; education and community services meet the needs of participants.This report also includes a section describing how the findings from the community compare and contrast with those of workers in a range of health, social support and education services from the first phase of the study. (See: “Breaking the Silence: Insights from WA Services Working with Aboriginal/ LGBTIQ+ People,”)

Breaking the silence: Insights from WA services working with Aboriginal/ LGBTIQ+ people: Organisations summary report 2021

The ‘Breaking the Silence’ research project is one of the first to focus on the unique experiences of Aboriginal and/or Torres Strait Islander LGBTIQ+ people living in Western Australia. The report presents the first phase of a twopart research project that explores how a range of health, social support and education organisations respond to the needs of Aboriginal and/or Torres Strait Islander people, living in Western Australia and identifying as LGBTIQ+. This report presents the findings of focus groups, interviews and surveys with staff employed within a range of organisations that work closely with Aboriginal and/or LGBTIQ+ individuals. The discussion explores the extent to which diverse health, social and emotional wellbeing, education and community services meet the needs of participants, how staff working in these organisations are supported and what else is needed to provide effective and responsive services for Aboriginal and/or Torres Strait Islander clients who also identify as LGBTIQ+. Please see the ’Breaking the Silence: Insights into the Lived Experiences of WA Aboriginal/LGBTIQ+ People, Community Summary Report’ on findings from a survey distributed to Aboriginal and/or Torres Strait Islander LGBTIQ+ in the community of Western Australia

Exploring the impact of disruption on university staff resilience using the dynamic interactive model of resilience

The unanticipated changes in Higher Education settings brought about as a result of COVID–19 resulted in a range of personal, pedagogical and organisational challenges. This paper reports on research undertaken within a university in South West England, exploring how the pandemic impacted the working practices of academic and professional staff, the implications of those changes and the factors the respondents interpreted as influencing their resilience. A mixed methods approach was adopted whereby data were gathered from 159 academic and professional staff members using an online survey. Nine respondents were then individually interviewed. The data were analysed using the Dynamic Interactive Model of Resilience (DIMoR) in order to explore protective and risk factors from the various systems surrounding the respondents, alongside their more personal vulnerabilities/invulnerabilities. The results highlight the importance of considering individual and wider contexts when analysing the potential for resilience to emerge in times of disruption. The significance of movement of proximal and distal influences depending on the individual and their context also emerged, offering implications for university leaders to consider in supporting staff within their institutions. The value of the DIMoR is discussed as a lens for analysis to support understanding and future action

Large-scale candidate gene study of leprosy susceptibility in the Karonga district of northern Malawi.

We present a large case-control candidate gene study of leprosy susceptibility. Thirty-eight polymorphic sites from 13 genes were investigated for their role in susceptibility to leprosy by comparing 270 cases with 452 controls in Karonga district, northern Malawi. Homozygotes for a silent T-->C change in codon 352 of the vitamin D receptor gene appeared to be at high risk (odds ratio [OR] = 4.3, 95% confidence interval [CI] = 1.6-11.4, P = 0.004), while homozygotes for the McCoy b blood group defining variant K1590E in exon 29 of the complement receptor 1 (formerly CD35) gene appeared to be protected (OR = 0.3, 95% CI = 0.1-0.8, P = 0.02). Borderline evidence for association with leprosy susceptibility was found for seven polymorphic sites in an additional six genes. Some of these apparent associations may be false-positive results from multiple comparisons, and several associations suggested by studies in other populations were not replicated here. These data provide evidence of inter-population heterogeneity in leprosy susceptibility

Effect of local anaesthetic infiltration on chronic postsurgical pain after total hip and knee replacement:The APEX randomised controlled trials

Total hip replacement (THR) and total knee replacement (TKR) are usually effective at relieving pain; however, 7% to 23% of patients experience chronic postsurgical pain. These trials aimed to investigate the effect of local anaesthetic wound infiltration on pain severity at 12 months after primary THR or TKR for osteoarthritis. Between November 2009 and February 2012, 322 patients listed for THR and 316 listed for TKR were recruited into a single-centre double-blind randomised controlled trial. Participants were randomly assigned (1:1) to receive local anaesthetic infiltration and standard care or standard care alone. Participants and outcomes assessors were masked to group allocation. The primary outcome was pain severity on the WOMAC Pain Scale at 12 months after surgery. Analyses were conducted using intention-to-treat and per-protocol approaches. In the hip trial, patients in the intervention group had significantly less pain at 12 months postoperative than patients in the standard care group (differences in means: 4.74; 95% confidence interval [CI]: 0.95-8.54; P = 0.015), although the difference was not clinically significant. Post hoc analysis found that patients in the intervention group were more likely to have none to moderate pain than severe pain at 12 months than those in the standard care group (odds ratio: 10.19; 95% CI: 2.10-49.55; P = 0.004). In the knee trial, there was no strong evidence that the intervention influenced pain severity at 12 months postoperative (difference in means: 3.83; 95% CI: −0.83 to 8.49; P = 0.107). In conclusion, routine use of infiltration could be beneficial in improving long-term pain relief for some patients after THR

PRomotion Of Physical activity through structured Education with differing Levels of ongoing Support for people at high risk of type 2 diabetes (PROPELS): study protocol for a randomized controlled trial.

BACKGROUND: The prevention of type 2 diabetes is recognised as a health care priority. Lifestyle change has proven effective at reducing the risk of type 2 diabetes, but limitations in the current evidence have been identified in: the promotion of physical activity; availability of interventions that are suitable for commissioning and implementation; availability of evidence-based interventions using new technologies; and physical activity promotion among ethnic minorities. We aim to investigate whether a structured education programme with differing levels of ongoing support, including text-messaging, can increase physical activity over a 4 year period in a multi-ethnic population at high risk of diabetes. METHODS/DESIGN: A multi-centre randomised controlled trial, with follow-up at 12 and 48 months. The primary outcome is change in ambulatory activity at 48 months. Secondary outcomes include changes to markers of metabolic, cardiovascular, anthropometric and psychological health along with cost-effectiveness. Participants aged 40-74 years for White European, or 25-74 years for South Asians, with an HbA1c value of between 6.0 and < 6.4% (42 and 47 mmol/mol) or with a previously recorded plasma glucose level or HbA1c value within the high risk (prediabetes) range within the last five years, are invited to take part in the trial. Participants are identified through primary care, using an automated diabetes risk score within their practice database, or from a database of previous research participants. Participants are randomly assigned to either: 1) the control group who receive a detailed advice leaflet; 2) the Walking Away group, who receive the same leaflet and attend a 3 hour structured education programme with annual maintenance sessions delivered in groups; or 3) the Walking Away Plus group, who receive the leaflet, attend the structured education programme with annual maintenance sessions, plus receive follow-on support through highly-tailored text-messaging and telephone calls to help to aid pedometer use and behaviour change. DISCUSSION: This study will provide new evidence for the long-term effectiveness of a structured education programme focused on physical activity, conducted within routine care in a multi-ethnic population in the UK. It will also investigate the impact of different levels of ongoing support and the cost-effectiveness of each intervention. TRIAL REGISTRATION: ISRCTN83465245 Trial registration date: 14/06/2012.The trial is funded by the Health Technology Assessment (HTA) Programme, National Institute for Health research. TY, MJD and KK are also supported by the NIHR Lifestyle and Physical Activity Biomedical Research Unit which is a partnership between University Hospitals of Leicester NHS Trust, Loughborough University and the University of Leicester and the NIHR Collaboration for Leadership in Applied Health Research and Care – East Midlands (NIHR CLAHRC – EM).This is the final version. It was first published by BioMed Central at http://www.trialsjournal.com/content/16/1/289

The association between air pollution and type 2 diabetes in a large cross-sectional study in Leicester: The CHAMPIONS Study

Background: Observational evidence suggests there is an association between air pollution and type 2 diabetes; however, there is high risk of bias. Objective: To investigate the association between air pollution and type 2 diabetes, while reducing bias due to exposure assessment, outcome assessment, and confounder assessment. Methods: Data were collected from 10,443 participants in three diabetes screening studies in Leicestershire, UK. Exposure assessment included standard, prevailing estimates of outdoor nitrogen dioxide and particulate matter concentrations in a 1 × 1 km area at the participant's home postcode. Three-year exposure was investigated in the primary analysis and one-year exposure in a sensitivity analysis. Outcome assessment included the oral glucose tolerance test for type 2 diabetes. Confounder assessment included demographic factors (age, sex, ethnicity, smoking, area social deprivation, urban or rural location), lifestyle factors (body mass index and physical activity), and neighbourhood green space. Results: Nitrogen dioxide and particulate matter concentrations were associated with type 2 diabetes in unadjusted models. There was no statistically significant association between nitrogen dioxide concentration and type 2 diabetes after adjustment for demographic factors (odds: 1.08; 95% CI: 0.91, 1.29). The odds of type 2 diabetes was 1.10 (95% CI: 0.92, 1.32) after further adjustment for lifestyle factors and 0.91 (95% CI: 0.72, 1.16) after yet further adjustment for neighbourhood green space. The associations between particulate matter concentrations and type 2 diabetes were also explained away by demographic factors. There was no evidence of exposure definition bias. Conclusions: Demographic factors seemed to explain the association between air pollution and type 2 diabetes in this cross-sectional study. High-quality longitudinal studies are needed to improve our understanding of the association

The effects of high HIV prevalence on orphanhood and living arrangements of children in Malawi, Tanzania, and South Africa

Using longitudinal data from three demographic surveillance systems (DSS) and a retrospective cohort study, we estimate levels and trends in the prevalence and incidence of orphanhood in South Africa, Tanzania, and Malawi in the period 1988–2004. The prevalence of maternal, paternal, and double orphans rose in all three populations. In South Africa—where the HIV epidemic started later, has been very severe, and has not yet stabilized—the incidence of orphanhood among children is double that of the other populations. The living arrangements of children vary considerably between the populations, particularly in relation to fathers. Patterns of marriage, migration, and adult mortality influence the living and care arrangements of orphans and non-orphans. DSS data provide new insights into the impact of adult mortality on children, challenging several widely held assumptions. For example, we find no evidence that the prevalence of child-headed households is significant or has increased in the three study areas

The STAR care pathway for patients with pain at 3 months after total knee replacement:a multicentre, pragmatic randomised controlled trial

BACKGROUND: Approximately 20% of people experience chronic pain after total knee replacement, but effective treatments are not available. We aimed to evaluate the clinical effectiveness and cost-effectiveness of a new care pathway for chronic pain after total knee replacement. METHODS: We did an unmasked, parallel group, pragmatic, superiority, randomised, controlled trial at eight UK National Health Service (NHS) hospitals. People with chronic pain at 3 months after total knee replacement surgery were randomly assigned (2:1) to the Support and Treatment After Replacement (STAR) care pathway plus usual care, or to usual care alone. The STAR intervention aimed to identify underlying causes of chronic pain and enable onward referrals for targeted treatment through a 3-month post-surgery assessment with an extended scope practitioner and telephone follow-up over 12 months. Co-primary outcomes were self-reported pain severity and pain interference in the replaced knee, assessed with the Brief Pain Inventory (BPI) pain severity and interference scales at 12 months (scored 0–10, best to worst) and analysed on an as-randomised basis. Resource use, collected from electronic hospital records and participants, was valued with UK reference costs. Quality-adjusted life-years (QALYs) were calculated from EQ-5D-5L responses. This trial is registered with ISRCTN, ISRCTN92545361. FINDINGS: Between Sept 6, 2016, and May 31, 2019, 363 participants were randomly assigned to receive the intervention plus usual care (n=242) or to receive usual care alone (n=121). Participants had a median age of 67 years (IQR 61 to 73), 217 (60%) of 363 were female, and 335 (92%) were White. 313 (86%) patients provided follow-up data at 12 months after randomisation (213 assigned to the intervention plus usual care and 100 assigned to usual care alone). At 12 months, the mean between-group difference in the BPI severity score was −0·65 (95% CI −1·17 to −0·13; p=0·014) and the mean between-group difference in the BPI interference score was −0·68 (−1·29 to −0·08; p=0·026), both favouring the intervention. From an NHS and personal social services perspective, the intervention was cost-effective (greater improvement with lower cost), with an incremental net monetary benefit of £1256 (95% CI 164 to 2348) at £20 000 per QALY threshold. One adverse reaction of participant distress was reported in the intervention group. INTERPRETATION: STAR is a clinically effective and cost-effective intervention to improve pain outcomes over 1 year for people with chronic pain at 3 months after total knee replacement surgery. FUNDING: National Institute for Health Research