An economic evaluation of Alexander Technique lessons or acupuncture sessions for patients with chronic neck pain : A randomized trial (ATLAS)

OBJECTIVES: To assess the cost-effectiveness of acupuncture and usual care, and Alexander Technique lessons and usual care, compared with usual GP care alone for chronic neck pain patients. METHODS: An economic evaluation was undertaken alongside the ATLAS trial, taking both NHS and wider societal viewpoints. Participants were offered up to twelve acupuncture sessions or twenty Alexander lessons (equivalent overall contact time). Costs were in pounds sterling. Effectiveness was measured using the generic EQ-5D to calculate quality adjusted life years (QALYs), as well as using a specific neck pain measure-the Northwick Park Neck Pain Questionnaire (NPQ). RESULTS: In the base case analysis, incremental QALY gains were 0.032 and 0.025 in the acupuncture and Alexander groups, respectively, in comparison to usual GP care, indicating moderate health benefits for both interventions. Incremental costs were £451 for acupuncture and £667 for Alexander, mainly driven by intervention costs. Acupuncture was likely to be cost-effective (ICER = £18,767/QALY bootstrapped 95% CI £4,426 to £74,562) and was robust to most sensitivity analyses. Alexander lessons were not cost-effective at the lower NICE threshold of £20,000/QALY (£25,101/QALY bootstrapped 95% CI -£150,208 to £248,697) but may be at £30,000/QALY, however, there was considerable statistical uncertainty in all tested scenarios. CONCLUSIONS: In comparison with usual care, acupuncture is likely to be cost-effective for chronic neck pain, whereas, largely due to higher intervention costs, Alexander lessons are unlikely to be cost-effective. However, there were high levels of missing data and further research is needed to assess the long-term cost-effectiveness of these interventions

Finishing the euchromatic sequence of the human genome

The sequence of the human genome encodes the genetic instructions for human physiology, as well as rich information about human evolution. In 2001, the International Human Genome Sequencing Consortium reported a draft sequence of the euchromatic portion of the human genome. Since then, the international collaboration has worked to convert this draft into a genome sequence with high accuracy and nearly complete coverage. Here, we report the result of this finishing process. The current genome sequence (Build 35) contains 2.85 billion nucleotides interrupted by only 341 gaps. It covers ∼99% of the euchromatic genome and is accurate to an error rate of ∼1 event per 100,000 bases. Many of the remaining euchromatic gaps are associated with segmental duplications and will require focused work with new methods. The near-complete sequence, the first for a vertebrate, greatly improves the precision of biological analyses of the human genome including studies of gene number, birth and death. Notably, the human enome seems to encode only 20,000-25,000 protein-coding genes. The genome sequence reported here should serve as a firm foundation for biomedical research in the decades ahead

Self-efficacy and embodiment associated with Alexander Technique lessons or with acupuncture sessions : a longitudinal qualitative sub-study within the ATLAS trial

Background and purpose: A large randomised controlled trial found that the provision of either Alexander Technique lessons or acupuncture, for those with chronic neck pain, resulted in significantly increased self-efficacy when compared with usual care alone. In turn, enhanced self-efficacy was associated with significant reductions in neck pain at 6 and 12 months. In this analysis we explore the perspectives of participants within the trial, with the aim of gaining a better understanding of how these interventions had an impact. Methods: We used a longitudinal qualitative approach; in-depth interviews, informed by a topic guide, were conducted with a sample of the trial population. Participants were interviewed twice: at around six months (n = 30) and twelve months (n = 26) after trial entry. Analysis was guided by the principles of grounded theory, and key themes were developed. Results: Five key themes emerged: pre-trial experiences of biomedical treatment against which subsequent interventions were compared; emergence of tangible benefits from the interventions; factors that contributed to the observed benefits, notably growing self-care and self-efficacy; a developing sense of embodiment as an integral part of the transformative process; and contribution of these factors to sustaining benefits over the longer term. Conclusions: In-depth interviews revealed a rich array of experiences. They gave insight into the positive impact of the interventions on development of self-care, self-efficacy and embodiment. These findings complement the quantitative trial data, providing a more nuanced understanding of the factors that underpin the previously quantified improvement in self-efficacy and its association with longer-term reductions in pain

Assistant or substitute: Exploring the fit between national policy vision and local practice realities of assistant practitioner job descriptions

Objectives To understand the extent to which the assistant practitioner role is described as 'assistive' in formal job descriptions and analyse whether the term 'assistive' has been stretched to encompass more 'substitutive' or 'autonomous' characteristics.Methods Sixteen AP job descriptions representing all clinical divisions across one UK acute NHS Hospital Trust were both macro- and micro-analysed for broad similarities and differences in line with Hammersley and Atkinson's analytical framework. The analysis specifically focused on how clinical tasks were related to clinical responsibility, from this the job descriptors were then indexed as belonging to one of five discrete categories.Results Our analysis revealed the following categories: fully assistive (n = 1), supportive/assistive (n = 7), supportive/substitutive (n = 4), substitutive/autonomous (n = 3) and fully autonomous (n = 1). From this, a number of anomalies manifest in the form of divergent organisational expectations regarding the AP role.Conclusions This study highlights a series of tensions extant between policy vision and implementation of the AP role in practice. Introduction of new healthcare roles requires compromise and negotiation, to shape and define what social space incumbents of these and existing roles will occupy. However the way in which new roles are defined will determine how they become embraced and embedded within future healthcare services.Assistant practitioner Job descriptions Role redesign Role confusion Social space Role ambiguity

Challenges and opportunities associated with the introduction and development of assistant practitioners supporting the work of ward-based registered nurses in Acute NHS Trusts in England

Objectives To understand the challenges and opportunities associated with the introduction of assistant practitioner (AP) roles supporting the work of ward-based registered nurses (RNs) in National Health Service (NHS) acute hospital trusts in England. Methods Three case studies of NHS acute hospital trusts. This paper presents qualitative findings, drawing on documentary data sources and data generated through interviews and focus group discussions. Results Introduction of APs into ward-based nursing teams has been variable, and often driven by external pressures rather than perceived organizational need. This, along with little national guidance, has created some confusion about the role, but at the same time has permitted flexible role development through ‘negotiated compromise’ at local level. While there are various areas of potential improvement in policy and practice, APs are generally perceived to have the potential to make a valuable contribution to patient care. Conclusions Findings from this study will help policy-makers, organizations and practitioners understand factors that enable and/or inhibit the integration of new assistant roles within existing occupational structures to develop innovative services and enhance patient care. These factors are important when considering how care will be delivered to maximize the skills of the entire nursing workforce

Mapping the introduction of assistant practitioner roles in acute NHS (hospital) trusts in England

Aims This mapping study describes current or planned introduction of assistant practitioner roles in English National Health Service Acute Hospital Trusts. Background In the last decade there has been a growth in nursing support workforce numbers and their scope of practice. An important United Kingdom support worker development is the Assistant Practitioner role. Method A national census was carried out (April 2007) via an emailed questionnaire to Directors of Nursing. Quantitative data were analysed using descriptive statistics. Qualitative data were analysed using thematic analysis. Results Eighty-five per cent (143/168) of Directors of Nursing, from all 10 English Strategic Health Authorities, responded. Forty-six per cent (n = 66) of Trusts had introduced assistant practitioners and 22% (n = 31) were planning to implement the role before 2009. There is wide variation in assistant practitioner numbers across and between Strategic Health Authorities, Trusts and clinical areas. Resistance to the role existed in 32% (n = 46) of Trusts. Reasons for resistance included no perceived need for the role, lack of evidence of effectiveness, financial constraints and professional and patient safety concerns. Implications for nursing management These findings, which contribute to the international evidence-base on health care support workers roles, provide nurse managers with numbers of assistant practitioners and their deployment. This is useful for Nurse Managers making workforce decisions