Development of a patient-reported palliative care-specific health classification system: the POS-E

BackgroundGeneric preference-based measures are commonly used to estimate quality-adjusted life-years (QALYs) to inform resource-allocation decisions. However, concerns have been raised that generic measures may be inappropriate in palliative care.ObjectiveOur objective was to derive a health-state classification system that is amenable to valuation from the ten-item Palliative Care Outcome Scale (POS), a widely used patient-reported outcome measure in palliative care.MethodsThe dimensional structure of the original POS was assessed using factor analysis. Item performance was assessed, using Rasch analysis and psychometric criteria, to enable the selection of items that represent the dimensions covered by the POS. Data from six studies of patients receiving palliative care were combined (N = 1011) and randomly split into two halves for development and validation. Analysis was undertaken on the development data, and results were validated by repeating the analysis with the validation dataset.ResultsFollowing Rasch and factor analyses, a classification system of seven items was derived. Each item had two to three levels. Rasch threshold map helped identify a set of 14 plausible health states that can be used for the valuation of the instrument to derive a preference-based index.ConclusionCombining factor analysis and Rasch analysis with psychometric criteria provides a valid method of constructing a classification system for a palliative care-specific preference-based measure. The next stage is to obtain preference weights so the measure can be used in economic evaluations in palliative care

Reducing weight and increasing physical activity in people at high risk of cardiovascular disease: a randomised controlled trial comparing the effectiveness of enhanced motivational interviewing intervention with usual care.

OBJECTIVE: The epidemic of obesity is contributing to the increasing prevalence of people at high risk of cardiovascular disease (CVD), negating the medical advances in reducing CVD mortality. We compared the clinical and cost-effectiveness of an intensive lifestyle intervention consisting of enhanced motivational interviewing in reducing weight and increasing physical activity for patients at high risk of CVD. METHODS: A three-arm, single-blind, parallel-group randomised controlled trial was conducted in consenting primary care centres in south London. We recruited patients aged 40-74 years with a QRisk2 score ≥20.0%, which indicates the probability of having a CVD event in the next 10 years. The intervention was enhanced motivational interviewing which included additional behaviour change techniques and was delivered by health trainers in 10 sessions over 1 year, in either group (n=697) or individual (n=523) format. The third arm received usual care (UC; n=522). The primary outcomes were physical activity (mean steps/day) and weight (kg). Secondary outcomes were changes in low-density lipoprotein cholesterol and CVD risk score. We estimated the relative cost-effectiveness of each intervention. RESULTS: At 24 months, the group and individual interventions were not more effective than UC in increasing physical activity (mean difference=70.05 steps, 95% CI -288.00 to 147.90 and mean difference=7.24 steps, 95% CI -224.01 to 238.50, respectively), reducing weight (mean difference=-0.03 kg, 95% CI -0.49 to 0.44 and mean difference=-0.42 kg, 95% CI -0.93 to 0.09, respectively) or improving any secondary outcomes. The group and individual interventions were not cost-effective at conventional thresholds. CONCLUSIONS: Enhancing motivational interviewing with additional behaviour change techniques was not effective in reducing weight or increasing physical activity in those at high CVD risk

Enhanced motivational interviewing for reducing weight and increasing physical activity in adults with high cardiovascular risk: the MOVE IT three-arm RCT.

BACKGROUND: Motivational interviewing (MI) enhanced with behaviour change techniques (BCTs) and deployed by health trainers targeting multiple risk factors for cardiovascular disease (CVD) may be more effective than interventions targeting a single risk factor. OBJECTIVES: The clinical effectiveness and cost-effectiveness of an enhanced lifestyle motivational interviewing intervention for patients at high risk of CVD in group settings versus individual settings and usual care (UC) in reducing weight and increasing physical activity (PA) were tested. DESIGN: This was a three-arm, single-blind, parallel randomised controlled trial. SETTING: A total of 135 general practices across all 12 South London Clinical Commissioning Groups were recruited. PARTICIPANTS: A total of 1742 participants aged 40-74 years with a ≥ 20.0% risk of a CVD event in the following 10 years were randomised. INTERVENTIONS: The intervention was designed to integrate MI and cognitive-behavioural therapy (CBT), delivered by trained healthy lifestyle facilitators in 10 sessions over 1 year, in group or individual format. The control group received UC. RANDOMISATION: Simple randomisation was used with computer-generated randomisation blocks. In each block, 10 participants were randomised to the group, individual or UC arm in a 4 : 3 : 3 ratio. Researchers were blind to the allocation. MAIN OUTCOME MEASURES: The primary outcomes are change in weight (kg) from baseline and change in PA (average number of steps per day over 1 week) from baseline at the 24-month follow-up, with an interim follow-up at 12 months. An economic evaluation estimates the relative cost-effectiveness of each intervention. Secondary outcomes include changes in low-density lipoprotein cholesterol and CVD risk score. RESULTS: The mean age of participants was 69.75 years (standard deviation 4.11 years), 85.5% were male and 89.4% were white. At the 24-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA [mean 70.05 steps, 95% confidence interval (CI) -288 to 147.9 steps, and mean 7.24 steps, 95% CI -224.01 to 238.5 steps, respectively] or in reducing weight (mean -0.03 kg, 95% CI -0.49 to 0.44 kg, and mean -0.42 kg, 95% CI -0.93 to 0.09 kg, respectively). At the 12-month follow-up, the group and individual intervention arms were not more effective than UC in increasing PA (mean 131.1 steps, 95% CI -85.28 to 347.48 steps, and mean 210.22 steps, 95% CI -19.46 to 439.91 steps, respectively), but there were reductions in weight for the group and individual intervention arms compared with UC (mean -0.52 kg, 95% CI -0.90 to -0.13 kg, and mean -0.55 kg, 95% CI -0.95 to -0.14 kg, respectively). The group intervention arm was not more effective than the individual intervention arm in improving outcomes at either follow-up point. The group and individual interventions were not cost-effective. CONCLUSIONS: Enhanced MI, in group or individual formats, targeted at members of the general population with high CVD risk is not effective in reducing weight or increasing PA compared with UC. Future work should focus on ensuring objective evidence of high competency in BCTs, identifying those with modifiable factors for CVD risk and improving engagement of patients and primary care. TRIAL REGISTRATION: Current Controlled Trials ISRCTN84864870. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 69. See the NIHR Journals Library website for further project information. This research was part-funded by the NIHR Biomedical Research Centre at South London and Maudsley NHS Foundation Trust and King's College London

Households’ responses to spousal job loss: ‘all change’ or ‘carry on as usual’?

Economic theory suggests that when a primary earner within a couple loses their job, one potential response is for the secondary earner to seek additional paid work to bolster their household finances. The empirical quantitative evidence regarding any such ‘added worker effect’ is mixed, and, to investigate why this might be, the article explores processes behind couples’ responses to job loss. Drawing on in-depth qualitative interviews conducted with a purposive sample selected from the Understanding Society Innovation Panel, the analysis examines: (a) anticipation surrounding job loss and job search responses; (b) the extent to which couples adopt long- or short-term labour market perspectives; and (c) whether couples seek to preserve their established division of paid and unpaid labour or re-configure their joint labour supply. Findings indicate that the use of additional spousal labour is only one response among many alternatives and it is typically invoked in cases of serious financial hardship. </jats:p

Magneto-transport study of intra- and intergrain transitions in the magnetic superconductors RuSr2GdCu2O8 and RuSr2(Gd1.5Ce0.5)Cu2O10

A characterization of the magnetic superconductors RuSr2GdCu2O8 [Ru-(1212)] and RuSr2(Gd1.5Ce0.5)Cu2O10 [Ru-(1222)] through resistance measurements as a function of temperature and magnetic field is presented. Two peaks in the derivative of the resistive curves are identified as intra- and intergrain superconducting transitions. Strong intragrain granularity effects are observed, and explained by considering the antiphase boundaries between structural domains of coherently rotated RuO6 octahedra as intragrain Josephson-junctions. A different field dependence of the intragrain transition temperature in these compounds was found. For Ru-(1212) it remains unchanged up to 0.1 T, decreasing for higher fields. In Ru-(1222) it smoothly diminishes with the increase in field even for a value as low as 100 Oe. These results are interpreted as a consequence of a spin-flop transition of the Ru moments. The large separation between the RuO2 layers in Ru-(1222) promotes a weak interlayer coupling, leading the magnetic transition to occur at lower fields. The suppression rate of the intragrain transition temperature is about five times higher for Ru-(1222), a result we relate to an enhancement of the 2D character of the vortex structure. A distinctive difference with conventional cuprates is the sharp increase in amplitude of the intergrain peak in both systems, as the field is raised, which is ascribed to percolation through a fraction of high quality intergrain junctions.Comment: Submitted for Physical Review

A Transport and Microwave Study of Superconducting and Magnetic RuSr2EuCu2O8

We have performed susceptibility, thermopower, dc resistance and microwave measurements on RuSr2EuCu2O8. This compound has recently been shown to display the coexistence of both superconducting and magnetic order. We find clear evidence of changes in the dc and microwave resistance near the magnetic ordering temperature (132 K). The intergranular effects were separated from the intragranular effects by performing microwave measurements on a sintered ceramic sample as well as on a powder sample dispersed in an epoxy resin. We show that the data can be interpreted in terms of the normal-state resistivity being dominated by the CuO2 layers with exchange coupling to the Ru moments in the RuO2 layers. Furthermore, most of the normal-state semiconductor-like upturn in the microwave resistance is found to arise from intergranular transport. The data in the superconducting state can be consistently interpreted in terms of intergranular weak-links and an intragranular spontaneous vortex phase due to the ferromagnetic component of the magnetization arising from the RuO2 planes.Comment: 20 pages including 6 figures in pdf format. To be published in Phys. Rev.

Magneto-Transport Properties of Doped RuSr2_2GdCu2_2O8_8

RuSr$_2$GdCu$_2$O$_8$, in which magnetic order and superconductivity coexist with $T_{Magnetic}$$\gg$$T_c$, is a complex material which poses new and important questions to our understanding of the interplay between magnetic and superconducting (SC) order. Resistivity, Hall effect and thermopower measurements on sintered ceramic RuSr$_2$GdCu$_2$O$_8$ are presented, together with results on a broad range of substituted analogues. The Hall effect and thermopower both show anomalous decreases below $T_{Magnetic}$ which may be explained within a simple two-band model by a transition from localized to more itinerant behavior in the RuO$_2$ layer at $T_{Magnetic}$.Comment: 10 pages, 7 figures, submitted to Phys. Rev. B., correspondence to [email protected]

Unusual Field-Dependence of the Intragrain Superconductive Transition in RuSr2EuCu2O8

A narrow intragrain phase-lock transition was observed in RuSr2EuCu2O8 under a magnetic field H up to a few Tesla. The corresponding transition temperature, T2, decreases rapidly (about 100 K/T at low fields) with H indicating that the grains of RuSr2EuCu2O8 behave like a Josephson-junction-array instead of a homogeneous bulk superconductor. Our data suggest that the bulk superconducting transition may occur on a length scale well below the grain size of 2 to 6 micrometer