Is telephone health coaching a useful population health strategy for supporting older people with multimorbidity? : An evaluation of reach, effectiveness and cost-effectiveness using a 'trial within a cohort'

BACKGROUND: Innovative ways of delivering care are needed to improve outcomes for older people with multimorbidity. Health coaching involves 'a regular series of phone calls between patient and health professional to provide support and encouragement to promote healthy behaviours'. This intervention is promising, but evidence is insufficient to support a wider role in multimorbidity care. We evaluated health coaching in older people with multimorbidity. METHODS: We used the innovative 'Trials within Cohorts' design. A cohort was recruited, and a trial was conducted using a 'patient-centred' consent model. A randomly selected group within the cohort were offered the intervention and were analysed as the intervention group whether they accepted the offer or not. The intervention sought to improve the skills of patients with multimorbidity to deal with a range of long-term conditions, through health coaching, social prescribing and low-intensity support for low mood. RESULTS: We recruited 4377 older people, and 1306 met the eligibility criteria (two or more long-term conditions and moderate 'patient activation'). We selected 504 for health coaching, and 41% consented. More than 80% of consenters received the defined 'dose' of 4+ sessions. In an intention-to-treat analysis, those selected for health coaching did not improve on any outcome (patient activation, quality of life, depression or self-care) compared to usual care. We examined health care utilisation using hospital administrative and self-report data. Patients selected for health coaching demonstrated lower levels of emergency care use, but an increase in the use of planned services and higher overall costs, as well as a quality-adjusted life year (QALY) gain. The incremental cost per QALY was £8049, with a 70-79% probability of being cost-effective at conventional levels of willingness to pay. CONCLUSIONS: Health coaching did not lead to significant benefits on the primary measures of patient-reported outcome. This is likely related to relatively low levels of uptake amongst those selected for the intervention. Demonstrating effectiveness in this design is challenging, as it estimates the effect of being selected for treatment, regardless of whether treatment is adopted. We argue that the treatment effect estimated is appropriate for health coaching, a proactive model relevant to many patients in the community, not just those seeking care. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ( ISRCTN12286422 )

Improving care for older people with long-term conditions and social care needs in Salford : the CLASSIC mixed-methods study, including RCT

BackgroundThe Salford Integrated Care Programme (SICP) was a large-scale transformation project to improve care for older people with long-term conditions and social care needs. We report an evaluation of the ability of the SICP to deliver an enhanced experience of care, improved quality of life, reduced costs of care and improved cost-effectiveness.ObjectivesTo explore the process of implementation of the SICP and the impact on patient outcomes and costs.DesignQualitative methods (interviews and observations) to explore implementation, a cohort multiple randomised controlled trial to assess patient outcomes through quasi-experiments and a formal trial, and an analysis of routine data sets and appropriate comparators using non-randomised methodologies.SettingSalford in the north-west of England.ParticipantsOlder people aged ≥ 65 years, carers, and health and social care professionals.InterventionsA large-scale integrated care project with three core mechanisms of integration (community assets, multidisciplinary groups and an ‘integrated contact centre’).Main outcome measuresPatient self-management, care experience and quality of life, and health-care utilisation and costs.Data sourcesProfessional and patient interviews, patient self-report measures, and routine quantitative data on service utilisation.ResultsThe SICP and subsequent developments have been sustained by strong partnerships between organisations. The SICP achieved ‘functional integration’ through the pooling of health and social care budgets, the development of the Alliance Agreement between four organisations and the development of the shared care record. ‘Service-level’ integration was slow and engagement with general practice was a challenge. We saw only minor changes in patient experience measures over the period of the evaluation (both improvements and reductions), with some increase in the use of community assets and care plans. Compared with other sites, the difference in the rates of admissions showed an increase in emergency admissions. Patient experience of health coaching was largely positive, although the effects of health coaching on activation and depression were not statistically significant. Economic analyses suggested that coaching was likely to be cost-effective, generating improvements in quality of life [mean incremental quality-adjusted life-year gain of 0.019, 95% confidence interval (CI) –0.006 to 0.043] at increased cost (mean incremental total cost increase of £150.58, 95% CI –£470.611 to £711.776).LimitationsThe Comprehensive Longitudinal Assessment of Salford Integrated Care study represents a single site evaluation, with consequent limits on external validity. Patient response rates to the cohort survey were ConclusionsThe SICP has been implemented in a way that is consistent with the original vision. However, there has been more rapid success in establishing new integrated structures (such as a formal integrated care organisation), rather than in delivering mechanisms of integration at sufficient scale to have a large impact on patient outcomes.Future workFurther research could focus on each of the mechanisms of integration. The multidisciplinary groups may require improved targeting of patients or disease subgroups to demonstrate effectiveness. Development of a proven model of health coaching that can be implemented at scale is required, especially one that would provide cost savings for commissioners or providers. Similarly, further exploration is required to assess the longer-term benefits of community assets and whether or not health impacts translate to reductions in care use.Trial registrationCurrent Controlled Trials ISRCTN12286422.FundingThis project was funded by the NIHR Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 6, No. 31. See the NIHR Journals Library website for further project information

Mechanisms Involved in Nicotinic Acetylcholine Receptor-Induced Neurotransmitter Release from Sympathetic Nerve Terminals in the Mouse Vas Deferens

Prejunctional nicotinic acetylcholine receptors (nAChRs) amplify postganglionic sympathetic neurotransmission, and there are indications that intraterminal Ca2+ stores might be involved. However, the mechanisms by which nAChR activation stimulates neurotransmitter release at such junctions is unknown. Rapid local delivery (picospritzing) of the nAChR agonist epibatidine was combined with intracellular sharp microelectrode recording to monitor spontaneous and field-stimulation-evoked neurotransmitter release from sympathetic nerve terminals in the mouse isolated vas deferens. Locally applied epibatidine (1 µM) produced ‘epibatidine-induced depolarisations’ (EIDs) that were similar in shape to spontaneous excitatory junction potentials (SEJPs) and were abolished by nonselective nAChR antagonists and the purinergic desensitizing agonist α,β-methylene ATP. The amplitude distribution of EIDs was only slightly shifted towards lower amplitudes by the selective α7 nAChR antagonists α-bungarotoxin and methyllcaconitine, the voltage-gated Na+ channel blocker tetrodotoxin or by blocking voltage-gated Ca2+ channels with Cd2+. Lowering the extracellular Ca2+ concentration reduced the frequency of EIDs by 69%, but more surprisingly, the Ca2+-induced Ca2+ release blocker ryanodine greatly decreased the amplitude (by 41%) and the frequency of EIDs by 36%. Ryanodine had no effect on electrically-evoked neurotransmitter release, paired-pulse facilitation, SEJP frequency, SEJP amplitude or SEJP amplitude distribution. These results show that activation of non-α7 nAChRs on sympathetic postganglionic nerve terminals induces high-amplitude junctional potentials that are argued to represent multipacketed neurotransmitter release synchronized by intraterminal Ca2+-induced Ca2+ release, triggered by Ca2+ influx directly through the nAChR. This nAChR-induced neurotransmitter release can be targeted pharmacologically without affecting spontaneous or electrically-evoked neurotransmitter release

P2X7 receptor signalling mechanisms underlying extracellular purine mediated retinal ganglion cell death in the human retina

EThOS - Electronic Theses Online ServiceGBUnited Kingdo