Effect of a telephonic alert system (Healthy Outlook) for patients with chronic obstructive pulmonary disease: cohort study with matched controls

Background: Healthy Outlook was a telephonic alert system for patients with Chronic Obstructive Pulmonary Disease (COPD) in the United Kingdom. It used routine meteorological and communicable disease reports to identify times of increased risk to health. We tested its effect on hospital use and mortality. Methods: Enrolees with a history of hospital admissions were linked to hospital administrative data. They were compared with control patients from local general practices, matched for demographic characteristics, health conditions, previous hospital use and predictive risk scores. We compared unplanned hospital admissions, admissions for COPD, outpatient attendances, planned admissions and mortality, over 12 months following enrolment. Results: Intervention and matched control groups appeared similar at baseline (n=1,413 in each group). Over the 12 months following enrolment, Healthy Outlook enrolees experienced more COPD admissions than matched controls (adjusted rate ratio 1.26, 95% CI, 1.05 to 1.52) and more outpatient attendances (adjusted rate ratio 1.08, 95% CI 1.03 to 1.12). Enrolees also had lower mortality rates over 12 months (adjusted odds ratio 0.61, 95% CI, 0.45 to 0.84). Conclusion: Healthy Outlook did not reduce admission rates, though mortality rates were lower. Findings for hospital utilisation were unlikely to have been affected by confounding

Evaluation of UK Integrated Care Pilots: research protocol

<span style="font-family: Arial; mso-bidi-font-size: 11.0pt;"><span style="font-size: small;"><p align="left"><strong>Background</strong>: In response to concerns that the needs of the aging population for well-integrated care were increasing, the English National Health Service (NHS) appointed 16 Integrated Care Pilots following a national competition. The pilots have a range of aims including development of new organisational structures to support integration, changes in staff roles, reducing unscheduled emergency hospital admissions, reduced length of hospital stay, increasing patient satisfaction, and reducing cost. This paper describes the evaluation of the initiative which has been commissioned.</p><p align="justify"><strong>Study design and data collection methods</strong>: A mixed methods approach has been adopted including interviews with staff and patients, non-participant observation of meetings, structured written feedback from sites, questionnaires to patients and staff, and analysis of routinely collected hospital utilisation data for patients/service users. The qualitative analysis aims to identify the approaches taken to integration by the sites, the benefits which result, the context in which benefits have resulted, and the mechanisms by which they occur.</p><p align="justify"><strong>Methods of analysis</strong>: The quantitative analysis adopts a 'difference in differences' approach comparing health care utilisation before and after the intervention with risk-matched controls. The qualitative data analysis adopts a 'theory of change' approach in which we triangulate data from the quantitative analysis with qualitative data in order to describe causal effects (what happens when an independent variable changes) and causal mechanisms (what connects causes to their effects). An economic analysis will identify what incremental resources are required to make integration succeed and how they can be combined efficiently to produce better outcomes for patients.</p><p><strong>Conclusion</strong>: This evaluation will produce a portfolio of evidence aimed at strengthening the evidence base for integrated care, and in particular identifying the context in which interventions are likely to be effective. These data will support a series of evaluation judgements aimed at reducing uncertainties about the role of integrated care in improving the efficient and effective delivery of healthcare.</p></span></span

A perfusion culture system for assessing bone marrow stromal cell differentiation on PLGA scaffolds for bone repair

Biomaterials development for bone repair is currently hindered by the lack of physiologically relevant in vitro testing systems. Here we describe the novel use of a bi-directional perfusion bioreactor to support the long term culture of human bone marrow stromal cells (BMSCs) differentiated on polylactic co-glycolic acid (PLGA). Primary human BMSCs were seeded onto porous PLGA scaffolds and cultured in static vs. perfusion culture conditions for 21 days in osteogenic vs. control media. PLGA scaffolds were osteoconductive, supporting a mature osteogenic phenotype as shown by the upregulation of Runx2 and the early osteocyte marker E11. Perfusion culture enhanced the expression of osteogenic genes Osteocalcin and Osteopontin. Extracellular matrix deposition and mineralisation were spatially regulated within PLGA scaffolds in a donor dependant manner. This, together with the observed upregulation of Collagen type X suggested an environment permissive for the study of differentiation pathways associated with both intramembranous and endochondral ossification routes of bone healing. This culture system offers a platform to assess BMSC behavior on candidate biomaterials under physiologically relevant conditions. Use of this system may improve our understanding of the environmental cues orchestrating BMSC differentiation and enable fine tuning of biomaterial design as we develop tissue-engineered strategies for bone regeneration

A study of patient outcomes in an acute hospital.

Outcome measures have been developed in an acute hospital for specific patient groups (primarily cholecystectomy, diabetes, coronary angioplasty and knee replacements). For each condition a set of indicators was derived which ranged from clinical and laboratory measures to measures of general health status. All indicators attempt to show changes in patient health over time. It has been shown possible to collect the necessary data for such outcomes measures. The costs and methods of data collection varied between conditions. Patient completed questionnaires were found to be particularly useful and in inpatient studies have given high response rates (over 95%) for postal follow-ups and have been validated by interviews. The differing ability of the various indicators to show clinical changes has been demonstrated. In all specialties there was found to be generally high levels of association between different indicators. The information collected on patient outcomes was presented at meetings of the various clinical teams and the value of the information in promoting practical change was examined. It was concluded that different indicators have different value in such reviews and that three key characteristics are identified. The first concerns whether the measures reflect clinical or patient's perceptions of health. The second concerns the extent to which an indicator is a direct measure of health or a proxy (or process) measure. The third concerns the extent to which an observed outcome indicator can be linked to particular processes of care. The study has generated support from the clinicians and it is suggested has changed their views on how they judge their own performance. In some instances practical changes have resulted form the presence of the outcome information. The potential future roles for outcome measurement in the health service is discussed

Alcohol-specific activity in hospitals in England

Alcohol-related harm is placing increasing demands on the NHS. At a time when unprecedented efficiencies need to be made by the NHS and local authorities, preventative action must be taken seriously. This analysis explores trends in alcohol-specific activity in hospitals due to alcohol poisoning and alcohol-related inpatient admissions by looking at six years of hospital activity data in England. The analysis also explores the use of hospital services before and after a diagnosis of alcohol-related liver disease and highlights opportunities for preventative action to reduce future alcohol-related harm in England

Evaluation of complex integrated care programmes: the approach in North West London

Background: Several local attempts to introduce integrated care in the English National Health Service have been tried, with limited success. The Northwest London Integrated Care Pilot attempts to improve the quality of care of the elderly and people with diabetes by providing a novel integration process across primary, secondary and social care organisations. It involves predictive risk modelling, care planning, multidisciplinary management of complex cases and an information technology tool to support information sharing. This paper sets out the evaluation approach adopted to measure its effect. Study design: We present a mixed methods evaluation methodology. It includes a quantitative approach measuring changes in service utilization, costs, clinical outcomes and quality of care using routine primary and secondary data sources. It also contains a qualitative component, involving observations, interviews and focus groups with patients and professionals, to understand participant experiences and to understand the pilot within the national policy context. Theory and discussion: This study considers the complexity of evaluating a large, multi-organisational intervention in a changing healthcare economy. We locate the evaluation within the theory of evaluation of complex interventions. We present the specific challenges faced by evaluating an intervention of this sort, and the responses made to mitigate against them. Conclusions: We hope this broad, dynamic and responsive evaluation will allow us to clarify the contribution of the pilot, and provide a potential model for evaluation of other similar interventions. Because of the priority given to the integrated agenda by governments internationally, the need to develop and improve strong evaluation methodologies remains strikingly important

Effect of telecare on use of health and social care services: findings from the Whole Systems Demonstrator cluster randomised trial

Objective: to assess the impact of telecare on the use of social and health care. Part of the evaluation of the Whole Systems Demonstrator trial. Participants and setting: a total of 2,600 people with social care needs were recruited from 217 general practices in three areas in England. Design: a cluster randomised trial comparing telecare with usual care, general practice being the unit of randomisation. Participants were followed up for 12 months and analyses were conducted as intention-to-treat. Data sources: trial data were linked at the person level to administrative data sets on care funded at least in part by local authorities or the National Health Service. Main outcome measures: the proportion of people admitted to hospital within 12 months. Secondary endpoints included mortality, rates of secondary care use (seven different metrics), contacts with general practitioners and practice nurses, proportion of people admitted to permanent residential or nursing care, weeks in domiciliary social care and notional costs. Results: 46.8% of intervention participants were admitted to hospital, compared with 49.2% of controls. Unadjusted differences were not statistically significant (odds ratio: 0.90, 95% CI: 0.75–1.07, P = 0.211). They reached statistical significance after adjusting for baseline covariates, but this was not replicated when adjusting for the predictive risk score. Secondary metrics including impacts on social care use were not statistically significant. Conclusions: telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use, at least in terms of results assessed over 12 months

A person based formula for allocating commissioning funds to general practices in England: development of a statistical model

Objectives To develop a formula for allocating resources for commissioning hospital care to all general practices in England based on the health needs of the people registered in each practic

Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial

Objective To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality