Impact of NICE guidance on laparoscopic surgery for inguinal hernias: analysis of interrupted time series

After the introduction of Bassini's procedure in the late 19th century, methods of repairing hernias changed little until the 1990s, when synthetic mesh and laparoscopic methods arrived. In contrast to the open mesh technique, laparoscopic surgery remains uncommon. In January 2001, the National Institute for Clinical Excellence (NICE) issued guidance that stated, "For repair of primary inguinal hernia, open [mesh] should be the preferred surgical procedure." We describe patterns of surgical repair of inguinal hernias and assess the impact of NICE's guidance

Engagement With Motivational Interviewing and Cognitive Behavioral Therapy Components of a Web-Based Alcohol Intervention, Elicitation of Change Talk and Sustain Talk, and Impact on Drinking Outcomes: Secondary Data Analysis

Background: Down Your Drink (DYD) is a widely used unguided online alcohol moderation program for the general public based on cognitive behavioural therapy (CBT) and motivational interviewing (MI), with many opportunities for free-text responses. / Objective: To assess participants’ use of key CBT and MI components, the presence of change and sustain talk within their responses, and whether these are associated with drinking outcomes after three months. / Methods: A secondary data-analysis was conducted on data from the definitive randomized trial of DYD, collected in 2008 (n=503). Past week alcohol use at baseline and three month follow-up was measured with the TOT-AL. Covariates included baseline alcohol use, age, gender, education level and word count of responses. Use of MI and CBT components and presence of change and sustain talk was coded by two independent coders (Cohen’s kappa range = 0.91-1). Linear model regressions on the full sample and a subsample of active users (n=411) are presented. / Results: Most commonly used components were the listing of pros and cons. Number of listed risky situations was associated with lower alcohol use at three months follow-up in both the full sample and the subsample (Badj = −2.10 95%CI −3.88 - −0.31, P = 0.02). Number of listed pros of drinking was only associated with higher alcohol use in the subsample (Badj = 3.12, 95%CI −0.55-6.80, P = 0.095). When the primary measure for alcohol use was log-transformed, number of strategies to deal with risky situations (Badj = 0.03, 95%CI 0.00 - 0.06, P = 0.02) and presence of any change talk (Badj =−0.46, 95%CI −0.86 - −0.06, P = 0.02) also predicted alcohol use. / Conclusions: An unguided online alcohol moderation program can elicit change and sustain talk. Number of noted risky situations can predict alcohol use at three month follow-up. Other components, namely number of strategies to deal with risky situations, number of listed pros, sustain talk and any presence of change talk, are also of interest, but need further research. Clinical Trial: Original trial registration: ISRCTN registry, ID ISRCTN31070347, http://www.isrctn.com/ISRCTN31070347

Evaluation of the effects of an offer of a monetary incentive on the rate of questionnaire return during follow-up of a clinical trial: a randomised study within a trial

BACKGROUND: A systematic review on the use of incentives to promote questionnaire return in clinical trials suggest they are effective, but not all studies have sufficient funds to use them. Promising an incentive once data are returned can reduce the cost-burden of this approach, with possible further cost-savings if the offer were restricted to reminder letters only. This study aimed to evaluate the effect of promising a monetary incentive at first mailout versus a promise on reminder letters only. METHODS: This was a randomised Study Within A Trial (SWAT) nested within BUMPES, a multicentre randomised controlled trial of maternal position in the late stage of labour in women with an epidural. The follow-up questionnaire asked for information on the women's health, wellbeing and health service use one year following the birth of their baby. Women who consented to be contacted were randomised to a promise of a monetary incentive at first mailout or a promise on reminder letters only. Women were given an option of completing the questionnaire on paper or on online. The incentive was posted out on receipt of a completed questionnaire. The primary outcome was the overall return rate, and secondary outcomes were the return rate without any chasing from the study office, and the total cost of the vouchers. RESULTS: A total of 1,029 women were randomised, 508 to the first mailout group and 518 to the reminder group. There was no evidence to suggest a difference between groups in the overall return rate (adjusted RR 1.03 (95 % CI 0.96 to 1.11), however the proportion returned without chasing was higher in the first mailout group (adjusted RR 1.22, 95 % CI 1.07 to 1.39). The total cost of the vouchers per participant was higher in the first mailout group (mean difference £4.56, 95 % CI £4.02 to £5.11). CONCLUSIONS: Offering a monetary incentive when a reminder is required could be cost-effective depending on the sample size of the study and the resources available to administer the reminder letters. TRIAL REGISTRATION: The BUMPES Trial is registered with Current Controlled Trials: ISRCTN35706297 , 26(th) August 2009

Service user, carer and provider perspectives on integrated care for older people with frailty, and factors perceived to facilitate and hinder implementation: A systematic review and narrative synthesis

© 2019 Sadler et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Introduction Older people with frailty (OPF) can experience reduced quality of care and adverse outcomes due to poorly coordinated and fragmented care, making this patient population a key target group for integrated care. This systematic review explores service user, carer and provider perspectives on integrated care for OPF, and factors perceived to facilitate and hinder implementation, to draw out implications for policy, practice and research. Methods Systematic review and narrative synthesis of qualitative studies identified from MEDLINE, CINAHL, PsycINFO and Social Sciences Citation Index, hand-searching of reference lists and citation tracking of included studies, and review of experts’ online profiles. Quality of included studies was appraised with The Critical Appraisal Skills Programme tool for qualitative research. Results Eighteen studies were included in the synthesis. We identified four themes related to stakeholder perspectives on integrated care for OPF: different preferences for integrated care among service users, system and service organisation components, relational aspects of care and support, and stakeholder perceptions of outcomes. Service users and carers highlighted continuity of care with a professional they could trust, whereas providers emphasised improved coordination of care between providers in different care sectors as key strategies for integrated care. We identified three themes related to factors facilitating and hindering implementation: perceptions of the integrated care intervention and target population, service organisational factors and system level factors influencing implementation. Different stakeholder groups perceived the complexity of care needs of this patient population, difficulties with system navigation and access, and limited service user and carer involvement in care decisions as key factors hindering implementation. Providers mainly also highlighted other organisational and system factors perceived to facilitate and hinder implementation of integrated care for OPF

Impact of Financial Incentives on Alcohol Consumption Recording in Primary Health Care Among Adults with Schizophrenia and Other Psychoses: A Cross-Sectional and Retrospective Cohort Study

AIMS: Lack of financial incentive is a frequently cited barrier to alcohol screening in primary care. The Quality and Outcomes Framework (QOF) pay for performance scheme has reimbursed UK primary care practices for alcohol screening in people with schizophrenia since April 2011. This study aimed to determine the impact of financial incentives on alcohol screening by comparing rates of alcohol recording in people with versus those without schizophrenia between 2000 and 2013. METHODS: Cross-sectional and retrospective cohort study. Alcohol data were extracted from The Health Improvement Network (THIN) database of UK primary care records using (a) Read Codes for level of alcohol consumption, (b) continuous measures of drinking (e.g. units a week) and (c) Read Codes for types of screening test. RESULTS: A total of 14,860 individuals (54% (8068) men and 46% (6792) women) from 409 general practices aged 18-99 years with schizophrenia were identified during April 2011-March 2013. Of these, 11,585 (78%) had an alcohol record, of which 99% (8150/8257) of Read Codes for level of consumption were eligible for recompense in the QOF. There was an 839% increase in alcohol recording among people with schizophrenia over the 13-year period (rate ratio per annum increase 1.19 (95% CI 1.18-1.20)) compared with a 62% increase among people without a severe mental illness (rate ratio per annum increase 1.04 (95% CI 1.03-1.05)). CONCLUSION: Financial incentives offered by the QOF appear to have a substantial impact on alcohol screening among people with schizophrenia in UK primary care. SHORT SUMMARY: Alcohol screening among people with schizophrenia increased dramatically in primary health care following the introduction of the UK pay for performance incentive scheme (Quality and Outcomes Framework) for severe mental illness, with an 839% rise (>8-fold increase) compared with a 62% increase among people without a over the 13-year study period (2000-2013)

Computer-Based Interventions for Problematic Alcohol Use:a Review of Systematic Reviews

PURPOSE: The aim of this review is to provide an overview of knowledge and knowledge gaps in the field of computer-based alcohol interventions by (1) collating evidence on the effectiveness of computer-based alcohol interventions in different populations and (2) exploring the impact of four specified moderators of effectiveness: therapeutic orientation, length of intervention, guidance and trial engagement.  METHODS: A review of systematic reviews of randomized trials reporting on effectiveness of computer-based alcohol interventions published between 2005 and 2015.  RESULTS: Fourteen reviews met the inclusion criteria. Across the included reviews, it was generally reported that computer-based alcohol interventions were effective in reducing alcohol consumption, with mostly small effect sizes. There were indications that longer, multisession interventions are more effective than shorter or single session interventions. Evidence on the association between therapeutic orientation of an intervention, guidance or trial engagement and reductions in alcohol consumption is limited, as the number of reviews addressing these themes is low. None of the included reviews addressed the association between therapeutic orientation, length of intervention or guidance and trial engagement.  CONCLUSIONS: This review of systematic reviews highlights the mostly positive evidence supporting computer-based alcohol interventions as well as reveals a number of knowledge gaps that could guide future research in this field

Online Health Check for Reducing Alcohol Intake among Employees:A Feasibility Study in Six Workplaces across England

BACKGROUND: Most hazardous and harmful drinkers are of working age and do not seek help with their drinking. Occupational health services are uniquely placed to universally screen employees across the range of socioeconomic and ethnic groups. The aim was to explore the feasibility and acceptability of offering electronic screening and brief intervention for alcohol misuse in the context of a health check in six different workplace settings.  METHODS AND FINDINGS: Employees were recruited from six workplaces across England, including three local authorities, one university, one hospital and one petro-chemical company. A total of 1,254 (8%) employees completed the health check and received personalised feedback on their alcohol intake, alongside feedback on smoking, fruit and vegetable consumption and physical activity. Most participants were female (65%) and of 'White British' ethnicity (94%), with a mean age of 43 years (SD 11). Participants were mostly in Intermediate occupations (58%), followed by Higher managerial / professional (39%) and Routine and manual occupations (2%). A quarter of participants (25%) were drinking at hazardous levels (33% male, 21% female), which decreased with age. Sixty-four percent (n=797) of participants completed online follow-up at three months. Most participants were supportive of workplaces offering employees an online health check (95%), their preferred format was online (91%) and many were confident of the confidentiality of their responses (60%). Whilst the feedback reminded most participants of things they already knew (75%), some were reportedly motivated to change their behaviour (13%).  CONCLUSIONS: Online health screening and personalised feedback appears feasible and acceptable, but challenges include low participation rates, potentially attracting 'worried well' employees rather than those at greatest health risk, and less acceptance of the approach among older employees and those from ethnic minority backgrounds and routine or manual occupations

Assertive outreach treatment versus care as usual for the treatment of high-need, high-cost alcohol related frequent attenders: study protocol for a randomised controlled trial

Background: Alcohol-related hospital admissions have doubled in the last ten years to >1.2m per year in England. High-need, high-cost (HNHC) alcohol-related frequent attenders (ARFA) are a relatively small subgroup of patients, having multiple admissions or attendances from alcohol during a short time period. This trial aims to test the effectiveness of an assertive outreach treatment (AOT) approach in improving clinical outcomes for ARFA, and reducing resource use in the acute setting. Methods: One hundred and sixty ARFA patients will be recruited and following baseline assessment, randomly assigned to AOT plus care as usual (CAU) or CAU alone in equal numbers. Baseline assessment includes alcohol consumption and related problems, physical and mental health comorbidity and health and social care service use in the previous 6 months using standard validated tools, plus a measure of resource use. Follow-up assessments at 6 and 12months after randomization includes the same tools as baseline plus standard measure of patient satisfaction. Outcomes for CAU+AOT and CAU at 6 and 12months will be compared, controlling for pre-specified baseline measures. Primary outcome will be percentage of days abstinent at 12months. Secondary outcomes include emergency department (ED) attendance, number and length of hospital admissions, alcohol consumption, alcohol-related problems, other health service use, mental and physical comorbidity 6 and 12months post intervention. Health economic analysis will estimate the economic impact of AOT from health, social care and societal perspectives and explore cost-effectiveness in terms of quality adjusted life years and alcohol consumption at 12-month follow-up. Discussion: AOT models piloted with alcohol dependent patients have demonstrated significant reductions in alcohol consumption and use of unplanned National Health Service (NHS) care, with increased engagement with alcohol treatment services, compared with patients receiving CAU. While AOT interventions are costlier per case than current standard care in the UK, the rationale for targeting HNHC ARFAs is because of their disproportionate contribution to overall alcohol burden on the NHS. No previous studies have evaluated the clinical and costeffectiveness of AOT for HNHC ARFAs: this randomized controlled trial (RCT) targeting ARFAs across five South London NHS Trusts is the first. Trial registration: International standard randomized controlled trial number (ISRCTN) registry: ISRCTN67000214, retrospectively registered 26/11/2016

DIgital Alcohol Management ON Demand (DIAMOND) feasibility randomised controlled trial of a web-based intervention to reduce alcohol consumption in people with hazardous and harmful use versus a face-to-face intervention: protocol.

BACKGROUND: "Hazardous and harmful" drinkers make up approximately 23 % of the adult population in England. However, only around 10 % of these people access specialist care, such as face-to-face extended brief treatment in community alcohol services. This may be due to stigma, difficulty accessing services during working hours, a shortage of trained counsellors and limited provision of services in many places. Web-based alcohol treatment programmes may overcome these barriers and may better suit people who are reluctant or unable to attend face-to-face services, but there is a gap in the evidence base for the acceptability, effectiveness and cost-effectiveness of these programmes compared with treatment as usual (TAU) in community alcohol services. This study aims investigate the feasibility of all parts of a randomised controlled trial (RCT) of a psychologically informed web-based alcohol treatment programme called Healthy Living for People who use Alcohol (HeLP-Alcohol) versus TAU in community alcohol services, e.g. recruitment and retention, online data collection methods, and the use and acceptability of the intervention to participants. METHODS: A feasibility RCT delivered in north London community alcohol services, comparing HeLP-Alcohol with TAU. Potential participants are aged ≥18 years referred or self-referred for hazardous and harmful use of alcohol, without co-morbidities or other complex problems. The main purpose of this study is to demonstrate the feasibility of recruiting participants to the study and will test online methods for collecting baseline demographic and outcome questionnaire data, randomising participants and collecting 3-month follow-up data. The acceptability of this intervention will be measured by recruitment and retention rates, automated log-in data collection and an online service satisfaction questionnaire. The feasibility of using tailored text message, email or phone prompt to maintain engagement with the intervention will also be explored. Results of the study will inform a definitive Phase 3 RCT. RESULTS: Recruitment started on 26 September 2014 and will run for 1 year. CONCLUSION: The proposed trial will provide data to inform a fully powered non-inferiority effectiveness and cost-effectiveness RCT comparing HeLP-Alcohol with TAU. TRIAL REGISTRATION: ISRCTN31789096