Comparing the cost-effectiveness and clinical effectiveness of a new community in-reach rehabilitation service with the cost-effectiveness and clinical effectiveness of an established hospital-based rehabilitation service for older people: a pragmatic randomised controlled trial with microcost and qualitative analysis – the Community In-reach Rehabilitation And Care Transition (CIRACT) study

Background: Older people represent a significant proportion of patients admitted to hospital as a medical emergency. Compared with the care of younger patients, their care is more challenging, their stay in hospital is much longer, their risk of hospital-acquired problems is much higher and their 28-day readmission rate is much greater. Objective: To compare the clinical effectiveness, microcosts and cost-effectiveness of a Community In-reach Rehabilitation And Care Transition (CIRACT) service with the traditional hospital-based rehabilitation (THB-Rehab) service in patients aged ≥ 70 years. Methods: A pragmatic randomised controlled trial with an integral health economic study and parallel qualitative appraisal was undertaken in a large UK teaching hospital, with community follow-up. Participants were individually randomised to the intervention (CIRACT service) or standard care (THB-Rehab service). The primary outcome was hospital length of stay; secondary outcomes were readmission within 28 and 91 days post discharge and super spell bed-days (total time in NHS care), functional ability, comorbidity and health-related quality of life, all measured at day 91, together with the microcosts and cost-effectiveness of the two services. A qualitative appraisal provided an explanatory understanding of the organisation, delivery and experience of the CIRACT service from the perspective of key stakeholders and patients. Results: In total, 250 participants were randomised (n = 125 CIRACT service, n = 125 THB-Rehab service). There was no significant difference in length of stay between the CIRACT service and the THB-Rehab service (median 8 vs. 9 days). There were no significant differences between the groups in any of the secondary outcomes. The cost of delivering the CIRACT service and the THB-Rehab service, as determined from the microcost analysis, was £302 and £303 per patient respectively. The overall mean costs (including NHS and personal social service costs) of the CIRACT and THB-Rehab services calculated from the Client Service Receipt Inventory were £3744 and £3603 respectively [mean cost difference £144, 95% confidence interval –£1645 to £1934] and the mean quality-adjusted life-years for the CIRACT service were 0.846 and for the THB-Rehab service were 0.806. The incremental cost-effectiveness ratio (ICER) from a NHS and Personal Social Services perspective was £2022 per quality-adjusted life-year. Although the CIRACT service was highly regarded by those who were most involved with it, the emergent configuration of the service working across organisational and occupational boundaries was not easily incorporated by the current established community services. Conclusions: The CIRACT service did not reduce hospital length of stay or short-term readmission rates compared with the standard THB-Rehab service, although it was highly regarded by those who were most involved with it. The estimated ICER appears cost-effective although it is subject to much uncertainty, as shown by points spanning all four quadrants of the cost-effectiveness plane. Microcosting work-sampling methodology provides a useful method to estimate the cost of service provision. Limitations in sample size, which may have excluded a smaller reduction in length of stay, and lack of blinding, which may have introduced some cross-contamination between the two groups, must be recognised. Reducing hospital length of stay and hospital readmissions remains a priority for the NHS. Further studies are necessary, which should be powered with larger sample sizes and use cluster randomisation (to reduce bias) but, more importantly, should include a more integrated community health-care model as part of the CIRACT team

A multiple timepoint pre-post evaluation of a ‘sexual respect’ dvd to improve competence in discussing sex with patients with disability

Sexual problems are common after chronic illnesses and disability, yet research indicates that this is a neglected area in healthcare services. Evaluation studies provide evidence of the effectiveness of education in enhancing professionals’ knowledge, skills, and comfort in addressing patients’ sexual concerns. However, there are limited evaluations aimed at improving ability to discuss sexuality when working with people with disabilities. The overall aim of this study was to evaluate a ‘Sexual Respect’ DVD as an intervention to improve competence in addressing ‘sexuality and disability’. A mixed methods design was used with both quantitative and qualitative components. Nursing students’ self-report ratings of knowledge, confidence, comfort and willingness (to discuss sexuality) levels were collected across four time points: baseline, pre-intervention, post-intervention, and follow-up. Data were analysed using one-way repeated measures ANOVAs with post hoc comparisons. Open-ended qualitative comments relating to the barriers and facilitators to discussing sexuality were analysed using content analysis and subsequent frequency analysis. Reported barriers included lack of knowledge about sex¬uality and disability issues, the patient’s level of disability, and waiting for the patient to raise sexuality issues first. Facilitators included education/training, written information, and if the patient raised it first. Overall, the DVD intervention had a significant and positive impact on nursing students’ self-reported knowledge, confidence, comfort and willingness levels. The findings are discussed in relation to the PLISSIT model, which emphasises the importance of a proactive approach to addressing sexuality issues

Fracture in the Elderly Multidisciplinary Rehabilitation (FEMuR): study protocol for a phase II randomised feasibility study of a multidisciplinary rehabilitation package following hip fracture

Objective: To conduct a rigorous feasibility study for a future definitive parallel-group randomised controlled trial (RCT) and economic evaluation of an enhanced rehabilitation package for hip fracture.Setting: Recruitment from 3 acute hospitals in North Wales. Intervention delivery in the community.Participants: Older adults (aged ≥65) who received surgical treatment for hip fracture, lived independently prior to fracture, had mental capacity (assessed by clinical team) and received rehabilitation in the North Wales area.Intervention: Remote randomisation to usual care (control) or usual care+enhanced rehabilitation package (intervention), including six additional home-based physiotherapy sessions delivered by a physiotherapist or technical instructor, novel information workbook and goal-setting diary.Primary and secondary outcome measures: Primary: Barthel Activities of Daily Living (BADL). Secondary measures included Nottingham Extended Activities of Daily Living scale (NEADL), EQ-5D, ICECAP capability, a suite of self-efficacy, psychosocial and service-use measures and costs. Outcome measures were assessed at baseline and 3-month follow-up by blinded researchers.Results: 62 participants were recruited, 61 randomised (control 32; intervention 29) and 49 (79%) completed 3-month follow-up. Minimal differences occurred between the 2 groups for most outcomes, including BADL (adjusted mean difference 0.5). The intervention group showed a medium-sized improvement in the NEADL relative to the control group, with an adjusted mean difference between groups of 3.0 (Cohen's d 0.63), and a trend for greater improvement in self-efficacy and mental health, but with small effect sizes. The mean cost of delivering the intervention was £231 per patient. There was a small relative improvement in quality-adjusted life year in the intervention group. No serious adverse events relating to the intervention were reported.Conclusions: The trial methods were feasible in terms of eligibility, recruitment and retention. The effectiveness and cost-effectiveness of the rehabilitation package should be tested in a phase III RCT

Avian community response to group-selection harvest on a mixed-forest American tree farm in west-central New Hampshire

Early-successional species of songbirds are in sharp decline especially in Eastern North America. These species colonize early-successional forest that are currently near historic lows for most of the Northeastern United States. Intentional management for these species often recruits predators, invasive plants or nest parasites, depending on landscape context. Managing for early-successional species can negatively affect late-successional species that depend on mature forest. Currently, habitat for arlysuccessional species is declining due to urban expansion and natural maturation of early-successional vegetation into more mature forests. By creating a mosaic of small group-selections within mature mixed deciduous-coniferous forest, we successfully recruited early-successional species without decreasing the abundance or reproductive performance of later-successional species. Through monitoring fledging success of three early-successional species, magnolia warbler (Setophaga magnolia), chestnutsided warbler (Setophaga penslyvanica), common yellow throat (Geothlypis trichas) and three late-successional species, black-throated blue warbler (Setophaga caerulescens), hermit thrush (Catharus guttatus) and ovenbird (Seiurus aurocapillus) we were able to assess the impact of the harvest on two suites of avian species. We conducted point counts one year prior to harvest and seven consecutive years postharvest, and documented habitat use of the post-harvest mosaic for these six species in 2017 and 2018. Though the first monitoring season (2017) did not include intensive monitoring of hermit thrush or ovenbird, both early and late successional species paired and fledged young at rates that suggest the habitat was suitable to each suite of species. Early-successional songbird species were 74% successful in fledging young when combining monitoring data from 2017 and 2018 and forest-interior species were 64% successful in fledging young. Point counts revealed that immediately postharvest, species richness increased and continued to increase significantly through the recruitment of several early successional species and persistence of the late successional species. We found that early-successional songbird species began to increase in abundance and richness after the fifth year post harvest with no negative pattern of decrease in forest-interior songbird species abundance and richness across years. We documented that through the group-selection cutting there were significantly more woody stems less than 2.5 cm in cut areas and less canopy cover when compared to mature forest. Contrary to our prediction there was no significant difference in the density of woody stems less than 8 cm in cut areas compared to mature forest. This is most likely due to the high amounts of herbaceous plants such as raspberry (Rubus spp.) in cut areas which did not contribute in the woody stem count. The density of stems less than 8cm was negatively correlated with nest success, though previous studies have shown opposite findings. None of the measured shrub and tree vegetation variables or ground cover variables had a significant correlation with successful nesting. The return rates of those species banded in 2018 were 39% for black-throated blue warblers, 25% for common yellow throats and 14% for chestnut sided warblers. More than half of New Hampshire is privately owned and so landowners and consulting foresters can play a critical role in sustaining early successional habitat without negatively impacting late-successional migratory birds

Group-Selection Harvest Increases Avian Diversity

Early-successional species of songbirds and their associated habitat are in sharp decline especially in eastern North America. Intentional management for these species often recruits predators, invasive plants or nest parasites, depending on landscape context. Managing for early-successional species can potentially negatively affect late-successional species dependent on mature forest. Creating a mosaic of group-selections within mature mixed deciduous-coniferous forest, we increased abundance of early-successional species while limiting negative impact on the abundance or reproductive performance of forest-interior species. Through monitoring fledging success of three early-successional species and three late successional species we will assist in assessing habitat suitability of these species. A better understanding of how to best assist these early-successional species without jeopardizing forest-interior species using strategic timber harvest management strategies can potentially diversify bird communities by including habitat across the succession spectrum. More than half of New Hampshire is privately owned and thus landowners and forestry professionals can significantly facilitate increasing early-successional habitat without negatively impacting late-successional migratory birds