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Steventon A.,The Nuffield Trust | Bardsley M.,The Nuffield Trust | Billings J.,New York University | Dixon J.,The Nuffield Trust | And 12 more authors.
Age and Ageing | Year: 2013

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 datasets 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 endpointsincluded 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 notstatistically 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. International Standard Randomised Controlled Trial Number Register ISRCTN43002091. © The Author 2013. Published by Oxford University Press on behalf of the British Geriatrics Society.


PubMed | The Nuffield Trust and University of Warwick
Type: Journal Article | Journal: Emergency medicine journal : EMJ | Year: 2014

Many health systems across the globe have introduced arrangements to deny payment for patients readmitted to hospital as an emergency. The purpose of this study was to develop an exploratory categorisation based on likely causes of readmission, and then to assess the prevalence of these different types.Retrospective analysis of 82 million routinely collected National Health Service hospital records in England (2004-2010) was undertaken using anonymised linkage of records at person-level. Numbers of 30-day readmissions were calculated. Exploratory categorisation of readmissions was applied using simple rules relating to International Classification of Diseases (ICD) diagnostic codes for both admission and readmission.There were 5804472 emergency 30-day readmissions over a 6-year period, equivalent to 7.0% of hospital discharges. Readmissions were grouped into hierarchically exclusive categories: potentially preventable readmission (1739519 (30.0% of readmissions)); anticipated but unpredictable readmission (patients with chronic disease or likely to need long-term care; 1141987 (19.7%)); preference-related readmission (53718 (0.9%)); artefact of data collection (16062 (0.3%)); readmission as a result of accident, coincidence or related to a different body system (1101818 (19.0%)); broadly related readmission (readmission related to the same body system (1751368 (30.2%)).In this exploratory categorisation, a large minority of emergency readmissions (eg, those that are potentially preventable or due to data artefacts) fell into groups potentially amenable to immediate reduction. For other categories, a hospitals ability to reduce emergency readmission is less clear. Reduction strategies and payment incentives must be carefully tailored to achieve stated aims.


PubMed | The Nuffield Trust and The Health Foundation
Type: Journal Article | Journal: BMJ open | Year: 2016

To assess the effects of a home-based telehealth intervention on the use of secondary healthcare and mortality.Observational study of a mainstream telehealth service, using person-level administrative data. Time to event analysis (Cox regression) was performed comparing telehealth patients with controls who were matched using a machine-learning algorithm.A predominantly rural region of England (North Yorkshire).716 telehealth patients were recruited from community, general practice and specialist acute care, between June 2010 and March 2013. Patients had chronic obstructive pulmonary disease, congestive heart failure or diabetes, and a history of associated inpatient admission. Patients were matched 1:1 to control patients, also selected from North Yorkshire, with respect to demographics, diagnoses of health conditions, previous hospital use and predictive risk score.Telehealth involved the remote exchange of medical data between patients and healthcare professionals as part of the ongoing management of the patients health condition. Monitoring centre staff alerted healthcare professionals if the telemonitored data exceeded preset thresholds. Control patients received usual care, without telehealth.Time to the first emergency (unplanned) hospital admission or death. Secondary metrics included time to death and time to first admission, outpatient attendance and emergency department visit.Matched controls and telehealth patients were similar at baseline. Following enrolment, telehealth patients were more likely than matched controls to experience emergency admission or death (adjusted HR 1.34, 95% CI 1.16 to 1.56, p<0.001). They were also more likely to have outpatient attendances (adjusted HR=1.25, 1.11 to 1.40, p<0.001), but mortality rates were similar between groups. Sensitivity analyses showed that we were unlikely to have missed reductions in the likelihood of an emergency admission or death because of unobserved baseline differences between patient groups.Telehealth was not associated with a reduction in secondary care utilisation.


PubMed | The Nuffield Trust and London School of Hygiene and Tropical Medicine
Type: Journal Article | Journal: Journal of public health (Oxford, England) | Year: 2015

Healthy Outlook was a telephonic alert system for patients with chronic obstructive pulmonary disease (COPD) in the UK. 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.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.Intervention and matched control groups appeared similar at baseline (n = 1413 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% confidence interval (CI), 1.05-1.52) and more outpatient attendances (adjusted rate ratio 1.08, 95% CI, 1.03-1.12). Enrolees also had lower mortality rates over 12 months (adjusted odds ratio 0.61, 95% CI, 0.45-0.84).Healthy Outlook did not reduce admission rates, though mortality rates were lower. Findings for hospital utilization were unlikely to have been affected by confounding.


Lewis G.,NHS England | Vaithianathan R.,University of Auckland | Vaithianathan R.,Singapore Management University | Wright L.,NHS Blood and Transplant | And 4 more authors.
International Journal of Integrated Care | Year: 2013

Background: Patients at high risk of emergency hospitalisation are particularly likely to experience fragmentation care. The virtual ward model attempts to integrate health and social care by offering multidisciplinary case management to people at high predicted risk of unplanned hospitalisation. Objective: To describe the care practice in three virtual ward sites in England and to explore how well each site had achieved meaningful integration. Method: Case studies conducted in Croydon, Devon and Wandsworth during 2011-2012, consisting of semi-structured interviews, workshops, and site visits. Results: Different versions of the virtual wards intervention had been implemented in each site. In Croydon, multidisciplinary care had reverted back to one-to-one case management. Conclusions: To integrate successfully, virtual ward projects should safeguard the multidisciplinary nature of the intervention, ensure the active involvement of General Practitioners, and establish feedback processes to monitor performance such as the number of professions represented at each team meeting.


PubMed | Anglia, Imperial College London, University of Manchester, The London School of Economics and Political Science and 4 more.
Type: Journal Article | Journal: Age and ageing | Year: 2014

to examine the costs and cost-effectiveness of second-generation telecare, in addition to standard support and care that could include first-generation forms of telecare, compared with standard support and care that could include first-generation forms of telecare.a pragmatic cluster-randomised controlled trial with nested economic evaluation. A total of 2,600 people with social care needs participated in a trial of community-based telecare in three English local authority areas. In the Whole Systems Demonstrator Telecare Questionnaire Study, 550 participants were randomised to intervention and 639 to control. Participants who were offered the telecare intervention received a package of equipment and monitoring services for 12 months, additional to their standard health and social care services. The control group received usual health and social care.incremental cost per quality-adjusted life year (QALY) gained. The analyses took a health and social care perspective.cost per additional QALY was 297,000. Cost-effectiveness acceptability curves indicated that the probability of cost-effectiveness at a willingness-to-pay of 30,000 per QALY gained was only 16%. Sensitivity analyses combining variations in equipment price and support cost parameters yielded a cost-effectiveness ratio of 161,000 per QALY.while QALY gain in the intervention group was similar to that for controls, social and health services costs were higher. Second-generation telecare did not appear to be a cost-effective addition to usual care, assuming a commonly accepted willingness to pay for QALYs.ISRCTN 43002091.


Poole R.,University of Cardiff | Gamper A.,University of Cardiff | Porter A.,The Nuffield Trust | Egbunike J.,Picker Institute Europe | Edwards A.,University of Cardiff
Family Practice | Year: 2011

Background and objective: Out-of-hours services for primary care provision are increasing in policy relevance. The aim of this qualitative study was to explore service users' recent experiences of out-of-hours services and to identify suggestions for improvement for services and practitioners involved. Methods: We used data from a cross-sectional survey of service users' self-reported experiences of 13 out-of-hours centres in Wales. Three hundred and forty-one respondents provided free-text comments focusing on suggestions for improvement within the survey instrument (the Out-ofhours Patient Questionnaire). A coding framework was based on previous literature focusing on patients' experiences of out-of-hours services, built upon and refined as it was systematically applied to the data. Emergent themes and subthemes were charted and interpreted to comprise the findings. Results: Central themes emerged from users' perspectives of the structure of out-of-hours services, process of care and outcomes for users. Themes included long waiting times, perceived quality of service user-practitioner communication, consideration for parents and children and accessibility of the service and medication. Suggestions for improving care were made across these themes, including triaging patients more effectively and efficiently, addressing specific aspects of practitioners' communication with patients, reconsidering the size of areas covered by services and number of professionals required for the population covered, extending GP and pharmacy opening times and medication delivery services. Conclusions: It is important to consider ways to address service users' principal concerns surrounding out-of-hours services. Debate is required about prioritizing and implementing potential improvements to out-of-hours services in the light of resource constraints. © The Authors 2010. Published by Oxford University Press.


PubMed | The Nuffield Trust and University College London
Type: Journal Article | Journal: Heart (British Cardiac Society) | Year: 2015

Remote ischaemic preconditioning (RIPC), using brief cycles of limb ischaemia/reperfusion, is a non-invasive, low-cost intervention that may reduce perioperative myocardial injury (PMI) in patients undergoing cardiac surgery. We investigated whether RIPC can also improve short-term clinical outcomes.One hundred and eighty patients undergoing elective coronary artery bypass graft (CABG) surgery and/or valve surgery were randomised to receive either RIPC (2-5min cycles of simultaneous upper arm and thigh cuff inflation/deflation; N=90) or control (uninflated cuffs placed on the upper arm and thigh; N=90). The study primary end point was PMI, measured by 72h area under the curve (AUC) serum high-sensitive troponin-T (hsTnT); secondary end point included short-term clinical outcomes.RIPC reduced PMI magnitude by 26% (-9.303 difference (CI -15.618 to -2.987) 72h hsTnT-AUC; p=0.003) compared with control. There was also evidence that RIPC reduced the incidence of postoperative atrial fibrillation by 54% (11% RIPC vs 24% control; p=0.031) and decreased the incidence of acute kidney injury by 48% (10.0% RIPC vs 21.0% control; p=0.063), and intensive care unit stay by 1day (2.0days RIPC (CI 1.0 to 4.0) vs 3.0days control (CI 2.0 to 4.5); p=0.043). In a post hoc analysis, we found that control patients administered intravenous glyceryl trinitrate (GTN) intraoperatively sustained 39% less PMI compared with those not receiving GTN, and RIPC did not appear to reduce PMI in patients given GTN.RIPC reduced the extent of PMI in patients undergoing CABG and/or valve surgery. RIPC may also have beneficial effects on short-term clinical outcomes, although this will need to be confirmed in future studies.ClinicalTrials.gov ID: NCT00397163.


Bardsley M.,The Nuffield Trust | Billings J.,New York University | Dixon J.,The Nuffield Trust | Georghiou T.,The Nuffield Trust | And 2 more authors.
Age and Ageing | Year: 2011

Background: the costs of delivering health and social care services are rising as the population ages and more people live with chronic diseases. Objectives: to determine whether predictive risk models can be built that use routine health and social care data to predict which older people will begin receiving intensive social care. Design: analysis of pseudonymous, person-level, data extracted from the administrative data systems of local health and social care organisations.Setting: five primary care trust areas in England and their associated councils with social services responsibilities.Subjects: people aged 75 or older registered continuously with a general practitioner in five selected areas of England (n = 155,905). Methods: multivariate statistical analysis using a split sample of data. Results: it was possible to construct models that predicted which people would begin receiving intensive social care in the coming 12 months. The performance of the models was improved by selecting a dependent variable based on a lower cost threshold as one of the definitions of commencing intensive social care. Conclusions: predictive models can be constructed that use linked, routine health and social care data for case finding in social care settings. © The Author 2011. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved.


Chitnis X.A.,The Nuffield Trust | Georghiou T.,The Nuffield Trust | Steventon A.,The Nuffield Trust | Bardsley M.J.,The Nuffield Trust
BMJ Supportive and Palliative Care | Year: 2013

Objective: To assess the effect of routinely delivered home-based end-of-life care on hospital use at the end of life and place of death. Design: Retrospective analysis using matched controls and administrative data. Setting: Community-based care in England. Participants: 29 538 people aged over 18 who received Marie Curie nursing support compared with 29 538 controls individually matched on variables including: age, socioeconomic deprivation, prior hospital use, number of chronic conditions and prior diagnostic history. Intervention: Home-based end-of-life nursing care delivered by the Marie Curie Nursing Service (MCNS), compared with end-of-life care available to those who did not receive MCNS care. Main outcome measures: Proportion of people who died at home; numbers of emergency and elective inpatient admissions, outpatient attendances and attendances at emergency departments in the period until death; and notional costs of hospital care. Results: Intervention patients were significantly more likely to die at home and less likely to die in hospital than matched controls (unadjusted OR 6.16, 95%CI 5.94 to 6.38, p<0.001). Hospital activity was significantly lower among intervention than matched control patients (emergency admissions: 0.14 vs 0.44 admissions per person, p<0.001) and average costs across all hospital services were lower (unadjusted average costs per person, £610 (intervention patients) vs £1750 (matched controls), p<0.001). Greater activity and cost differences were seen in those patients who had been receiving home nursing for longer. Conclusions: Home-based end-of-life care offers the potential to reduce demand for acute hospital care and increase the number of people able to die at home.

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