Economic assessment of the impact of telecare on the use of social care resources using a zero-inflated, hierarchical linear statistical model.

INTRODUCTION: There is an ever-increasing demand for social care in the UK, with expenditure predicted to double to £56 billion by 2038/39. Many councils are under budget restrictions putting pressure on the number of services provided and their quality. Telecare complements social care and involves the implementation of technology to keep individuals more independent. METHODS: This study utilised a retrospective time-series analysis of data provided by Lancashire County Council between the period January-2013 to March-2018. A generalised linear mixed model (GLMM) was used to control for potential confounders. Two groups were identified: those using telecare (telecare group, n = 699) and those who did not (control group, n = 839). RESULTS: The fixed effects data showed that telecare group start £75 per week lower in cost and as time progressed this reduced further by 9p per service user per week. In contrast, control group costs rose 5p per week per user. This effect was independent of age but was affected by measure of dependency. Analysis was then utilised to make predictions based on weighted averages. The scenario showed a total difference of £4,949 per service user over the whole year. A second scenario pro-rata'd costs for the full year showed a difference of £6,214, where telecare would avoid costs of £17 million per year. DISCUSSION: This analysis demonstrates that there is evident potential for the use of telecare to reduce social care resource use and costs. This study also highlights the use of a GLMM as a novel method of analysing observed data by controlling confounders.

Choosing and using methodological search filters: searchers' views.

BACKGROUND: Search filters or hedges are search strategies developed to assist information specialists and librarians to retrieve different types of evidence from bibliographic databases. The objectives of this project were to learn about searchers' filter use, how searchers choose search filters and what information they would like to receive to inform their choices. METHODS: Interviews with information specialists working in, or for, the National Institute for Health and Care Excellence (NICE) were conducted. An online questionnaire survey was also conducted and advertised via a range of email lists. RESULTS: Sixteen interviews were undertaken and 90 completed questionnaires were received. The use of search filters tends to be linked to reducing a large amount of literature, introducing focus and assisting with searches that are based on a single study type. Respondents use numerous ways to identify search filters and can find choosing between different filters problematic because of knowledge gaps and lack of time. CONCLUSIONS: Search filters are used mainly for reducing large result sets (introducing focus) and assisting with searches focused on a single study type. Features that would help with choosing filters include making information about filters less technical, offering ratings and providing more detail about filter validation strategies and filter provenance.

Understanding care closer to home for ill children and young people.

AIM: To gather evidence to support the implementation of standard six of the National Service Framework for Children, Young People and Maternity Services (Department of Health and Department for Education and Skills 2004), which states that care should be provided as close to home as possible. METHODS: A mixed methods study comprising of a systematic review, a national survey of provision of care closer to home (CCTH), four in-depth, qualitative case studies and a cost analysis. FINDINGS: The systematic review suggests that CCTH is no less clinically effective than hospital care. Services identified by the survey fall into three distinct models of provision. Case study data show that families preferred CCTH, but staff face difficulties at organisational and practice levels. Cost analysis suggests there can be cost savings with CCTH, but several factors influence these. CONCLUSION: CCTH may be an effective and feasible option for children and young people who are ill.

Glucocorticoid replacement therapy and fibrinolysis in patients with hypopituitarism.

BACKGROUND: Hypopituitarism is associated with increased cardiovascular mortality, and it has been suggested that unphysiological glucocorticoid replacement regimens might contribute to this risk. Traditional glucocorticoid replacement regimens have often led to excessive serum cortisol levels. The hypercortisolaemia of Cushing's syndrome is associated with an increased risk of thromboembolism. OBJECTIVE: To examine whether short-term higher-dose hydrocortisone replacement regimens adversely affect the fibrinolytic system. DESIGN: Crossover study comparing tailored low-dose (LD) glucocorticoid regimen (mean, 17·5 mg hydrocortisone daily), with a traditional high-dose (HD, 30-mg hydrocortisone daily) regimen for 2 weeks. PATIENTS: Ten patients with hypopituitarism and ACTH deficiency - median (range) age, 59 (41-75) years - and 10 age- and sex-matched controls. Nine patients had growth hormone deficiency (five replaced), nine patients had TSH deficiency (nine replaced), eight had gonadotrophin deficiency (five replaced). During the study, other pituitary hormone replacement therapy remained unchanged. Patients with acromegaly and Cushing's syndrome were excluded. MEASUREMENTS: Hourly serum cortisol for 11 h, plasminogen activator inhibitor-1 (PAI-1), tissue plasminogen activator (tPA) and fibrinogen levels after 2 weeks of treatment with both LD and HD regimens. RESULTS: No overall significant differences were found between the three groups using the Kruskal-Wallis test: PAI-1: [median (range)] HD, 25 (5-53) ng/ml; LD, 21 (4-56) ng/ml; controls, 27 (8-51); P = 0·3; tPA: HD, 10 (5-15) ng/ml; LD, 10 (4-13) ng/ml; controls 10 (3-13); P = 0·46; and fibrinogen: HD, 2·5 (1·8-3·5) g/l; LD, 3·0 (2·3-4·4) g/l; controls, 2·6 (1·6-3·2): P = 0·97 In addition, no significant differences between HD and LD using Wilcoxon's paired test; PAI-1 (P = 0·91), tPAag (P = 0·47) and fibrinogen (P = 0·09). CONCLUSIONS: An increased dose of hydrocortisone for 2 weeks creates excessive glucocorticoid exposure, but does not significantly affect fibrinolytic-coagulation parameters.

Interpretation of the short Synacthen test in the presence of low cortisol-binding globulin: two case reports.

CONTEXT: Ten percent of serum total cortisol (TC) is unbound; the remainder is bound to cortisol-binding globulin (CBG) and, to a lesser extent, albumin. CBG concentrations can drop significantly, particularly in critical illness, resulting in a low TC although the free, active, cortisol may be normal or increased. In the context of a low CBG, the diagnosis of pituitary-adrenal insufficiency with measurements of TC is difficult. OBJECTIVE: To remind clinicians of the difficulty in interpreting TC when the CBG is low, the circumstances when CBG concentrations may decrease and that measurement of CBG and calculation of the free cortisol index can help in the assessment of pituitary-adrenal reserve. CASE: We present two patients at risk of primary and secondary adrenal insufficiency with a poor response to 250 microg Synacthen. In both cases we confirmed low CBG concentrations but a normal free cortisol index (FCI), confirming normal pituitary-adrenal reserve. INTERVENTION: In case one, we have been able to avoid long-term steroid replacement therapy. We continue to reduce the steroid dose in case 2 but have been limited by the need for high-dose steroid treatment for exacerbations of the patient's airways disease. CONCLUSION: The use of TC in the assessment of the hypothalamic-pituitary-adrenal (HPA) axis may give rise to misleading results if the CBG concentration is low. The FCI may be a better marker of pituitary-adrenal reserve in these subjects. Clinicians should be cautious when interpreting abnormal cortisol results and we emphasize the importance of good clinical assessment.

Hepatitis C nightmare. Interview by Charlotte Alderman.

Sustaining a needlestick injury resulted in nurse Dianne Wright contracting hepatitis C infection in 2003. Despite 24 weeks of gruelling treatment, she continued to work. A blood test taken at six weeks after the injury confirmed hepatitis C. Treatment with ribavirin and interferon lasted 24 weeks. Hepatitis C virus was undetectable half way through treatment. Viral clearing was confirmed at the end of treatment and six and 12 months later.

Failure to normalize parathyroid hormone during treatment of vitamin D deficiency in Asian patients.

OBJECTIVE: Vitamin D deficiency and osteomalacia remain commonplace within the Asian community in Bradford. The treatment of vitamin D deficiency and osteomalacia is cheap and effective, but there are few data on long-term outcomes. Studies have suggested that a minority of patients fail to normalize parathyroid hormone (PTH) levels during therapy with vitamin D. This study aimed to determine what proportion of Asian patients with vitamin D deficiency and secondary hyperparathyroidism normalize PTH levels following therapy with oral vitamin D and to examine reasons for failure to normalize PTH. DESIGN: This study examined the impact of an oral regimen of vitamin D 800 i.u. (20 micrograms) and calcium 1000 mg daily, on PTH levels within an endocrinology outpatient clinic. patients 51 (4M:47F) Asian patients, median age 39 years (range 16-77 years) with vitamin D deficiency (25-hydroxyvitamin D < 25 nmol/l) and secondary hyperparathyroidism (PTH > 5.7 pmol/l). MEASUREMENTS: All patients had at least one follow-up measurement of PTH and calcium during treatment. A subgroup of patients gave consent for examination of GP-prescribing records to indirectly asses adherence to therapy. RESULTS: PTH normalized in only 28/51 (55%) patients (group N) and failed to normalize in 23/51 (45%) patients (group F). Baseline patient characteristics including: age, basal serum 25-hydroxyvitamin D (25OHD), basal serum PTH, basal serum calcium and post treatment serum calcium, were similar in groups N and F. Mild hypercalcaemia occurred in only two (3.9%) patients. The proportion of prescriptions collected by patients in group N was 75 (17-100)% and in group F was 17 (0-100)%, P < 0.0001. CONCLUSIONS: This study has demonstrated that long-term oral treatment with vitamin D and calcium, fails to normalize PTH in a significant proportion of patients with vitamin D deficiency and osteomalacia. This is most likely related to lack of adherence to long-term treatment. Improved ways of treating this condition need to be explored.

What's the evidence that NICE guidance has been implemented? Results from a national evaluation using time series analysis, audit of patients' notes, and interviews.

OBJECTIVES: To assess the extent and pattern of implementation of guidance issued by the National Institute for Clinical Excellence (NICE). DESIGN: Interrupted time series analysis, review of case notes, survey, and interviews. SETTING: Acute and primary care trusts in England and Wales. PARTICIPANTS: All primary care prescribing, hospital pharmacies; a random sample of 20 acute trusts, 17 mental health trusts, and 21 primary care trusts; and senior clinicians and managers from five acute trusts. MAIN OUTCOME MEASURES: Rates of prescribing and use of procedures and medical devices relative to evidence based guidance. RESULTS: 6308 usable patient audit forms were returned. Implementation of NICE guidance varied by trust and by topic. Prescribing of some taxanes for cancer (P < 0.002) and orlistat for obesity (P < 0.001) significantly increased in line with guidance. Prescribing of drugs for Alzheimer's disease and prophylactic extraction of wisdom teeth showed trends consistent with, but not obviously a consequence of, the guidance. Prescribing practice often did not accord with the details of the guidance. No change was apparent in the use of hearing aids, hip prostheses, implantable cardioverter defibrillators, laparoscopic hernia repair, and laparoscopic colorectal cancer surgery after NICE guidance had been issued. CONCLUSIONS: Implementation of NICE guidance has been variable. Guidance seems more likely to be adopted when there is strong professional support, a stable and convincing evidence base, and no increased or unfunded costs, in organisations that have established good systems for tracking guidance implementation and where the professionals involved are not isolated. Guidance needs to be clear and reflect the clinical context.