Level of attendance at the English National Health Service Diabetes Prevention Programme and risk of progression to type 2 diabetes.

BACKGROUND: We evaluated the dose-response relationship between the level of attendance at the English National Health Service Diabetes Prevention Programme (DPP) and risk of progression to type 2 diabetes amongst individuals participating in the programme. METHODS: We linked data on DPP attendance for 51,803 individuals that were referred to the programme between 1st June 2016 and 31st March 2018 and attended at least one programme session, with primary care records of type 2 diabetes diagnoses from the National Diabetes Audit up to 31st March 2020. Weibull survival regressions were used to estimate the association between the number of programme sessions attended and risk of progression to type 2 diabetes. RESULTS: Risk of developing type 2 diabetes declined significantly for individuals attending seven of the 13 programme sessions and continued to decline further up to 12 sessions. Attending the full 13 sessions was associated with a 45.5% lower risk (HR: 0.545 95% CI: 0.455 to 0.652). Compared to individuals that only partially attended the programme, attendance at 60% or more of the sessions was associated with a 30.7% lower risk of type 2 diabetes (HR: 0.693 95% CI: 0.645 to 0.745). CONCLUSIONS: Reducing the risk of progression to type 2 diabetes through diabetes prevention programmes requires a minimum attendance level at seven of the 13 programme sessions (54%). Retaining participants beyond this minimum level yields further benefits in diabetes risk reduction. Commissioners may wish to consider altering provider payment schedules to incentivise higher retention levels beyond 60% of programme sessions.

Evaluating the Short-Term Costs and Benefits of a Nationwide Diabetes Prevention Programme in England: Retrospective Observational Study.

BACKGROUND: Prevention programmes typically incur short-term costs and uncertain long-term benefits. We use the National Health Service (NHS) England Diabetes Prevention Programme (NHS-DPP) to investigate whether behaviour change programmes may be cost-effective even within the short-term participation period. METHODS: We analysed 384,611 referrals between June 2016 and March 2019. We estimated NHS costs using implementation costs and provider payments. We used linear regressions to relate utility changes to the number of sessions attended, based on responses to the five-level EQ-5D (EQ-5D-5L) at baseline and final session for 18,959 participants. We then calculated the corresponding quality-adjusted life year (QALY) change for all 384,611 referrals by combining the estimated regression coefficients with the observed level of attendance, with individuals that did not attend any programme sessions being assumed to experience zero benefit. In secondary analysis, we added weight change, recorded for 18,105 participants to the regression and applied predicted values to all referrals with missing weight change values estimated using multiple imputation with chained equations. We then estimated the cost-per-QALY generated. RESULTS: Average cost per referral was £119 (standard deviation: £118; 2020 price year, UK £ Sterling). Each session attended was associated with a 0.0042 increase in utility (95% confidence interval (CI): 0.0025-0.0059). This generated 1,773 QALYs across all referrals (95% CI: 889-2,656). Cost-per-QALY was £24,929 (95% CI: £16,635-49,720) when implementation costs were excluded. Secondary analysis showed each session attended and kilogram of weight lost were associated with 0.0034 (95% CI: 0.0016-0.0051) and 0.0025 (95% CI: 0.0020-0.0031) increases in utility, respectively. These generated 1,542 QALYs, at a cost-per-QALY of £28,661 when implementation costs were excluded. CONCLUSION: Participants experienced small utility gains from session attendance and weight loss during their programme participation. These benefits alone made this low-cost behaviour change programme potentially cost-effective in the short-term.

Does recruiting patients to diabetes prevention programmes via primary care reinforce existing inequalities in care provision between general practices? A retrospective observational study.

BACKGROUND: Primary care plays a crucial role in identifying patients' needs and referring at-risk individuals to preventive services. However, well-established variations in care delivery may be replicated in this prevention activity. OBJECTIVE: To examine whether recruiting patients to the English NHS Diabetes Prevention Programme via primary care reinforces existing inequalities in care provision between practices, in terms of clinical quality, accessibility and resources. METHODS: We generated annual practice-level counts of referrals across the first 4 years of the programme (June 2016 to March 2020). These were linked to 15 indicators of practice clinical quality, access and resources measured during 2018/19. We used random effects Poisson regressions to examine associations between referrals and these indicators, controlling for practice and population characteristics, for 6871 practices in England. RESULTS: On average, practices made 3.72 referrals per 1000 population annually and rates varied substantially between practices. Referral rates were positively associated with the quality of clinical care provided. A 1 SD higher level of achievement on Quality and Outcomes Framework diabetes indicators was associated with an 11% (95% CI: 8% to 14%) higher referral rate. This positive association was consistent across all five clinical quality indicators. There was no association between referral rates and accessibility, overall payments or staffing. Associations between referrals and receiving different supplementary payments over the core contract were mixed, with 8%-11% lower referral rates for some payments but not for others. CONCLUSION: Recruiting patients to diabetes prevention programmes via primary care reinforces existing inequalities between general practices in the clinical quality of care they provide. This leaves patients registered with practices providing lower quality clinical care even more disadvantaged. Providing additional support to lower quality practices or using alternative recruitment methods may be necessary to avoid differential engagement in prevention programmes from widening these variations and potential health inequalities further.

Population level impact of the NHS Diabetes Prevention Programme on incidence of type 2 diabetes in England: An observational study.

Background: The NHS Diabetes Prevention Programme (DPP) is the first nationwide type 2 diabetes prevention programme targeting people with prediabetes. It was rolled out across England from 2016 in three waves. We evaluate the population level impact of the NHS DPP on incidence rates of type 2 diabetes. Methods: We use data from the National Diabetes Audit, which records all individuals across England who have been diagnosed with type 2 diabetes by 2019. We use difference-in-differences regression models to estimate the impact of the phased introduction of the DPP on type 2 diabetes incidence. We compare patients registered with the 3,282 general practices enrolled from 2016 (wave 1) and the 1,610 practices enrolled from 2017 (wave 2) to those registered with the 1,584 practices enrolled from 2018 (final wave). Findings: Incidence rates of type 2 diabetes in wave 1 practices in 2018 and 2019 were significantly lower than would have been expected in the absence of the DPP (difference-in-differences Incident Rate Ratio (IRR) = 0·938 (95% CI 0·905 to 0·972)). Incidence rates were also significantly lower than expected for wave 2 practices in 2019 (difference-in-differences IRR = 0·927 (95% CI 0·885 to 0·972)). These results remained consistent across several robustness checks. Interpretation: Introduction of the NHS DPP reduced population incidence of type 2 diabetes. Longer follow-up is required to explore whether these effects are maintained or if diabetes onset is delayed. Funding: This research was funded by the National Institute for Health and Care Research (Health Services and Delivery Research, 16/48/07 - Evaluating the NHS Diabetes Prevention Programme (NHS DPP): the DIPLOMA research programme (Diabetes Prevention - Long Term Multimethod Assessment)). The views and opinions expressed in this manuscript are those of the authors and do not necessarily reflect those of the NHS, the National Institute for Health and Care Research or the Department of Health and Social Care.

Unseen patterns of preventable emergency care: Emergency department visits for ambulatory care sensitive conditions.

OBJECTIVE: Admissions for ambulatory care sensitive conditions (ACSCs) are often used to measure potentially preventable emergency care. Visits to emergency departments with ACSCs may also be preventable care but are excluded from such measures if patients are not admitted. We established the extent and composition of this preventable emergency care. METHODS: We analysed 1,505,979 emergency department visits (5% of the national total) between 1 April 2015 and 31 March 2017 at six hospital Trusts in England, using International Classification of Diseases diagnostic coding. We calculated the number of visits for each ACSC and examined the proportions of these visits that did not result in admission by condition and patient characteristics. RESULTS: 11.1% of emergency department visits were for ACSCs. 55.0% of these visits did not result in hospital admission. Whilst the majority of ACSC visits were for acute rather than chronic conditions (59.4% versus 38.4%), acute visits were much more likely to conclude without admission (70.3% versus 33.4%). Younger, more deprived and ethnic minority patients were less likely to be admitted when they visited the emergency department with an ACSC. CONCLUSIONS: Over half of preventable emergency care is not captured by measures of admissions. The probability of admission at a preventable visit varies substantially between conditions and patient groups. Focussing only on admissions for ACSCs provides an incomplete and skewed picture of the types of conditions and patients receiving preventable care. Measures of preventable emergency care should include visits in addition to admissions.

Clarifying the concept of avoidable emergency department attendance.

Emergency department attendances are rising in several countries. Many of the policies aimed at reducing emergency department attendances are based on the assumption that a proportion of current utilization is 'avoidable' and therefore could be reduced. In considering how to achieve this aim, it is important to first understand the problem. In this essay, we review the literature on the concept and identification of avoidable emergency department attendances in England. We identified three areas of inconsistency surrounding avoidable emergency department attendances: the terminology, the underlying definition, and the method used to identify avoidable attendances. We offer a more nuanced definition which may better support action to reduce emergency department activity. Recognizing that there are different types of undesirable utilization which vary by underlying causes and potential solutions will aid policy makers in identifying areas where policies targeting reductions in emergency department attendances would best be directed.

How sensitive are avoidable emergency department attendances to primary care quality? Retrospective observational study.

BACKGROUND: Improvements in primary care quality are often proposed as a solution to rises in emergency department (ED) attendances. However, there is little agreement on what constitutes an avoidable attendance, and the relationship between primary care quality and ED demand remains poorly understood. OBJECTIVE: To estimate the size of the associations between primary care quality and volumes of ED attendances classified as avoidable. METHODS: Retrospective observational study of all attendances at EDs in England during 2015/2016, applying three definitions of avoidable attendance. We linked practice-level counts of attendances to seven measures of primary care access, patient experience and clinical quality for 7521 practices. We used count data regressions to associate attendance counts with levels of quality. We then calculated proportions of attendances associated with levels of primary care quality below the national average. RESULTS: Attendance volumes were negatively related to three of the seven quality measures. Incidence rate ratios (IRRs) for all attendances associated with 10 percentage-point differences in quality were 0.987 for clinical quality and 0.987 for easy telephone access and 0.978 for ability to get an appointment. These associations were relatively stronger for narrower definitions of avoidable attendances (for the narrowest definition, IRRs=0.966, 0.976 and 0.934, respectively) but represented fewer attendances in absolute terms. 341 000 (2.4%) attendances were associated with levels of primary care quality below the national average in 2015/2016. CONCLUSION: ED attendances are sensitive to primary care quality, but magnitudes of these associations are small. Attendances are much less responsive to differences in primary care quality than indicated by estimates of the prevalence of avoidable attendances. This may explain the failure of initiatives to reduce attendances through primary care improvements.

Designing and using incentives to support recruitment and retention in clinical trials: a scoping review and a checklist for design.

BACKGROUND: Recruitment and retention of participants are both critical for the success of trials, yet both remain significant problems. The use of incentives to target participants and trial staff has been proposed as one solution. The effects of incentives are complex and depend upon how they are designed, but these complexities are often overlooked. In this paper, we used a scoping review to 'map' the literature, with two aims: to develop a checklist on the design and use of incentives to support recruitment and retention in trials; and to identify key research topics for the future. METHODS: The scoping review drew on the existing economic theory of incentives and a structured review of the literature on the use of incentives in three healthcare settings: trials, pay for performance, and health behaviour change. We identified the design issues that need to be considered when introducing an incentive scheme to improve recruitment and retention in trials. We then reviewed both the theoretical and empirical evidence relating to each of these design issues. We synthesised the findings into a checklist to guide the design of interventions using incentives. RESULTS: The issues to consider when designing an incentive system were summarised into an eight-question checklist. The checklist covers: the current incentives and barriers operating in the system; who the incentive should be directed towards; what the incentive should be linked to; the form of incentive; the incentive size; the structure of the incentive system; the timing and frequency of incentive payouts; and the potential unintended consequences. We concluded the section on each design aspect by highlighting the gaps in the current evidence base. CONCLUSIONS: Our findings highlight how complex the design of incentive systems can be, and how crucial each design choice is to overall effectiveness. The most appropriate design choice will differ according to context, and we have aimed to provide context-specific advice. Whilst all design issues warrant further research, evidence is most needed on incentives directed at recruiters, optimal incentive size, and testing of different incentive structures, particularly exploring repeat arrangements with recruiters.

How do hospitals respond to price changes in emergency departments?

Little is known about how prospective provider payment affects the provision of services led by unpredictable demand. We investigate hospital responses to a 32% increase in price for two treatments in emergency departments in England in April 2011 using data on 11,532,304 attendances (79 hospitals) between 2009/2010 and 2013/2014. We compare changes in the volumes of these two treatments to a treatment not attracting additional reimbursement using a difference-in-differences framework. Additional reimbursement led to 76% and 152% increases in the volumes of the two incentivised treatments. Hospitals received an additional £64.4 M between April 2011 and March 2014 for providing these treatments, of which 40% (£25.9 M) was attributable to the unanticipated hospital response to the price increase. We use time in treatment to distinguish real increases in treatment from reductions in undercoding or increases in upcoding. The association between the recorded receipt of these treatments and time spent in treatment was the same before and after the price increase, and there was no association between hospital-specific increases in recorded treatment volumes and changes in treatment times. The persistence of the treatment time increment suggests the increase in recorded treatment was a real increase in provision of treatments.

Is telephone health coaching a useful population health strategy for supporting older people with multimorbidity? An evaluation of reach, effectiveness and cost-effectiveness using a 'trial within a cohort'.

BACKGROUND: Innovative ways of delivering care are needed to improve outcomes for older people with multimorbidity. Health coaching involves 'a regular series of phone calls between patient and health professional to provide support and encouragement to promote healthy behaviours'. This intervention is promising, but evidence is insufficient to support a wider role in multimorbidity care. We evaluated health coaching in older people with multimorbidity. METHODS: We used the innovative 'Trials within Cohorts' design. A cohort was recruited, and a trial was conducted using a 'patient-centred' consent model. A randomly selected group within the cohort were offered the intervention and were analysed as the intervention group whether they accepted the offer or not. The intervention sought to improve the skills of patients with multimorbidity to deal with a range of long-term conditions, through health coaching, social prescribing and low-intensity support for low mood. RESULTS: We recruited 4377 older people, and 1306 met the eligibility criteria (two or more long-term conditions and moderate 'patient activation'). We selected 504 for health coaching, and 41% consented. More than 80% of consenters received the defined 'dose' of 4+ sessions. In an intention-to-treat analysis, those selected for health coaching did not improve on any outcome (patient activation, quality of life, depression or self-care) compared to usual care. We examined health care utilisation using hospital administrative and self-report data. Patients selected for health coaching demonstrated lower levels of emergency care use, but an increase in the use of planned services and higher overall costs, as well as a quality-adjusted life year (QALY) gain. The incremental cost per QALY was £8049, with a 70-79% probability of being cost-effective at conventional levels of willingness to pay. CONCLUSIONS: Health coaching did not lead to significant benefits on the primary measures of patient-reported outcome. This is likely related to relatively low levels of uptake amongst those selected for the intervention. Demonstrating effectiveness in this design is challenging, as it estimates the effect of being selected for treatment, regardless of whether treatment is adopted. We argue that the treatment effect estimated is appropriate for health coaching, a proactive model relevant to many patients in the community, not just those seeking care. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ( ISRCTN12286422 ).