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<?xml version="1.0" encoding="UTF-8"?><rss version="2.0" xmlns:content="http://purl.org/rss/1.0/modules/content/" xmlns:wfw="http://wellformedweb.org/CommentAPI/" xmlns:dc="http://purl.org/dc/elements/1.1/" xmlns:atom="http://www.w3.org/2005/Atom" xmlns:sy="http://purl.org/rss/1.0/modules/syndication/" xmlns:slash="http://purl.org/rss/1.0/modules/slash/" > <channel> <title>NIHR Evidence</title> <atom:link href="https://evidence.nihr.ac.uk/feed/" rel="self" type="application/rss+xml" /> <link>https://evidence.nihr.ac.uk/</link> <description>Informative and accessible health and care research</description> <lastBuildDate>Mon, 24 Mar 2025 14:02:56 +0000</lastBuildDate> <language>en-GB</language> <sy:updatePeriod> hourly </sy:updatePeriod> <sy:updateFrequency> 1 </sy:updateFrequency> <generator>https://wordpress.org/?v=6.7.2</generator> <item> <title>Prostate cancer research: what's next?</title> <link>https://evidence.nihr.ac.uk/collection/prostate-cancer-research-whats-next/</link> <dc:creator><![CDATA[Martha Powell]]></dc:creator> <pubDate>Tue, 25 Mar 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=66163</guid> <description><![CDATA[Prostate cancer is the most common cancer in men, with more than 55,000 new cases each year in the UK. Most men with localised cancer (confined to the prostate) are likely to live for a long time.  Treatment options for localised cancer are based on how likely the cancer is to spread beyond the prostate. ...]]></description> <content:encoded><![CDATA[ Prostate cancer is the most common cancer in men, with <a href="https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/incidence#heading-Zero" target="_blank" rel="noreferrer noopener">more than 55,000 new cases each year</a> in the UK. Most men with localised cancer (<a href="https://prostatecanceruk.org/prostate-information-and-support/just-diagnosed/localised-prostate-cancer" target="_blank" rel="noreferrer noopener">confined to the prostate</a>) are likely to live for a long time.  Treatment options for localised cancer are based on how likely the cancer is to spread beyond the prostate. Based on the available evidence including findings from the <a href="https://www.nejm.org/doi/10.1056/NEJMoa1606220?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200www.ncbi.nlm.nih.gov" target="_blank" rel="noreferrer noopener">landmark NIHR trial</a>, <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa1606221" target="_blank" rel="noreferrer noopener">ProtecT</a>, guidelines from the <a href="https://www.nice.org.uk/guidance/ng131" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE)</a> recommend offering men with lower risk localised cancer active surveillance, surgery or radiotherapy. Active surveillance means closely monitoring prostate cancer, rather than treating it straight away. Men with a higher risk that their cancer will spread beyond the prostate are recommended surgery or radiotherapy. But more can be done to optimise treatment for the future. In March 2025, an NIHR Evidence webinar brought together 3 large, ongoing NIHR randomised controlled trials that could improve prostate cancer care. All involve men with localised cancer, but with different levels of risk of their cancer spreading beyond the prostate: <ul class="wp-block-list"> <li>The <a href="https://fundingawards.nihr.ac.uk/award/NIHR152027" target="_blank" rel="noreferrer noopener">ATLAS trial </a>is looking at whether regular MRI scans improve active surveillance in low to medium risk prostate cancer compared to standard care</li> <li>The <a href="https://fundingawards.nihr.ac.uk/award/17/150/01" target="_blank" rel="noreferrer noopener">PART trial </a>is examining whether treating only the part of the prostate containing the cancer is as effective as treating the whole prostate, and has fewer side effects, for medium risk prostate cancer</li> <li>The <a href="https://fundingawards.nihr.ac.uk/award/NIHR152686" target="_blank" rel="noreferrer noopener">ELIPSE trial</a> is looking at whether to remove lymph nodes, as well as the whole prostate, during surgery for high risk prostate cancer.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="could-regular-mri-scans-improve-active-surveillance-for-low-to-medium-risk-prostate-cancer">Could regular MRI scans improve active surveillance for low to medium risk prostate cancer?</h2> <a href="https://www.sciencedirect.com/science/article/pii/S2588931124001767#b0025" target="_blank" rel="noreferrer noopener">Increasing numbers of men</a> with low and certain types of medium risk localised prostate cancer are choosing active surveillance rather than treatment. This is because these cancers grow slowly, or not at all, and treatments can cause side-effects. However, if the cancer does progress, it may be <a href="https://prostatecanceruk.org/prostate-information-and-support/treatments/active-surveillance#differences-between-active-surveillance-and-watchful-waiting" target="_blank" rel="noreferrer noopener">noticed late</a>.  Active surveillance involves regular tests. Currently, <a href="https://www.nice.org.uk/guidance/ng131/chapter/Recommendations#localised-and-locally-advanced-prostate-cancer" target="_blank" rel="noreferrer noopener">NICE</a> recommends prostate specific antigen (PSA) blood tests every 3-6 months and a rectal exam every 12 months. A magnetic resonance imaging (MRI) scan is recommended 12 to 18 months after starting active surveillance if an MRI scan was not done before the first biopsy, or where there is concern about clinical or PSA change. There is <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC7443696/" target="_blank" rel="noreferrer noopener">some evidence</a> that regular MRI scans could improve active surveillance, but a definitive clinical trial is needed. At the webinar, Archana Gopalakrishnan, a clinical research fellow in urology at Imperial College London, presented the <a href="https://fundingawards.nihr.ac.uk/award/NIHR152027" target="_blank" rel="noreferrer noopener">ATLAS (Approaches To Long-Term Active Surveillance) trial</a>. The trial is exploring whether the addition of regular MRI scans improves on current standard care at detecting progression of prostate cancer. The trial includes men on active surveillance for low to medium risk prostate cancer.  <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe title="Could regular MRI scans improve active surveillance for low to medium risk prostate cancer?" width="1200" height="675" src="https://www.youtube.com/embed/dS7FDU25MHo?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> <h2 class="wp-block-heading" class="wp-block-heading" id="is-limiting-treatment-to-the-part-of-the-prostate-containing-cancer-as-effective-as-treating-the-whole-prostate-for-medium-risk-cancer">Is limiting treatment to the part of the prostate containing cancer as effective as treating the whole prostate for medium risk cancer?</h2> Treating the whole prostate with surgery or radiotherapy (radical treatment) is effective, but can result in urinary, bowel, and sexual <a href="https://www.nice.org.uk/guidance/ng131/chapter/recommendations" target="_blank" rel="noreferrer noopener">side effects</a>. Some men have cancer on one side of the prostate and new technologies make it possible to treat part of the prostate only (<a href="https://www.ncbi.nlm.nih.gov/books/NBK526326/" target="_blank" rel="noreferrer noopener">partial ablation</a>). Partial ablation may reduce side effects compared to radical treatment, but a trial is needed to ensure it is safe and effective. At the webinar, Richard Bryant, Associate Professor of Urology and Clinical Lead for Urology at Oxford University Hospitals NHS Foundation Trust presented the <a href="https://fundingawards.nihr.ac.uk/award/17/150/01" target="_blank" rel="noreferrer noopener">PART trial (A randomised controlled trial of Partial prostate Ablation versus Radical Treatment)</a>, which is comparing the effectiveness of the two treatment options for men with medium risk prostate cancer. The findings will provide evidence on the treatments’ comparative benefits and risks to help inform decision-making. <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe title="Is treating part of the prostate as effective as treating the whole prostate for medium risk cancer?" width="1200" height="675" src="https://www.youtube.com/embed/0yf06XcgCdM?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> <h2 class="wp-block-heading" class="wp-block-heading" id="does-removing-lymph-nodes-at-the-same-time-as-surgery-to-remove-the-prostate-improve-outcomes-for-localised-high-risk-prostate-cancer">Does removing lymph nodes at the same time as surgery to remove the prostate improve outcomes for localised high-risk prostate cancer?</h2> Surgery to remove the whole prostate (radical prostatectomy) is <a href="https://www.nice.org.uk/guidance/ng131/chapter/Recommendations#localised-and-locally-advanced-prostate-cancer" target="_blank" rel="noreferrer noopener">recommended</a> for people with localised cancer at high risk of spreading beyond the prostate. Some surgeons believe that removing the lymph nodes from the pelvis during surgery can reduce the risk of the cancer returning, but <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC8407534/" target="_blank" rel="noreferrer noopener">research is limited</a>. Further, removing these lymph nodes can lead to <a href="https://prostatecanceruk.org/prostate-information-and-support/treatments/surgery" target="_blank" rel="noreferrer noopener">complications</a>, such as swelling in the scrotum, and in one or both legs, which can be painful and limit mobility.  At the webinar, Krishna Narahari, a consultant urologist at the University Hospital of Wales described the <a href="https://fundingawards.nihr.ac.uk/award/NIHR152686" target="_blank" rel="noreferrer noopener">ELIPSE Study (a randomised controlled trial comparing the clinical and cost-effectiveness of lymph node removal in patients undergoing curative surgery for localised high-risk prostate cancer)</a>. The trial is comparing lymph node removal to no lymph node removal in people with localised high-risk prostate cancer undergoing radical prostatectomy. The findings will help men with prostate cancer and their surgeons make informed decisions about their care. <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe title="Is lymph node removal effective in people having curative surgery for high-risk prostate cancer?" width="1200" height="675" src="https://www.youtube.com/embed/0ZbvJNAnoSU?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> <hr class="wp-block-separator has-alpha-channel-opacity"/> How to cite this Collection: NIHR Evidence; Prostate cancer research: what's next?; March 2025; doi: Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Population-level policies on risk factors for dementia could reduce costs</title> <link>https://evidence.nihr.ac.uk/alert/population-level-policies-on-risk-factors-for-dementia-could-reduce-costs/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 20 Mar 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=66091</guid> <description><![CDATA[Population-level interventions that target risk factors for dementia (such as high blood pressure, smoking and obesity) save money and give people extra years in good health, a modelling study found. They include, for example, legislation to reduce salt and sugar in food, or introduce low emission zones. These interventions reduce individual responsibility for lifestyle changes ...]]></description> <content:encoded><![CDATA[ Population-level interventions that target risk factors for dementia (such as high blood pressure, smoking and obesity) save money and give people extra years in good health, a modelling study found. They include, for example, legislation to reduce salt and sugar in food, or introduce low emission zones. These interventions reduce individual responsibility for lifestyle changes and benefit all sectors of society. Given the likely increase in the number of people with dementia as our population ages, the benefits of these population-level policies could outweigh their costs. The researchers hope their findings will encourage policymakers to implement population-level interventions. <a href="https://www.nhs.uk/conditions/dementia/" target="_blank" rel="noreferrer noopener">More information about dementia can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-can-population-level-policies-on-dementia-risk-factors-save-money">The issue: Can population-level policies on dementia risk factors save money?</h2> More than <a href="https://www.nhs.uk/conditions/dementia/about-dementia/what-is-dementia/" target="_blank" rel="noreferrer noopener">944,000 people in the UK are living with dementia</a>; the NHS estimates that by 2030 this will rise to more than 1 million. The total <a href="https://www.alzheimers.org.uk/blog/how-much-does-dementia-care-cost" target="_blank" rel="noreferrer noopener">cost of dementia in the UK is £42 billion</a>; most (63%) is shouldered by people with dementia and their families. <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01296-0/abstract" target="_blank" rel="noreferrer noopener">A recent Lancet report</a> states that high blood pressure, smoking and other risk factors account for up to 45% of dementia diagnoses worldwide. Action to reduce these risks might therefore delay or prevent dementia in many people. Individual-level interventions (dietary advice and help to stop smoking, for instance) are effective, but they tend to bring most benefit to people at lowest risk (such as those with better education or more resources). Population-level approaches (reducing the salt in the food we buy, for instance, or increasing the price of cigarettes) might be more effective than individual interventions across the whole population. In this study, researchers modelled the likely costs and impact of population-level approaches to reduce risk factors for dementia. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers analysed the impact of population-level policies (on salt, sugar, tobacco, and so on) that had not been introduced in England (or were in place but could be extended). The policies aim to reduce risk factors for dementia such as high blood pressure, heavy drinking, air pollution and obesity. Previous research had explored the impact of these risk factors on dementia. Researchers also had data on the effectiveness of each intervention at reducing a risk factor. They brought the evidence together to estimate how many extra years in good health (quality-adjusted life-years or QALYs) people would have if a population-level approach was introduced. They calculated the combined cost savings of reducing dementia risk factors over the course of an individual’s life (for the NHS, social care and informal care, in 2021 prices) and then extrapolated to the overall benefit over future generations. They estimate that: <ul class="wp-block-list"> <li>reduced salt in food could give 39,433 quality-adjusted life-years (equivalent to 39,433 people each having an additional year of good health) and save £2.4 billion</li> <li>reduced sugar in food could give 17,985 quality-adjusted life-years and save £1 billion</li> <li>low emission zones in English cities with populations of 100,000 or more could give 5119 quality-adjusted life-years and save £260 million</li> <li>minimum alcohol unit pricing could give 4767 extra years in good health and save £280 million </li> <li>a 10% increase in cigarette prices could give 2277 quality-adjusted life-years and save £157 million</li> <li>compulsory bike helmets for children aged 5 to 18 years could give 1554 quality-adjusted life-years and save £91 million.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> All population-level approaches in this analysis improved health and led to savings for the NHS, social care and informal care. Legislation to reduce salt and sugar in processed food led to the biggest increase in years of good health, and the greatest savings. Some risk factors for dementia (high blood pressure, obesity and diabetes) are expected to increase in the next few decades as the population ages. Population-level approaches address the risk factors, without placing the responsibility for behaviour change solely on individuals. The potential benefits could outweigh the initial costs of implementing such policies. Dementia prevention is not usually part of the evaluation of population-level interventions. This study shows that including dementia prevention would probably increase the estimated benefits of interventions. The findings are in line with a <a href="https://www.thelancet.com/article/S2468-2667(20)30116-X/fulltext" target="_blank" rel="noreferrer noopener">New Zealand study</a> that found that food taxes led to health gains and cost-savings. The study relied on observational data from previous research to estimate the impact of the policy approaches to reduce dementia. The evidence used was good quality, but observational studies do not directly prove that the interventions themselves cause the reduction in dementia. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> Further research could confirm how much each factor increases dementia risk in the UK, since the estimates used in this study were drawn from international research. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Mukadam N, and others. <a href="https://doi.org/10.1016/S2666-7568(24)00117-X" target="_blank" rel="noreferrer noopener">Benefits of population-level interventions for dementia risk factors: an economic modelling study for England</a>. The Lancet Health Longevity 2024; 5: 100611. A press release from NIHR about the study. <a href="https://www.nihr.ac.uk/news/public-health-measures-to-reduce-dementia-risk-could-save-up-to-4-billion/36441" target="_blank" rel="noreferrer noopener">Public health measures to reduce dementia risk could save up to £4 billion</a>. August 2024. An article about the impact of hearing loss on dementia risk. Munro KJ, Dawes P. <a href="https://www.entandaudiologynews.com/features/audiology-features/post/commentary-dementia-hearing-loss-and-the-danger-of-professional-rabbit-holes" target="_blank" rel="noreferrer noopener">Commentary: dementia, hearing loss, and the danger of professional rabbit holes</a>. ENT & Audiology News. September 2024. Funding: This study was funded by the <a href="https://www.sscr.nihr.ac.uk/dementia-research-programme/" target="_blank" rel="noreferrer noopener">NIHR Three Schools’ Dementia Research Programme</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1016/S2666-7568(24)00117-X" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Hospital at home and virtual wards: What works?</title> <link>https://evidence.nihr.ac.uk/collection/hospital-at-home-and-virtual-wards-what-works/</link> <dc:creator><![CDATA[lauren.hoskin@nihr.ac.uk]]></dc:creator> <pubDate>Tue, 18 Mar 2025 10:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=66133</guid> <description><![CDATA[Hospital at home and virtual wards provide safe alternatives to hospital care in the community. There is considerable variation in how they are operationalised at a local level. In general, their common feature is to provide healthcare in people’s homes through a multidisciplinary clinical team. Care is delivered both remotely and face to face. They ...]]></description> <content:encoded><![CDATA[ Hospital at home and virtual wards provide safe alternatives to hospital care in the community. There is considerable variation in how they are operationalised at a local level. In general, their common feature is to provide healthcare in people’s homes through a multidisciplinary clinical team. Care is delivered both remotely and face to face. They aim to help avoid admission as well as facilitate rapid discharge. The models vary in terms of who leads the service; the hours of operation; the staffing model; the conditions they support; the length of support; how technology is used; and how patients and professionals access the service. In March 2025, NIHR Evidence held a webinar showcasing research on 2 home-based alternatives to hospital care from 3 evidence reviews: admission avoidance hospital at home and virtual wards for people with frailty. Definitions for these models can vary, but for the purposes of this webinar, we have used the following definitions. <ol class="wp-block-list"> <li>Admission avoidance hospital at home - active treatment by healthcare professionals in the patient's home for a condition that would otherwise require acute hospital inpatient care, and always for a limited time period.  </li> <li>Virtual wards for people with frailty - care is provided to the patient in their own home; a multidisciplinary team makes decisions and plans care remotely from the patient and provides oversight of care.</li> </ol> The webinar addressed: <ul class="wp-block-list"> <li>the key elements of hospital at home and virtual wards</li> <li>their impact on outcomes</li> <li>their impact on service costs</li> <li>factors that contribute to their success.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="background">Background</h2> An ageing population, with increasing numbers of people living with frailty, are placing growing demands on hospital services. A 2022 Health Foundation projection suggested that based on current trends England could need between <a href="https://www.health.org.uk/sites/default/files/upload/publications/2022/Final_Beds_analysis_July2022.pdf" target="_blank" rel="noreferrer noopener">23,000 - 39,000 additional hospital beds by 2030/31</a>. On <a href="https://www.england.nhs.uk/nhsimpact/resources-and-materials/integrated-urgent-and-emergency-care-improvement/expanding-care-outside-hospital/#:~:text=expanding%20virtual%20wards.-,Expanding%20and%20better%20joining%20up%20new%20types%20of%20care%20outside,of%20community%20mental%20health%20services." target="_blank" rel="noreferrer noopener">current estimates</a> 1 in 5 emergency hospital admissions are avoidable. <a href="https://www.nuffieldtrust.org.uk/resource/delayed-discharges-from-hospital" target="_blank" rel="noreferrer noopener">The number of people who faced discharge delays increased by 43% between 2021 and 2024</a>, reaching a peak of 14,096 people per day in January 2024. Aside from the inappropriate use of hospital resources, there are compelling reasons to reduce the reliance on hospitals from a patient’s perspective. A long hospital stay can reduce someone’s independence and trigger a move from home to long-term supported care with associated emotional and financial cost. This is particularly true for <a href="https://www.nice.org.uk/about/what-we-do/into-practice/measuring-the-use-of-nice-guidance/impact-of-our-guidance/niceimpact-dementia/ch3-hospital-care" target="_blank" rel="noreferrer noopener">vulnerable people, such as the growing number of people with dementia</a>. Shifting care from hospital to the community is <a href="https://www.gov.uk/government/news/government-issues-rallying-cry-to-the-nation-to-help-fix-nhs#:~:text=The%20public%20engagement%20exercise%20will,sickness%20to%20prevention" target="_blank" rel="noreferrer noopener">core to the government’s ambition</a> to build a health and social care system fit for the future. The success of home based alternatives to hospital care will be key to the achievement of this ambition. <h2 class="wp-block-heading" class="wp-block-heading" id="hospital-at-home-outcomes-costs-and-factors-for-success">Hospital at home: outcomes, costs and factors for success</h2> The first presentation was delivered by Sasha Shepperd, Professor of Health Services Research, University of Oxford and Graham Ellis, Professor at Glasgow Caledonian Universities, geriatrician, and Deputy Chief Medical Officer for Scotland. Their talk focused on hospital at home, including effectiveness, costs and factors for success. It drew upon findings from <a href="https://www.journalslibrary.nihr.ac.uk/hsdr/HTAF1569" target="_blank" rel="noreferrer noopener">a randomised trial of hospital at home versus hospital admission</a> and 2 Cochrane evidence reviews authored by Sasha Shepperd: <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD007491.pub3/full" target="_blank" rel="noreferrer noopener">Admission avoidance hospital at home</a> and <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD014765.pub2/full?highlightAbstract=hospital%7Chospit%7Chome" target="_blank" rel="noreferrer noopener">Factors influencing the implementation of hospital at home</a>. <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe loading="lazy" title="Hospital at home: outcomes, costs and factors for success" width="1200" height="675" src="https://www.youtube.com/embed/QnM8UjJkMOQ?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> The findings from the Cochrane reviews showed that there was no difference in the number of deaths after 6 months, or readmissions to hospital 3 to 12 months after being admitted to hospital at home or a hospital. Patient satisfaction was higher for hospital at home and treatment costs and the number of people in residential care after 6 months were lower compared to hospital care. Research indicated that maintaining routines at home facilitated faster recovery. Key factors to support successful implementation included: having staff with acute care experience; effective teamwork and task sharing; and time-limited services. <h2 class="wp-block-heading" class="wp-block-heading" id="virtual-wards-for-people-with-frailty">Virtual wards for people with frailty</h2> Around 10% of people aged over 65 live with frailty. This figure rises to between 25 to 50% for those aged over 85. <a href="https://www.ageuk.org.uk/our-impact/policy-research/frailty-in-older-people/understanding-frailty/" target="_blank" rel="noreferrer noopener">People with frailty lose their in-built reserves and their health becomes increasingly vulnerable to events such as an infection or change in medication or environment</a>. Discharging people with frailty from hospital and managing people with frailty at home who are acutely unwell can be a challenge. Maggie Westby, Senior Research Associate, NIHR Applied Research Collaboration West, presented findings from <a href="https://academic.oup.com/ageing/article/53/3/afae039/7625490" target="_blank" rel="noreferrer noopener">a rapid realist review on virtual wards for people with frailty</a>. <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe loading="lazy" title="Virtual wards for people with frailty: a realist review" width="1200" height="675" src="https://www.youtube.com/embed/1cJpvjPfkII?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> The review informed a <a href="https://bristol.ac.uk/policybristol/policy-briefings/virtual-wards-frailty/" target="_blank" rel="noreferrer noopener">policy brief</a> for commissioners, which made recommendations for virtual wards for people with frailty. These included: <ul class="wp-block-list"> <li>virtual wards require 5 building blocks – common standards agreements, information sharing, appropriate multidisciplinary team composition, multidisciplinary meetings ('virtual ward rounds'), and a virtual ward coordinator</li> <li>virtual wards enabling the delivery of frailty management</li> <li>ensure patient and carer involvement and empowerment, such as communication via a known point of contact and shared decision making</li> <li>motivate professionals to work together – a ‘team-of-teams’ providing mutual support, trusting in shared goals, and reciprocal learning through team meetings</li> <li>work with primary care and integrated neighbourhood teams on a whole-system approach – provide reactive care to those experiencing a frailty crisis as well as proactive care to those at high risk of a crisis and ensure continuity of proactive care after discharge.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="conclusion">Conclusion</h2> The webinar concluded with the researchers’ priorities for home-based alternatives to hospital care. These included: <ul class="wp-block-list"> <li>ensuring staff are properly trained and work effectively as a team</li> <li>supporting family members and carers to care for their loved one at home - these individuals are often not in full health themselves</li> <li>locating virtual wards within a whole system approach to frailty management, with proactive care to prevent frailty crises.</li> </ul> <hr class="wp-block-separator has-alpha-channel-opacity"/> How to cite this Collection: NIHR Evidence; Hospital at home and virtual wards: What works?; March 2025; doi: 10.3310/nihrevidence_66104 Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Culturally-adapted therapy improved postnatal depression in British South Asian women</title> <link>https://evidence.nihr.ac.uk/alert/culturally-adapted-therapy-improved-postnatal-depression-in-british-south-asian-women/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 13 Mar 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=66043</guid> <description><![CDATA[Cognitive behavioural therapy (CBT) is recommended for women with postnatal depression. But there is limited evidence for the effectiveness of this talking therapy in minority ethnic groups. Researchers developed culturally-adapted therapy. They found that it helped British women from South Asian backgrounds (Pakistani, Indian, Bangladeshi and Sri Lankan) to recover from postnatal depression faster than ...]]></description> <content:encoded><![CDATA[ Cognitive behavioural therapy (CBT) is recommended for women with postnatal depression. But there is limited evidence for the effectiveness of this talking therapy in minority ethnic groups. Researchers developed culturally-adapted therapy. They found that it helped British women from South Asian backgrounds (Pakistani, Indian, Bangladeshi and Sri Lankan) to recover from postnatal depression faster than usual care alone. The researchers hope their findings will encourage further development and commissioning of culturally-adapted CBT for postnatal depression. <a href="https://www.nhs.uk/mental-health/conditions/post-natal-depression/overview/" target="_blank" rel="noreferrer noopener">More information about postnatal depression can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-is-standard-therapy-for-postnatal-depression-suitable-for-everyone">The issue: is standard therapy for postnatal depression suitable for everyone?</h2> More than 1 in 10 women experience postnatal depression (depression within a year of giving birth, usually starting in the few weeks after birth). <a href="https://assets.publishing.service.gov.uk/media/605c5e61d3bf7f2f0d94183a/The_best_start_for_life_a_vision_for_the_1_001_critical_days.pdf" target="_blank" rel="noreferrer noopener">A child’s first years (conception to age 2)</a> provide the foundation for a healthy life. Untreated postnatal depression is linked with <a href="https://core.ac.uk/reader/35437734?utm_source=linkout" target="_blank" rel="noreferrer noopener">childhood difficulties</a> (for example, reduced growth, and intellectual, social and emotional development and behavioural problems). Postnatal depression is estimated to cost around £75,000 per mother and child over the course of their lifetime (2012/2013 prices) through poor mental health, loss of productivity and unpaid care. Most costs (£53,000; 70%) are for the child. The <a href="https://www.nice.org.uk/guidance/cg192" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence</a> (NICE) recommends cognitive behavioural therapy (CBT) for women with postnatal depression who typically have persistent symptoms that impact daily life (such as sadness, low energy, loss of interest in daily activities). However, fewer than half the women with these symptoms seek or access treatment. People from British ethnic minorities are less likely than others to engage with NHS talking therapies. Further, there is little evidence to show the effectiveness and acceptability of standard CBT among minority ethnic groups. Stigma, language and cultural barriers can be barriers to both diagnosis and treatment. Researchers adapted group CBT for British women of South Asian backgrounds. Their <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC6350293/" target="_blank" rel="noreferrer noopener">Positive Health Programme</a> provides education about depression, tailored for women from a British South Asian background. It addresses issues such as a lack of confidence, alongside the positive role of religion and spirituality in mental health. The programme was delivered by NHS researchers with backgrounds in psychology but little experience of delivering psychological therapies. The study compared the impact of this programme with usual care among women from South Asian backgrounds. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Researchers invited 732 British South Asian women with infants younger than 1 year to take part in the study. About half (55%) were Pakistani, others were Indian (24%), Bangladeshi (18%) or Sri Lankan (3%). On average, they were 32 years old with a 24-week-old baby on entry to the study. The study was carried out between 2017 and 2020 in 5 UK centres (including GP surgeries and community settings). All women received usual care (which included GP care, referral to talking therapies and antidepressant medication as needed). Half the women (368) were assigned by chance to receive the adapted therapy in addition. The adapted therapy was given as 12 group sessions in 4 months. Each session lasted 60-90 minutes and was delivered in the languages participants preferred. Researchers assessed depression (using the <a href="https://en.wikipedia.org/wiki/Hamilton_Rating_Scale_for_Depression" target="_blank" rel="noreferrer noopener">Hamilton Depression Rating Scale</a>) at the start of the study, at 4 months and at 12 months. The main outcome was recovery from depression at 4 months. Group sessions were delivered in person in community venues, and online during the COVID-19 pandemic. Overall, at 4 months, from 562 responses, more women in the adapted therapy group (49%) had recovered from depression than in the usual care group (37%). The researchers accounted for depression score at the beginning of the study, number of other children and education level. After these adjustments, women in the adapted therapy group were almost twice as likely to have recovered as those in the usual care group. At 12 months, women in both groups were similarly likely to have recovered from depression (54% for both groups). Women who received the adapted therapy showed significant improvement over usual care in the participants’ sense of parenting competence at 12 months, but not at 4 months. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> Among women from British South Asian backgrounds, culturally-adapted group therapy could lead to faster recovery from postnatal depression, compared with usual care. This could protect mothers and their children from subsequent problems, and in turn reduce the future societal costs linked with postnatal depression. The intervention does not address domestic violence and abuse; interviews found this to be a major cause of postnatal depression. The researchers suggest that further research into interventions for postnatal depression incorporates strategies to tackle domestic violence and abuse.   The findings might not be generalisable to other minority ethnic groups, the researchers caution. <h2 class="wp-block-heading" class="wp-block-heading" id="how-was-the-study-carried-out">How was the study carried out?</h2> The researchers’ <a href="https://issbd.org/wp-content/uploads/2022/12/ISSBD_newsletter_20-1.pdf" target="_blank" rel="noreferrer noopener">strategies</a> for gathering participants included: <ul class="wp-block-list"> <li>community engagement; researchers attended community children’s groups, sought to involve faith leaders and participants’ families and arranged regular drop-in sessions over tea that were open to the community</li> <li>use of relevant languages (such as Urdu or Bengali; participants were asked what language they would prefer for group sessions)</li> <li>staff training in cultural competence, including ethical considerations</li> <li>appropriate use of social media</li> <li>full ethical approval that was obtained through the usual process and adapted to ensure respect for participants’ cultural background (for example, some participants wanted family engagement and consent to be a shared decision to respect the cultural household dynamics).</li> </ul> Senior CBT therapists provided appropriate training and supervision to ensure the safety of participants and session facilitators. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> Further research could explore strategies for scale-up and consider how to sustain the treatment benefit. The researchers are trialling a brief version of the programme (4 sessions only) which could offer a cost-effective alternative; this study indicated that 4 sessions could be helpful. The team is also planning to test a fully remote version. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Husain N, and others. <a href="https://doi.org/10.1016/S0140-6736(24)01612-X" target="_blank" rel="noreferrer noopener">Efficacy of a culturally adapted, cognitive behavioural therapy-based intervention for postnatal depression in British south Asian women (ROSHNI-2): a multicentre, randomised controlled trial.</a> Lancet 2024; 404: 1430 – 1443. Press release from the University of Nottingham: <a href="https://www.nottingham.ac.uk/news/study-on-british-south-asian-maternal-health" target="_blank" rel="noreferrer noopener">https://www.nottingham.ac.uk/news/study-on-british-south-asian-maternal-health</a> Further detail about the programme: Husain N, and others. <a href="https://www.sciencedirect.com/science/article/pii/S0001691823001506?via%3Dihub" target="_blank" rel="noreferrer noopener">Exploratory RCT of a group psychological intervention for postnatal depression in British mothers of South Asian origin - ROSHNI-D</a>. Acta Psychologica 2023; 238: 103974. Funding: This study was funded by the <a href="https://www.nihr.ac.uk/research-funding/funding-programmes/health-technology-assessment" target="_blank" rel="noreferrer noopener">NIHR Health Technology Assessment</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1016/S0140-6736(24)01612-X" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Vaping is linked with breathing issues in young people</title> <link>https://evidence.nihr.ac.uk/alert/vaping-is-linked-with-breathing-issues-in-young-people/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 11 Mar 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65921</guid> <description><![CDATA[Vaping is increasingly common among young people. It is less harmful than smoking, but not without risk, particularly for people who have never smoked. Researchers surveyed 39,214 young people and found that: More information on quitting smoking and vaping can be found on the NHS website. The issue: is vaping harmful for young people? It ...]]></description> <content:encoded><![CDATA[ Vaping is increasingly common among young people. It is less harmful than smoking, but not without risk, particularly for people who have never smoked. Researchers surveyed 39,214 young people and found that: <ul class="wp-block-list"> <li>those who vaped were more likely to have breathing issues than those who did not</li> <li>the more they vaped, the higher their chance of breathing issues.</li> </ul> <a href="https://www.nhs.uk/better-health/quit-smoking/" target="_blank" rel="noreferrer noopener">More information on quitting smoking and vaping can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-is-vaping-harmful-for-young-people">The issue: is vaping harmful for young people?</h2> It is unclear whether vaping itself, or specific vape flavours, devices, or vape liquids are linked with breathing issues. This study explored these potential links in young people.    <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Researchers surveyed 39,214 young people (aged 16 to 19) from the US, Canada, and England about vaping and smoking. Surveys were carried out in 2020 and 2021 as part of the <a href="https://itcproject.org/" target="_blank" rel="noreferrer noopener">International Tobacco Control Policy Evaluation Project</a>. Young people with asthma were excluded from the analysis. Half the participants were male (52%), most (65%) were white, and almost a quarter (23%) came from a deprived background. Most had never vaped (64%) nor smoked (70%). Few vaped regularly (10% vaped at least once in the past 30 days) or were former vape users (6%). Several (20%) had experimented with vaping (up to 10 times).     The researchers asked young people if they had breathing issues (breathlessness, wheezing, chest pain, phlegm, cough) in the past week. Overall, more than a quarter (28%) reported experiencing a breathing issue. Results were adjusted for factors such as age, sex, ethnicity and socio-economic status. The researchers found that those who had vaped (but not smoked) in the past month: <ul class="wp-block-list"> <li>had more chance of breathing issues than those who neither smoked nor vaped</li> <li>had a similar chance of breathing issues to those who had smoked (but not vaped)</li> <li>had less chance of breathing issues than those who smoked and vaped.</li> </ul> A second analysis found that, compared to those who had never vaped: <ul class="wp-block-list"> <li>those who had ever used vapes (former users and those who had experimented) reported more breathing issues</li> <li>current users were more likely to report breathing issues.</li> </ul> The more often people vaped, the more likely they were to report breathing issues. Those who had vaped more than 20 days in the past month were about twice as likely as never-users to report breathing problems. On types of vape, the researchers found that nicotine salts (rather than free-base) may be associated with more breathing issues, though many respondents did not know which they used. Disposable vapes were associated with an increased risk of some symptoms. More young people who usually used multiple flavours reported symptoms (51%) than those who usually used tobacco flavours (34%). Associations between vaping and breathing issues were generally similar across countries. <h2 class="wp-block-heading" class="wp-block-heading" id="how-robust-are-the-findings">How robust are the findings?</h2> The study found links between vaping and breathing issues. Overall, breathing issues were relatively common, even among those who had never smoked or vaped. The study captured breathing issues but not their severity, therefore some of the breathing issues reported may not be concerning. The survey took place during the pandemic when people may have been more aware of breathing issues; those with COVID-19 were excluded from some analyses.  The study could not account for the strength of nicotine in the vapes people used, poor air quality or being exposed to other people’s smoke or vapes. Cannabis use, which may explain some of the breathing problems, was accounted for, but it is likely that some young people did not report their use. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The UK Government is consulting on its <a href="https://www.gov.uk/government/publications/the-tobacco-and-vapes-bill-creating-a-smoke-free-uk-and-tackling-youth-vaping/tobacco-and-vapes-bill-creating-a-smoke-free-uk-and-tackling-youth-vaping" target="_blank" rel="noreferrer noopener">Tobacco and Vapes Bill</a>, introduced in November 2024. Its headline intervention is to incrementally increase the age at which people in the UK can buy cigarettes. The Bill also proposes restrictions on vaping, including banning marketing and sponsorship of vapes. It includes powers to regulate flavours and packaging so that they do not appeal to children, and to ban vaping in smoke-free public places and workplaces. The researchers call for more research on the overall safety of vaping in young people, and on the effects of different types of nicotine and vapes and the various flavours. They say that improved labelling would allow thorough investigation of ingredients. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Brose LS, and others. <a href="https://doi.org/10.1186/s12916-024-03428-6" target="_blank" rel="noreferrer noopener">Associations between vaping and self‑reported respiratory symptoms in young people in Canada, England and the US</a>. BMC Medicine 2024; 22. DOI: 10.1186/s12916-024-03428-6. Information about vaping from <a href="https://ash.org.uk/resources/view/addressing-common-myths-about-vaping-putting-the-evidence-in-context" target="_blank" rel="noreferrer noopener">Action on Smoking and Health (ASH)</a>. An article about vaping and young people by the <a href="https://www.nhs.uk/better-health/quit-smoking/help-others-quit/young-people-and-vaping/#:~:text=Vaping%20is%20not%20for%20children,it%20is%20not%20risk%2Dfree." target="_blank" rel="noreferrer noopener">NHS</a>. Information on taking part in NIHR research on <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=vaping&location=" target="_blank" rel="noreferrer noopener">vaping</a> and <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=smoking&location=" target="_blank" rel="noreferrer noopener">smoking</a>. Funding: <a href="https://www.nihr.ac.uk/research-funding/funding-programmes/public-health-research" target="_blank" rel="noreferrer noopener">NIHR Public Health Research Commissioned Call</a>. Conflicts of Interest: None declared. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Adult social care: how to improve support for people at risk through homelessness, learning disabilities or dementia</title> <link>https://evidence.nihr.ac.uk/collection/adult-social-care-how-to-improve-support-for-people-at-risk-through-homelessness-learning-disabilities-or-dementia/</link> <dc:creator><![CDATA[Martha Powell]]></dc:creator> <pubDate>Thu, 06 Mar 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=66104</guid> <description><![CDATA[Adult social care helps older people and those living with a disability or physical or mental illness to live independently, and stay well and safe. In England in 2023/24, around 1.59 million people worked in the adult social care sector, providing a huge range of activities, from personal care and safeguarding to end-of-life care. Inclusion needs ...]]></description> <content:encoded><![CDATA[ Adult social care helps older people and those living with a disability or physical or mental illness to <a href="https://www.kingsfund.org.uk/insight-and-analysis/data-and-charts/key-facts-figures-adult-social-care" target="_blank" rel="noreferrer noopener">live independently, and stay well and safe</a>. In England in 2023/24, <a href="https://www.skillsforcare.org.uk/Adult-Social-Care-Workforce-Data/Workforce-intelligence/publications/national-information/The-state-of-the-adult-social-care-sector-and-workforce-in-England.aspx" target="_blank" rel="noreferrer noopener">around 1.59 million people</a> worked in the adult social care sector, providing a huge range of activities, from personal care and safeguarding to end-of-life care. Inclusion needs to be at the heart of this work, ensuring all groups can access the care and support they need. In February 2025, NIHR Evidence hosted a webinar that brought together research focusing on seldom heard groups, who are frequently most at risk. The webinar included research that could improve the care of those experiencing homelessness, people with learning disabilities, and people living with dementia. <h2 class="wp-block-heading" class="wp-block-heading" id="safeguarding-for-people-experiencing-homelessness">Safeguarding for people experiencing homelessness</h2> Adult <a href="https://www.scie.org.uk/safeguarding/adults/introduction/what-is/" target="_blank" rel="noreferrer noopener">safeguarding</a> protects a person’s right to live in safety, free from abuse and neglect. People and organisations need to work together to stop abuse and neglect, while promoting the adult’s wellbeing and having regard to their wishes, feelings and beliefs. Safeguarding needs to recognise that adults may be unclear or unrealistic about their personal circumstances; the <a href="https://www.local.gov.uk/sites/default/files/documents/25.158%20Briefing%20on%20Adult%20Safeguarding%20and%20Homelessness_03_1.pdf" target="_blank" rel="noreferrer noopener">relationship with the provision of care and support can be complex</a>. There are examples of good practice, but there are also barriers.  Jess Harris is a Research Fellow at the Health & Social Care Workforce Research Unit at King’s College London. She led an NIHR School for Social Care Research funded study on <a href="https://www.kcl.ac.uk/research/homelessness-and-self-neglect" target="_blank" rel="noreferrer noopener">strengthening adult safeguarding responses to homelessness and self-neglect</a>. <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe loading="lazy" title="Safeguarding for people experiencing homelessness and self-neglect" width="1200" height="675" src="https://www.youtube.com/embed/IKAj4LsTFHw?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> <h2 class="wp-block-heading" class="wp-block-heading" id="end-of-life-planning-for-people-with-learning-disabilities">End of life planning for people with learning disabilities</h2> <a href="https://www.kcl.ac.uk/ioppn/assets/fans-dept/leder-2022-v2.0.pdf" target="_blank" rel="noreferrer noopener">Many people with learning disabilities have complex care needs and are at risk of health inequalities and premature death</a>. Research suggests that staff may <a href="https://journals.sagepub.com/doi/10.1177/02692163241250218" target="_blank" rel="noreferrer noopener">lack the necessary skills, confidence and support</a> to engage people with learning disabilities in end-of-life planning.  As a result, the deaths of people with learning disabilities are frequently unplanned for, and poorly managed.  Irene Tuffrey-Wijne is Professor of Intellectual Disability & Palliative Care at Kingston University, London. She leads a programme of research and development on learning disability, bereavement and palliative care. She presented a <a href="https://www.victoriaandstuart.com/" target="_blank" rel="noreferrer noopener">video</a> about <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/jar.70019" target="_blank" rel="noreferrer noopener">research into end-of-life planning for people with learning disabilities</a>. <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe loading="lazy" title="Co-producing a toolkit for end-of-life care planning with people with learning disabilities" width="1200" height="675" src="https://www.youtube.com/embed/9lleYOvZS3U?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> <h2 class="wp-block-heading" class="wp-block-heading" id="dementia-champions-in-the-homecare-sector">Dementia Champions in the homecare sector</h2> People with dementia make up around <a href="https://www.alzheimers.org.uk/get-involved/our-campaigns/quality-social-care" target="_blank" rel="noreferrer noopener">60% of all those receiving personal care at home in the UK</a>, yet research suggests that less than half of care staff have received any kind of dementia training. <a href="https://www.wyevalley.nhs.uk/visitors-and-patients/county-hospital-acute/inpatients/dementia-care/dementia-champions.aspx" target="_blank" rel="noreferrer noopener">Dementia Champions</a> work across health and social care services. They are a valuable source of information, support and advice for homecare staff, but are not well established in the homecare sector.  Monica Leverton is a Research Fellow in the NIHR Policy Research Unit in Health & Social Care Workforce at King’s College London. Her work focuses on ageing, dementia, and the social care workforce. She was principal investigator of the <a href="https://www.sscr.nihr.ac.uk/projects/p207/" target="_blank" rel="noreferrer noopener">Dementia Champions in homecare project</a>, which explored how the role could develop. <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe loading="lazy" title="Supporting the role of Dementia Champions in the homecare sector" width="1200" height="675" src="https://www.youtube.com/embed/Hj3-TCHC2SU?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> <hr class="wp-block-separator has-alpha-channel-opacity"/> <hr class="wp-block-separator has-alpha-channel-opacity"/> How to cite this Collection: NIHR Evidence; Adult social care: how to improve support for people at risk through homelessness, learning disabilities or dementia; March 2025; doi: 10.3310/nihrevidence_66104 Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Which drugs are best for migraine attacks?</title> <link>https://evidence.nihr.ac.uk/alert/which-drugs-are-best-for-migraine-attacks/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 04 Mar 2025 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=66054</guid> <description><![CDATA[Researchers ranked oral treatments for migraine attacks in an analysis of 137 studies. They found that: The researchers hope their findings will inform clinical guidelines and help with shared decision-making during consultations. More information about migraine can be found on the NHS website. The issue: what should I take for a migraine attack? A migraine ...]]></description> <content:encoded><![CDATA[ Researchers ranked oral treatments for migraine attacks in an analysis of 137 studies. They found that: <ul class="wp-block-list"> <li>drugs called triptans (for instance sumatriptan) were more effective than other medicines</li> <li>non-steroidal anti-inflammatories (ibuprofen, for instance) were the next most effective group</li> <li>the newest medicines available (for instance, rimegepant) were less effective than non-steroidal anti-inflammatory drugs.</li> </ul> The researchers hope their findings will inform clinical guidelines and help with shared decision-making during consultations. <a href="https://www.nhs.uk/conditions/migraine/" target="_blank" rel="noreferrer noopener">More information about migraine can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-what-should-i-take-for-a-migraine-attack">The issue: what should I take for a migraine attack?</h2> A migraine attack usually feels like a severe headache with throbbing pain on one side of the head. It often comes with other symptoms such as <a href="https://www.nhsinform.scot/illnesses-and-conditions/brain-nerves-and-spinal-cord/migraine/" target="_blank" rel="noreferrer noopener">nausea</a>. Attacks can last between 2 hours and 3 days; some people have attacks rarely while others might have several a week. According to <a href="https://migrainetrust.org/wp-content/uploads/2021/08/State-of-the-Migraine-Nation-population-rapid-review.pdf" target="_blank" rel="noreferrer noopener">The Migraine Trust</a>, in 2021 around 10 million adults in the UK were living with migraine. Around <a href="https://migrainetrust.org/wp-content/uploads/2022/05/All-about-migraine-toolkit-for-MPs-The-Migraine-Trust.pdf" target="_blank" rel="noreferrer noopener">43 million workdays are lost because of migraine every year, and the condition accounts for many (4%) primary care consultations</a>. The <a href="https://cks.nice.org.uk/topics/migraine/management/adults/#:~:text=National%20Institute%20for%20Health%20and%20Clinical%20Excellence%20(NICE)%20guidance%20on,aspirin%20(900%20mg)%20or%20paracetamol" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence</a> (NICE) recommends pain relief (such as ibuprofen or paracetamol) for migraine attacks, and where this is insufficient, add or replace with a triptan (for instance sumatriptan). But some people cannot take triptans (those at risk of cardiovascular or <a href="https://www.leedsth.nhs.uk/services/vascular-service/your-condition-and-treatment/" target="_blank" rel="noreferrer noopener">vascular diseases</a>, for instance). In 2023, a newer drug (<a href="https://www.nice.org.uk/guidance/ta919" target="_blank" rel="noreferrer noopener">rimegepant</a>) that could be used instead of triptans became available in the UK. Most studies on the effectiveness of migraine drugs have been sponsored by the pharmaceutical industry. A <a href="https://training.cochrane.org/handbook/current/chapter-11#:~:text=Network%20meta%2Danalysis%20produces%20estimates,ranking%20and%20hierarchy%20of%20interventions" target="_blank" rel="noreferrer noopener">network meta-analysis</a> brings together many studies with different sponsors, which reduces the potential bias in findings. Researchers used this approach to explore which oral medicines were most effective for migraine attacks. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The analysis included 137 randomised controlled trials that, between them, included all drugs licenced for acute migraine in the UK and elsewhere. The trials included a total of 89,445 adults with migraine. The team conducted a network meta-analysis to rank all drugs, from different studies. The researchers considered the immediate effect of a drug (freedom from pain 2 hours after taking it). In the 153 comparisons included, all active drugs were more effective than placebo (sugar pill). The chance of being pain-free at 2 hours was: <ul class="wp-block-list"> <li>highest with most triptans (migraine-specific painkillers) such as eletriptan (37%) or sumatriptan (29%)</li> <li>slightly lower with non-steroid drugs that reduce inflammation such as diclofenac potassium (26%) or ibuprofen (20%)</li> <li>lowest with drugs that reduce temperature such as paracetamol (19%) or new migraine-specific painkillers ubrogepant (also 19%) or rimegepant (18%); naratriptan was similar (17%).</li> </ul> A second outcome (from 105 comparisons) was the impact of the drug over the course of the day. The study found that the chance of being pain-free 2-24 hours after taking a drug was: <ul class="wp-block-list"> <li>increased by most drugs (paracetamol and naratriptan performed the worst)</li> <li>most effectively increased by ibuprofen (38% chance) and eletriptan (26%).</li> </ul> Panels of patients and clinicians identified important side effects of drugs: chest pain, dizziness, fatigue, nausea, paraesthesia (pins and needles, or numbness of the skin), and sedation. The researchers found that: <ul class="wp-block-list"> <li>eletriptan was associated with more chest pain, dizziness and fatigue than other drugs; other triptans (sumatriptan and zolmitriptan) were associated with dizziness</li> <li>diclofenac potassium was associated with nausea</li> <li>ubrogepant was associated with chest pain.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> This study gives the most comprehensive analysis to date of the effectiveness of drugs for migraine. The findings on both benefits and harms should inform shared decision-making. The results imply that triptans are the most effective treatments for migraine when people do not have certain other conditions. Triptans were more effective than newer and more expensive drugs such as rimegepant. The findings suggest that diclofenac potassium or ibuprofen might be the next best treatment when triptans are not suitable. The studies included in the analysis varied in certainty. For the impact on pain at 2 hours, few (8%) studies were rated moderate certainty; 74% were very low certainty. For freedom from pain at 24 hours, most (90%) were very low certainty. More high-quality research is needed to evaluate drugs for migraine. The analysis did not include studies that analysed drugs used in combination and only included drugs taken by mouth. The researchers did not account for clinical issues that might inform decision making, for instance headache caused by medication overuse. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> <a href="https://doi.org/10.1186/s10194-018-0839-1" target="_blank" rel="noreferrer noopener">Previous research</a> has shown that even in wealthy countries, migraine-specific medications (including triptans) are underused. More research is needed to explore the safety of triptans in people with vascular disease and to determine the cost-effectiveness of medications. The researchers hope their findings will inform future guidelines. They hope that triptans will be included in the <a href="https://www.who.int/groups/expert-committee-on-selection-and-use-of-essential-medicines/essential-medicines-lists" target="_blank" rel="noreferrer noopener">WHO List of Essential Medicines</a> to promote access to this effective treatment in all countries. The researchers have made their <a href="https://github.com/EGOstinelli/NMA-on-migraine/" target="_blank" rel="noreferrer noopener">dataset freely and fully available</a> for others to review.<a id="_msocom_1"></a> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Karlsson WK, and others. <a href="https://doi.org/10.1136/bmj-2024-080107" target="_blank" rel="noreferrer noopener">Comparative effects of drug interventions for the acute management of migraine episodes in adults: systematic review and network meta-analysis</a>. British Medical Journal 2024; 386: e080107. <a href="https://www.psych.ox.ac.uk/news/triptans-found-to-be-the-most-effective-drug-for-acute-migraine-sufferers" target="_blank" rel="noreferrer noopener">Triptans found to be the most effective drug for acute migraine sufferers</a>. A press release on this study from the University of Oxford Department of Psychiatry. 19 September 2024. <a href="https://migrainetrust.org/live-with-migraine/healthcare/treatments/acute-medicines/" target="_blank" rel="noreferrer noopener">Information</a> from The Migraine Trust. An <a href="https://evidence.nihr.ac.uk/alert/chronic-migraine-which-drugs-are-best/">NIHR Evidence summary</a> about what treatments are best for preventing migraine attacks. Funding: This study was funded by the <a href="https://oxfordhealthbrc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Oxford Health Biomedical Research Centre</a>. Conflicts of Interest: Several of the study authors have received funding from several pharmaceutical companies that produce migraine drugs. See <a href="https://doi.org/10.1136/bmj-2024-080107" target="_blank" rel="noreferrer noopener">paper</a> for full details. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>COVID-19 vaccine during pregnancy reduces risks to mother and baby</title> <link>https://evidence.nihr.ac.uk/alert/covid-19-vaccine-during-pregnancy-reduces-risks-to-mother-and-baby/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 27 Feb 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=66017</guid> <description><![CDATA[Recent research provides evidence to back the safety and effectiveness of the COVID-19 vaccine for pregnant women. Compared with women who were not vaccinated, women vaccinated during pregnancy had a reduced risk of: The issue: should pregnant women have the COVID-19 vaccine? Pregnant women with COVID-19 are more likely to develop severe COVID-19 and related ...]]></description> <content:encoded><![CDATA[ Recent research provides evidence to back the safety and effectiveness of the COVID-19 vaccine for pregnant women. Compared with women who were not vaccinated, women vaccinated during pregnancy had a reduced risk of: <ul class="wp-block-list"> <li>blood pressure disorders during pregnancy</li> <li>giving birth by caesarean section</li> <li>their newborn needing admission to intensive care.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-should-pregnant-women-have-the-covid-19-vaccine">The issue: should pregnant women have the COVID-19 vaccine?</h2> Pregnant women with COVID-19 are more likely to develop severe COVID-19 and related ill health than non-pregnant women of similar age. Research has shown that COVID-19 vaccines reduce death and illness severity; however, most studies excluded pregnant women. Information was therefore lacking on the safety and effectiveness of these vaccines during pregnancy. Researchers analysed evidence on the safety and effectiveness of COVID-19 vaccines in women before or during pregnancy. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> This research was based on studies published between 2019 and 2023 from countries around the world. All followed groups of women over time and compared outcomes among those who received the vaccine with those who did not. The researchers considered studies that adjusted for maternal age, diabetes, high blood pressure, body mass index, gestational age and education. They assessed the impact of vaccination on COVID-related health, pregnancy and baby outcomes. Compared to unvaccinated women, those who received a vaccine: <ul class="wp-block-list"> <li>were less likely (61% less) to develop COVID-19 during pregnancy (4 studies including 23,927 women) and much less likely (94% less) to be admitted to hospital because of COVID-19 (2 studies including 868 women)</li> <li>had less chance (12% less) of high blood pressure or other blood pressure disorders during pregnancy (2 studies including 115,085 women)</li> <li>were less likely (9% less) to have a caesarean section (6 studies including 30,192 women)</li> <li>had babies that were less likely (8% less) to be admitted to neonatal intensive care units (2 studies including 54,569 women)</li> <li>had a higher chance (17% more) of developing gestational diabetes (2 studies involving 115,085 women).</li> </ul> Pain at injection site was reported by most women (77%) who received the vaccine (11 studies involving 27,195 women). Other side-effects were less frequent, for instance fatigue was reported by 29% of women in 14 studies involving 72,671 women. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The findings mirror those from studies carried out in the general population, and show that, among pregnant women, the COVID-19 vaccine reduced risks related to COVID-19. In addition, the vaccine reduced the risk of common pregnancy complications such as high blood pressure, caesarean sections and neonatal admissions.   The increased risk of gestational diabetes with vaccination was found in 2 different populations in a single study. The researchers say this link needs to be explored further. Many of the studies carried a moderate or severe risk of bias. This analysis could not establish whether the timing of the vaccine during pregnancy affected outcomes. Further, data are still lacking about long-term effects of the vaccine on mothers such as low platelet levels (<a href="https://www.nnuh.nhs.uk/departments/haematology-department/non-malignant-haematology/immune-thrombocytopenia/" target="_blank" rel="noreferrer noopener">thrombocytopenia</a>), which can increase bruising and bleeding) and inflamed heart muscle (<a href="https://www.bhf.org.uk/informationsupport/conditions/myocarditis" target="_blank" rel="noreferrer noopener">myocarditis</a>). <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The <a href="https://journals.lww.com/clinicalobgyn/abstract/2024/09000/covid_19_in_pregnancy__an_update_for_clinicians.15.aspx" target="_blank" rel="noreferrer noopener">findings have been used to inform healthcare professionals and women</a> about the safety of the vaccine. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Fernández-García S, and others. <a href="https://doi.org/10.1136/bmjgh-2023-014247" target="_blank" rel="noreferrer noopener">Effectiveness and safety of COVID-19 vaccines on maternal and perinatal outcomes: a systematic review and meta-analysis</a>. BMJ Global Health 2024; 9: e014247. A press release from the University of Birmingham about this research: <a href="https://www.news-medical.net/news/20240614/COVID-19-vaccination-in-pregnancy-lowers-risk-of-cesarean-section-hypertension.aspx" target="_blank" rel="noreferrer noopener">COVID-19 vaccination in pregnancy lowers risk of cesarean section, hypertension</a>. Research on birth outcomes among women vaccinated against COVID-19 before pregnancy: Suseeladevi AK, and others. <a href="https://doi.org/10.1016/j.lanepe.2024.101025" target="_blank" rel="noreferrer noopener">COVID-19 vaccination and birth outcomes of 186,990 women vaccinated before pregnancy: an England-wide cohort study</a> The Lancet Regional Health Europe 2024; 45: 101025. Research about the impact of COVID-19 and vaccination on pregnancy outcomes: Raffetti E, and others. <a href="https://www.thelancet.com/journals/lanepe/article/PIIS2666-7762(24)00204-7/fulltext" target="_blank" rel="noreferrer noopener">COVID-19 diagnosis, vaccination during pregnancy, and adverse pregnancy outcomes of 865,654 women in England and Wales: a population-based cohort study</a>. The Lancet Regional Health Europe 2024; 45: 101037. The <a href="https://www.birmingham.ac.uk/research/who-collaborating-centre/pregcov" target="_blank" rel="noreferrer noopener">PregCOV-19LSR group</a> conducts reviews of research about the impact of COVID-19 on pregnancy. Funding: This study was funded by the <a href="https://www.birminghambrc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Birmingham Biomedical Research Centre</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1136/bmjgh-2023-014247" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Children in deprived areas are most at risk of avoidable poisoning by medicines</title> <link>https://evidence.nihr.ac.uk/alert/children-in-deprived-areas-are-most-at-risk-of-avoidable-poisoning-by-medicines/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 25 Feb 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65930</guid> <description><![CDATA[Researchers examined hospital admissions for children (aged 0 - 11 years) poisoned with medicines between 1998 and 2018. The vast majority of poisonings in this age group are known to be unintentional. The team found that admissions for poisoning by paracetamol increased, while those for poisoning by prescribed drugs (such as antidepressants or opioids) decreased. ...]]></description> <content:encoded><![CDATA[ Researchers examined hospital admissions for children (aged 0 - 11 years) poisoned with medicines between 1998 and 2018. The vast majority of poisonings in this age group are known to be unintentional. The team found that admissions for poisoning by paracetamol increased, while those for poisoning by prescribed drugs (such as antidepressants or opioids) decreased. Compared with children living in the least deprived areas, those living in the most deprived areas: <ul class="wp-block-list"> <li>were more likely to be admitted to hospital for any medicinal poisoning (30% more)</li> <li>were twice as likely to be admitted for poisoning by a prescribed drug.</li> </ul> The researchers hope their findings will encourage more public health campaigns and targeted messages about medicinal safety, especially for those living in more deprived areas. They stress that deprivation status was derived from the address of a child’s GP and might not reflect individual households. <a href="https://www.nhs.uk/conditions/poisoning/symptoms/" target="_blank" rel="noreferrer noopener">More information about poisoning can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-how-often-are-children-admitted-to-hospital-because-of-medicinal-poisoning">The issue: how often are children admitted to hospital because of medicinal poisoning?</h2> Accidental poisoning of children by medicines is dangerous and preventable. Between April 2023 and April 2024, around 1426 children aged 0 to 9 years were admitted to hospital as a result, according to <a href="https://digital.nhs.uk/data-and-information/publications/statistical/hospital-admitted-patient-care-activity/2023-24" target="_blank" rel="noreferrer noopener">NHS England</a>. <a href="https://doi.org/10.1136/archdischild-2013-305298" target="_blank" rel="noreferrer noopener">Previous research</a> found that children in the most deprived areas were most at risk. In recent years, over-the-counter medicines (such as aspirin, ibuprofen, anti-congestion remedies and sore throat lozenges) have become more widely available, and more prescriptions of prescribed medicines have been issued. This could have increased avoidable poisonings. Equally, the introduction of child-proof caps and packaging, along with other public health interventions, might have reduced the risk. This research assessed the risk of accidental poisoning by different medicines among young children, and explored the link between deprivation and risk. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Researchers examined electronic health records of almost 1.5 million children aged 0 to 11 years registered at 399 general practices in England. The main outcome was hospital admission from medicine poisoning between 1998 and 2018. The 3 most common categories of medicine poisoning account for most (60%) of all poisonings. They are: <ul class="wp-block-list"> <li>paracetamol</li> <li>drugs with dependency or withdrawal risk (including opioids such as codeine, antidepressants and antianxiety drugs)</li> <li>over-the-counter pain relief and anti-cold drugs that do not contain paracetamol.</li> </ul> The study found that the incidence of children’s admissions due to these 3 categories of medicines combined did not change over the study period. Overall, 3,621 children experienced 3,685 hospital admissions. Young children (aged 2 - 4 years) were much more likely (90% more likely) to be admitted to hospital than older children (aged 5 - 11 years). Over the course of the study, hospital admissions for: <ul class="wp-block-list"> <li>paracetamol increased by 43% over the study period (and accounted for 33% of all poisoning admissions)</li> <li>drugs with dependency or withdrawal risk decreased by 33% (and accounted for 14% of all poisoning admissions)</li> <li>over-the-counter drugs did not change over the study period (and accounted for 13% of all poisoning admissions).</li> </ul> Compared with children in the least deprived areas, those from the most deprived: <ul class="wp-block-list"> <li>were at greater risk of poisoning from drugs in all 3 categories (30% more risk)</li> <li>were almost twice as likely to be admitted because of poisonings from drugs with a risk of dependency or withdrawal.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> Overall, childhood hospital admissions for poisoning by the 3 categories of drug in this study did not change between 1998 and 2018. Admissions for paracetamol poisoning increased. But admissions for drugs with a risk of dependency or withdrawal decreased, even though prescriptions for opioids increased between 2000 and 2012. The researchers say that messages around safe storage of medicines have led to positive changes in behaviour with prescribed medication. However, people may consider easily available medicines such as paracetamol less dangerous. The researchers stress that these drugs should be stored safely, in a raised, locked cupboard out of reach of children, in the same way as prescribed medicines. More drugs with a risk of dependency or withdrawal are prescribed to adults in the most deprived areas, which is reflected in the increased risk to children living there. More targeted messaging about storing medicines safely could help people living in more deprived areas, the researchers say. The findings strengthen the argument for measures such as home safety assessments as recommended by the <a href="https://www.nice.org.uk/guidance/qs107/resources/preventing-unintentional-injury-in-under-15s-pdf-75545242682821" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence</a> (NICE). Deprivation status, derived from the address of the general practice where children were registered, might not reflect households’ actual status. The study focused on hospital admissions; findings might therefore not be generalisable to less serious poisonings. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers have shared their results with the <a href="https://www.rospa.com/" target="_blank" rel="noreferrer noopener">Royal Society for the Prevention of Accidents</a> and <a href="https://www.childsafety.co.uk/" target="_blank" rel="noreferrer noopener">KidRapt</a> (a UK company that works with charities and local authorities to prevent children's accidents at home). <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Tyrrell E, and others. <a href="https://doi.org/10.1186/s13690-024-01268-7" target="_blank" rel="noreferrer noopener">Patterns and trends of medicinal poisoning substances: a population-based cohort study of injuries in 0-11 year old children from 1998-2018</a>. Archives of Public Health 2024; 82: 50. Information about what to do if a child has swallowed a medicine accidentally from the <a href="https://www.what0-18.nhs.uk/parentscarers/worried-your-child-unwell/poisoningaccidental-swallowing" target="_blank" rel="noreferrer noopener">Royal College of Paediatrics and Child Health</a>. The research team’s website: <a href="https://www.nottingham.ac.uk/research/groups/injuryresearch/index.aspx" target="_blank" rel="noreferrer noopener">Injury Epidemiology and Prevention Research</a> Funding: This study was funded by the <a href="https://www.spcr.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR School for Primary Care Research</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1186/s13690-024-01268-7" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>What impact does hearing loss have on dementia risk?</title> <link>https://evidence.nihr.ac.uk/alert/what-impact-does-hearing-loss-have-on-dementia-risk/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Wed, 19 Feb 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65974</guid> <description><![CDATA[A comprehensive review of research explored the link between adult-onset hearing loss, dementia, and problems with thinking and memory (cognitive impairment). Researchers found that: The findings support suggestions that addressing hearing loss might reduce the risk of some types of dementia. More information about hearing loss can be found on the NHS website. The issue: ...]]></description> <content:encoded><![CDATA[ A comprehensive review of research explored the link between adult-onset hearing loss, dementia, and problems with thinking and memory (cognitive impairment). Researchers found that: <ul class="wp-block-list"> <li>hearing loss was linked to an increased risk of mild to severe cognitive problems, including mild cognitive impairment and Alzheimer’s disease</li> <li>hearing loss was not linked to an increased risk of vascular dementia</li> <li>the greater the hearing loss, the higher the risk of dementia.</li> </ul> The findings support suggestions that addressing hearing loss might reduce the risk of some types of dementia. <a href="https://www.nhs.uk/conditions/hearing-loss/" target="_blank" rel="noreferrer noopener">More information about hearing loss can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-how-harmful-is-hearing-loss">The issue: how harmful is hearing loss?</h2> The <a href="https://rnid.org.uk/2024/06/why-the-number-of-people-with-hearing-loss-has-increased/" target="_blank" rel="noreferrer noopener">Royal National Institute for Deaf People</a> estimates that 18 million people in the UK have hearing loss in one or both ears. Some experts describe <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(24)01296-0/abstract" target="_blank" rel="noreferrer noopener">hearing loss as a modifiable risk factor for dementia</a>, but previous findings are mixed. <a href="https://jamanetwork.com/journals/jamaneurology/fullarticle/2799139" target="_blank" rel="noreferrer noopener">A 2022 systematic review</a> found that people with hearing loss who <a href="https://jamanetwork.com/journals/jamaneurology/fullarticle/2799139" target="_blank" rel="noreferrer noopener">use hearing aids or cochlear implants have a reduced risk of developing dementia</a>. Similarly, a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01406-X/abstract" target="_blank" rel="noreferrer noopener">large randomised controlled trial</a> found that hearing aids reduced the risk of cognitive decline by 48% in 70 – 84 year olds with untreated hearing loss (including people with low cognitive scores). However, hearing aids did not reduce dementia risk in those at low risk. The current review pulled together previous research on hearing loss and dementia. Researchers assessed the link between hearing loss on dementia subtypes. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Researchers analysed 50 studies from the US, East Asia, Europe and Australia in a total of 1.5 million people. All studies explored the link between adult-onset hearing loss and cognitive outcomes, but outcomes were described in different ways (dementia for example, rather than Alzheimer’s disease). The review considered the severity and type of cognitive impairment along with the degree of hearing loss; and looked at the impact of age and length of follow-up (at least 2 years for all participants). In half the studies, participants either self-reported hearing loss or had a history of hearing loss; in the remainder, they were assessed at the start of the study. Those with hearing loss at the beginning of each study were compared to those with no hearing loss. Over the course of a study, people with hearing loss had: <ul class="wp-block-list"> <li>an increased risk of dementia (35% increase in 30 studies) and Alzheimer’s disease (56% increase in 4 studies)</li> <li>an increased risk of mild cognitive impairment (29% in 3 studies)</li> <li>an increased risk of unspecified cognitive decline (also 29% increase in 9 studies)</li> <li>no link between vascular dementia and hearing loss (in 3 studies).</li> </ul> The research suggested that: <ul class="wp-block-list"> <li>both mild and moderate to severe hearing loss were associated with increased dementia risk (7 studies for each finding)</li> <li>the greater the hearing loss, the greater the risk of cognitive decline (every 10 <a href="https://en.wikipedia.org/wiki/Decibel" target="_blank" rel="noreferrer noopener">decibel </a>decrease in hearing was associated with 16% increase in dementia risk; 2 studies)</li> <li>the link between hearing loss and dementia did not vary according to age at the start of the study (35 studies), or length of follow-up (37 studies).<a id="_msocom_1"></a></li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The findings support the suggestion that adult-onset hearing loss might be a cause of dementia. Results were consistent across studies, despite differences in the people included, and the type of cognitive impairment they looked at.  Adult-onset hearing loss can be treated, most often with hearing aids. Following on from this study, the researchers went on to explore the <a href="https://academic.oup.com/ageing/article/54/1/afaf004/7965371" target="_blank" rel="noreferrer noopener">impact of wearing hearing aids</a> on mild cognitive impairment. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The team has since included hearing loss as a risk factor for dementia in another NIHR-funded programme. The researchers developed an app (<a href="https://fundingawards.nihr.ac.uk/award/NIHR203670" target="_blank" rel="noreferrer noopener">ENHANCE</a>) which, with coaching support, aims to encourage people to adopt healthier lifestyles and reduce their risk of dementia. It targets hearing loss along with other risk factors such as high blood pressure, diabetes, physical inactivity and low mood. The app includes cognitive games to keep the mind active, educational health-related videos to encourage healthy behaviour, and tools for tracking health behaviours. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Yu R-C, and others. <a href="https://doi.org/10.1016/j.arr.2024.102346" target="_blank" rel="noreferrer noopener">Adult-onset hearing loss and incident cognitive impairment and dementia - A systematic review and meta-analysis of cohort studies</a>. Ageing Research Reviews 2024; 98: 102346. Evidence about dementia prevention and care: <a href="https://doi.org/10.1016/S0140-6736(24)01296-0" target="_blank" rel="noreferrer noopener">Dementia prevention, intervention, and care: 2024 report of the Lancet standing Commission</a>. The Lancet Commissions 2024; 404: 572 – 628. The experiences of people with cognitive impairment using hearing aids. Gregory, Sarah, and others. <a href="https://doi.org/10.1177/2050312120904572" target="_blank" rel="noreferrer noopener">Experiences of hearing aid use among patients with mild cognitive impairment and Alzheimer’s disease dementia: a qualitative study</a>. SAGE Open Medicine 2020; 8: 205031212090457. An NIHR Evidence summary: <a href="https://evidence.nihr.ac.uk/alert/how-to-identify-dementia-in-people-with-hearing-loss/">How to identify dementia in people with hearing loss</a>. An article about hearing loss and dementia. Munro K J, Dawes P. <a href="https://www.entandaudiologynews.com/features/audiology-features/post/commentary-dementia-hearing-loss-and-the-danger-of-professional-rabbit-holes" target="_blank" rel="noreferrer noopener">Commentary: dementia, hearing loss, and the danger of professional rabbit holes</a>. ENT & Audiology News September 2024. Funding: This study was supported by the <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/programme-grants-for-applied-research.htm" target="_blank" rel="noreferrer noopener">NIHR Programme Grants for Applied Research</a>, the <a href="https://www.uclhospitals.brc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">University College London Hospitals Biomedical Research Centre</a> and <a href="https://www.alzheimersresearchuk.org/" target="_blank" rel="noreferrer noopener">Alzheimer's Research UK</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1016/j.arr.2024.102346" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Can we improve care for women at risk of early birth?</title> <link>https://evidence.nihr.ac.uk/alert/can-we-improve-care-for-women-at-risk-of-early-birth/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 13 Feb 2025 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65908</guid> <description><![CDATA[Some hospitals have established a preterm birth pathway to predict, prevent, and prepare for early births. This study reviewed and made suggestions on how best to implement the pathway. These included: Obstetricians, midwives, hospital managers, and professional bodies for maternity care could use the findings to improve care.   More information on premature birth can be ...]]></description> <content:encoded><![CDATA[ Some hospitals have established a preterm birth pathway to predict, prevent, and prepare for early births. This study reviewed and made suggestions on how best to implement the pathway. These included: <ul class="wp-block-list"> <li>better staff training on early birth and the pathway</li> <li>multidisciplinary preterm teams</li> <li>women-centered care. </li> </ul> Obstetricians, midwives, hospital managers, and professional bodies for maternity care could use the findings to improve care.   <a href="https://www.nhs.uk/pregnancy/labour-and-birth/signs-of-labour/premature-labour-and-birth/" target="_blank" rel="noreferrer noopener">More information on premature birth can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-can-we-improve-the-health-of-babies-born-early">The issue: Can we improve the health of babies born early?</h2> In the UK, 1 in 12 babies (8%) are born early (or prematurely) before 37 weeks. Babies born early are at higher risk of dying as newborns and of long-term health issues. The <a href="https://www.england.nhs.uk/long-read/saving-babies-lives-version-3/" target="_blank" rel="noreferrer noopener">NHS’ Saving Babies Lives Care Bundle</a> recommends creating a pathway to predict, prevent, and prepare for early births. The guidance suggests that midwives assess all women for their risk of an early birth, with those at intermediate or high risk referred for further screening and possible interventions (a procedure to prevent the cervix opening too early, for instance). Since this guidance was published, the number of preterm birth clinics in England has risen from 30 (in 2017) to 78 (in 2021).   As more preterm birth clinics are being set up, this analysis evaluated the early birth pathway; it provides evidence-based advice on how to improve implementation.    <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The analysis included 29 research papers. The team interviewed 5 people who developed guidance for the pathway, and conducted a national survey of practice (96 hospitals in England responded). In-depth analysis at 3 hospitals with a pathway included interviews with 11 women and 13 staff, observation of practice in appointments with 87 women, and a review of local guidelines. 1. Risk assessments and referrals Staff sometimes lacked knowledge about risk assessments and how women could reduce their risk, the research found. Referrals were often double checked by senior staff, wasting time and effort, and undermining the junior members of staff. Practical issues (outdated computer systems, for instance) prevented or slowed down risk assessments and referrals. The researchers suggested: <ul class="wp-block-list"> <li>improved education and training on early birth; removal of barriers to assessment including adding checklists to computer systems, for example</li> <li>prompts for staff (via posters and email reminders) to promote risk assessments and referrals</li> <li>a culture of learning created by senior staff, encouraging staff to ask for help. </li> </ul> 2. Preterm birth clinic Units with a named preterm consultant and midwife, with specialist skills, delivered effective care. In these units, staff trusted each other, skills were passed on, and variation in care was reduced. Where a single staff member had specialist training (such as using ultrasound to measure the cervix), units struggled when that person was absent. Specialist multidisciplinary teams could improve care, the researchers say. They suggest that individual units: <ul class="wp-block-list"> <li>audit their practice, and hold regular team meetings to discuss the care of women with complex needs</li> <li>are supported by local networks, which ensure sharing of resources (such as guidelines)</li> <li>all hold clinics on the same day so staff from different units can support each other.</li> </ul> The research team called for: <ul class="wp-block-list"> <li>clinical staff to flag issues to managers to speed up resolution</li> <li>hospital managers to improve hospital and clinic environments and ensure that necessary equipment is on hand, so that women and staff do not have to walk long distances through the hospital for tests</li> <li>managers to ensure that necessary training on specific scanning techniques is provided and that staff have protected time to attend; the Royal College of Obstetricians and Gynaecologists could extend its curriculum to include them.</li> </ul> 3. Women-centred care Women were reassured by continuity of care and seeing professionals who were aware of their medical history. Attending to routine aspects of pregnancy (such as birth plans and antenatal classes) helped women not to feel defined by their high-risk status. Focusing on what women can do, instead of what they cannot, and asking about preferences for birth, helped women feel in control. The researchers suggested:   <ul class="wp-block-list"> <li>greater continuity of care; women could have the contact details of their lead member of staff</li> <li>clinicians to signpost support, including relevant charities, such as <a href="https://www.tommys.org/" target="_blank" rel="noreferrer noopener">Tommy’s</a>  </li> <li>hospital managers to ask women and staff for feedback on the pathway and be ready to adapt services.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The researchers hope their suggestions will improve the implementation of the pathway for early birth risk assessment. They recognised that clinics work with tight budgets and have staffing shortages. Several of their suggestions do not require additional money or staff.   <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The study was carried out before the updated version 3 of the <a href="https://www.england.nhs.uk/long-read/saving-babies-lives-version-3/" target="_blank" rel="noreferrer noopener">Saving Babies Lives Care Bundle</a> was published. The researchers’ suggestions are in line with version 3 of the care bundle, and extend its recommendations. For example, the bundle recommends that clinics have access to transvaginal scans; the researchers suggest that scans would best be provided by the clinic itself.   Since the research was published, a screening test (Fetal Fibronectin biomarker swab) has been taken off the market. The NHS now advises use of alternatives (Actim Partus and/or PartoSure). The team is carrying out 2 further studies; one on the newly developed role of preterm birth midwives, another is a national questionnaire on early birth practice. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Carlisle N, and others. <a href="https://doi.org/10.1186/s43058-024-00594-9" target="_blank" rel="noreferrer noopener">IMplementation of the Preterm Birth Surveillance PAthway: a RealisT evaluation (The IMPART Study)</a>. Implementation Science Communication 2024; 5: 1 – 15.  <a href="https://mft.nhs.uk/saint-marys/services/maternity-services-obstetrics/specialist-antenatal-clinics-and-services/preterm-birth-prevention-clinic/" target="_blank" rel="noreferrer noopener">Information on preterm birth prevention clinics</a>. A<a href="https://www.routledge.com/Preterm-Birth-A-Handbook-for-Midwives/Carlisle-Carter/p/book/9781032461939?srsltid=AfmBOopKJAnTPZYKgFa4Whxo3JRoOI7Ujv-jZ1EoKx8SM6ekgjhjV6iC" target="_blank" rel="noreferrer noopener"> book on early birth for midwives</a> written by the study authors. Information and support from the charity <a href="https://www.tommys.org/pregnancy-information/premature-birth/risk-premature-birth" target="_blank" rel="noreferrer noopener">Tommy’s</a>. Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=Pregnancy&location=" target="_blank" rel="noreferrer noopener">NIHR research on pregnancy</a>. Funding: This study was supported by the <a href="https://arc-sl.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Applied Research Collaboration South London</a> and the <a href="https://www.nihr.ac.uk/career-development/research-career-funding-programmes" target="_blank" rel="noreferrer noopener">NIHR Clinical Doctoral Research Fellowship Programme</a>. Conflicts of Interest: None relevant. Full disclosures are provided in the <a href="https://doi.org/10.1186/s43058-024-00594-9" target="_blank" rel="noreferrer noopener">original paper</a>.   Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Walking just 2 weeks after ankle surgery is safe for many</title> <link>https://evidence.nihr.ac.uk/alert/walking-just-2-weeks-after-ankle-surgery-is-safe-for-many/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 11 Feb 2025 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65866</guid> <description><![CDATA[After surgery for a broken ankle, it is common practice for people to be told to keep weight off their ankle for 6 weeks. However, some surgeons encourage people to walk again after 2 weeks. This trial compared the safety of walking after 2 weeks with waiting 6 weeks. Researchers found that 4 months after ...]]></description> <content:encoded><![CDATA[ After surgery for a broken ankle, it is common practice for people to be told to keep weight off their ankle for 6 weeks. However, some surgeons encourage people to walk again after 2 weeks. This trial compared the safety of walking after 2 weeks with waiting 6 weeks. Researchers found that 4 months after surgery, people in both groups had: <ul class="wp-block-list"> <li>similar ankle function (including pain, stiffness, and walking ability)</li> <li>a similar number of complications.</li> </ul> This research found that walking earlier is safe for many people. Encouraging people to walk earlier after ankle surgery could help them get back to normal activities sooner and save the NHS money. <a href="https://www.nhs.uk/conditions/broken-ankle/" target="_blank" rel="noreferrer noopener">More information on broken ankles can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-when-can-i-safely-walk-after-surgery-for-a-broken-ankle">The issue: when can I safely walk after surgery for a broken ankle?</h2> Ankle fractures are a common injury; in the UK, around 190 people break their ankle every day. Some can be treated with a cast or a boot alone, but others need surgery to ensure their bones heal correctly. After surgery for a broken ankle, most people are told to avoid putting weight on their ankle for 6 weeks (delayed weight-bearing). This can mean that they have extended hospital stays, need help getting around, face delays in returning to work, and rely on social care more. Other people are encouraged to walk only 2 weeks after surgery (early weight-bearing). There are concerns that early weight-bearing might lead to healing problems, misaligned bones, and an increase in the need for further operations. Others argue that delayed weight-bearing increases the risk of blood clots and muscle wasting. This study compared the safety of waiting 2 weeks to walk after surgery for a broken ankle with waiting 6 weeks. It also analysed hospital and social care costs.   <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The study involved 561 adults who had surgery for a broken ankle at 23 UK hospitals. Half were encouraged to walk 2 weeks after surgery, the others to wait 6 weeks. The groups had similar characteristics, most participants (64%) were women, and their average age was 50 years. The main outcome at 4 months was <a href="https://www.physio-pedia.com/Olerud-Molander_Ankle_Score" target="_blank" rel="noreferrer noopener">a measure of ankle function</a>, including symptoms (such as pain and stiffness) and people’s ability to put weight on their ankle (climbing stairs and running, for example). Scores within 6 points (out of 100) of each other were considered equal. 243 in the 2-week group and 237 in the 6-week group provided data for this outcome. The researchers found that at 4 months, the 2-week group: <ul class="wp-block-list"> <li>had similar ankle function (score: 66) to the 6-week group (61)</li> <li>had a similar likelihood of complications (16% people) as the 6-week group (14%)</li> <li>had a similar number of unplanned surgeries due to complications (8%) as the 6-week group (6%)</li> <li>cost the NHS and social services less (£725) than the 6-week group (£785; based on <a href="https://www.england.nhs.uk/publication/2021-22-national-cost-collection-data-publication/" target="_blank" rel="noreferrer noopener">2021/22 costs</a>).</li> </ul> Ankle function was similar between groups for different ages, sexes, and types of ankle surgery. After 1 year, there was no difference between groups in ankle function. People in the 2-week group had slightly (but not significantly) less time off work in the 6 weeks after surgery. This saved society an average of £722 per person. Years of life in good health (QALYs) were also higher for people in the 2-week group. <a href="https://doi.org/10.1016/j.injury.2024.111763" target="_blank" rel="noreferrer noopener">Interviews with 29 participants found that</a> recovery took longer than people expected. They were unsure if their symptoms were normal; many wanted more information: “Even just a little leaflet would be good… To say you're getting back on your feet.” People valued spending time with physiotherapists but access to physiotherapy varied between hospitals. For most, pain did not greatly limit their recovery, but the fear of pain and injury did: “When you've been in the cast for a few weeks and then you get transferred into the boot…it is quite frightening.” <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The study suggests that walking 2 weeks after surgery for a broken ankle is as safe as waiting 6 weeks and costs the NHS and social care less. This means that people could return to normal activities earlier. Clinicians could inform patients of the findings when discussing their rehabilitation. Policymakers could consider ways to encourage more clinicians to recommend a 2-week waiting period; from 2019 to 2021, just <a href="https://doi.org/10.1016/j.foot.2019.02.005" target="_blank" rel="noreferrer noopener">11% of people were recommended this approach</a>.  The authors stress that surgeons considered that many people (42% of the 2,218 assessed) needed to wait for the full 6 weeks after surgery before walking; these people were therefore ineligible for inclusion in this study. This means the findings may be less generalisable to people with more serious fractures. In addition, many people in the 6-week group (38%) did not wait the full period before walking, which may have affected the findings. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The findings from the study have been included in a <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD005595.pub4/full" target="_blank" rel="noreferrer noopener">Cochrane review</a> on rehabilitation after ankle fractures. The researchers hope the findings will inform <a href="https://www.nice.org.uk/guidance/ng38/chapter/Recommendations" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE) guidelines</a> on fractures. The researchers plan to audit UK practice for ankle fracture recovery in 2025. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Bretherton CP, and others. <a href="https://doi.org/10.1016/s0140-6736(24)00710-4" target="_blank" rel="noreferrer noopener">Early versus delayed weight-bearing following operatively treated ankle fracture (WAX): a non-inferiority, multicentre, randomised controlled trial</a>. The Lancet 2024; 403: 2787 – 2797.  A podcast about the study from <a href="https://www.cochrane.org/podcasts/10.1002/14651858.CD005595.pub4" target="_blank" rel="noreferrer noopener">Cochrane</a>. Information on recovering from a broken ankle from the <a href="https://www.kch.nhs.uk/wp-content/uploads/2023/01/pl-994.1-simple-ankle-fractures.pdf" target="_blank" rel="noreferrer noopener">NHS</a>. Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=ankle%20fracture&location=" target="_blank" rel="noreferrer noopener">NIHR research on ankle fracture</a>.   Funding: This study was funded by the <a href="https://www.nihr.ac.uk/research-funding/funding-programmes/research-for-patient-benefit" target="_blank" rel="noreferrer noopener">NIHR Research for Patient Benefit programme</a>. It was also supported by the <a href="https://www.qmul.ac.uk/nihr-bartsbrc/" target="_blank" rel="noreferrer noopener">NIHR Barts Biomedical Research Centre</a>, the <a href="https://www.arc-oxtv.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Applied Research Collaboration Oxford and Thames Valley</a>, and an <a href="https://www.nihr.ac.uk/career-development/research-career-funding-programmes/professorships-and-senior-investigators" target="_blank" rel="noreferrer noopener">NIHR Senior Investigator award</a>. Conflicts of Interest: None relevant. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>D-mannose does not prevent urinary tract infections</title> <link>https://evidence.nihr.ac.uk/alert/d-mannose-does-not-prevent-urinary-tract-infections-utis/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 06 Feb 2025 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65884</guid> <description><![CDATA[D-mannose is often marketed as a dietary supplement that prevents urinary tract infections (UTIs). There is little research to support this. Researchers therefore compared D-mannose to a dummy supplement (fructose) in women seeking GP advice for frequent UTIs. After 6 months, those taking D-mannose had: D-mannose does not prevent UTIs among women with recurrent UTIs ...]]></description> <content:encoded><![CDATA[ D-mannose is often marketed as a dietary supplement that prevents urinary tract infections (UTIs). There is little research to support this. Researchers therefore compared D-mannose to a dummy supplement (fructose) in women seeking GP advice for frequent UTIs. After 6 months, those taking D-mannose had: <ul class="wp-block-list"> <li>no reduction in suspected UTIs for which they contacted primary care</li> <li>no reduction in laboratory-confirmed UTIs</li> <li>no reduction in hospital admissions for UTIs.</li> </ul> D-mannose does not prevent UTIs among women with recurrent UTIs presenting to primary care, the authors conclude. <a href="https://www.nhs.uk/conditions/urinary-tract-infections-utis/" target="_blank" rel="noreferrer noopener">More information on urinary tract infections can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-is-d-mannose-helpful-for-utis">The issue: is D-mannose helpful for UTIs?</h2> Urinary tract infections (UTIs) affect the organs involved in peeing, including the bladder, urethra (the tube that allows urine to pass out of the bladder), and kidneys. They are more common in women than men; 1 in 2 women will have a UTI in their lifetime, and about 1 in 4 who have a first UTI will go on to have frequent, or recurrent, infections (2 in 6 months or 3 in a year). UTIs negatively impact women’s personal, social and working lives. The <a href="https://www.nice.org.uk/guidance/ng112/chapter/Recommendations" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE)</a> recommends daily, low-dose antibiotics as an option to prevent frequent UTIs in women. However, taking them long-term can increase the chance of bacteria becoming resistant, and the antibiotics ineffective. Other options include vaginal oestrogen and methenamine hippurate (an antiseptic drug, not an antibiotic). The guidelines note that some women self-care with cranberry products or D-mannose. D-Mannose is a sugar found in some fruits and vegetables, and sold as a dietary supplement. It has been thought to stop bacteria that cause UTIs attaching to bladder lining cells. However, it is not prescribed on the NHS and there is little evidence to support its use.   Researchers assessed whether D-mannose prevents UTIs in women with frequent infections. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The study included 99 GP practices in England and Wales who invited women with recurrent urinary tract infections (UTIs) to take part. They ranged in age from 18 to 93; the average was 59 years. The majority (64%) were postmenopausal. Half the women took 2 grams of D-mannose every day; the others took 2 grams of fructose sugar (control). The main outcome was the number who sought medical help for a suspected UTI within 6 months of the start of the study. 298 from the D-mannose group and 289 from the control group provided data for this outcome. The researchers found that after 6 months, D-mannose made little difference to: <ul class="wp-block-list"> <li>the number of women who contacted a healthcare provider with suspected UTIs (51% D-mannose group; 56% control group)</li> <li>the number of hospital admissions for UTIs (2% D-mannose group; 1% control group)</li> <li>other secondary outcomes such as the number of laboratory-confirmed UTIs or courses of prescribed antibiotics.</li> </ul> The study included fewer pre- than postmenopausal women. However, the lack of effect of D-mannose on suspected UTIs was similar in pre- and postmenopausal women. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The study suggests that D-mannose is not effective at preventing urinary tract infections (UTIs) in women who have frequent infections. Primary care clinicians could discuss these findings with women who are considering taking D-mannose. This trial was designed to evaluate real life use of preventive medicines, including self-administration and missed doses. Women measured out D-mannose and fructose using a scoop, so some may have taken more or less than was intended. More than 2 in 3 reported taking the D-mannose at least 3 days a week for 15 weeks of the study so some doses may have been missed. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers have contacted NICE about their guidance on D-mannose. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Hayward G, and others. <a href="https://doi.org/10.1001/jamainternmed.2024.0264" target="_blank" rel="noreferrer noopener">D-Mannose for Prevention of Recurrent Urinary Tract Infection Among Women: A Randomized Clinical Trial</a>. JAMA Internal Medicine 2024; 184: 619 – 628.  Information and support from <a href="https://bladderhealthuk.org/" target="_blank" rel="noreferrer noopener">Bladder Health UK</a>. A summary of a paper about another <a href="https://evidence.nihr.ac.uk/alert/methenamine-as-good-as-antibiotics-preventing-urinary-tract-infections/">non-antibiotic alternative to prevent frequent UTIs in women</a>.   Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=urinary%20tract%20infections&location=" target="_blank" rel="noreferrer noopener">NIHR research on urinary tract infections</a>. Funding: This study was funded by the <a href="https://www.spcr.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR School for Primary Care Research</a>. Christopher Butler received support as an NIHR senior investigator. Additional support was provided by the <a href="https://www.imperial.ac.uk/medicine/hpru-amr/" target="_blank" rel="noreferrer noopener">NIHR Health Protection Research Unit on Healthcare Associated Infections and Antimicrobial Resistance</a>, the <a href="https://oxfordbrc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Oxford Biomedical Research Centre</a>, and the <a href="https://www.nihr.ac.uk/explore-nihr/academy-programmes/integrated-academic-training.htm" target="_blank" rel="noreferrer noopener">NIHR Academic Clinical Lectureship programme</a>. Conflicts of Interest: None reported. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Recurrent UTIs: more urine testing would improve choice of antibiotic</title> <link>https://evidence.nihr.ac.uk/alert/recurrent-utis-more-urine-testing-would-improve-choice-of-antibiotic/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 04 Feb 2025 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65792</guid> <description><![CDATA[Daily antibiotics are often prescribed as a preventive treatment for women who have frequent or recurrent urinary tract infections (UTIs). In this Welsh database study, researchers found that 6% of women had recurrent UTIs over a 10-year period. Antibiotic resistant urine infections were common in this group, yet many women did not have urine tests ...]]></description> <content:encoded><![CDATA[ Daily antibiotics are often prescribed as a preventive treatment for women who have frequent or recurrent urinary tract infections (UTIs). In this Welsh database study, researchers found that 6% of women had recurrent UTIs over a 10-year period. Antibiotic resistant urine infections were common in this group, yet many women did not have urine tests (to identify bacteria and check for bacterial resistance to antibiotics) before being prescribed preventive antibiotics. The researchers call for more urine testing for women with recurrent UTIs, as per <a href="https://uroweb.org/guidelines/urological-infections" target="_blank" rel="noreferrer noopener">international guidelines</a>, to inform decisions about what antibiotic is best for them.   <a href="https://www.nhs.uk/conditions/urinary-tract-infections-utis/" target="_blank" rel="noreferrer noopener">More information on UTIs can be found on the NHS website</a>.<a id="_msocom_1"></a> <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-how-are-recurrent-utis-managed">The issue: how are recurrent UTIs managed?</h2> Urinary tract infections (UTIs) affect the organs involved in peeing, including the bladder, urethra (the tube that transports urine out of the body), and kidneys. Estimates vary on how common recurrent UTIs are in women (from 3% to 44% in different studies). The <a href="https://www.nice.org.uk/guidance/ng112/chapter/Recommendations" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE) guidelines</a> state that daily, low-dose antibiotics are an option for the prevention of UTIs among women who have recurrent UTIs. However, if bacteria develop resistance to this long-term treatment, the antibiotics can become ineffective and the infections difficult to treat. Urine tests are recommended for women with, or suspected of having, recurrent UTIs. The tests can identify the presence of bacteria, and whether there is resistance to antibiotics. This informs the choice of antibiotic. This study explored how common recurrent UTIs are in women and the use of preventive antibiotics. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers searched a database of primary care records in Wales to find data on women who were diagnosed with recurrent UTIs (2+ in 6 months, or 3+ in a year), and women who were prescribed preventive antibiotics specifically for UTIs (trimethoprim, nitrofurantoin, or cefalexin), from 2010 to 2020. They assessed the associated urine test results from the same women from 2015 to 2020. In total, 6% of women in the database had recurrent UTIs; 2% were prescribed preventive antibiotics. The number of women with recurrent UTIs increased around the average age of the menopause and continued to rise with age. Prescriptions for preventive antibiotics followed a similar pattern. The most common antibiotic used was trimethoprim. The researchers found that: <ul class="wp-block-list"> <li>only half (49%) the women prescribed preventive antibiotics were diagnosed with recurrent UTIs before they started treatment</li> <li>most (81%) women who were diagnosed with recurrent UTIs had a urine test in the previous year</li> <li>about 2 in 3 (64%) women taking preventive antibiotics received a urine test result before starting treatment</li> <li>many women with recurrent UTIs had urine infections resistant to trimethoprim (40%) and amoxicillin (57%); some (19%) women prescribed trimethoprim as a preventive antibiotic had UTIs that were resistant to it.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The researchers call for more regular urine testing before starting preventive treatment for recurrent UTIs as many women’s infections show resistance to commonly prescribed preventive antibiotics. This could help inform the choice of both short-term (treatment of UTIs) and preventive antibiotics among women with recurrent urine infections. The study provides information about how common recurrent UTIs are among women. However, the analysis may be an underestimate as it did not include women presenting to out-of-hours general practice and accident and emergency departments if they did not require hospital admission. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> This analysis was part of a <a href="https://impart.yolasite.com/" target="_blank" rel="noreferrer noopener">larger project that aims to develop a decision aid</a> to support discussions between women and clinicians about how to prevent recurrent UTIs.   Information from this study will be included in resources by the UK Health Security Agency’s <a href="https://elearning.rcgp.org.uk/mod/book/view.php?id=12652" target="_blank" rel="noreferrer noopener">TARGET (treat antibiotics responsibly, guidance, education, tools)</a> team. <a id="_msocom_1"></a> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Sanyaolu L, and others. <a href="https://doi.org/10.3399/bjgp.2024.0015" target="_blank" rel="noreferrer noopener">Recurrent urinary tract infections and prophylactic antibiotic use in women: a cross-sectional study in primary care</a>. British Journal of General Practice 2024; 74: e619 – e627. <a href="https://elearning.rcgp.org.uk/mod/book/view.php?id=12652" target="_blank" rel="noreferrer noopener">Resources for clinicians on reducing antibiotic prescribing</a> from the UK Health Security Agency’s TARGET (treat antibiotics responsibly, guidance, education, tools) team. A Royal College of General Practitioners <a href="https://rcgp.my.site.com/s/lt-event?id=a1USg000000y06nMAA&site=a0d1i00000aKQbhAAG" target="_blank" rel="noreferrer noopener">webinar on managing recurrent UTIs</a> due to take place in March 2025. A <a href="https://www.wsh.nhs.uk/CMS-Documents/Services/Urology/Recurrent-UTI-Booklet.pdf" target="_blank" rel="noreferrer noopener">booklet for patients on frequent UTIs</a>. Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=urinary%20tract%20infections&location=" target="_blank" rel="noreferrer noopener">NIHR research on urinary tract infections</a>. Funding: This study was funded by <a href="https://healthandcareresearchwales.org/" target="_blank" rel="noreferrer noopener">Health and Care Research Wales</a>. Conflicts of Interest: None declared. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>What support do people with long COVID need to return to work?</title> <link>https://evidence.nihr.ac.uk/alert/what-support-do-people-with-long-covid-need-to-return-to-work/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 30 Jan 2025 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65781</guid> <description><![CDATA[People with long COVID can struggle to return to, and stay in, employment due to fluctuating and unpredictable symptoms. Interviews with people with long COVID highlighted the problems they face. The researchers call for employers to recognise that some staff with long COVID could be considered disabled under the Equality Act (where long COVID has, ...]]></description> <content:encoded><![CDATA[ People with long COVID can struggle to return to, and stay in, employment due to fluctuating and unpredictable symptoms. Interviews with people with long COVID highlighted the problems they face. The researchers call for employers to recognise that some staff with long COVID could be considered disabled under the Equality Act (where long COVID has, or is likely to have, a substantial and long-term negative effect on an individual’s ability to undertake normal daily activities). Workplace adjustments and flexible support where necessary help employees return to and stay in work. The researchers hope their findings will help employers to support staff with long COVID. <a href="https://www.nhs.uk/conditions/covid-19/long-term-effects-of-covid-19-long-covid/" target="_blank" rel="noreferrer noopener">More information about long COVID can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-returning-to-work-with-long-covid">The issue: returning to work with long COVID</h2> According to the <a href="https://www.nice.org.uk/guidance/ng188/chapter/1-Identification" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE)</a>, people have long COVID if they have symptoms (such as fatigue and brain fog) 12 weeks or more after their initial infection. In March 2023, the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/prevalenceofongoingsymptomsfollowingcoronaviruscovid19infectionintheuk/30march2023#:%EF%BF%A2%EF%BE%88%EF%BE%BC:text=Figure%201%3A%201.9%20million%20people,as%20of%205%20March%202023" target="_blank" rel="noreferrer noopener">Office of National Statistics</a> estimated that almost 2 million people in the UK experienced ongoing COVID-19 symptoms for at least 1 year. Research has shown that <a href="https://www.thelancet.com/journals/eclinm/article/PIIS2589-5370(21)00299-6/fulltext" target="_blank" rel="noreferrer noopener">physical or cognitive exertion and stress trigger symptoms in most (up to 87%) people</a> with long COVID. Readiness to return to work can be difficult to predict because of the fluctuating nature of long COVID. The <a href="https://www.gov.uk/definition-of-disability-under-equality-act-2010" target="_blank" rel="noreferrer noopener">Equality Act 2010</a> protects people with disabilities from unlawful discrimination and facilitates welfare and workplace support. Employers are obliged to consider the effect a condition has on an individual; decisions on whether someone is considered disabled are taken case-by-case, depending on personal circumstances.   The current study investigated the experiences of people returning to paid employment while living with long COVID. <h2 class="wp-block-heading" class="wp-block-heading" id="perspectives-of-people-with-long-covid-returning-to-work">Perspectives of people with long COVID returning to work</h2> Researchers analysed phone and video interviews with 65 people with long COVID taken from 3 UK studies conducted between March 2021 and July 2022. Most (80%) were aged between 30 and 60. Many were women (75%) and white (69%). Half (51%) were employed in public sector jobs; healthcare and education (14% participants in each) were the largest sectors. The researchers asked people how long COVID affected their lives and its impact on employment and ability to work. They identified 4 main themes. 1. Altered identity Most people were keen to return to work; they missed the social contact, the feeling of purpose and they worried about the financial implications of losing their job. Having long COVID could lead to a loss of identity. One person said: ‘[Long Covid] was suddenly a big part of my identity… A substantial part of my earning capacity all gone overnight…’ Some felt unable to disclose the full extent of their symptoms due to concerns about being judged as less capable or losing their job. They described debilitating, work-related symptoms such as problems with thinking, memory and making decisions. 2. Between classifications Sickness absence policies that classify employees in binary terms such as healthy, ill, able or disabled do not accurately describe people with unpredictable illnesses that vary in severity, like long COVID. Some participants fluctuated between being (almost) able to work and being completely unable to work. One said: ‘[Policies at work] record you as either ill or you’re well, nothing in between.’ Returning to work too soon could worsen symptoms, but having repeated sick notes was dispiriting; some felt they had to repeatedly show employers they had a legitimate illness. Remote working could mask the severity of symptoms. 3. Disabling or engaging workplaces Some people were expected to maintain the same pace as their colleagues. Most said a standard 4-week phased return to work was not suitable for fluctuating impairments; more gradual and tailored returns were more effective. Some were offered additional workplace adjustments (flexible hours, frequent breaks and adapted roles, for instance): ‘[my employer] worked with me to look at how the role could be reduced… and then they created a new role that allowed me, to still add value. They reduced hours, they gave me complete control and flexibility of my diary.’ When appropriate occupational health support was provided it could enable a sustainable return to work. 4. Adjustment work People described doing so-called adjustment work to help them get back to work, for instance limiting the time spent sitting and standing, and cutting back on leisure activities to prioritise energy for work. One person said: ‘I’ve realised that being able to lie down or recline is the way for me to be able to get more out of myself because my fatigue is driven by being upright…’ Some participants had to repeatedly explain symptoms to managers and colleagues and justify their need for workplace adjustments. For those who could not return to their previous level of work, the challenges of navigating the benefits system were heightened by their long COVID symptoms, such as fatigue and brain fog. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The Equality Act is intended to protect workers’ rights. Employers are obliged to consider the effect of a condition, including long COVID, on an individual worker. Where long COVID has, or is likely to have, a substantial and long-term negative effect on someone’s ability to undertake normal daily activities, they could be considered disabled under the Act. This entitles them to workplace welfare and support, and reduces additional administrative work. Long COVID is a relatively new condition, and employers may struggle to support their staff effectively. This research found that people who had the autonomy to shape their workload around fluctuating symptoms were able to keep working. Research into long COVID is at an early stage, and more needs to be known about diagnostic tests, treatments and the consequences of returning to work. Sustained employment is linked with health benefits, but to benefit, people with long COVID need workplace and welfare support systems. The study did not include many people who work in sectors such as supermarkets and transport. These groups are likely to have been exposed to COVID-19 early in the pandemic, when symptoms were more severe and before vaccines became available. The findings may therefore not be entirely representative of the general population. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> These findings have informed a new <a href="https://www.stir.ac.uk/research/hub/contract/1851299" target="_blank" rel="noreferrer noopener">study</a>, funded by the Scottish Government’s Chief Scientist Office. The new work explores what having long COVID is like for professionals who deliver public services and work in demanding ‘front-line’ jobs, for instance nurses, teachers, ambulance clinicians and police officers. Its goal is to understand how employers can help people return to work, and to explore the impact of staff absences for long COVID on colleagues. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Anderson E, and others. <a href="https://doi.org/10.1080/09687599.2024.2331722" target="_blank" rel="noreferrer noopener">Episodic disability and adjustments for work: the ‘rehabilitative work’ of returning to employment with long COVID</a>. Disability & Society 2024; 1 – 24. The interviews in this study were carried out in 3 UK studies, from the <a href="https://www.cso.scot.nhs.uk/wp-content/uploads/COV-LTE-04-Final-Report.pdf" target="_blank" rel="noreferrer noopener">Scottish Chief Scientist Office</a>, the <a href="https://fundingawards.nihr.ac.uk/award/COV-LT2-0005" target="_blank" rel="noreferrer noopener">NIHR</a> and the <a href="https://gtr.ukri.org/projects?ref=ES%2FV016032%2F1" target="_blank" rel="noreferrer noopener">Economic and Social Research Council</a> Information from the same team on <a href="https://hexi.ox.ac.uk/Long-Covid-In-Adults/overview" target="_blank" rel="noreferrer noopener">adults’ experiences of long COVID</a>. <a href="https://www.fom.ac.uk/wp-content/uploads/longCOVID_guidance_04_small.pdf" target="_blank" rel="noreferrer noopener">Guidance for healthcare professionals about helping people with long COVID return to work</a> from the Faculty of Occupational Medicine. An NIHR Evidence summary: <a href="https://evidence.nihr.ac.uk/alert/how-much-does-long-covid-cost-individuals-informal-carers-and-society/">How much does long COVID cost individuals, informal carers, and society?</a> Funding: This study was funded by the the <a href="https://www.nihr.ac.uk/about-us/what-we-do/covid-19/long-COVID" target="_blank" rel="noreferrer noopener">NIHR</a>, <a href="https://www.cso.scot.nhs.uk/" target="_blank" rel="noreferrer noopener">Chief Scientist Office</a> and <a href="https://www.ukri.org/councils/esrc/" target="_blank" rel="noreferrer noopener">Economic and Social Research Council</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1080/09687599.2024.2331722" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Water births do not increase risks for mother or baby</title> <link>https://evidence.nihr.ac.uk/alert/water-births-do-not-increase-risks-for-mother-or-baby/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 28 Jan 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65746</guid> <description><![CDATA[Researchers analysed data on women without pregnancy complications who used a birthing pool during labour. Some women got out of the pool due to medical complications during labour or because they wanted pain relief that cannot be given in water. Among women without labour complications, compared with leaving the pool to give birth, giving birth ...]]></description> <content:encoded><![CDATA[ Researchers analysed data on women without pregnancy complications who used a birthing pool during labour. Some women got out of the pool due to medical complications during labour or because they wanted pain relief that cannot be given in water. Among women without labour complications, compared with leaving the pool to give birth, giving birth in the pool led to: <ul class="wp-block-list"> <li>no increase in serious tears (from vagina to anus)</li> <li>no increase in baby deaths, neonatal admissions with breathing support, or infections requiring antibiotics among babies.</li> </ul> The study could reassure women and healthcare professionals about the safety of water births. Clinicians could discuss these findings with pregnant women considering using a birthing pool during labour. <a href="https://www.nhs.uk/pregnancy/labour-and-birth/signs-of-labour/what-happens-at-the-hospital-or-birth-centre/" target="_blank" rel="noreferrer noopener">More information on waterbirths can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-are-water-births-safe">The issue: are water births safe?</h2> The <a href="https://www.nice.org.uk/guidance/ng235/chapter/Recommendations" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE)</a> recommends birthing pools as a pain relief option during labour for women without pregnancy complications. Some women leave the water before birth, others give birth in the pool. There have been reports of infections, newborn babies inhaling water, and higher rates of perineal tears during water births. While NICE has stated that the evidence is not strong enough to discourage these births, some professionals remain reluctant to promote water births. This study explored the safety of giving birth in water. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The analysis included 60,402 women without pregnancy or labour complications who used a birthing pool during labour between 2015 – 2022 in the UK. 39,627 gave birth in the water and 20,775 gave birth out of the water. Among women, the main outcome was serious perineal tears (from vagina to anus) during birth. Among babies, it was a combination of baby deaths in hospital, neonatal admissions with breathing support or antibiotics given into a vein.   Rates of most outcomes were the same with water births, compared with births out of water. The researchers found: <ul class="wp-block-list"> <li>no difference in the numbers of serious tears (2.5% water births; 3.8% births out of water)</li> <li>no difference in the combined outcome of baby deaths, neonatal admissions, or antibiotic prescriptions (2.7% water births; 4.4% births out of water).</li> </ul> Baby deaths were extremely rare in both groups (2 per 10,000 waterbirths; 3 per 10,000 births out of water). Few babies were admitted to a neonatal unit after birth (1.5% waterbirths; 0.8% births out of water) or needed intravenous antibiotics (1.8% waterbirths; 2.9% births out of water).   Among women who had given birth before, serious tears were less common with waterbirths (1.1%) than births out of water (1.7%). Among women giving birth to their first baby, the likelihood of tears was the same between groups. There was also no difference for most other outcomes: the mother bleeding, manually removing the placenta, delayed start to breastfeeding, or shoulder dystocia (when a baby's shoulder gets stuck behind the mother's pubic bone). Umbilical cord snapping (which can abruptly stop the flow of blood to the baby) was more common with waterbirths (1%) than with births out of water (0.3%). <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The study provides reassurance about the safety of water births. Clinicians could discuss these findings with women considering using a birthing pool. Women who received specialist care before giving birth were excluded from the main analysis, which reflects NHS care: women with identified problems during labour are referred to an obstetrician. The remaining women (giving birth in or out of water) are under midwifery care. When midwives identify problems during labour or close to birth, providing there is time to get out safely, women are advised to leave the water. Rates of midwife concerns were therefore higher among births out of water. Further analysis of births with no such concerns found no increase in complications with water births for women or their babies. The researchers say that although umbilical cord snapping was more likely with waterbirths, the difference between groups was relatively small, and uncommon overall. Previous studies have suggested that a randomised controlled trial comparing the safety of water births versus out of water births would not be possible. This study used a maternity care database and the researchers caution that data used from NHS maternity records could not be checked for accuracy. In addition, infant readmissions to hospital were not assessed because babies are often readmitted to children’s units rather than maternity units. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers have informed NICE about their study and hope it will inform future guidance. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Sanders J, and others. <a href="https://doi.org/10.1111/1471-0528.17878" target="_blank" rel="noreferrer noopener">Maternal and neonatal outcomes among spontaneous vaginal births occurring in or out of water following intrapartum water immersion: The POOL cohort study</a>. British Journal of Obstetrics and Gynaecology 2024; 129: 950 – 958. A study of women’s views on water births: Milosevic S, and others. <a href="https://doi.org/10.1016/j.midw.2019.102554" target="_blank" rel="noreferrer noopener">Factors influencing the use of birth pools in the United Kingdom: Perspectives of women, midwives and medical staff</a>. Midwifery 2019; 79: 1 – 8. A summary of the study’s main findings from <a href="https://www.cardiff.ac.uk/__data/assets/pdf_file/0011/2821790/POOL-Study-Using-a-pool-during-labour-and-birth.pdf" target="_blank" rel="noreferrer noopener">Cardiff University</a>. Information about water births from the charity <a href="https://www.tommys.org/pregnancy-information/giving-birth/where-can-i-give-birth/how-prepare-water-birth" target="_blank" rel="noreferrer noopener">Tommy's</a> and the <a href="https://www.nct.org.uk/labour-birth/different-types-birth/water-birth/how-labour-water-or-have-water-birth" target="_blank" rel="noreferrer noopener">National Childbirth Trust</a>. Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=Pregnancy&location=" target="_blank" rel="noreferrer noopener">NIHR research on pregnancy</a>. Funding: <a href="https://www.nihr.ac.uk/research-funding/funding-programmes/health-technology-assessment" target="_blank" rel="noreferrer noopener">Health Technology Assessment Programme</a> Commissioned Call, with support from <a href="https://healthandcareresearchwales.org/" target="_blank" rel="noreferrer noopener">Health and Care Research Wales</a>. Conflicts of Interest: None relevant. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>What is the impact of a gradual reduction of antipsychotics?</title> <link>https://evidence.nihr.ac.uk/alert/what-is-the-impact-of-a-gradual-reduction-of-antipsychotics/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 23 Jan 2025 09:00:31 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65756</guid> <description><![CDATA[Podcast: What is the impact of a gradual reduction of antipsychotics? In this podcast, Helen Saul, Editor in Chief of NIHR Evidence, discusses the impact of a gradual reduction of antipsychotics with study author Joanna Moncrieff, Professor of Critical and Social Psychiatry, UCL and Rachel Upthegrove, Professor of Psychiatry, formerly at the University of Birmingham ...]]></description> <content:encoded><![CDATA[ <h2 class="wp-block-heading" class="wp-block-heading" id="podcast-what-is-the-impact-of-a-gradual-reduction-of-antipsychotics">Podcast: What is the impact of a gradual reduction of antipsychotics?</h2> In this podcast, Helen Saul, Editor in Chief of NIHR Evidence, discusses the impact of a gradual reduction of antipsychotics with study author Joanna Moncrieff, Professor of Critical and Social Psychiatry, UCL and Rachel Upthegrove, Professor of Psychiatry, formerly at the University of Birmingham and now at the University of Oxford & Consultant Psychiatrist, Early Intervention and Psychosis Services. <div id="buzzsprout-player-16428135"></div><script src="https://www.buzzsprout.com/1833774/episodes/16428135-what-is-the-impact-of-a-gradual-reduction-of-antipsychotics.js?container_id=buzzsprout-player-16428135&player=small" type="text/javascript" charset="utf-8"></script> <section class="guten-block block-accordion "> <div class="row"> <div class="column small-12"> <div class="tabs"> <div class="tab"> <input type="checkbox" id="chck-block_206944bd66476fca512943611f702bdb-1"> <label class="tab-label has-background has-blue-background-color " for="chck-block_206944bd66476fca512943611f702bdb-1">Audio Transcript</label> <div class="tab-content"> Podcast transcript: What is the impact of a gradual reduction of antipsychotics?   [MUSIC] 0:08 Helen Saul: Hello, and welcome. In this podcast from the NIHR, we will be looking at psychosis and the potential benefits and harms of reducing the dose of antipsychotic medicines. During a psychotic episode, people lose some contact with reality. They might see, hear or believe things that other people don’t. Their thoughts, ideas and speech may become fast and confusing; these symptoms can cause severe distress, and change people’s behaviour. Antipsychotic medicines reduce the risk of psychotic episodes – and they are recommended for long-term use by people with schizophrenia or recurrent psychosis. But the medicines can have such unpleasant side effects that people prescribed these drugs may want to reduce or to stop them. Today we are discussing an NIHR trial in which people were supported to gradually reduce their antipsychotic treatment. My name is Helen Saul, and I’m the editor in chief of the NIHR Evidence website. I have 2 guests with me today. Welcome first to author Joanna Moncrieff. 1:20 Joanna Moncrieff: Thank you for having me. I’m a professor of critical and social psychiatry at the at University College, London, and I was the chief investigator for the what was called the RADAR program, research into antipsychotic discontinuation and reduction which was funded by the NIHR as I said. 01:38 Helen Saul: Okay. And Rachel Upthegrove. 01:40 Rachel Upthegrove: Hi! Thanks for inviting me. So, yes, my name is Rachel Upthegrove. I’m a professor of psychiatry and youth mental health at the University of Birmingham, and a consultant psychiatrist in early intervention and psychosis services, where I’ve worked for over 20 years. 01:56 Helen Saul: Thank you. Rachel, could you outline for us the impact of recurrent psychosis on someone’s life? 2:04 Rachel Upthegrove: Psychosis in itself can be very impactful for people’s function in terms of ability to maintain roles, jobs, relationships. And because the onset of the illness is between late late teens and early twenties, for the majority of people, this is a critical period for developing those social roles as in jobs, relationships, place in society. 2:28 Helen Saul: And you’d see antipsychotic drugs as an important part of treatment? 2:33 Rachel Upthegrove: Coming from the background I do, from from early intervention, our our aim has always been to reduce the impact of psychosis and reduce what we call the duration of untreated psychosis by intervening early after someone has made or had a first episode of psychosis. So antipsychotic medication, we know, is effective in 75 to 80% of people for treating an acute psychotic episode, and in early intervention. So, that’s part of psychological, social, peer support and other interventions, but as a very key, as a very key part. 3:06 Helen Saul: What about the side effects of these drugs, Rachel? 3:10 Rachel Upthegrove: All medication or everything, every treatment would have potential side effects. So psychological interventions, social interventions, but also medication has potential for side effects. In terms of antipsychotics, these can be broadly grouped into things that might affect what we call extrapyramidal side effects, so, muscle stiffness, tremor, rigidity. The more, sort of, second generation antipsychotics might have a little bit more emphasis on other things like weight gain and sedation and and also can affect, sort of, hormone levels, so prolactin, so they can stop periods and and cause and cause other prolactin-related side effects. So, they do have a range of side effects that that people want to to avoid by getting dosing regimes right. And and and all medication has side effects that that as a as a prescriber you talk to your patient about, and would be honest with them about potential for side effects as well as potential for benefits. 4:14 Joanna Moncrieff: I just think it’s important to emphasise they are, they are really significant. 4:18 Rachel Upthegrove: Yeah. And this is a and this is treating a significant illness. So, I think that yes. 4:21 Joanna Moncrieff: Yes, of course. 4:24 Helen Saul: Joanna, you led a trial called RADAR exploring the impact of gradually reducing antipsychotic treatment. Before we discuss that work, perhaps you could tell us what previous research has shown? 4:37 Joanna Moncrieff: So, there have been lots of studies that have compared continuing with antipsychotic medication with coming off it and being given a placebo instead or just coming off it altogether. And those studies generally show that people who come off the medication are more likely to have a relapse and end up in hospital. But one of the reasons for doing the RADAR study was that those studies have almost all taken people off antipsychotics very quickly and we know that there are withdrawal effects, including agitation and sleep problems. There’s also possibly a link between withdrawal and psychosis itself, so that it may be that withdrawal increases the risk of having a psychotic relapse that’s specifically related to the withdrawal process rather than the underlying condition. 5:30 Helen Saul: So what approach did the RADAR study take, Joanna? 5:34 Joanna Moncrieff: The trial was aimed at people who had recurrent episodes of psychosis or a diagnosis of schizophrenia. And what we did was identify them. We excluded people who were thought to have very, very severe risks of of harming themselves or harming other people if they were, if they came off medication, but otherwise our inclusion criteria were fairly fairly broad. We recruited people from secondary care mental health services and once people consented to to join the study, then they had a baseline assessment, and then they were randomized either to continue on their current dose of medication, more or less. People could make adjustments for side effects, obviously, but they were encouraged to stay stay on their current dose if they could. Or they were randomised to have a gradual reduction of their medication, supported and overseen by their treating clinician. And people came into the the trial on all sorts of different medication regimes, different sorts of antipsychotics, and different combinations of antipsychotics in some cases. So what we did was, we drew up a schedule for each individual for for a gradual reduction of their medication that that their clinicians could follow. But we also emphasized that the reduction was meant to be flexible, and you know, people weren’t, weren’t to be forced to continue to reduce if they, you know, were having a life crisis, or if the reduction was going badly, and their symptoms were coming back. So it was meant to be flexible. And then people were followed up at 6 months, a year, and the main follow up was 2 years after randomization. 7:29 Helen Saul: And what was happening at 2 years? What were your main findings? 7:33 Joanna Moncrieff: What we found was that people who had been randomised to reduction were more likely to relapse than people who were randomised to maintenance treatment. We defined relapse quite stringently. Our main relapse outcome was readmission to hospital with with a psychotic episode. So so that was the result in terms of relapse, which was disappointing, because we hoped that we could reduce the rate of relapse. I don’t think we ever thought that there would be no relapses, but we hoped that by doing this gradual reduction process, we could at least have lower relapses than than were seen in other maintenance studies, but in fact, the relapse rate was around about the same as as in most maintenance studies, the readmission rate, the hospitalisation rate, anyway. 8:23 Helen Saul: But your main outcome was social functioning. Could you explain what that means, please? 8:28 Joanna Moncrieff: Social functioning really means, how, how are people able to get on with their day to day lives. Are people able to go to work? Are people able to look after themselves, attend to their personal care? Do their shopping and cooking? Are people able to get on with other people, both their close family members, but also members of the public, are people able to take part in in leisure activities as well as well as work activities. So it’s that’s that’s what social functioning means. 9:01 Helen Saul: And was there an improvement in social functioning with a reduction in antipsychotics? 9:05 Joanna Moncrieff: We had hypothesised that maybe there might be an improvement in social functioning at our 2 year outcome, although I think we always thought that was a little bit optimistic. The Dutch study that we had modeled the study on had only found the improvement in social functioning at their 7 year follow up, in fact. But anyway, we we looked at social functioning at 2 years. There was no improvement in the group who’d been randomised to reduction, but there was no detrimental effect either. There was no difference between people who had been randomised to reduction and people who had been randomised to maintenance treatment in terms of their social functioning or in terms of their symptom levels at follow-up or their quality of life or their medication side effects, even though they’d they’d reduced their medication quite a bit. So that was a surprising finding. Or their satisfaction levels, or any of the other outcomes that we looked at. 10:01 Helen Saul: So what was your response to your own findings, Joanna? You said the increase in relapse was disappointing. 10:08 Joanna Moncrieff: It was disappointing. As I say, I hoped I hoped that we could at least have reduced relapse rates a little bit, and I think it’s, you know, I think it’s interesting and important to know the sort of gradual reduction we did, anyway, which was over about a year to 18 months, doesn’t significantly reduce relapse rates. It’s possible that doing reduction over a longer period might might be better. So that was disappointing. I think it’s also important to emphasize, though, that our study, like other studies, found that not everyone relapses. In fact, overall there’s an increased risk of relapse but for each individual it doesn’t mean that each individual will relapse if they stop their medication. 10:53 So the point of the RADAR study was always to provide information for people to make informed decisions about the the risks and benefits of treatment. And so, the RADAR study, along with, along with other studies of antipsychotic reduction does show that there’s an increased risk, but not an inevitable risk of having a relapse. I should also mention that we at the same time, as publishing our the main paper detailing the quantitative results of the study, we published our qualitative study. In our qualitative study, we interviewed 23 people who’d been involved in the antipsychotic reduction programme in in detail, and we made a point of selecting people who’d had various outcomes, not not just people who’d done well with reduction, but people who’d done badly with the reduction, people who’d relapsed, and people who hadn’t been able to even make a reduction. 11:50 And in that study, what what was really interesting was that that many of the people in the reduction group felt had felt a sense of empowerment through the process of reduction, even if it had not worked out well for them, and had come out in some cases thinking, “Okay, well, I’ve had a go now. I you know. Now I know I’ve just got to stay on the medication”, in some cases feeling “Okay, maybe it didn’t work out this time, but maybe if I did it more slowly or carefully in in the future it might be possible to work for it to work out.” So I think that was that was also an an important finding for me that there was something about doing the trial and offering people the possibility of having a supported reduction with a clinician that that that benefited people. 12:40 Helen Saul: Thank you. Rachel, how do these findings chime with your clinical experience? 12:48 Rachel Upthegrove: Well, I think I think the first thing to say is, Joanna sums it up very nicely, and that that the study fits in with what we already already know is that in a previous trial that if you reduce antipsychotic medication, there is a significantly increased risk of relapse. And you know, previous trial trials have done that. So whenever we’re talking with patients in a collaborative way about treatment options and treatment decisions, it is weighing up that that evidence and balance of risk. So the risk of relapse for for somebody might be very different than the risk of relapse for somebody else, given, you know, past experience of psychosis and everyone’s individual risk history, versus the side effects of medication. So this is what what we do day to day. This is what this is what prescribers, psychiatrists, nurse prescribers, allied health specialist prescribers should be doing as part of good care anyway, you know, having that having that individual conversation about the risks of you reducing or stopping medication will be. And you know, particularly in in my practice, this is this is something that we would do. 14:00 So the the trial, you know, reinforces that evidence. That that reducing antipsychotic medication in contains with it a risk of relapse in and of itself. Certainly, one of the main, you know, ways that we can prevent relapse is continuing antipsychotic medication. I think that one of the things that that we also need to be really really cognisant of is there’s also very clear evidence that for a certain percentage of people every relapse carries with it a risk of treatment non-response. So, 15 or 20% of people will have one episode of psychosis and never have another episode. You know, 30% of people, 25% or 30% people might develop treatment resistance, so difficult to treat symptoms from the first episode, and everybody else is in the middle. 14:56 But this group in the middle, every episode, a percentage of people don’t recover fully. So there’s risk in relapse. And it’s just really important that in trials, and in clinical practice, we are very, very clear with those risks of relapse. So it’s the risk of social functioning, maintaining work, maintaining relationships, but also the risk of, if we need to re-instigate treatment after a period off treatment that it may not be as effective as as it has been before. And and so we just need to, you know, to take the evidence from the RADAR trial in this context, as as reinforcing the risks of of relapse. And certainly within the 2 years not improving social functioning. 15:45 Joanna Moncrieff: So I agree agree with Rachel that you know, relapse can have profound personal and social consequences. Some patients desperately want to avoid having a relapse and have had really bad experiences in the past, people who’ve had recurrent episodes. For some people it is less significant. So I think you know that that is an individual thing. There isn’t evidence that relapse in itself causes a bad outcome. The majority of studies actually show that people who’ve had a relapse overall get back to the level of functioning and and level of symptoms that they were at before. There’s nothing about having the relapse that makes this sort of condition worse, other than obviously the social and psychological consequences of it. 16:29 And and actually, we’ve been looking at data from the RADAR study on this as well. And people who’ve had a relapse don’t do any worse in terms of their social functioning and symptom scores at the end of follow up. 16:44 Helen Saul: Clearly there is ongoing debate about the specific harms of relapse. Rachel, what would you see as a research priority? 16:53 Rachel Upthegrove: The real question that that remains in my day to day practice, and other people working with with young people with first episode psychosis that we’re seeing when they’ve had one episode, how do I know? How do I know if I’m going to be in the 20% or you know. And and is there any way of improving our individual prediction for what we need to do for this patient? And that wasn’t what the RADAR study was designed to do. But I think to move ahead, we need to move from big trials of groups of people who perhaps already have a significant risk of relapse to understanding for for me, with all of my risk factors well, my experience, is it a sensible thing? Is there any evidence at an individual patient level that actually dose reduction or dose discontinuation is a sensible thing to think about? 17:45 Helen Saul: Would you like to come in on this, Joanna? 17:49 Joanna Moncrieff: People have been trying to do this for, you know, decades and decades to identify people who might have a relapse, and people who might not, whether that’s, you know, during medication reduction or just in general and it’s proved very, very difficult to identify. And again, we’ve been looking at this and not really found any any strong predictors, and there are almost no studies that that replicate any any relapse predictors. So I think we need to accept that we can’t predict who’s going to have a relapse or not, and we should just assume that everyone has has the same chances and and go on that. 18:30 Rachel Upthegrove: I would just come come back on that a little bit because I agree with Joanna that we’ve we’ve not been able to develop a tool that is clinically useful in terms of relapse prediction. On the other hand, we just haven’t had the access to the to to the size of the data we need to do accurate individual level prediction. So I think that’s still a challenge for our field in terms of using the harmonized outcomes, having sort of a collaborative approach. So we can, we can have access to that data. And I wouldn’t say that that’s ever going to be something we should give up on trying to do until we’ve until we’ve given it as good as go as there have been another branches of medicine or or health, with the same volume and scale of data. 19:18 Helen Saul: Thank you, Rachel. Joanna, where do you see the next steps in research? 19:24 Joanna Moncrieff: I’d like to see research that helps support patients to make informed decisions really about their treatment and be more involved in treatment decisions, particularly people who’ve had, who’ve had multiple episodes because I think first episode services are are quite good at engaging patients in these sort of discussions. But the trouble is often patients who’ve had a number of episodes just get left, and everyone assumes they, you know, they should just stay on medication forever. And and I think some of those people have really quite a poor quality of life, because of all the side effects that we’ve been talking about. 20:02 Helen Saul: Thank you. And Rachel, what would your take home message be? 20:08 Rachel Upthegrove: I certainly agree with the last point in terms of making sure and advocating for best care for people with severe mental illness throughout their throughout their lives and throughout their, you know, the duration of their illness and and it comes back to from what this trial and other trials have shown is that because of that risk of relapse, you know, when we’re reducing doses and and discontinuing doses of medication, this really does need to be an engaged individual discussion with a trusted prescriber who can help people weigh up their risk of relapse and work with them to to find the optimum dose of medication. And that that will help for symptoms and reduce the symptom side effect profile. 21:01 And that’s just good medicine, right? That’s what we should be doing with our patient and saying these medications work, they have side effects. What is the best thing that we can do with you? Because if we don’t have that that conversation, patients don’t take the advice that we’re giving them, and they don’t take the medication. They they will stop on their own and and stop suddenly and and stop, because that that interaction with your prescriber is, you know, is very important, and and that individual choice based on the evidence of risk, it is something that we should, we should be doing. 21:37 I think a a take home message is is that relapse contains risk, and that varies by individual to individual. For some people that risk includes serious self-harm, suicidality, or risk of significant social functioning social, you know, impact on their social functioning. And so for every individual patient, we need to have an informed conversation with people before they reduce medication or stop medication but amongst everything else, work with patients in a trusted relationship around their prescribing choices. 22:19 Helen Saul: Thank you, Rachel. And a final word from you, Joanna? 22:22 Joanna Moncrieff: Yes, I mean I would I would go along with a lot of that. I do agree. There are some people who, you know, the the risks of the risks that may they may run if they have a relapse are very high, but there are many people who where that’s not such a consideration, who, I think, really deserve to be given the opportunity to try and reduce their medication, if that’s what they want to, as long as they are informed of the risks and have all the information, both from RADAR and from other evidence about the pros and cons of that process, and as long as they, you know, have have clinical support during it. 22:58 Helen Saul: Thank you, Joanna Moncrieff and Rachel Upthegrove, for joining me today and sharing your views. This is an episode of the NIHR podcast, I’m Helen Saul, and thank you for listening. If you have thoughts or comments on this or any other episode, please contact us at <a href="mailto:evidence@nihr.ac.uk">evidence@nihr.ac.uk</a> and do visit our website, which is <a href="https://evidence.nihr.ac.uk/alert/stressing-personal-benefits-of-covid-vaccine-could-reduce-hesitancy/">evidence.nihr.ac.uk</a>. [MUSIC OUT] </div> </div> </div> </div> </div> </section> Antipsychotic medicines reduce the risk of psychotic episodes in people with schizophrenia and long-term psychosis. But the drugs can have troublesome side effects such as drowsiness, dizziness and dulled emotions. Researchers investigated the pros and cons of a gradual process of reduction and discontinuation of antipsychotics in people with long-term psychosis. After 2 years, compared with those who were allocated to continue the same dose, the research found that people who were assigned to reduce and stop their antipsychotics: <ul class="wp-block-list"> <li>had no improvement in social functioning (a measure combining people’s ability to look after themselves, work, study and take part in family and social activities)  </li> <li>had more relapses.</li> </ul> The researchers stress that most people lowered their dose without relapsing. The findings could inform discussions with people who are considering reducing or stopping antipsychotics. <a href="https://www.nhs.uk/mental-health/conditions/psychosis/" target="_blank" rel="noreferrer noopener">More information on psychosis can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-what-happens-when-you-reduce-and-stop-antipsychotic-medicine">The issue: what happens when you reduce and stop antipsychotic medicine?</h2> During a psychotic episode, people lose some contact with reality; they may see, hear or believe things that others do not. <a href="https://www.nice.org.uk/guidance/cg178/chapter/Recommendations" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE) guidelines</a> recommend long-term antipsychotics (maintenance therapy) for people with schizophrenia and long-term psychosis. In 2023, <a href="https://media.nhsbsa.nhs.uk/press-releases/6558c2e9-b44c-4aa8-9bbd-f69ec0e6dd80/nhs-releases-latest-mental-health-medicines-statistics" target="_blank" rel="noreferrer noopener">650,000 people in England were treated with antipsychotic medicines</a>. The side effects of these drugs include drowsiness, dizziness, dulled emotions and weight gain; long-term use is associated with diabetes, heart disease and neurological effects. Side-effects can also reduce people’s quality of life; many therefore want to stop or lower their antipsychotic dose. Previous trials showed that stopping antipsychotics increased the risk of relapse compared with those who stayed on the same dose. However, in these trials people often stopped their medication quickly, which can lead to withdrawal symptoms (such as pain, anxiety and sleeplessness), which can make relapse more likely, and follow-up was usually short-term. Some evidence suggests that in the long-term, some people may do better without antipsychotics.  In the current study, researchers investigated the benefits and risks of gradually reducing antipsychotic dose over 12 – 18 months, with regular monitoring. They followed people up 2 years after starting the study. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The study included 253 adults with schizophrenia or long-term psychosis from 19 NHS Trusts in England. People who posed a risk to themselves or others, or had had a mental health crisis or hospital admission in the previous month, were not included. Half (126 participants) gradually reduced their medication (reduction group); the others (127) stayed on the same dose (maintenance group). Most (66%) were men and white (67%), and the average age was 46. About two thirds had been involved with mental health services for more than 10 years.   Each person in the reduction group had a personalised plan; doses were reduced every 2 months, with the aim of stopping medication after 12 to 18 months if possible. People in the reduction group reduced their dose by up to 67% on average at some point during the study; at 24 months the average dose was 33% less than at the start. Data for the main outcome of social functioning was provided by 90 people in the reduction group and 94 in the maintenance group. A secondary outcome was the number of severe relapses (requiring hospitalisation). The researchers found that at 2 years, compared to the maintenance group, people in the reduction group: <ul class="wp-block-list"> <li>had no improvement in social functioning (a measure combining people’s ability to look after themselves, work, study and take part in family and social activities)</li> <li>had no improvement in side effects, quality of life, symptoms, bodyweight or other outcomes</li> <li>were twice as likely to relapse (25%) as those in the maintenance group (13%).</li> </ul> Half of those in the reduction group (49 people) had 93 serious adverse events (mostly hospital admissions for relapse). Fewer in the maintenance group (29 people) had 64 serious adverse events. <a href="https://doi.org/10.1016/j.eclinm.2023.102135" target="_blank" rel="noreferrer noopener">In-depth interviews with 26 participants who reduced or discontinued their dose</a> revealed that many had a positive experience. Some felt empowered: “Reducing it each time made me feel closer to feeling that I’m capable to not have to take it.” Others described a valuable learning experience: “I feel more like myself I think. Even when it’s negative I still feel like I can recognise where it’s coming from, it’s part of me.” Dose reduction helped some people accept that they needed medication, which made it easier for them to continue with it. Others had mixed emotions: “I functioned as an average human being… But I also had this timebomb ticking away underneath me where I feared a psychosis rebound. And [it] did happen.”  <a href="https://doi.org/10.1016/j.jval.2024.07.017" target="_blank" rel="noreferrer noopener">An economic analysis from the same project</a> found that costs (including medications, service use and unpaid care) in reduction and maintenance groups were similar, as were years of life in good health (QALYs). Years at full capability, however, were significantly lower in the reduction arm. The paper concluded that gradual reduction and discontinuation of antipsychotics over 2 years is unlikely to be cost-effective (compared with maintenance) for people with long-term psychosis. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> This is the first trial to explore a gradual antipsychotic dose reduction for people with schizophrenia and long-term psychosis. Reduced doses increased people’s risk of relapse without increasing their social activity. However, as with previous studies, most people (75%) who reduced their medication did not relapse. The qualitative research suggested some had found the process of reducing medication useful. Despite guideline recommendations, many people taking antipsychotics want to reduce their dose. This study found no improvement in social activity or other outcomes (such as bodyweight, quality of life, or side effects) with dose reduction over 2 years, and around 1 in 4 people relapsed. However, the researchers say that other evidence suggests improvements in social functioning may take longer to materialise, and that the pattern of relapses may change over the longer term. Longer-term follow-up is ongoing. In the meantime, clinicians could discuss these findings with people considering reducing or stopping antipsychotics. Participants in this study were taking relatively low doses of antipsychotics on average, which does not represent the whole population with long-term psychosis. Some of the trial took place during the pandemic, which reduced people’s ability to socialise (part of the main outcome of the study). <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers are assessing the long-term (4 to 7 year) outcomes of dose reduction in a follow-up study. Further research could investigate if reducing people’s medication even more gradually (over years rather than months) might reduce the risk of relapse. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Moncrieff J, and others. <a href="https://doi.org/10.1016/S2215-0366(23)00258-4" target="_blank" rel="noreferrer noopener">Antipsychotic dose reduction and discontinuation versus maintenance treatment in people with schizophrenia and other recurrent psychotic disorders in England (the RADAR trial): an open, parallel-group, randomised controlled trial</a>. Lancet Psychiatry 2023; 10: 848–59. People’s experiences of reducing antipsychotics in the RADAR trial: Morant N, and others. <a href="https://doi.org/10.1016/j.eclinm.2023.102135" target="_blank" rel="noreferrer noopener">Experiences of reduction and discontinuation of antipsychotics: a qualitative investigation within the RADAR trial</a>. eClinical Medicine 2023; 64. DOI: 10.1016/j.eclinm.2023.102135. Information on <a href="https://www.mind.org.uk/information-support/drugs-and-treatments/antipsychotics/side-effects/" target="_blank" rel="noreferrer noopener">coming off antipsychotics</a> and <a href="https://www.mind.org.uk/information-support/drugs-and-treatments/antipsychotics/side-effects/" target="_blank" rel="noreferrer noopener">the side effects of antipsychotics</a> from Mind. A blog about stopping antipsychotics by <a href="https://www.kcl.ac.uk/news/withdrawing-from-antipsychotics-an-analysis" target="_blank" rel="noreferrer noopener">King’s College London</a>.   Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=Schizophrenia&location=" target="_blank" rel="noreferrer noopener">NIHR research on schizophrenia</a>.   NIHR research on <a href="https://evidence.nihr.ac.uk/alert/how-to-choose-the-right-antidepressant-or-antipsychotic/">how to choose the right antidepressant or antipsychotic</a> Funding: <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/programme-grants-for-applied-research.htm" target="_blank" rel="noreferrer noopener">NIHR Programme Grant for Applied Research</a>. Conflicts of Interest: Two authors have unpaid roles at the <a href="https://www.criticalpsychiatry.co.uk/" target="_blank" rel="noreferrer noopener">Critical Psychiatry Network</a> and two authors have an unpaid role on the <a href="https://iipdw.org/iipdw-home/#:~:text=The%20International%20Institute%20for%20Psychiatric,withdraw%20from%20their%20psychiatric%20drugs." target="_blank" rel="noreferrer noopener">International Institute for Psychiatric Drug Withdrawal</a>. Another author has a paid role at <a href="https://www.outro.com/" target="_blank" rel="noreferrer noopener">Outro Health</a>. One author has received fees and funding from pharmaceutical companies. Full disclosures are available on the original <a href="https://doi.org/10.1016/S2215-0366(23)00258-4" target="_blank" rel="noreferrer noopener">research paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Hospitalisation for COVID-19 is linked with long-term mental health and thinking problems</title> <link>https://evidence.nihr.ac.uk/alert/hospitalisation-for-covid-19-is-linked-with-long-term-mental-health-and-thinking-problems/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 21 Jan 2025 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65682</guid> <description><![CDATA[Researchers assessed the long-term mental health and cognitive abilities of people who were hospitalised with COVID-19. Many people, 2 to 3 years after their infection, had: The researchers call for more support for people with these problems following hospitalisation for COVID-19. More information on long COVID can be found on the NHS website. The issue: ...]]></description> <content:encoded><![CDATA[ Researchers assessed the long-term mental health and cognitive abilities of people who were hospitalised with COVID-19. Many people, 2 to 3 years after their infection, had: <ul class="wp-block-list"> <li>thinking problems, equivalent to a loss of 10 IQ points</li> <li>depression or anxiety</li> <li>fatigue</li> <li>shorter working hours or a change of job, usually because of poor health.</li> </ul> The researchers call for more support for people with these problems following hospitalisation for COVID-19. <a href="https://www.nhs.uk/conditions/covid-19/long-term-effects-of-covid-19-long-covid/" target="_blank" rel="noreferrer noopener">More information on long COVID can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-can-severe-covid-19-infections-cause-long-term-mental-health-problems">The issue: can severe COVID-19 infections cause long-term mental health problems?</h2> Up to a year after a COVID-19 infection, people are at increased risk of mental health conditions (including depression and anxiety) and cognitive problems (affecting reasoning, understanding, memory). Risks are greater among people who were hospitalised. This study investigated whether mental health and cognitive problems persist 2 to 3 years after hospitalisation for COVID-19. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The study included 475 adults who were hospitalised with a COVID-19 infection (between February 2020 and March 2021) and had not been vaccinated. They had all taken part in <a href="https://doi.org/10.1016/s2213-2600(21)00383-0" target="_blank" rel="noreferrer noopener">a previous study exploring the effects of the disease after discharge</a>. Most (60%) were men and their average age was 58 years. Participants completed online cognitive tests, and reported their symptoms of depression, anxiety and fatigue. They also reported whether they felt they had memory problems, if they had changed job, and why. The researchers found that 2 – 3 years after being hospitalised with COVID-19: <ul class="wp-block-list"> <li>participants had worse memory and attention scores than others of similar social, economic and educational background; the average loss (equivalent to 10 IQ points) is likely to make a noticeable difference to their ability to work and interact socially</li> <li>most reported at least mild symptoms of depression (75%), anxiety (54%), fatigue (62%), or self-reported memory problems (52%)</li> <li>many had severe symptoms of depression (22%), fatigue (25%), or self-reported memory problems (25%)</li> <li>many (27%) had changed jobs or reduced their working hours; the most common reason was poor health.</li> </ul> Overall, symptoms of depression, anxiety, and fatigue were more severe at 2–3 years than after 6 or 12 months, and new symptoms appeared. People who had symptoms at 6 months were most likely to report new symptoms at 2–3 years. Changing jobs was strongly linked with memory and attention problems, whether self-reported or identified by tests. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> Mental health and cognition problems were more severe 2–3 years after hospitalisation for COVID-19, than after 6 months. The researchers suggest that intervening early (after 6 months, for example) might improve long-term mental health and thinking problems in this group. The researchers suggest that many people may have changed job because they could no longer meet the cognitive demands, rather than because of a lack of energy, interest or confidence. They call for more support for people with cognitive problems following COVID-19. These findings may not be generalisable to everyone with severe COVID-19. Participants were hospitalised during the first wave of the pandemic and were not vaccinated at the time of the infection. In addition, few (20%) of those invited took part in the study. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers call for further research to develop effective interventions for people with long-term mental health and thinking problems following hospitalisation for COVID-19.   <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="46" height="67" />How does this research fit with my current practice? What else do I need to know? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Taquet M, and others. <a href="https://doi.org/10.1016/s2215-0366(24)00214-1" target="_blank" rel="noreferrer noopener">Cognitive and psychiatric symptom trajectories 2–3 years after hospital admission for COVID-19: a longitudinal, prospective cohort study in the UK</a>. Lancet Psychiatry 2024; 11: 696 – 708.  A podcast about the study on <a href="https://www.youtube.com/watch?v=6DZ3U5bAlpo&t=11s" target="_blank" rel="noreferrer noopener">YouTube</a>. Professional commentary on the study from the <a href="https://www.sciencemediacentre.org/expert-reaction-to-study-looking-at-cognitive-and-psychiatric-symptom-trajectories-2-3-years-after-hospital-admission-for-covid-19/" target="_blank" rel="noreferrer noopener">Science Media Centre</a>. Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=covid&location=" target="_blank" rel="noreferrer noopener">NIHR research on COVID</a>. Read other <a href="https://evidence.nihr.ac.uk/browse-content/?_sf_s=long+covid">NIHR Evidence on long COVID</a>. Funding: This study was supported by an <a href="https://www.nihr.ac.uk/about-us/what-we-do/covid-19" target="_blank" rel="noreferrer noopener">NIHR/UK Research and Innovation Rapid Response to COVID Initiative</a> grant and the <a href="https://oxfordhealthbrc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Oxford Health Biomedical Research Centre</a>. Conflicts of Interest: Multiple authors have received fees and funding from pharmaceutical companies. <a href="https://doi.org/10.1016/s2215-0366(24)00214-1" target="_blank" rel="noreferrer noopener">See paper for full details</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Older people who take statins live longer in better health</title> <link>https://evidence.nihr.ac.uk/alert/older-people-who-take-statins-live-longer-in-better-health/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 16 Jan 2025 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65725</guid> <description><![CDATA[People aged 70 and older who take statins live longer in good health than those who do not, regardless of whether they have cardiovascular disease, a modelling study found. Both standard and high-intensity treatment was cost-effective in this age group. The researchers hope their findings will encourage clinicians to recommend statins for the 5 million ...]]></description> <content:encoded><![CDATA[ People aged 70 and older who take statins live longer in good health than those who do not, regardless of whether they have cardiovascular disease, a modelling study found. Both standard and high-intensity treatment was cost-effective in this age group. The researchers hope their findings will encourage clinicians to recommend statins for the 5 million or so older people in the UK who are not currently taking them. <a href="https://www.nhs.uk/conditions/statins/" target="_blank" rel="noreferrer noopener">More information about statins can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-do-people-over-70-benefit-from-statins">The issue: Do people over 70 benefit from statins?</h2> Statins are a group of medicines that can lower people’s risk of cardiovascular conditions (including <a href="https://www.nhs.uk/conditions/coronary-heart-disease/" target="_blank" rel="noreferrer noopener">heart disease</a> and <a href="https://www.nhs.uk/conditions/stroke/" target="_blank" rel="noreferrer noopener">stroke</a>) by reducing levels of harmful cholesterol (low-density lipoprotein or LDL cholesterol. According to the <a href="https://www.bhf.org.uk/informationsupport/treatments/statins" target="_blank" rel="noreferrer noopener">British Heart Foundation</a>, statins are one of the most prescribed drugs in the UK; around 7 – 8 million adults take them. <a href="https://www.nhs.uk/conditions/statins/" target="_blank" rel="noreferrer noopener">People are usually prescribed statins</a> if they are diagnosed with cardiovascular disease or have a high chance of developing it over the next 10 years. The risk increases further with age but only around 40% of people aged 70 and older in England are prescribed a statin. <a href="https://www.acpjournals.org/doi/10.7326/M14-1430" target="_blank" rel="noreferrer noopener">Previous research</a> suggested that the benefit of statins in this age group could be offset by even a small increase in adverse effects. But a <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)31942-1/fulltext" target="_blank" rel="noreferrer noopener">more recent analysis</a> highlighted the safety and effectiveness of statins in older people. The current study modelled the effects and cost-effectiveness of statins in people aged 70 and older using recent data.   <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Researchers analysed data from 20,122 UK adults aged 70 years and older who had contributed data to large health studies (<a href="https://www.ukbiobank.ac.uk/" target="_blank" rel="noreferrer noopener">UK Biobank</a> and <a href="https://www.ucl.ac.uk/epidemiology-health-care/research/epidemiology-and-public-health/research/whitehall-ii" target="_blank" rel="noreferrer noopener">Whitehall II</a>). Most were white (97%), more than half were male (56%), and most (15,019) had no history of cardiovascular disease. In previous work, the researchers developed a model (the <a href="https://bjgp.org/content/74/740/e189" target="_blank" rel="noreferrer noopener">Cardiovascular disease microsimulation model</a>) to predict participants’ years in good health (<a href="https://en.wikipedia.org/wiki/Quality-adjusted_life_year#:~:text=One%20quality%2Dadjusted%20life%20year,health%20equates%20to%201%20QALY." target="_blank" rel="noreferrer noopener">quality-adjusted life years or QALYs</a>) and healthcare costs (2021 prices for generic statins). They considered standard intensity treatment (which reduces LDL cholesterol by 35 – 45%; for instance, 20mg atorvastatin daily) and high-intensity treatment (which reduces LDL cholesterol by 45% or more; such as 40 – 80mg atorvastatin daily). The study projected that, across groups of men and women aged 70 and older with different levels of LDL cholesterol before treatment, compared with not taking statins: <ul class="wp-block-list"> <li>standard statin therapy would add between 3 and 8 extra months in good health</li> <li>high-intensity statin therapy would add a further 0.5 to 1.6 months in good health.</li> </ul> The benefits of statins varied but were greatest in men without cardiovascular disease but with higher levels of LDL cholesterol before treatment. Both intensities were likely to be cost-effective. Compared to not taking a statin: <ul class="wp-block-list"> <li>standard statin therapy cost between £116 and £3,502 per year of good health</li> <li>high-intensity statin therapy cost between £2,213 and £11,778 per extra year of good health further to standard statin therapy.</li> </ul> Statins were cost effective for all groups with greatest cost-effectiveness among those at highest risk (men with cardiovascular disease or high levels of LDL cholesterol).   <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The findings suggest that prescribing older people statins increases their years in good health and is cost-effective. Both standard and high-intensity treatments are beneficial and cost-effective. Earlier <a href="https://www.bmj.com/content/372/bmj.n135" target="_blank" rel="noreferrer noopener">research</a> showed that side-effects reported in randomised controlled studies of statin therapy were also reported by people not taking statins. More data on statin use in older people will be helpful, but the researchers say their findings suggest delaying statin treatment in millions of older people while waiting for new evidence is not justified. Few data were available in this study for people older than 75 years with no history of cardiovascular conditions (3149 people; 21% of all participants). Statins remained beneficial and cost-effective for these people, but the small number of people in this group in the study means this finding is also less certain. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> More research is ongoing and 2 studies are scheduled to complete in 2026. They will add to the evidence about statin use in people aged 75 years and older who do not have <a href="https://www.nhs.uk/conditions/atherosclerosis/" target="_blank" rel="noreferrer noopener">atherosclerotic cardiovascular disease</a> (narrowed arteries). <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="37" height="53" /> How does this research fit with my current practice? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Mihaylova B, and others. <a href="https://doi.org/10.1136/heartjnl-2024-324052" target="_blank" rel="noreferrer noopener">Lifetime effects and cost-effectiveness of statin therapy for older people in the United Kingdom: a modelling study</a>. Heart 2024; 110: 1277 – 1285. Mihaylova B, and others. <a href="https://www.journalslibrary.nihr.ac.uk/hta/KDAP7034" target="_blank" rel="noreferrer noopener">Assessing long-term effectiveness and cost-effectiveness of statin therapy in the UK: a modelling study using individual participant data sets</a>. Health Technology Assessment 2024; 28. Burns, C. <a href="https://pharmaceutical-journal.com/article/news/statin-prescribing-in-england-at-record-high-show-nice-data" target="_blank" rel="noreferrer noopener">Statin prescribing in England at record high, show NICE data</a>. Pharmaceutical Journal 2024; 313. <a href="https://evidence.nihr.ac.uk/alert/statins-not-likely-to-cause-muscle-pain-stiffness/">Statins do not commonly cause muscle pain and stiffness</a>. An NIHR Evidence summary. 18 October 2021. Funding: <a href="https://www.nihr.ac.uk/research-funding/funding-programmes/health-technology-assessment" target="_blank" rel="noreferrer noopener">Health Technology Assessment Programme</a> Commissioned Call. Conflicts of Interest: Several of the study authors have received funding from pharmaceutical companies. See <a href="https://doi.org/10.1136/heartjnl-2024-324052" target="_blank" rel="noreferrer noopener">paper</a> for full details. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>What is the impact of COVID-19 on memory and thinking?</title> <link>https://evidence.nihr.ac.uk/alert/what-is-the-impact-of-covid-19-on-memory-and-thinking/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 14 Jan 2025 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65659</guid> <description><![CDATA[Brain fog (difficulty remembering, concentrating and thinking) has been linked with COVID-19. Researchers analysed the cognitive performance of more than 140,000 people. They included people whose symptoms of COVID-19 had not resolved, those who had resolved symptoms (including symptoms that had been persistent), and others who had not had COVID-19. They found that memory and ...]]></description> <content:encoded><![CDATA[ Brain fog (difficulty remembering, concentrating and thinking) has been linked with COVID-19. Researchers analysed the cognitive performance of more than 140,000 people. They included people whose symptoms of COVID-19 had not resolved, those who had resolved symptoms (including symptoms that had been persistent), and others who had not had COVID-19. They found that memory and thinking were most impacted by COVID-19 in people who: <ul class="wp-block-list"> <li>were infected by early strains of the virus</li> <li>had unresolved symptoms for more than 12 weeks</li> <li>had been admitted to intensive care.</li> </ul> The findings contribute to understanding of the impact of COVID-19 on memory and thinking. <a href="https://www.nhs.uk/covid-19-advice-and-services/" target="_blank" rel="noreferrer noopener">More information about COVID-19 can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-what-factors-influence-the-impact-of-covid-19-on-memory-and-thinking">The issue: what factors influence the impact of COVID-19 on memory and thinking</h2> <a href="https://www.nhs.uk/conditions/covid-19/covid-19-symptoms-and-what-to-do/" target="_blank" rel="noreferrer noopener">COVID-19</a> has been linked with brain fog. But data on the long-term impact of COVID-19 on memory and thinking is largely lacking. Researchers sought to identify factors associated with cognitive deficits lasting up to a year or more. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> This study, in 2022, included more than 140,000 people who had taken part in previous work (<a href="https://www.reactstudy.org/" target="_blank" rel="noreferrer noopener">REACT study</a>, which investigated how many people had been infected with COVID-19, when and where). Participants completed a cognitive assessment to measure aspects of cognitive performance such as memory and planning. The researchers compared the performance of people whose symptoms of COVID-19 had not resolved, those who had resolved symptoms (including symptoms that had been persistent), and those who had not had COVID-19.   They found that cognitive impairments could last more than a year after COVID-19. People who had COVID-19 for short periods of time (less than 12 weeks), and those who had persistent symptoms that eventually resolved, had slight cognitive deficits unlikely to be evident to them in everyday life (equivalent to 3 IQ points). Memory, reasoning, and planning were the aspects of cognitive function most affected by COVID-19. Compared with those who had not had COVID-19, people were more likely to have moderate cognitive impairment if they: <ul class="wp-block-list"> <li>were infected with the original strain of the virus (almost twice as likely)</li> <li>had ongoing symptoms (more than twice as likely)</li> <li>had been admitted to intensive care (almost 4 times more likely).</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The researchers found that on average, COVID-19 was associated with slight deficits in cognitive performance that are unlikely to affect everyday life. These deficits were greater for people who were infected earlier in the pandemic, had unresolved persistent symptoms or, in particular, had been admitted to intensive care. The researchers say it is reassuring that later strains of the virus had a smaller association with cognitive function. It was promising for people with long COVID that those whose persistent symptoms had finally resolved performed at similar levels to those whose illness was short-term or who had asymptomatic infections. People who reported cognitive symptoms were slightly more likely to complete the assessment than those who did not report symptoms, meaning the data could overestimate the proportion of people with cognitive deficits. The researchers did not know participants’ cognitive scores before COVID-19, which means it is not possible to conclude that the scores had changed because of the infection, although they undertook thorough analyses to account for potentially confounding factors. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> These findings strengthen the evidence for the long-term impact of COVID-19 on cognition. The researchers call for more research into the different ways that COVID-19 has affected people over the longer term and the mechanisms that underpin those effects. People left with cognitive difficulties following COVID-19 need greater support and understanding, they say.   <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="44" height="64" /> What do these results mean for my practice? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Hampshire A, and others. <a href="https://doi.org/10.1056/NEJMoa2311330" target="_blank" rel="noreferrer noopener">Cognition and memory after COVID-19 in a large community sample</a>. New England Journal of Medicine 2024; 390: 806 – 818. Information about the larger project this study is part of can be found on the <a href="https://www.imperial.ac.uk/medicine/research-and-impact/groups/react-study/studies/" target="_blank" rel="noreferrer noopener">Imperial College website</a>. <a href="https://evidence.nihr.ac.uk/browse-content/?_sf_s=long+covid">Read more NIHR Evidence on long Covid</a> Funding: This study was funded by the <a href="https://www.nihr.ac.uk/about-us/what-we-do/covid-19/long-COVID" target="_blank" rel="noreferrer noopener">NIHR Long COVID Programme</a> and UK Research and Innovation. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2311330" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>What is the impact of admitting a young person to a psychiatric unit far from home?</title> <link>https://evidence.nihr.ac.uk/alert/what-is-the-impact-of-admitting-a-young-person-to-a-psychiatric-unit-far-from-home/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 09 Jan 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65618</guid> <description><![CDATA[Researchers interviewed young people, parents and carers, and healthcare professionals with relevant experience. They found that young people admitted to psychiatric units a long way from home could face difficulties keeping in touch with home, organising home leave and returning to school. Rarely, distant admissions could be beneficial: a young person could find distance empowering, ...]]></description> <content:encoded><![CDATA[ Researchers interviewed young people, parents and carers, and healthcare professionals with relevant experience. They found that young people admitted to psychiatric units a long way from home could face difficulties keeping in touch with home, organising home leave and returning to school. Rarely, distant admissions could be beneficial: a young person could find distance empowering, and it could give their families respite. The team hopes its insights will form the basis of national policy to provide more support to young people admitted far from home, and their families. <a href="https://www.nhs.uk/mental-health/children-and-young-adults/mental-health-support/" target="_blank" rel="noreferrer noopener">More information about mental health support for children and young people can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-many-young-people-are-admitted-to-psychiatric-units-far-from-home">The issue: many young people are admitted to psychiatric units far from home</h2> Young people (aged 17 and below) with severe and/or complex mental health difficulties (depression, psychosis, eating disorders and/or suicide risk, for example) might need to be admitted to a child and adolescent mental health unit if treatment in the community is not adequate or safe. However, the availability of beds in these units varies across the UK. This means that finding a bed, particularly when it is needed quickly, can be challenging. As a result, many young people are admitted to units far from their home. In 2017, <a href="https://www.bmj.com/content/362/bmj.k3769" target="_blank" rel="noreferrer noopener">most (61%) clinical commissioning groups had admitted at least one young person to a mental health unit outside their area</a>; 1 in 3 had sent young people at least 100 miles away from home. Researchers explored the impact of at-distance admissions (50 miles or more from home, or outside of their NHS commissioning region) on young people, their parents or carers, and healthcare professionals. <h2 class="wp-block-heading" class="wp-block-heading" id="what-is-the-impact-of-at-distance-psychiatric-admissions-for-young-people">What is the impact of at-distance psychiatric admissions for young people?</h2> Researchers interviewed 28 young people aged 13 to 17 years, and 19 parents or carers, with experience of a psychiatric admission within the previous year in England. Most participants were female (77%), and White British (66%). Admissions were both at-distance (more than 50 miles away from home), or more local but outside of their NHS commissioning region. The team also interviewed 51 healthcare professionals in England who had cared for a young person admitted to a psychiatric unit. Interviews were by video, phone or face to face between 2021 and 2022. They drew out themes from the interviews covering the admission, care at a distance, and discharge. The admission Young people and parents or carers felt informed but not involved in the decision to admit to a distant unit. They felt they lacked influence and had limited alternatives; some felt pressure to accept the bed offered. Healthcare professionals were upset by the lack of beds, and the uncertainty. Some young people were desperate and took the first bed available. Parents and carers could feel relieved to have their child somewhere safe. One parent said: ‘…we were actually relieved because we thought it’s better that she’s in the care of professionals who could deal with this rather than us who you know, could easily make a mistake and make things worse.’ Some young people had only a day or two’s notice about a bed becoming available and were afraid of being far from home. They welcomed easily accessible information (a digital book about the unit, or a welcome pack). One young person said: ‘I got to see like what the environment sort of looked like and how things would work with like your care team and MDT [multidisciplinary team]...’ Care at a distance Challenges in keeping in touch, especially when mobile phone use was restricted, could lead to feelings of isolation. Parents’ and carers’ health was sometimes impacted. One parent said: ‘There were times when actually I felt suicidal myself, because I thought there’s no help, like I felt so lonely and frustrated… Trying to constantly phone …and hearing nothing back, was just soul destroying.’ A lack of regular visits worsened feelings of sadness. Parents or carers could struggle because of the time and cost of travel and accommodation; healthcare professionals called for more support. One psychiatrist said: ‘… They just couldn’t afford to go and see her. We tried all sorts of different funding streams to see if we could get some money through social care, we even tried charities...it was just awful. There’s just not that support there for the families.’ On occasion, less contact with family could be positive. It could give the young person a break from a complex social situation, reduce their concerns about being recognised, and/or be empowering. It could also give the family respite. Discharge Arranging home leave was more difficult from a distance. One young person said: ‘…If my home leaves were going bad, like almost every time, then like it would have been a nightmare having to bring me back at the time.’ The prospect of being discharged without periods of home leave first could be daunting for young people. Discharge planning could be limited. Schools tended not to provide additional support for young people admitted far away from home which meant they missed a lot of education and could find reintegration difficult. But some young people remained in touch with their school or care coordinator, and were more able to work remotely. Similarly, young people had limited contact with their local child and adolescent mental health services (CAMHS) team when admitted far away. This reduced continuity of care; re-establishing links could be difficult. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> Clinical urgency can lead to at-distance admissions. The interviews highlight the impact of at-distance admissions on young people, parents or carers, and healthcare professionals. They provide insights into how to make these admissions less difficult. Good practice, such as providing clear information, could reduce some of the negative impacts.   Most of the young people were interviewed while still in hospital, and could not reflect on the whole process, especially returning home. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The study suggests that at-distance psychiatric admissions could be improved for young people and their families with: <ul class="wp-block-list"> <li>co-produced, easily accessible information to reassure young people and their families before admission; this is helpful whether the admission is local or distant</li> <li>better communication between services to understand which young people might benefit most from an at-distance admission, and who might need to be transferred closer to home prior to discharge to ease the transition out of hospital.</li> </ul> The researchers are developing a Far Away From Home checklist, which is a list of considerations for healthcare professionals admitting a young person at-distance. They hope it will improve the experience of admission for the young person and their family, and reduce barriers to discharge. A national policy is needed to support the families of young people who have been admitted far from home, the researchers say. They would like it to incorporate the Far Away From Home checklist, along with a standardised template of information (developed with young people and parents) that inpatient units would make publicly available. At-distance admissions need to be costed to include additional funding for families’ travel, accommodation and childcare costs, they say. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="42" height="60" /> How can I act on this new knowledge? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Roe J, and others. <a href="https://doi.org/10.1136/bmjment-2024-300991" target="_blank" rel="noreferrer noopener">Experiences and impact of psychiatric inpatient admissions far away from home: a qualitative study with young people, parents/carers and healthcare professionals</a>. BMJ Mental Health 2024; 27: 1 – 9. The findings are summarised in this <a href="https://www.youtube.com/watch?v=ukjUtWMvvqs" target="_blank" rel="noreferrer noopener">animation</a> and were discussed at a <a href="https://www.youtube.com/watch?v=brYdMNlG4Kk" target="_blank" rel="noreferrer noopener">webinar in March 2024</a>. An <a href="https://arc-eoe.nihr.ac.uk/news-blogs/blogs/working-experts-experience-improve-mental-health-outcomes" target="_blank" rel="noreferrer noopener">NIHR article</a> about supporting discharge. Information about mental health in children and young people can be found on the <a href="https://www.youngminds.org.uk/" target="_blank" rel="noreferrer noopener">Young Minds</a> charity website. An NIHR Evidence Collection about mental healthcare for children and young people: <a href="https://evidence.nihr.ac.uk/collection/children-young-people-mental-health-learning-disability-autism-inpatient-settings/">Experience of children and young people cared for in mental health, learning disability and autism inpatient settings</a>. Funding: This study was funded jointly by several NIHR Applied Research Collaborations (ARCs): <a href="https://arc-em.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">East Midlands</a>, <a href="https://arc-eoe.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">East of England</a>, <a href="https://www.arc-wm.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">West Midlands</a>, <a href="https://www.arc-oxtv.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">Oxford and Thames Valley</a>, <a href="https://arc-gm.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">Greater Manchester</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1136/bmjment-2024-300991" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>How to help the NHS reduce or stop low value surgery</title> <link>https://evidence.nihr.ac.uk/alert/how-to-help-the-nhs-reduce-or-stop-low-value-surgery/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 07 Jan 2025 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65609</guid> <description><![CDATA[Low value surgery comes with risks and costs that outweigh benefits. Reducing or stopping this surgery could save the NHS time and money, and save people from undergoing surgical procedures that may not benefit them. NHS initiatives exist to identify low value procedures; researchers have developed an alternative method to shortlist potentially low value procedures ...]]></description> <content:encoded><![CDATA[ Low value surgery comes with risks and costs that outweigh benefits. Reducing or stopping this surgery could save the NHS time and money, and save people from undergoing surgical procedures that may not benefit them. NHS initiatives exist to identify low value procedures; researchers have developed an alternative method to shortlist potentially low value procedures quickly, easily, and regularly. Decision-makers can then review these procedures. The team analysed hospital records to identify surgical procedures that varied from region to region, or had seen a rapid increase in the numbers carried out. They found that many did not have strong evidence of cost-effectiveness to support them. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-low-value-care-wastes-nhs-time-and-money">The issue: low value care wastes NHS time and money</h2> Low value procedures are not effective or cost-effective for some or all of those treated. The NHS <a href="https://www.england.nhs.uk/evidence-based-interventions/" target="_blank" rel="noreferrer noopener">Evidence Based Interventions programme</a> draws on NICE guidelines, international recommendations, regional variation in care, and other resources to identify these procedures. This is a thorough process that takes time. Researchers developed a simpler method. They predicted that high regional variation could indicate uncertainty about a procedure’s effectiveness. A rapid increase in the number of procedures carried out suggests that evidence of its effectiveness might need to be checked before the procedure becomes established. In this study, the researchers tested their method of identifying potentially low value care. They also explored what research supported the value for money offered by those procedures. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers examined hospital records in England from 2014 to 2019. They identified the 5% of surgical procedures that showed the greatest variation or growth over a 5-year period, adjusted for the local population’s age, sex, ethnicity and level of deprivation. They then reviewed evidence (including NICE guidance, systematic reviews, economic studies) of the procedures’ effectiveness and value for money. They found 10 procedures with high regional variation or high growth. For 8 of them, there was little or no evidence of cost-effectiveness. They were: <ul class="wp-block-list"> <li> hip replacements (with cemented pelvic or femur component, but not both)</li> <li>shoulder replacements (without cement)</li> <li>joint surgery for traumatic dislocations and fractures</li> <li>removal of bone or tissue pressing on nerves in the neck</li> <li>nerve destruction with radio waves to alleviate pain in the spine</li> <li>deep brain electrical stimulation for involuntary muscle spasms</li> <li>prostate removal for prostate cancer.</li> </ul> Of these, hip replacements and prostate removal had evidence of effectiveness but no clear evidence of being cost-effective compared to alternative therapies. Another 2 procedures, weight loss surgery and a type of total knee replacement (uncemented), varied across regions but were cost-effective compared to non-surgical approaches.<a id="_msocom_1"></a> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> Methods used in this study could provide a quick and relatively effective way of helping NHS commissioners to identify procedures that may have low value, the researchers say. These procedures may need to be investigated in further research, stopped, reduced or reserved for groups of the population most likely to benefit. The cost-effectiveness of the 8 procedures identified needs to be investigated more thoroughly. The researchers note that clinical trials of some are ongoing, for example, the <a href="https://fundingawards.nihr.ac.uk/award/NIHR127457" target="_blank" rel="noreferrer noopener">RADICAL trial of nerve destruction with radio waves to alleviate pain in the spine</a>. A reduction in low value care could save the NHS time and money, while protecting patients from undergoing procedures that are unlikely to help them. Regular reviews of procedures, using these and other methods, could help to identify those that may have low value and optimise services, the researchers say. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> This research is part of a wider move within the NHS to ensure that treatment and care is based on sound evidence. It overlaps with NHS England’s <a href="https://gettingitrightfirsttime.co.uk/" target="_blank" rel="noreferrer noopener">Getting it Right First Time</a> initiative, which uses in-depth reviews and benchmarking to encourage NHS Trusts to share best practice. Reducing unnecessary care is part of this. Alongside the current study, these researchers <a href="https://fundingawards.nihr.ac.uk/award/NIHR130547" target="_blank" rel="noreferrer noopener">are evaluating the success of the NHS’s Evidence Based Interventions programme in reducing procedures identified as low value</a>. In future, they hope their methods will be widely taken up and accelerate the process of identifying and reducing low value care. NHS England, the Academy of Royal Medical Colleges and local commissioners can use this methodology to identify procedures for which guidance on appropriate use is most needed, the team says. Research funders can use this methodology to identify topics for which better evidence is required to ensure fairer access to cost-effective care across the NHS. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Jones T, and others. <a href="https://doi.org/10.1177/13558196241252053" target="_blank" rel="noreferrer noopener">Identifying potentially low value surgical care: A national ecological study in England</a>. Journal of Health Services Research & Policy 2024; 29: 223 – 229. An <a href="https://arc-w.nihr.ac.uk/research/projects/identifying-low-value-operations-that-the-nhs-could-reduce-or-stop/" target="_blank" rel="noreferrer noopener">NIHR article</a> about the study. An article about low value care: Mafi JN and Parchman M. <a href="https://doi.org/10.1136/bmjqs-2017-007477" target="_blank" rel="noreferrer noopener">Low-value care: an intractable global problem with no quick fix</a>. BMJ Quality and Safety 2024; 27: 333 – 336.  First paper from the researchers' assessment of the Evidence Based Interventions programme: Glynn J, and others. <a href="https://doi.org/10.1371/journal.pone.0290996" target="_blank" rel="noreferrer noopener">Did the evidence-based intervention (EBI) programme reduce inappropriate procedures, lessen unwarranted variation or lead to spill-over effects in the National Health Service?</a> PLoS ONE 2023; 18: e0290996. Funding: <a href="https://arc-w.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Applied Research Collaboration (ARC) West</a>. Conflicts of Interest: None declared. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Pneumonia vaccine is effective in people with inflammatory diseases</title> <link>https://evidence.nihr.ac.uk/alert/pneumonia-vaccine-is-effective-in-people-with-inflammatory-diseases/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 17 Dec 2024 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65233</guid> <description><![CDATA[The pneumococcal vaccine protects against pneumonia, meningitis and sepsis. Among people with inflammatory diseases (such as arthritis and inflammatory bowel disease), researchers found that the vaccine: The findings reassure that the vaccine is effective and safe for people with these conditions. They highlight the need to increase vaccine uptake.   More information on the pneumococcal ...]]></description> <content:encoded><![CDATA[ The pneumococcal vaccine protects against pneumonia, meningitis and sepsis. Among people with inflammatory diseases (such as arthritis and inflammatory bowel disease), researchers found that the vaccine: <ul class="wp-block-list"> <li>reduced the risk of hospitalisation and death from pneumonia</li> <li>had low uptake</li> <li>was not linked with disease flares.</li> </ul> The findings reassure that the vaccine is effective and safe for people with these conditions. They highlight the need to increase vaccine uptake.   <a href="https://www.nhs.uk/vaccinations/pneumococcal-vaccine/" target="_blank" rel="noreferrer noopener">More information on the pneumococcal vaccine can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-people-with-inflammatory-diseases-are-at-risk-of-pneumonia">The issue: people with inflammatory diseases are at risk of pneumonia</h2> In the UK, 1 in 30 adults has an inflammatory disease such as inflammatory bowel disease (IBD), lupus, rheumatoid arthritis and spondylarthritis (a group of arthritic conditions). Inflammatory diseases are caused by inappropriate and excessive inflammation driven by the immune system. They are treated with drugs that dampen the immune system. These medicines reduce the immune response. People taking them are therefore at increased risk of infections, such as pneumonia and meningitis. A pneumococcal vaccine is <a href="https://cks.nice.org.uk/topics/immunizations-pneumococcal/#:~:text=The%20following%20groups%20of%20people,clinical%20risk%20of%20pneumococcal%20disease." target="_blank" rel="noreferrer noopener">recommended for people with inflammatory diseases</a>. In this study, the researchers evaluated the effectiveness, uptake and safety of the pneumococcal vaccine in this group of people.   <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers analysed patient records for adults with inflammatory diseases in the UK from 1997 to 2019. All participants were taking medicine that dampened the immune system. The researchers compared data for: <ul class="wp-block-list"> <li>1,884 people who were hospitalised due to pneumonia versus 10,476 who were not </li> <li>781 who died of pneumonia versus 4,540 who did not die</li> <li>10,549 who were prescribed antibiotics for a lower respiratory tract infection in primary care versus 43,981 who were not.</li> </ul> Participants were matched according to age and sex; differences in smoking status, deprivation and other factors were accounted for. People were followed up from their first diagnosis of an inflammatory disease either until 2019, or until they were hospitalised or had died from pneumonia, received antibiotics for a lower respiratory tract infection in primary care, or their primary care record ended. Compared with not having a pneumococcal vaccine, being vaccinated was associated with: <ul class="wp-block-list"> <li>30% reduced risk of hospitalisation due to pneumonia</li> <li>40% reduced risk of death from pneumonia</li> <li>24% reduced risk of a lower respiratory tract infection.</li> </ul> In a <a href="https://doi.org/10.1093/rheumatology/keae160" target="_blank" rel="noreferrer noopener">related study</a>, the researchers analysed vaccine uptake among 32,277 people with inflammatory diseases. Just over half (57%) had the pneumococcal vaccine; uptake was lower in those younger than 45 years (32%) and those with inflammatory bowel disease (42%). A separate analysis involved people who were vaccinated and presented to primary care with joint pain or a joint condition flare up (2,002 people) or an IBD flare (451). In this group, vaccination was not associated with joint pain or rheumatic or IBD flares. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The research suggests that the pneumococcal vaccine protects against hospitalisation and death due to pneumonia in people with inflammatory diseases; it also provides reassurance that the vaccine is not associated with disease flares. However, vaccine uptake is low. A fear of flares can be a barrier to vaccination; clinicians could therefore discuss the reassuring findings with people who have these conditions and are considering vaccination. The researchers caution that the link between vaccination and a reduction in lower respiratory tract infections requiring antibiotics should be interpreted with caution, as some of the data are uncertain. It is possible that some people were prescribed antibiotics for a viral rather than a bacterial infection they say, due to risk-averse prescribing for those with weakened immune systems. The study shows a link between vaccination and a reduction in hospitalisation and death but was not set up to prove that the vaccine was the cause. The researchers cannot be certain that the deaths and hospitalisations due to pneumonia were caused by the bacteria the vaccine targets. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers are talking with patient partners and patient organisations about how to share the findings of the study with patients and the wider public. Based on their advice, the team is co-producing patient information leaflets, infographics and animations on the benefit of vaccination for those with inflammatory conditions. They will be translated into the 5 most spoken non-English languages to ensure the information is accessible to diverse UK populations. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="43" height="62" /> Can I act on this new knowledge? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Nakafero G, and others. <a href="https://doi.org/10.1016/S2665-9913(24)00128-0" target="_blank" rel="noreferrer noopener">Effectiveness of pneumococcal vaccination in adults with common immune-mediated inflammatory diseases in the UK: a case–control study</a>. Lancet Rheumatology 2024; 6: 615 – 624. The uptake and safety study: Nakafero G, and others. <a href="https://doi.org/10.1093/rheumatology/keae160" target="_blank" rel="noreferrer noopener">Uptake and safety of pneumococcal vaccination in adults with immune-mediated inflammatory diseases: a UK wide observational study</a>. Rheumatology 2024. DOI: 10.1093/rheumatology/keae160. A study exploring barriers and enablers of vaccine uptake for people with inflammatory diseases: Fuller A, and others. <a href="https://doi.org/10.1371/journal.pone.0267769" target="_blank" rel="noreferrer noopener">Barriers and facilitators to vaccination uptake against COVID-19, influenza, and pneumococcal pneumonia in immunosuppressed adults with immune-mediated inflammatory diseases: A qualitative interview study during the COVID-19 pandemic</a>. PLOS One 2022; 17: 1 – 14. A video with <a href="https://www.youtube.com/watch?v=Vaj3rmDNQEU&t=2s" target="_blank" rel="noreferrer noopener">information about pneumococcal vaccines</a>. Information and support from <a href="https://versusarthritis.org/" target="_blank" rel="noreferrer noopener">Versus Arthritis</a>, <a href="https://crohnsandcolitis.org.uk/" target="_blank" rel="noreferrer noopener">Crohn’s and Colitis UK</a>, and <a href="https://lupusuk.org.uk/" target="_blank" rel="noreferrer noopener">Lupus UK</a>.   Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=inflammatory%20diseases&location=" target="_blank" rel="noreferrer noopener">NIHR research on inflammatory diseases</a>. Funding: This study was funded by the <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/research-for-patient-benefit.htm" target="_blank" rel="noreferrer noopener">NIHR Research for Patient Benefit Programme</a>. Conflicts of Interest: Some authors have received fees and funding from pharmaceutical companies. See <a href="https://doi.org/10.1016/S2665-9913(24)00128-0" target="_blank" rel="noreferrer noopener">paper for full details</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Brain training improved thinking, memory and attention in older people</title> <link>https://evidence.nihr.ac.uk/alert/brain-training-improved-thinking-memory-and-attention-in-older-people/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 12 Dec 2024 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65203</guid> <description><![CDATA[Researchers invited 6,544 people aged 50 years and older to take part in brain training activities that challenge people to think and solve problems. Half did brain training for 3 minutes every day; half completed fake exercises. After 6 weeks, compared with the fake exercise group, those who did brain training saw improvements in: The ...]]></description> <content:encoded><![CDATA[ Researchers invited 6,544 people aged 50 years and older to take part in brain training activities that challenge people to think and solve problems. Half did brain training for 3 minutes every day; half completed fake exercises. After 6 weeks, compared with the fake exercise group, those who did brain training saw improvements in: <ul class="wp-block-list"> <li>thinking and problem-solving</li> <li>memory</li> <li>attention.</li> </ul> The improvements were small, but any improvement in older people’s brain health could have a big impact at the population level, the researchers say. <a href="https://www.nhs.uk/conditions/dementia/about-dementia/what-is-dementia/" target="_blank" rel="noreferrer noopener">More information on dementia can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-does-brain-training-improve-thinking-and-memory-in-older-people">The issue: does brain training improve thinking and memory in older people?</h2> Dementia is a group of conditions (including <a href="https://www.nhs.uk/conditions/alzheimers-disease/" target="_blank" rel="noreferrer noopener">Alzheimer’s disease</a>) associated with ongoing decline in memory and thinking. <a href="https://www.alzheimers.org.uk/about-us/news-and-media/facts-media" target="_blank" rel="noreferrer noopener">Around 1 million people in the UK have dementia</a> and it is the <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/bulletins/deathsregistrationsummarytables/2022#:~:text=Dementia%20and%20Alzheimers%20disease%20was,for%2010.3%25%20(59%2C356%20deaths)" target="_blank" rel="noreferrer noopener">leading cause of death in England and Wales</a>. Many people have <a href="https://doi.org/10.1212/con.0000000000000313" target="_blank" rel="noreferrer noopener">impaired brain health long before dementia is diagnosed</a>. Brain training exercises (such as crosswords and sudoku) have been shown to <a href="https://doi.org/10.1001%2Fjama.296.23.2805" target="_blank" rel="noreferrer noopener">improve thinking in older adults</a>. In this study, researchers tested a brain training tool in older adults, with and without a higher genetic risk of Alzheimer’s disease. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Participants were aged 50 years and older; the average age was 62 years. Most (79%) were women. Half (3,279 people) carried out a 3-minute online brain training task (deciding whether statements about images are true or false) every day for 6 weeks. The other half (3,265 people) matched pictures (fake exercises) for the same period. The researchers assessed 617 participants for a gene that puts people at higher risk of Alzheimer’s disease (ApoE4): 17% had the gene; 83% did not. The main outcome was improvement in thinking and problem-solving skills over the 6 weeks of the study. This was measured using a different task to the brain training exercise. 1,739 people from the brain training group and 1,736 from the other group provided data. The researchers found that, compared with people who matched pictures, those who did brain training had improvements in: <ul class="wp-block-list"> <li>thinking and problem-solving (small improvement)</li> <li>memory (small improvement)</li> <li>attention (medium improvement).</li> </ul> These improvements were also seen in people at higher genetic risk of Alzheimer’s disease. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> Brain training for 3 minutes a day could improve the brain health of older adults. The effect for each individual is small, but any improvement in older adults’ cognition could represent considerable benefit across the population, the researchers say. The short duration of the exercises, and the online format could help people to engage with tasks at any time, and continue with them over the long term. People at higher risk of Alzheimer’s disease benefitted as much or slightly more than others. In the future, clinicians could encourage people known to be at risk of Alzheimer’s to start brain training. Though the researchers say that anyone can start it at any age.  Participants were generally better educated than the general population. There was a high proportion of women, and relatively few were from ethnic minorities, so the findings may not be generalisable. There was also a high dropout rate (50%), though this is in line with other digital studies. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> People can sign up to use the brain training tool and take part in studies testing it on the <a href="http://www.protectstudy.org.uk" target="_blank" rel="noreferrer noopener">PROTECT UK website</a>. In future, the researchers intend to develop an app based on the tool. The researchers are carrying out further studies exploring how to build the tool into a brain monitoring and health pathway for people showing early signs of memory and thinking problems. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="41" height="59" /> How can I act on this knowledge? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Corbett A, and others. <a href="https://doi.org/10.1016/j.jamda.2024.03.008" target="_blank" rel="noreferrer noopener">Impact of Short-Term Computerized Cognitive Training on Cognition in Older Adults With and Without Genetic Risk of Alzheimer’s Disease: Outcomes From the START Randomized Controlled Trial</a>. Journal of the American Medical Directors Association 2024; 25: 860 – 865. A previous study showing that the tool improves day-to-day function: Corbett A, and others. <a href="https://doi.org/10.1016/j.jamda.2015.06.014" target="_blank" rel="noreferrer noopener">The Effect of an Online Cognitive Training Package in Healthy Older Adults: An Online Randomized Controlled Trial</a>. Journal of the American Medical Directors Association 2015; 16: 990 – 997. A blog about brain training from <a href="https://www.ageuk.org.uk/information-advice/health-wellbeing/mind-body/staying-sharp/looking-after-your-thinking-skills/exercise-for-the-brain/" target="_blank" rel="noreferrer noopener">Age UK</a>. A video about brain training from the <a href="https://www.youtube.com/watch?v=MjGcXaF_C1s&t=4s" target="_blank" rel="noreferrer noopener">Alzheimer's Society</a>. Information and support from <a href="https://www.dementiauk.org/" target="_blank" rel="noreferrer noopener">Dementia UK</a>.  Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=Alzheimer%27s%20disease&location=" target="_blank" rel="noreferrer noopener">NIHR research on Alzheimer’s disease</a>. Funding: This study was funded by the <a href="https://www.maudsleybrc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Maudsley Biomedical Research Centre (BRC)</a> and the <a href="https://www.exeterbrc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Exeter BRC</a>. Conflicts of Interest: Some authors received fees and funding from pharmaceutical companies. Full disclosures are available in the <a href="https://doi.org/10.1016/j.jamda.2024.03.008" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Group-based intervention reduced opioid use among people with long-term pain</title> <link>https://evidence.nihr.ac.uk/alert/group-based-intervention-reduced-opioid-use-among-people-with-long-term-pain/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 10 Dec 2024 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65161</guid> <description><![CDATA[Many people take opioids to relieve long-term pain not caused by cancer. But opioids can cause other health problems and be difficult to discontinue. Researchers found that, compared with usual care, a group-based intervention with one-to-one support for people on opioids: From interviews with participants, the researchers provide suggestions to help increase the success of ...]]></description> <content:encoded><![CDATA[ Many people take opioids to relieve long-term pain not caused by cancer. But opioids can cause other health problems and be difficult to discontinue. Researchers found that, compared with usual care, a group-based intervention with one-to-one support for people on opioids: <ul class="wp-block-list"> <li>helped them discontinue their medication</li> <li>did not increase the impact of pain on everyday life.</li> </ul> From interviews with participants, the researchers provide suggestions to help increase the success of interventions to reduce opioid use. <a href="https://www.england.nhs.uk/patient-safety/fayes-story-good-practice-when-prescribing-opioids-for-chronic-pain/" target="_blank" rel="noreferrer noopener">More information about opioid use can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-how-best-to-discontinue-opioids">The issue: how best to discontinue opioids?</h2> <a href="https://www.nice.org.uk/guidance/ng193/resources/chronic-pain-primary-and-secondary-in-over-16s-assessment-of-all-chronic-pain-and-management-of-chronic-primary-pain-pdf-66142080468421" target="_blank" rel="noreferrer noopener">NHS England</a> states that opioid drugs (including morphine, tramadol and fentanyl), which are commonly used in end-of-life care, are also effective treatments for short-lived pain not caused by cancer. However, these drugs have side effects and they are not recommended as treatments for long-term pain by the <a href="https://www.england.nhs.uk/long-read/reducing-long-term-opioid-use/" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence</a> (NICE). Despite this, data collected by <a href="https://www.england.nhs.uk/long-read/reducing-long-term-opioid-use/" target="_blank" rel="noreferrer noopener">NHS England</a> in January 2021 showed that more than 1 million people in England received opioids for more than 3 months. In this study, researchers explored whether a group-based intervention could help people with long-term pain (not caused by cancer) reduce (taper) or stop their opioid treatment. <h2 class="wp-block-heading" class="wp-block-heading" id="did-the-intervention-reduce-opioid-use">Did the intervention reduce opioid use?</h2> The <a href="https://jamanetwork.com/journals/jama/fullarticle/2805141" target="_blank" rel="noreferrer noopener">overall study</a> included 608 adults from general practices across the England. They all had long-term pain (not caused by cancer) and had taken opioids on most days for at least 3 months. Participants were 61 years old on average; most (60%) were women and White British (96%). Everyone in the study received enhanced usual care (a self-help booklet called My Opioid Manager and a relaxation CD). Half (305) received, in addition, the I-WOTCH programme. This consists of 3 day-long group sessions (delivered over 3 weeks) facilitated by a trained nurse and someone with lived experience of tapering opioids. The groups provided education about opioids, and covered pain self-management, motivation, and goals to reduce opioids. They included case studies of people who had successfully tapered their opioids. People in the I-WOTCH group also had up to 4 one-to one-sessions with the nurse to work towards a shared decision to taper the opioids. Nurses provided support and individualised the tapering according to each person’s needs; tapering could be slowed and paused as required. Nurses used an app (developed as part of the research programme) to devise the individualised tapering plan; GPs signed off the plan with each participant. Half the intervention group (144 people; 47%) attended the whole programme, with most (190 people; 62%) attending at least one group session plus a one-to-one session with a nurse. Most participants provided data on whether they were still taking opioids (433 people) and completed a questionnaire about how much pain interfered with their life (439 people). After one year, people who received the intervention: <ul class="wp-block-list"> <li>were 4 times more likely to discontinue opioids (65/225; 29%) than the usual care group (15/208 people; 7%)</li> <li>had pain with similar impact on everyday life to the usual care group.</li> </ul> Few people (1%) who received the intervention needed additional medical care for possible opioid withdrawal symptoms (including shortness of breath, fever and pain). Serious side effects were slightly more common in the intervention than in the usual care group, but were often unrelated to the intervention. <h2 class="wp-block-heading" class="wp-block-heading" id="how-did-the-intervention-help">How did the intervention help?</h2> In a separate part of the project, researchers <a href="https://bmjopen.bmj.com/content/13/12/e074603" target="_blank" rel="noreferrer noopener">interviewed 40 study participants (20 from each group), plus 18 nurses and other facilitators of the intervention</a>. Interviewees stressed the complexity of living with long-term pain; many people have multiple health problems, and their lives revolve around their pain, pain relief, healthcare appointments and procedures. People generally found the groups supportive and encouraging, and most ran smoothly. Some could be disrupted by group members. Interviewees suggested that tapering is most likely to succeed when: <ul class="wp-block-list"> <li>the time is right; when someone is ready to taper, feels informed, motivated and confident</li> <li>support is available at all stages of tapering from family, GP or an intervention such as the educational group</li> <li>group interventions allow people to share information and skills in pain management, discuss and explore their fears and motivations.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> This study found that a group-based intervention increased the numbers of people who stopped taking opioids. It did not alter the impact of pain on their everyday life. People were generally positive about the educational groups, but fewer than half attended all sessions. The research team notes that participants might have been more committed to reducing their opioids, than others. In addition, most of those who took part were White British. This means the findings might not apply to everyone taking long-term opioids. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers are working with Integrated Care Boards in London to implement the I-WOTCH programme, with a view to a wider roll out. The <a href="https://jamanetwork.com/journals/jama/fullarticle/2805141" target="_blank" rel="noreferrer noopener">trial report</a> won the <a href="https://esraeurope.org/grants-awards/" target="_blank" rel="noreferrer noopener">European Society of Regional Anaesthesia and Pain Therapy</a> Best Chronic Pain Paper Award in 2024. The <a href="https://bmjopen.bmj.com/content/10/11/e037243" target="_blank" rel="noreferrer noopener">cost-effectiveness analysis</a> will be published soon. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of Sandhu HK, and others. <a href="https://jamanetwork.com/journals/jama/fullarticle/2805141" target="_blank" rel="noreferrer noopener">Reducing opioid use for chronic pain with a group-based intervention. A randomized clinical trial</a>. Journal of the American Medical Association 2023; 329: 1745 – 1756. and Nichols VP, and others. <a href="https://doi.org/10.1136/bmjopen-2023-074603" target="_blank" rel="noreferrer noopener">'It was a joint plan we worked out together'. How the I-WOTCH programme enabled people with chronic non-malignant pain to taper their opioids: a process evaluation</a>. BMJ Open 2023; 13: e074603. Sandhu HK, and others. <a href="https://doi.org/10.1136/bmjopen-2021-053725" target="_blank" rel="noreferrer noopener">Development and testing of an opioid tapering self-management intervention for chronic pain: I-WOTCH</a>. BMJ Open 2022; 12: e053725. <a href="https://www.nhs.uk/live-well/pain/ways-to-manage-chronic-pain/" target="_blank" rel="noreferrer noopener">Information about chronic pain can be found on the NHS website</a>. Funding: <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-technology-assessment.htm" target="_blank" rel="noreferrer noopener">NIHR Heath Technology Assessment</a> Commissioned Call. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://jamanetwork.com/journals/jama/fullarticle/2805141" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Endometriosis, fibroids and heavy periods: long-term research supports treatment decisions</title> <link>https://evidence.nihr.ac.uk/collection/endometriosis-fibroids-and-heavy-periods-long-term-research-supports-treatment-decisions/</link> <dc:creator><![CDATA[lauren.hoskin@nihr.ac.uk]]></dc:creator> <pubDate>Wed, 04 Dec 2024 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64953</guid> <description><![CDATA[Heavy periods, endometriosis, fibroids, and other women’s health conditions are a huge burden to many. Symptoms can continue for many years, make everyday life a challenge, and have a negative impact on work, school, relationships, social life, self-esteem and emotional wellbeing. Stigma and misinformation mean many women suffer in silence. Treatments are available, but clinicians ...]]></description> <content:encoded><![CDATA[ Heavy periods, endometriosis, fibroids, and other <a href="https://obgyn.onlinelibrary.wiley.com/doi/full/10.1002/ijgo.15211" target="_blank" rel="noreferrer noopener">women’s health conditions are a huge burden to many</a>. Symptoms can continue for many years, make everyday life a challenge, and have a negative impact on work, school, relationships, social life, self-esteem and emotional wellbeing. <a href="https://committees.parliament.uk/writtenevidence/124972/pdf/" target="_blank" rel="noreferrer noopener">Stigma and misinformation</a> mean many women suffer in silence. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-none" > <div class="row"> <div class="columns small-12 large-8"> <a href="https://www.nhs.uk/conditions/heavy-periods/" target="_blank" rel="noopener">Heavy periods</a>: Women may have to change sanitary products every 1 – 2 hours, use both a pad and a tampon, bleed through to clothes or have periods that last 7 days or more. <a href="https://www.nhs.uk/conditions/endometriosis/" target="_blank" rel="noopener">Endometriosis</a>: Cells similar to the lining of the womb grow elsewhere in the body. They may break down and bleed during a period, which can cause severe pain. <a href="https://www.nhs.uk/conditions/fibroids/" target="_blank" rel="noopener">Fibroids</a>: Growths of muscle and fibrous tissue develop in or around the womb. Not all cause symptoms. </div> </div> </section> Treatments are available, but clinicians and women need sufficient information to make <a href="https://www.england.nhs.uk/personalisedcare/shared-decision-making/" target="_blank" rel="noreferrer noopener">shared decisions</a> about care. High quality evidence comparing the benefits and risks of different treatments, alongside women’s preferences, values and beliefs, can help women receive the care that is right for them. <blockquote class="wp-block-quote is-layout-flow wp-block-quote-is-layout-flow"> “Shared decision-making is the principal mechanism for ensuring that patients get the care they need and no less, the care they want, and no more…” </blockquote> - <a href="https://assets.kingsfund.org.uk/f/256914/x/73b4098901/making_shared_decisions_making_reality_july_2011.pdf" target="_blank" rel="noreferrer noopener">Making Shared Decision Making a Reality: No Decision About Me, Without Me</a> (2011) At the NIHR Evidence webinar (November 2024), researchers presented their findings on the long-term effects of treatments for heavy periods, endometriosis and fibroids. Attendees included clinicians, members of the public, and NHS decision makers, highlighting broad interest in women’s health, and the need for information. The webinar asked:  <ul class="wp-block-list"> <li>how do treatments for heavy periods compare after 10 years?</li> <li>which hormonal treatment best prevents pain 3 years after endometriosis surgery?</li> <li>which fibroid procedure has better outcomes after 4 years?</li> </ul> This Collection summarises the 3 research projects presented at the webinar and includes video clips from the speakers. <h2 class="wp-block-heading" class="wp-block-heading" id="1-heavy-periods-the-coil-and-oral-medicines-are-similarly-effective-over-10-years">1. Heavy periods: the coil and oral medicines are similarly effective over 10 years</h2> <blockquote class="wp-block-quote is-layout-flow wp-block-quote-is-layout-flow"> “Many women and girls don't like talking about their periods, or they believe nothing can be done… Whilst attitudes are changing, there is an unmet need for treatments for heavy periods.” </blockquote> - Jane Daniels, Professor of Clinical Trials, University of Nottingham <a href="https://www.womens-health-concern.org/wp-content/uploads/2022/12/08-WHC-FACTSHEET-HeavyPeriods-NOV2022-B.pdf" target="_blank" rel="noreferrer noopener">Up to 1 in 3 women have heavy periods</a>. The <a href="https://doi.org/10.3310/hta19880" target="_blank" rel="noreferrer noopener">original ECLIPSE randomised controlled trial</a> (2005 - 2009) investigated whether the coil or oral medicines (tranexamic acid, mefenamic acid, combined oestrogen-progestogen, or progestogen alone) are more effective at reducing the impact of heavy periods. The study included 571 women from 63 UK general practices. Their average age was 42 and most (82%) were white.  Both treatments were effective. At 2 years, the impact of heavy menstrual bleeding was less for women who received the coil, compared with the oral medicines, but by 5 years, the impact was similarly reduced in both groups. At the webinar, Jane Daniels, Professor of Clinical Trials, University of Nottingham, presented <a href="https://doi.org/10.3310/JHSW0174" target="_blank" rel="noreferrer noopener">10 year outcomes of the ECLIPSE trial</a>. The original participants were asked to complete a questionnaire; 206 women answered questions about their periods, symptoms and quality of life. 36 women were interviewed in depth. <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe loading="lazy" title="Heavy periods: how effective are the coil and oral medicines over 10 years?" width="1200" height="675" src="https://www.youtube.com/embed/TL8-tKiYgMg?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> <h3 class="wp-block-heading" class="wp-block-heading" id="ongoing-treatment-and-outcomes-at-10-years">Ongoing treatment and outcomes at 10 years</h3> Among 206 women at 10 years: <ul class="wp-block-list"> <li>half (106) had reached the menopause</li> <li>60 had had surgery</li> <li>88 were using the coil; either alone (67) or in combination with oral treatments (21)  </li> <li>89 had stopped all treatments for heavy periods.</li> </ul> Some women retained their coil after the menopause because they were concerned that their bleeding would return, or because they wanted its ongoing hormonal effects. None of those who were through the menopause continued to take oral treatments. Surgery was similarly likely, whether women initially had the coil or oral treatment. But both treatments remained effective for many women.  Women’s decisions about treatment were influenced by changes in their personal and working lives, and their requirements for contraception. They were concerned about the impact of treatment on their fertility, health, and as a cause of early menopause. Quality-of-life improvements were maintained up to 10 years for the 88 women still using the coil or oral treatments. Improvements in pain, discomfort and mental health continued (compared to before treatment).  <h3 class="wp-block-heading" class="wp-block-heading" id="what-impact-do-heavy-periods-have-on-everyday-life">What impact do heavy periods have on everyday life?</h3> Women in the study described the anxiety, embarrassment, and disruption to their lives caused by heavy periods, before they started treatment. Several bled through products onto clothes and bedding. One said: “[I would have to] throw clothes away because there was so much blood on them.”  Heavy bleeding could affect relationships, work and mental health, often leading to anxiety and a lack of confidence: “it always made me really anxious, I would get very tearful.” More than half the women interviewed had positive interactions with clinicians, even if they had to try multiple treatments. They felt informed and knew what to expect from treatment. But some said they were ‘fobbed off’ and told that the bleeding was normal. <h3 class="wp-block-heading" class="wp-block-heading" id="clinicians-can-support-women-to-make-informed-decisions">Clinicians can support women to make informed decisions</h3> Treatments prescribed by GPs improved quality of life for most women over the long-term. These findings could help doctors and women make shared decisions about managing heavy periods.  The research stressed that women need a clear explanation in the initial consultation when there is no obvious cause for the problem, or if tests would help. They need to know that treatment may need to be changed over time. After starting treatment, contact points with healthcare professionals such as when the coil needs to be changed or for cervical screening, are ideal opportunities to discuss progress. <h2 class="wp-block-heading" class="wp-block-heading" id="2-endometriosis-long-acting-progestogens-and-the-contraceptive-pill-similarly-reduce-pain-after-surgery">2. Endometriosis: long-acting progestogens and the contraceptive pill similarly reduce pain after surgery</h2> <a href="https://committees.parliament.uk/writtenevidence/124972/pdf/" target="_blank" rel="noreferrer noopener">Around 1 in 10 women have endometriosis</a>. Surgery for endometriosis can improve symptoms, but recurrence of pain is common. <a href="https://www.nice.org.uk/guidance/ng73/chapter/Recommendations" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE) guidelines</a> recommend the contraceptive pill and progestogens to treat endometriosis-related pain.  At the webinar, Justin Clark, Consultant Gynaecologist, Birmingham Women's Hospital and Honorary Professor, University of Birmingham, presented data from the <a href="https://doi.org/10.3310/SQWY6998" target="_blank" rel="noreferrer noopener">PRE-EMPT randomised controlled trial</a>. It explored whether the contraceptive pill or long-acting progestogens are better at preventing pain 3 years after surgery for endometriosis. The randomised controlled trial included women who had surgery for endometriosis: 205 were randomised to long-acting progestogens (a long-acting injection of medroxyprogesterone acetate every three months or a coil) and 200 to the contraceptive pill. Most women (91%) were white and their average age was 29. <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe loading="lazy" title="Endometriosis: are progestogens or the contraceptive pill better at preventing pain after surgery?" width="1200" height="675" src="https://www.youtube.com/embed/62IXE5WZBVU?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> <h3 class="wp-block-heading" class="wp-block-heading" id="both-treatments-improved-endometriosis-related-pain-at-3-years">Both treatments improved endometriosis-related pain at 3 years</h3> Both groups saw approximately a 40% reduction in endometriosis-related pain after 3 years compared to before surgery (the main outcome); there was no significant difference between groups. Results were the same across subgroups, including type of progestogen. The Endometriosis Health Profile-30 questionnaire assesses the impact of endometriosis on women’s lives. Both groups had improved scores for most aspects of life, including emotional wellbeing and work life, compared with before surgery. There were no consistent differences between groups.  Neither fatigue nor quality of life were significantly improved by either treatment at 3 years. <h3 class="wp-block-heading" class="wp-block-heading" id="fewer-women-on-long-acting-progestogens-required-additional-treatment">Fewer women on long-acting progestogens required additional treatment </h3> Use of long-acting progestogens reduced the risk of additional treatments and further surgery compared with the contraceptive pill. Women in the long-acting progestogen group had fewer (73) additional treatments or procedures than those in the contraceptive pill group (97). <h3 class="wp-block-heading" class="wp-block-heading" id="uncertainty-remains-over-which-treatment-is-more-cost-effective">Uncertainty remains over which treatment is more cost-effective </h3> The contraceptive pill was associated with higher costs per woman (£2,470) but slightly more quality adjusted life years (equivalent to 1 year in perfect health; 1.98) than long-acting progestogens (£1,937, 1.94, respectively). A cost-effectiveness analysis suggested only a 61% chance that the contraceptive pill was more cost-effective; uncertainty remains over which treatment offers more value for money. <h3 class="wp-block-heading" class="wp-block-heading" id="outcomes-for-long-acting-progestogens-and-the-contraceptive-pill-are-similar">Outcomes for long-acting progestogens and the contraceptive pill are similar </h3> The findings support current guidance to prescribe hormonal treatment after surgery for endometriosis. <blockquote class="wp-block-quote is-layout-flow wp-block-quote-is-layout-flow">  “This trial suggests we should be offering women either type of hormonal treatment to prevent symptomatic recurrence of endometriosis. The findings should hopefully help shared decision making.” </blockquote> - Justin Clark Clinicians could share these findings with women to improve shared decision making. Further research could compare these treatments with newer ones, such as dienogest. In the Q&A, Justin Clark said that relatively few women in the study were from ethnic minorities and that more research is needed in this group.  For women unable to tolerate hormonal medications, Justin Clark said that surgery alone may be an option, though evidence suggests that hormonal medications improve pain symptoms further. Women could be referred to a pain clinic or use other pain relieving drugs, he said. <h2 class="wp-block-heading" class="wp-block-heading" id="3-fibroids-myomectomy-and-uterine-artery-embolisation-have-similar-long-term-outcomes">3. Fibroids: myomectomy and uterine artery embolisation have similar long-term outcomes</h2> <a href="https://www.nhs.uk/conditions/fibroids/" target="_blank" rel="noreferrer noopener">2 in 3 women will have a fibroid in their lifetime</a> (not all of which cause symptoms). Hysterectomies are the most common treatment for removing fibroids but many women opt for womb-preserving procedures. These include myomectomy (surgical removal of fibroids) and uterine artery embolisation (UAE; blocking the blood vessels that supply fibroids).   The original <a href="https://doi.org/10.3310/ZDEG6110" target="_blank" rel="noreferrer noopener">FEMME randomised controlled trial</a> (2012 - 2015) compared outcomes for myomectomy or UAE among 254 premenopausal women with symptomatic fibroids. Their average age was 41 and a similar proportion of women were white (46%) or black (40%). At 2 years, both treatments improved quality of life, but myomectomy was significantly better than UAE. At the webinar, Jane Daniels <a href="https://doi.org/10.1016/j.eurox.2021.100139" target="_blank" rel="noreferrer noopener">presented outcomes for the 81 women in the myomectomy group and 67 in the UAE group who provided data at year 4</a>. <figure class="wp-block-embed is-type-video is-provider-youtube wp-block-embed-youtube wp-embed-aspect-16-9 wp-has-aspect-ratio"><div class="wp-block-embed__wrapper"> <iframe loading="lazy" title="Long-term outcomes for women with fibroids: myomectomy compared with uterine artery embolisation" width="1200" height="675" src="https://www.youtube.com/embed/7bxz9il_yB0?feature=oembed" frameborder="0" allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture; web-share" referrerpolicy="strict-origin-when-cross-origin" allowfullscreen></iframe> </div></figure> <h3 class="wp-block-heading" class="wp-block-heading" id="both-treatments-improved-quality-of-life-symptoms-and-satisfaction">Both treatments improved quality of life, symptoms and satisfaction</h3> At 4 years, both procedures improved health-related quality of life but myomectomy was no longer significantly better (as it was at year 2). Most women (76%) were happy with the procedure they had and if they could go back in time, would make the same choice again. Menstrual bleeding scores were similar in both groups; most menstruating women reported regular or fairly regular periods (77% for myomectomy and 75% for UAE). Further procedures were more common in the UAE group (22) than in the myomectomy group (13) .  <h3 class="wp-block-heading" class="wp-block-heading" id="myomectomy-is-slightly-more-cost-effective-than-uae">Myomectomy is slightly more cost-effective than UAE</h3> <a href="https://doi.org/10.1111/1471-0528.16781" target="_blank" rel="noreferrer noopener">The mean total cost to the NHS was £8,010 for the myomectomy group and £8,362 for the UAE group</a> (based on 2018/19 costs). Quality adjusted life years were higher for myomectomy (0.82) than UAE (0.73). Myomectomy was therefore more cost-effective over 4 years. Nevertheless, the total differences in costs and quality adjusted life years were small. <h3 class="wp-block-heading" class="wp-block-heading" id="outcomes-for-myomectomy-and-uae-are-similar-over-4-years">Outcomes for myomectomy and UAE are similar over 4 years </h3> <blockquote class="wp-block-quote is-layout-flow wp-block-quote-is-layout-flow"> “It's important that GPs, gynaecologists and other health care professionals discuss both procedures as an alternative to a hysterectomy, and allow women a choice, where both are viable options.” </blockquote> - Jane Daniels Clinicians could discuss both treatments with women considering surgery for fibroids. The differences between treatments in effectiveness and cost-effectiveness were small.   In the Q&A, several attendees raised the difficulty of being diagnosed with fibroids, endometriosis, and heavy periods. The panellists said that both women and clinicians can consult <a href="https://www.nice.org.uk/guidance/ng88/chapter/Recommendations" target="_blank" rel="noreferrer noopener">NICE guidelines</a> to understand what treatments and support are recommended, and when. Women can be assured that their views matter in choosing the right treatment for them; they are encouraged to share their preferences with clinicians. <h2 class="wp-block-heading" class="wp-block-heading" id="conclusion">Conclusion</h2> <blockquote class="wp-block-quote is-layout-flow wp-block-quote-is-layout-flow"> “In the absence of a clear difference in clinical outcomes, listening to patients and respecting their preferences is really important.” </blockquote> - Justin Clark In these 3 studies, the long-term outcomes of different treatments for heavy periods, endometriosis, and fibroids were similar. Clinicians need to listen to women and ask about their priorities and preferences to help them make informed decisions about their care.     Shared decision making is the starting point for delivering high-quality care. This Collection provides high-quality evidence to underpin discussions between women and their clinicians about overlooked and undertreated conditions: heavy periods, endometriosis, and fibroids. <h2 class="wp-block-heading" class="wp-block-heading" id="resources">Resources </h2> <a href="https://evidence.nihr.ac.uk/collection/womens-health-why-women-feel-unheard/">Women’s Health: Why do women feel unheard?</a> <a href="https://www.nice.org.uk/guidance/ng88/chapter/Recommendations" target="_blank" rel="noreferrer noopener">NICE guidance on heavy periods</a> Support and information from <a href="https://www.wellbeingofwomen.org.uk/" target="_blank" rel="noreferrer noopener">Wellbeing of Women</a>, <a href="https://www.endometriosis-uk.org/get-support" target="_blank" rel="noreferrer noopener">Endometriosis UK</a>, <a href="https://www.theendometriosisfoundation.org/" target="_blank" rel="noreferrer noopener">The Endometriosis Foundation</a>, <a href="http://www.britishfibroidtrust.org.uk/" target="_blank" rel="noreferrer noopener">The British Fibroid Trust</a> and the <a href="https://menstrualhealthproject.org.uk/" target="_blank" rel="noreferrer noopener">Menstrual Health Project</a> <a href="https://www.rcog.org.uk/guidance/browse-all-guidance/" target="_blank" rel="noreferrer noopener">Guidance from the Royal College of Obstetricians and Gynaecologists </a> <a href="https://menstrualcyclesupport.com/" target="_blank" rel="noreferrer noopener">Menstrual Cycle Support</a> - a free online course to help women them manage their menstrual cycle <hr class="wp-block-separator has-alpha-channel-opacity"/> How to cite this Collection: NIHR Evidence; Endometriosis, fibroids and heavy periods: long-term research supports treatment decisions; November 2024; doi: 10.3310/nihrevidence_64953 Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>People on long waiting lists use more healthcare resources than others</title> <link>https://evidence.nihr.ac.uk/alert/people-on-long-waiting-lists-use-more-healthcare-resources-than-others/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 03 Dec 2024 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65083</guid> <description><![CDATA[People waiting more than 18 weeks for NHS treatments used more healthcare resources than others, research found. Healthcare resource use differed depending on what treatment people were waiting for. The researchers say initiatives to reduce waiting list backlogs should consider the extra healthcare use among people on the waiting list alongside the costs of the ...]]></description> <content:encoded><![CDATA[ People waiting more than 18 weeks for NHS treatments used more healthcare resources than others, research found. Healthcare resource use differed depending on what treatment people were waiting for. The researchers say initiatives to reduce waiting list backlogs should consider the extra healthcare use among people on the waiting list alongside the costs of the treatment. <a href="https://www.nhs.uk/nhs-services/hospitals/guide-to-nhs-waiting-times-in-england/" target="_blank" rel="noreferrer noopener">More information about NHS waiting lists can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-what-impact-do-long-waiting-lists-have-on-healthcare-use">The issue: what impact do long waiting lists have on healthcare use?</h2> In March 2020, almost 4 million people were waiting for NHS treatment; <a href="https://www.england.nhs.uk/rtt/" target="_blank" rel="noreferrer noopener">by June 2024, this had risen to almost 8 million</a>. Before the pandemic, the NHS met its target of treating people within <a href="https://www.england.nhs.uk/rtt/" target="_blank" rel="noreferrer noopener">18 weeks of referral</a> for 86% people. By March 2022, fewer people (62%) were treated in this time. Understanding the healthcare use of people waiting for treatment helps to plan future healthcare resources. Researchers explored whether people waiting for treatment used more healthcare resources (such as GP appointments and prescriptions, community mental health consultations and calls to NHS 111) than those not waiting. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers examined electronic health records for the Bristol, North Somerset and South Gloucestershire Integrated Care System (ICS). They included data on 44,616 people who had waited more than 18 weeks for elective (non-emergency) treatment between June and December 2021; their average age was 53 years. Each person waiting was matched with 200 others, on average, who had the same condition but were not waiting for treatment. The study covered 18 hospital specialties, including general surgery, gynaecology, ophthalmology and trauma and orthopaedic. Overall, people waiting for treatment used more healthcare resources than those who were not waiting, especially in some specialties. For example, compared with those not waiting for treatment: <ul class="wp-block-list"> <li>people waiting for general surgery (4,355 people) had an average of 2 more primary care prescriptions and 2 more secondary care contacts per year</li> <li>people waiting for gastroenterology treatment (2,185) had an average of 6 more primary care prescriptions and 2 more secondary care contacts per year</li> <li>people waiting for trauma and orthopaedic treatment (6,889) had an average of 2 more contacts with primary care, 4 more primary care prescriptions, and 4 additional contacts with secondary care per year</li> <li>people waiting for respiratory treatment (1,342) had an average of 5 more primary care prescriptions and 6 more secondary care contacts per year.</li> </ul> People waiting for cardiothoracic surgery had the largest increase in secondary care use (17 additional secondary care contacts per year compared to those not waiting for treatment). However, this represents less burden on the NHS than other specialties as few (29 people in this study) were waiting more than 18 weeks. Those waiting for oral surgery, ophthalmology, gynaecology and dermatology services had the smallest increase in healthcare use (50% or more people waiting for these services did not use extra healthcare). The greatest increases in healthcare use were in primary and secondary care contacts, and in prescriptions; the smallest were in helpline calls, emergency calls, community and mental health services (fewer than 25% people waiting used more of these services). <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The findings highlight the hidden costs of keeping people waiting for treatment. This will help decision makers determine care needs, minimise harm and support future strategic planning. Initiatives to reduce waiting lists need to factor in the costs of the procedure, along with additional resources used by people on the waiting list. The number of people waiting over 18 weeks for treatment varied between specialties, but much of the extra demand for healthcare contact fell on secondary care. The researchers say that many of the extra prescriptions may have been repeat prescriptions, which represent an administrative burden on primary care.   The researchers caution that the study did not prove that differences in health service use were caused by long waits for treatment. The study matched people based on their health conditions, but did not account for the severity of those conditions. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers presented their findings at meetings with Bristol, North Somerset, and South Gloucestershire Integrated Care Board (ICB). As a result, colleagues working within the Integrated Care system are considering how best to take the work forward. Further research will improve understanding of the system-wide impacts of waiting lists, and what initiatives might best reduce backlogs. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="40" height="58" /> Can I act on these findings? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: James C, and others. <a href="https://doi.org/10.1186/s12913-024-10931-2" target="_blank" rel="noreferrer noopener">The cost of keeping patients waiting: retrospective treatment-control study of additional healthcare utilisation for UK patients awaiting elective treatment</a>. BMC Health Services Research 2024; 24: 556. A press release by the Bristol Biomedical Research Centre summarising the study findings: <a href="https://www.bristolbrc.nihr.ac.uk/news/longer-hospital-wait-times-are-leading-to-patients-accessing-more-healthcare-services/" target="_blank" rel="noreferrer noopener">Longer hospital wait times are leading to patients accessing more healthcare services</a>. Funding: This study was funded by the <a href="https://arc-w.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Applied Research Collaboration West</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1186/s12913-024-10931-2" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>System-level changes are essential to improve the psychological wellbeing of NHS staff</title> <link>https://evidence.nihr.ac.uk/alert/system-level-changes-are-essential-to-improve-the-psychological-wellbeing-of-nhs-staff/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 28 Nov 2024 08:30:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65088</guid> <description><![CDATA[Researchers reviewed the literature to investigate the causes of psychological ill-health (stress and anxiety, for instance) among nurses, midwives and paramedics. They identified solutions, and recommended that senior leaders, managers and team leaders, along with nurses, midwives and paramedics: The researchers produced guidance for NHS leaders at all levels, and staff, to help implement the ...]]></description> <content:encoded><![CDATA[ Researchers reviewed the literature to investigate the causes of psychological ill-health (stress and anxiety, for instance) among nurses, midwives and paramedics. They identified solutions, and recommended that senior leaders, managers and team leaders, along with nurses, midwives and paramedics: <ul class="wp-block-list"> <li>improve working conditions (through regular breaks and appropriate facilities, for example)</li> <li>address the blame culture and assume staff are doing their best in difficult situations</li> <li>expect staff to experience psychological ill-health and take a preventive approach</li> <li>shift from individual interventions only (such as mindfulness or resilience training, which can be important) to include a focus on system-level culture change.</li> </ul> The researchers produced <a href="https://workforceresearchsurrey.health/projects-resources/cup2/" target="_blank" rel="noreferrer noopener">guidance</a> for NHS leaders at all levels, and staff, to help implement the suggestions. <a href="https://www.nhsemployers.org/health-and-wellbeing" target="_blank" rel="noreferrer noopener">More information about psychological wellbeing support can also be found on the NHS Employers website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-the-impact-of-nhs-staff-psychological-ill-health">The issue: the impact of NHS staff psychological ill-health</h2> The NHS needs healthy, motivated staff to provide high-quality patient care. Nurses, midwives and paramedics make up more than half (56%) of all clinical staff in the NHS; they have high rates of psychological ill-health. High-pressure environments, with heavy workloads and staff shortages, are linked to psychological ill-health. The <a href="https://www.nhsstaffsurveys.com/results/national-results/" target="_blank" rel="noreferrer noopener">2023 NHS staff survey</a> reported that almost half (42%) of all staff felt unwell because of work-related stress in the 12 months before the survey. 1 in 3 (32%) felt there were enough staff to enable them to do their job properly; most (74%) said they faced unrealistic time pressures sometimes, often or always. 1 in 3 (30%) felt burnt out because of their work, and rates were highest in nurses, midwives and paramedics. Psychological ill-health increases sick leave and staff resignations; it can also mean that some staff may be working when not well enough to perform their duties (presenteeism). The quality of patient care suffers as a result. <a href="https://eppi.ioe.ac.uk/cms/Portals/0/IPPO%20NHS%20Staff%20Wellbeing%20report_LO160622-1849.pdf" target="_blank" rel="noreferrer noopener">Psychological ill-health among staff costs the NHS</a> an estimated £12 billion per year, or more. The NHS could save up to £1 billion by successfully tackling this issue. The researchers investigated causes of psychological ill-health in nurses, midwives and paramedics in more detail, and explored what might help. <h2 class="wp-block-heading" class="wp-block-heading" id="what-contributes-to-work-related-psychological-ill-health">What contributes to work-related psychological ill-health?</h2> The researchers examined more than 200 research papers and reports. They found that aspects of the job and workplace, rather than the profession itself, increased the risk of psychological ill-health. For example, staff in roles that exposed them to trauma, newly qualified staff and lone workers were especially vulnerable. Conflicting priorities and tensions in the healthcare system could make it difficult to promote psychological wellness in staff. For example, where: <ul class="wp-block-list"> <li>a fragmented approach to staff wellbeing focuses on individuals and acute episodes of stress, and does not recognise long-term workplace challenges</li> <li>a blame culture makes staff fearful to speak up if they have concerns, and managers don't listen</li> <li>the needs of the system override staff needs so that for example, staff prioritise work needs above their own needs (and take on additional shifts to cover staff shortages, for instance).</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="how-can-healthcare-organisations-improve-staffs-psychological-wellbeing">How can healthcare organisations improve staff’s psychological wellbeing?</h2> As a result of their findings, the researchers suggest that organisations: <ul class="wp-block-list"> <li>invest in <a href="https://workforceresearchsurrey.health/projects-resources/addressing-unprofessional-behaviours-between-healthcare-staff/" target="_blank" rel="noreferrer noopener">long-term approaches</a> to staff wellbeing that address organisational stressors (for example, provide wellbeing and psychological support, reduce bullying and harassment, and invest in spaces and places for staff to share experiences, such as in <a href="https://www.pointofcarefoundation.org.uk/our-programmes/schwartz-rounds/about-schwartz-rounds/" target="_blank" rel="noreferrer noopener">Schwartz Rounds</a>); use an <a href="https://www.england.nhs.uk/publication/nhs-health-and-wellbeing-framework/" target="_blank" rel="noreferrer noopener">evidence-based framework</a> to evaluate interventions</li> <li>reduce stigma and address the blame culture; assume staff are doing their best in difficult conditions</li> <li>improve the working environment by prioritising staff’s essential needs (access to hot food, lockers, showers, rest and break rooms, car parking).</li> </ul> The researchers suggest that front-line staff <a href="https://workforceresearchsurrey.health/projects-resources/impact-of-covid-19-on-nurses/" target="_blank" rel="noreferrer noopener">co-design interventions</a>, tailored where possible to local, organisational and workforce needs. For example, staff may need a shared space during times of stress rather than investment in expensive online apps. During the pandemic, staff created What’s App groups to maintain contact with colleagues who had been redeployed elsewhere. These groups helped meet the need for support from each other. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> Researchers need to work with service providers to meet the changing needs of diverse groups of professionals. More research is needed to help design, implement and evaluate complex interventions. The researchers have produced a <a href="https://workforceresearchsurrey.health/projects-resources/cup2/" target="_blank" rel="noreferrer noopener">summary, guidance and a webinar of their work</a> for leaders, nurses, midwives and paramedics. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="42" height="60" /> How can I act on the new knowledge? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Maben J, and others. <a href="https://doi.org/10.3310/TWDU4109" target="_blank" rel="noreferrer noopener">Causes and solutions to workplace psychological ill-health for nurses, midwives and paramedics: the Care Under Pressure 2 realist review</a>. Health and Social Care Delivery Research 2024; 12. Taylor C, and others. <a href="https://qualitysafety.bmj.com/content/33/8/523" target="_blank" rel="noreferrer noopener">Care under pressure 2: a realist synthesis of causes and interventions to mitigate psychological ill health in nurses, midwives and paramedics</a>. British Medical Journal Quality & Safety 2024; 33: 523 – 538. A <a href="https://workforceresearchsurrey.health/projects-resources/cup2/" target="_blank" rel="noreferrer noopener">guide</a> for nurses, midwives, paramedics, their teams and managers and leaders. <a href="https://www.nice.org.uk/guidance/ng212/chapter/Recommendations#strategic-approaches-to-improving-mental-wellbeing-in-the-workplace" target="_blank" rel="noreferrer noopener">Mental wellbeing at work</a>. National Institute of Clinical Excellence guideline (NG212). March 2022. Mental health support from the <a href="https://www.england.nhs.uk/supporting-our-nhs-people/support-now/" target="_blank" rel="noreferrer noopener">NHS</a> for staff; plus the <a href="https://www.practitionerhealth.nhs.uk/national-services" target="_blank" rel="noreferrer noopener">NHS Practitioner Health</a> website provides a list of national services and support groups for NHS staff. Strategies and support for stress from the <a href="https://www.rcn.org.uk/Get-Help/Managing-stress/Strategies-and-support" target="_blank" rel="noreferrer noopener">Royal College of Nursing</a>. <a href="https://www.hee.nhs.uk/sites/default/files/documents/NHS%20%28HEE%29%20-%20Mental%20Wellbeing%20Commission%20Report.pdf" target="_blank" rel="noreferrer noopener">NHS Staff and Learners’ Mental Wellbeing Commission report</a>. A report from the King’s Fund. <a href="https://www.kingsfund.org.uk/insight-and-analysis/reports/courage-compassion-supporting-nurses-midwives" target="_blank" rel="noreferrer noopener">The courage of compassion. Supporting nurses and midwives to deliver high-quality care</a>. September 2020. Funding: This study was funded by the NIHR <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-and-social-care-delivery-research.htm" target="_blank" rel="noreferrer noopener">Health and Social Care Delivery Research programme</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.3310/TWDU4109" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Community perinatal mental health teams reduced women’s risk of mental illness relapse</title> <link>https://evidence.nihr.ac.uk/alert/community-perinatal-mental-health-teams-reduced-womens-risk-of-mental-illness-relapse/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 26 Nov 2024 08:47:27 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65004</guid> <description><![CDATA[Community perinatal mental health teams support women before and during pregnancy, and in the 12 months after giving birth. Researchers found that in areas of the country where teams were available, women who had previous contact with psychiatric services: Secondary findings in areas with teams included a lower risk of premature (early) birth, but a ...]]></description> <content:encoded><![CDATA[ Community perinatal mental health teams support women before and during pregnancy, and in the 12 months after giving birth. Researchers found that in areas of the country where teams were available, women who had previous contact with psychiatric services: <ul class="wp-block-list"> <li>were more likely to access mental health support</li> <li>had a lower risk of relapse requiring hospital admission in the year after giving birth.</li> </ul> Secondary findings in areas with teams included a lower risk of premature (early) birth, but a slightly higher risk of stillbirth, child death, and babies with low birthweight. More research is needed to confirm these findings and explore potential reasons. The researchers say their findings suggest that community perinatal mental health teams improve the mental health of women during and after pregnancy. <a href="https://www.england.nhs.uk/mental-health/perinatal/" target="_blank" rel="noreferrer noopener">More information on perinatal mental health can be found on the NHS website</a>.<a id="_msocom_1"></a> <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-how-to-support-pregnant-women-with-a-history-of-mental-illness">The issue: how to support pregnant women with a history of mental illness</h2> Women who have previously had severe mental illness, such as bipolar disorder or severe depression, are at increased risk of relapse after giving birth. A 2016 review showed that <a href="https://psychiatryonline.org/doi/10.1176/appi.ajp.2015.15010124" target="_blank" rel="noreferrer noopener">many (37%) women with bipolar disorder relapsed after childbirth</a>. Other research suggests that <a href="https://doi.org/10.1016/s2215-0366(23)00200-6" target="_blank" rel="noreferrer noopener">women with a history of mental illness are more likely to give birth prematurely (10%) than other women (7%)</a>. Community perinatal mental health teams were launched in England in 2016 to improve access to mental healthcare for pregnant women. They aim to prevent and treat episodes of mental illness during pregnancy and after birth. The service offers psychological interventions, medication advice, help with bonding with the baby, and emergency referrals to appropriate clinicians. However, there is little research evaluating the service. This study assessed whether access to community perinatal mental health teams reduced the risk of relapse after birth among women with a history of mental illness. The researchers also looked at pregnancy outcomes. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The study was based on the records of women with a history of mental health illness who gave birth in England from 2016 to 2018. Almost half (31,276) had access to community perinatal mental health teams; the others (39,047) did not. Participants had been in contact with a secondary mental health service in the 10 years before their pregnancy. Women who gave birth to more than one baby were excluded. The main outcome was the number of women who had a relapse requiring a psychiatric hospital admission or being seen by the crisis resolution team in the year after birth. Researchers found that in areas where community perinatal mental health teams were available:   <ul class="wp-block-list"> <li>more women accessed mental healthcare (32%) than in areas without teams (26%)</li> <li>fewer women relapsed (3.6%) than in areas without teams (4.5%).</li> </ul> Fewer women had a preterm birth (10.1%) in areas where the service was available than in areas without teams (11.1%). However, the researchers also found that in areas where community perinatal mental health teams were available: <ul class="wp-block-list"> <li>stillbirth and infant death was slightly more common (0.5% births) than in areas without teams (0.4%)</li> <li>more babies had low birthweight (7.2%) than in areas without teams (6.6%).</li> </ul> Overall, there was no difference in adverse pregnancy outcomes in areas with or without community perinatal mental health teams. Total mental healthcare costs were £111 higher per woman giving birth to a single baby in areas with teams than areas without (based on 2018/19 costs). <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> This study provides evidence that community perinatal mental health teams increase access to mental healthcare and reduce the risk of relapse. Greater access to these teams across the UK could improve mental health outcomes for women during pregnancy and after birth. Community perinatal mental health teams are unique to the UK and the researchers say that other countries could benefit from similar services. There is no simple explanation for the increased risk of stillbirth, child death, and low birthweight babies in areas with access to teams. The researchers suggest that mental health could sometimes have been prioritised over physical health in women with a history of mental illness. The researchers caution that the study considered women’s potential access to community perinatal mental health teams; it did not look at whether they actually accessed the service. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers suggest that closer working between community perinatal mental health teams and other maternity services could improve care for pregnant women with a history of mental illness. Mental health services have expanded and are now more embedded in maternity services. Further research is needed to explore whether community perinatal mental health teams are associated with adverse pregnancy outcomes. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="44" height="64" /> How can I act on this research? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Gurol-Urganci I, and others. <a href="https://doi.org/10.1016/s2215-0366(23)00409-1" target="_blank" rel="noreferrer noopener">Community perinatal mental health teams and associations with perinatal mental health and obstetric and neonatal outcomes in pregnant women with a history of secondary mental health care in England: a national population-based cohort study</a>. Lancet Psychiatry 2024; 11: 174 – 82. A <a href="https://www.bbc.co.uk/programmes/m001pmhb" target="_blank" rel="noreferrer noopener">BBC Women’s Hour podcast</a> and a <a href="https://www.theguardian.com/lifeandstyle/2023/aug/14/women-with-poor-mental-health-have-50-higher-risk-of-preterm-birth" target="_blank" rel="noreferrer noopener">Guardian article</a> about research related to this study. Information and support about postnatal depression and perinatal mental health from <a href="https://www.mind.org.uk/information-support/types-of-mental-health-problems/postnatal-depression-and-perinatal-mental-health/" target="_blank" rel="noreferrer noopener">Mind</a>. Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=perinatal%20mental%20health&location=" target="_blank" rel="noreferrer noopener">NIHR research on perinatal mental health</a>. Funding: <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-and-social-care-delivery-research.htm" target="_blank" rel="noreferrer noopener">NIHR Health and Social Care Delivery Research Programme</a> Commissioned Call. Conflicts of Interest: None declared. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Amoxicillin is effective for many people hospitalised with pneumonia</title> <link>https://evidence.nihr.ac.uk/alert/amoxicillin-is-effective-for-many-people-hospitalised-with-pneumonia/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Fri, 22 Nov 2024 06:41:37 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65042</guid> <description><![CDATA[Amoxicillin (a narrow-spectrum antibiotic) was as effective as co-amoxiclav (a broad-spectrum antibiotic which targets a wider range of bacteria) for people admitted to hospital with pneumonia, regardless of its severity. Research found that 30-day death rates were similar whether people received co-amoxiclav or amoxicillin. The findings will encourage clinicians to follow guidelines and prescribe amoxicillin ...]]></description> <content:encoded><![CDATA[ Amoxicillin (a narrow-spectrum antibiotic) was as effective as co-amoxiclav (a broad-spectrum antibiotic which targets a wider range of bacteria) for people admitted to hospital with pneumonia, regardless of its severity. Research found that 30-day death rates were similar whether people received co-amoxiclav or amoxicillin. The findings will encourage clinicians to follow guidelines and prescribe amoxicillin for low- or moderate-severity community-acquired pneumonia. The researchers say this could help reduce the spread of antimicrobial resistance. More research is needed before guidelines could be changed to recommend amoxicillin for severe pneumonia. <a href="https://www.nhs.uk/conditions/pneumonia/" target="_blank" rel="noreferrer noopener">More information about pneumonia can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-are-narrow-spectrum-antibiotics-effective-for-severe-pneumonia">The issue: are narrow-spectrum antibiotics effective for severe pneumonia?</h2> Infections caused by bacteria that are resistant to antibiotics can be difficult to treat. Resistance is increased by using antibiotics that work on many types of bacteria (broad-spectrum antibiotics such as <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5820700/" target="_blank" rel="noreferrer noopener">co-amoxiclav</a>). To limit the spread of resistance, <a href="https://www.nice.org.uk/guidance/ng138/chapter/Recommendations" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE)</a> guidelines recommend that clinicians use this class of antibiotics only when essential. Pneumonia is an infection of the lungs, usually caused by bacteria. Symptoms include a cough, shortness of breath, and chest pain. Each year in the UK, <a href="https://www.asthmaandlung.org.uk/conditions/pneumonia/what-is-it" target="_blank" rel="noreferrer noopener">5 to 10 in every 1000</a> adults develop community-acquired pneumonia. Most recover in 2 to 4 weeks, but older people and those with heart or lung conditions are at risk of serious illness and hospital admission. NICE recommends amoxicillin (a narrow-spectrum antibiotic) for low- to moderate-severity pneumonia. Co-amoxiclav (a broad-spectrum antibiotic) is recommended only for severe pneumonia. However, many people with non-severe pneumonia are prescribed co-amoxiclav when they arrive at hospital.  In this study, researchers compared co-amoxiclav with amoxicillin for people arriving at hospital with community-acquired pneumonia. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Researchers analysed the electronic health records of 4586 adults (aged 16 and over) admitted to hospital with pneumonia in Oxfordshire between 2016 and 2023. Most (96%) were White, half (52%) were male, and their average age was 79 years. 3167 received co-amoxiclav and 1419 received amoxicillin 12 hours prior to or up to 24 hours after their admission. As expected, people with the most severe pneumonia, and with other health conditions, were more likely to be prescribed co-amoxiclav. The researchers accounted for such differences to compare people who were similarly unwell but received different treatments. People in one treatment group were matched and compared to someone with similar risks (such as pneumonia severity) in the other group.<s></s> 30 days after admission, the researchers found: <ul class="wp-block-list"> <li>a similar risk of dying whether people were prescribed co-amoxiclav or amoxicillin</li> <li>taking additional antibiotics (for instance, clarithromycin or doxycycline to treat other rarer causes of pneumonia) did not change the risk of death within 30 days.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The findings support NICE guidelines in encouraging clinicians to use amoxicillin for mild to moderate pneumonia. In this study, 3490 (76%) of the patients studied had mild to moderate pneumonia. More widespread use of amoxicillin, a narrow-spectrum antibiotic, could help reduce the spread of antibiotic resistance. NICE guidelines suggest reserving co-amoxiclav for people with severe pneumonia. The study found that clinicians tended to follow this guideline; people with severe disease, and other conditions, were more likely to be prescribed co-amoxiclav. However, when results were adjusted for this difference, amoxicillin was as effective as co-amoxiclav at treating community-acquired pneumonia, at all levels of disease severity. But this study was not a randomised controlled trial, and this finding is not conclusive. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> A randomised controlled trial is needed to directly compare amoxicillin with co-amoxiclav for people with severe pneumonia, the researchers say. They also call for better diagnostics and tools to identify those most in need of broad-spectrum antibiotics, such as people at risk of antibiotic-resistant or atypical infections. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="45" height="65" /> Can I act on this research? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Wei J, and others. <a href="https://doi.org/10.1016/j.jinf.2024.106161" target="_blank" rel="noreferrer noopener">No evidence of difference in mortality with amoxicillin versus co-amoxiclav for hospital treatment of community-acquired pneumonia</a>. Journal of Infection 2024; 88(6): 106161. <a href="https://www.who.int/campaigns/world-amr-awareness-week" target="_blank" rel="noreferrer noopener">World AMR Awareness Week</a> takes place from 18 to 24 November each year. Funding: This study was funded by the<a href="https://www.herc.ox.ac.uk/research/dce-research-at-herc/studies-15/health-protection-research-unit-in-healthcare-associated-infections-and-antimicrobial-resistance" target="_blank" rel="noreferrer noopener"> NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance at Oxford University</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1016/j.jinf.2024.106161" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Is surgery the best option? Research provides alternatives</title> <link>https://evidence.nihr.ac.uk/collection/is-surgery-the-best-option-research-provides-alternatives/</link> <dc:creator><![CDATA[Martha Powell]]></dc:creator> <pubDate>Thu, 21 Nov 2024 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=65060</guid> <description><![CDATA[This Collection brings together 5 examples from research that could reduce the need for surgery. They highlight less invasive options with reduced risks that give some patients similar or better outcomes. The findings support decision making, and offer value for money for the NHS. The information will be useful for policymakers and those commissioning and ...]]></description> <content:encoded><![CDATA[ This Collection brings together 5 examples from research that could reduce the need for surgery. They highlight less invasive options with reduced risks that give some patients similar or better outcomes. The findings support decision making, and offer value for money for the NHS. The information will be useful for policymakers and those commissioning and delivering services.  The <a href="https://www.england.nhs.uk/statistics/wp-content/uploads/sites/2/2024/10/Aug24-RTT-SPN-Publication-PDF-388K-v2.pdf" target="_blank" rel="noreferrer noopener">NHS waiting list in England for consultant-led hospital treatment</a> (diagnosis, surgery or another treatment) stands at 7.6 million (August 2024). The biggest waiting list, at over 850,000, is to see a specialist in trauma and orthopaedics, for a hip or knee replacement for example. While people wait, they are often in pain and their condition may deteriorate. Reducing these waiting lists is a challenge for the NHS with no simple answer. An <a href="https://assets.kingsfund.org.uk/f/256914/x/43ac620e93/strategies_reduce_waiting_times_2022.pdf" target="_blank" rel="noreferrer noopener">NIHR-funded report</a> described a combination of activities that increase the supply and manage the demand for healthcare. Recent evidence from <a href="https://www.health.org.uk/news-and-comment/blogs/surgical-hubs-key-to-tackling-hospital-waiting-lists" target="_blank" rel="noreferrer noopener">The Health Foundation</a> has shown the potential of <a href="https://gettingitrightfirsttime.co.uk/hvlc/surgical-hubs/" target="_blank" rel="noreferrer noopener">NHS surgical hubs</a> to reduce waiting lists for surgery.  Another strategy to free up operating theatres, staff time, and other surgical resources is to consider whether surgery is the best option for patients. Strong NIHR research has shown that non-surgical alternatives (including watch and wait), can offer similar or better outcomes, but with fewer risks or side effects, and may be a better choice for some people.  NHS policymakers, commissioners, managers and clinicians could consider that: <ul class="wp-block-list"> <li><a href="#gallstones">a watch and wait approach reduces the need for surgery among people with uncomplicated symptomatic gallstones</a></li> <li><a href="#hips">one-stage is as good as 2-stage surgery to replace infected artificial hips</a></li> <li><a href="#prostate">opting for active monitoring of low or intermediate-risk localised prostate cancer has the same high survival rates as surgery or radiotherapy after 15 years, and avoids the side effects of radical treatment for many men</a></li> <li><a href="#frailty">non-surgical approaches give better outcomes than emergency surgery for people with severe frailty admitted to hospital with severe gut problems</a></li> <li><a href="#plaster">a plaster cast is as good as surgery for a broken scaphoid bone in the wrist</a></li> </ul> <h2 class="wp-block-heading" id="gallstones">A watch and wait approach reduces the need for surgery among people with uncomplicated symptomatic gallstones</h2> <figure class="wp-block-image size-full"><img loading="lazy" decoding="async" width="1600" height="700" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/11/Gallstones-2.png" alt="An infographic comparing treatment options for uncomplicated symptomatic gallstones: 'watch and wait' versus surgery. On the left side, a message with a pain target symbol states, 'Similar levels of pain with both.' On the right side, a message with a coin symbol shows that 'Watch and wait costs less: £1,477 vs £2,510.'" At the top, there's a title with an icon of a gallbladder containing stones that reads, "Uncomplicated symptomatic gallstones: watch and wait vs surgery." class="wp-image-65061"/></figure> <a href="https://www.nhs.uk/conditions/gallstones/" target="_blank" rel="noreferrer noopener">Gallstones</a> are small stones that form in the gallbladder. They do not usually cause symptoms or need to be treated. If they become trapped, however, they can cause severe abdominal pain. <a href="https://www.nhs.uk/conditions/gallbladder-removal/" target="_blank" rel="noreferrer noopener">Standard treatment for symptomatic gallstones</a> is laparoscopic (keyhole) surgery to remove the gallbladder (cholecystectomy). This surgery is common; <a href="https://www.england.nhs.uk/publication/2018-19-national-cost-collection-data-publication/" target="_blank" rel="noreferrer noopener">more than 60,000 cholecystectomies were performed in England in 2018/19</a>, at a cost of around £200 million to the NHS.  However, surgery carries its own risks and some people continue to experience symptoms afterwards, for reasons that remain unclear. An alternative approach is to adopt a ‘watch and wait’ strategy before operating to see if pain resolves.  <a href="https://evidence.nihr.ac.uk/alert/gallstones-surgery-might-not-always-be-needed/" target="_blank" rel="noreferrer noopener">A randomised trial</a> (C-GALL) involved 434 adults with uncomplicated symptomatic gallstones (gallstones that caused pain but not more serious problems such as jaundice). Half the participants were in the surgery group; half in the watch and wait group (painkillers when needed and advice on steps to take if symptoms flare up). If symptoms became too severe, those in the watch and wait group could opt for surgery to prevent and treat further pain. The research compared the outcomes of both groups.  The study found that after 18 months, pain was the same in both groups. Most (67%) people in the surgery group had received surgery; most of the others had refused surgery, or were on a waiting list. Some (25%) in the watch and wait group had surgery; but most neither had surgery nor were waiting for it. Watch and wait cost less (£1,477 per patient) than surgery (£2,510 per patient, based on NHS costs, 2019/20). There was no difference in quality of life over 24 months from when people started the study, meaning watch and wait was highly likely to be cost-effective.  The findings could support shared decision-making between clinicians and people with uncomplicated symptomatic gallstones. Performing fewer surgeries for gallstones could avoid the associated risks for many people, provide a similar outcome, and save NHS resources. The findings are beginning to influence practice, the researchers say, and allow people to opt for watch and wait rather than being listed for surgery immediately. <h2 class="wp-block-heading" id="hips">One-stage surgery is as good as 2-stage surgery to replace infected artificial hips</h2> <figure class="wp-block-image size-full"><img loading="lazy" decoding="async" width="1600" height="700" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/11/Hip-surgery.png" alt="An infographic comparing one-stage versus two-stage surgery for replacing infected artificial hips. The title reads, 'Replacing infected artificial hips,' with an icon of a hip joint. On the left, a green banner with a checkmark symbol indicates benefits of '1-stage surgery': As effective at relieving pain Faster recovery More cost-effective On the right, a red banner with an X symbol outlines downsides of '2-stage surgery': More complications More support needed from district nurses More expensive." class="wp-image-65062"/></figure> <a href="https://www.nhs.uk/conditions/hip-replacement/" target="_blank" rel="noreferrer noopener">Hip replacements</a> are carried out to treat pain and stiffness most commonly caused by <a href="https://www.nhs.uk/conditions/osteoarthritis/" target="_blank" rel="noreferrer noopener">osteoarthritis</a>. This is a common procedure; in 2022, <a href="https://reports.njrcentre.org.uk/hips-all-procedures-activity/H02v2NJR?reportid=B5FEC459-C763-4354-A5CD-1F2FCAE75C1B&defaults=DC__Reporting_Period__Date_Range=%22MAX%22,JYS__Filter__Calendar_Year__From__To=%22max-max%22,R__Filter__Country=%22All%22,H__Filter__Joint=%22Hip%22" target="_blank" rel="noreferrer noopener">more than 100,000 people in England, Wales and Northern Ireland had a first hip replacement</a>. Most people recover well afterwards, but some develop an infection in the artificial joint (<a href="https://www.journalslibrary.nihr.ac.uk/pgfar/HDWL9760#/s1" target="_blank" rel="noreferrer noopener">1–2 people for every 100 who have a hip replacement</a>).  Infection can cause severe pain or disability. People may need surgery to remove their artificial hip and the infected tissue, and replace the artificial joint. This can be carried out in one or 2 surgeries. The 2-stage approach allows surgeons to ensure, as far as possible, that the infection is gone before they implant a new joint. But this can delay the replacement of the joint for weeks or months. A one-stage surgical approach, in which infected tissue and implants are removed, and the new joint inserted in a single operation, is also available.  <a href="https://evidence.nihr.ac.uk/alert/one-stage-hip-revisions-are-as-good-as-2-stage-surgery-to-replace-infected-artificial-hips/" target="_blank" rel="noreferrer noopener">A randomised trial</a> (INFORM), involved 138 adults requiring surgery to replace an artificial hip after infection. The research compared how well people recovered from the different surgical approaches. The study found that, after 18 months, one-stage surgery was as effective as a 2-stage approach at relieving pain and improving hip stiffness and function (ability to carry out everyday activities). One-stage operations resulted in fewer complications during surgery, patients recovered more quickly, and it was more cost-effective (a benefit of over £11,000 for healthcare and personal social services based on UK costs, 2018/19). People who underwent 2-stage surgery required more support from district nurses and home care workers.  One-stage surgery is not always feasible, but the researchers recommend its use whenever possible. The team worked with expert stakeholders to produce <a href="https://boneandjoint.org.uk/Article/10.1302/2633-1462.44.BJO-2022-0155.R1" target="_blank" rel="noreferrer noopener">best practice guidelines</a> based on their results. The implementation of the guidelines could improve treatment pathways and care nationally, the researchers say.  <h2 class="wp-block-heading" id="prostate">Opting for active monitoring of low or intermediate-risk localised prostate cancer has the same high survival rates as surgery or radiotherapy after 15 years, and avoids the side effects of radical treatment for many men</h2> <figure class="wp-block-image size-full"><img loading="lazy" decoding="async" width="1600" height="700" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/11/Prostate-cancer.png" alt="An infographic comparing outcomes of active monitoring versus surgery or radiotherapy for prostate cancer. At the top, a title reads, 'Same high survival rates for active monitoring of prostate cancer as for surgery or radiotherapy.' On the left, a group of icons representing people illustrates that 'Only 3% of men had died from prostate cancer 15 years on, with no differences between active monitoring, surgery, or radiotherapy.' On the right, two comparison boxes list treatment details: 'Surgery and radiotherapy' – associated with a higher risk of side effects like incontinence and difficulty with erections. 'Active monitoring' – associated with a higher risk of cancer spread but fewer side effects" class="wp-image-65063"/></figure> Prostate cancer is the most common cancer in men, with <a href="https://www.cancerresearchuk.org/health-professional/cancer-statistics/statistics-by-cancer-type/prostate-cancer/incidence#heading-Zero" target="_blank" rel="noreferrer noopener">more than 55,000 new diagnoses each year</a> in the UK. While some localised cancers (<a href="https://prostatecanceruk.org/prostate-information-and-support/just-diagnosed/localised-prostate-cancer" target="_blank" rel="noreferrer noopener">confined to the prostate</a>) will become harmful and need treatment, most grow slowly, or not all, and may not cause any problems or reduce life expectancy. It is difficult to predict reliably whether and how the cancer will grow. The conventional radical treatments for localised prostate cancer are surgery or radiotherapy. These treatments carry side effects, including leakage of urine or faeces (incontinence) and difficulty getting an erection. An alternative treatment option is active monitoring, which involves regular blood tests, clinical examinations, scans and sometimes biopsies, with radical treatment offered only if the cancer progresses. A long-running randomised trial (ProtecT) involved 1,643 men with localised prostate cancer. It compared the 3 treatment approaches: active monitoring, surgery and radiotherapy. Long-term follow-up has recently been published. 15 years after diagnosis, <a href="https://www.nejm.org/doi/full/10.1056/NEJMoa2214122?query=featured_home" target="_blank" rel="noreferrer noopener">3% of men had died from prostate cancer</a>, with no differences between treatment approaches. The risk that the cancer had spread outside the prostate was low in all 3 groups, but was reduced by half in men who had radical treatment (surgery or radiotherapy) compared to active monitoring (5% versus 9%). After 15 years, 1 in 4 men in the active monitoring group (24%) had not needed surgery, radiotherapy or any other prostate cancer treatment and were spared the negative side effects. <a href="https://evidence.nejm.org/doi/full/10.1056/EVIDoa2300018" target="_blank" rel="noreferrer noopener">Overall quality of life was similar</a> in all treatment groups, but each had different side effects. For example, over 12 years, men in the surgery group were more likely to have urine leakage and difficulty getting an erection, whereas leakage of faeces was more likely in the radiotherapy group.  Over 10 years, <a href="https://www.nature.com/articles/s41416-020-0978-4" target="_blank" rel="noreferrer noopener">NHS costs were lower</a> for active monitoring (£5,913) than radiotherapy (£7,361) and surgery (£7,519, based on NHS costs, 2014/15). Active monitoring was the most likely cost-effective option for younger men, radiotherapy for older men. More follow-up is needed to find out which treatment is most cost-effective over a man’s lifetime. Earlier findings from the same study have already changed practice through <a href="https://www.nice.org.uk/guidance/ng131/chapter/Recommendations#localised-and-locally-advanced-prostate-cancer" target="_blank" rel="noreferrer noopener">updated NICE guidance</a> (2021). These additional long-term outcomes give individual men and clinicians more information on which to base the decision on the best approach to manage localised prostate cancer. Men need to weigh up the trade-offs between possible benefits in cancer control with surgery and radiotherapy, and a higher risk of spread, but fewer side effects with active monitoring, in the context of high survival rates, to enable well-informed treatment decisions. <h2 class="wp-block-heading" id="frailty">Alternatives to emergency surgery are better for people with severe frailty admitted to hospital with acute gut problems</h2> <figure class="wp-block-image size-full"><img loading="lazy" decoding="async" width="1600" height="700" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/11/Gut-problems.png" alt="" class="wp-image-65064"/></figure> Large numbers of people with digestive (gut) conditions that start suddenly, such as <a href="https://www.nhs.uk/conditions/appendicitis/#:~:text=Appendicitis%20typically%20starts%20with%20a,may%20make%20the%20pain%20worse." target="_blank" rel="noreferrer noopener">acute appendicitis</a> and <a href="https://www.nhs.uk/conditions/hernia/" target="_blank" rel="noreferrer noopener">abdominal wall hernia</a>, are admitted to hospital as an emergency. Many people have surgery; around <a href="https://cks.nice.org.uk/topics/appendicitis/" target="_blank" rel="noreferrer noopener">50,000 emergency appendectomies</a> are carried out each year in the UK, for example. Other people will be treated with alternative, non-emergency surgery approaches, such as medicines, non-surgical procedures such as drainage of an abscess, or later surgery. <a href="https://academic.oup.com/bjsopen/article/5/6/zrab094/6429824" target="_blank" rel="noreferrer noopener">Hospitals vary considerably in their use of emergency surgery versus alternative approaches</a>.  <a href="https://evidence.nihr.ac.uk/alert/do-people-with-severe-gut-problems-need-emergency-surgery/" target="_blank" rel="noreferrer noopener">Recent research (the ESORT study)</a> was based on more than 887,000 patient records of people with 5 common acute gut conditions: diverticular disease (inflamed pockets in the lining of the bowel), cholelithiasis (swelling of the gallbladder), appendicitis, abdominal wall hernia and blocked bowel. The study explored whether emergency surgery improves outcomes or is more cost-effective than other approaches to care. It looked at the cost-effectiveness of emergency surgery compared to alternatives for different subgroups of patients, including according to their level of frailty before the emergency admission. Overall, for each condition, emergency surgery was not more effective or cost-effective than other approaches. For people with severe frailty (data from over 27,000 patient records across the 5 conditions), outcomes were worse following emergency surgery than alternative approaches. Patients were in hospital for more days (between 6 and 39 more days depending on the gut condition) within the 3-month follow-up period if they had emergency surgery rather than alternative approaches, and emergency surgery was not cost-effective. Depending on the condition, the average costs at 1 year were between £7700 and £19,300 (2019/20 prices) lower with alternative approaches to emergency surgery compared to emergency surgery. For people with severe frailty, outcomes may be better and average costs lower if alternative approaches to emergency surgery are used. The findings emphasise the <a href="https://evidence.nihr.ac.uk/collection/frailty-research-shows-how-to-improve-care/" target="_blank" rel="noreferrer noopener">need for frailty assessments</a> as part of preoperative checks for emergency admissions for acute conditions. The researchers say these assessments could identify people who would benefit more from alternative approaches to emergency surgery which include drug treatment, non-surgical procedures or later surgery. <h2 class="wp-block-heading" id="plaster">Plaster cast is as good as surgery for a broken scaphoid bone in the wrist</h2> <figure class="wp-block-image size-full"><img loading="lazy" decoding="async" width="1600" height="700" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/11/Plaster-cast.png" alt="An infographic comparing a plaster cast for a broken scaphoid bone in the wrist. In the centre is a set of scales, on one side it says "surgery" with the cost of £2,350. There is also a message saying "more likely to lead to potentially serious complications". On the other side it says "plaster cast" with the cost of £727. THe message says "no difference in pain, grop and wrist movement"" class="wp-image-65065"/></figure> Fractures of the scaphoid bone in the wrist occur most commonly in younger men; they are usually the result of a fall onto an outstretched hand. It has been estimated that <a href="https://boneandjoint.org.uk/Article/10.1302/0301-620X.98B5.36938" target="_blank" rel="noreferrer noopener">around 7,200 fractures are diagnosed</a> each year. They are a significant public health problem as they affect people in their most productive working years. A broken scaphoid bone is usually a straightforward injury. But if it does not heal normally, arthritis usually develops in the wrist. Traditionally, scaphoid fractures were treated by immobilising the wrist in a plaster cast. The last two decades, however, saw an <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30931-4/abstract" target="_blank" rel="noreferrer noopener">increasing trend to perform surgery to fix the injury, by putting a small screw across the break</a>. This was despite the lack of good evidence that surgery led to better outcomes. <a href="https://evidence.nihr.ac.uk/alert/plaster-cast-equals-surgery-broken-scaphoid-wrist-swifft/" target="_blank" rel="noreferrer noopener">A high quality trial (SWIFFT)</a> comparing the 2 approaches has provided much needed clarity.  The study involved 439 mostly male (83%) participants with a confirmed scaphoid fracture displaced by 2 mm or less. It found that plaster casts are just as effective as surgery. After 1 year, there was no significant difference in wrist pain, grip or wrist movement between the two groups. There was also no difference in the number of days absent from work due to the wrist injury. Surgery was more likely to lead to potentially serious complications, such as infection and nerve complications, and costs to the NHS were significantly higher. For each patient, over 1 year, surgery cost £2,350 compared with £727 for plaster cast treatment, based on 2017/18 costs. The researchers have continued to follow the progress of the patients. New findings have shown that after 5 years <a href="https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/scaphoid-waist-internal-fixation-for-fractures-swifft-trial-v1/" target="_blank" rel="noreferrer noopener">there are still no important differences between wrist pain, grip or wrist movement between the two groups</a>. The research suggests that by opting for a plaster cast, patients can avoid the risk of surgery, while hospitals can keep service delivery simple and cost effective, without compromising patient outcomes. The study has influenced <a href="https://www.bssh.ac.uk/_userfiles/pages/files/professionals/Trauma%20standards/Scaphoid%20standards.pdf" target="_blank" rel="noreferrer noopener">practice standards</a> and has had an immediate impact. Even during the trial, the researchers say there was a shift away from surgery to simply treating with a plaster cast. <h2 class="wp-block-heading" class="wp-block-heading" id="conclusion">Conclusion</h2> This Collection brings together examples from research showing that, for a range of conditions, surgery is not always necessary, nor the best option. Non-invasive alternatives can produce similar or better outcomes for patients, avoid the risks associated with surgery and save money for the NHS. This evidence will support shared decision making between individuals and clinicians when considering the most appropriate approach. It will allow people to consider the benefits and harms of the options available, alongside outcomes that are important to them. People with uncomplicated gallstones may prefer to avoid surgery and instead choose a watch and wait approach. Men with localised prostate cancer may opt for active monitoring to reduce the likelihood of the side effects of radical treatment.  The research shows that surgery can even result in poorer outcomes. People with severe frailty had worse outcomes after emergency surgery for gut problems; alternative approaches would be better. And 2-stage surgery rather than a single procedure to replace infected artificial hips led to more complications and slower recovery. Our 5 examples provide evidence that delaying, reducing or avoiding surgery altogether can be the best approach for some patients; it can indeed optimise their care. At the same time, non-surgical approaches release valuable operating theatre and staff time, and free up surgical resources. Patients, clinicians, and commissioners could all benefit from careful consideration of the evidence in this Collection for alternatives to surgery. <hr class="wp-block-separator has-alpha-channel-opacity"/> Author: Jemma Kwint, Senior Research Fellow, NIHR How to cite this Collection: NIHR Evidence; Is surgery the best option? Research provides alternatives; November 2024; doi: 10.3310/nihrevidence_65060 Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Care home app reduced residents’ hospital admissions</title> <link>https://evidence.nihr.ac.uk/alert/care-home-app-reduced-residents-hospital-admissions/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Mon, 18 Nov 2024 07:38:14 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64927</guid> <description><![CDATA[An NHS-owned app (HealthCall Digital Care Homes) records care home residents’ health information when they become unwell. The information in the app can be accessed by clinicians at a community hub who advise on people’s treatment. Researchers found that this approach led to: More information on Health Call can be found on the NHS website. The ...]]></description> <content:encoded><![CDATA[ An NHS-owned app (HealthCall Digital Care Homes) records care home residents’ health information when they become unwell. The information in the app can be accessed by clinicians at a community hub who advise on people’s treatment. Researchers found that this approach led to: <ul class="wp-block-list"> <li>fewer emergency hospital admissions</li> <li>fewer attendances at emergency departments</li> <li>shorter hospital stays.</li> </ul> <a href="https://nhshealthcall.co.uk/" target="_blank" rel="noreferrer noopener">More information on Health Call can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-can-an-app-reduce-residents-need-for-hospital-care">The issue: can an app reduce residents’ need for hospital care?</h2> More than <a href="https://www.carehome.co.uk/advice/care-home-stats-number-of-settings-population-workforce" target="_blank" rel="noreferrer noopener">441,000 people live in a care home in the UK</a>. Many have poor health and hospital admissions can be hazardous for them due to the risk of infections, confusion and falls. The HealthCall Digital Care Homes app is used by care home staff to record residents’ blood pressure, temperature and other observations when they become unwell. Along with information on how the resident is feeling, this data is sent electronically to a community hub where clinicians can advise on the best treatment for each resident. Previously, resident health information was usually provided by care home staff over phone calls, which could take a long time. This study assessed the impact of the app on unplanned hospital care and the associated costs. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The study included 8,702 care home residents from 118 care homes in England (from 2018 to 2021). Most participants (65%) were women, and their average age was 85 years. The researchers linked app data to hospital records.  They assessed residents’ use of hospital care before and after their data were recorded in the app. Participants remained in the study until they died or moved away. Overall, when staff began recording health information in the app, residents’: <ul class="wp-block-list"> <li>emergency hospital admissions dropped by 25%</li> <li>emergency attendances dropped by 11%</li> <li>hospital stays became shorter by 11%.</li> </ul> Use of the app reduced costs by £57 per resident for the NHS in 2018; savings increased to £113 per resident in 2021 (calculations were based on 2019 – 2020 costings, extrapolated to 2021).  These costs do not include the initial set up (including staff training) or purchase of app technology. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The study suggests that the HealthCall Digital Care Homes app, or similar monitoring technologies, could safely reduce care home residents’ contact with hospitals. The researchers say that, with the app, health issues were identified earlier and shared decision making between care home and community clinical staff improved. If the cost savings found in this analysis (£57 per resident) were replicated across the UK, the researchers say it could save the NHS £247 million each year (based on 2019 – 2020 figures). The study was carried out in the North East of England so the findings might be less generalisable to the rest of the UK. Some of the study took place during the pandemic, which is likely to have had an impact on hospital admissions, for instance. The researchers did not have the data to adjust their findings for resident characteristics (such as age and ethnicity) and conditions; this may have impacted the results. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The findings from the study were shared with NHS England to inform their roll out of digital technologies in care homes. Staff will need to be trained before the system can be rolled out in other homes. In the study, the researchers allowed 90 minutes for training staff on how and when to use the app, how to take the observations, what normal values are (though they were not expected to interpret readings) and troubleshooting. The researchers say further research is needed in larger populations over longer periods to determine the true impact of the tool. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="41" height="59" /> How does this research fit with my current practice? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Garner A, and others. <a href="https://doi.org/10.1093/ageing/afae004" target="_blank" rel="noreferrer noopener">The impact of digital technology in care homes on unplanned secondary care usage and associated costs</a>. Age and Ageing 2024; 53 1 – 7. An article about the study from <a href="https://nhshealthcall.co.uk/news/digital-remote-monitoring-technology-care-home/" target="_blank" rel="noreferrer noopener">Health Data Research UK</a> and <a href="https://nhshealthcall.co.uk/news/digital-remote-monitoring-technology-care-home/" target="_blank" rel="noreferrer noopener">Health Call</a>. A report on emergency hospital admissions from care homes by <a href="https://www.health.org.uk/publications/reports/emergency-admissions-to-hospital-from-care-homes" target="_blank" rel="noreferrer noopener">The Health Foundation</a>. Funding: The study was supported by the <a href="https://arc-yh.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Yorkshire and Humber Applied Research Collaboration</a>. Conflicts of Interest: None declared.  Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>What support do young carers find helpful?</title> <link>https://evidence.nihr.ac.uk/alert/what-support-do-young-carers-find-helpful/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 14 Nov 2024 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64984</guid> <description><![CDATA[Young carers are children or young adults who care for a family member with long-term physical or mental health issues, substance misuse, or disability. Researchers explored the needs of young carers and the people they care for. They found that young carers wanted support to be: More information on support for young carers can be ...]]></description> <content:encoded><![CDATA[ Young carers are children or young adults who care for a family member with long-term physical or mental health issues, substance misuse, or disability. Researchers explored the needs of young carers and the people they care for. They found that young carers wanted support to be: <ul class="wp-block-list"> <li>well signposted and accessible</li> <li>empathetic, trustworthy and confidential</li> <li>inclusive</li> <li>proactive but not intrusive.   </li> </ul> <a href="https://www.nhs.uk/conditions/social-care-and-support-guide/support-and-benefits-for-carers/being-a-young-carer-your-rights/" target="_blank" rel="noreferrer noopener">More information on support for young carers can be found on the NHS website</a>. <h2 class="wp-block-heading" id="block-dd86bd96-c408-4b9d-9130-23bf642681e1">The issue: what support do young carers find helpful?</h2> In 2021, <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/socialcare/articles/unpaidcarebyagesexanddeprivationenglandandwales/census2021" target="_blank" rel="noreferrer noopener">the Census reported 127,000 young carers (aged 5 to 18) in England and Wales</a>. These young people often have poorer health, wellbeing, education, and job prospects than their peers who are not carers. The UK Government has developed policies to assist young carers via social workers and mental health support, for instance. However, support varies across regions and some report issues with services (such as a lack of availability). This study investigated what support young carers (aged 9 – 25) and their families find helpful and how services could better meet their needs.   <h2 class="wp-block-heading" id="block-f53ef92f-434a-48f2-9885-b95a863b7765">What’s new?</h2> Researchers interviewed 133 unpaid young carers and 17 cared-for parents; most took part in focus groups, but 10 were interviewed individually. Participants were from a diverse range of communities, family structures and cultures. The researchers found that 4 key types of support were important for young carers: <ul class="wp-block-list"> <li>support for their parent (or other person being cared for), for example from social care workers or occupational therapists</li> <li>young carer support services</li> <li>mental health support</li> <li>school support (such as supportive and understanding staff, and time out cards to leave early when needed).</li> </ul> The researchers identified features of care that young carers valued. <ol class="wp-block-list"> <li>Access. Support could be hard to navigate and understand: “the carers allowance… just isn’t really talked about and then it’s hard to find [by] yourself.” Young carers appreciated referrals to appropriate services, as long as they didn’t feel passed around (retelling their story repeatedly, for instance). They appreciated support in trying out a new service, such as a young carers group.</li> <li>Listening and understanding . Many valued having someone to talk to who would validate their feelings: “I can’t talk to my mum about that kind of stuff.” Young carers appreciated support that was adapted to their family’s needs, including taking place at convenient times and choosing what to talk about.</li> <li>Trust and confidentiality. It could take  time to build trust in support workers; carers wanted to speak with people who had an understanding of the sorts of issues faced by young carers. They wanted to be asked for their permission to share sensitive information. Several had experienced broken confidentiality: “You put trust in them and then they tell other teachers and don’t help.” Some had a deep mistrust of social services, and some parent care recipients feared intervention from child protection services.</li> <li>Inclusion. Young carers wanted to be involved in decisions, and to be considered in the care plan of the person they cared for: “We’re the best judges of our needs, ask us, instead of trying to guess.” However, involving young carers sometimes conflicted with their parent or care recipients’ wishes (such as disclosing health information).</li> <li>Proactivity but not intrusion. Some types of support were felt to add pressure on the family, and young carers sometimes felt pressured by services to accept support: “[It’s] good that they help, but it’s sometimes too much. You don’t need help, but it doesn’t stop.” Carers wanted to be able to change their mind about the support they received. They wanted some support (such as young carer groups) to be provided more frequently or last longer: “There’s not always enough support in young carers [groups] because there is so many young carers.” It was distressing when services ended without warning.<a id="_msocom_1"></a></li> </ol> <h2 class="wp-block-heading" id="block-08af7519-b982-4063-93d6-7439266aac35">Why is this important?</h2> The researchers hope their findings will inform improvements in support for young carers so that they and their families have more capacity to fulfil their goals. Young carers valued services but said they could be improved. They wanted more of some types of support, but less of some more negative aspects of support. The researchers say that services could be improved, and costs potentially reduced, by providing support that better meets people’s needs and by minimising support they don’t value.  Existing legislation protects young carers from providing care that poses a risk to their wellbeing, education or life chances. Implementation of this legislation varies, and the researchers say more needs to be done to make flexible and adaptable support for young carers available more widely. Young carers have a wide range of experiences and a range of views on what kind of support is helpful. This underlines the importance of a flexible, listening approach that adapts to the needs of the carer and their family and involves them in decisions. The researchers found evidence of many aspects of support which were valuable to young carers and their families, and were appreciated, but some interactions with services were not beneficial. They conclude that listening to young carers and their families can enable support that adapts to their changing circumstances and preferences.<a id="_msocom_1"></a> <h2 class="wp-block-heading" id="block-8f627807-1838-48d7-b8e3-a37941c6b0aa">What’s next?</h2> The researchers suggest that young carers would benefit from: <ul class="wp-block-list"> <li>improved support for the people they care for (such as more support from a care worker)</li> <li>support from services that takes account of the whole family, and their strengths and needs</li> <li>clear and accessible information about support services, and help in accessing and trying out services.</li> </ul> The researchers held 3 events in England in 2023, which were planned and delivered by young carers. At each, they shared their findings and discussed how to integrate them into practice with local practitioners and decisionmakers. The researchers are conducting a further study investigating <a href="https://www.fundingawards.nihr.ac.uk/award/NIHR205161" target="_blank" rel="noreferrer noopener">how the right sort of support for young carers can be made available in a way that meets the needs of the whole family</a>. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="59" height="86" /> What have I learned? How can I act on the new knowledge? </div> </div> </section> <h2 class="wp-block-heading" id="block-1cfeae03-e057-4ba0-b676-b95f4b2f0970">You may be interested to read</h2> This is a summary of: Stevens M, and others. <a href="https://doi.org/10.1371/journal.pone.0300551" target="_blank" rel="noreferrer noopener">Young carers’ experiences of services and support: What is helpful and how can support be improved?</a> PLOS One 2024; 19: e0300551. Another journal article from the same project: Brimblecombe N, and others. <a href="https://doi.org/10.1371/journal.pone.0310766" target="_blank" rel="noreferrer noopener">Understanding the unmet support needs of young and young adult carers and their families</a>. PLOS One 2024; 19: e0310766. A full report of the study: Brimblecombe N, and others. <a href="https://doi.org/10.3310/ABAT6761" target="_blank" rel="noreferrer noopener">Types and aspects of support that young carers need and value, and barriers and enablers to access: the REBIAS-YC qualitative study</a>. Health and Social Care Delivery Research 2024; 12. DOI: 10.3310/ABAT6761. Information and support for young carers from the <a href="https://carers.org/getting-support-if-you-are-a-young-carer-or-young-adult-carer/getting-support-if-you-are-a-young-carer-or-young-adult-carer" target="_blank" rel="noreferrer noopener">Carers Trust</a>. An <a href="https://www.lse.ac.uk/cpec/news/support-for-young-carers" target="_blank" rel="noreferrer noopener">article about the study</a> by the researchers. Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=young%20carers&location=" target="_blank" rel="noreferrer noopener">NIHR research on young carers</a>. An <a href="https://arc-eoe.nihr.ac.uk/news-blogs/news-latest/shaping-future-carer-research-through-regional-network" target="_blank" rel="noreferrer noopener">article about a network of carers and researchers in the East of England</a>. Funding: <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-and-social-care-delivery-research.htm" target="_blank" rel="noreferrer noopener">NIHR Health Services and Delivery Research programme Commissioned Call</a>. Conflicts of Interest: None declared. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Local green spaces are linked with better mental health</title> <link>https://evidence.nihr.ac.uk/alert/local-green-spaces-are-linked-with-better-mental-health/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 12 Nov 2024 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64959</guid> <description><![CDATA[Podcast: Local green spaces and mental health In this podcast, Helen Saul, Editor in Chief of NIHR Evidence, and study author Sarah Rodgers, Professor of Health Informatics, University of Liverpool, discuss the impact of local green spaces on people's mental health. Researchers analysed data on more than 2 million people in Wales over 10 years ...]]></description> <content:encoded><![CDATA[ <h2 class="wp-block-heading" class="wp-block-heading" id="podcast-local-green-spaces-and-mental-health">Podcast: Local green spaces and mental health</h2> In this podcast, Helen Saul, Editor in Chief of NIHR Evidence, and study author Sarah Rodgers, Professor of Health Informatics, University of Liverpool, discuss the impact of local green spaces on people's mental health. <div id="buzzsprout-player-16063755"></div><script src="https://www.buzzsprout.com/1833774/episodes/16063755-local-green-spaces-are-linked-with-better-mental-health.js?container_id=buzzsprout-player-16063755&player=small" type="text/javascript" charset="utf-8"></script> <section class="guten-block block-accordion "> <div class="row"> <div class="column small-12"> <div class="tabs"> <div class="tab"> <input type="checkbox" id="chck-block_090329b268b5ac3d85684a0ec0dad73a-1"> <label class="tab-label has-background has-blue-background-color " for="chck-block_090329b268b5ac3d85684a0ec0dad73a-1">Audio Transcript</label> <div class="tab-content"> Podcast transcript: Local green spaces are linked with better mental health   [Music] 0.08 Helen Saul: Welcome to this podcast from the NIHR on the impact of green spaces on our mental health. Living near to green and blue spaces, such as parks, lakes, or beaches, is associated with better mental health. But exactly why is not clear. It could be that these spaces themselves reduce stress levels, encourage us to exercise and socialise, and improve air quality. Or it might just be that people living in these areas are wealthier and therefore healthier than others in the population. Today we’ll be discussing a huge study that set out to untangle these effects. My name is Helen Saul, and I’m the editor in chief of the NIHR Evidence website. I am speaking with author Professor Sarah Rodgers. Perhaps you’d like to introduce yourself, Sarah. 0.58 Sarah Rodgers: Hello, Helen! So I am, as you said, a Professor of health informatics at the University of Liverpool, and I’ve got a background in geography and epidemiology. So, I thought this study seemed appropriate for me and my background, thinking about how the environment impacts health. 1.18 Helen Saul: There’s obviously previous research on green spaces and mental health. Why was this study needed? 1.27 Sarah Rodgers: Existing studies mainly had small cohorts of people, so, a few 100 or 1,000 and assessed changes over a short period of time. And they didn’t really focus that much on the socio-economic inequalities as well. And so because those studies were cross sectional, we aren’t really sure if the person’s health caused them to move to a different environment because of their general life chances being impacted by poor health, for example, and wanting, you know, to have to stay in the middle of an urban city where they didn’t want to be, or they’ve proactively been able to move out to a green and nicer place already. 2.08 Helen Saul: So how did you address this in your study? 2.11 Sarah Rodgers: So, yeah. So, the way we set up our current study allowed us to be sure that the exposure to green or blue space came before the outcome, so we could test more precisely if the green or blue spaces were preventing the ill health. And I think that was a really useful advance. So, what we were able to do was use the household linkages from people’s homes and then link the environment around their home to their health records. So, in this case we linked to the GP records in Wales for about 2 million people. So, we were looking for their health conditions over time, monthly or quarterly, we can do that. And then this was with anonymised data, which means that all the identifiers, so their names and addresses were removed. And so, the researchers access the data without ever knowing who the person is or where they live. 3.05 Helen Saul: And you were looking both at people’s immediate surroundings at home and their potential access to green spaces? 3.13 Sarah Rodgers: Yes, that’s right. So, we thought that if we looked at a short distance from home, and we looked at the greenness, we called that ambient greenness around the home, within about 2 or 300 metres, people could actually see this from their front door, so they wouldn’t have to make any effort to get the benefits from it, it would just be there. But then we also looked at their access within about a mile of home. So that in that case, that’s their sort of potential to access those green spaces because we weren’t sure whether they actually would have visited that space at that time. 3.52 Helen Saul: So, what did you find? How did these two measures relate to mental health? 3.58 Sarah Rodgers: That was really interesting. We found quite a strong association with the ambient greenness. So, when we looked at the routinely collected health data for more than 2 million adults, we saw that people’s home surroundings and their potential to access green or blue spaces was associated with a reduction in anxiety or depression that they reported to their general practitioner. So, having the top third amount of greenness immediately from their sort of front door reduced their likelihood of anxiety or depression by 20%. So, they were a fifth less likely to need to go to their GP for help. And then we saw some reduction, a smaller reduction, but still a reduction of 7% in terms of the potential to access these green or blue spaces within a longer distance from home. So, for every 360 metres to their nearest space, there was a 7% increased likelihood of a common mental health disorder, the anxiety or depression. 5.04 Helen Saul: And did the results differ for people who had a previous mental health diagnosis and those who didn’t? 5.11 Sarah Rodgers: Yes, so they were different, we wanted to make, to kind of look back at people, firstly, who’d had an anxiety and depression episode a long time ago to see what impacts this has had. And we found that adults who’d had an old diagnosis of up to 8 years earlier had an even lower chance of having a common mental health disorder. So, this was 32% less, compared to 16% for those who didn’t have that old historical diagnosis. 5.44 Helen Saul: That’s a huge difference within, presumably, a vulnerable population. 5.51 Sarah Rodgers: Yes, yes, that is, it is quite a massive difference, and we think this is a big advance because of how we structured the data, and how we were able to use all of those data more precisely to be able to look at their health condition and see whether their preceding exposure to green or blue spaces had an impact potentially on their health conditions. 6.17 Helen Saul: You also looked at different groups of the population. Which groups did you find were most likely to benefit from green surroundings and better potential access? 6.27 Sarah Rodgers: So, we looked at different stratifications of deprivation. So, what we found was there was an association of common mental health disorders and the likelihood of potential green blue space access. For adults living in the most deprived areas, that was a 10% reduction. And that was a stronger association than for those living in the least deprived areas which only saw a 6% reduction. So that indicates that there are really great benefits, greater benefits to mental health for people living in the deprived areas with more green or blue spaces. So, they had, you know fewer overall resources, but they had these green or blue spaces that they were taking, potentially, taking some advantage of which is good to see. 7.23 Helen Saul: Well, it’s very interesting that the people who needed it most benefited most. 7.29 Sarah Rodgers: Yes, definitely, it’s really interesting to see those patterns in terms of deprivation and inequalities, and to know that there is the potential to have nicer spaces making an impact on people who need these spaces the most. What I’m trying to do now is work with local government and different stakeholders. So, when they are designing new spaces, we are trying to work out how we can help our local government engage with the local community, to empower the local community, to co-design those spaces with the people who need them the most, and maybe even so design those spaces with those people in mind, with those people themselves. 8.29 And that’s what we’re doing with this new UK Prevention Research Partnership called Groundswell that I’m involved with. So, we’re taking the data a step forward and looking on the ground and working with people designing those spaces. So, I think the impact of the NIHR project that we were funded for is a really good baseline, and that’s helping us now to work on the ground with people about this co-design element. 9.00 Helen Saul: Well, we’d like to wish you the best of luck with that important work, Sarah, and thank you very much for joining me today and for your description of an incredible study. This is an episode of the NIHR podcast, I’m Helen Saul, and thank you for listening. If you have thoughts or comments on this or any other episodes, please contact us at evidence@nihr.ac.uk, and do visit our website, which is evidence.nihr.ac.uk. [9.34 Music] </div> </div> </div> </div> </div> </section> Researchers analysed data on more than 2 million people in Wales over 10 years to explore the impact of green spaces on mental health. They linked information about people’s mental health with information about the greenness of their home’s immediate surroundings and how close they lived to green or blue spaces (such as parks, lakes, and beaches). They found that people had a lower risk of anxiety and depression if: <ul class="wp-block-list"> <li>their home’s immediate surroundings (within 200-300 metres) were greener</li> <li>they could access green and blue spaces nearby.</li> </ul> The researchers say that local authorities could improve the mental health of their community by increasing the greenery in their towns and cities and improving access to green and blue spaces. <a href="https://www.nhs.uk/mental-health/" target="_blank" rel="noreferrer noopener">More information on mental health can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-how-do-green-spaces-impact-mental-health">The issue: how do green spaces impact mental health?</h2> Green and blue spaces could improve mental health through the opportunities they provide to socialise and exercise; it could also be that these spaces improve air quality. But other factors, such as wealth, may explain this difference. <a href="https://doi.org/10.1007%2Fs00127-021-02159-w" target="_blank" rel="noreferrer noopener">Wealthier people tend to have better mental health</a> and live in areas with more green space; it is unclear whether the improvement is linked with the wealth or the greenness. This study aimed to tease out the impact of green and blue spaces alone, regardless of wealth or other factors. Researchers analysed how living in areas with more green space, or how close the nearest green and blue space was to someone’s house (access), affected people’s mental health. They also considered if the effect of green space on mental health differed between more and less wealthy areas. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The study was based on the GP records of 2.3 million people from Wales (aged 16 and older) from 2008 – 2019. The researchers searched anonymised patient records for a diagnosis of anxiety or depression, and for their home address(es). Each year, the researchers rated the greenness (trees, parks and gardens, for instance) of each person’s immediate home surroundings using satellite images. This was greenness that people could see from their front door; it required no effort to access. They also measured how close people’s houses were to green and blue spaces (within 1,600 metres), and the number of these spaces, using survey maps for each person, each year. People who died or moved away from Wales were excluded from the study. If they moved within Wales, they were still included (along with the greenness of their new location). The researchers adjusted the results according to sex, age, deprivation and other factors.  Both measures of greenness (home surroundings, and local green and blue spaces) reduced the risk of anxiety and depression. The researchers found that: <ul class="wp-block-list"> <li>the highest level of greenness of home surroundings was associated with 20% less anxiety and depression than the middle level; the middle level with 20% less than the lowest level</li> <li>every 10% increase in access to green and blue spaces was linked with a 7% reduction in risk of anxiety and depression</li> <li>people in poorer areas benefitted more (10% reduced risk of anxiety and depression) from access to green and blue spaces than those in richer areas (6% reduced risk).</li> </ul> Every additional 360 metres from the nearest green or blue space was linked with a 5% higher risk of anxiety and depression. People with a previous diagnosis (anxiety and depression before 2008) benefitted more than others from green home surroundings, but not from greater access to green spaces. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> This is the largest, most comprehensive study to show that a green home environment, and access to green and blue spaces, protect against anxiety and depression. These findings support local authorities’ and policymakers’ efforts to add green spaces to towns and cities, and to increase access to them. This could improve the wellbeing of everyone, but especially those in deprived areas where the positive effects of green spaces were greatest. A strength of the study was that it linked individual health records, to measurements taken over time of the greenness of home surroundings, and access to green and blue spaces. It therefore accounted for house moves or removal of a public green space, for example. The long follow up period (10 years) meant that changes in people’s mental health could be detected reliably.   People in poorer areas benefitted most from good access to green spaces, possibly because people in poorer areas are less able than others to make use of green and blue spaces further from home. The study relied on primary care records to assess anxiety or depression; some people may have had either condition without seeking help from their GP. The quality of green spaces in terms of lighting, safety, or cleanliness, was not explored. It may be that living beside a poorly maintained park, for example, is not beneficial to mental health. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers say increased greenery in towns and cities could improve mental health in the population, especially for people in more deprived areas and those with a history of anxiety and depression. Green and blue spaces have other benefits such as improving air quality, and providing habitats for wildlife. The researchers suggest that policymakers and communities work together to improve access to these spaces and to ensure that the spaces meet people’s needs, and are well-maintained, for example. Green spaces that are accessible and safe, with security measures and ramps for wheelchair users, for example, are likely to bring most benefit.  The researchers are working with local communities on a project called <a href="https://www.groundswelluk.org/" target="_blank" rel="noreferrer noopener">GroundsWell</a>, which is co-designing green and blue spaces with the aim of improving access. Another project, <a href="https://www.phiuk.org/healthy-urban-places" target="_blank" rel="noreferrer noopener">Healthy Urban Places</a>, is bringing together researchers, communities, local governments, and other organisations to co-produce research on what makes a healthy place. For example, what features are most important for health, and how changes to local areas can improve health and reduce inequalities. <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="36" height="52" /> What have I learned? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Geary RS, and others. <a href="https://doi.org/10.1016/S2542-5196(23)00212-7" target="_blank" rel="noreferrer noopener">Ambient greenness, access to local green spaces, and subsequent mental health: a 10-year longitudinal dynamic panel study of 2·3 million adults in Wales</a>. Lancet Planetary Health 2023; 7: E809 – 818. An <a href="https://evidence.nihr.ac.uk/alert/open-spaces-and-community-cohesion-improve-wellbeing/">NIHR Evidence Summary</a> on how open spaces improve wellbeing. A <a href="https://www.who.int/europe/publications/i/item/WHO-EURO-2016-3352-43111-60341" target="_blank" rel="noreferrer noopener">report from the World Health Organisation</a> on the effect of access to green spaces on health. An <a href="https://www.oxfordhealth.nhs.uk/news/green-spaces-do-wonders-for-your-mental-health/" target="_blank" rel="noreferrer noopener">NHS article</a> on how access to green spaces can improve your mental health. An article about the project by <a href="https://beyondgreenspace.net/2023/10/31/new-paper-greenspace-and-mental-health-a-longitudinal-dynamic-panel-study-in-wales/" target="_blank" rel="noreferrer noopener">Beyond Greenspace</a>. Further work from the same group on relationships between natural environments, health and wellbeing: Rodgers SE, and others. <a href="https://doi.org/10.1002/lrh2.10461" target="_blank" rel="noreferrer noopener">Creating a learning health system to include environmental determinants of health: The GroundsWell experience</a>. Learning Health Systems 2024; 8:e10461. Funding: <a href="https://www.nihr.ac.uk/research-funding/funding-programmes/public-health-research" target="_blank" rel="noreferrer noopener">NIHR Public Health Research Programme</a> Commissioned Call. The author is supported by the <a href="https://arc-nwc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Applied Research Collaboration North West Coast</a>. The study used the Secure Anonymised Information Linkage (SAIL) Databank, funded by <a href="https://healthandcareresearchwales.org/" target="_blank" rel="noreferrer noopener">Health and Care Research Wales</a>. Conflicts of Interest: No relevant conflicts of interest. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Sexual assault referral centres provide high-quality support</title> <link>https://evidence.nihr.ac.uk/alert/sexual-assault-referral-centres-provide-high-quality-support/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 07 Nov 2024 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=63995</guid> <description><![CDATA[Sexual assault referral centres (SARCs) offer survivors of sexual violence medical care, emotional support, and forensic services. They refer survivors to independent sexual violence advisors and other services. A review of 21 of the centres in England found that people who accessed them: Based on their findings, the researchers made suggestions about how to improve ...]]></description> <content:encoded><![CDATA[ Sexual assault referral centres (SARCs) offer survivors of sexual violence medical care, emotional support, and forensic services. They refer survivors to independent sexual violence advisors and other services. A review of 21 of the centres in England found that people who accessed them: <ul class="wp-block-list"> <li>were positive about the support they received</li> <li>reported improvements in symptoms of post-traumatic stress disorder (PTSD) after 1 year</li> <li>often experienced delays in accessing follow-on mental healthcare.</li> </ul> Based on their findings, the researchers made suggestions about how to improve services.   <a href="https://www.nhs.uk/live-well/sexual-health/help-after-rape-and-sexual-assault/" target="_blank" rel="noreferrer noopener">Help after rape and sexual assault can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="how-effective-are-sexual-assault-referral-centres">How effective are sexual assault referral centres?</h2> Sexual violence violates human rights and is a serious threat to a person’s health and wellbeing across their life. In England and Wales, <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/crimeandjustice/bulletins/sexualoffencesinenglandandwalesoverview/march2022#:~:text=The%20CSEW%20estimated%20that%201.1,women%20and%201.2%25%20men)." target="_blank" rel="noreferrer noopener">more than a million adults are sexually assaulted each year</a>; <a href="https://www.csacentre.org.uk/research-resources/research-evidence/scale-nature-of-abuse/the-scale-and-nature-of-child-sexual-abuse/" target="_blank" rel="noreferrer noopener">15% of girls and 5% of boys are sexually assaulted by the age of 16</a>. Without specialist support, the consequences of sexual violence can get worse over time, damaging survivors’ mental and physical health, and impacting their social and economic wellbeing. Poor responses from clinicians, criminal justice agencies and wider society can increase survivors’ isolation and contribute to the long-term harms they experience.   Sexual assault referral centres are often the first point of care for adults, young people and children subjected to abuse. There are over 50 centres across England and around 30,000 survivors access them each year. They provide survivors with crisis support, care for medical needs and sexual health, and the choice to have a forensic medical examination to collect evidence. They support people who wish to report the abuse to the police. In a mixed methods study, researchers explored users’ experiences of sexual assault referral centres, and evaluated the care pathways they followed afterwards. These included NHS, social care and voluntary sector services, independent sexual violence advisors (who advocate for survivors through the criminal justice process), police and criminal justice services.   <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers analysed data on 335 survivors who accessed 21 sexual assault referral centres across England. Their average age was 32 years, most were women (90%) and white (85%). Survivors went on to access a range of services. These were mostly voluntary organisations (such as <a href="https://rapecrisis.org.uk/get-help/want-to-talk/" target="_blank" rel="noreferrer noopener">Rape Crisis</a> and mental health charities) followed by independent sexual violence advisors, the police and criminal justice agencies, and the NHS (mainly GPs, mental health and sexual health services). Participants rated their experience of different services; they were mostly positive about sexual assault referral centres and the voluntary sector (few interactions, 1% and 4% respectively, were experienced as harmful). Feedback was mixed about wider NHS services (including general practice and sexual health clinics, for example, but not SARCs) and the police and criminal justice service (15% and 25% of interactions, respectively, were experienced as harmful). On entry to the study (100 days on average after accessing sexual assault referral centres), most survivors (71%) had probable PTSD. This proportion was reduced 1 year later (but remained high, at 55%). PTSD was highest among people with adverse childhood experiences, those with poor mental health before the sexual assault, and economic difficulties.   People who use sexual assault referral centres differ from survivors in the general population, the authors note. Many participants (44%) accessed the sexual assault referral centre within 10 days of the sexual trauma and many (38%) had a forensic medical examination; most (77%) had 4 or more adverse childhood experiences. The researchers interviewed 42 people from marginalised groups, such as those from ethnic minority groups, with insecure housing, or disabilities. Survivors found counselling effective but difficult to access because of long waiting lists and restrictions on the number of sessions they could have. Some saw mental healthcare as inappropriate and lacking in flexible options for those with complex trauma (for example, symptoms of PTSD coupled with problems managing emotions and relationships). <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> This analysis provides evidence of good practice at sexual assault referral centres in England. They initiate pathways of care for many people after sexual assault, involve multiple agencies and promote access to justice. They may therefore minimise the long-term social, emotional and physical harms of abuse. Sexual assault referral centres offer excellent care, the researchers say, but are underused, partly due to a lack of awareness among the public. Police forces signpost people to the service, but other areas (including primary care) lack awareness.   People with adverse childhood experiences, long-term mental health problems and economic disadvantage are particularly at risk of PTSD following sexual assault. These groups may need targeted support and access to counselling. Researchers collected data from 2019 to 2022, and did not evaluate care that has become available more recently. In addition, the study had no comparison group and cannot conclude that access to sexual assault referral centres reduced PTSD symptoms. Findings may not be applicable to groups of people not represented in this study. The researchers also carried out a <a href="https://doi.org/10.1002/14651858.CD013456.pub2" target="_blank" rel="noreferrer noopener">review of 36 trials on psychological and social interventions</a>. Among survivors of sexual violence, interventions such as cognitive behavioural therapy (CBT), eye movement desensitisation re-processing and newer treatments like trauma‐sensitive yoga led to reductions in PTSD and depression. Other work highlighted the impact of how care was provided, and the value of offering choices of therapeutic support, a positive environment and good rapport with the provider. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers will now work with NHS England to promote uptake of their findings. They suggest that services for people who have experienced sexual violence could be improved with: <ul class="wp-block-list"> <li>raised awareness among the public about sexual assault referral centres</li> <li>strengthened local partnerships between the police, specialist statutory and voluntary sexual assault and abuse services and the NHS</li> <li>specialist training and support for NHS staff on trauma-informed care</li> <li>tailored support for survivors with risk factors for PTSD (such as long-term mental health issues, which were the main barrier to accessing care and justice)</li> <li>development of the role of independent sexual violence advisors to include more specialised advocacy for lesbian, gay, bisexual or trans (LGBTQI+) survivors, and those with complex needs</li> <li>greater choice of interventions within NHS mental health services.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: O’Doherty L, and others. <a href="https://www.journalslibrary.nihr.ac.uk/hsdr/CTGF3870/#/abstract">Care and support by Sexual Assault Referral Centres (SARCs) in England for survivors of sexual violence and abuse: a mixed-methods study (MESARCH)</a>. Health and Social Care Delivery Research 2024; 12: 1 – 168.  <a href="https://www.nhs.uk/live-well/sexual-health/help-after-rape-and-sexual-assault/" target="_blank" rel="noreferrer noopener">Information on sexual assault referral centres</a> including where your nearest one is. Information and support from <a href="https://thesurvivorstrust.org/" target="_blank" rel="noreferrer noopener">The Survivors Trust</a>. A rape and sexual abuse support line from <a href="https://rapecrisis.org.uk/get-help/want-to-talk/" target="_blank" rel="noreferrer noopener">Rape Crisis</a>. An <a href="https://evidence.nihr.ac.uk/alert/sexual-assault-lasting-effects-teenagers-mental-health-education/">NIHR Evidence summary</a> on the effect of sexual assault on teenager’s mental health. Funding: <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-and-social-care-delivery-research.htm" target="_blank" rel="noreferrer noopener">NIHR Health and Social Care Delivery Research Commissioned Call</a>. Conflicts of Interest: No relevant conflicts of interest. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>What drives unprofessional behaviour in healthcare?</title> <link>https://evidence.nihr.ac.uk/alert/what-drives-unprofessional-behaviour-in-healthcare/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 05 Nov 2024 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64843</guid> <description><![CDATA[Researchers found that unprofessional behaviour such as rudeness or bullying may become embedded in the workplace when staff are disempowered, teams lack cohesion, and managers are unaware of the behaviour. They found that unprofessional behaviour can reduce staff wellbeing, contribute to mental and physical health problems among staff, impact patient safety and compromise the quality ...]]></description> <content:encoded><![CDATA[ Researchers found that unprofessional behaviour such as rudeness or bullying may become embedded in the workplace when staff are disempowered, teams lack cohesion, and managers are unaware of the behaviour. They found that unprofessional behaviour can reduce staff wellbeing, contribute to mental and physical health problems among staff, impact patient safety and compromise the quality of patient care. Unprofessional behaviour was most likely to be directed at staff who are female, new, disabled or from minority groups. The researchers suggest that improved working conditions and staff collaboration could reduce unprofessional behaviour in healthcare. They hope their findings will encourage healthcare organisations to tackle unprofessional behaviour. <a href="https://www.england.nhs.uk/supporting-our-nhs-people/health-and-wellbeing-programmes/civility-and-respect/" target="_blank" rel="noreferrer noopener">More information about civility and respect at work can be found on the NHS England website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-why-might-some-healthcare-staff-behave-unprofessionally">The issue: Why might some healthcare staff behave unprofessionally?</h2> Unprofessional behaviours (rudeness, harassment and bullying, for instance) in healthcare distress and harm colleagues. The <a href="https://www.nhsstaffsurveys.com/results/national-results/" target="_blank" rel="noreferrer noopener">2023 NHS staff survey</a> revealed that 18% of NHS staff experienced harassment, bullying or abuse from their colleagues; 10% reported these behaviours from their managers. Unprofessional behaviours increase staff burnout, absences and resignations. They impact patient care and safety. Researchers investigated why staff might behave unprofessionally and what impact that behaviour could have. This study is part of a <a href="https://workforceresearchsurrey.health/projects-resources/addressing-unprofessional-behaviours-between-healthcare-staff/" target="_blank" rel="noreferrer noopener">larger research project</a> that aims to develop interventions to improve workplace behaviour in healthcare. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Researchers examined 109 reports, including journal articles and grey literature (written by professional organisations, for example). They worked with professional standards bodies, patients, members of the public, and healthcare staff who had lived experience of unprofessional behaviour (either witnessing the behaviour, or being on the receiving end). They used a review method called realist synthesis which goes beyond asking whether something works, and asks for whom it works, in what circumstances and why. The aim is to generate a theory that can be tested further. The researchers identified 5 main drivers of unprofessional behaviour: <ul class="wp-block-list"> <li>disempowered staff who feel undervalued</li> <li>harmful workplace processes and cultures (high job demands because of understaffing, for instance, and senior staff who themselves display unprofessional behaviour)</li> <li>a lack of team cohesion and support, which can be caused by shift working</li> <li>reduced ability to speak up</li> <li>managers who lack awareness or recognition of unprofessional behaviours, and take no action.</li> </ul> The drivers of unprofessional behaviour also reduced the ability of staff to cope with it. Staff could feel unable to report, challenge or address incidents. This in turn increased unprofessional behaviour and reduced staff wellbeing (contributing to mental and physical health problems such as burnout). Staff who are female, new, disabled or from ethnic minorities were most likely to be on the receiving end of unprofessional behaviour. People’s response to unprofessional behaviour varies according to their circumstances, for instance whether they feel valued and have a supportive team. The study found that unprofessional behaviour could reduce patient safety and the quality of care provided through: <ul class="wp-block-list"> <li>staff losing confidence in their abilities, and having impaired concentration</li> <li>medical errors and patient safety concerns being ignored or going unreported</li> <li>breakdown of staff relationships, communication and trust.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> A better understanding of the drivers of unprofessional behaviour will help address it effectively and could improve care and reduce costs. A hospital in the US <a href="https://www.researchgate.net/profile/Michael-Leiter/publication/51482447_The_Impact_of_Civility_Interventions_on_Employee_Social_Behavior_Distress_and_Attitudes/links/09e4150bc94726f296000000/The-Impact-of-Civility-Interventions-on-Employee-Social-Behavior-Distress-and-Attitudes.pdf" target="_blank" rel="noreferrer noopener">reduced staff absences by 38%</a> after it introduced an intervention to reduce unprofessional behaviour. The documents included in this study covered settings similar to the NHS, plus studies reporting an intervention (there is little UK research on interventions). Further research could test the theories generated and explore whether they apply to different settings such as primary care, or private healthcare institutions. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers have produced <a href="https://workforceresearchsurrey.health/projects-resources/addressing-unprofessional-behaviours-between-healthcare-staff/" target="_blank" rel="noreferrer noopener">guidance to help healthcare professionals</a> address unprofessional behaviours; they plan to explore how the guidance is being used. To date, the focus has been on individual ‘bad apples’. However, teams and organisations are responsible for addressing unprofessional behaviour, and the researchers call for the focus to shift from individuals who behave unprofessionally to workplace culture. The researchers suggest that interventions need to: <ul class="wp-block-list"> <li>address systemic problems, and foster a work environment in which staff feel able to speak up rather than just removing people who behave unprofessionally</li> <li>encourage staff to intervene when they see unprofessional behaviour or suspect it is about to happen (when safe to do so)</li> <li>support managers to listen and act on staff concerns</li> <li>promote trust; the behaviour of managers and senior leaders needs to match the values being called for and they need to be held to account for historic instances of unprofessional behaviour</li> <li>be designed for all groups of staff across the organisation and benefit everyone</li> <li>be flexible and tailored to different situations, even if this makes them difficult to evaluate.</li> </ul> <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color has-padding has-padding-1x" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="71" height="102" /> Do I agree with these findings? How can I act on the new knowledge? </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Aunger JA, and others. <a href="https://doi.org/10.1186/s12913-023-10291-3" target="_blank" rel="noreferrer noopener">Drivers of unprofessional behaviour between staff in acute care hospitals: a realist review</a>. BMC Health Services Research 2023; 23: 1326. An NIHR Journals Library report from the same project: Aunger JA, and others. <a href="https://doi.org/10.3310/PAMV3758" target="_blank" rel="noreferrer noopener">Why do acute healthcare staff behave unprofessionally towards each other and how can these behaviours be reduced? A realist review</a>. Health and Care Delivery Research 2024; 12: 25. A video by one of the researchers: <a href="https://www.youtube.com/watch?v=MU0ZKg9zHP8" target="_blank" rel="noreferrer noopener">How unprofessional behaviours between healthcare staff arise and can be addressed</a> An NIHR Evidence summary about <a href="https://evidence.nihr.ac.uk/alert/freedom-to-speak-up-guardians-need-more-support-study-finds/">Freedom to speak up guardians</a>. <a href="https://www.socialpartnershipforum.org/system/files/2021-09/BMA-review-Workplace-bullying-and-harassment-of-doctors.pdf" target="_blank" rel="noreferrer noopener">Workplace bullying and harassment of doctors: A review of recent research</a> from the British Medical Association. <a href="https://www.bma.org.uk/advice-and-support/equality-and-diversity-guidance/bullying-and-harassment-guidance/promoting-a-positive-working-environment" target="_blank" rel="noreferrer noopener">Promoting a positive working environment</a> from the British Medical Association <a href="https://www.kingsfund.org.uk/insight-and-analysis/reports/workforce-race-inequalities-inclusion-nhs" target="_blank" rel="noreferrer noopener">Workforce race inequalities and inclusion in NHS providers</a> from The King’s Fund. Funding: This study was funded by the <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-and-social-care-delivery-research.htm" target="_blank" rel="noreferrer noopener">NIHR Health and Social Care Delivery Research programme</a>. Conflicts of Interest: The study authors declare no conflicts of interest. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Gallstones: surgery might not always be needed</title> <link>https://evidence.nihr.ac.uk/alert/gallstones-surgery-might-not-always-be-needed/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 31 Oct 2024 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64805</guid> <description><![CDATA[A study compared 2 treatments for gallstones: surgery to remove the gallbladder or a watch and wait approach. After 18 months: The findings could support shared decision-making between clinicians and people with uncomplicated gallstones. More information on gallstones can be found on the NHS website. The issue: is surgery for gallstones necessary? Gallstones are stones ...]]></description> <content:encoded><![CDATA[ A study compared 2 treatments for gallstones: surgery to remove the gallbladder or a watch and wait approach. After 18 months: <ul class="wp-block-list"> <li>both approaches were associated with similar levels of pain</li> <li>the watch and wait approach was less costly than surgery.</li> </ul> The findings could support shared decision-making between clinicians and people with uncomplicated gallstones. <a href="https://www.nhs.uk/conditions/gallstones/" target="_blank" rel="noreferrer noopener">More information on gallstones can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-is-surgery-for-gallstones-necessary">The issue: is surgery for gallstones necessary?</h2> Gallstones are stones that form in the gallbladder; they become more common with age. They do not usually cause symptoms or complications, but if they become trapped, they can cause severe abdominal pain. Painful attacks can occur and need medical attention. <a href="https://doi.org/10.1016/j.hpb.2016.12.011" target="_blank" rel="noreferrer noopener">International guidelines</a> recommend surgery to remove the gallbladder (cholecystectomy) as first-line treatment for people with gallstones who experience pain or other symptoms. However, surgery carries its own risks and some people continue to experience symptoms afterwards, for reasons that remain unclear. An alternative option is to adopt a ‘watch and wait’ strategy before operating to see if symptoms resolve. This study compared the outcomes of a watch and wait approach with those of surgery. It included people whose gallstones caused pain but had not yet led to more serious problems such as infection, jaundice or sepsis.<a id="_msocom_1"></a><a id="_msocom_1"></a> <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The study included 434 adults with confirmed gallstones from 20 UK hospitals. Most (79%) were women and their average age was 50 years. Participants had symptoms (pain, for instance) but no gallstone-related complications (such as jaundice).  Half the participants were in the surgery group; half in the watch and wait group (these people took painkillers when needed and received self-management advice). If symptoms became too severe, those in the watch and wait group could opt for surgery. By 18 months, most (67%) people in the surgery group had received surgery; most of the others had refused surgery, or were on a waiting list. Some (25%) in the watch and wait group had surgery; but most neither had surgery nor were waiting for it. The researchers found that: <ul class="wp-block-list"> <li>pain was the same in both groups after 18 months</li> <li>surgery cost the NHS more per participant (£2,510) than watch and wait (£1,477) after 24 months</li> <li>there was no difference in quality of life over 24 months from when people started the study, meaning watch and wait was highly likely to be cost-effective.</li> </ul> <a href="https://doi.org/10.3310/MNBY3104" target="_blank" rel="noreferrer noopener">There were no meaningful differences in quality of life, or the need for further treatment up to 24 months</a> from the beginning of the study. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The researchers say that, at 18 months, a watch and wait approach is as effective as surgery for people with uncomplicated gallstones. The findings could improve shared decision making for people with gallstones. Some (15% people) in the surgery group refused surgery. The researchers suggest this could indicate a willingness among people with gallstones not to undergo surgery. Performing fewer surgeries for gallstones could avoid the associated risks for many people. Also, in England in 2019, <a href="https://www.england.nhs.uk/publication/2019-20-national-cost-collection-data-publication/?msclkid=a717fabdba4111ecae08168a6a0b8189" target="_blank" rel="noreferrer noopener">gallbladder removals cost the NHS more than £200 million</a>. More people following a watch and wait approach could, therefore, save NHS resources. The researchers caution that their findings apply only to people who have uncomplicated gallstones. More research is needed for those with gallstone-related complications (such as infections). <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> <div class="wp-block-columns is-layout-flex wp-container-core-columns-is-layout-1 wp-block-columns-is-layout-flex"> <div class="wp-block-column is-layout-flow wp-block-column-is-layout-flow"> Longer-term follow up is needed in this group (people with gallstones causing pain alone). It could show how the effectiveness and value for money of the 2 approaches change over time. Further research could also explore whether some groups would benefit from earlier surgery. </div> <div class="wp-block-column is-layout-flow wp-block-column-is-layout-flow"> <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-border has-text-color has-blue-color has-padding has-padding-none" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-64773 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Lightbulb-3.png" alt="" width="46" height="66" /> Can I act on this knowledge? What else do I need to know? </div> </div> </section> </div> </div> The results of this study are beginning to influence practice, and to allow patients to opt for watch and wait rather than being listed for surgery immediately. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Ahmed I, and others. <a href="https://doi.org/10.1136/bmj-2023-075383" target="_blank" rel="noreferrer noopener">Effectiveness of conservative management versus laparoscopic cholecystectomy in the prevention of recurrent symptoms and complications in adults with uncomplicated symptomatic gallstone disease (C-GALL trial): pragmatic, multicentre randomised controlled trial</a>. British Medical Journal 2023; 383: 1 – 12. An <a href="https://www.england.nhs.uk/wp-content/uploads/2023/11/PRN00250-dst-making-a-decision-about-gallstones.pdf" target="_blank" rel="noreferrer noopener">NHS decision guide</a> for people considering treatment options for gallstones. Information on gallstones from the <a href="https://britishlivertrust.org.uk/information-and-support/liver-conditions/gallstones/" target="_blank" rel="noreferrer noopener">British Liver Trust</a>. <a href="https://www.nice.org.uk/guidance/cg188/" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE) guidelines</a> on gallstone disease.  Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=Gallstones&location=" target="_blank" rel="noreferrer noopener">NIHR research on gallstone disease</a>. Funding: This study was funded by the <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-technology-assessment.htm" target="_blank" rel="noreferrer noopener">NIHR Health and Technology Assessment programme</a>. Conflicts of Interest: None relevant. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>More people with inflammatory bowel disease could benefit from flu vaccination</title> <link>https://evidence.nihr.ac.uk/alert/more-people-with-inflammatory-bowel-disease-could-benefit-from-flu-vaccination/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 29 Oct 2024 09:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64668</guid> <description><![CDATA[Flu vaccines are recommended for people with inflammatory bowel disease (IBD). Researchers found that during the 2018 – 2019 flu season, among people with IBD: The researchers say there is a need to promote timely flu vaccination among people with IBD. More information on flu vaccines and inflammatory bowel disease can be found on the ...]]></description> <content:encoded><![CDATA[ Flu vaccines are recommended for people with inflammatory bowel disease (IBD). Researchers found that during the 2018 – 2019 flu season, among people with IBD: <ul class="wp-block-list"> <li>flu vaccine uptake was low and most who were vaccinated received them late</li> <li>vaccination was associated with a reduction in death from any cause </li> <li>vaccination was not associated with IBD flares.</li> </ul> The researchers say there is a need to promote timely flu vaccination among people with IBD. More information on <a href="https://www.nhs.uk/vaccinations/flu-vaccine/" target="_blank" rel="noreferrer noopener">flu vaccines</a> and <a href="https://www.nhs.uk/conditions/inflammatory-bowel-disease/" target="_blank" rel="noreferrer noopener">inflammatory bowel disease</a> can be found on the NHS website. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-how-common-is-flu-vaccination-in-people-with-inflammatory-bowel-disease">The issue: how common is flu vaccination in people with inflammatory bowel disease?</h2> More than <a href="https://www.nottingham.ac.uk/news/rates-of-crohns-and-colitis-have-been-vastly-underestimated-for-decades-says-new-study" target="_blank" rel="noreferrer noopener">540,000 people in the UK have inflammatory bowel disease</a> (IBD), which means their immune system attacks their gut and causes painful sores (ulcers) and inflammation. IBD includes <a href="https://www.nhs.uk/conditions/crohns-disease/" target="_blank" rel="noreferrer noopener">Crohn's disease</a> (inflammation can be anywhere in the gut, from mouth to bottom) or <a href="https://www.nhs.uk/conditions/ulcerative-colitis/" target="_blank" rel="noreferrer noopener">ulcerative colitis</a> (inflammation is in the large bowel only). Symptoms include severe stomach pain and diarrhoea. Medications that dampen the immune response can improve IBD symptoms; however, they can also leave people more vulnerable to infections. <a href="https://doi.org/10.1136/gutjnl-2019-318484" target="_blank" rel="noreferrer noopener">Flu vaccines are recommended for people with IBD on immune-suppressing drugs</a>, but <a href="https://doi.org/10.1007/s10620-019-05494-w" target="_blank" rel="noreferrer noopener">research suggests that uptake is low</a>. This could be due to the belief that flu vaccines cause IBD flares, or because of the lack of data on their effectiveness in people with IBD. This study investigated the uptake of flu vaccines in people with IBD, how effective they are in this population, and whether they are associated with IBD flares. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers examined the patient records of 13,631 adults with inflammatory bowel disease (IBD) on immune-supressing drugs (or 5-aminosalicylates) during the September 2018 – September 2019 flu season. Half were men; participants’ average age was 53 years. The researchers found that: <ul class="wp-block-list"> <li>overall, half (50%) received a flu vaccine, with few (32%) vaccinated before the flu circulated in the community</li> <li>vaccination was associated with fewer deaths from any cause (27% less)</li> <li>vaccination was not associated with reduced hospital admissions for pneumonia, or with primary care visits for flu-like illness or respiratory tract infections.</li> </ul> Few (33%) people at low risk of ill health (those aged 64 or under with no other long-term conditions) were vaccinated. More (69%) people at high risk (those aged 65 or over and those with additional conditions) were vaccinated. Being older, female, or having additional conditions were linked with higher vaccine uptake. The researchers examined data for 1,076 people who had a disease flare during the study period. They found that vaccination was not linked with flares.  <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> This study shows that relatively few people with inflammatory bowel disease (IBD) are vaccinated against flu, particularly when they need it most (before flu spreads in the community). The study also provides reassurance that flu vaccines are not associated with IBD flares, and may reduce deaths. The researchers call for promotion of timely flu vaccine uptake among people with IBD, particularly those with extra risks (other long-term conditions and older age).   Flu vaccination rates increased after the COVID-19 pandemic. The researchers say that vaccination rates among people with IBD may be higher now than when this research was carried out Vaccination was not linked with a reduction in flu-like illness. This could be because people were infected by viruses other than flu, which the vaccine does not protect against. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The research team is producing patient information leaflets and infographics to highlight the benefit of vaccination for those with inflammatory conditions, including IBD. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Nakafero G, and others. <a href="https://doi.org/10.1136/bmjgast-2024-001370" target="_blank" rel="noreferrer noopener">Uptake, safety and effectiveness of inactivated influenza vaccine in inflammatory bowel disease: a UK-wide study</a>. BMJ Open Gastroenterology 2024; 11.  DOI:10.1136/bmjgast-2024-001370. Information and support from <a href="https://crohnsandcolitis.org.uk/" target="_blank" rel="noreferrer noopener">Crohn’s and Colitis UK</a>. An <a href="https://evidence.nihr.ac.uk/collection/promoting-vaccination-the-right-approach-for-the-right-group/" target="_blank" rel="noreferrer noopener">NIHR Evidence Collection on promoting vaccine uptake in different populations</a>. Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=Inflammatory%20bowel%20disease&location=" target="_blank" rel="noreferrer noopener">NIHR research on IBD</a>.   Funding: This study was funded by the <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/research-for-patient-benefit.htm" target="_blank" rel="noreferrer noopener">NIHR Research for Patient Benefit programme</a>. Conflicts of Interest: Some authors received fees and funding from pharmaceutical companies. Full disclosures are available on the <a href="https://doi.org/10.1136/bmjgast-2024-001370" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Frailty: research shows how to improve care</title> <link>https://evidence.nihr.ac.uk/collection/frailty-research-shows-how-to-improve-care/</link> <dc:creator><![CDATA[Martha Powell]]></dc:creator> <pubDate>Thu, 24 Oct 2024 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64717</guid> <description><![CDATA[People who live extra years of life in good health can participate in, and therefore strengthen, societies. However, extra years of life dominated by poor health and frailty increase dependency and the need for care.   Without preventive action, frailty will become more prevalent as the population ages. Just over a half of people aged over ...]]></description> <content:encoded><![CDATA[ People who live extra years of life in good health can participate in, and therefore strengthen, societies. However, extra years of life dominated by poor health and frailty increase dependency and the need for care.   Without preventive action, frailty will become more prevalent as the population ages. Just<a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10158172/pdf/afad058.pdf" target="_blank" rel="noreferrer noopener"> over a half of people aged over 85</a> live with moderate or severe frailty and the number in that age group is expected to double between 2016 and 2041 <a href="https://assets.publishing.service.gov.uk/media/6674096b64e554df3bd0dbc6/chief-medical-officers-annual-report-2023-web-accessible.pdf" target="_blank" rel="noreferrer noopener">(Chief Medical Officer Annual Report, 2023).</a>  Frailty will place increasing demands on health and care services, <a href="https://www.england.nhs.uk/rightcare/toolkits/frailty/" target="_blank" rel="noreferrer noopener">demands that services are already finding hard to meet</a>. This Collection brings together evidence from the NIHR and elsewhere to help commissioners and healthcare providers address the challenge. The evidence we present supports improvements in the quality of care for people with frailty in the community, and in hospital.  <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-border has-text-color has-black-color has-padding has-padding-2x" > <div class="row"> <div class="columns small-12 large-8"> <h2 id="what-is-frailty">What is frailty?</h2> <a href="https://www.bgs.org.uk/sites/default/files/content/resources/files/2018-05-23/fff_full.pdf" target="_blank" rel="noreferrer noopener">Frailty</a> is a state of health which is more common among older adults. People with frailty lose their in-built reserves and their health becomes increasingly vulnerable to events such as an infection or change in medication or environment. This group of older people is at risk of adverse outcomes such as disability, falls, hospital admission, and the need for long-term care. </div> </div> </section> The likelihood of severe frailty increases sharply with age, but more younger people are living with the condition. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10158172/pdf/afad058.pdf" target="_blank" rel="noreferrer noopener">A 2023 analysis</a> of over 2 million primary care records found that the average age of frailty onset was 69 years; however 19% of younger people (50-64 years) had mild to moderate frailty. Few in this younger age bracket (3%) had moderate or severe frailty, compared with many more (58%) of those aged over 85. Deprivation, Asian ethnicity, female sex and living in an urban area all increased the risk of living with frailty.  <a href="https://link.springer.com/article/10.14283/jfa.2021.55" target="_blank" rel="noreferrer noopener">Analysis of population based survey and demographic data</a> from 2020 found wide geographic variation in the prevalence of frailty. Some areas had 4 times more frailty than others. The Chief Medical Officer described in his <a href="https://assets.publishing.service.gov.uk/media/6674096b64e554df3bd0dbc6/chief-medical-officers-annual-report-2023-web-accessible.pdf" target="_blank" rel="noreferrer noopener">2023 annual report</a>, the increasing concentrations of older people in rural, semi-rural and coastal areas of England. Data from the English Longitudinal study of ageing  (2002-2017) found people from the most deprived areas were <a href="https://pmc.ncbi.nlm.nih.gov/articles/PMC10061942/#:~:text=most%20advantaged%20ones.-,Living%20in%20more%20deprived%20neighbourhood%20and%20poorer%20wealth%20was%20associated,did%20not%20change%20over%20time." target="_blank" rel="noreferrer noopener">twice as likely to experience frailty</a>. <a href="https://www.emerald.com/insight/content/doi/10.1108/HCS-05-2020-0007/full/html" target="_blank" rel="noreferrer noopener">One study </a>of homeless people found high rates of premature frailty, suggesting a needs-based rather than age-based approach is needed to reduce health inequalities. <blockquote class="wp-block-quote is-layout-flow wp-block-quote-is-layout-flow"> “If we choose, ostrich-like, to ignore the growing concentration of older adults and their inevitable healthcare needs in these geographical areas, we are not undertaking proper responsible planning and will have a far harder landing as the population in those areas inexorably age.” <cite> <a href="https://assets.publishing.service.gov.uk/media/6674096b64e554df3bd0dbc6/chief-medical-officers-annual-report-2023-web-accessible.pdf" target="_blank" rel="noreferrer noopener">Chief Medical Officer Annual Report, 2023</a></cite></blockquote> Frailty increases someone's need for care and support. A <a href="https://academic.oup.com/ageing/article/53/2/afae010/7604256" target="_blank" rel="noreferrer noopener">2024 analysis</a> of over 2 million primary care records (2006-2017) found that people with severe frailty are nearly 6 times more likely to be admitted to hospital than those who do not have frailty; their average hospital costs are 9 times greater. Even people with mild frailty are twice as likely to be admitted to hospital than those who do not have frailty, and their average hospital costs are 3 times greater. At a population level, the large numbers of people with mild and moderate frailty means this group costs services most. However, frailty is not an inevitable consequence of ageing. Emerging evidence suggests that physical activity and diet can delay the onset of frailty, and reduce its severity. A 2020 <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508740/pdf/40520_2020_Article_1559.pdf" target="_blank" rel="noreferrer noopener">literature review</a> pointed to the potential benefits of physical activity (including resistance training, aerobic exercise and balance-based exercise such as Tai Chi) and dietary changes (increased protein intake and a Mediterranean diet rich in vegetables, fruits, cereals, olive oil and fish). Similarly, a <a href="https://www.bmj.com/content/bmj/377/bmj-2021-068788.full.pdf" target="_blank" rel="noreferrer noopener">large randomised control trial (SPRINTT, 2022)</a> found that regular physical activity combined with dietary advice, improved the mobility of people with frailty. <h2 class="wp-block-heading" class="wp-block-heading" id="care-in-the-community-for-people-with-frailty">Care in the community for people with frailty</h2> <div class="wp-block-media-text is-stacked-on-mobile" style="grid-template-columns:26% auto"><figure class="wp-block-media-text__media"><img loading="lazy" decoding="async" width="800" height="800" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Risk-factors-2.png" alt="" class="wp-image-64718 size-full"/></figure><div class="wp-block-media-text__content"> <a href="https://www.england.nhs.uk/ourwork/clinical-policy/older-people/improving-care-for-older-people/" target="_blank" rel="noreferrer noopener">National policy</a> encourages services to identify and actively manage frailty; GPs are required to identify frailty in people aged over 65. A range of community services have been developed to better support people with frailty in the community. They aim to avoid hospital admission and/or support earlier discharge, enabling people with frailty to stay independent and in their homes. </div></div> <h3 class="wp-block-heading" class="wp-block-heading" id="key-components-of-high-quality-frailty-care-in-the-community">Key components of high quality frailty care in the community</h3> <figure class="wp-block-image size-full is-resized"><img loading="lazy" decoding="async" width="1600" height="700" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Risk-factors-2-1.png" alt="6 sqaures reading: holistic assessment, multidisciplinary team consultations, continuity of care, care coordination tailored to complexity, individualised tratment and self management support, medication review" class="wp-image-64720" style="width:840px;height:auto"/></figure> Click on the headings below to read about research that could improve frailty care. <section class="guten-block block-accordion "> <div class="row"> <div class="column small-12"> <div class="tabs"> <div class="tab"> <input type="checkbox" id="chck-block_8166182b20f26ee6d9c21479b6681c36-1"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_8166182b20f26ee6d9c21479b6681c36-1">Comprehensive geriatric assessment in the community may reduce unplanned hospital admissions</label> <div class="tab-content"> Comprehensive Geriatric Assessment (CGA) is a multidisciplinary assessment of someone’s medical, functional, psychological and social capability. It is carried out by a team including doctors, nurses, physiotherapists and occupational therapists, to ensure that people’s problems are identified and managed appropriately. A <a href="https://www.cochranelibrary.com/cdsr/doi/10.1002/14651858.CD012705.pub2/full" target="_blank" rel="noopener">2022 Cochrane review</a> concluded that comprehensive geriatric assessments (CGAs) for people living with frailty in the community had no impact on death or nursing home admissions but might reduce the risk of unplanned hospital admission. A<a href="https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(23)00190-3/fulltext" target="_blank" rel="noopener"> 2023 umbrella review</a> of systematic reviews found evidence that community-based CGA could: <ul> <li style="font-weight: 400;" aria-level="1">improve medication, patient functioning, and quality of care</li> <li style="font-weight: 400;" aria-level="1">reduce hospital admissions.</li> </ul> The British Geriatric Society <a href="https://www.bgs.org.uk/sites/default/files/content/resources/files/2019-02-08/BGS%20Toolkit%20-%20FINAL%20FOR%20WEB_0.pdf" target="_blank" rel="noopener">toolkit</a> provides guidance for primary care practitioners on CGA in the community. This recommends falls risk assessment, for which the <a href="https://academic.oup.com/ageing/article/51/9/afac205/6730755?login=false" target="_blank" rel="noopener">World Falls Guidelines</a> provide international expert consensus advice. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_8166182b20f26ee6d9c21479b6681c36-2"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_8166182b20f26ee6d9c21479b6681c36-2">Primary Care Medical Home could improve quality of life and reduce hospital admissions</label> <div class="tab-content"> <a href="https://www.england.nhs.uk/new-care-models/pch/" target="_blank" rel="noopener">Primary Care Medical Home (PCMH) </a>brings together health and social care professionals in a team. The team provides enhanced personalised and preventive care for the local community; generally, a defined population of between 30,000 and 50,000. <a href="https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(23)00190-3/fulltext" target="_blank" rel="noopener">An umbrella review of 29 systematic reviews </a> (14 with meta-analysis) concluded that the evidence for holistic assessment-based interventions was inconsistent; it suggested that health and social care improvers need to carefully consider their own context when designing interventions. However, it found that PCMH could: <ul> <li style="font-weight: 400;" aria-level="1">improve health-related quality of life and mental health</li> <li style="font-weight: 400;" aria-level="1">reduce hospital admissions</li> <li style="font-weight: 400;" aria-level="1">improve self-management</li> </ul> </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_8166182b20f26ee6d9c21479b6681c36-3"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_8166182b20f26ee6d9c21479b6681c36-3">Hospital at Home is supported by evidence, but more robust evaluations of virtual wards are needed</label> <div class="tab-content"> <a href="https://academic.oup.com/ageing/article/52/1/afac319/6974849">Hospital at home and virtual wards</a> are alternatives to inpatient care. Hospital at home services provide face-to-face care at home through a multidisciplinary team based in the community. Virtual wards, led and managed by hospitals, deliver acute care at home. People are monitored and treated using a combination of remote and face-to-face care. Virtual wards rely on technology such as apps, technology platforms, wearables and devices such as pulse oximeters. A 2023<a href="https://academic.oup.com/ageing/article/52/1/afac319/6974849" target="_blank" rel="noopener"> rapid evidence synthesis</a> found good evidence for Hospital at Home, but concluded that more robust evaluations of virtual wards are needed. The researchers called for better guidance on aspects of virtual wards provision such as team characteristics, outcome selection and data protection. Living systematic reviews that are continuously updated, could help capture an evolving evidence base. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_8166182b20f26ee6d9c21479b6681c36-4"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_8166182b20f26ee6d9c21479b6681c36-4">Research identifies enablers and barriers to successful community care</label> <div class="tab-content"> The<a href="https://www.thelancet.com/journals/lanhl/article/PIIS2666-7568(23)00190-3/fulltext" target="_blank" rel="noopener"> 2023 umbrella review</a> of systematic reviews concluded that core components of successful community-based models include: <ul> <li style="font-weight: 400;" aria-level="1">holistic assessment</li> <li style="font-weight: 400;" aria-level="1">multidisciplinary team consultations</li> <li style="font-weight: 400;" aria-level="1">continuity of care</li> <li style="font-weight: 400;" aria-level="1">care coordination tailored to complexity</li> <li style="font-weight: 400;" aria-level="1">individualised treatment and self management support</li> <li style="font-weight: 400;" aria-level="1">medication review.</li> </ul> The review called for better methods to identify people with frailty who need intervention, and more clearly-defined roles and responsibilities for multidisciplinary team members. Barriers to implementation included: high workload, professional time constraints, perverse incentives of payment systems, and poorly-integrated computer systems. </div> </div> </div> </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="hospital-care-for-people-with-frailty">Hospital care for people with frailty</h2> <div class="wp-block-media-text is-stacked-on-mobile" style="grid-template-columns:25% auto"><figure class="wp-block-media-text__media"><img loading="lazy" decoding="async" width="800" height="800" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Risk-factors-1.png" alt="" class="wp-image-64722 size-full"/></figure><div class="wp-block-media-text__content"> The <a href="https://www.longtermplan.nhs.uk/wp-content/uploads/2019/01/nhs-long-term-plan-june-2019.pdf" target="_blank" rel="noreferrer noopener">NHS Long Term Plan</a> (2019) promoted acute frailty services with skilled multidisciplinary teams delivering Comprehensive Geriatric Assessments. NHS England developed a <a href="https://www.england.nhs.uk/long-read/frail-strategy/#frailty-is-everyone-s-business" target="_blank" rel="noreferrer noopener">FRAIL strategy</a> to support improvements in hospital care. This encourages rapid clinical frailty assessment; support from multidisciplinary acute frailty service if needed; a Comprehensive Geriatric Assessment; a patient-centred approach; rapid supported discharge. </div></div> In this section, we consider the current state of acute frailty services in hospitals. We look at evidence for services to address the needs of people with frailty and point the way to improvement in their quality of care. This includes Advanced Care Planning and Comprehensive Geriatric Assessment. People with frailty are at particular risk of falls, immobility, delirium, continence problems, inappropriate medication and surgery.  <h3 class="wp-block-heading" class="wp-block-heading" id="key-components-of-high-quality-frailty-care-in-hospital">Key components of high quality frailty care in hospital</h3> <figure class="wp-block-image size-full"><img loading="lazy" decoding="async" width="1600" height="700" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/10/Risk-factors-4.png" alt="Eight tiles that say: Comprehensive geriatric assessment, advanced care planning, test for delirium, good continence care, information on falls prevention, mediation review, improved communication, home first - default for discharge" class="wp-image-64719"/></figure> Click on the headings below to read about research that could improve frailty care. <section class="guten-block block-accordion "> <div class="row"> <div class="column small-12"> <div class="tabs"> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-1"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-1">The quality of acute frailty services varies </label> <div class="tab-content"> Most trusts have an acute frailty team to assess and triage patients. But the <a href="https://gettingitrightfirsttime.co.uk/wp-content/uploads/2021/09/Geriatric-Medicine-Sept21h.pdf" target="_blank" rel="noopener">Getting it Right First Time review (2021) </a>found variation in teams’ working methods and effectiveness. Trusts did not routinely monitor or evaluate frailty assessments. A <a href="https://link.springer.com/article/10.1186/s12877-021-02679-9#Ack1" target="_blank" rel="noopener">2019 day of care survey </a>found that two fifths of the 129 hospitals included did not have a routine frailty screening policy. Half did not have dedicated frailty units. Even those with screening policies had variable rates of assessment; most people at risk were not assessed. The<a href="https://www.ncbi.nlm.nih.gov/books/NBK540056/" target="_blank" rel="noopener"> HoW-CGA study</a> (2019) found that frailty or other risk stratification tools were used by some trusts only (30%). Multidisciplinary assessment and management was routine in wards specialising in older people’s care but less common elsewhere. Assessments tended to be informal. The HoW-CGA study piloted a <a href="https://www.bgs.org.uk/resources/how-cga-introduction-to-the-service-level-toolkit" target="_blank" rel="noopener">CGA toolkit </a>in oncology and surgery (an area not specialising in older people’s care) in three hospital sites. Pilot sites made limited progress in incorporating CGA during the study period, despite a good history of multidisciplinary collaboration. The researchers concluded that competing priorities and divergent views about professional responsibilities were barriers to the use of CGA clinical toolkits by non-geriatric teams. They suggested that an extended period of service development with geriatrician support could help. The <a href="https://www.scfn.org.uk/about" target="_blank" rel="noopener">Specialised Clinical Frailty Network</a>, set up in 2018, combined learning from the HoW-CGA study with quality improvement methods to enhance the experience and outcomes of older people with frailty who have specialised healthcare needs. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC9761464/pdf/futurehealth-9-3-286.pdf" target="_blank" rel="noopener">Research</a> concluded that frailty assessments could be introduced, and more frailty-orientated services delivered, without reliance on geriatricians. The Acute Frailty Network and NHS Elect have gone on to develop a range of tools including a frailty dashboard (see additional resources listed below). </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-2"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-2">Frailty assessment on admission to hospital can save lives and keep people at home</label> <div class="tab-content"> A <a href="https://ora.ox.ac.uk/objects/uuid:bb71e5dd-bce2-4d8b-a563-17b2021078a6/download_file?file_format=application%2Fpdf&safe_filename=Boucher_et_al_2023_Prevalence_and_outcomes.pdf&type_of_work=Journal+article" target="_blank" rel="noopener">2023 systematic review</a> found that among older people admitted as an unplanned emergency to hospital, moderate to severe frailty increases their length of stay, their likelihood of being discharged to somewhere other than home, and the risk of death. People with severe frailty were at greatest risk. The authors concluded “the available evidence justifies more widespread screening for both the presence and severity of frailty with clinically administered tools, such as the Clinical Frailty Scale, to inform care and target Comprehensive Geriatric Assessment and interventions.” A 2019 <a href="https://www.journalslibrary.nihr.ac.uk/hsdr/hsdr07100#/scientific-summary" target="_blank" rel="noopener">systematic review</a> found that older patients who have a CGA on admission to hospital are more likely to survive and be in their own home at follow-up. The <a href="https://www.ncbi.nlm.nih.gov/books/NBK540056/" target="_blank" rel="noopener">HoW-CGA large mixed methods study</a> (2019) estimated that in a hospital admitting 1000 older people per month, around 200 would be classified as severely frail. The application of routine CGAs might result in 12 more people of this group being alive, and 40 fewer people being admitted to long-term care. The CGA may lead to a small <a href="https://www.journalslibrary.nihr.ac.uk/hsdr/hsdr07100#/scientific-summary" target="_blank" rel="noopener">increase in costs</a>, but the evidence on cost-effectiveness was of low certainty. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-3"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-3">Advance care planning could improve care but is rarely used</label> <div class="tab-content"> <a href="https://www.england.nhs.uk/wp-content/uploads/2022/03/universal-principles-for-advance-care-planning.pdf" target="_blank" rel="noopener">Advance care planning</a> involves a voluntary person-centred discussion between an individual and their care providers about their preferences and priorities for future care. When advance care planning is done well, treatment focuses on what matters most to an individual in a personalised, holistic way, and helps them to live as well as possible. For example, people living with frailty may prefer less aggressive treatment, but these preferences are often not known or respected. A 2020 <a href="https://spcare.bmj.com/content/bmjspcare/10/2/164.full.pdf" target="_blank" rel="noopener">systematic review</a> found that although 74%–84% of older inpatients are receptive to advance care planning, only 0%–5% have plans in place.<a href="https://www.bmj.com/content/340/bmj.c1345" target="_blank" rel="noopener"> One randomised controlled trial</a> found that advance care planning improved outcomes. The review concluded that better understanding could improve end-of-life care for older people living with frailty. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-4"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-4">The 4AT test can rule out delirium</label> <div class="tab-content"> Delirium is a state of confusion, with disturbances in attention, consciousness, and the capacity to think and process information. It develops over hours to days. Delirium can be <a href="https://www.nice.org.uk/guidance/cg103" target="_blank" rel="noopener nofollow noreferrer">treated</a>. Untreated, it is associated with considerable distress along with poorer outcomes including increased mortality and cognitive decline. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3549230/pdf/bmjopen-2012-001772.pdf" target="_blank" rel="noopener nofollow noreferrer">Up to one in five adult patients in hospital have delirium, but only half have a diagnosis documented in their notes.</a> A<a href="https://link.springer.com/article/10.1007/s41999-022-00737-y#Abs2" target="_blank" rel="noopener"> large multicentre study (2023)</a> based on 2019 data found that the risk of delirium increased with the severity of frailty, and that those with most severe frailty were least likely to have their delirium diagnosed. The researchers recommended risk stratification for all patients for delirium. The 4 ‘A’s test (4AT: Arousal, Attention, Abbreviated Mental Test – 4, Acute change) is a short, easy-to-administer screening tool that can be used by non-specialists. <a href="https://www.journalslibrary.nihr.ac.uk/hta/hta23400#/scientific-summary" target="_blank" rel="noopener">A 2019 NIHR study (based on 2017 data)</a> found that the 4AT can rule out delirium or identify those who need more detailed testing. It could improve the speed and accuracy of treatment. This would save money and improve outcomes. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-5"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-5">Continence care needs to be prioritised</label> <div class="tab-content"> Incontinence can cause distress and loss of dignity for older people living with frailty. It is often <a href="https://www.england.nhs.uk/ourwork/clinical-policy/older-people/frailty/frailty-resources/#incontinence" target="_blank" rel="noopener">overlooked </a>or <a href="https://www.journalslibrary.nihr.ac.uk/hsdr/QUVV2680#/abstract" target="_blank" rel="noopener">poorly managed</a> in hospital settings. A previous NIHR Evidence Collection looked at <a href="https://evidence.nihr.ac.uk/collection/continence-dementia-and-care-that-preserves-dignity/">continence care for people with dementia.</a> Many of the same lessons can be applied to people with frailty. These include: <ul> <li style="font-weight: 400;" aria-level="1">prioritisation of continence care in all settings; it needs to be seen as a key component of high quality care</li> <li style="font-weight: 400;" aria-level="1">training for staff in all settings, encouraging them to promote personal dignity and safety including the use of appropriate language and delivery of personalised, sensitive care for incontinence including appropriate choice of products</li> <li style="font-weight: 400;" aria-level="1">a proactive approach to continence problems among staff, meaning they raise issues and address them in care plans to promote people’s independence</li> <li style="font-weight: 400;" aria-level="1">adaptation of care environments to help people safely use the toilet</li> <li style="font-weight: 400;" aria-level="1">agreement on, and monitoring of key quality indicators for continence by organisations, including capturing the use of pads.</li> </ul> NICE provides <a href="https://cks.nice.org.uk/topics/faecal-incontinence-in-adults/diagnosis/assessment/" target="_blank" rel="noopener">guidance on managing faecal incontinence</a> and recommends case finding for all at risk groups; this includes people with frailty. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-6"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-6">Individualised information about falls prevention helps patients and carers</label> <div class="tab-content"> Falling can cause distress, pain, injury, loss of confidence, loss of independence and mortality. Falls in hospitals are the most commonly reported patient safety incident, with more than <a href="https://www.gov.uk/government/publications/falls-applying-all-our-health/falls-applying-all-our-health" target="_blank" rel="noopener">240,000 reported in acute hospitals</a> and mental health trusts in England and Wales. A 2022 <a href="https://academic.oup.com/ageing/article/51/5/afac077/6581612" target="_blank" rel="noopener">systematic review</a> of interventions concluded that patient and staff education can reduce falls in hospital. There was evidence to support multi-factorial interventions but not for chair alarms, bed alarms, wearable sensors or scored risk assessment tools. Guidelines to prevent falls are followed more closely by some hospitals than others. An <a href="https://www.journalslibrary.nihr.ac.uk/hsdr/JWQC5771#/abstract" target="_blank" rel="noopener">NIHR study (2024) </a>recommended that Trusts should: <ul> <li style="font-weight: 400;" aria-level="1">clarify roles and responsibilities in relation to falls prevention</li> <li style="font-weight: 400;" aria-level="1">ensure processes and systems support a multidisciplinary approach</li> <li style="font-weight: 400;" aria-level="1">reduce the bureaucratic burden associated with falls risk assessment and monitoring</li> <li style="font-weight: 400;" aria-level="1">encourage staff to provide patients with individualised information on risks and falls prevention.</li> </ul> </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-7"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-7">People with frailty need appropriate prescribing </label> <div class="tab-content"> Frailty is associated with the regular use of at least 5 medications (polypharmacy), poor clinical outcomes and a risk of inappropriate prescribing. This includes over- and under-prescribing as well as misprescribing. Acute admissions are a valuable opportunity to optimise medications, and evaluate whether they provide a net benefit or net harm. <a href="https://www.nice.org.uk/guidance/NG5" target="_blank" rel="noopener">NICE provides </a>guidance on medicine optimisation. A <a href="https://www.nice.org.uk/guidance/NG5" target="_blank" rel="noopener">systematic review (2022)</a> included studies of medicines optimisation of people with frailty aged 65 years and over in an acute hospital. While there was little evidence that it improved clinical outcomes or saved money, the evidence available suggested that it was safe and feasible. The researchers recommended systematic identification of people with frailty in hospital. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-8"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-8">Volunteers can improve activity levels</label> <div class="tab-content"> <a href="https://www.bgs.org.uk/resources/deconditioning-awareness" target="_blank" rel="noopener">Up to 60 per cent of older people lose functional abilities including mobility during a stay in hospital; </a>some prematurely move to a care home as a result. Keeping people active in hospital can reduce their decline, but in busy clinical settings, professional staff may struggle to encourage mobility. In 2012, the Royal College of Nursing reported that <a href="https://buckinghamshire.moderngov.co.uk/Data/BCC%20RoCoOPiaHS/201206071000/Agenda/Care%20of%20Older%20People%20in%20a%20Hospital%20Setting%20-%20from%20a%20national%20perspective.pdf" target="_blank" rel="noopener">59% of nurses felt that promoting mobility was one of the aspects of care most frequently neglected</a> due to time pressure. In a <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/hex.13588" target="_blank" rel="noopener">2022 analysis of patient and carer opinions</a>, a quarter of carers observed a deterioration in their relatives’ condition after spending too long stationery and in bed. In a small <a href="https://academic.oup.com/ageing/article/49/2/283/5576112" target="_blank" rel="noopener">mixed methods study (2020)</a>, volunteers encouraged twice daily mobility and bedside exercises in people with an average age of 86. This study demonstrated the feasibility of the intervention, including the recruitment, training and retention of volunteers. The intervention was acceptable to healthcare professionals and patients. Controlled trials are needed to explore the impact of this volunteer-led physical activity intervention on patient outcomes and its cost-effectiveness in different healthcare settings. The <a href="https://www.bgs.org.uk/resources/deconditioning-awareness" target="_blank" rel="noopener">British Geriatrics Society produces </a>resources for staff and patients to encourage more mobility. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-9"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-9">Improvements in diet and exercise before admission can reduce complications after surgery</label> <div class="tab-content"> People with frailty are at risk of complications after surgery. Prehabilitation is a programme of exercise, improved diet and psychological support in advance of admission to hospital, with the aim of reducing risk. A <a href="https://www.clinicalnutritionjournal.com/article/S0261-5614(24)00015-3/fulltext" target="_blank" rel="noopener">systematic review</a> (2024) found prehabilitation reduced hospital stay by 1 day, and decreased severe complications in patients who were frail, older, and undergoing elective abdominal surgery. Prehabilitation was feasible, safe, and posed a minimal risk of complications. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-10"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-10">Patients and carers want better communication </label> <div class="tab-content"> Recent studies have explored the needs of people with frailty when they are in hospital; they conclude that communication with patients and carers could be improved. <a href="https://journals.sagepub.com/doi/10.1177/2374373520969253" target="_blank" rel="noopener">An analysis of feedback from 609 patients across 12 hospitals</a>, found that current communication, particularly on admission, first assessment, and at discharge, could leave people with frailty feeling distressed. Noisy and busy emergency departments are challenging for older people living with frailty, according to a study on<a href="https://emj.bmj.com/content/emermed/39/10/726.full.pdf" target="_blank" rel="noopener"> emergency care</a> (2022). It found that this group prefers to receive care in a calm and quiet setting, where they are comfortable and have basic physical needs met. For example, they need access to food and drink while waiting. Older people with frailty were concerned that staff could be unresponsive when they called for attention, especially those who needed assistance with toileting. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_326cc8867e10ef4be82ac55168c75732-11"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_326cc8867e10ef4be82ac55168c75732-11">Home first should be the default pathway for discharge </label> <div class="tab-content"> The number of patients in acute hospitals who were ready to leave but were delayed increased by 43% from June 2021 (an average of 8,545 patients per day) to June 2024 (<a href="https://www.nuffieldtrust.org.uk/resource/delayed-discharges-from-hospital" target="_blank" rel="noopener">12,223 patients per day)</a>. Older people living with any level of frailty are <a href="https://www.england.nhs.uk/rightcare/wp-content/uploads/sites/40/2019/07/frailty-toolkit-june-2019-v1.pdf" target="_blank" rel="noopener">more likely to have delayed transfers of care</a>. NHS England provides <a href="https://www.gov.uk/government/publications/hospital-discharge-and-community-support-guidance/hospital-discharge-and-community-support-guidance" target="_blank" rel="noopener">comprehensive guidance</a> on discharge, and recommends “the default pathway for people with frailty should be home first, with recovery support at home to regain functional ability after discharge.” An<a href="https://bmjopenquality.bmj.com/content/bmjqir/12/4/e002515.full.pdf" target="_blank" rel="noopener"> evaluation</a> (2022) of the Discharge to Assess (Home First) model suggested the need for: <ul> <li style="font-weight: 400;" aria-level="1">a shared understanding of local processes (an operation policy)</li> <li style="font-weight: 400;" aria-level="1">high standards of communication between teams and with patients and carers</li> <li style="font-weight: 400;" aria-level="1">operational oversight of the pathway</li> <li style="font-weight: 400;" aria-level="1">measurement of outcomes for service users and carers to facilitate continuous improvement.</li> </ul> </div> </div> </div> </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="conclusion">Conclusion</h2> In our ageing population, the numbers of people living with frailty are growing rapidly, with some areas disproportionately affected. Yet frailty is not an inevitable consequence of ageing. There is growing evidence that physical activity and a good diet could help delay the onset of frailty and reduce its severity. Prevention strategies could contain demand and control expenditure.  People with frailty, particularly severe frailty, are at risk of some of the poorest outcomes from hospital care; their care also consumes the highest resource. Systematically screening and assessing patients for frailty, particularly in hospital, will save lives and help people to retain their independence. Research suggests ways to mitigate their heightened risks from falls, immobility, delirium, continence problems, inappropriate medication and surgery.  Studies show unwarranted variations in hospital and community care. Issues to be addressed include poor communication both between professionals and with patients; lack of clarity about roles and responsibilities; failure to monitor outcomes that are important to patients; workforce pressures.  Unanswered questions remain about the best models of prevention and care, particularly in the community, as well as the implications for the health and social care workforce. Ongoing studies from the NIHR (see below) should help provide answers. <section class="guten-block block-accordion "> <div class="row"> <div class="column small-12"> <div class="tabs"> <div class="tab"> <input type="checkbox" id="chck-block_99b3413d50b88162034d9b1c50bdad37-1"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_99b3413d50b88162034d9b1c50bdad37-1">Some important NIHR research on frailty in progress - not yet completed/published</label> <div class="tab-content"> <a href="https://fundingawards.nihr.ac.uk/award/15/43/07" target="_blank" rel="noopener">Individually randomised controlled multi-centre trial to determine the clinical and cost effectiveness of a home-based exercise intervention for older people with frailty as extended rehabilitation following acute illness or injury, including embedded process evaluation</a> Chief Investigator: Professor Andrew Clegg End date: May 2023 <a href="https://fundingawards.nihr.ac.uk/award/NIHR131319" target="_blank" rel="noopener">Developing the evidence and associated service model to support older people living with frailty to manage their pain and to reduce its impact on their lives: a mixed method, co-design study.</a> Chief investigator: Dr Lesley Brown End date: March 2025 Main output will be a Pain and Frailty Service Commissioning Pack to support commissioning of services aligned with the needs of older people with frailty and pain. <a href="https://fundingawards.nihr.ac.uk/award/RP-PG-0216-20003" target="_blank" rel="noopener">Personalised care planning to improve quality of life for older people with frailty</a> Chief investigator: Professor Andrew Clegg End date: August 2025 This study aims to investigate whether Personalised Care Planning for older people with frailty can improve quality of life and reduce use of health and social care services. <a href="https://fundingawards.nihr.ac.uk/award/NIHR134305" target="_blank" rel="noopener">Planning for Frailty: Optimal Health and Social Care Workforce Organisation Using Demand-led Simulation Modelling (FLOWS)</a> Chief Investigator: Dr Bronagh Walsh End date: October 2025 Research Question: What is the present, and expected, size and composition of the health and social care workforce required to provide care for the frail older population? The primary objective of this study is the creation of a simulation model that will inform service and workforce planning to meet health and social care needs associated with frailty. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_99b3413d50b88162034d9b1c50bdad37-2"> <label class="tab-label has-background has-blue-background-color has-text-color has-white-color" for="chck-block_99b3413d50b88162034d9b1c50bdad37-2">Other guidance and resources</label> <div class="tab-content"> <h3 id="nice">NICE</h3> <a href="https://stpsupport.nice.org.uk/frailty/index.html" target="_blank" rel="noopener">Improving care and support for people with frailty: How NICE resources can support local priorities</a> <h3 id="frailty-resources-on-nhse-website">Frailty resources on <a href="https://www.england.nhs.uk/ourwork/clinical-policy/older-people/frailty/frailty-resources/" target="_blank" rel="noopener">NHSE website</a></h3> To support health and care professionals and commissioners in the development of patient-centred services that enable people to age well there is a range of material available to improve understanding of frailty as a long term condition <h3 id="british-geriatric-society">British Geriatric Society</h3> <a href="https://www.bgs.org.uk/resources/frailty-hub-introduction-to-frailty" target="_blank" rel="noopener">Frailty Hub</a> <h3 id="acute-frailty-network-afn">Acute Frailty Network (AFN)</h3> <a href="https://www.acutefrailtynetwork.org.uk/Resources" target="_blank" rel="noopener">The AFN provides guidance and resources</a> <h3 id="quality-indicators-for-geriatric-emergency-care">Quality indicators for geriatric emergency care</h3> <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7364502/pdf/13049_2020_Article_756.pdf" target="_blank" rel="noopener">Quality indicators for a geriatric emergency care (GeriQ-ED) – an evidence-based delphi consensus approach to improve the care of geriatric patients in the emergency department</a> <h3 id="specialised-clinical-frailty-network-scfn">Specialised clinical frailty network (SCFN)</h3> <a href="https://www.scfn.org.uk/home" target="_blank" rel="noopener">The Specialised Clinical Frailty Network </a>supports specialised healthcare teams to improve the way specialised care and treatment is tailored to the needs and preferences of individuals living with frailty. The Network is a clinically led quality improvement collaborative. Resources include <a href="https://www.scfn.org.uk/s/SCFN-Frailty-Toolkit-September-2021-FINAL.pdf" target="_blank" rel="noopener">Specialised Clinical Frailty Toolkit</a>. <h3 id="skills-for-health">Skills for Health</h3> <a href="http://www.skillsforhealth.org.uk/services/item/607-frailty-core-capabilities-framework" target="_blank" rel="noopener">Skills for Health, NHS England and Health Education England Frailty Framework of Core Capabilities</a> <h3 id="pathway">Pathway</h3> In addition to other impacts on health, being homeless accelerates ageing. <a href="https://www.pathway.org.uk/issues/frailty/" target="_blank" rel="noopener">Pathway’s work</a> in the area to date includes contributions to research, with particular reference to the experience of frailty in hostel settings. <h3 id="previous-nihr-evidence-review-2017">Previous NIHR Evidence review (2017)</h3> <a href="https://evidence.nihr.ac.uk/themedreview/comprehensive-care-older-people-with-frailty-in-hospital/" target="_blank" rel="noopener">NIHR on older patients living in hospital with frailty</a> </div> </div> </div> </div> </div> </section> Author: Candace Imison, Deputy Director of Dissemination and Knowledge Mobilisation, NIHR How to cite this Collection: NIHR Evidence; Frailty: research shows how to improve care; October 2024; doi: 10.3310/nihrevidence_64717 Disclaimer: This publication is not a substitute for professional healthcare advice. It provides information about research which is funded or supported by the NIHR. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Urinary problems in men: self-management advice is helpful</title> <link>https://evidence.nihr.ac.uk/alert/urinary-problems-in-men-self-management-advice-is-helpful/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 22 Oct 2024 08:10:27 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64551</guid> <description><![CDATA[Men with urinary problems may need to pass urine more often, or have difficulties passing urine. Researchers developed a booklet of self-management advice, and found that, compared with usual care, giving the booklet led to: The improvement in men’s symptoms was relatively small, but the researchers say that more men could benefit from self-management advice ...]]></description> <content:encoded><![CDATA[ Men with urinary problems may need to pass urine more often, or have difficulties passing urine. Researchers developed a booklet of self-management advice, and found that, compared with usual care, giving the booklet led to: <ul class="wp-block-list"> <li>greater improvements in men's symptoms</li> <li>similar costs to the NHS.</li> </ul> The improvement in men’s symptoms was relatively small, but the researchers say that more men could benefit from self-management advice for urinary problems. <a href="https://www.baus.org.uk/_userfiles/pages/files/Patients/Leaflets/Male%20LUTS.pdf" target="_blank" rel="noreferrer noopener">More information about lower urinary tract symptoms is available from British Association of Urological Surgeons</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-does-self-management-advice-help-men-with-urinary-problems">The issue: does self-management advice help men with urinary problems?</h2> Urinary problems, such as needing to pass urine more often, urgently or during the night, and difficulties passing urine, may be caused by an enlarged prostate, impaired bladder function, or both. Problems become more common as men age; nearly one-third of all men older than 65 years are affected. Symptoms can cause distress, disrupt sleep or, for example, mean that trips have to be planned around available toilets. <a href="https://www.nice.org.uk/guidance/cg97/chapter/recommendations" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence guidelines</a> recommend offering advice to men with urinary problems (pelvic floor exercises and lifestyle changes, for instance) before trying tablets or surgery. It is not known how helpful this advice is. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers invited 1,077 men with troublesome urinary problems from 30 GP surgeries in England. Half were randomly allocated to receive self-management advice and were directed to relevant sections of <a href="https://www.imperial.ac.uk/media/imperial-college/medicine/surgery-cancer/clinical-trials/Worthington_Waterworks-A5-Booklet-MD-v2.pdf" target="_blank" rel="noreferrer noopener">a patient booklet</a> developed by the researchers. They were also contacted by clinicians (nurses and healthcare assistants) 3 times over 12 weeks to encourage them to follow the advice. The others received usual care, which varied but could include advice, medication, referral to a consultant, or continuing to live with symptoms. The main outcome of the study, based on 424 men in the advice group and 463 in the usual care group, was improvement in urinary problems at 12 months. Compared with usual care, those who received self-management advice: <ul class="wp-block-list"> <li>had a greater improvement in their symptoms; the overall improvement was slightly less than is considered meaningful</li> <li>reported slightly better quality of life and felt better about their urinary problems.</li> </ul> There was no difference between groups in the likelihood of a urology referral or adverse event. Costs to the NHS per patient were similar in both groups. The researchers also interviewed 58 men with urinary problems. Many had been unaware of self-management techniques for urinary problems before they took part. Those receiving the booklet generally welcomed the advice, and said it improved their symptoms and their understanding of their urinary problems. They appreciated their problems being taken seriously and not dismissed as a normal part of getting older. By contrast, men in the usual care group were often resigned to their symptoms, and felt that they would not change. Some said that opportunities for detailed self-management advice had been missed in GP consultations.<a id="_msocom_1"></a> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The self-management advice provided a small, sustained benefit in men’s urinary problems and offered value for money. Men appreciated the advice and the control it offered over their symptoms. The improvement in symptoms did not reach the study’s target; the overall change was slightly below the level considered meaningful. The researchers say that the advice is still beneficial because the improvement was sustained 1 year after initial contact; many men did have a meaningful improvement and improved quality of life. The lack of awareness of self-management for urinary problems among men reinforces the importance of the advice, they say. Almost all (98%) men in the study were white; further work is required to show that the findings apply to people of other ethnicities. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers suggest that more men could be given the self-management advice booklet at a relatively low cost. In addition, nurses and healthcare assistants need minimal training to advise men with urinary problems using the resources provided by the trial. At least one of the research sites is continuing to use the intervention. Better awareness of self-management for urinary problems could reduce the numbers referred for more serious interventions, such as surgery. The researchers are working with their local primary care services to develop a guide for primary care clinicians on assessing urinary problems, including helping patients keep a bladder diary. The guide will appear as a prompt on their computer when they begin these consultations. In addition, an adapted version of the booklet developed for this study is being used in <a href="https://www.bristol.ac.uk/news/2023/may/globalresearch-award.html" target="_blank" rel="noreferrer noopener">another study supporting the health of older people in Zimbabwe</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Worthington J, and others. <a href="https://doi.org/10.3310/GVBC3182" target="_blank" rel="noreferrer noopener">Lower urinary tract symptoms in men: the TRIUMPH cluster RCT</a>. Health Technology Assessment 2024; 28; 1 – 162. Information on prostate problems from the <a href="https://www.nhs.uk/conditions/prostate-problems/" target="_blank" rel="noreferrer noopener">NHS</a>. Information and support about urinary problems in men from <a href="https://www.betterhealth.vic.gov.au/health/conditionsandtreatments/prostate-gland-and-urinary-problems" target="_blank" rel="noreferrer noopener">Better Health</a>. Funding: <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-technology-assessment.htm" target="_blank" rel="noreferrer noopener">NIHR Health Technology Assessment Commissioned Call</a>. Conflicts of Interest: Several authors have received fees and funding from pharmaceutical companies. See <a href="https://doi.org/10.3310/GVBC3182" target="_blank" rel="noreferrer noopener">paper for full details</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Pilonidal sinus: what type of surgery is best?</title> <link>https://evidence.nihr.ac.uk/alert/pilonidal-sinus-what-type-of-surgery-is-best/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 17 Oct 2024 08:25:40 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64449</guid> <description><![CDATA[A pilonidal sinus is a small hole, often full of hairs, found where the buttocks divide; it can become infected and cause pain. People can have a minor procedure to clean the wound, or more major surgery to remove infected skin and tissue. A study involving 667 people with pilonidal sinus found that, compared with ...]]></description> <content:encoded><![CDATA[ A pilonidal sinus is a small hole, often full of hairs, found where the buttocks divide; it can become infected and cause pain. People can have a minor procedure to clean the wound, or more major surgery to remove infected skin and tissue. A study involving 667 people with pilonidal sinus found that, compared with tissue-removing surgery, minor procedures were: <ul class="wp-block-list"> <li>associated with less pain, fewer complications and a faster recovery</li> <li>more likely to fail to resolve the condition.</li> </ul> The findings will inform decision-making between clinicians and people considering surgery for their pilonidal sinuses. <a href="https://www.nhs.uk/conditions/pilonidal-sinus/" target="_blank" rel="noreferrer noopener">More information on pilonidal sinus can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-how-effective-are-different-surgical-approaches-for-pilonidal-sinus">The issue: how effective are different surgical approaches for pilonidal sinus?</h2> Pilonidal sinuses mainly affect <a href="https://cks.nice.org.uk/topics/pilonidal-sinus-disease/" target="_blank" rel="noreferrer noopener">younger people (aged 15 to 30)</a>, men, and those who are overweight. They often go unnoticed unless they become infected. Infections can cause pain, swelling, and skin abscesses; they can make it difficult for people to sit down. Abscesses resulting from pilonidal sinuses are usually drained as an emergency. The aim of surgery is then to clean the sinus, encourage healing and avoid further infection. Clinicians may simply scrape out the pilonidal sinus to remove hairs; they may or may not glue the hole closed. Alternatively, they may use a small camera to look inside and clean the hole (endoscopic pilonidal sinus treatment) or use a laser to destroy it. In more extensive tissue-removing surgery, all affected skin is removed. The wound may be left to heal naturally, or closed using skin flaps from elsewhere on the bottom. Tissue-removing surgeries are usually (but not always) performed on people with more severe disease. In this study, researchers compared different surgical approaches for pilonidal sinuses. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The study included 667 people with pilonidal sinus disease (aged 16 years or older). Most (73%) were male and their average age was 27. Most (60%) participants had tissue-removing surgery and the rest (40%) had minor procedures. Follow-up data at 6 months was provided by 477 people (71%). The researchers found that minor procedures were associated with: <ul class="wp-block-list"> <li>less pain after 7 days (scoring 1.9 on a scale from 0 – 10) compared with tissue-removing surgery (3.4)</li> <li>fewer complications (36% of participants) after 6 months compared with tissue-removing surgery (54%)</li> <li>a faster return to normal activities (after 7 days) compared with tissue-removing surgery (32 days)</li> <li>faster healing (30 days) compared with tissue removing surgery (70 days).</li> </ul> Treatment failure was defined as the need for further surgery, recurrence of pilonidal sinus, or adverse events related to the disease. People who had a minor procedure were around 10% more likely to have treatment failure than those who had tissue-removing surgery. After 6 months, a quarter of all participants had an unhealed wound and 1 in 10 had not returned to normal activities. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> Minor procedures were associated with less pain, fewer complications and faster recovery than tissue-removing surgery. However, they also had a greater chance of treatment failure. The findings will inform shared decision-making between clinicians and people with pilonidal sinuses. The findings highlighted the overall high rate of complications after surgery. Tissue-removing surgery was associated with a long period of recovery; minor procedures with a high risk of recurrence. These rates were higher than those reported in <a href="https://doi.org/10.1038/s41598-018-20143-4" target="_blank" rel="noreferrer noopener">other studies</a>. The researchers say more research is needed to improve outcomes and the burden of surgery for people with pilonidal sinuses. Only 71% of people provided data at 6 months, which reduced the strength of the findings; this was mainly due to the COVID-19 pandemic. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> Most participants underwent tissue-removing surgery. The researchers suggest that commissioners and policymakers could ensure that minor procedures are more widely available, and encourage clinicians to discuss potential advantages with people with pilonidal sinuses. A speedy recovery benefits people with pilonidal sinuses, their family, their work and the economy. In this study, researchers observed the outcomes of different types of surgery but could not conclude which procedures were best. The team is planning a randomised controlled trial to compare different approaches. The researchers plan to host workshops for surgeons to improve the care of people with pilonidal sinus. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Brown SR, and others. <a href="https://doi.org/10.3310/KFDQ2017" target="_blank" rel="noreferrer noopener">Treatment options for patients with pilonidal sinus disease: PITSTOP, a mixed-methods evaluation</a>. Health Technology Assessment 2024; 28: 1 - 113. Other research from the same project: Brown SR, and others. <a href="https://doi.org/10.1093/bjs/znae009" target="_blank" rel="noreferrer noopener">Real-world practice and outcomes in pilonidal surgery: Pilonidal Sinus Treatment Studying The Options (PITSTOP) cohort</a>. British Journal of Surgery 2024; 111. DOI: 10.1093/bjs/znae009. Information on pilonidal sinus from <a href="https://patient.info/skin-conditions/pilonidal-sinus-leaflet" target="_blank" rel="noreferrer noopener">Patient</a>. <a href="https://www.youtube.com/shorts/R3bN3_6REEM" target="_blank" rel="noreferrer noopener">Lived experience of pilonidal sinus</a> on YouTube. A <a href="https://www.youtube.com/shorts/L7oXVxEAdUs" target="_blank" rel="noreferrer noopener">short video explaining pilonidal sinuses</a> and alternative treatments.  guidelines the latest are due to be published in BJS but have not been yet. Guidelines due out soon. Ojo D, Gallo G, Kleijnen J et al. European Society of Coloproctology Guidelines for the management of Pilonidal Disease. In press BJS 2024. A study of patient views on pilonidal sinus surgeries: Strong E, and others. <a href="https://doi.org/10.1111/codi.15606" target="_blank" rel="noreferrer noopener">Patient decision-making and regret in pilonidal sinus surgery: a mixed-methods study</a>. Colorectal Disease 2021; 23: 1487 – 1498. And: Banks J, and others. <a href="https://doi.org/10.1111/codi.17152" target="_blank" rel="noreferrer noopener">Decision regret following surgical management of pilonidal disease</a>. Colorectal Disease 2024; 00: 1–7. Funding: <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-technology-assessment.htm" target="_blank" rel="noreferrer noopener">NIHR Health Technology Assessment Commissioned Call</a>. Conflicts of Interest: None relevant. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Stop smoking intervention in emergency departments helps people quit</title> <link>https://evidence.nihr.ac.uk/alert/stop-smoking-intervention-in-emergency-departments-helps-people-quit/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 15 Oct 2024 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64502</guid> <description><![CDATA[Researchers explored whether an opportunistic stop smoking intervention (advice, a vape starter pack and a referral to stop smoking services), was effective for people attending the emergency department (A&E). At 6 months, more people who received the intervention had quit smoking compared with people who received advice only. This suggests that emergency departments could be ...]]></description> <content:encoded><![CDATA[ Researchers explored whether an opportunistic stop smoking intervention (advice, a vape starter pack and a referral to stop smoking services), was effective for people attending the emergency department (A&E). At 6 months, more people who received the intervention had quit smoking compared with people who received advice only. This suggests that emergency departments could be a useful setting in which to help people quit smoking, the researchers say. The findings may encourage the implementation of stop smoking initiatives wherever people interact with the health service, including in emergency departments. <a href="https://www.nhs.uk/live-well/quit-smoking/nhs-stop-smoking-services-help-you-quit/" target="_blank" rel="noreferrer noopener">More information about quitting smoking can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-are-stop-smoking-services-in-emergency-departments-effective">The issue: are stop smoking services in emergency departments effective?</h2> <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2022" target="_blank" rel="noreferrer noopener">In 2022, around 6.4 million people in the UK smoked</a>. Smoking-related illnesses (<a href="https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-public-health/2021/part-2-mortality#:~:text=Deaths%20estimated%20to%20be%20attributable,%25%20from%202009%20(82%2C000)" target="_blank" rel="noreferrer noopener">including respiratory diseases, cancer and heart disease</a>) caused around <a href="https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-public-health/2023/part-1-hospital-admissions" target="_blank" rel="noreferrer noopener">74,600 deaths</a> in 2019 and more than <a href="https://digital.nhs.uk/data-and-information/publications/statistical/statistics-on-public-health/2023/part-1-hospital-admissions" target="_blank" rel="noreferrer noopener">408,000 hospital admissions</a> in 2022 – 2023 in England. Encouraging people to stop smoking prevents premature deaths and reduces healthcare use. It also addresses health inequalities: smoking accounts for about <a href="https://assets.publishing.service.gov.uk/media/5a822dc740f0b6230269b419/Towards_a_Smoke_free_Generation_-_A_Tobacco_Control_Plan_for_England_2017-2022__2_.pdf" target="_blank" rel="noreferrer noopener">half the difference in life expectancy</a> between the poorest and the richest (about 4.5 years of the total 9 year life expectancy difference). <a href="https://doi.org/10.1186/s44201-022-00006-5" target="_blank" rel="noreferrer noopener">People who attend emergency departments are more likely than others to smoke</a>. Stop smoking interventions in this setting have shown promise. Researchers compared an intervention (vape starter pack, advice and referral) with written information about stop smoking services. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Researchers invited 972 adults attending 1 of 6 emergency departments in the UK to take part in the trial in 2022. All smoked daily and none used a vape daily. Half (484 people) received an intervention delivered by a smoking cessation advisor: up to 15 minutes’ advice tailored to the patient, a vape starter kit and advice on how to use it and a referral to stop smoking services. The others (488 people) received written information signposting them to stop smoking services. At 6 months, researchers sent participants surveys asking about their smoking status. The main outcome was abstinence, confirmed by a carbon monoxide reading (but few supplied this). At 6 months: <ul class="wp-block-list"> <li>in the intervention group, 113 (23%) said they had quit; this was confirmed in 35 people (7% of the original 484)</li> <li>in the signposting group, 63 (13%) said they had quit; this was confirmed in 20 people (4% of the original 488).</li> </ul> The researchers assumed that those who did not submit a carbon monoxide reading at 6 months were still smoking. The intervention therefore led to confirmed quitting in 7% people at 6 months, compared with 4% of those given signposting only. No serious adverse events related to the intervention were reported. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> This is the first trial to show that a stop smoking intervention delivered in emergency departments including vapes helps people quit smoking, even among a group not actively looking to give up. Smoking accounts for <a href="https://www.longtermplan.nhs.uk/online-version/chapter-2-more-nhs-action-on-prevention-and-health-inequalities/smoking/" target="_blank" rel="noreferrer noopener">more years of life lost than any other modifiable risk factor</a>. Half of those who smoked agreed to take part in the trial, which suggests that emergency departments are an acceptable setting for an opportunistic intervention. People who attend emergency departments are more likely than others to smoke and to come from deprived communities. Stop smoking interventions in emergency departments could therefore reduce health inequalities. The researchers assumed that people who did not respond were still smoking. This may not be true, and the intervention might have more impact in practice than in the trial. In addition, the signposting-only group discussed smoking with the researchers, which is not typical of care in the emergency department. The signposting-only group might therefore have been more likely to quit than others who received typical care (no discussion about smoking). <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> The researchers held a webinar on this research with <a href="https://ash.org.uk/" target="_blank" rel="noreferrer noopener">Action on Smoking and Health</a> (ASH), and set up a <a href="https://app.onlinesurveys.jisc.ac.uk/s/uea/costed-action-group" target="_blank" rel="noreferrer noopener">group</a> to help trusts roll-out the intervention. As of June 2024, the group had 61 members representing local authorities and NHS trusts from 30 areas across England. The researchers are developing a toolkit to help with implementation. This intervention required dedicated staff (smoking cessation advisors who were not necessarily clinicians), training, and vape starter kits. The research team is evaluating the cost-effectiveness of the intervention. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Pope I, and others. <a href="https://doi.org/10.1136/emermed-2023-213824" target="_blank" rel="noreferrer noopener">Cessation of smoking trial in the emergency department (COSTED): a multicentre randomised controlled trial</a>. Emergency Medicine Journal 2024; 41: 276 – 282. A <a href="https://www.youtube.com/watch?v=GvVdz1Ek-Os" target="_blank" rel="noreferrer noopener">YouTube video</a> sharing the experiences of participants who took part in the study. A <a href="https://www.podcasts.ox.ac.uk/march-2024-ian-pope" target="_blank" rel="noreferrer noopener">podcast</a> detailing the findings of the study. A related paper from the same research group: Ward E, and others. <a href="https://doi.org/10.1111/add.16633" target="_blank" rel="noreferrer noopener">How do people quit smoking using e-cigarettes? A mixed-methods exploration of participant smoking pathways following receiving an opportunistic e-cigarette-based smoking cessation intervention</a>. Addiction 2024; 10.1111/add.16633. An NIHR news story based on this study: <a href="https://www.nihr.ac.uk/news/handing-out-vapes-in-aande-helps-smokers-quit/35790" target="_blank" rel="noreferrer noopener">Handing out vapes in A&E helps smokers quit</a> Funding: <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-technology-assessment.htm" target="_blank" rel="noreferrer noopener">NIHR Health Technology Assessment Commissioned Call</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1136/emermed-2023-213824" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Can peer support workers benefit mental health services?</title> <link>https://evidence.nihr.ac.uk/alert/can-peer-support-workers-benefit-mental-health-services/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 10 Oct 2024 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64594</guid> <description><![CDATA[Peer support workers use their lived experience of mental health difficulties (such as anxiety, psychosis or substance abuse) to support service users or carers. A review of the best available evidence found that peer support could aid recovery, depression (particularly perinatal depression), and self-belief. It found that service users valued peer support workers, and that ...]]></description> <content:encoded><![CDATA[ Peer support workers use their lived experience of mental health difficulties (such as anxiety, psychosis or substance abuse) to support service users or carers. A review of the best available evidence found that peer support could aid recovery, depression (particularly perinatal depression), and self-belief. It found that service users valued peer support workers, and that peer support workers themselves had improved wellness and recovery. However, peer support workers needed: <ul class="wp-block-list"> <li>more clarity about their role</li> <li>better training, supervision and pay.</li> </ul> Although the included evidence was of low quality, the researchers hope their findings will help commissioners considering implementing this service. <a href="https://www.hee.nhs.uk/our-work/mental-health/new-roles-mental-health/peer-support-workers" target="_blank" rel="noreferrer noopener">More information about peer support workers can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-how-can-peer-support-in-mental-health-work-better">The issue: how can peer support in mental health work better?</h2> <a href="https://www.healthcareers.nhs.uk/explore-roles/psychological-therapies/roles-psychological-therapies/peer-support-worker" target="_blank" rel="noreferrer noopener">Peer support workers</a> draw on their own experiences to support users of mental health services or their carers. They may be former service users or carers. Peer support has historically been voluntary and unpaid but is now being incorporated into the structure of mental health services. The <a href="https://www.hee.nhs.uk/sites/default/files/documents/NHS Peer Support Worker Benchmarking report.pdf" target="_blank" rel="noreferrer noopener">numbers of peer support workers</a> employed by NHS England increased from 48 in 2016, to 862 in 2019. Peer support workers share coping strategies with people with mental health problems, and aim to provide hope and an example of recovery. Peer support might be provided in one-to-one or group sessions, online or face-to-face. Group sessions can be informal (crafts, gardening, walking or other activities) or formal (structured support in perinatal mental health, for instance). The researchers aimed to provide clinicians, policymakers and researchers with an assessment of peer support: its effectiveness, experiences, and what influences its implementation. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The analysis was based on 35 reviews of paid peer support interventions in mental health. Each review included between 95 and 40,927 participants. Most reviews were low or very low quality; only 1 was high quality. <h3 class="wp-block-heading" class="wp-block-heading" id="how-effective-is-peer-support">How effective is peer support?</h3> In 23 reviews, the effectiveness of peer support was mixed; many reviews showed no effect. There was some evidence that it may reduce perinatal depression, reduce hospitalisation in severe mental illness, improve confidence and help people live fulfilling lives even if they still have mental health symptoms. The few reviews (4) that reported on cost, suggested that peer support was low cost and potentially cost-saving. <h3 class="wp-block-heading" class="wp-block-heading" id="what-helps-implement-peer-support">What helps implement peer support?</h3> The 9 reviews on implementation suggested that successful peer support services: <ul class="wp-block-list"> <li>are co-designed with people with lived experience</li> <li>have clear job descriptions and guidelines for peer support workers</li> <li>offer appropriate training, supervision and pay for peer support workers</li> <li>focus on helping people live fulfilling lives even when they have mental health symptoms (<a href="https://www.hra.nhs.uk/planning-and-improving-research/application-summaries/research-summaries/implementation-of-recovery-oriented-practice-in-mental-health-services/" target="_blank" rel="noreferrer noopener">a recovery-oriented approach</a>) rather than tackling symptoms alone</li> <li>have receptive leadership, and a supportive and trusting workplace culture, with effective collaboration between peer support workers and non-peer staff.</li> </ul> <h3 class="wp-block-heading" class="wp-block-heading" id="how-do-people-experience-peer-support">How do people experience peer support?</h3> In 11 reviews, people described the benefits and challenges of peer support. Peer support workers said their role improved their own wellness, recovery, self-esteem, personal growth and social connections. Some used the role as a route back to employment. Service users valued peer support workers’ lived experience of mental health problems. They felt that peer support workers had more empathy than other staff, and gave service users hope of recovery. However, the role lacked clarity, which made peer support workers uncertain about when they could disclose their personal experiences to service users. Pay was often low; some felt undervalued. Some service users lacked trust in peer support workers’ knowledge because of the lack of formal training. While some peer support workers felt accepted within teams, others experienced negative attitudes from non-peer staff. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> This is one of the largest reviews of peer support to date. Many peer support workers found their role enjoyable, and said that it helped their own recovery. They were valued by service-users. This research provides insights on how to implement the role successfully. This research, which summarised reviews of peer support, was based on the best evidence available, but that evidence is low quality. Control groups varied across studies (usual care, active controls and waiting list controls), and some research was old (from before 1980). More research is needed; but the <a href="https://www.tandfonline.com/doi/full/10.1080/09638237.2024.2332798" target="_blank" rel="noreferrer noopener">varied nature of peer support makes it challenging to evaluate the role</a>. Barriers to successful implementation of peer support workers included a lack of time, resources, training certification and appropriate funding. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> <a href="https://imroc.org/" target="_blank" rel="noreferrer noopener">ImROC</a> (Implementing Recovery through Organisational Change), an organisation that supports peer support implementation, recommends training and ongoing professional development. The findings of this review are in line with ImROC’s recommendations. The researchers say formal career pathways for peer support workers might address some barriers to implementation of the role, but these pathways are still in early development. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Cooper R, and others. <a href="https://doi.org/10.1186/s12916-024-03260-y" target="_blank" rel="noreferrer noopener">The effectiveness, implementation, and experiences of peer support approaches for mental health: a systematic umbrella review</a>. BMC Medicine 2024; 22. A <a href="https://evidence.nihr.ac.uk/collection/mental-health-crises-how-to-improve-care/">webinar Collection from NIHR Evidence</a> about mental health crisis. A <a href="https://www.ucl.ac.uk/psychiatry/peer-support-session" target="_blank" rel="noreferrer noopener">panel discussion</a> about the paper by the authors. Guidelines for peer support workers for the <a href="https://www.peersupportworks.org/wp-content/uploads/2021/02/nationalguidelines_updated.pdf" target="_blank" rel="noreferrer noopener">UK</a> and the <a href="https://tucollaborative.org/wp-content/uploads/Action-Agenda_Final-corrected.pdf" target="_blank" rel="noreferrer noopener">US</a>. Funding: This study was funded by the <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/policy-research.htm" target="_blank" rel="noreferrer noopener">NIHR Policy Research Programme</a>. Conflicts of Interest: One of the study authors is the director of a consultancy company that provides peer support training and consultancy. See <a href="https://bmcmedicine.biomedcentral.com/articles/10.1186/s12916-024-03260-y" target="_blank" rel="noreferrer noopener">paper</a> for full details. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Schoolchildren with asthma face different risks at different ages</title> <link>https://evidence.nihr.ac.uk/alert/schoolchildren-with-asthma-face-different-risks-at-different-ages/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 08 Oct 2024 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64276</guid> <description><![CDATA[A study of more than 119,000 school-aged children compared the features of asthma at different ages. They found that: The findings suggest that a child's age could inform treatment and management strategies, including advice on avoiding triggers and weight management. More information on asthma can be found on the NHS website. The issue: does a ...]]></description> <content:encoded><![CDATA[ A study of more than 119,000 school-aged children compared the features of asthma at different ages. They found that: <ul class="wp-block-list"> <li>children aged 5 to 8 years were most at risk of having an asthma attack; this group was also most likely to have a delayed diagnosis</li> <li>children aged 9 years and over were more likely to have an attack if they were obese or sensitised to air particles (such as pollen)</li> <li>young people aged 12 to 16 years were most likely to be potentially under-treated; 1 in 5 used short-acting relievers only for 2 years.</li> </ul> The findings suggest that a child's age could inform treatment and management strategies, including advice on avoiding triggers and weight management. <a href="https://www.nhs.uk/conditions/asthma/" target="_blank" rel="noreferrer noopener">More information on asthma can be found on the NHS website</a>. <section class="guten-block block-wysiwyg has-background has-pastel-orange-background-color has-border has-text-color has-blue-color has-padding has-padding-none" > <div class="row"> <div class="columns small-12 large-8"> <div>UPDATE (04/12/2024): This summary was updated on publication of new <a href="https://www.nice.org.uk/guidance/ng245/chapter/Recommendations" target="_blank" rel="noopener">NICE guidelines</a>.</div> </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-does-a-childs-age-matter-in-the-diagnosis-and-management-of-asthma">The issue: does a child’s age matter in the diagnosis and management of asthma?</h2> More than <a href="https://www.england.nhs.uk/childhood-asthma/" target="_blank" rel="noreferrer noopener">1 million children are being treated for asthma in the UK</a>. The main treatments are short-acting relievers, which open airways and relieve asthma attacks; and long-acting preventers, which reduce inflammation in the lungs and prevent attacks.    Asthma is treated differently in children aged 1 to 5 compared with older children (such as the medications they can be offered). <a href="https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/" target="_blank" rel="noreferrer noopener">British Thoracic Society guidelines</a> separate children aged 5 – 11 years from adolescents. However, until a <a href="https://www.nice.org.uk/guidance/ng245/chapter/Recommendations" target="_blank" rel="noreferrer noopener">recent update</a>, National Institute for Health and Care Excellence (NICE) guidelines on the management of asthma were similar for younger (5 to 11 years) and older children (12 to 16 years). These age groups are considered separately in the updated version (in which children 12 years and older are included alongside adults). Children’s growth and development could change the nature of asthma; a child’s age might also change how healthcare professionals help them manage their condition. Researchers therefore assessed the features of asthma, including its management and the risk of asthma attacks, in different age groups. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Researchers analysed the medical records (from primary and secondary care) of 119,611 children with asthma in England from 2004 to 2021. The study included 61,940 children aged 5 to 8 years; 32,316 aged 9 to 11 years; and 25,355 young people aged 12 to 16 years. They were followed up until they entered the next age group, or to the end of the study. The study looked at how asthma and related conditions changed with age, including how likely participants were to have an asthma attack, or to have a delayed diagnosis (which the researchers defined as receiving asthma treatments before they received a diagnosis of asthma). The study found that: <ul class="wp-block-list"> <li>5 – 8 year olds were most likely to have an asthma attack (14% of these children had an attack in every whole year, compared to 7% among 12 – 16-year-olds)</li> <li>delayed diagnosis was most common in the youngest children</li> <li>young people aged 12 – 16 years were least likely to receive both long-acting preventers and short-acting relievers; 1 in 5 used short-acting relievers only for 2 years.</li> </ul> For children of all ages, being from a more deprived area and having a delayed diagnosis increased the risk of an asthma attack. Other risk factors varied with age. Compared with the other age groups: <ul class="wp-block-list"> <li>5 – 8 year olds were more likely to have an asthma attack if they were male, had eczema or food and drug allergies</li> <li>those aged 9 and above were more likely to have an asthma attack if they were obese or allergic to air particles. </li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The findings imply that childhood asthma could be diagnosed and managed more effectively. Better understanding of the impact of age could increase diagnoses and improve treatment choices for all. For example, younger children may need more help preventing asthma attacks. Young people aged 12 to 16 may need a medicine review to ensure they are using both short-term relievers and long-term preventers. Some might also benefit from help with weight management as being overweight can increase the chance of an attack. Fewer than half (40%) of the children had a recorded body mass index (BMI) in this study; the researchers call for BMIs to be recorded routinely in asthma consultations. In all ages, delayed diagnoses were linked with asthma attacks, but this was particularly common in the youngest group. Early diagnosis gives children access to annual reviews, an asthma management plan, and resources to learn about their condition.   <a href="https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma" target="_blank" rel="noreferrer noopener">British Thoracic Society guidelines on the management of asthma</a> were updated in 2016. In this long-term study, most data were from before 2016, which could explain why some children received short-acting relievers only for extended periods. This is no longer recommended. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> <a href="https://www.nice.org.uk/guidance/ng245/chapter/Recommendations" target="_blank" rel="noreferrer noopener">Updated NICE guidelines</a> on the management of asthma now consider children aged 5 – 11 separately from those aged 12 and above. <a href="https://www.brit-thoracic.org.uk/quality-improvement/guidelines/asthma/" target="_blank" rel="noreferrer noopener">British Thoracic Society guidelines issued in 2016</a> stated that people using short-term relievers regularly should also use long-term preventers. One approach to this is known as maintenance and reliever therapy (MART); this was recommended to adults with a history of asthma attacks on medium dose inhaled corticosteroids (long-acting preventers). It is now recommended as part of the treatment pathway in the 2024 NICE guidelines for children aged 5 and older. However, MART is not licenced for children under 12 years old, so this use would be off-label. The researchers call for trials to test its safety and effectiveness in younger children. They also call for trials to consider narrower age categories for children with asthma. In <a href="https://doi.org/10.1016/j.chest.2024.10.036" target="_blank" rel="noreferrer noopener">further research among children with asthma</a>, the same team found that less than half received the recommended asthma reviews, inhaler technique checks, and asthma management plans. Children who received all of these interventions had a reduced chance of an asthma exacerbation (reduction of approximately 30% in 12 months). <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Khalaf Z, and others. <a href="https://doi.org/10.1136/thorax-2023-220603" target="_blank" rel="noreferrer noopener">Influence of age on clinical characteristics, pharmacological management and exacerbations in children with asthma</a>. Thorax 2024; 79: 112 – 119. Information and support from <a href="https://www.asthmaandlung.org.uk/" target="_blank" rel="noreferrer noopener">Asthma and Lung UK</a>. Facts on childhood asthma from the <a href="https://stateofchildhealth.rcpch.ac.uk/evidence/long-term-conditions/asthma/" target="_blank" rel="noreferrer noopener">Royal College of Paediatrics and Child Health</a>. A video on <a href="https://www.youtube.com/watch?v=AjjVAgAfnGY" target="_blank" rel="noreferrer noopener">spotting the signs of childhood asthma</a>.   Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=Asthma&location=" target="_blank" rel="noreferrer noopener">NIHR research on asthma</a>. Funding: This study was funded by the <a href="https://imperialbrc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Imperial Biomedical Research Centre</a>. Conflicts of Interest: None declared. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>How best to deliver cognitive remediation as an early intervention in psychosis?</title> <link>https://evidence.nihr.ac.uk/alert/how-best-to-deliver-cognitive-remediation-as-an-early-intervention-in-psychosis/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 03 Oct 2024 07:53:53 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64485</guid> <description><![CDATA[Cognitive remediation aims to help people with psychosis improve their cognitive abilities (such as problem-solving) and daily function, so that they can maintain a job and relationships, for example. National Institute for Health and Care Excellence (NICE) guidelines recommend cognitive remediation for psychosis which is severe and resistant to other approaches (complex psychosis), but not ...]]></description> <content:encoded><![CDATA[ Cognitive remediation aims to help people with psychosis improve their cognitive abilities (such as problem-solving) and daily function, so that they can maintain a job and relationships, for example. <a href="https://www.nice.org.uk/guidance/ng181/chapter/Recommendations" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence (NICE) guidelines</a> recommend cognitive remediation for psychosis which is severe and resistant to other approaches (complex psychosis), but not yet for people with early psychosis.  Among people with early psychosis, researchers compared group delivery of cognitive remediation with 1-to-1 sessions. They found that both approaches were more effective in the short-term than treatment as usual and offered good value for money. The findings suggest that cognitive remediation, delivered either via groups or 1-to-1 sessions, is effective and cost-effective as an early intervention in psychosis. <a href="https://www.nhs.uk/mental-health/conditions/psychosis/overview/" target="_blank" rel="noreferrer noopener">More information on psychosis can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-is-1-to-1-or-group-cognitive-remediation-best-for-psychosis">The issue: is 1-to-1 or group cognitive remediation best for psychosis?</h2> People with psychosis lose some contact with reality. They might see or hear things that do not exist (hallucinations) or have an unshakeable belief in something untrue (delusion). Most people with a diagnosis of psychosis also have cognitive problems (such as poor memory or problem-solving skills) that interfere with their recovery and with achieving personal goals. <a href="https://www.england.nhs.uk/south/our-work/mental-health/early-intervention-in-psychosis/" target="_blank" rel="noreferrer noopener">Early Intervention in Psychosis services</a> support people who are at risk of, or who have had a first episode of psychosis. <a href="https://www.rethink.org/campaigns-and-policy/campaign-with-us/resources-and-reports/briefing-early-intervention-in-psychosis-eip/" target="_blank" rel="noreferrer noopener">Intervening early can improve people’s long-term outcomes</a>, and, for example, improve physical health and educational performance. The service aims to improve <a href="https://orygen.org.au/Training/Resources/Psychosis/Manuals/Keeping-on-Track-Functional-Recovery-in-Early-Psy" target="_blank" rel="noreferrer noopener">functional recovery</a> (the ability to carry out everyday tasks or achieve personal goals) as well as preventing relapse. Improved cognitive skills allow people to achieve their goals. In cognitive remediation, a therapist works with someone with psychosis to improve their cognitive and meta-cognitive skills (thinking about thinking, which includes attention, memory, and planning). The therapy helps people translate these skills to everyday life to achieve their recovery goals (such as staying in work or education). In this study, researchers compared cognitive remediation delivered individually, in group sessions or carried out independently. They wanted to identify which approach was most effective and offered better value for money. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers invited people with first episode psychosis (aged 16 to 45) from 11 Early Intervention for Psychosis services in England. Most participants (73%) were men, and their average age was 26 years. All participants received standard care, which involves education and employment support, along with medication. Some received cognitive remediation, in addition. Cognitive remediation was delivered digitally using <a href="https://www.circuitstherapyinfo.com/" target="_blank" rel="noreferrer noopener">CIRCuiTSTM</a>. This therapy programme sets exercises and real-life tasks to help people learn strategies and practice using new cognitive and metacognitive skills to solve problems. A trained therapist provided different levels of support. The study compared groups who received standard care plus:   <ul class="wp-block-list"> <li>cognitive remediation in 1-to-1 sessions with a therapist twice weekly for 10 and a half weeks (112 people)</li> <li>cognitive remediation in group sessions 3 times weekly for 12 weeks, in groups of up to 4 (134 people)</li> <li>cognitive remediation independently with access to a therapist for up to half an hour per week for 12 weeks (65 people)</li> <li>no extra intervention (66 people).</li> </ul> The primary outcome at 15 weeks was functional recovery: participants rated how successfully they had met personal goals such as returning to work or education. At 15 weeks, functional recovery: <ul class="wp-block-list"> <li>was better among those who received cognitive remediation in 1-to-1 or group sessions than among those who received standard care  </li> <li>was similarly improved among people who had 1-to-1 versus group sessions</li> <li>was no better among people who had cognitive remediation delivered independently, compared with those who received standard care alone.</li> </ul> At 6 months, there was no difference in functional recovery between those who had cognitive remediation (1-to-1 and group session combined average score) and those who had standard care.   Cognitive remediation cost slightly more than standard care. The cost of an extra quality-adjusted life-year (equivalent to 1 year in perfect health) was £4,306 extra for group and £3,170 more for 1-to-1 cognitive remediation sessions, compared with treatment as usual. Calculations were based on <a href="https://www.england.nhs.uk/publication/nhs-improvement-annual-report-and-accounts-2018-19/" target="_blank" rel="noreferrer noopener">2018</a> to <a href="https://www.pssru.ac.uk/project-pages/unit-costs/unit-costs-2020/" target="_blank" rel="noreferrer noopener">2020</a> figures. Adverse events were similar between groups and there were no serious adverse events related to cognitive remediation. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> Cognitive remediation helped people achieve personal goals and offered value for money for those with first-episode psychosis. It could be delivered in 1-to-1 sessions or in a group. Both approaches had similar costs for the extra quality-adjusted life years, below the NICE threshold for new therapies (£20,000), meaning both are likely to be cost-effective. The impact of cognitive remediation on functional recovery declined over time. People were initially less enthusiastic about group sessions, but once they engaged with the therapy, they found both approaches acceptable. However, overall, the independent delivery group did not engage sufficiently with cognitive remediation for it to be any more effective than standard care alone. Full attendance was low. Most participants received 1 therapy session (93%). Those who failed to attend 6 sessions (38% for groups; 23% for 1-to-1 sessions) were considered to have dropped out. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> In further research, the team found that <a href="https://doi.org/10.1016/j.schres.2024.04.001" target="_blank" rel="noreferrer noopener">remote delivery of cognitive remediation for people with psychosis using CIRCuiTSTM was acceptable and convenient</a>; the authors concluded that it may help people continue with treatment. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Wykes T, and others. <a href="https://doi.org/10.1093/schbul/sbac214" target="_blank" rel="noreferrer noopener">Cognitive Remediation Works But How Should We Provide It? An Adaptive Randomized Controlled Trial of Delivery Methods Using a Patient Nominated Recovery Outcome in First-Episode Participants</a>. Schizophrenia Bulletin 2023; 49: 614 – 625. <a href="https://www.youtube.com/watch?v=Tvo_Ycrjwlw" target="_blank" rel="noreferrer noopener">A video explaining cognitive remediation and the Circuits app</a>. A larger report on the study’s findings: Wykes T, and others. <a href="https://www.journalslibrary.nihr.ac.uk/pgfar/LMFP9667/#/abstract" target="_blank" rel="noreferrer noopener">Cognitive remediation therapy to enhance cognition and improve recovery in early psychosis: the ECLIPSE research programme including an RCT</a>. Programme Grants for Applied Research 2024; 12: 1 – 84.  <a href="https://www.circuitstherapyinfo.com/" target="_blank" rel="noreferrer noopener">Information on the cognitive remediation software used in this study</a>. <a href="https://www.mind.org.uk/information-support/types-of-mental-health-problems/psychosis/useful-contacts/" target="_blank" rel="noreferrer noopener">Contacts for support with psychosis</a>. Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=Psychosis&location=" target="_blank" rel="noreferrer noopener">NIHR research on psychosis</a>. Funding: This study was funded by funded by an <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/programme-grants-for-applied-research.htm" target="_blank" rel="noreferrer noopener">NIHR Applied Programme Grant</a> and the <a href="https://www.maudsleybrc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">NIHR Maudsley Biomedical Research Centre</a>. Conflicts of Interest: Til Wykes and Clare Reeder developed a cognitive remediation software used in this study. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>How to make remote consultations safer</title> <link>https://evidence.nihr.ac.uk/alert/how-to-make-remote-consultations-safer/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 01 Oct 2024 08:05:32 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64497</guid> <description><![CDATA[Remote consultations by telephone or video have become common in primary care. Researchers assessed the safety of remote consultations (including NHS 111); they found 95 safety incidents across the UK between 2015 and 2023. Researchers interviewed and observed GP staff, and made suggestions to improve the safety of remote consultations. They say it is important ...]]></description> <content:encoded><![CDATA[ Remote consultations by telephone or video have become common in primary care. Researchers assessed the safety of remote consultations (including NHS 111); they found 95 safety incidents across the UK between 2015 and 2023. Researchers interviewed and observed GP staff, and made suggestions to improve the safety of remote consultations. They say it is important to give clear advice about what to do if symptoms do not improve, and suggest that remote consultations should not be offered: <ul class="wp-block-list"> <li>for some conditions (breathing problems, new psychosis, or acute chest or stomach pain, for example)</li> <li>when a parent is very concerned about a child</li> <li>when a condition has not resolved as expected or has worsened after a previous remote consultation</li> <li>to people who might struggle to understand or be understood (such as those with limited English or learning difficulties).</li> </ul> The team suggests ways to make remote consultations safer and more effective. <a href="https://www.england.nhs.uk/long-read/remote-consulting/" target="_blank" rel="noreferrer noopener">More information about remote consultations can be found on the NHS England website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-are-remote-consultations-safe">The issue: are remote consultations safe?</h2> Remote consultations allow people to consult clinicians without leaving home. Providing remote clinical care and triage (determining the urgency of a condition) can help staff meet rising demand, and be <a href="https://www.gmc-uk.org/professional-standards/learning-materials/remote-prescribing-high-level-principles" target="_blank" rel="noreferrer noopener">convenient for patients</a>. Media stories have linked avoidable deaths and missed cancers with remote consultations. Researchers investigated safety incidents associated with remote consultations, and made suggestions about how to improve safety. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> Safety incidents from remote primary care consultations are rare: 95 across the UK between 2015 and 2023. Researchers analysed these incidents via 100 formal interviews and numerous on-the-job interviews with practice staff, plus interviews with 10 GP trainers, 10 GP trainees, and 6 clinical safety experts (from Government, arm’s length bodies and health boards). Safety incidents led to harm or serious risk of harm; examples included missed or delayed diagnoses, underestimation of severity or urgency and incorrect or delayed treatment. Serious harm was most often caused by a combination of inappropriate consultation type, poor relationship building, limited information gathering, limited physical assessment, wrong choice of clinical pathway and failure to consider social circumstances. The researchers suggested that remote consultations are not appropriate: <ul class="wp-block-list"> <li>for conditions that require physical examination or tests (including breast lump, breathing difficulties, sudden chest or stomach pain)</li> <li>when conditions have not resolved as expected (including increased parental concern about a child)</li> <li>for people who might struggle with telephone or video communication (including those with limited English or learning difficulties, or people with multiple conditions and complex needs).</li> </ul> Practical suggestions for primary care could be to: <ul class="wp-block-list"> <li>use video calls instead of audio calls if a clinician has a hunch that the patient might be very unwell, and arrange for a physical examination if indicated</li> <li>provide effective safety-netting verbally and in writing (this could be through a text or email), including next steps for the patient if their condition worsens or doesn’t resolve as expected</li> <li>adopt organisation and system-level measures (adequate staffing, staff training and improved continuity of care for vulnerable people with complex needs).</li> </ul> Patients and carers could: <ul class="wp-block-list"> <li>think about how to clearly describe symptoms before the appointment, even if they have previously described them to a clinician</li> <li>consider having someone else present for the appointment to help them explain the problem</li> <li>ask what happens after the appointment and what to do if symptoms do not improve.</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> These findings could improve patient safety and support clinicians in remote consultations. Staff could benefit from training on effective use of the telephone. Creative and flexible actions by staff (adapting standard procedures to take account of patients’ unique needs) can help reduce safety incidents, the researchers say. The safety incidents analysed in this study included deaths and serious harm. The researchers had limited data on less serious incidents, which were less likely to be reported. The findings do not directly compare the safety of different consultation types. It is not possible to say that a remote consultation caused harm, since in some cases a face-to-face consultation could have led to the same outcome. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> Since the findings were published, the researchers have worked with members of the public to develop <a href="https://www.phc.ox.ac.uk/files/resources/how-to-get-the-most-out-of-your-telephone-appointment.jpg" target="_blank" rel="noreferrer noopener">resources</a> detailing the steps people can take to get the safest care. They have delivered national training sessions and <a href="https://resolution.nhs.uk/2024/02/16/learning-from-remote-consultations-in-general-practice/" target="_blank" rel="noreferrer noopener">produced guidance</a> with NHS Resolution in England and GP education events in Northern Ireland. With research partner The Nuffield Trust, they have produced a <a href="https://www.nuffieldtrust.org.uk/resource/getting-the-best-out-of-the-new-world-of-remote-and-digital-general-practice" target="_blank" rel="noreferrer noopener">policy brief</a> which includes advice on making remote consultations safer. The researchers are working with the Royal College of General Practitioners Wales and Scotland to create resources for the parliaments of the devolved nations. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Payne R, and others. <a href="https://doi.org/10.1136/bmjqs-2023-016674" target="_blank" rel="noreferrer noopener">Patient safety in remote primary care encounters: multimethod qualitative study combining Safety I and Safety II analysis</a>. BMJ Quality and Safety 2023;0:1–14.  A <a href="https://www.youtube.com/watch?v=iwL7q4WylXs&t=17s" target="_blank" rel="noreferrer noopener">webinar summarising the findings of this study</a>, as well as the broader project it was part of, Remote by Default 2. An <a href="https://evidence.nihr.ac.uk/alert/safety-netting-in-general-practice-manage-uncertain-diagnoses/">NIHR Evidence summary</a> about safety-netting in primary care. Information from the <a href="https://www.gmc-uk.org/professional-standards/ethical-hub/remote-consultations" target="_blank" rel="noreferrer noopener">General Medical Council</a> about when it is safe to prescribe during a remote consultation. Information from the <a href="https://elearning.rcgp.org.uk/mod/page/view.php?id=10812" target="_blank" rel="noreferrer noopener">Royal College of General Practitioners</a> for GPs about remote consultations. A paper exploring the use of video consultations in urgent primary care settings: Payne RE, Clarke A. <a href="https://doi.org/10.3399/BJGPO.2023.0025" target="_blank" rel="noreferrer noopener">How and why are video consultations used in urgent primary care settings in the UK? A focus group study</a>. British Journal of General Practice Open 2023; 7. Funding: This study was funded by the <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-and-social-care-delivery-research.htm" target="_blank" rel="noreferrer noopener">NIHR Health and Social Care Delivery Research</a>. Conflicts of Interest: No relevant conflicts were declared. Full disclosures are available on the <a href="https://doi.org/10.1136/bmjqs-2023-016674" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Is the NHS Health Check improving our population’s health?</title> <link>https://evidence.nihr.ac.uk/alert/is-the-nhs-health-check-improving-our-populations-health/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Thu, 26 Sep 2024 08:00:37 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=63380</guid> <description><![CDATA[This study found that the NHS Health Check is reducing cardiovascular diseases and improving prevention of other diseases through early detection and timely intervention. Researchers compared the health records of nearly 50,000 people who had an NHS Health Check, with a similar number, matched according to their health, who did not. During follow up (of ...]]></description> <content:encoded><![CDATA[ This study found that the NHS Health Check is reducing cardiovascular diseases and improving prevention of other diseases through early detection and timely intervention. Researchers compared the health records of nearly 50,000 people who had an NHS Health Check, with a similar number, matched according to their health, who did not. During follow up (of 9 years on average), those who attended the check had a lower risk of: <ul class="wp-block-list"> <li>dementia</li> <li>heart attack</li> <li>death.</li> </ul> The researchers suggest that the checks allow for one-to-one review of health behaviours, and earlier identification and treatment of underlying conditions. They say there is a need to encourage more people to attend and engage with these appointments. <a href="https://www.nhs.uk/conditions/nhs-health-check/" target="_blank" rel="noreferrer noopener">More information on NHS Health Checks can be found on the NHS website</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-do-nhs-health-checks-improve-health-in-the-long-term">The issue: do NHS Health Checks improve health in the long term?</h2> The NHS Health Check programme aims to prevent conditions such as heart attack and stroke. The checks are for people in England aged 40 - 74 who do not have pre-existing conditions. They are carried out every 5 years in primary care and include blood tests and questions about health habits. People are given advice and/or treatment according to their assessed risk and NICE guidelines. In this study, researchers assessed how effectively NHS Health Checks prevent diseases in the longer-term.  <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers assessed health records of people from the UK Biobank: 48,602 people who had an NHS Health Check (or the Scottish equivalent, <a href="https://www.healthscotland.com/keep-well.aspx" target="_blank" rel="noreferrer noopener">Keep Well</a>) with the same number who did not. People were matched according to age, sex, other health factors (such as smoking status and alcohol intake) and deprivation. Most were women (59%) and white (96%); they were followed up for 9 years on average. In line with previous research, diagnoses of diabetes, high blood pressure and cholesterol were higher in the group that had the check than the group that did not in the 1-2 years after the check.   Overall, compared with the group that did not, those who had a health check had lower rates of: <ul class="wp-block-list"> <li><a href="https://www.nhs.uk/conditions/atrial-fibrillation/" target="_blank" rel="noreferrer noopener">atrial fibrillation</a> (irregular, often fast heart rate; 9% lower)</li> <li>dementia (19% lower)</li> <li>heart attack (15% lower)</li> <li><a href="https://www.nhs.uk/conditions/acute-kidney-injury/#:~:text=Acute%20kidney%20injury%20(AKI)%20is,as%20the%20name%20might%20suggest." target="_blank" rel="noreferrer noopener">acute kidney problems</a> (23% lower)</li> <li><a href="https://www.nhs.uk/conditions/cirrhosis/#:~:text=Cirrhosis%20is%20scarring%20(fibrosis)%20of,the%20liver%2C%20such%20as%20hepatitis." target="_blank" rel="noreferrer noopener">liver cirrhosis</a> (44% lower)</li> <li>death (23% lower).</li> </ul> <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> The NHS Health Check was linked with a reduced risk of death and illness in the longer-term. Diagnoses of high blood pressure and cholesterol were higher in the group that had the check in the first 2 years. These conditions do not have symptoms in their early stages and may have been picked up only because of the check. Similarly, the reduced risk of liver cirrhosis could be because people who attend health checks are more likely to have their liver function tested with a simple blood test. Identifying conditions early can trigger behaviour change or medications that preserve health longer and thereby reduce the risk of more serious conditions in later years. This may explain the better health of the group that had the check. In addition, the check establishes a relationship between clinicians and patients and allows for more careful monitoring of existing and potential health issues over time. This database study shows a link between attending NHS Health Check and an improvement in health; it does not prove that the Health Check itself caused the improvement. Findings are based on data from the UK Biobank whose participants are overall healthier and wealthier than the rest of the population. Also, most participants in the study were White British. The findings may therefore not be fully generalisable to the whole population or to people of other ethnicities. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> <a href="https://doi.org/10.1136/bmjopen-2021-052832" target="_blank" rel="noreferrer noopener">Almost half (46%) of those invited for an NHS Health Check, attend</a>. The researchers say there is a need to encourage more people to attend these appointments and for support to be provided to those who would benefit. This is particularly important for those in less wealthy areas. They hope their findings are used in public health campaigns about the importance of the checks. In a <a href="https://doi.org/10.1136/bmjebm-2023-112518" target="_blank" rel="noreferrer noopener">related study</a>, the data collected in the NHS Health Check was used to assess the risk of 10 diseases, such as dementia and heart failure, rather than the single cardiovascular risk score currently generated from the check. The researchers are planning to validate their findings in a larger, nationally-representative database. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: McCracken C, and others. <a href="https://doi.org/10.1186/s12916-023-03187-w" target="_blank" rel="noreferrer noopener">NHS Health Check attendance is associated with reduced multiorgan disease risk: a matched cohort study in the UK Biobank</a>. BMC Medicine 2023; 22: 1 – 13.  Articles about this study from <a href="https://www.newscientist.com/article/2413550-do-routine-check-ups-actually-improve-our-health/" target="_blank" rel="noreferrer noopener">New Scientist</a>, <a href="https://www.thesun.co.uk/health/25449450/nhs-midlife-health-mot-reduce-risk-early-death-study/" target="_blank" rel="noreferrer noopener">The Sun</a>, and <a href="https://www.mirror.co.uk/news/health/free-nhs-health-check-offer-31952970" target="_blank" rel="noreferrer noopener">The Mirror</a>. Information on staying healthy from <a href="https://www.nhs.uk/live-well/" target="_blank" rel="noreferrer noopener">NHS Live Well</a>. A paper about the inequality of support people receive after an NHS Health Check: Duddy C, and others. <a href="https://doi.org/10.1136/bmjopen-2022-064237" target="_blank" rel="noreferrer noopener">Understanding what happens to attendees after an NHS Health Check: a realist review</a>. BMJ Open 2022; 12: e064237. Funding: This study was supported by the <a href="https://oxfordbrc.nihr.ac.uk/" target="_blank" rel="noreferrer noopener">Oxford NIHR Biomedical Research Centre</a> and the <a href="https://www.nihr.ac.uk/explore-nihr/academy-programmes/hee-nihr-integrated-clinical-and-practitioner-academic-programme.htm" target="_blank" rel="noreferrer noopener">NIHR Integrated Academic Training programme</a>. Conflicts of Interest: Several authors received fees and funding from pharmaceutical and biotechnology companies. Full disclosures are available on the <a href="https://doi.org/10.1186/s12916-023-03187-w" target="_blank" rel="noreferrer noopener">original paper</a>. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Is long COVID linked with orthostatic intolerance?</title> <link>https://evidence.nihr.ac.uk/alert/is-long-covid-linked-with-orthostatic-intolerance/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 24 Sep 2024 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64342</guid> <description><![CDATA[People with orthostatic intolerance may feel dizzy or weak when standing because of insufficient blood going to the brain and muscles. They may, as a result, have either a fast heartbeat or low blood pressure. Researchers found that, compared with healthy volunteers, people with long COVID were more likely to have: The researchers say people ...]]></description> <content:encoded><![CDATA[ People with orthostatic intolerance may feel dizzy or weak when standing because of insufficient blood going to the brain and muscles. They may, as a result, have either a fast heartbeat or low blood pressure. Researchers found that, compared with healthy volunteers, people with long COVID were more likely to have: <ul class="wp-block-list"> <li>previous symptoms of orthostatic intolerance</li> <li>symptoms such as dizziness or palpitations when standing up.</li> </ul> The researchers say people with long COVID would benefit from being tested for orthostatic intolerance.   The NHS website has more information on <a href="https://www.nhs.uk/conditions/postural-tachycardia-syndrome/" target="_blank" rel="noreferrer noopener">postural orthostatic tachycardia syndrome</a> and <a href="https://www.guysandstthomas.nhs.uk/health-information/postural-hypotension" target="_blank" rel="noreferrer noopener">postural hypotension</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="the-issue-how-common-is-orthostatic-intolerance-in-people-with-long-covid">The issue: how common is orthostatic intolerance in people with long COVID?</h2> Symptoms of orthostatic intolerance can occur when someone is standing and their blood pools in the lower limbs. As a result, they may have either an increased heart rate (postural orthostatic tachycardia syndrome) or a drop in blood pressure (postural hypotension). Symptoms include dizziness, fainting, nausea, palpitations, tremors and weakness. Studies suggest that <a href="https://doi.org/10.3390/healthcare10102105" target="_blank" rel="noreferrer noopener">many people with long COVID report symptoms of orthostatic intolerance</a>. This study aimed to find out how common these symptoms are among people with long COVID.   <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The study included 277 adults with long COVID from 8 long COVID clinics across the UK. They were compared to 50 healthy volunteers of similar age and sex. Most (63%) were women and their average age was 48 years. Participants were asked if they had experienced symptoms typical of orthostatic intolerance since contracting COVID-19. They also took a <a href="https://batemanhornecenter.org/wp-content/uploads/2016/09/NASA-Lean-Test-Instructions-1.pdf" target="_blank" rel="noreferrer noopener">NASA (National Aeronautics and Space Administration) Lean Test</a> at home or in the clinic. This test involves recording blood pressure, heart rate, and symptoms (of orthostatic intolerance) while lying down and then repeated at every minute of standing (against a wall) for up to 10 minutes. The researchers found that many people with long COVID had: <ul class="wp-block-list"> <li>a history of symptoms of orthostatic intolerance (47%)</li> <li>symptoms of orthostatic intolerance during the lean test (52%)</li> <li>standing fast heartbeat during the lean test (7%).</li> </ul> None of the healthy volunteers had any of these signs or symptoms. A similar proportion of people with long COVID (8%) and healthy volunteers (10%) had low blood pressure during the lean test. But while all of those with long COVID had symptoms, none of the healthy volunteers did. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> These findings confirm people with long COVID are more likely than others to have orthostatic intolerance, and that these problems are relatively common. About half of the people with long COVID and orthostatic intolerance had symptoms. The researchers say that many symptoms of long COVID (such as dizziness, chest pain, palpitations and cognitive impairment) are similar to those of orthostatic intolerance. Clinicians could therefore consider performing the lean test on everyone with long COVID, regardless of their symptoms, they say. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> As a result of this study, many long COVID clinics in the UK and elsewhere routinely carry out the lean test. The researchers say that everyone with long COVID, even those not attending clinics, would benefit from a lean test. It could ensure that they receive appropriate lifestyle advice and treatment, where necessary. The study showed that the test can be performed at home; this could make its widespread use feasible. This study was part of a larger study, <a href="https://locomotion.leeds.ac.uk/" target="_blank" rel="noreferrer noopener">LOCOMOTION</a>, which aimed to identify the best way to treat and support people with long COVID. The team have produced a <a href="https://locomotion.leeds.ac.uk/outputs/locomotion-webinar/" target="_blank" rel="noreferrer noopener">series of webinars presenting the findings of their studies</a>. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Lee C, and others. <a href="https://doi.org/10.1002/jmv.29486" target="_blank" rel="noreferrer noopener">Prevalence of orthostatic intolerance in long covid clinic patients and healthy volunteers: A multicenter study</a>. Journal of Medical Virology 2024; 96: 1 – 11.  Information and support for people with long COVID from <a href="https://www.bhf.org.uk/informationsupport/heart-matters-magazine/news/coronavirus-and-your-health/long-covid" target="_blank" rel="noreferrer noopener">The British Heart Foundation</a>. Information on checking people with long COVID for standing circulation problems: Espinosa-Gonzalez AB, and others. <a href="https://doi.org/10.1136/bmj-2022-073488" target="_blank" rel="noreferrer noopener">Orthostatic tachycardia after COVID-19</a>. The British Medical Journal 2023; 230: e073488. Information for GPs on caring for people with long COVID: Greenhalgh T, and others. <a href="https://doi.org/10.1136/bmj-2022-072117" target="_blank" rel="noreferrer noopener">Long covid—an update for primary care</a>. The British Medical Journal 2022; 378: e072117. Information on taking part in <a href="https://bepartofresearch.nihr.ac.uk/results/search-results?query=Long%20COVID&location=" target="_blank" rel="noreferrer noopener">NIHR research on long COVID</a>. Funding: This study was funded by an <a href="https://www.nihr.ac.uk/about-us/our-key-priorities/covid-19/researching-the-long-term-impact.htm" target="_blank" rel="noreferrer noopener">NIHR long COVID grant</a>. Conflicts of Interest: None relevant. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Dialysis for kidney failure: evidence to improve care</title> <link>https://evidence.nihr.ac.uk/collection/dialysis-for-kidney-failure-evidence-to-improve-care/</link> <dc:creator><![CDATA[lauren.hoskin@nihr.ac.uk]]></dc:creator> <pubDate>Wed, 18 Sep 2024 07:57:23 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=63287</guid> <description><![CDATA[In the UK, more than 3 million people live with moderate to severe chronic kidney disease (stages 3-5). People with the most severe disease have kidney failure; they have lost most (85-90%) of their kidney function.  To stay alive, people with kidney failure either need dialysis (regular treatment to filter waste products from the blood) ...]]></description> <content:encoded><![CDATA[ In the UK, more than <a href="https://www.kidneyresearchuk.org/wp-content/uploads/2023/06/Economics-of-Kidney-Disease-full-report_accessible.pdf" target="_blank" rel="noreferrer noopener">3 million people</a> live with moderate to severe <a href="https://www.nhs.uk/conditions/kidney-disease/" target="_blank" rel="noreferrer noopener">chronic kidney disease </a>(stages 3-5). People with the most severe disease have <a href="https://kidneycareuk.org/kidney-disease-information/stages-of-kidney-disease/stage-5-ckd5-kidney-disease/" target="_blank" rel="noreferrer noopener">kidney failure</a>; they have lost most (85-90%) of their kidney function.  To stay alive, people with kidney failure either need <a href="https://www.nhs.uk/conditions/dialysis/" target="_blank" rel="noreferrer noopener">dialysis</a> (regular treatment to filter waste products from the blood) or a <a href="https://www.nhsbt.nhs.uk/organ-transplantation/kidney/" target="_blank" rel="noreferrer noopener">kidney transplant</a>. <a href="https://ukkidney.org/sites/renal.org/files/UK%20Renal%20Registry%20Annual%20Report%202022%20Patient%20Summary.pdf" target="_blank" rel="noreferrer noopener">In 2022</a>, more than 70,000 adults in the UK were receiving these treatments, including more than 30,000 on dialysis. The risk of kidney failure <a href="https://ukkidney.org/sites/renal.org/files/Ethnicity%20Disparities%202023%20Final.pdf" target="_blank" rel="noreferrer noopener">varies with ethnicity</a>. Adults of Black, Asian or Mixed ethnicity are more likely to develop kidney failure, and at a younger age on average, than those of White ethnicity. People of Black and Mixed ethnicity are the youngest groups to start treatment. Dialysis is an intensive treatment that is burdensome for patients and those that care for them. It is associated with a particularly <a href="https://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1003954#sec027" target="_blank" rel="noreferrer noopener">poor quality of life</a>. Some frailer, usually elderly, people with kidney failure choose <a href="https://www.kidneyresearchuk.org/kidney-health-information/living-with-kidney-disease/care-and-treatments-for-people-with-kidney-failure/choosing-not-to-start-dialysis/" target="_blank" rel="noreferrer noopener">supportive care</a> to manage their symptoms rather than go through the rigours of dialysis.  <a href="https://www.kidneyresearchuk.org/wp-content/uploads/2023/06/Economics-of-Kidney-Disease-full-report_accessible.pdf" target="_blank" rel="noreferrer noopener">In 2023</a>, dialysis cost the NHS £1.05 billion, an estimated cost of £34,000 per year, per patient. <h2 class="wp-block-heading" class="wp-block-heading" id="what-is-dialysis">What is dialysis?</h2> <section class="guten-block block-wysiwyg has-background has-pastel-teal-background-color has-text-color has-blue-color" > <div class="row"> <div class="columns small-12 large-8"> <img loading="lazy" decoding="async" class="wp-image-63613 alignleft" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/07/What-is-dialysis-4.png" alt="What is dialysis?" width="190" height="380" /><a href="https://kidneycareuk.org/kidney-disease-information/kidney-conditions/kidney-failure/" target="_blank" rel="noopener">Dialysis</a> is a lifesaving treatment for kidney failure. It artificially removes waste products and unwanted water from your blood. You can choose between haemodialysis and peritoneal dialysis. <ul> <li>In haemodialysis your blood is washed through a machine, either in hospital or at home.</li> <li>In peritoneal dialysis, fluid is passed into your abdomen to draw waste products out of nearby blood vessels. When the fluid is removed, the waste goes with it. This is done at home.</li> </ul> Most people receiving dialysis (<a href="https://gettingitrightfirsttime.co.uk/wp-content/uploads/2021/09/Renal-Medicine-Sept21k.pdf" target="_blank" rel="noopener">nearly 90% in 2018</a>) have haemodialysis, usually in hospital or a specialist unit. This typically involves 3 visits a week for 4-hour sessions. Dialysis can have an enormous impact on quality of life for those undergoing treatment, and for their families and carers. “I actually view dialysis as work to some extent … I have at least 32 hours of obligations during the week … Altogether that’s 40 hours a week I spend on being sick. And then there’s not much time left for doing nice things.” (<a href="https://journals.sagepub.com/doi/10.1177/1359105319853340" target="_blank" rel="noopener">male, 58 years</a>) </div> </div> </section> <a href="https://www.kidneyresearchuk.org/wp-content/uploads/2019/02/Research-Strategy-Document.pdf" target="_blank" rel="noreferrer noopener">Kidney Research UK</a> highlights the need to transform treatment through research, to make ‘dialysis more tolerable, reduce the burden of treatment and monitoring, and improve quality of life for people living with kidney disease.’ The NIHR has invested in research to improve clinical outcomes for people receiving dialysis and value for money for the NHS. Research is exploring ways to increase dialysis at home rather than in hospital, reduce complications, improve heart health, and more. This Collection brings together examples of research, including both published and ongoing studies funded by the NIHR. Several had additional support from Kidney Research UK. The information presented is intended for healthcare professionals who care for people with, or at risk of kidney failure, and for those managing and commissioning services. <h2 class="wp-block-heading" class="wp-block-heading" id="1-dialysis-for-kidney-failure-what-does-research-tell-us">1. Dialysis for kidney failure: what does research tell us?</h2> <blockquote class="wp-block-quote is-style-plain is-layout-flow wp-block-quote-is-layout-flow"> “Dialysis is a gruelling treatment and it is only by research focusing on things that matter to patients that the quality of life of people with kidney failure requiring dialysis can be improved." </blockquote> Edwina Brown, Consultant Nephrologist and Professor of Renal Medicine, Imperial College Renal & Transplant Centre and Imperial College London <figure class="wp-block-image size-full"><img loading="lazy" decoding="async" width="1600" height="900" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/07/Research-tile-new-2.png" alt="" class="wp-image-63669"/></figure> Read on to find out about published NIHR research which could improve dialysis and related care. Click on each heading below for the evidence <section class="guten-block block-accordion "> <div class="row"> <div class="column small-12"> <div class="tabs"> <div class="tab"> <input type="checkbox" id="chck-block_d44999a9ac54a85f40c29b4046980480-1"> <label class="tab-label has-background has-pastel-teal-background-color has-text-color has-black-color" for="chck-block_d44999a9ac54a85f40c29b4046980480-1">People need support and education to choose home dialysis</label> <div class="tab-content"> “Having a treatment choice if your kidneys fail is a vital part of kidney care and being able to share the decision on where to and how to dialyse helps the person to feel a little more in control of their life.” Fiona Loud, Policy Director, <a href="https://www.kidneycareuk.org/" target="_blank" rel="noopener">Kidney Care UK</a> <a href="https://gettingitrightfirsttime.co.uk/wp-content/uploads/2021/09/Renal-Medicine-Sept21k.pdf" target="_blank" rel="noopener">Dialysis at home</a> can improve quality of life and independence, as well as offering good value for the NHS. <a href="https://ukkidney.org/sites/renal.org/files/UKKA%2026th%20Annual%20Report%20Chapter%203%20-%20Prevalence%20-%202024-07-07.pdf" target="_blank" rel="noopener">But in 2022</a>, an average of only 17% (1 in 6) of people in the UK had dialysis at home; this varied between 0%-34% depending on where people were treated. <a href="https://www.nice.org.uk/guidance/ng107/chapter/Recommendations#choosing-modalities-of-renal-replacement-therapy-or-conservative-management" target="_blank" rel="noopener">NICE guidance</a> recommends that people be offered a choice over where and what type of dialysis they have. NHS services aim to reduce the impact of cost on people’s choice. Those having home dialysis may be entitled to <a href="https://www.england.nhs.uk/wp-content/uploads/2018/08/Haemodialysis-to-treat-established-renal-failure-in-the-home.pdf" target="_blank" rel="noopener">help with the costs of running equipment at home</a>. Those treated in hospital or specialist units are offered <a href="https://www.england.nhs.uk/commissioning/spec-services/npc-crg/group-a/renal-services/transport-support-for-patients-attending-in-centre-haemodialysis/" target="_blank" rel="noopener">help with transport costs</a> to and from dialysis sessions. Recent research explored why people do not choose home dialysis, and what might help. The findings could inform shared decision making between doctors and their patients. <a href="https://bmjopen.bmj.com/content/14/2/e082386" target="_blank" rel="noopener">A study involving 1,707 patients</a> in Wales found that barriers to home dialysis include a lack of motivation and confidence in their ability to self-manage treatment, a lack of home support, and unsuitable housing. People who chose home dialysis were younger, had fewer additional conditions, were less frail and had higher quality of life scores. Only half of those who initially chose home dialysis, went on to receive it. Researchers found this was not associated with deprivation, age, gender, hospitalisation, travel time or other factors. Reasons included that patients had already received a transplant, that they changed their mind, or had a change in family circumstances. <a href="https://evidence.nihr.ac.uk/alert/why-dont-people-have-kidney-dialysis-at-home/" target="_blank" rel="noopener">In another study</a>, the same research team worked with people with kidney disease and their families (50 in all), 68 health and social care professionals, dialysis providers and kidney charities in Wales to explore barriers to home dialysis and how to overcome them. People with kidney disease were concerned about changes to their home, or of their family becoming carers. Hospital dialysis was often presented as ‘the norm’ by healthcare professionals, and some people welcomed the regular social contact at dialysis sessions. Suggested solutions included peer support from people who were themselves having dialysis and who could explain what home dialysis involves. The researchers say that people with kidney disease need better education materials. Professionals need to be more familiar with home dialysis and ready to discuss the impact of treatment on working, family and social life. Resources such as the <a href="https://kidneyresearchuk.org/wp-content/uploads/2019/05/KR-decision-Aid-DOWNLOAD.pdf" target="_blank" rel="noopener">Decision Aid Booklet</a> can help people make a decision about which dialysis treatment fits best into their life. “Whether it is storage space, costs or emotional and mental health challenges, the confidence to carry out a life-maintaining medical treatment at home needs kindness and patience. Information, education, and flexibility can really help.” Fiona Loud, Policy Director, <a href="https://www.kidneycareuk.org/" target="_blank" rel="noopener">Kidney Care UK</a> As part of a larger NIHR study (<a href="https://www.fundingawards.nihr.ac.uk/award/NIHR128364" target="_blank" rel="noopener">Inter-CEPt</a>), other researchers <a href="https://journals.sagepub.com/doi/full/10.1177/08968608241232200" target="_blank" rel="noopener">examined home dialysis services through a staff survey at English kidney centres</a>. They received 180 responses from 50 out of the 51 kidney centres. The organisation and delivery of services varied between centres. The most supportive clinical environments had a positive organisational culture, leadership and staff attitudes. These environments were most likely to increase uptake of home dialysis, the researchers concluded. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_d44999a9ac54a85f40c29b4046980480-2"> <label class="tab-label has-background has-pastel-teal-background-color has-text-color has-black-color" for="chck-block_d44999a9ac54a85f40c29b4046980480-2">The weekly break from hospital dialysis can harm patients</label> <div class="tab-content"> “Kidney patients are some of the most monitored people on the planet. But unfortunately, three weekly sessions do not go evenly into seven days. For many years, specialists have believed the two-day break was a problem for patients. This work confirms that the problem is very real and should inform discussions about how to address it”. James Fotheringham, Consultant Nephrologist, Sheffield Kidney Institute Kidney specialists have long been concerned about the possible implications of the weekly two-day break from hospital-based haemodialysis. But their concerns have not been reliably tested. People receiving dialysis have a regular schedule of appointments. They typically receive dialysis either on Mondays/Wednesdays/Fridays, or on Tuesdays/Thursdays/Saturdays, with each session lasting about 4 hours. Even if they attend all their sessions, they have a two-day period without dialysis. <a href="https://evidence.nihr.ac.uk/alert/the-weekly-break-from-dialysis-is-harmful-to-patients-with-kidney-failure/" target="_blank" rel="noopener">Research based on data from 3.8 million sessions of dialysis</a>, from 9,397 patients in 15 European countries, found an increase in hospital admissions and deaths associated with this break in treatment. If patients miss a scheduled session, the serious health risks increase dramatically. The research found that it is most harmful if patients skip the first session of the weekly cycle. When that happens, they go four days without dialysis. The stark negative impacts of missing a dialysis session suggest that healthcare professionals need to make the potential harms clear to patients who are not attending all their sessions, the researchers say. It also emphasises the need for research into different ways of delivering dialysis in hospitals. One approach could be overnight dialysis; the <a href="https://fundingawards.nihr.ac.uk/award/NIHR127440" target="_blank" rel="noopener">NIHR NightLife Study</a> is examining the potential of this compared to standard, daytime care. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_d44999a9ac54a85f40c29b4046980480-3"> <label class="tab-label has-background has-pastel-teal-background-color has-text-color has-black-color" for="chck-block_d44999a9ac54a85f40c29b4046980480-3">Distress is common among people on dialysis; talking could help</label> <div class="tab-content"> “I don’t feel I could just phone them up and say ‘well I’m feeling really down today and feel really bad and had enough and I just want to give up the dialysis for good’. . . They’ve not been trained for counselling and things like that, they’ve been trained for doing the dialysis.” <a href="https://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241629#pone.0241629.ref012" target="_blank" rel="noopener">Interviewee receiving dialysis</a> Kidney failure, and chronic kidney disease more generally, is associated with <a href="https://www.kidneyresearchuk.org/wp-content/uploads/2023/05/CentreforMHKRUK_TheCaseForChange.pdf" target="_blank" rel="noopener">poor mental wellbeing</a>. Waiting for a transplant is stressful and dialysis can make other medical conditions worse. It also has side effects such as fatigue, which can impact mood. Poor mental wellbeing is associated with worse outcomes for people with kidney disease; <a href="https://www.nice.org.uk/guidance/ng203/resources/chronic-kidney-disease-assessment-and-management-pdf-66143713055173" target="_blank" rel="noopener">NICE guidance</a> therefore recommends support groups or counselling, for example, to address the psychological aspects of coping with kidney disease. People with kidney failure receiving dialysis are at <a href="https://www.kidneyresearchuk.org/wp-content/uploads/2023/05/CentreforMHKRUK_TheCaseForChange.pdf" target="_blank" rel="noopener">increased risk</a> of poor psychological outcomes compared to transplant or supportive care. Researchers wanted to understand more about mild to moderate distress in people with kidney failure to find ways to help. <a href="https://bmjopen.bmj.com/content/9/5/e027982" target="_blank" rel="noopener">First, they carried out a survey</a> of people who were either receiving dialysis, waiting to start dialysis, or had a kidney transplant at 4 hospital Trusts in the West Midlands. 1,040 people completed the survey. Overall, 1 in 3 (33%) people with kidney failure had mild to moderate distress. This was most likely in patients on dialysis for 2 years or more (36%), and least likely among transplant patients (29%). Being younger, female, or of black and minority ethnic group increased the chance of distress. Over 40% of people reported needing support. <a href="https://evidence.nihr.ac.uk/alert/what-support-do-people-with-kidney-failure-need/" target="_blank" rel="noopener">Next, the researchers interviewed 46 people who had taken part in the survey</a> and had mild to moderate distress. Most were on dialysis (24 people) or waiting for dialysis (8 people); 14 had a transplant. People described their distress and how it affected their ability to manage their condition and develop coping strategies. Their experiences point to the support they need. More education could help people prepare emotionally for their treatment. People showing signs of distress could benefit from sessions with a psychologist. Half of the hospital kidney units had an on-site psychologist, but even in these units, sessions were limited and not routinely offered to people expressing distress. Other staff members could benefit from training to recognise and respond to distress, and to help people manage their treatment. People felt staff did not have the time to listen to them. Many said it was helpful to have someone on the kidney unit they could talk to about their distress, even when there were no solutions. Staff need to be encouraged to talk about distress as a normal part of the care they provide, the researchers say. Some of the Trusts that took part in the study have made changes to their kidney units as a result. For example, staff in some units now ask people directly about their emotional state, rather than waiting for them to volunteer the information. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_d44999a9ac54a85f40c29b4046980480-4"> <label class="tab-label has-background has-pastel-teal-background-color has-text-color has-black-color" for="chck-block_d44999a9ac54a85f40c29b4046980480-4">Cycling during dialysis improves heart health, but not quality of life</label> <div class="tab-content"> The benefits of exercise on physical and mental health are well known, but staying fit is a challenge for people on dialysis. Two trials looked at the impact of cycling during regular haemodialysis sessions, compared to usual dialysis care. One trial looked at heart health (<a href="https://fundingawards.nihr.ac.uk/award/CS-2013-13-014" target="_blank" rel="noopener">CYCLE-HD</a>), the other quality of life (<a href="https://fundingawards.nihr.ac.uk/award/12/23/09" target="_blank" rel="noopener">PEDAL</a>). Dialysis can have long-term effects on the heart, which can get worse over time and lead to heart failure. The first trial (CYCLE-HD) looked at whether cycling for 30 minutes during dialysis could reduce these effects. 101 patients completed the trial (51 in the cycling group, 50 in the usual care group). <a href="https://www.kidney-international.org/article/S0085-2538(21)00269-6/abstract" target="_blank" rel="noopener">After 6 months, those in the cycling group showed improvements in heart health compared to those receiving usual care</a>. Their hearts were a more ‘normal’ size and they had less stiffness of major blood vessels. These improvements could reduce people’s risk of dying from heart disease. <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8207470/" target="_blank" rel="noopener">The intervention was also value for money (cost-effective) for the NHS</a> and should be implemented across the country as a priority, the researchers say. Dialysis affects people’s quality of life and the second trial (PEDAL) looked at whether cycling for more than 20 minutes during treatment sessions could help. 243 patients completed assessments at the start and end of the trial (127 in the cycling group, 116 in the usual care group). <a href="https://www.journalslibrary.nihr.ac.uk/hta/hta25400#/abstract" target="_blank" rel="noopener">After 6 months there was no difference in quality of life between those offered cycling and those not</a>. Less than half (47%) of those in the exercise group completed their cycling sessions. Interviews with participants revealed possible reasons, including days with increased symptoms such as tiredness, and the impact of their other conditions. Further research looking at a more individualised approach to exercise is needed, the researchers say. The first trial (CYCLE-HD) also examined quality of life. This was not its main outcome measurement but, in line with the findings of PEDAL, found no effect of cycling during dialysis on quality of life. They did, however, find a clear effect on heart health. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_d44999a9ac54a85f40c29b4046980480-5"> <label class="tab-label has-background has-pastel-teal-background-color has-text-color has-black-color" for="chck-block_d44999a9ac54a85f40c29b4046980480-5">Setting post-dialysis target weights: extra measurements do not improve on clinical judgement</label> <div class="tab-content"> Preserved kidney function is associated with better survival and improved quality of life. Most people starting haemodialysis still have some kidney function, and it helps to maintain this for as long as possible. Clinicians set a target weight for the end of a dialysis session to manage how much fluid is removed during haemodialysis. They need to set the target weight as accurately as possible; if it is set too low, too much fluid is removed and this may accelerate loss of remaining kidney function. Researchers wanted to find out if bioimpedance spectroscopy, which calculates target weight independently by measuring fluid and body composition (how much water, muscle and fat, for example), could help guide clinicians. <a href="https://www.fundingawards.nihr.ac.uk/award/14/216/01" target="_blank" rel="noopener">In a recent randomised trial (BISTRO)</a>, involving 439 people from 34 dialysis centres, clinicians used a new standardised protocol to set patients’ post-dialysis target weight. For half of the patients, target weight was set by clinical judgement only. For the other half, clinicians additionally had information about target weight from bioimpedance measurements. <a href="https://www.kidney-international.org/article/S0085-2538(23)00394-0/fulltext#%20" target="_blank" rel="noopener">Using the new protocol, clinicians were as good at setting the target weight whether or not they had extra information from spectroscopy.</a> The researchers had expected that about 25% of people would lose their kidney function after 1 year. Instead, they found that in both groups, less than 25% had lost their kidney function by 2 years. Use of the standardised protocol to avoid too much fluid loss during haemodialysis was associated with better than expected preservation of kidney function. The researchers concluded that a standardised protocol needs to be considered the basis of routine care. There is no need to add bioimpedance to improve on clinical judgement, they say. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_d44999a9ac54a85f40c29b4046980480-6"> <label class="tab-label has-background has-pastel-teal-background-color has-text-color has-black-color" for="chck-block_d44999a9ac54a85f40c29b4046980480-6">Fistulas used for haemodialysis: drug-coated balloons do not improve outcomes</label> <div class="tab-content"> Haemodialysis requires reliable access to a person’s blood. Joining a vein onto an artery in the arm (an <a href="https://kidneycareuk.org/kidney-disease-information/treatments/vascular-access-for-dialysis/haemodialysis-access-with-an-arteriovenous-fistula/" target="_blank" rel="noopener">arteriovenous fistula</a>) creates a large, robust blood vessel suitable for regular haemodialysis. <a href="https://www.journalslibrary.nihr.ac.uk/eme/eme08130/#/scientific-summary" target="_blank" rel="noopener">However, the veins in these fistulas are prone to narrowing (stenosis)</a>. Narrowed segments are treated with a balloon inserted into the vein, but the benefit can be short-lived. The segments often narrow again and then the fistula may block, be abandoned, or require retreatment. This is a burden for patients and costly for the NHS and has prompted a search for ways to improve treatment. <a href="https://fundingawards.nihr.ac.uk/award/13/94/10" target="_blank" rel="noopener">A randomised trial</a> involving 212 patients investigated whether balloons coated in paclitaxel (a drug used to treat cancer) provided longer-lasting treatment than standard balloons, by reducing the recurrence of narrowing. <a href="https://www.kidney-international.org/article/S0085-2538(21)00347-1/fulltext" target="_blank" rel="noopener">Paclitaxel-coated balloons provided no additional benefit</a> compared to standard balloons. There were no significant differences in any outcome, including adverse events and quality of life. However, other trials have suggested benefits, so uncertainties remain. </div> </div> <div class="tab"> <input type="checkbox" id="chck-block_d44999a9ac54a85f40c29b4046980480-7"> <label class="tab-label has-background has-pastel-teal-background-color has-text-color has-black-color" for="chck-block_d44999a9ac54a85f40c29b4046980480-7">Peritoneal dialysis: catheters can be safely inserted without surgery</label> <div class="tab-content"> “This research encourages me to expand the delivery of peritoneal dialysis as part of future service provision. Solutions are needed to help clinicians and centres to develop expertise in all aspects of home dialysis.” Barny Hole, Kidney doctor in training and NIHR Academic Clinical Lecturer in the Healthcare Needs of Older People <a href="https://www.nhs.uk/conditions/dialysis/what-happens/" target="_blank" rel="noopener">Peritoneal dialysis</a> involves pumping dialysis fluid through a thin tube (catheter) into the space inside a person’s abdomen (the peritoneal cavity). The catheter is inserted in the abdomen and left there permanently. A catheter can be inserted under general anaesthetic by a surgeon, or without a general anaesthetic by a physician using a needle (medical insertion). Medical insertions have become more common in recent years due to a lack of access to surgeons and theatre space; they also have the advantage of being possible in people who are not well enough to have a general anaesthetic. <a href="https://evidence.nihr.ac.uk/alert/kidney-failure-medical-insertion-of-catheters-for-peritoneal-dialysis-is-as-safe-as-surgery/" target="_blank" rel="noopener">A recent study provides reassurance that medical insertions are a safe option</a>. It included data on 769 people, who had a first abdominal catheter insertion. Just over half (58%) had surgical insertions; the others medical insertions. The main outcome was the number of safety events (catheter removal, leak, infection, and further procedures, for instance) 1 year after insertion. Medical insertions were associated with fewer safety events (55%) than surgical insertions (63%), fewer infections (3%) than surgical infections (11%), but more catheter removals (22%) than surgical insertions (18%). Hospitals that offered both approaches had the best outcomes. The researchers suggest this could be because it allows clinicians to decide what approach is best for the patient. They say outcomes could be improved if more hospitals were able to offer both approaches. Clinicians could consider the advantages of each approach when discussing with a patient which is best for them. </div> </div> </div> </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="2-dialysis-for-kidney-failure-what-research-is-ongoing">2. Dialysis for kidney failure: what research is ongoing?</h2> The NIHR continues to invest in research to improve the lives of people receiving dialysis. Ongoing studies include randomised controlled trials looking at whether night-time dialysis in hospital can improve quality of life, and whether lowering blood phosphate levels keep the heart and blood vessels healthy and help people feel better. Other studies are testing whether vitamin D3 supplements improve survival, or whether adding filtration to regular haemodialysis improves survival and reduces life-threatening hospital admissions. The <a href="https://www.kidney-international.org/article/S0085-2538%2824%2900692-6/fulltext" target="_blank" rel="noreferrer noopener">UNPACK study</a> looked at how older people choose between dialysis and conservative care. Other research, due to be published soon, includes the final results of the <a href="https://www.fundingawards.nihr.ac.uk/award/NIHR128364" target="_blank" rel="noreferrer noopener">Inter-CEPt study</a> on an evidence-based intervention to reduce the inequity of access to home dialysis. <figure class="wp-block-image size-full"><img loading="lazy" decoding="async" width="1600" height="900" src="https://evidence.nihr.ac.uk/wp-content/uploads/2024/07/Research-ongoing-new-1.png" alt="" class="wp-image-63670"/></figure> <section class="guten-block block-accordion "> <div class="row"> <div class="column small-12"> <div class="tabs"> <div class="tab"> <input type="checkbox" id="chck-block_b1554162b59c49728bc22e8308619d4a-1"> <label class="tab-label has-background has-pastel-teal-background-color has-text-color has-black-color" for="chck-block_b1554162b59c49728bc22e8308619d4a-1">Read more about ongoing research</label> <div class="tab-content"> Does preparing for dialysis or conservative care lead to better quality of life? <a href="https://fundingawards.nihr.ac.uk/award/15/57/39" target="_blank" rel="noopener">Prepare for Kidney Care: a randomised controlled trial of preparing for responsive management versus preparing for renal dialysis in advanced kidney disease</a> How do older people choose between dialysis and conservative care? <a href="https://www.kidney-international.org/article/S0085-2538%2824%2900692-6/fulltext" target="_blank" rel="noopener">The UNPACK study: A choice experiment of older patients’ preferences for kidney failure treatments NOW PUBLISHED</a> Does night-time haemodialysis improve quality of life? <a href="https://fundingawards.nihr.ac.uk/award/NIHR127440" target="_blank" rel="noopener">A randomised controlled trial assessing the effectiveness and cost effectiveness of thrice weekly, extended, in-centre nocturnal haemodialysis versus standard care using a mixed methods approach.</a> Do vitamin D3 supplements improve survival and quality of life in people having dialysis? <a href="https://fundingawards.nihr.ac.uk/award/14/49/127" target="_blank" rel="noopener">Survival Improvement with Cholecalciferol in Patients on Dialysis the SIMPLIFIED registry trial</a> Do larger volumes of substitution fluid during dialysis improve cardiovascular health? <a href="https://fundingawards.nihr.ac.uk/award/15/80/52" target="_blank" rel="noopener">The High-volume Haemodiafiltration vs High-flux Haemodialysis Registry Trial (H4RT)</a> Does lowering blood phosphate levels make any difference to the health of people having dialysis? <a href="https://www.fundingawards.nihr.ac.uk/award/NIHR127873" target="_blank" rel="noopener">Pragmatic randomised trial of High Or Standard PHosphAte Targets in End-stage kidney disease – The PHOSPHATE trial</a> Which type of anaesthesia is better when creating a fistula? <a href="https://www.fundingawards.nihr.ac.uk/award/NIHR130567" target="_blank" rel="noopener">Anaesthesia Choice for Creation of ArtEriovenous FiStulae (ACCESs study) A randomised controlled trial comparing clinical (one-year functional patency rate) and cost-effectiveness of regional versus local anaesthesia for primary arteriovenous fistula form</a> Can ultrasound help identify early problems with a fistula? <a href="https://www.fundingawards.nihr.ac.uk/award/17/27/11" target="_blank" rel="noopener">Surveillance of arteriovenous fistulae in haemodialysis</a> </div> </div> </div> </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="conclusion">Conclusion</h2> <blockquote class="wp-block-quote is-style-plain is-layout-flow wp-block-quote-is-layout-flow"> "As a patient, being in control and knowledgeable has supported me to make the best decisions. The biggest decision I took was choosing nocturnal dialysis which has been transformative.” </blockquote> Nick Palmer, Patient Ambassador and Involvement Lead, <a href="https://kidneycareuk.org/" target="_blank" rel="noreferrer noopener">Kidney Care UK</a> Thousands of people with kidney failure have dialysis. It is a life-saving treatment, but it is gruelling for them and costly for the NHS. The examples in this Collection provide evidence that could improve care and outcomes. Home dialysis can give people on dialysis a better quality of life than hospital-based dialysis. It also offers good value for money for the NHS. Yet few people take this option. Research explored the reasons why, and found that better information and peer support could encourage people to have dialysis at home. The finding that professional culture in kidney units may need to develop so as to support people considering home dialysis as their first option is supported by <a href="https://education.ukkidney.org/course/daylife" target="_blank" rel="noreferrer noopener">a national initiative, DAYlife</a>. Maintaining quality of life for people on dialysis is a challenge. Research is exploring interventions, such as cycling during dialysis. This innovation improved heart health, but did not impact quality of life. Many people on dialysis report distress, and research shows that this could be helped by active mental health support. Other research highlighted the skill of clinicians at setting targets to preserve kidney function and avoid excessive fluid removal during haemodialysis; extra information from bioimpedance technology brought no added benefit. Medical insertion of peritoneal dialysis catheters was as safe as surgery in another study; hospitals that offer both have the best outcomes. The harms of the weekly two-day break from haemodialysis increase dramatically if additional treatment sessions are missed. Ongoing research into night-time dialysis could reduce missed sessions in future. Other research continues to push for improvements. This is good news for people with kidney failure. Their quality of life will benefit from high-quality evidence-based care. <hr class="wp-block-separator has-alpha-channel-opacity"/> Author: Jemma Kwint, Senior Research Fellow, NIHR, in collaboration with <a href="https://www.kidneyresearchuk.org/" target="_blank" rel="noreferrer noopener">Kidney Research UK</a> How to cite this Collection: NIHR Evidence; Dialysis for kidney failure: evidence to improve care; September 2024; doi: 10.3310/nihrevidence_63287 Disclaimer: This Collection is based on research which is funded or supported by the NIHR. It is not a substitute for professional healthcare advice. Please note that views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> <item> <title>Chronic migraine: which drugs are best?</title> <link>https://evidence.nihr.ac.uk/alert/chronic-migraine-which-drugs-are-best/</link> <dc:creator><![CDATA[Kathrin Fischer]]></dc:creator> <pubDate>Tue, 17 Sep 2024 08:00:00 +0000</pubDate> <category><![CDATA[Uncategorised]]></category> <guid isPermaLink="false">https://evidence.nihr.ac.uk/?p=64388</guid> <description><![CDATA[People with chronic migraine (attacks on 15 or more days per month) may need prescription drugs to help them manage their condition. Researchers analysed studies on drugs to prevent migraine attacks. They found that: The findings add to existing knowledge about which preventive treatments are most effective for people with chronic migraine. More information about ...]]></description> <content:encoded><![CDATA[ People with chronic migraine (attacks on 15 or more days per month) may need prescription drugs to help them manage their condition. Researchers analysed studies on drugs to prevent migraine attacks. They found that: <ul class="wp-block-list"> <li>all drugs tested reduced the number of days people had headaches and migraine attacks</li> <li>newer drugs (for instance, eptinezumab and erenumab) were more effective than traditional ones (such as topiramate)</li> <li>traditional drugs were cheaper but had more adverse events than newer ones.</li> </ul> The findings add to existing knowledge about which preventive treatments are most effective for people with chronic migraine. <a href="https://www.nhs.uk/conditions/migraine/" target="_blank" rel="noreferrer noopener">More information about migraine can be found on the NHS website</a>. <section class="guten-block block-wysiwyg has-background has-pastel-orange-background-color has-border has-text-color has-blue-color has-padding has-padding-none" > <div class="row"> <div class="columns small-12 large-8"> UPDATE (3/10/24): The Journal’s Library report, <a href="https://www.journalslibrary.nihr.ac.uk/hta/AYWA5297/#/abstract" target="_blank" rel="noopener">Preventive drug treatments for adults with chronic migraine: a systematic review with economic modelling</a>, has been published. </div> </div> </section> <h2 class="wp-block-heading" class="wp-block-heading" id="which-drugs-prevent-migraine-attacks">Which drugs prevent migraine attacks?</h2> Migraines feel like severe headaches, often with throbbing pain on one side; other symptoms may include <a href="https://www.nationalmigrainecentre.org.uk/understanding-migraine/what-is-migraine/#:~:text=If%20you%20have%20headache%20attacks,medical%20professional%20for%20a%20diagnosis." target="_blank" rel="noreferrer noopener">nausea, blurred vision and a need to rest</a>. Around <a href="https://migrainetrust.org/understand-migraine/" target="_blank" rel="noreferrer noopener">2 in 100 people in the UK</a> have chronic migraine. The condition can be disabling, lead to time off work and reduced quality of life. Treatments (including triptans) are available for migraine attacks when they occur, but they are not suitable for regular use. Preventive drugs can reduce the impact of chronic migraine. Most of the newer drugs can be prescribed only by a specialist (neurologist); some can be prescribed by GPs (or GPs can continue prescribing drugs started by a specialist). Several drugs are recommended by the <a href="https://www.nice.org.uk/guidance/cg150/chapter/Key-priorities-for-implementation" target="_blank" rel="noreferrer noopener">National Institute for Health and Care Excellence</a> (NICE). But the evidence is mixed and it is unclear which is the most effective. Newer drugs (<a href="https://www.nice.org.uk/guidance/TA871/chapter/1-Recommendations" target="_blank" rel="noreferrer noopener">eptinezumab, </a><a href="https://www.nice.org.uk/guidance/TA682/chapter/1-Recommendations" target="_blank" rel="noreferrer noopener">erenumab</a>, <a href="https://www.nice.org.uk/guidance/TA764/chapter/1-Recommendations" target="_blank" rel="noreferrer noopener">fremanezumab</a> and <a href="https://www.nice.org.uk/guidance/TA659/chapter/1-Recommendations" target="_blank" rel="noreferrer noopener">galcanezumab</a>), usually given by monthly injection, are reserved for people in whom 3 previous treatments have failed. Researchers compared the effectiveness of medications, including newer treatments, for people with chronic migraine. All of the drugs in the report are approved by NICE. <h2 class="wp-block-heading" class="wp-block-heading" id="whats-new">What’s new?</h2> The researchers looked at 12 trials involving 7,909 people in all; each trial included 200 or more adults with chronic migraine. Most trials compared a preventive drug with a dummy drug (placebo). There were no eligible trials of commonly-used preventive drugs, such as amitriptyline or propranolol. In 8 trials (of eptinezumab, erenumab, fremanezumab, galcanezumab, botulinum toxin A, and topiramate), all drugs reduced the number of days with headache (rather than a migraine attack). They found: <ul class="wp-block-list"> <li>the most effective was eptinezumab 300mg (which reduced the number of days with headache by 2.5 per month more than placebo)</li> <li>the least effective was topiramate 100mg (which reduced the number of days with headache by 1.1 per month more than placebo).</li> </ul> In 11 trials of the same drugs, all reduced the number of days with a migraine attack. They found: <ul class="wp-block-list"> <li>the most effective was monthly fremanezumab (which reduced the number of days with a migraine attack by 2.8 per month more than placebo)</li> <li>the least effective was topiramate 100mg (which reduced the number of days with a migraine attack by 1.5 per month more than placebo).</li> </ul> In 10 trials, all drugs apart from topiramate, were more effective than placebo at improving headache-related quality of life. Headache-related quality of life assesses the extent of someone’s pain or discomfort, and how often headaches limit their daily activities. The same team reviewed 33 studies on the <a href="https://neurologyopen.bmj.com/content/6/1/e000616" target="_blank" rel="noreferrer noopener">adverse events</a> of 10 drugs. They found that amitriptyline and topiramate were linked with the most adverse events, especially relating to the nervous system (tingling or numbness of the skin, for example). Newer treatments had fewer adverse events. On price, topiramate was the only drug within the limit set by NICE (£30,000 per year of good health). However, topiramate gave only slightly more years of good health (QALYs) than a dummy pill (placebo). In addition, girls or women who could become pregnant need long-acting contraception (such as the coil or implant) before they are prescribed topiramate. Eptinezumab was the most expensive treatment but gave the largest increase in years in good health. <h2 class="wp-block-heading" class="wp-block-heading" id="why-is-this-important">Why is this important?</h2> Migraine drugs effectively reduced the number of days people had headaches or migraine attacks in this study. They also improved quality of life. Differences between drugs were modest, the researchers say. The effectiveness study did not include other drugs used to prevent migraine attacks in England and Scotland (amitriptyline, propranolol, candesartan or flunarizine) because of limitations in the evidence. Nearly all studies compared drugs with placebo; this means the findings do not compare drugs directly with one another. Therefore, conclusions about the most and least effective drugs need to be treated with caution. Most trials in this analysis included participants with and without medication overuse, which could have made the preventive treatments appear less effective than they really are.   <h2 class="wp-block-heading" class="wp-block-heading" id="whats-next">What’s next?</h2> More research is needed to determine the effectiveness and value for money of traditional, cheaper, preventive drugs for people with chronic migraine. The adverse events related to newer and traditional drugs also need to be compared, the researchers say. <a href="https://openresearch.nihr.ac.uk/articles/4-16" target="_blank" rel="noreferrer noopener">At a consensus workshop</a> run by the research team, participants prioritised comparison of 2 treatments (calcitonin gene-related peptide monoclonal antibodies, and botulinum toxin A). Candesartan and flunarizine were the drugs the group most wanted to see compared with placebo. <h2 class="wp-block-heading" class="wp-block-heading" id="you-may-be-interested-to-read">You may be interested to read</h2> This is a summary of: Naghdi S, and others.<a href="https://doi.org/10.1186/s10194-023-01696-w" target="_blank" rel="noreferrer noopener"> Clinical effectiveness of pharmacological interventions for managing chronic migraine in adults: a systematic review and network meta‑analysis</a>. The Journal of Headache and Pain 2023; 24: 164. Mistry H, and others. <a href="https://doi.org/10.1186/s10194-023-01686-y" target="_blank" rel="noreferrer noopener">Competing interests for migraine: a headache for decision-makers</a>. The Journal of Headache and Pain 2023; 24: 162. Naghdi S, and others. <a href="https://doi.org/10.1136/bmjno-2023-000616" target="_blank" rel="noreferrer noopener">Adverse and serious adverse events incidence of pharmacological interventions for managing chronic and episodic migraine in adults: a systematic review</a>. BMJ Neurology Open 2024; 6: e000616. Khanal S, and others. <a href="https://doi.org/10.1186/s10194-022-01492-y" target="_blank" rel="noreferrer noopener">A systematic review of economic evaluations of pharmacological treatments for adults with chronic migraine</a>. The Journal of Headache and Pain 2022; 23: 122 More information and regular events about migraine, including tips for how to manage symptoms, can be found on <a href="https://migrainetrust.org/" target="_blank" rel="noreferrer noopener">The Migraine Trust</a> website. The <a href="https://bnf.nice.org.uk/treatment-summaries/migraine/" target="_blank" rel="noreferrer noopener">British National Formulary</a> describes the drugs that might be used for migraine prevention. Self-management tips can be found on the National Migraine Centre’s podcast, <a href="https://www.nationalmigrainecentre.org.uk/understanding-migraine/heads-up-podcast/" target="_blank" rel="noreferrer noopener">Heads Up</a>. Funding: <a href="https://www.nihr.ac.uk/explore-nihr/funding-programmes/health-technology-assessment.htm" target="_blank" rel="noreferrer noopener">NIHR Health Technology Assessment Commissioned Call</a>. Conflicts of Interest: One of the study authors has received funding from several pharmaceutical companies that produce drugs for migraine. See <a href="https://doi.org/10.1186/s10194-023-01696-w" target="_blank" rel="noreferrer noopener">paper</a> for full details. Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) at the time of publication. They do not necessarily reflect the views of the NHS, the NIHR or the Department of Health and Social Care. ]]></content:encoded> </item> </channel> </rss>