Matthew Glover

Purpose: We conducted a distributional cost-effectiveness analysis (DCEA) using routinely collected data to estimate the population health and health inequality impacts of the National Abdominal Aortic Aneurysm Screening Programme (NAAASP) in England. Methods: An existing discrete event simulation model of AAA screening was adapted to examine differences between socioeconomic groups defined by Index of Multiple Deprivation, obtained from an analysis of secondary data sources. We examined the distributional cost-effectiveness of being invited versus not invited at age 65 y to screen using a National Health Service perspective. Changes in inequality were valued using a measure of equally distributed equivalent health. Results: The net health benefits of population screening (317 quality-adjusted life-years [QALYs] gained) were disproportionately accounted for by the effects on those living in more advantaged areas. The NAAASP improved health on average compared with no screening, but the health opportunity cost of the programme exceeded the QALY gains for people living in the most deprived areas, resulting in a negative net health impact for this group (106 QALYs lost) that was driven by differences in the need for screening. Consequently, the NAAASP increased health inequality at the population level. Given current estimates for inequality aversion in England, screening for AAA remains the optimal strategy. Conclusion: Examination of the distributional cost-effectiveness of the NAAASP in England using routinely collected data revealed a tradeoff between total population health and health inequality. Study findings suggest that the NAAASP provides value for money despite health impacts being disseminated to those who are more advantaged. Highlights: This study examines the population health and health inequality effects of the National Abdominal Aortic Aneurysm Screening Programme (NAAASP) between socioeconomic groups defined by Index of Multiple Deprivation. Findings suggest a tradeoff between total population health and health inequality. Given current estimates for inequality aversion in England, screening remains the optimal strategy relative to not screening. Opportunities remain to reduce inequality effects for those most vulnerable through targeted approaches.

Some text in this abstract and article has been reproduced from Taylor et al. (Taylor C, Ollis L, Lyon RM, Williams J, Skene SS, Bennett K, et al.; SEE-IT Trial Group. The SEE-IT Trial: emergency medical services Streaming Enabled Evaluation In Trauma: a feasibility randomised controlled trial. Scand J Trauma Resusc Emerg Med 2024;32:7). This is an Open Access article distributed in accordance with the terms of the Creative Commons Attribution (CC BY 4.0) license, which permits others to distribute, remix, adapt and build upon this work, for commercial use, provided the original work is properly cited. See: https://creativecommons.org/licenses/by/4.0/. The text below includes minor additions and formatting changes to the original text. Background: The use of bystander video livestreaming from scene in emergency medical services is becoming increasingly common to inform decisions about the resources and support required. Possible benefits include clinical and financial gains, but evidence is sparse. We aimed to investigate the feasibility of conducting a definitive randomised controlled trial of its use in major trauma incidents. Objectives: To obtain data required to design a subsequent randomised controlled trial. To test trial processes. To embed a process evaluation. Design: A feasibility randomised controlled trial with embedded process and economic evaluations where working shifts (n = 62) in 6 trial weeks were randomised 1 : 1 to video livestreaming or standard care only; and two observational substudies: (1) assessment of acceptability in a diverse inner-city emergency medical service that routinely uses video livestreaming; and (2) assessment of staff well-being in an emergency medical service that does not use livestreaming (for comparison to the trial site). Qualitative data collection included observations (286 hours) and interviews with staff (n = 25) and bystander callers (n = 2). Setting: A pre-hospital emergency medical service in South-East England, with follow-up in associated major trauma centres and trauma units; substudies in (1) London and (2) East of England emergency medical services. Participants: (1) Patients involved in trauma incidents (n = 269); (2) bystander callers (n = 11); and (3) ambulance service staff (n = 67). Intervention: Video livestreaming using GoodSAM’s Instant-On-Scene. Main outcome measures: Progression to a definitive randomised controlled trial based on four pre-defined criteria and consideration of qualitative data: (1) ≥ 70% bystanders with smartphones agreeing and able to activate livestreaming; (2) ≥ 50% requests to activate livestreaming resulting in footage being viewed; (3) helicopter emergency medical services stand-down rate reducing by ≥ 10% due to livestreaming; and (4) no evidence of psychological harm to bystanders or staff caused by livestreaming. Results: Sixty-two shifts were randomised, contributing 240 eligible incidents (132 control; 108 intervention). In a further three shifts, we randomised by individual call, which contributed four eligible incidents (two control; two intervention), thereby totalling 244 incidents involving 269 patients. Video livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to access medical records to assess appropriateness of dispatch) and bystander recruitment (to measure potential harm) were both low (58/269, 22% of patients, 4/244, 2% of bystanders). Two progression criteria were met: (1) 86% of bystanders with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in viewed footage; and two were indeterminate due to insufficient data: (3) 2/6 (33%) stand-down due to livestreaming; and (4) no evidence of psychological harm from survey, observations or interviews. In substudy (i), dispatch staff reported that non/limited English language and older age may present barriers to video livestreaming. Limitations: Poor recruitment of patients and bystanders limited assessment of appropriateness of dispatch decisions and potential psychological harm. Conclusions: Video livestreaming is feasible to implement, acceptable to both bystanders and dispatchers, and may aid dispatch decision-making, but further assessment of benefits and harm is required. Future work: Findings support the design and conduct of a future multicentre study taking account of different triage systems and dispatch personnel, potentially using an alternative to a randomised controlled trial due to rapid uptake of video livestreaming in this setting. Funding: This synopsis presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130811.

Background: Coronavirus disease-2019 was associated with significant mortality and morbidity in care homes in 2020–1. Repurposed antiviral drugs might reduce morbidity and mortality through reducing viral transmission, infection, replication and inflammation. We aimed to compare the safety and efficacy of potential antiviral drugs in care home residents. Methods: We designed a cluster-randomised, open-label, blinded end-point platform trial to test drugs in a postexposure prophylaxis paradigm. Participants aged 65+ years from United Kingdom care homes, with or without nursing, were eligible for participation. Care homes were to be allocated at random by computer to administer 42 days of antiviral agent (ciclesonide or niclosamide) plus standard care versus standard care alone to residents. The primary outcome at 60 days after randomisation comprised the most serious outcome, which was defined as all-cause mortality, all-cause hospitalisation, severe acute respiratory syndrome coronavirus 2 infection or no infection. Analysis would be by intention to treat using ordinal logistic regression. Other outcomes included individual components of the primary outcome, transmission, plus health economic and process evaluation outcomes. The planned sample size was 300 care homes corresponding to 9600 residents. With ~40% of care homes predicted to develop an outbreak during the trial, we needed to recruit 750 homes/24,000 residents. Results: We initiated the trial including protocol, approvals, insurance, website, database, data algorithms, intervention selection and training materials. We built a network of principal investigators and staff (91) and care homes (299) to support the trial. However, we never contracted care homes or general practitioners since the trial was stopped in September 2021, as vaccination in care homes had significantly reduced infections. Multiple delays significantly delayed the start date, such as: (1) reduced prioritisation of pandemic trials in 2021; (2) cumbersome mechanisms for choosing the investigational medicinal products; (3) contracting between National Institute for Health and Care Research and the investigational medicinal product manufacturers; (4) publicising the investigational medicinal products; (5) identification of sufficient numbers of care homes; (6) identification and contracting with several thousand general practitioners; (7) limited research nurse availability and (8) identification of adequate insurance to cover care homes for research. Generic challenges included working across the four home nations with their different structures and regulations. Limitations: The feasibility of contracting between the sponsor and the principal investigators, general practitioners and care homes; screening, consent and treatment of care home residents; data acquisition and the potential benefit of postexposure prophylaxis were never tested. Conclusions: The success of vaccination meant that the role of postexposure prophylaxis of coronavirus disease-2019 in care home residents was not tested. Significant progress was made in developing the infrastructure and expertise necessary for a large-scale clinical trial of investigational medicinal products in United Kingdom care homes. Future work: The role of postexposure prophylaxis of coronavirus disease-2019 in care home residents remains undefined. Significant logistical barriers to conducting research in care homes need to be removed urgently before future studies are possible. Further work is required to develop the infrastructure for clinical trials of investigational medicinal products in care homes. Serious consideration should be given to building and then hibernating a pandemic-ready platform trial suitable for care home research. Funding: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme as award number NIHR133443.

This article consists of a citation of a published article describing research funded by the Health and Social Care Delivery Research programme under project number NIHR130811, and is provided as as part of the complete record of research outputs for this project. The original publication is available at: https://doi.org/10.1186/s13049-024-01179-0 Background: Use of bystander video livestreaming from scene to Emergency Medical Services (EMS) is becoming increasingly common to aid decision making about the resources required. Possible benefits include earlier, more appropriate dispatch and clinical and financial gains, but evidence is sparse. Methods: A feasibility randomised controlled trial with an embedded process evaluation and exploratory economic evaluation where working shifts during six trial weeks were randomised 1:1 to use video livestreaming during eligible trauma incidents (using GoodSAM Instant-On-Scene) or standard care only. Pre-defined progression criteria were: (1) ≥ 70% callers (bystanders) with smartphones agreeing and able to activate live stream; (2) ≥ 50% requests to activate resulting in footage being viewed; (3) Helicopter Emergency Medical Services (HEMS) stand-down rate reducing by ≥ 10% as a result of live footage; (4) no evidence of psychological harm in callers or staff/dispatchers. Observational sub-studies included (i) an inner-city EMS who routinely use video livestreaming to explore acceptability in a diverse population; and (ii) staff wellbeing in an EMS not using video livestreaming for comparison to the trial site. Results: Sixty-two shifts were randomised, including 240 incidents (132 control; 108 intervention). Livestreaming was successful in 53 incidents in the intervention arm. Patient recruitment (to determine appropriateness of dispatch), and caller recruitment (to measure potential harm) were low (58/269, 22% of patients; 4/244, 2% of callers). Two progression criteria were met: (1) 86% of callers with smartphones agreed and were able to activate livestreaming; (2) 85% of requests to activate livestreaming resulted in footage being obtained; and two were indeterminate due to insufficient data: (3) 2/6 (33%) HEMS stand down due to livestreaming; (4) no evidence of psychological harm from survey, observations or interviews, but insufficient survey data from callers or comparison EMS site to be confident. Language barriers and older age were reported in interviews as potential challenges to video livestreaming by dispatchers in the inner-city EMS. Conclusions: Progression to a definitive RCT is supported by these findings. Bystander video livestreaming from scene is feasible to implement, acceptable to both 999 callers and dispatchers, and may aid dispatch decisionmaking. Further assessment of unintended consequences, benefits and harm is required. Trial registration: ISRCTN 11449333 (22 March 2022). https://www.isrctn.com/ISRCTN11449333 Funding: This publication was funded by the Health and Social Care Delivery Research programme as a part of award number NIHR130811. This article reports on one component of the research award Emergency medical services Streaming Enabled Evaluation In Trauma: The SEE-IT trial. For more information about this research please view the award page [https://fundingawards.nihr.ac.uk/award/NIHR130811] DOI: https://doi.org/10.1186/s13049-024-01179-0

This article consists of a citation of a published article describing research funded by the Health and Social Care Delivery Research programme under project number NIHR130811, and is provided as as part of the complete record of research outputs for this project. The original publication is available at: https://doi.org/10.1186/s12873-024-01015-9 Background: Timely dispatch of appropriate emergency medical services (EMS) resources to the scene of medical incidents, and/or provision of treatment at the scene by bystanders and medical emergency lay callers (referred to as ‘callers’ in this review) can improve patient outcomes. Currently, in dispatch systems worldwide, prioritisation of dispatch relies mostly on verbal telephone information from callers, but advances in mobile phone technology provide means for sharing video footage. This scoping review aimed to map and identify current uses, opportunities, and challenges for using video livestreaming from callers’ smartphones to emergency medical dispatch centres. Methods: A scoping review of relevant published literature between 2007 and 2023 in the English language, searched within MEDLINE; CINAHL and PsycINFO, was descriptively synthesised, adhering to the PRISMA extension for scoping reviews. Results: Twenty-four articles remained from the initial search of 1,565 articles. Most studies were simulation-based and focused on emergency medical dispatchers’ (referred to as ‘dispatcher/s’ in this review) assisted video cardiopulmonary resuscitation (CPR), predominantly concerned with measuring how video impacts CPR performance. Nine studies were based on real-life practice. Few studies specifically explored experiences of dispatchers or callers. Only three articles explored the impact that using video had on the dispatch of resources. Opportunities offered by video livestreaming included it being: perceived to be useful; easy to use; reassuring for both dispatchers and callers; and informing dispatcher decision-making. Challenges included the potential emotional impact for dispatchers and callers. There were also concerns about potential misuse of video, although there was no evidence that this was occurring. Evidence suggests a need for appropriate training of dispatchers and video-specific dispatch protocols. Conclusion: Research is sparse in the context of video livestreaming. Few studies have focussed on the use of video livestreaming outside CPR provision, such as for trauma incidents, which are by their nature time-critical where visual information may offer significant benefit. Further investigation into acceptability and experience of the use of video livestreaming is warranted, to understand the potential psychological impact on dispatchers and callers. Keywords: EMERGENCY MEDICAL DISPATCH, EMERGENCY MEDICAL SERVICES, VIDEO LIVESTREAMING, CALLERS, SMARTPHONE, REVIEW Funding: This publication was funded by the Health and Social Care Delivery Research programme as a part of award number NIHR130811. This article reports on one component of the research award Emergency medical services Streaming Enabled Evaluation In Trauma: The SEE-IT trial. For more information about this research please view the award page [https://fundingawards.nihr.ac.uk/award/NIHR130811] DOI: https://doi.org/10.1186/s12873-024-01015-9

Background: Quality of life and care varies between and within the care homes in which almost half a million older people live and over half a million direct care staff (registered nurses and care assistants) work. The reasons are complex, understudied and sometimes oversimplified, but staff and their work are a significant influence. Objective(s): To explore variations in the care home nursing and support workforce; how resident and relatives’ needs in care homes are linked to care home staffing; how different staffing models impact on care quality, outcomes and costs; how workforce numbers, skill mix and stability meet residents’ needs; the contributions of the care home workforce to enhancing quality of care; staff relationships as a platform for implementation by providers. Design: Mixed-method (QUAL-QUANT) parallel design with five work packages. WP1 – two evidence syntheses (one realist); WP2 – cross-sectional survey of routine staffing and rated quality from care home regulator; WP3 – analysis of longitudinal data from a corporate provider of staffing characteristics and quality indicators, including safety; WP4 – secondary analysis of care home regulator reports; WP5 – social network analysis of networks likely to influence quality innovation. We expressed our synthesised findings as a logic model. Setting: English care homes, with and without nursing, with various ownership structures, size and location, with varying quality ratings. Participants: Managers, residents, families and care home staff. Findings: Staffing’s contribution to quality and personalised care requires: managerial and staff stability and consistency; sufficient staff to develop ‘familial’ relationships between staff and residents, and staff–staff reciprocity, ‘knowing’ residents, and skills and competence training beyond induction; supported, well-led staff seeing modelled behaviours from supervisors; autonomy to act. Outcome measures that capture the relationship between staffing and quality include: the extent to which resident needs and preferences are met and culturally appropriate; resident and family satisfaction; extent of residents living with purpose; safe care (including clinical outcomes); staff well-being and job satisfaction were important, but underacknowledged. Limitations: Many of our findings stem from self-reported and routine data with known biases – such as under reporting of adverse incidents; our analysis may reflect these biases. COVID-19 required adapting our original protocol to make it feasible. Consequently, the effects of the pandemic are reflected in our research methods and findings. Our findings are based on data from a single care home operator and so may not be generalised to the wider population of care homes. Conclusions: Innovative and multiple methods and theory can successfully highlight the nuanced relationship between staffing and quality in care homes. Modifiable characteristics such as visible philosophies of care and high-quality training, reinforced by behavioural and relational role modelling by leaders can make the difference when sufficient amounts of consistent staff are employed. Greater staffing capacity alone is unlikely to enhance quality in a cost-effective manner. Social network analysis can help identify the right people to aid adoption and spread of quality and innovation. Future research should focus on richer, iterative, evaluative testing and development of our logic model using theoretically and empirically defensible – rather than available – inputs and outcomes. Study registration: This study is registered as PROSPERO CRD42021241066 and Research Registry registration: 1062. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 15/144/29) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 8. See the NIHR Funding and Awards website for further award information.

Background: Abdominal aortic aneurysm (AAA) screening programmes have been established for men in the UK to reduce deaths from AAA rupture. Whether or not screening should be extended to women is uncertain. Objective: To evaluate the cost-effectiveness of population screening for AAAs in women and compare a range of screening options. Design: A discrete event simulation (DES) model was developed to provide a clinically realistic model of screening, surveillance, and elective and emergency AAA repair operations. Input parameters specifically for women were employed. The model was run for 10 million women, with parameter uncertainty addressed by probabilistic and deterministic sensitivity analyses. Setting: Population screening in the UK. Participants: Women aged ≥ 65 years, followed up to the age of 95 years. Interventions: Invitation to ultrasound screening, followed by surveillance for small AAAs and elective surgical repair for large AAAs. Main outcome measures: Number of operations undertaken, AAA-related mortality, quality-adjusted life-years (QALYs), NHS costs and cost-effectiveness with annual discounting. Data sources: AAA surveillance data, National Vascular Registry, Hospital Episode Statistics, trials of elective and emergency AAA surgery, and the NHS Abdominal Aortic Aneurysm Screening Programme (NAAASP). Review methods: Systematic reviews of AAA prevalence and, for elective operations, suitability for endovascular aneurysm repair, non-intervention rates, operative mortality and literature reviews for other parameters. Results: The prevalence of AAAs (aortic diameter of ≥ 3.0 cm) was estimated as 0.43% in women aged 65 years and 1.15% at age 75 years. The corresponding attendance rates following invitation to screening were estimated as 73% and 62%, respectively. The base-case model adopted the same age at screening (65 years), definition of an AAA (diameter of ≥ 3.0 cm), surveillance intervals (1 year for AAAs with diameter of 3.0–4.4 cm, 3 months for AAAs with diameter of 4.5–5.4 cm) and AAA diameter for consideration of surgery (5.5 cm) as in NAAASP for men. Per woman invited to screening, the estimated gain in QALYs was 0.00110, and the incremental cost was £33.99. This gave an incremental cost-effectiveness ratio (ICER) of £31,000 per QALY gained. The corresponding incremental net monetary benefit at a threshold of £20,000 per QALY gained was –£12.03 (95% uncertainty interval –£27.88 to £22.12). Almost no sensitivity analyses brought the ICER below £20,000 per QALY gained; an exception was doubling the AAA prevalence to 0.86%, which resulted in an ICER of £13,000. Alternative screening options (increasing the screening age to 70 years, lowering the threshold for considering surgery to diameters of 5.0 cm or 4.5 cm, lowering the diameter defining an AAA in women to 2.5 cm and lengthening the surveillance intervals for the smallest AAAs) did not bring the ICER below £20,000 per QALY gained when considered either singly or in combination. Limitations: The model for women was not directly validated against empirical data. Some parameters were poorly estimated, potentially lacking relevance or unavailable for women. Conclusion: The accepted criteria for a population-based AAA screening programme in women are not currently met. Future work: A large-scale study is needed of the exact aortic size distribution for women screened at relevant ages. The DES model can be adapted to evaluate screening options in men. Study registration: This study is registered as PROSPERO CRD42015020444 and CRD42016043227. Funding: The National Institute for Health Research Health Technology Assessment programme.

Markov models are often used to evaluate the cost-effectiveness of new healthcare interventions but they are sometimes not flexible enough to allow accurate modeling or investigation of alternative scenarios and policies. A Markov model previously demonstrated that a one-off invitation to screening for abdominal aortic aneurysm (AAA) for men aged 65 y in the UK and subsequent follow-up of identified AAAs was likely to be highly cost-effective at thresholds commonly adopted in the UK (£20,000 to £30,000 per quality adjusted life-year). However, new evidence has emerged and the decision problem has evolved to include exploration of the circumstances under which AAA screening may be cost-effective, which the Markov model is not easily able to address. A new model to handle this more complex decision problem was needed, and the case of AAA screening thus provides an illustration of the relative merits of Markov models and discrete event simulation (DES) models. An individual-level DES model was built using the R programming language to reflect possible events and pathways of individuals invited to screening v. those not invited. The model was validated against key events and cost-effectiveness, as observed in a large, randomized trial. Different screening protocol scenarios were investigated to demonstrate the flexibility of the DES. The case of AAA screening highlights the benefits of DES, particularly in the context of screening studies.

Building on an approach applied to cardiovascular and cancer research, we estimated the economic returns from United Kingdom public- and charitable-funded musculoskeletal disease (MSD) research that arise from the net value of the improved health outcomes in the United Kingdom. To calculate the economic returns from MSD-related research in the United Kingdom, we estimated (1) the public and charitable expenditure on MSD-related research in the United Kingdom between 1970 and 2013; (2) the net monetary benefit (NMB), derived from the health benefit in quality adjusted life years (QALYs) valued in monetary terms (using a base-case value of a QALY of £25,000) minus the cost of delivering that benefit, for a prioritised list of interventions from 1994 to 2013; (3) the proportion of NMB attributable to United Kingdom research; and (4) the elapsed time between research funding and health gain. The data collected from these four key elements were used to estimate the internal rate of return (IRR) from MSD-related research investments on health benefits. We analysed the uncertainties in the IRR estimate using a one-way sensitivity analysis. Expressed in 2013 prices, total expenditure on MSD-related research from 1970 to 2013 was £3.5 billion, and for the period used to estimate the rate of return, 1978-1997, was £1.4 billion. Over the period 1994–2013 the key interventions analysed produced 871,000 QALYs with a NMB of £16 billion, allowing for the net NHS costs resulting from them and valuing a QALY at £25,000. The proportion of benefit attributable to United Kingdom research was 30% and the elapsed time between funding and impact of MSD treatments was 16 years. Our best estimate of the IRR from MSD-related research was 7%, which is similar to the 9% for CVD and 10% for cancer research. Our estimate of the IRR from the net health gain to public and charitable funding of MSD-related research in the United Kingdom is substantial, and justifies the research investments made between 1978 and 1997. We also demonstrated the applicability of the approach previously used in assessing the returns from cardiovascular and cancer research. Inevitably, with a study of this kind, there are a number of important assumptions and caveats that we highlight, and these can inform future research.