Health Economics and Outcomes - CLAHRC Community e-newsletter Issue 86

Published Date: 30 Aug 2019

Welcome to the community e-newsletter for the NIHR CLAHRCs, bringing you news from across the thirteen collaborations and the health services research community.


East of England: Register now for our 'Mindfulness for Workforce Wellbeing' event bringing together health & social care practitioners and researchers on 8th October, Cambridge
PenCLAHRC: Our Contribution to a national how-to guide to help accelerate the spread of ‘game-changing’ mechanical thrombectomy emergency treatment for acute stroke - More…

CLAHRC Yorkshire and Humber 
Health Economics and Outcomes Measurements in Yorkshire and Humber
Cardiac rehabilitation
The clinical benefits of cardiac rehabilitation (CR) after a heart attack are well known, however, uptake is poor, and there has been almost no research into the cost-effectiveness of the current approach, or the potential gains from increasing uptake. Furthermore, the impact of inequality is significant, with uptake almost 40% less in the most deprived. 
We produced a mathematical model to explore the population health and NHS cost implications of cardiac rehabilitation given the effectiveness demonstrated in the latest systematic review of trial evidence.  We concluded that CR was cost-effective, with the potential to save 20,000 lives and 50,000 hospital admissions over a 10 year period if uptake was increased to the 85% target.  These findings have significantly impacted on policy discussions, being the justification for increasing uptake in England in both the NHS Long Term Plan and the British Heart Foundation’s Turning Back the Tide Framework.
Contact: Seb Hinde

ReQoL Implementation work
Following the success of last year’s Recovering Quality of Life (ReQoL) in Practice conference, we launched an online Community of Practice (CoP).  The ReQoL CoP is an online space where people implementing or wishing to implement ReQoL within their Trust can come together to share learning about the implementation issues, processes, barriers and facilitators. 
The CoP currently features posts from:

  • Tracy Gilzene on how Berkshire Healthcare NHS Foundation Trust decided what outcome measures to use and how they rolled ReQoL out.
  • Hilary Charlton on implementation of ReQoL in Sussex Partnership NHS Foundation Trust,
  • Gail Harrison on her experience in Leeds and York Partnership NHS Foundation Trust of introducing ReQoL in the Rehabilitation and Recovery service.
  • Anne Crawford-Docherty, Recovery College, Black Country Partnership NHS Foundation Trust on how they are embedding ReQoL 20 in their Care Programme Approach. 

If you would like to join the CoP, please email

Using capability wellbeing measures to inform outcome-based commissioning at Gloucestershire CCG
Healthcare commissioners need to look at both the costs and benefits of individual services when deciding which services should be provided for people locally.
It is usually possible to work out the cost of services, but it is harder to measure how much they are helping people. This is particularly the case when services benefit the patient in ways beyond their physical health.
In this study, CLAHRC West are working with commissioners in Gloucestershire Clinical Commissioning Group (CCG) to test the use of a different way of measuring outcomes aimed at assessing patients’ ‘capability wellbeing’, which means their ability to do and be things in life that are important to them.
Read more

CLAHRC South London
Evaluating an innovative mental health service in Lambeth
A team of improvement science specialists from King’s Improvement Science at CLAHRC South London have completed an evaluation of work at the Lambeth Living Well Network Hub, an innovative primary care-based mental health service in Lambeth. The Hub opened in June 2015 and acts as an access point for Lambeth residents who need advice and support about mental health problems and mental wellbeing.
The evaluating team included health economists. They examined Hub activity and costs and the impact on Lambeth resident referrals received by local secondary mental health services using electronic patient records data. The Hub was found to be a relatively low cost (and high volume) service. After adjusting for wider referral trends, it was estimated to have reduced referrals into local assessment and liaison teams in Lambeth by 20% (around 44 referrals per month).
Read more.

Evaluating the impact of obesity in pregnancy on health service costs
Health economists within the Centre of Implementation Science at the CLAHRC have assessed the impact of obesity in pregnancy and retention of early pregnancy weight on health service contacts and costs. The health economists analysed data from a feasibility trial being conducted by the CLAHRC’s maternity and women’s health researchers. They found that:

  • The costs of contact with health professionals and services for pregnancy-related reasons were estimated to be 62% higher for women who fell within the body mass index (BMI) obese range at first antenatal booking, compared to women who fell within the overweight range.
  • The additional costs of A&E attendance by overweight and obese pregnant women who retained their weight postnatally over 12 months, crudely translated into an extra 60 to 65 visits per 100 women.

Read how the researchers are helping new mothers to lose weight

An economic perspective on childhood obesity
National concern about obesity is reflected in recent government policies. There is debate, however, over how best, and to what extent, it is appropriate to intervene. A PenCLAHRC-supported PhD project, ‘An economic perspective on childhood obesity: exploring the causes and consequences of childhood obesity’ seeks to create a more detailed understanding of the causes and consequences of childhood obesity by employing an economics perspective to help design more effective public policy to address the issue.
Economic analyses can add insight to how people make choices over food, health and obesity. Economics puts a spotlight on the key trade-offs people confront and how these are affected by the circumstances they can and can’t control. Using current statistical data and literature on childhood obesity the project aims to estimate the future impact of childhood obesity on health events/outcomes and broader societal outcomes, employing an econometric framework to explore potential causes.

Cost effectiveness of screening and community treatment for Chronic Viral Hepatitis
Chronic viral hepatitis can lead to cirrhosis and death in a large proportion of those infected and its prevalence is at least ten times greater in the migrant community compared to the indigenous community. Data indicate that mortality and morbidity in ethnic minority groups with chronic viral hepatitis is growing rapidly, with UK studies showing that access to therapy for patients is poor, with only a minority going on to receive treatment. Early identification allows effective therapy for patients, shown by NICE to be highly cost effective.
Strategies that improve access to treatment are likely to have a major impact on treatment uptake but alternatives to hospital-based treatment have not been studied. PenCHORD, have contributed economic modelling to a collaborative project to help determine the cost effectiveness of screening and therapy and whether community treatment improves and increases the engagement of patients accessing effective therapies.
Read more.

Discussing services for self-harm prevention in Parliament
Ground-breaking research by CLAHRC Oxford supported researchers into the cost of hospital care for people who self-harm emphasises the pressing need for more effective clinical services and prevention initiatives. The economic case presented bolsters the compelling argument to improve services for those who self-harm, given the increasing incidence and the impact it can have on people’s lives.
Published in the Lancet Psychiatry the researchers showed that showed that the average cost for each episode of self-harm was £809, with higher costs for adolescents than adults. They estimated that if such costs apply to all self-harm episodes presenting to hospitals in England the overall cost to the NHS amounts to £162 million each year.
The researchers were invited to present these findings to the All-Party Parliamentary Group on Suicide and Self-harm Prevention.
Read more here and here.

Making a difference early in psychosis
Psychosis can completely derail a person’s life, leading to long-term mental and physical disability. It’s also a very stigmatised and misunderstood condition. It’s also far more common than people might think, with latest estimates indicating that 0.7% of adults across England aged 16 and over experienced psychosis in 2014.
Our evaluation of early treatment for psychosis services shows it results in a much better outlook for patients and saves the NHS a significant amount of money.
This work informed updated clinical guidelines recommending a two-week referral for patients showing signs of psychosis, meaning they now get rapid access to treatment, get better faster and can go on to lead healthier lives.
Read more here and here

CLAHRC North West London
Cost-Effectiveness Analysis of Comprehensive Medication Review For Patients Acutely Admitted To Hospital
Problematic polypharmacy can lead to adverse drug events, drug-drug interactions, low adherence, reduced quality of life and increased treatment costs. Comprehensive medication review (CMR) is a patient-centred intervention of examining all current medications aiming to reach an agreement with the patient about treatment. A systematic literature review found that CMR may reduce emergency department contacts by 27%. However, the cost-effectiveness of CMR in the UK NHS acute care setting is so far unknown.
NIHR funded PhD student Tomasz Szymański aims to estimate the cost-effectiveness of CMR compared with usual care for patients (≥ 65 yo) acutely admitted to hospital from the perspective of the NHS. A decision analytic model was developed to assess the costs and health consequences associated with CMR over 12 months. Primary Analysis showed the cost-effectiveness of CMR compared to the control arm was dependent on time taken to complete the intervention by pharmacists.
Read more

CLAHRC North West Coast
The impact of free access to swimming pools on children's participation in swimming. A comparative regression discontinuity study.
Objective was to investigate the extent to which providing children with free swimming access during school holidays increased participation in swimming and whether this effect differed according to the socioeconomic deprivation of the neighbourhoods in which children lived.
The setting was a local authority (LA) in North West England with outcome measures of number of children swimming, and the number of swims, per 100 population in 2014.
Summary of Results: Free swimming during the summer holidays was associated with an additional 6% of children swimming and an additional 33 swims per 100 children per year. The effects were greatest in areas with intermediate levels of deprivation.
Outcome: Providing free facilities for children in disadvantaged areas is likely to increase swimming participation and may help reduce inequalities in physical activity.
Read more

Socio-economic factors influencing A&E attendances
The aim of this study was to identify the most important determinants of accident and emergency (A&E) attendance in disadvantaged areas. A total of 3510 residents from 20 disadvantaged neighbourhoods in the North West Coast area completed a comprehensive public health survey.
Participants were asked to complete general background information, information about their physical health, mental health, lifestyle, social issues, housing and environment, work and finances and healthcare service usage.
This is one of the first surveys to explore a comprehensive set of socio-economic factors as well as proximity to both GP and A&E services as predictors of A&E attendance in disadvantaged areas. Findings from this study suggest the need to address both socioeconomic issues, such as employment and housing quality, as well as structural issues, such as public transport and access to primary care, to reduce the current burden on A&E departments.

CLAHRC North Thames
Economic case for extended thrombectomy treatment times for stroke
In a podcast hosted by the International Journal of Stroke, CLAHRC North Thames health economist Dr Pizzo discusses her work on improving the treatment of stroke patients in the crucial first 24 hours after the condition strikes.
Ischaemic stroke is the most common type of stroke, occurring when a blood clot blocks an artery cutting blood flow to part of the brain. The podcast is based on a paper Dr Pizzo published earlier this year which demonstrated the benefit of mechanical thrombectomy - an intervention to remove clots - performed between 6 and 24 hours in acute ischemic stroke.
Current economic evidence supports the intervention only within 6 hours, but the published research showed that extended thrombectomy treatment times, of up to 24 hours, may result in better long-term outcomes for a larger cohort of patients.
Contact Elena Pizzo

CLAHRC Greater Manchester 
Evaluation of 7 day access in primary care
Working in collaboration with NHS England Greater Manchester and the Greater Manchester Health and Social Care Partnership, we conducted an evaluation of the roll out of 7 day access to primary care across the Greater Manchester region.
Semi-structured interviews explored the processes by which implementation took place, and quantitative data-sets assessed the nature and levels of activity associated with the provision of 7 day access and its impact on the use of secondary care and out-of-hours services.
The findings have informed the piloting and subsequent roll-out of 7 day access to the 4 million residents of Greater Manchester, and beyond as an academic partner on an evaluation of NHS England’s £100 million GP Access Fund programme. This has ensured that decision making by commissioners about service models of 7 day access nationally are informed by a high-quality and reliable evidence base.
Read more

Greater Manchester workforce in primary care
Working closely with NHS England Greater Manchester and the Greater Manchester Health and Social Care Partnership to explore long-term workforce challenges in general practice across the region. One work package from this project was to conduct a baseline audit of the total staff employed in general practice across Greater Manchester, to enable a better understanding of current workforce capacity.
Variations in workforce were found across and within CCGs but there was limited evidence of variations in workforce over time. Data coverage is a concern with existing workforce data sources and a key element of the work involved assessing how representative the findings are. These findings have informed the primary care workforce strategy for Greater Manchester.
Read more.

CLAHRC East of England 
Valuing Health Related Quality of Life (HRQoL) outcomes in heart failure: the valuable study   
Heart failure is common, affecting over 0.5 million in the UK, and annually costs the NHS over £2.3 billion. It impacts on people's quality of life (QoL). Making optimal decisions about service provision necessitates understanding how people value QoL improvements. CLAHRC EoE researchers (including Helen Hall, a former CLAHRC EoE Fellow) are working to understand the value placed on different outcomes.
In Valuable, 23 people with heart failure and their carers were interviewed. Recruited from Great Yarmouth and Waveney (a ‘population in focus’ for the ARC EoE from October 2019), participants took part in four focus and two consensus groups. Nominal group technique ascertained patient priorities for improving QoL.
Ultimately, the generated evidence will help ensure that decisions made by CCGs, NICE and other decision-makers focus on the most meaningful improvement for patients.
Contact Helen Hall:

Estimating the loss in quality of life (QoL) associated with an asthma-related crisis event
For her CLAHRC EoE PhD, Christina-Jane Crossman-Barnes asked 121 patients to complete a range of outcome measures. From these, the loss in QoL associated with an asthma-related crisis event resulting in an accident and emergency attendance, or hospital admission, was estimated. Consequently, studies that capture outcomes in terms of such events will now be able to convert their outcomes into QALYs, as recommended by the National Institute for Health and Care Excellence (NICE). Recommendations about whether NHS provision of particular interventions constitutes value for money can thereby be more readily made as a result of these findings. Results have been published in Crossman-Barnes et al., (2018) and Crossman-Barnes et al. (2019).

CLAHRC East Midlands
Coping with distress about your health
Severe health anxiety is persistent worry about health, which is thought to occur in about 5% of the general population. It can lead to increased, unscheduled/urgent use of health services.
A CLAHRC East Midlands study investigated whether remotely delivered Cognitive Behavioural Therapy (rCBT), via video calling or phone, improved clinical and economic outcomes.
rCBT was shown to bring patients significant improvements in health anxiety at 6 months, maintained at 12 months, compared to those who accessed usual treatment. General anxiety, depression and overall health also improved at 12 months.
There were cost savings of £1,000 per patient (over 12 months) in terms of reduced use of NHS services. The study suggests that targeted rCBT is an effective and cost-saving method of improving self-management in repeat users of unscheduled care who have previously been difficult to engage with traditional mental health services.
Read more