NHS Resources Research Articles

WP1.8 - No, we can’t repair your hernia: An audit to assess pre-operative optimisation for umbilical hernia repair

Abstract Aims The European Hernia Association recently published guidelines which clearly outline the importance of pre-operative optimisation for those undergoing elective umbilical/epigastric hernias. The main factors of importance are: smoking cessation and BMI <35. This audit aimed to identify if we are adequately optimising our patients. Methods We retrospectively evaluated all elective umbilical hernia repairs from 1st January 2022- 31st December 2022 within a district general hospital setting. Clinic letters and pre-operative records were used to ascertain smoking status, BMI and diabetic control (HbA1c). Results 60 umbilical hernias were performed in our district general hospital setting from 1st January 2022- 31st December 2022. Of these patients, 12% (N=7) were known smokers and 13% (N=8) had a BMI of over 35 documented. Additionally, only in 15 cases, was there clear documentation of the patient smoking status. Out of these patients, 9 were subsequently found to be non-smokers and 6 remained smokers despite being given smoking cessation advice. Furthermore, in 10% (N=6) of these cases, there was poor diabetic control (HbA1c > 48), which was not addressed in clinic pre-operatively. Conclusion Patient factors such as smoking, obesity and diabetic control have been shown to significantly increase the rate of post-operative wound infections and complications. Patients are not being adequately optimised for elective procedures which puts them at increased risk of complications and increases the burden on limited NHS resources.

A randomised, two-arm (1:1 ratio), double blind, placebo controlled phase III trial to assess the efficacy, safety, cost and cost-effectiveness of Rituximab in treating de novo or relapsing NS in patients with MCD/FSGS (TURING)

BackgroundMinimal Change Disease (MCD) and Focal Segmental Glomerulosclerosis (FSGS) are a spectrum of disease causing the nephrotic syndrome (NS), characterised by proteinuria with debilitating oedema, as well as a high risk of venous thromboembolic disease and infection. Untreated, 50–60% patients with FSGS progress to end stage kidney disease after 5 years. These diseases respond to immunosuppression with high dose glucocorticoids, but 75% will relapse as the glucocorticoids are withdrawn, leading to significant morbidity associated with prolonged use. In children, the B cell depleting monoclonal antibody rituximab reduces relapse risk, but this drug has not been tested in randomised controlled trial in adults.Methods130–150 adults with new or relapsing MCD/FSGS, from UK Renal Units, are being randomised to receive either rituximab (two 1 g infusions two weeks apart) or placebo. Partipicipants are recruited when they present with nephrosis, and all are treated with glucocorticoids as per KDIGO guidelines. Once in remission, prednisolone is withdrawn according to a pre-specified regimen. If in remission at 6 months, participants receive a further dose of trial drug. If they relapse, they are unblinded, and if they have received placebo, they are offered open label rituximab with protocolised prednisolone as in the main phase of the trial. The primary end point is time from remission to relapse. A number of secondary endpoints will be assessed including the effect of rituximab on: (1) NHS and societal resource use and hence cost: (2) safety: (3) other measures of efficacy, such as achievement of partial and complete remission of NS and the preservation of renal function: (4) health status of participant.Trial RegistrationTURING received ethical approval on 14 Jun 2019 - REC reference: 19/LO/0738. It is registered on EudraCT, with ID number: 2018-004611-50, with a start date of 2019-06-14.

1080 Evaluating the Impact of Bariatric Surgery Tourism on an Emergency Upper GI Service: A Case Series

Abstract Aim The number of individuals seeking weight loss surgery has been increasing globally. It is not uncommon for patients to travel abroad for these procedures due to various reasons, such as cost savings or availability. This audit identifies patients who underwent bariatric surgery abroad and subsequently presented to our hospital, observes trends in presentation, types and frequencies of complications, and management strategies employed. Method A retrospective case study of medical records of patients who presented acutely following gastric bypass, sleeve, or gastric band operations abroad between January 2018 to July 2023 was performed. Results A total of 21 patients were identified. 17 (81%) were female, with mean age 42.2 years. 15 (71.4%) patients presented between 2022-2023, and 5 (33.3%) of these were diagnosed with leak. 11 (52.4%) had undergone sleeve gastrectomy, 6 (28.5%) Roux-en-Y gastric bypass and 4 (19%) gastric band. Operations were performed in 11 different countries, with 10 (47.6%) performed in Turkey. The commonest presenting complaint was abdominal pain (71%). Average Length of stay was 9.1 days (range 1-45). 9 patients (42.9%) had multiple attendances (range 2-6). 7 (33.3%) underwent surgery; 3 laparoscopic removal of gastric band, and 4 emergency procedures for leak, involving either laparotomy and/or endoscopic therapy. Conclusions The number of patients presenting with complications of bariatric surgery tourism has increased year-on-year. This is leading to a growing burden on NHS resources. Healthcare professionals, policymakers, and patients themselves must be aware about the importance of follow-up when deciding to undergo weight loss surgery abroad. A national audit is also warranted.

#1664 Assessing vascular access thrombectomy service adherence to GIRFT recommendations: single centre experience

Abstract Background and Aims Studies showed that early thrombectomy of dialysis vascular access (VA) is associated with better outcomes [1], especially for native VA [2]. Timely treatment of VA thrombosis within 24-48 hours is recommended by GIRFT to minimize access loss and requirement for dialysis line insertion [3]. Our centre has approximately 430 HD patients but has no on-site vascular surgery or vascular access interventional radiology (IR) service. Wait time for elective VA surgery or fistuloplasty is >8 weeks and VA surveillance is based on routine clinical monitoring. VA prevalence is 62% AV fistula (AVF), 2% AV graft (AVG), 36% central venous catheter (CVC). Fistula thrombectomy is provided at another centre, with increasing waiting times over recent years due to shortage of interventional radiologists. This study evaluates adherence to GIRFT recommendations for patients at our centre requiring thrombectomy and will identify potential local strategies to reduce fistula thrombosis and CVC use. Method In a 24-months’ retrospective cohort analysis of maintenance HD patients with permanent VA, we obtained data on: Results 44 patients with permanent VA developed VA thrombosis. The median waiting time for thrombectomy was 8 days (Fig. 1). Post-intervention primary patency rate was 71% at 3-months and 60% at 6-months (Fig. 2). 61% of patients required hospital admission with a 12-day median length of stay, with total inpatient admission days of 403 days over 2 years (2022-2023), and total cost of £246,065 (Figs. 3 and 4). The median CFD-extended was 356 days, i.e. 9 days/patient/year with VA-related complications (Fig. 5). Conclusion This study shows that our centre's VA thrombectomy service falls far outside the GIRFT recommendation of intervention within 24-48 hours. The high associated rates of CVC use, inpatient bed days and avoidable costs place a heavy burden on patient outcomes and NHS resources. The ideal solution of an on-site thrombectomy service is difficult to achieve due to lack of vascular IR support. In response to this study, we now aim to reduce thrombosis rates by training additional interventional nephrologists in elective fistuloplasty, implementing a robust VA surveillance to improve early detection of malfunctioning VA suitable for elective intervention and improving staff education on fistula care.

P115 Thousands of rheumatoid arthritis & juvenile idiopathic arthritis patients benefit from interactive National Rheumatoid Arthritis Society broadcasts

Abstract Background/Aims Pressures on NHS services results in many rheumatology patients missing out on vital information that can support them in understanding and managing their conditions. During the COVID pandemic, NRAS took to social media to host regular live interactive broadcasts to keep people informed on the latest regarding vaccines, staying safe and treatments etc. These proved such a successful way of communicating with people not just across the entire UK but often those from other countries that ‘NRAS Lives’ have become a monthly resource offering covering a multitude of relevant to RA and JIA topics. Methods Originally utilising just Facebook NRAS became aware that this particular platform wasn’t being accessed by all our beneficiaries. At the beginning of 2023 NRAS began to use a new streaming platform ‘StreamYard’ that opened up the opportunity to stream broadcasts on Facebook, Twitter, LinkedIn and YouTube simultaneously, hence reaching many more people living with RA or JIA and rheumatology health professionals. NRAS Lives are hosted on the last Wednesday of every month with usually a panel of guests presenting on a chosen topic and individuals having the ability to pre-submit questions to be addressed on the night relating to the topic as well as the opportunity to post live questions throughout the broadcast. Results As of September 2023 NRAS has hosted eight interactive educational broadcasts reaching almost 15,000 people. Providing people with inflammatory arthritis the opportunity to hear from key opinion leaders and experts regardless of where they are located in the UK or across the world, or their ability to access such opportunities locally. Topics covered include BSR’s new Pregnancy Guidelines; Foot Health & Orthotics; Mental Health & Wellbeing; Support for young adults with IA; Importance of Exercise; Rheumatology Research for All; Remote Monitoring explained with upcoming topics in 2023 being Stress & RA (uneasy bedfellows) and Men with RA ‘The Men’s Rheum’. All live broadcasts are recorded and then hosted on the NRAS YouTube channel and are being freely accessed for ongoing patient and health professional education. Conclusion With more and more patients being moved onto PIFU pathways as well as NHS resources being severely restricted in their ability to offer face to face patient education or indeed for health professionals to have access to experts from a wide variety of backgrounds, these NRAS Lives are bridging those increasing gaps in knowledge sharing. The NRAS YouTube channel is a developing accessible, free library of information which complements other NRAS and NHS resources for both patients and health professionals. Disclosure C.B. Jacklin: None.

Is traditional stone clinic the optimal use of NHS resources?

There is no clear guidance on the efficacy of stone follow-up. NICE have been unable to make recommendations with current published evidence. The aim of this study was to understand the patient journey resulting in surgical intervention, and whether traditional stone follow-up is effective. A retrospective review of patients undergoing ureteroscopy (URS) or percutaneous nephrolithotomy (PCNL) over a 3year period identified 471 patients who underwent these procedures to treat stone disease. Records were interrogated for the following: symptoms, mechanism of booking, reason for intervention, stone size, stone location, risk factors and previous follow-up. Of 471 patients who underwent intervention, 168 were booked from stone clinic follow-up (36%). Of these, 96% were symptomatic and 4% were asymptomatic. When risk factors were removed, this figure was reduced to 1%. Sepsis rate for emergency admissions differs between those followed up (13%) versus new presentations (19)%. There was no statistically significant difference in the outpatient imaging frequency between patients booked from an emergency admission (80% having imaging every 6months) and those from the clinic (82%). Our Hospital provides on average 650 stone clinic appointments a year with a cost of £93,000. Given the low rate of intervention in patients with asymptomatic renal stones, a symptomatic, direct-access emergency stone clinic could be a better model of care and use of NHS resources. Urgent research is required in this area to further assess if this is the case.

Rejection of Fecal Immunochemical Tests Within the Lower Gastrointestinal Diagnostic Pathway: A Cohort Study.

The fecal immunochemical test (FIT) helps triage primary care patients at risk of colorectal cancer (CRC). Improving FIT returns has received recent attention, however uncertainty exists regarding the accurate completion of samples provided for laboratory analysis. This study aims to identify the rejection rate of returned FIT samples and determine rejection causes. FIT samples from symptomatic patients within South Yorkshire, Bassetlaw, and North Derbyshire are processed at a central laboratory. Tests requests are made from 225 GP practices, which serve an estimated 2 million population. This study describes a retrospective review of FIT samples received in the central laboratory between 01/09/19 and 31/12/22. Locally held data was interrogated in March 2023 to determine the number of FIT samples received and rejected during the study period. Documented reasons for rejection were explored to identify common themes. Total FIT specimens received during the study period was 126 422. Of these, 5190 (4.1%) were rejected. Monthly rejection rates fell from 17.4% in September 2019 to 1.3% in December 2022 (P < .001). Sampling errors were the most frequent cause for FIT rejection (2151/5190), with other causes including: expired specimen; no sample collection date/ time, no request form, incomplete patient information and illegible handwriting. This is the first study exploring FIT rejection rates in symptomatic primary care patients, which shows improvements in rejection rates over time. Targeted interventions could improve rejection rates further, thereby reducing NHS resource use and costs and diagnostic delays.

Cost-effectiveness requirements for implementing artificial intelligence technology in the Women’s UK Breast Cancer Screening service

The UK NHS Women’s National Breast Screening programme aims to detect breast cancer early. The reference standard approach requires mammograms to be independently double-read by qualified radiology staff. If two readers disagree, arbitration by an independent reader is undertaken. Whilst this process maximises accuracy and minimises recall rates, the procedure is labour-intensive, adding pressure to a system currently facing a workforce crisis. Artificial intelligence technology offers an alternative to human readers. While artificial intelligence has been shown to be non-inferior versus human second readers, the minimum requirements needed (effectiveness, set-up costs, maintenance, etc) for such technology to be cost-effective in the NHS have not been evaluated. We developed a simulation model replicating NHS screening services to evaluate the potential value of the technology. Our results indicate that if non-inferiority is maintained, the use of artificial intelligence technology as a second reader is a viable and potentially cost-effective use of NHS resources.

1028 Why Is Changing Old Habits So Hard?

Abstract Aim Acute uncomplicated diverticulitis (AUD) has been traditionally managed by inpatient admission for bowel rest, intravenous antibiotics, and fluids. World Society of Emergency Surgery (WSES) updated their guidelines in 2020 recommending that patients with AUD with no significant co-morbidities or immunocompromise should be treated in an ambulatory setting. This full audit cycle aimed to assess the compliance with these guidelines at our trust. Method Retrospective data collection was conducted from June 2021 to July 2021 (1st cycle). Inclusion criteria was applied: CT proven AUD, patients below the age of 80 with the ability to tolerate oral intake, had full mental capacity and were not immunocompromised. Educational sessions for clinicians and nurses were implemented to inform of current guidelines. Data was re-audited from June 2022 to July 2022 (2nd cycle). Results The first cycle included a total of 31 patients with AUD matching our inclusion criteria where 45% of patients were treated via ambulatory care. Two patients had re-presented but didn’t require admission. The second cycle had a total of 19 patients 47% of which were managed ambulatory. Average length of hospital stay between the inpatient and outpatient groups were 2-3 days versus 4.5 hours. Conclusions The compliance rate with current guidelines increased by 2%, however remained low. With low re- presentation rates and re-admission rates, this audit shows that patients with AUD could be safely managed in ambulatory setting. Shifting engrained mindsets and improving compliance with the current guidelines could greatly save NHS resources and alleviate existing bed pressures.

843 Asymptomatic Bacteriuria at Flexible Cystoscopy- Can We Reduce Cancellations?

Abstract Introduction At our trust patients with nitrite positive urinalysis attending for flexible cystoscopy (FC) are rescheduled, placing a heavy burden on over stretched NHS resources. It is accepted that asymptomatic bacteriuria (AB) affects up to 20% of patients over 70. Catheters, stents, and recent antibiotics for a urinary tract infection also significantly increases this risk. Recent evidence suggests that proceeding to cystoscopy in patients with AB is safe, and we evaluated our cohort of patients to identify what proportion of our patients it would be safe to proceed in. Method We reviewed all outpatient FC over a four-month period. We interrogated cancelled FC procedures where patients were cancelled for a nitrite positive urinalysis. Information recorded included result of urine culture, whether an antibiotic was prescribed and risk factors for AB. Results 1241 FC were performed. Mean age was 78.4. In a total, 61 patients (4.9%) were postponed due to nitrite positive urinalysis. 58 (95.1%) patients were asymptomatic, of which 31 (53.4%) demonstrated bacterial growth on culture. Risk factors for AB included catheters (n = 14), a ureteric stent (n = 2), regular antibiotics for recurrent UTIs (n = 27). Conclusions Data collected confirms our cohort is at high risk of AB. Based on the findings from Trail et al, we propose that proceeding to FC in patients with asymptomatic bacteriuria is safe and intend to implement this change in our department. This will reduce demand on FC waiting lists and improve time to diagnosis.

598 Expediting the journey of venous disease management by adopting (one stop vein clinic)

Abstract Introduction As a third of the UK's population is estimated to be affected by varicose veins, which cause around 10% of complications, varicose veins represents a significant part of the surgical workload. To receive their diagnosis and be listed for treatment, patients must attend two outpatient appointments interrupted by ultrasound scans provided by radiographers. Statistical analysis indicated that there was a significant delay from referral to treatment exceeding eight months as a result of a shortage of radiographers which resulted in a delayed ultrasound. Aims Speeding up the management can be achieved by incorporating diagnostic imaging input within the outpatient department by creating a One Stop Clinic where the patient will be examined in the clinic and undergo ultrasound scan by the same vascular surgeon before receiving the management plan in the same setting. Methods A project was started on March 2022 by allowing a vascular surgeon to scan patients under supervision of a radiologist till he is confident to perform it independently. Data showed that 111 patients were scanned in 8 months and were provided the decision plan to intervene immediately following the scan. Treatment was received within 6 weeks following the clinic visit. Conclusion In addition to benefitting patients by providing immediate management plans and early treatment, one-stop vein clinics will also assist in saving the NHS resources, clinic spaces, and costs. Furthermore, it will reduce the workload of radiographers and assist vascular surgeons in mastering the skills of ultrasound, which are becoming a cornerstone of modern vascular surgery.

Outcome monitoring and risk stratification after cardiac procedure in neonates, infants, children and young adults born with congenital heart disease: protocol for a multicentre prospective cohort study (Children OMACp)

IntroductionCongenital heart disease (CHD) represents the most common birth defect, affecting from 0.4% to 1.2% of children born in developed countries. The survival of these patients has increased significantly, but...

Rationing of resources in the National Health Service.

The National Health Service was set up to provide healthcare to every citizen, based not on the ability to pay, but on need. However, the Secretary of State for Health's duty under section 1 of the National Health Service Act 2006 to promote a comprehensive health service is to provide services that can be provided within the resources available. As those resources are not unlimited, it is necessary to ration them. The issue of rationing of resources in the NHS came up again in R (Wallpott) v Welsh Health Specialised Services Committee and Aneurin Bevan University Health Board [2021] EWHC 3291 (Admin). This paper reviews that case and comments on it, looking at why there is rationing of NHS resources and at the approach of the courts to the issue. It concludes that, although rationing of NHS resources is controversial, it is lawful and necessary.

THE HIPHOP STUDY: A FEASIBILITY STUDY FOR A RANDOMIZED CONTROLLED TRIAL OF HYBRID VERSUS CEMENTED TOTAL HIP ARTHROPLASTY

Studies have shown that 10–30% patients do not achieve optimal function outcomes after total hip replacement (THR). High quality randomised controlled trials (RCTs) evaluating the clinical and cost-effectiveness of techniques to improve functional outcomes after THR are lacking. We performed this study to evaluate the feasibility of a RCT comparing patient-reported functional outcomes after hybrid or fully cemented THR (ISRCTN11097021).Patients were recruited from two centres and randomised to receive either a fully cemented or hybrid THR. Data collection included Patient Reported Outcome Measures (PROMs), non-serious adverse events of special interest (AESI), serious adverse device effects (SADE) and NHS resource use. Qualitative interviews were undertaken to understand a) patient experiences of study processes and their reasons for taking part or not, and b) to understand surgeons’ perceptions of the study, factors affecting willingness to participate, and barriers to implementation of the future RCT findings.The target of 40 patients were successfully recruited for the feasibility RCT; the ratio of successful recruitment to eligible patients was 0.61 across both sites. Treatment crossovers occurred in four patients, all related to bone quality. Four patients were withdrawn due to not undergoing surgery within the study window because of the pandemic. Follow-up was 100% and PROMs were completed by all patients at all time points. The feasibility of conducting a within-trial cost-utility analysis was demonstrated. Interviews were conducted with 27 patients and 16 surgeons. Patients and surgeons generally found the study procedures acceptable and workable. Some declined participation because they did not want treatment allocated at random, or because blinding was off-putting. Surgeons’ perceptions of equipoise varied, and implementation of findings from the future RCT would need to recognise the ‘craft’ nature of surgery and the issue of training.We conclude that a full RCT with economic analysis will be both feasible and practicable, although mechanisms to safely implement potential changes to practice because of RCT findings may need consideration by the wider arthroplasty community.

E043 Work resources for people with rheumatic and MSK conditions

Abstract Background/Aims Supporting people with health conditions to remain in work is a UK government priority. We aimed to understand what resources are available from national charities for people with rheumatic and musculoskeletal conditions (RMDs), where people look for information about their condition, how helpful they find information, and identify areas for improvement. Methods National RMD charities were identified, and individual charity websites searched for information on work, and the frequency and extent to which these included key topics. Ten patient contributors provided feedback on the usefulness of topics covered and any gaps. Questions on type and experiences of information accessed were included in a UK cross-sectional web-based survey of people who reported a RMD diagnosis. The survey was co-designed with patient partners and disseminated to charities and social media channels between 30/8/21-26/11/21. Results 18 national RMD charities were identified, and available work information summarised (Table 1). There was significant variation in work information provided, with limited internal signposting between charities to those with more comprehensive resources. External signposting to NHS and government resources was variable and differences in work policy across devolved nations often not acknowledged. 859 people completed the survey. Charity websites, clinical services and friends/family were common sources of information. Compared to people with inflammatory RMDs, those with non-inflammatory RMDs were more likely to be employed/not working because of illness (76.9% v. 64%) and more likely to report difficultly accessing information about their condition (63.8% v. 36.4%). Our patient partners found navigating work information challenging. Improvements suggested included using simpler language and signposting to ‘bona fide’ information. Patients wanted positive patient stories, help with ‘soft skills’ e.g., how to have constructive conversations with their employer, and better employer training. Conclusion Charities have a key role in providing information but could improve signposting between charity websites and to external resources, including positive patient vignettes, and clearer language. People with non-inflammatory conditions feel their information needs are not being met. This provides important guidance to inform development of resources to support people with RMDs to work. Disclosure N. Mishra: None. G. Macfarlane: None. E. Wainwright: None. C. Jenkins: None. M. McAllister: None. K. Walker-Bone: None. R. Hollick: None.

P054 Utilising a pharmacist-designed best value biologic and targeted synthetic shared decision-making tool to empower patients, support clinicians and save NHS resources

Abstract Background/Aims The dynamic pipeline and complex pricing of b/tsDMARD therapies make it challenging for clinicians to compare cost of treatments when undertaking shared decision making with patients in the clinic setting. NHSE have funded development of a Rheumatology Pharmacist designed, web based, best value biologic and targeted synthetic shared decision-making tool (BVBTS-SDMT) using live pricing from the Commercial Medicines Unit. A clinical workbook and treatment pathways have been developed to support the tool. Clinical parameters are entered into the tool, creating a list of available therapies in order of increasing cost relative to the patient’s weight and indication. Treatment pathways are consulted and clinical parameters (e.g. disease phenotype, co-morbidities, response to previous treatment) and patient preferences (e.g. route and frequency of administration, frequency of drug monitoring, personal beliefs) are discussed with the patient and documented in the clinical workbook. Inappropriate therapies are eliminated, identifying the most cost-effective treatment option for the patient synchronously during the consultation. This study explores the potential patient, clinician and cost benefits of adopting the tool in practice. Methods A random sample of 51 patients referred to the rheumatology non-medical prescribing team for starting b/tsDMARDs between 2019 and 2022 were recruited. Electronic records including referral email, patient notes and b/tsDMARD database were evaluated and recorded factors influencing shared decision making were analysed. Two rheumatology specialist pharmacists independently reviewed the historical clinical decision making to determine if the most cost-effective treatment option was chosen once all clinical factors and patient parameters were considered, using a record of historic treatment prices from retrospective homecare invoices and commissioning reports. Differentials between most cost-effective treatment and chosen treatment were calculated. Secondary outcome of comprehensiveness of clinical record was also analysed. Results Between 2019-2022, use of the BVBTS-SDMT would have saved an average of £1,695 per patient in the n = 51 sample. For the 210, 173 and 258 patients newly started on b/tsDMARDs in the years 2019-2020, 2020-21 and 2021-22 respectively, a total of £1,086,495 would have been saved if the tool had been in use. Clinical parameters, patient preferences and cost consideration affecting shared decision making were documented in 49%, 12% and 0% (respectively) of the 51 recruited patients’ clinical records. Conclusion This baseline data collection demonstrates use of the BVBTS-SDMT, in collaboration with treatment pathways and a clinical workbook, has potential to facilitate robust, consistent and methodological shared decision making with patients, encourage accurate reporting in patient records and save NHS money. This is a transformative approach to shared decision making; deviating from the traditional method of giving patients a couple of options to consider and instead working collaboratively through a shared decision-making process to find the most appropriate and cost-effective treatment option for the patient. Disclosure N. Mathews: None. C. McKenzie: None. E. Rose-Parfitt: None.

Pralsetinib for RET Fusion-Positive Advanced Non-small-Cell Lung Cancer: An Evidence Review Group Perspective of a NICE Single Technology Appraisal.

The National Institute for Health and Care Excellence (NICE) invited the manufacturer (Roche) of pralsetinib (Gavreto®), as part of the single technology appraisal (STA) process, to submit evidence for the clinical effectiveness and cost effectiveness of pralsetinib for the treatment of adult patients with rearranged during transfection (RET) fusion-positive advanced non-small-cell lung cancer (NSCLC) not previously treated with a RET inhibitor. Kleijnen Systematic Reviews Ltd, in collaboration with University Medical Center Groningen, was commissioned to act as the independent Evidence Review Group (ERG). This paper summarizes the company submission (CS), presents the ERG's critical review of the clinical and cost-effectiveness evidence in the CS, highlights the key methodological considerations, and describes the development of the NICE guidance by the Appraisal Committee. The CS reported data from the ARROW trial. ARROW is a single-arm, multicenter, non-randomized, open-label, multi-cohort study in patients with RET fusion-positive NSCLC and other advanced solid tumors. The CS included both untreated and pre-treated RET fusion-positive NSCLC patients, among other disease types. The comparators in the untreated population were pembrolizumab + pemetrexed + chemotherapy and pembrolizumab monotherapy. The comparators for the pre-treated population were docetaxel monotherapy, docetaxel + nintedanib, and platinum-based chemotherapy ± pemetrexed. As no comparators were included in ARROW, an indirect treatment comparison was conducted to estimate relative effectiveness. The ERG's concerns included the immaturity of data, small sample size, and lack of comparative safety evidence. The ERG considers the clinical evidence presented to be insufficiently robust to inform the economic model. Even when all the ERG preferred assumptions were implemented in the model, uncertainty remained on a number of issues, such as the appropriateness of the hazard ratios and the methods and data used to derive them, long-term efficacy of pralsetinib, and direct evidence for health-related quality of life (HRQoL). NICE did not recommend pralsetinib within its marketing authorization for treating RET fusion-positive advanced non-small-cell lung cancer (NSCLC) in adults who have not had a RET inhibitor before. The uncertainty of the clinical evidence and the estimates of cost effectiveness were too high to be considered a cost-effective use of NHS resources. Therefore, pralsetinib was not recommended for routine use.

Cost-effectiveness of rapid assessment of potential ischaemic heart disease with CT coronary angiography

ObjectivesTo estimate the cost-effectiveness of early CT coronary angiography (CTCA) for intermediate risk patients with suspected acute coronary syndrome (ACS), compared with standard careMethodsWe performed within-trial economic analysis using data...

43. A Quality Improvement Project: Utilising sedation for Maxillofacial Paediatric Emergency Department patients – an alternative to General Anaesthetic

Background: Treatment of Maxillofacial paediatric emergencies is performed under general anaesthetic (GA) more often than alternative sedation techniques. ‘SIGN’ guidance includes utilising sedation. GA risks include morbidity, mortality and anxiety, which increase with multiple GA’s or reduced age. Dental extractions is the leading reason for paediatric GA’s in the UK and costs the NHS £30m pa. Awareness and utilisation of sedation by Maxillofacial teams could reduce GA admissions, thereby improving quality and safety, whilst reducing burden on NHS resources.

The neurogenic bladder: developing a consensus bladder and bowel management pathway for people with MS.

This article outlines how the bladder can be affected in neurological conditions such as multiple sclerosis (MS) and the impact this has on patient quality of life and NHS resources. A group of MS and bladder and bowel nurse specialists has developed consensus bladder pathways in the hope that all nurses in contact with patients who are likely to have neurogenic bladder symptoms become 'bladder aware'.