UK Health System Research Articles

Associations between extreme heat and hospital length of stay among those hospitalised with cardiovascular disease in Greater London: a population-based longitudinal study between 2007–2019

BackgroundIt is unclear whether a relationship exists between extreme heat and hospital length of stay in the UK. Using healthcare and climate data this study explores the effects of extreme heat on hospital length of stay for individuals hospitalised with cardiovascular disease, a common heat-sensitive condition, in Greater London. MethodsThis longitudinal study included patients registered to General Practices in Greater London (8·908 million inhabitants), hospitalised with cardiovascular disease during summer months of 2007–19. Administrative healthcare data was derived from Clinical Practice Research Datalink and Hospital Episode Statistics. Climate data from the Meteorological Office. The study exposure was extreme heat on day of hospital admission, defined using maximum daily temperature as per the UK Health Security Agency (low-level [28–31·9°C]; medium-level [32–39·9°C]; high-level [≥40°C]). The study outcome was hospital length of stay (days). In main analyses, linear fixed-effects models were used with fixed-effects for practice-by-calendar-day and practice-by-year and inclusion of covariates (daily rainfall, age, sex, deprivation, primary diagnosis, comorbidity). Findings24 435 hospital admissions were included. There were 72 low-level heat days, 11 medium-level heat days and 0 high-level heat days. There was no evidence of association between extreme heat and length of stay in unadjusted (0·03; 95% CI –0·10 to 0·15), and fully adjusted models (0·03; 95% CI –0·09 to 0·16). During medium-level heat, there was a significant association in unadjusted models (–0·27; 95% CI –0·50 to –0·03), and models adjusted by rainfall (–0·26; 95% CI –0·50 to –0·03), age (–0·25; 95% CI –0·45 to –0·04), sex (–0·25; 95% CI –0·46 to –0·05) and deprivation (–0·25; 95% CI –0·45 to –0·04). However, accounting for primary diagnosis (–0·15; 95% CI –0·44 to 0·14) and comorbidity (–0·17; 95% CI –0·46 to 0·12), there was no longer a significant association. InterpretationThis first UK-based study did not identify an association between low-level or medium-level heat on day of hospital admission and hospital length of stay. Further work is needed to evaluate the effects of extreme heat on the UK health system. FundingRP discloses funding from the Oxford Martin School as part of the Future of Cooling Programme. This funding allowed access to the data and paid for research assistant time to support the data management and partial analysis. The funder had no role in designing the question, the analysis or the interpretation of the results.

What are the health system impacts of engaging with global health activity? A qualitative study

Abstract Background Global health partnerships between high-income health systems and low- and middle-income countries (LMICs) are becoming more common as there is an appreciation of the need for collaboration to solve global health issues through knowledge and skill exchange. However, partnership evaluations largely focus on the benefits to individual participants and recipient systems, with little evidence of the impacts on the high-income system. Therefore, the aim of this study was to explore the health system-wide impacts of engaging with global health activity and consider the arguments for and against adopting these partnerships. Methods We carried out semi-structured interviews with individuals from three UK health systems that engage with global health activity to explore their motivations to in doing so. Transcripts were thematically analysed. Results We found that engagement in global health activity can contribute to workforce recruitment, retention, development, and upskilling, benefiting the system. Examples were also given of system-wide clinical, reputational, and economic benefits. However, this activity impacts short term staffing and can cause personal emotional issues that systems need to support. We also explored facilitators of engaging in global health work which included operational support, supporting healthcare staff to engage, and system acceptance. Barriers included lack of senior buy-in, opportunity access inequities, operational challenges, and the current UK health system challenges. Conclusions This study demonstrated the potentially significant system-level benefits of engaging in global health activity. These focused on improved workforce, which is a major public health issue worldwide. We have also identified system characteristics, such as buy-in and operational support, which influence success. We hope this work provides a building block demonstrating there are benefits to be had for donor health systems, but barriers must be overcome. Key messages • The potential benefits and drawbacks that may arise from high-income health systems engaging in global health, as well as facilitators and barriers, are explored. • This study creates a foundation to understand donor-system benefits and encourages further research, particularly in systems who do not engage with global health activity to understand why this is.

The Networked Data Lab: using linked data to understand intermediate care services in the United Kingdom

Intermediate care (IC) is short-term care aimed at maximising patients’ independence. Across the UK, scaling up IC is included in post-pandemic recovery plans. This could reduce pressures on acute services through timely discharge or preventing admissions. The issues IC seeks to address are common across high-income countries. The Networked Data Lab is a network of analytical teams embedded in the UK health and care system. Each year, we support five local partners with acquisition, linkage and analysis of health and social care datasets. Our 2023-24 project is focused on IC. Patients and the public (PP) played an integral role in throughout our project. We established a panel of individuals with lived experience of IC to assist with the research questions, interpretation, and communication of results. Our partners all consult PP in their areas to inform their analyses. Our partners’ analyses of linked patient-level data on IC will provide information about who is receiving IC, changes over time and outcomes for patients. We are also analysing national linked data for England on intermediate care following hospital discharge. Preliminary results include: The age and health needs of people receiving bed-based intermediate care has increased over time (Grampian, Scotland) Intermediate care following a hospital admission is more common for emergency admissions than elective admissions (Leeds, England) Large variation in intermediate care delivery between neighbouring boroughs (North West London, England) Full results are expected in April 2024. Our work highlights the importance of linking data to answer important health and care questions.

Navigating challenges and shaping futures through mental health nursing in the United Kingdom.

WHAT IS KNOWN ON THE SUBJECT?: Mental health nurses in the UK play a critical role in providing care, advocating for patients and navigating the complexities associated with mental health challenges. Acknowledging and supporting the efforts of mental health nurses is essential for advancing mental health care, promoting inclusivity and fostering community resilience amidst ongoing challenges within existing health care organisations. WHAT THIS PAPER ADDS TO EXISTING KNOWLEDGE?: Highlights the integral role of mental health nurses in the UK's health system as both care providers and advocates, underpinning the importance of addressing the growing demand for mental health services Introduces innovative digital tools like the 'Hub of Hope' and the potential of social prescribing as effective strategies for improving access to mental health care and support. Emphasises the need for enhanced support and recognition of mental health nurses to ensure the sustainable advancement of mental health services and the well-being of communities. WHAT ARE THE IMPLICATIONS FOR PRACTICE?: Mental health nurses should integrate innovative digital tools like the 'Hub of Hope' into their practice to improve signposting and access to mental health resources for individuals in need. There is a critical need for ongoing education and support for mental health nurses within practice settings to maintain their well-being and enhance their ability to provide holistic care despite increasing clinical demands. Advocacy for increased investment in mental health resources and support for research activities lead by mental health nurses is essential to address current service gaps and promote the development of more effective interventions.

Estimation of the direct health and indirect societal costs of diabetes in the UK using a cost of illness model.

The direct cost of diabetes to the UK health system was estimated at around £10 billion in 2012. This analysis updates that estimate using more recent and accurate data sources. A pragmatic review of relevant data sources for UK nations was conducted, including population-level data sets and published literature, to generate estimates of costs separately for Type 1, Type 2 and gestational diabetes. A comprehensive cost framework, developed in collaboration with experts, was used to create a population-based cost of illness model. The key driver of the analysis was prevalence of diabetes and its complications. Estimates were made of the excess costs of diagnosis, treatment and diabetes-related complications compared with the general UK population. Estimates of the indirect costs of diabetes focused on productivity losses due to absenteeism and premature mortality. The direct costs of diabetes in 2021/22 for the UK were estimated at £10.7 billion, of which just over 40% related to diagnosis and treatment, with the rest relating to the excess costs of complications. Indirect costs were estimated at £3.3 billion. Diabetes remains a considerable cost burden in the UK, and the majority of those costs are still spent on potentially preventable complications. Although rates of some complications are reducing, prevalence continues to increase and effective approaches to primary and secondary prevention continue to be needed. Improvements in data capture, data quality and reporting, and further research on the human and financial implications of increasing incidence of Type 2 diabetes in younger people are recommended.

Developing a competency framework for integrated care working across healthcare, social care and allied professions

Background/Aims For integrated care to truly become embedded in the UK health and social care system, there is need for a shared understanding of what integrated care looks like at the local level. This study aimed to identify the competencies and behaviours required for working across the full range of health and social care services in the Bedfordshire, Luton and Milton Keynes Integrated Care System. Methods A multi-method approach was used to develop and refine the competency framework. An extensive evidence review of academic and practitioner literature was used to create the initial framework by synthesising previous frameworks. Four multi-agency focus groups were held to conduct utility testing and refine the framework. Quantitative testing was carried out using an 89-item online survey, including questions on the framework, a range of personal and work-related outcomes, and demographic characteristics. The survey was distributed to staff working across 13 different agencies within the integrated care system. Associations between variables were assessed using Spearman's Rho, using the Statistical Package for the Social Sciences. Results The evidence review identified 21 relevant competency frameworks, originating from nine different countries, which were used to create the integrated care competency framework. A total of 91 staff members completed the survey, with results showing acceptable reliability and validity of the final framework (item total correlation >0.2; inter-item correlation ≤0.9). Differences were found between agencies and occupational groups in terms of their integrated care competencies. Those with shorter tenure described greater use of integrated care competencies. Those who demonstrated more integrated care competencies also saw their work as more meaningful and enjoyed greater levels of support from their peers. Conclusions This is the first UK framework of integrated care competencies to be subjected to empirical testing. Initial testing supports the validity and reliability of the framework, as well as showing the positive outcomes associated with integrated working. This framework could be developed and rolled out on a wider scale to support integrated care working.

Development of an implementation science informed "Test Evidence Transition" program to improve cancer outcomes.

Translation of cancer research into practice takes around 15 years. Programs informed by implementation science methods and frameworks offer potential to improve cancer outcomes by addressing the implementation gap. We describe the development of a Test Evidence Transition (TET) program which provides funding and support to health system delivery teams and project design and evaluation partners working together to achieve three objectives: Test innovations to support optimal cancer pathways that transform clinical practice; Evidence the process, outcome, and impact of implementation; and work with strategic partners to ensure the Transition of best practice into effective and equitable adoption across UK health systems. Phase 1 launched in April 2023. Teams with the capability and motivation to implement evidence-based pathway innovations were identified and invited to submit expressions of interest. Following peer-review, teams were supported to develop full proposals with input from academics specializing in health services research, evaluation, and implementation science. Projects were selected for funding, providing an opportunity to implement and evaluate innovations with support from academic and health system partners. TET aims to improve cancer outcomes by identifying and addressing local-level barriers to evidence-based practice and translating findings into consistent and equitable adoption across health systems. Phase 1 projects focus on pathway innovations in diagnosis for breast and prostate cancer. We are now launching Phase 2, focusing on colorectal cancer.

Cost-effectiveness of nivolumab combined with chemotherapy as a first-line therapy for patients with unresectable or metastatic urothelial carcinoma

Background: Urothelial carcinoma is a significant health concern in the United States (US), with high mortality and economic burdens. The CheckMate-901 trial showed promising survival benefits for nivolumab combined with gemcitabine and cisplatin followed by nivolumab maintenance therapy (nivolumab-combination) as first-line treatment of unresectable or metastatic urothelial carcinoma (UC), but its cost-effectiveness is unclear. Objectives: This study aimed to evaluate the cost-effectiveness of the nivolumab-combination versus standard chemotherapy (gemcitabine–cisplatin) for advanced UC from the perspective of healthcare payers in the US. Design: A model-based pharmacoeconomic evaluation. Methods: Based on the CheckMate-901 study, a three-state Markov model (progression-free, progression, and death) was developed to evaluate the cost-effectiveness of nivolumab-combination versus gemcitabine–cisplatin as a first-line treatment for unresectable or metastatic UC. The model’s outputs included quality-adjusted life years (QALYs) and costs and were used to calculate the incremental cost-effectiveness ratio (ICER). Costs included drug prices, adverse event management, and healthcare resource utilization from a US healthcare payer’s perspective. State utilities were derived from published literature. One-way sensitivity analysis and probabilistic sensitivity analysis were used to test model robustness. Scenario analyses for drug costs in the UK and Australian health systems were performed. Results: Compared with gemcitabine–cisplatin, the nivolumab-combination resulted in an additional 0.416 QALYs at an incremental cost of $90,523, yielding an ICER of $217,527 per QALY. Sensitivity analyses indicated significant impacts from the cost of nivolumab maintenance therapy. Conclusion: Compared with gemcitabine–cisplatin, nivolumab-combination therapy is not cost-effective for unresectable or metastatic UC at a $100,000 per QALY threshold. High drug prices in the US significantly impact cost-effectiveness, highlighting the need for price negotiations and healthcare policy adjustments to balance innovation incentives and patient affordability.

Facilitators for increasing dental attendance of people from vulnerable groups: a rapid review of evidence relevant to the UK

AbstractObjective To rapidly review facilitators of access for vulnerable groups and to evaluate their effectiveness.Methods Data sources: MEDLINE via Ovid. Publications in English from 2000. Data selection: Research involving ‘vulnerable groups' relevant to UK health systems, with a primary outcome of increasing attendance. Data extraction: One author extracted and tabulated data. These were audited by a second author. Data synthesis: A narrative synthesis was produced.Results Data from 31 studies were available for ten vulnerable groups: people with learning, physical or sensory disabilities (n = 8); people experiencing homelessness (n = 6); prisoners (n = 4); asylum-seekers and refugees (n = 3); people living in socioeconomically deprived areas (n = 3); people with severe mental health conditions (n = 2); vulnerable children (n = 2); dependent older people (n = 1); Gypsy, Roma or Traveller groups (n = 1); and people with drug dependency (n = 1). Many facilitators involved organisational reform and more integration of health, social and other services. Other facilitators included: modification of premises; team development and skill-mix use; and awareness of needs and flexible services to meet them. Few studies evaluated effectiveness.Conclusion Although facilitators for access for vulnerable groups have been proposed, there is little evidence to support or refute their effectiveness. Efforts are needed to promote access for vulnerable groups in the UK with evaluation plans embedded.

HPR54 Policy Approaches to the Regulation and Reimbursement of Pediatric Medicines: Comparing Canadian, European, and UK Health Systems

HPR54 Policy Approaches to the Regulation and Reimbursement of Pediatric Medicines: Comparing Canadian, European, and UK Health Systems

Abstract 16635: Cost Effectiveness Analysis of the Percutaneous Revascularization for Ischemic Left Ventricular Dysfunction REVIVED Trial Data

Introduction. Evidence on survival benefits of percutaneous coronary intervention (PCI) in patients with severe ischemic left ventricular systolic dysfunction (ILVD) is scant. The REVIVED trial showed that, compared to optimal medical therapy (OMT), revascularisation by PCI did not reduce the incidence of death from any cause or heart failure hospitalization (HF); it also failed to provide sustained improvements in health-related quality of life. REVIVED data are used to evaluate the economic consequences and health outcomes of PCI+OMT and OMT alone in HF patients in the UK. Methods. 700 patients with ILVD were randomised to either PCI+OMT or OMT. Healthcare resource use and patient-reported health outcomes data EuroQol on each patient were collected at baseline and over a period of 8 years post randomisation (median follow up of 3.5 years). Health resources were costed using publicly available national unit costs from the perspective of the UK health system. Within trial mean total costs and quality adjusted life years (QALYs) were estimated and incremental cost effectiveness was evaluated. Regression analysis on total costs and total QALYs was used to adjust for clinically relevant baseline covariables. Probabilistic sensitivity analysis was used to reflect parameter uncertainty. Results. Statistical modelling identified gender, BMI, hypertension, diabetes, NYHA grade and previous hospitalisation as the most relevant baseline predictors of costs and benefits. Over the 8 years of fu, patients undergoing PCI yielded, on average, similar health benefits (4.13 QALYs IC [4.10 - 4.16]) at higher costs (£14,674 IC[£14,334 - £15,014]), compared to OMT (4.16 QALYs [4.13 - 4.19]; £5154 IC [£5,034 - £5,273]). Conclusion. We found no difference in total QALYs between arms and PCI+OMT was not cost-effective compared to OMT, given its additional costs. Therefore, a strategy of routine PCI to treat ILVSD does not appear to be a justifiable use of healthcare resources.

“Zero to Hero”: Conceptualising Time as a Moderator of Nurses’ Emotional Labour on the Front Line

Aim. We aimed to conceptualise how environmental, institutional, and organisational dynamics of the ED underpin and “moderate” nurses’ emotional labour. Background. Around the globe, EDs are struggling to meet rising patient demand including both UK health systems and public services in the US. In spite of these challenges and the intense and distinctive nature of EDs, an exploration of emotional labour is largely missing from current understanding. This is important, in part because emotional labour is established as an indicator of wellbeing including intention to leave, burnout, and compassion fatigue. We understand little of how the environment moderates emotional labour, and our study addressed this problem in the ED. Understanding the moderators of emotional labour, organisational perspective also offers theoretical development. Methods. Ethnography enabled immersion in the ED setting, gathering the lived experiences and narratives of the ED nursing team. This included 200 hours of observation at one District General Hospital and one Major Trauma Centre in the English NHS with 35 semistructured concurrent formal interviews. Results/Conclusions. The ED calls for an extensive spectrum of emotional labour from staff, influenced and moderated by the restrictions on resources, particularly time. We argue that, despite the often short nature of interactions undertaken in ED, the labour required is effortful and gruelling for staff. Understanding the relevance of environmental elements, namely, time, to the emotional labour offers tangible opportunities for improvement. These new understandings can underpin solutions to negative consequences of this work. Suggested measures and interventions to alleviate the impact of emotional labour should be prioritised by policy makers and those tasked with managing, designing, and leading the delivery of care in ED. Implications for Profession and/or Patient Care. The more “sped up” a service is required to be, the higher the likelihood of emotional labour is. In light of the challenges facing healthcare services around the world and the increased throughput through services, particularly in ED, this is important. This is also critical when considering that there are well-established relationships between emotional labour and wellbeing in nursing. Understanding the relevance of the healthcare environment to staff members’ experiences of emotional labour is critical in designing solutions which counterbalance the potentially negative consequences of this work.

Improving primary care based post-diagnostic support for people living with dementia and carers: Developing a complex intervention using the Theory of Change.

The need to improve support following a diagnosis of dementia is widely recognised, but it is unclear how this can best be achieved within UK health and social care systems. A task-shared and task-shifted approach has been recommended, but there is limited guidance on how to achieve this in practice. As part of a programme of research, we developed an intervention to enhance the role of primary care in post-diagnostic care and support for people living with dementia and carers. We used the Theory of Change to develop a complex intervention informed by initial literature reviews and qualitative work. The intervention was developed through an iterative series of workshops, meetings and task groups with a range of stakeholders, including the multidisciplinary project team, people living with dementia and carers, service managers, frontline practitioners, and commissioners. 142 participants contributed to intervention development through face-to-face or virtual meetings. The intervention comprises three complementary strands of work focusing on: developing systems, delivering tailored care and support, and building capacity and capability. Clinical dementia leads, based in primary care networks, will facilitate the intervention providing tailored expertise and support. The Theory of Change proved useful in providing structure and engaging stakeholders. The process was challenging, took longer and was less participative than intended due to restrictions caused by the COVID-19 pandemic. We will next conduct a feasibility and implementation study to explore whether the intervention can be successfully delivered within primary care. If successful, the intervention offers practical strategies for delivering a task-shared and task-shifted approach to post-diagnostic support that could be adapted for similar health and social care contexts internationally.

The benefits and burden of health financing in Indonesia: analyses of nationally representative cross-sectional data

Indonesia has committed to deliver universal health coverage by 2024. Reforming the country's health-financing system is key to achieving this commitment. We aimed to evaluate how the benefits and burden of health financing are distributed across income groups and the extent to which Indonesia has achieved equity in the funding and delivery of health care after financing reforms. We conducted benefit incidence analyses (BIA) and financing incidence analyses (FIA) using cross-sectional nationally representative data from several datasets. Two waves (Feb 1 to April 30, 2018, and Aug 1 to Oct 31, 2019) of the Equity and Health Care Financing in Indonesia (ENHANCE) study household survey involving 7500 households from ten of the 34 provinces in Indonesia were used to obtain health and socioeconomic status data for the BIA. Two waves (2018 and 2019) of the National Socioeconomic Survey (SUSENAS), the most recent wave (2014) of the Indonesian Family Life Survey, and the 2017 and 2018 National Health Accounts were used to obtain data for the FIA. In the BIA, we calculated a concentration index to assess the distribution of health-care benefits (-1·0 [pro-poor] to 1·0 [pro-rich]), considering potential differences in health-care need. In the FIA, we evaluated the equity of health-financing contributions by socioeconomic quintiles by calculating the Kakwani index to assess the relative progressivity of each financing source. Both the BIA and FIA compared results from early 2018 (baseline) with results from late 2019. There were 31 864 participants in the ENHANCE survey in 2018 compared with 31 215 in 2019. Women constituted 50·5% and men constituted 49·5% of the total participants for each year. SUSENAS had 1 131 825 participants in 2018 compared with 1 204 466 in 2019. Women constituted 49·9% of the participants for each year, whereas men constituted 51·1%. The distribution of health-care benefits in the public sector was marginally pro-poor; people with low income received a greater proportion of benefits from health services than people with high income between 2018 (concentration index -0·008, 95% CI -0·075 to 0·059) and 2019 (-0·060, -0·139 to 0·019). The benefit incidence in the private health sector was significantly pro-rich in 2018 (0·134, 0·065 to 0·203, p=0·0010) and 2019 (0·190, -0·192 to 0·572, p=0·0070). Health-financing incidence changed from being moderately progressive in 2018 (Kakwani index 0·034, 95% CI 0·030 to 0·038) to mildly regressive in 2019 (-0·030, -0·034 to -0·025). Although Indonesia has made substantial progress in expanding health-care coverage, a lot remains to be done to improve equity in financing and spending. Improving comprehensiveness of benefits will reduce out-of-pocket spending and allocating more funding to primary care would improve access to health-care services for people with low income. UK Health Systems Research Initiative, UK Department of International Development, UK Economic and Social Research Council, UK Medical Research Council, and Wellcome Trust.

Very rapid insight generation to support UK health and care systems: An AHSN approach.

COVID-19 challenges are well documented. Academic Health Science Networks (AHSNs) are a key partner to NHS and care organizations. In response to managing COVID-19 challenges, Wessex AHSN offered rapid insight generation and rapid evaluation to local NHS and care systems to capture learning during this period. This novel "Rapid Insight" approach involved one-off online deliberative events with stakeholders to generate insights linked to specific, priority areas of interest, followed by rapid analysis and dissemination of the findings. Key objectives were to enable system leaders to build their adaptive leadership capability and learn from the experience of COVID-19 to inform recovery planning and system support. Rapid Insight (RI) gathered together health and care professionals into a tightly managed, virtual forum to share system intelligence. Focused questions asked about the systems' response to the pandemic, what changes to continue and sustain, or discontinue. Participants responded simultaneously to each question using the virtual chat function. Immediate thematic analysis of the chat conducted in 48-72 h by paired analysts for each question strengthened analytical integrity. Mind maps, the key output, provided easily assimilated information and showed linkages between themes. Telephone or virtual interviews of key informants (health and care professionals and patients) and routinely collected data were synthesized into short reports alongside several RI events. However, insufficient time limited the opportunities to engage diverse participants (e.g., mental health users). Data from RI can scope the problem and immediate system needs, to stimulate questions for future evaluative work. RI facilitated a shared endeavor to discover "clues in the system" by including diverse opinions and experience across NHS and care organizations. Although these rapid virtual events saved on travel time, digital exclusion might constrain participation for some stakeholders which needs other ways to ensure inclusion. Successful rapid engagement required Wessex AHSN's existing system relationships to champion RI and facilitate participant recruitment. RI events "opened the door" to conversations between up to 150 multi-professional clinicians to share their collective response to COVID-19. This paper focuses on the RI approach with a case example and its further development.

Comparative cost-effectiveness of alternative imaging and surveillance schedules for testicular seminoma in the TRISST trial.

408 Background: Risk of radiation exposure from standard computed tomography (CT) surveillance is a major concern in the management of stage I seminoma testis patients. The TRISST randomized trial (NCT00589537) demonstrated that effective monitoring could be achieved with a reduced scan schedule or using Magnetic Resonance Imaging (MRI) instead of CT. Here, TRISST data is used to evaluate the economic consequences and health outcomes of different surveillance schedules in seminoma patients in the UK. Methods: 669 men were randomized to 4 surveillance groups undergoing 7 CTs over 5 years, 3 CTs over 3 years, 7 MRIs, or 3 MRIs of the retroperitoneum. Resource use (including investigations, scans, hospitalisations and treatment for relapse) and health outcomes data (EQ-5D 3L) on each patient were collected at baseline and over a period of 6 years after randomization. Health resources were costed using publicly available national unit costs. Within-trial mean total costs and quality-adjusted life years (QALYs) were estimated for each alternative schedule. Under the perspective of the UK health system, cost-effectiveness was evaluated using a cost per QALY gained framework. Probabilistic sensitivity analysis was used to reflect parameter uncertainty and evaluate results robustness. Results: Since only 82 men (12%) relapsed, most health resource consumption (76%) happened during the disease-free period. Patients undergoing 7 MRIs yielded, on average, slightly higher health benefits (5.20 QALYs) but at higher costs (GBP £6,632, see table). Compared to 7 CTs, 7 MRIs was estimated to have 63% probability of being cost-effective at a system willingness to pay threshold of £20k/QALY. 3 MRIs had similar costs and benefit to 7 CTs, whereas 3CTs was more expensive than 7 CTs and 3 MRIs, providing marginal additional benefits. Conclusions: Overall, small differences exist in total costs and total QALYs between different strategies. A 7 scan MRI schedule yielded more health benefits than other strategies, but at higher costs. Considering possible capacity constraints with MRI, the reduced radiation exposure relative to CT, and non-inferiority for clinical outcomes in the primary analysis, a 3 scan MRI schedule may be the best option to replace current CT-based longer surveillance practice. Clinical trial information: NCT00589537 . [Table: see text]

Palliative care, homelessness, and restricted or uncertain immigration status.

People experiencing homelessness have limited access to palliative care support despite high levels of ill health and premature mortality. Most research exploring these challenges in the United Kingdom has focused on people living in hostels or temporary accommodation. People with uncertain or restricted immigration status are often unable to access this accommodation due to lack of entitlement to benefits. There is little research about the experiences of those in the United Kingdom who cannot access hostels or temporary accommodation due to restricted or uncertain immigration status with regards to palliative and end-of-life care access. To explore the barriers to palliative and end-of-life care access for people with uncertain or restricted immigration status, who are experiencing homelessness and have advanced ill health, and the experiences of UK hospices of supporting people in this situation. A multi-method cross-sectional study. An online survey for hospice staff followed by online focus groups with staff from inclusion health, homelessness and palliative care services, charities and interviews with people experiencing homelessness. Fifty hospice staff responded to the online survey and 17 people participated in focus groups and interviews (focus groups: n = 10; interviews: n = 7). The survey demonstrated how hospices are not currently supporting many people with restricted or uncertain immigration status who are homeless and that hospice staff have received limited training around eligibility for entitlements or National Health Service (NHS) care. Interview and focus group data demonstrated high levels of unmet need. Reasons for this included a lack of consistency around eligibility for support from local authorities, issues relating to NHS charging, and mistrust and limited knowledge of the UK health and social care system. These barriers leave many people unable to access care toward the end of their lives. To advocate for and provide compassionate palliative and end-of-life care for people with uncertain immigration status, there is need for more legal literacy, with training around people's entitlement to care and support, as well as easier access to specialist legal advice.

PS-C36-9: A REVIEW OF THE PHARMACOKINETIC PROFILES OF THE 40 MOST COMMONLY PRESCRIBED CARDIOMETABOLIC MEDICATIONS

Objective: To collate the pharmacokinetic (PK) parameters of the 40 most commonly prescribed cardiometabolic medications from published literature to provide a useful reference source for clinicians when interpreting results of chemical adherence testing. Design and Methods: Non-adherence to medication is a prime cause of treatment failure and costs the UK health system approximately £500 million annually. A recent meta-analysis on adherence to 7 cardiovascular drug classes revealed a non-adherence rate of 43%. Chemical adherence testing (CAT) by liquid chromatography tandem mass spectrometry (LC-MS/MS) is an objective method for testing patient adherence to medication and has been proven to be effective in managing disease progression. To improve result interpretation, factors including dose time, sample collection, and PK need to be better understood. The list of the most commonly prescribed drugs was obtained using the NHS Prescription Cost Analysis 2020/2021. Data on the pharmacokinetic parameters was collected from original papers from the following sources: Lexicomp: Medical Library Goodmans & Gilmans: The pharmacological basis of therapeutics, 13th edition Clarks analysis of drugs and poisons 4th edition Martindale: The complete drug reference All original manuscripts were reviewed, filtered and graded, following a robust criteria. The collected PK parameters focused on the bioavailability, volume of distribution, peak concentration, minimum plasma concentration, time to peak concentration, half-life, clearance and urine excretion. Results: A total of 3004 papers were initially screened for pharmacokinetic data, of which, 274 papers were relevant. These papers were further filtered, a total 84 papers adhered to the criteria for grading. Propranolol was one of the most prescribed cardiometabolic drugs with 6,124,180 prescriptions issued in the UK between 2020–2021. The half-life for Propranolol 80 mg (3.5 h), the peak time (1.5 h), the peak concentration (49 ± 8 ng/mL). Edoxaban was prescribed 1,584,638 times in the time period selected. Mean PK parameters for steady state levels of Edoxaban were: bioavailability (99.7%), urine excretion (44.7 ± 14.8%), clearance (535 ± 15.5 mL/min), volume of distribution (426 ± 30.7 L), half-life (9.2 ± 30.5 h), peak time (2 ± 1.03) and peak concentration (507 ± 17.3 ng/mL). Conclusions: This is one of the first studies to utilise a criteria for collecting and grading of PK parameters from published literature for common cardiometabolic medications. Medications have diverse pharmacokinetic profiles hence; systematic collection of these parameters will be a useful reference for clinicians when interpreting results of CAT for medication presence in patient samples.

HPR11 Could DiGA be a Role-Model for a New Digital Health Process in the UK?

To assess the market access and pricing process for digital health applications in Germany and its applicability into a UK health systems environment.

Cost-effectiveness of 5 fraction and partial breast radiotherapy for early breast cancer in the UK: model-based multi-trial analysis

PurposeWe estimated the cost-effectiveness of 4 radiotherapy modalities to treat early breast cancer in the UK. In a subgroup of patients eligible for all modalities, we compared whole-breast (WB) and partial breast (PB) radiotherapy delivered in either 15 (WB15F, PB15F) or 5 fractions (WB5F, PB5F). In a subgroup ineligible for PB radiotherapy, we compared WB15F to WB5F.MethodsWe developed a Markov cohort model to simulate lifetime healthcare costs and quality-adjusted life years (QALYs) for each modality. This was informed by the clinical analysis of two non-inferiority trials (FAST Forward and IMPORT LOW) and supplemented with external literature. The primary analysis assumed that radiotherapy modality influences health only through its impact on locoregional recurrence and radiotherapy-related adverse events.ResultsIn the primary analysis, PB5F had the least cost and greatest expected QALYs. WB5F had the least cost and the greatest expected QALYs in those only eligible for WB radiotherapy. Applying a cost-effectiveness threshold of £15,000/QALY, there was a 62% chance that PB5F was the cost-effective alternative in the PB eligible group, and there was a 100% chance that WB5F was cost-effective in the subgroup ineligible for PB radiotherapy.ConclusionsHypofractionation to 5 fractions and partial breast radiotherapy modalities offer potentially important benefits to the UK health system.