Transcript 10) Laurence Moore SEWAHSP - School of Medicine

Moving upstream:
SEWAHSP and Public Health
Laurence Moore
DECIPHer
Schools of Social Sciences and Medicine
Cardiff University
•
•
•
•
•
Why move upstream?
Action outside NHS to support NHS needs
How to more forward
Local excellence
Future potential
Upstream-Downstream
Why focus upstream?
A: To Improve Public Health
Since 1900, the average life expectancy for
Americans has increased by about 30
years. Public health initiatives account for
about 25 of those additional years.
*Turnock, BJ. Public Health: What it is and How it Works, 3rd Edition.
Sudbury, MA: Jones and Bartlett Publishers, 2004.
Top 10 Public Health Achievements
 Increased average lifespan
1900: 49 years
1999: 75 years




Sanitation and water
Vaccination
Control of Infectious Disease
Safer Workplaces
Top 10 Public Health Achievements





Healthier mothers and babies
Family planning
Safer food
Heart disease and stroke prevention
Smoking
Public health improvements = 20 years added to lifespan
Medical improvements = 5 years added to lifespan
Why focus upstream?
B: To Help Sustain NHS
Wanless: critical importance of public health in defining the
affordability of the NHS
Threats to NHS sustainability:
• Health inequalities
• Obesity
• Alcohol
• Diabetes
• Chronic disease
• Mental Health
• Cancer
All avoidable!
Nice in theory
“Health promotion doesn’t work”
“No evidence base"
Nice in theory
“Health promotion doesn’t work”
“No evidence base"
Owen et al (2011) J Public Health
“With pressure on budgets and fundamental
changes underway in the NHS and public health
structure, there is a need for evidence to support
the case for investing in public health
interventions. This is the first study to provide a
comprehensive list of the cost-effectiveness of
public health interventions. Using a standard set
of methods, the analysis has shown that the vast
majority of public health interventions
considered thus far by NICE are highly costeffective.”
Cost-effective solutions often lie
outside the NHS
• As with infectious disease…..
• …environmental health….
• effective preventative actions lie outside the
NHS
How to move forward?
• Transdisciplinary action research partnerships
– Researchers from multiple disciplines working with
policy and practice partners on NHS priorities
– Behavioural, social, environmental, organisational
sciences as well as medical and health sciences
– Applied team science focussing on research
questions identified by service partners
– Multiphase projects, complex interventions
– What works, for whom, under what circumstances,
why and at what cost?
“Funded by the National Institute for Social Care
and Health Research (NISCHR) in October
2006, the South East Wales Trials Unit draws
together existing expertise in trials and other
well designed multi-centre studies to form an
experienced team to support excellence in
Wales.”



Around 55 staff
Psychologists, statisticians, dieticians, midwives,
sociologists, IT specialists, qualitative
researchers etc
2011/12 running 62 studies totalling £44,355,865
Sample subheading sample heading
Knowledge Exchange Cycle
Front line
Innovation
Local focus
Practice /
Policy
Evidence gaps
Research questions
Ivory towers
Synthesis and
translation
Evidence generation
REF / RAE
Research
Agenda
Publications
Excellent environment to support applied
public health / primary care research
and translation to improve services
• Service-relevant applied research questions to
drive agenda and resource allocation
• Attract excellent research teams to form
around these questions
• Requires supportive processes and criteria
– DECIPHer/PHIRN RDG model
– SEWTU model
– Bristol Health Partners HIT model
Stemming the tide of antibiotic
resistance (STAR). A blended learning
programme addressing appropriate
antibiotic prescribing in general practice.
What the clinicians said?
• GPs were concerned about the issue of antimicrobial resistance and
agreed it was growing.
• Many said they infrequently encountered its consequences in their
practice and some questioned the evidence linking their prescribing
decisions to resistance and poorer outcomes for their patients.
• They felt conflicted by their apparent inability to influence the
problem in the face of many other competing demands.
• They would welcome more information about resistance patterns
locally, and felt that undergraduate and graduate education about
antimicrobial prescribing and resistance should be enhanced.
• A few mentioned that a heightened awareness of antimicrobial
resistance locally may cause them to prescribe more second line
agents as empirical therapy
What next?
• A group of clinicians, psychologists,
statisticians, web designers, educationalists,
health economists etc got together.
• We developed a theory based ‘blended
learning’ programme to promote appropriate
antibiotic prescribing.
Method
• The study is a randomized controlled trial
with general practices as the unit of
randomization and analysis.
• Process evaluation.
• Cost effectiveness evaluation
Study Recruitment and Training
 70 practices recruited across Wales
 68 practices randomised (2 withdrew)
 33 practices each in the Experimental and Control Group
 Experimental Group:
 33 seminars completed
 127 GPs/NPs completed online training
 31 process evaluation interviews conducted
 Control group:
 117 GPs/NPs participating
Results: Cost Effectiveness
• The mean cost of the STAR Educational
Program was £2,923 per practice (SD =
£1,187).
• There was a 5.5% reduction in the cost of
dispensed antibiotics in the intervention
group compared to the control (p = 0.07)
equivalent to a reduction of about £830 a
year for an average intervention practice.
4 year follow-up data
• After controlling for baseline dispensing
rate, there was a 6.2% (95% CI=1.7%,
10.6%) reduction in total oral antibiotic
dispensing for the 4th year following the
intervention in the intervention group
compared to the control group (p = 0.009).
What can we take from these
results?
• The STAR programme led to a statistically and clinically
important reduction in antibiotic prescribing at one and four
years following intervention delivery
• Achieved with no evidence of increased complications or
reconsultations
• A relatively brief intervention of around 5 hours can make an
important difference even 48 months down the line
• Readily implemented in practice at low cost and cost effective,
probably cost saving
Study Publications
•
•
•
Effectiveness of multifaceted educational programme to reduce
antibiotic dispensing in primary care: practice based randomised
controlled trial.
Butler CC, Simpson SA, Dunstan F, Rollnick S, Cohen D, Gillespie D,
Evans MR, Health SL, Alam MF, Bekkers MJ, Evans J, Moore L, Howe R,
Hayes J, Hare M, Hood K, BMJ , Volume 344 (2012) pp.d8173-d8173
Enhancing the quality of antibiotic prescribing in primary care:
qualitative evaluation of a blended learning intervention.
Bekkers MJ, Simpson SA, Dunstan F, Hood K, Hare M, Evans J, Butler CC,
STAR Study Team None, BMC Fam Pract , Volume 11 (2010) pp.34-34
Stemming the Tide of Antibiotic Resistance (STAR): a protocol for a
trial of a complex intervention addressing the 'why' and 'how' of
appropriate antibiotic prescribing in general practice.
Simpson SA, Butler CC, Hood K, Cohen D, Dunstan F, Evans MR, Rollnick
S, Moore L, Hare M, Bekkers MJ, Evans J, STAR Study Team None, BMC
Fam Pract , Volume 10 (2009) pp.20-20
A peer-led social network based
smoking prevention intervention for
adolescents: findings from a
randomised trial in UK schools
(The ASSIST study)
ASSIST intervention
• Developed in response to discussions with Health
Authority and in partnership with them & WG
• Year 8 (aged 12-13)
• Not a ‘typical’ school-based peer-led intervention
• Influential students nominated by their year group
• Trained to be ‘peer supporters’ to diffuse norms of
non- smoking behaviour through their social networks
• Adapted from Kelly’s (1997) sexual health ‘gay hero’ /
Popular Opinion Leader in US mid-west
Peer nomination
•
•
•
•
Did not want only ‘high-achieving’ females
Did want influential students
Did want a mix (sex, friendship group, behaviour)
Identified through three questions:
– Who do you respect in Year 8 at your school?
– Who are good leaders in sports or other group
activities in Year 8 at your school?
– Who do you look up to in Year 8 at your school?
• Viral marketing through social networks
Peer supporter training
• Parental consent obtained
• Peer supporters given two days of training off
school premises
• Training delivered by outside trainers
• Peer supporters trained to intervene in everyday
situations (e.g. at break-time, after school) to
encourage other Year 8 students not to smoke
What evidence do we have that it is
effective?
Campbell R et al. Lancet 2008;371:1595–1602
Study design
Randomised controlled trial: 59 schools (10,730 pupils)
Two centres: Bristol and Cardiff
Outcome evaluation
–
–
–
self-reported smoking status (questionnaires)
salivary cotinine status (saliva samples)
baseline, post intervention, Year 1 and Year 2
Process evaluation
Economic evaluation
Social network analysis
Results, Conclusions, Impact
• ASSIST intervention is effective in reducing adolescent
smoking
• Findings generalisable to range of schools
• If implemented on a UK-wide basis could prevent
40,000 14-15 year olds taking up smoking
• Recommended by NICE
• Cost effective under highly conservative assumptions
• Company set up by Universities to license intervention
• Now implemented across Wales and England
Future potential
• Alignment of LHB, Public Health Wales and
Welsh Government priorities
• Excellent data linkage to support service
evaluation, trials, needs assessment and
epidemiology – SE Wales Laboratory
• SEWTU and DECIPHer
– Excellence in high quality applied translational
research in primary care and public health