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Background Global health policy recommends exclusive breastfeeding until infants are 6 months. Little is known about the cost-effectiveness of breastfeeding promotion strategies. This paper presents a systematic search and narrative review of economic evaluations of strategies to support or promote breastfeeding. The aim of the review is to bring together current knowledge to guide researchers and commissioners towards potentially cost-effective strategies to promote or support breastfeeding. Methods Searches were conducted of electronic databases, including MEDLINE and Scopus, for economic evaluations relevant to breastfeeding, published up to August 2019. Records were screened against pre-specified inclusion/exclusion criteria and quality was assessed using a published checklist. Costs reported in included studies underwent currency conversion and inflation to a single year and currency so that they could be compared. The review protocol was registered on the PROSPERO register of literature reviews (ID, CRD42019141721). Results There were 212 non-duplicate citations. Four were included in the review, which generally indicated that interventions were cost-effective. Two studies reported that breastfeeding promotion for low-birth weight babies in critical care is associated with lower costs and greater health benefits than usual care and so is likely to be cost-effective. Peer-support for breastfeeding was associated with longer duration of exclusivity with costs ranging from £19–£107 per additional month (two studies). Conclusions There is limited published evidence on the cost-effectiveness of strategies to promote breastfeeding, although the quality of the current evidence is reasonably high. Future studies should integrate evaluations of the effectiveness of strategies with economic analyses.

Background There is some evidence that incentive-based strategies effectively encourage smoking cessation in the perinatal period. Incentives could be part of policies aiming to increase breastfeeding rates. This systematic review aimed to summarise current evidence to guide researchers and policymakers towards potentially effective incentive-based strategies for increasing breastfeeding. Methods Searches of electronic literature databases were conducted (MEDLINE, Scopus, Embase, CINAHL, and PsycInfo) for evaluations of incentive-based strategies to promote breastfeeding published up to August 2024. Identified studies were screened against pre-specified inclusion criteria: studies focusing on promoting or sustaining breastfeeding; an incentive intervention given to mothers or households; a comparator of standard or usual care or an alternative non-incentive intervention; random allocation to treatment group; evaluation of at least one quantitative outcome measure related to breastfeeding. The following were excluded: literature reviews; conference abstracts; protocol papers; animal studies. Key study information was extracted from included records and they were critically appraised using a published checklist (CASP RCT). The results were presented and synthesised narratively. The review protocol was published on the PROSPERO literature review register. Results Database searches identified 64 non-duplicate records, and 2 additional records were identified through citation searching of previously published reviews. There were 7 records (from 6 studies) included in the review. Four studies included a total of 260 participants, and the other two studies included a total of 3418 households. Most studies were either conducted in low-income countries (3 of 6) or with low-income mothers in the United States (2 of 6). Some studies reported positive effects of incentives on breastfeeding intention, initiation, prevalence, and duration of exclusive breastfeeding, although others reported neutral findings. Incentives and study designs were heterogeneous, the studies were generally small, and results may not be generalisable to other settings/population groups. Conclusions There is some evidence that incentives may improve breastfeeding outcomes, although the quantity and quality of current evidence are both low. Future studies should ensure that sample sizes are sufficiently large and that core breastfeeding outcomes are defined and collected.

To assess implementation of the Saving Babies Lives (SBL) Care Bundle, a collection of practice recommendations in four key areas, to reduce stillbirth in England. A retrospective cohort study of 463,630 births in 19 NHS Trusts in England using routinely collected electronic data supplemented with case note audit (n = 1,658), and surveys of service users (n = 2,085) and health care professionals (n = 1,064). The primary outcome was stillbirth rate. Outcome rates two years before and after the nominal SBL implementation date were derived as a measure of change over the implementation period. Data were collected on secondary outcomes and process outcomes which reflected implementation of the SBL care bundle. The total stillbirth rate, declined from 4.2 to 3.4 per 1,000 births between the two time points (adjusted Relative Risk (aRR) 0.80, 95% Confidence Interval (95% CI) 0.70 to 0.91, P<0.001). There was a contemporaneous increase in induction of labour (aRR 1.20 (95%CI 1.18-1.21), p<0.001) and emergency Caesarean section (aRR 1.10 (95%CI 1.07-1.12), p<0.001). The number of ultrasound scans performed (aRR 1.25 (95%CI 1.21-1.28), p<0.001) and the proportion of small for gestational age infants detected (aRR 1.59 (95%CI 1.32-1.92), p<0.001) also increased. Organisations reporting higher levels of implementation had improvements in process measures in all elements of the care bundle. An economic analysis estimated the cost of implementing the care bundle at ~£140 per birth. However, neither the costs nor changes in outcomes could be definitively attributed to implementation of the SBL care bundle. Implementation of the SBL care bundle increased over time in the majority of sites. Implementation was associated with improvements in process outcomes. The reduction in stillbirth rates in participating sites exceeded that reported nationally in the same timeframe. The intervention should be refined to identify women who are most likely to benefit and minimise unwarranted intervention. The study was registered on (NCT03231007); www.clinicaltrials.gov.

Background The AFFIRM intervention aimed to reduce stillbirth and neonatal deaths by increasing awareness of reduced fetal movements (RFM) and implementing a care pathway when women present with RFM. Although there is uncertainty regarding the clinical effectiveness of the intervention, the aim of this analysis was to evaluate the cost-effectiveness. Methods A stepped-wedge, cluster-randomised trial was conducted in thirty-three hospitals in the United Kingdom (UK) and Ireland. All women giving birth at the study sites during the analysis period were included in the study. The costs associated with implementing the intervention were estimated from audits of RFM attendances and electronic healthcare records. Trial data were used to estimate a cost per stillbirth prevented was for AFFIRM versus standard care. A decision analytic model was used to estimate the costs and number of perinatal deaths (stillbirths + early neonatal deaths) prevented if AFFIRM were rolled out across Great Britain for one year. Key assumptions were explored in sensitivity analyses. Results Direct costs to implement AFFIRM were an estimated £95,126 per 1,000 births. Compared to standard care, the cost per stillbirth prevented was estimated to be between £86,478 and being dominated (higher costs, no benefit). The estimated healthcare budget impact of implementing AFFIRM across Great Britain was a cost increase of £61,851,400/year. Conclusions Perinatal deaths are relatively rare events in the UK which can increase uncertainty in economic evaluations. This evaluation estimated a plausible range of costs to prevent baby deaths which can inform policy decisions in maternity services. Trial registration The trial was registered with www.ClinicalTrials.gov , number NCT01777022 .

Background The stillbirth rate in Tanzania remains high. Greater engagement with antenatal care may help to reduce stillbirths. We investigated which characteristics of antenatal care clinics are preferred by pregnant women in Tanzania. Methods We conducted an unlabelled discrete choice experiment (DCE) with think-aloud interviews. Participants were pregnant women, regardless of parity/gestation, from the Mwanza and Manyara regions of Tanzania. We asked participants to choose which of two hypothetical antenatal clinics they would rather attend. Clinics were described in terms of transport mode, cleanliness, comfort, visit content, and staff attitude. Each participant made 12 choices during the experiment, and a purposively selected sub-set simultaneously verbalised the rationale for their choices. We analysed DCE responses using a multinomial logit model adjusted for study region, and think-aloud data using the Framework approach. Results We recruited 251 participants split evenly between the 2 geographical regions. Staff attitude was the most important attribute in clinic choice and dominated the think-aloud narratives. Other significant attributes were mode of transport (walking was preferred) and content of clinic visit (preference was stronger with each additional element of care provided). Cleanliness of the clinic was not a significant attribute overall and the think-aloud exercise identified a willingness to trade-off cleanliness and comfort for respectful care. Conclusion Women would prefer to attend a clinic with kind staff which they can access easily. This study suggests that exploration of barriers to providing respectful care, and enabling staff to deliver it, are important areas for future investment. The DCE shows us what average preferences are; antenatal care that is aligned with identified preferences should increase uptake and engagement versus care which does not acknowledge them.

Background Reducing stillbirth and early neonatal death is a national priority in the UK. Current evidence indicates this is potentially achievable through application of four key interventions within routine maternity care delivered as the National Health Service (NHS) England’s Saving Babies’ Lives care bundle. However, there is significant variation in the degree of implementation of the care bundle between and within maternity units and the effectiveness in reducing stillbirth and improving service delivery has not yet been evaluated. This study aims to evaluate the impact of implementing the care bundle on UK maternity services and perinatal outcomes. Methods The Saving Babies’ Lives Project Impact and Results Evaluation (SPiRE) study is a multicentre evaluation of maternity care delivered through the Saving Babies’ Lives care bundle using both quantitative and qualitative methodologies. The study will be conducted in twenty NHS Hospital Trusts and will include approximately 100,000 births. It involves participation by both service users and care providers. To determine the impact of the care bundle on pregnancy outcomes, birth data and other clinical measures will be extracted from maternity databases and case-note audit from before and after implementation. Additionally, this study will employ questionnaires with organisational leads and review clinical guidelines to assess how resources, leadership and governance may affect implementation in diverse hospital settings. The cost of implementing the care bundle, and the cost per stillbirth avoided, will also be estimated as part of a health economic analysis. The views and experiences of service users and service providers towards maternity care in relation to the care bundle will be also be sought using questionnaires. Discussion This protocol describes a pragmatic study design which is necessarily limited by the availability of data and limitations of timescales and funding. In particular there was no opportunity to prospectively gather pre-intervention data or design a phased implementation such as a stepped-wedge study. Nevertheless this study will provide useful practice-based evidence which will advance knowledge about the processes that underpin successful implementation of the care bundle so that it can be further developed and refined. Trial registration www.clinicaltrials.gov NCT03231007 (26th July 2017)

ObjectiveTo evaluate the safety of implementing structured medication optimisation reviews (SMORs) for patients with atrial fibrillation (AF) prescribed direct oral anticoagulants (DOACs). SMORs aimed to improve quality of care and facilitate large-scale alignment with national prescribing guidance (to switch patients onto edoxaban).InterventionComplex intervention including a SMOR embedded within primary care electronic patient records alongside clinical decision support tools.DesignDoubly robust difference-in-difference analysis using linked electronic health records, comparing changes in prescribing and bleeding admissions in patients undergoing SMOR with those in patients not reviewed.SettingSefton (intervention area) and Liverpool (comparator area) in the Northwest of England.ParticipantsAll patients with AF prescribed a DOAC in 2022.Main outcomes and measuresProportion of patients prescribed apixaban, proportion of patients prescribed edoxaban and rate of emergency hospital admissions for bleeding-related events.ResultsThe proportion of patients in Sefton prescribed edoxaban increased from 19% to 35%; 13% (95% CI 11% to 14%) of the increase was associated with the SMOR. There was an 11-percentage point decrease in patients prescribed apixaban (95% CI −12% to −10%). Undergoing review was associated with a non-significant reduction in the risk of bleeding admissions (eight fewer admissions per 1000 people reviewed per year; 95% CI −22 to 6).ConclusionsSMORs can be delivered at scale and used to switch medications for a large proportion of people. There was no evidence of an increased risk of admissions for bleeding complications in AF patients following a large-scale switch from apixaban to edoxaban supported by SMORs. Such reviews could improve prescribing quality and patient safety by ensuring patients are on the most appropriate dose and choice of DOAC and lead to cost savings to health services (by facilitating a switch to a better value product) while not increasing risks for patients.

ObjectivesTo estimate the number and burden of medication errors associated with prescription information transfer within the National Health Service (NHS) in England and the impact of implementing an interoperable prescription information system (a single digital prescribing record shared across NHS settings) in reducing these errors.MethodsWe constructed a probabilistic mathematical model. We estimated the number of transition medication errors that would be undetected by standard medicines reconciliation, based on published literature, and scaled this up based on the annual number of hospital admissions. We used published literature to estimate the proportion of errors that lead to harm and applied this to the number of errors to estimate the associated burden (healthcare resource use and deaths). Finally, we used reported effect sizes for electronic prescription information sharing interventions to estimate the impact of implementing an interoperable prescription information system on number of errors and resulting harm.ResultsAnnually, around 1.8 million (95% credibility interval (CrI) 1.3 to 2.6 million) medication errors were estimated to occur at hospital transitions in England, affecting approximately 380 000 (95% CrI 260 397 to 539 876) patient episodes. Harm from these errors affects around 31 500 (95% CrI 22 407 to 42 906) patients, with 36 500 (95% CrI 25 093 to 52 019) additional bed days of inpatient care (costing around £17.8 million (95% CrI £12.4 to £24.9 million)) and >40 (95% CrI 9 to 146) deaths. Assuming the implementation of an interoperable prescription information system could reduce errors by 10% and 50%, there could be 180 000–913 000 fewer errors, 3000–15 800 fewer people who experience harm and 4–22 lives saved annually.ConclusionsAn interoperable prescription information system could provide major benefits for patient safety. Likely additional benefits include healthcare professional time saved, improved patient experience and care quality, quicker discharge and enhanced cross-organisational medicines optimisation. Our findings provide vital safety and economic evidence for the case to adopt interoperable prescription information systems.

AbstractObjectiveTo investigate risks of multiple adverse outcomes associated with use of antipsychotics in people with dementia.DesignPopulation based matched cohort study.SettingLinked primary care, hospital and mortality data from Clinical Practice Research Datalink (CPRD), England.PopulationAdults (≥50 years) with a diagnosis of dementia between 1 January 1998 and 31 May 2018 (n=173 910, 63.0% women). Each new antipsychotic user (n=35 339, 62.5% women) was matched with up to 15 non-users using incidence density sampling.Main outcome measuresThe main outcomes were stroke, venous thromboembolism, myocardial infarction, heart failure, ventricular arrhythmia, fracture, pneumonia, and acute kidney injury, stratified by periods of antipsychotic use, with absolute risks calculated using cumulative incidence in antipsychotic users versus matched comparators. An unrelated (negative control) outcome of appendicitis and cholecystitis combined was also investigated to detect potential unmeasured confounding.ResultsCompared with non-use, any antipsychotic use was associated with increased risks of all outcomes, except ventricular arrhythmia. Current use (90 days after a prescription) was associated with elevated risks of pneumonia (hazard ratio 2.19, 95% confidence interval (CI) 2.10 to 2.28), acute kidney injury (1.72, 1.61 to 1.84), venous thromboembolism (1.62, 1.46 to 1.80), stroke (1.61, 1.52 to 1.71), fracture (1.43, 1.35 to 1.52), myocardial infarction (1.28, 1.15 to 1.42), and heart failure (1.27, 1.18 to 1.37). No increased risks were observed for the negative control outcome (appendicitis and cholecystitis). In the 90 days after drug initiation, the cumulative incidence of pneumonia among antipsychotic users was 4.48% (4.26% to 4.71%) versus 1.49% (1.45% to 1.53%) in the matched cohort of non-users (difference 2.99%, 95% CI 2.77% to 3.22%).ConclusionsAntipsychotic use compared with non-use in adults with dementia was associated with increased risks of stroke, venous thromboembolism, myocardial infarction, heart failure, fracture, pneumonia, and acute kidney injury, but not ventricular arrhythmia. The range of adverse outcomes was wider than previously highlighted in regulatory alerts, with the highest risks soon after initiation of treatment.

ObjectivesAnxiety and/or depression during pregnancy or year after childbirth is the most common complication of childbearing. Economic evaluations of interventions for the prevention or treatment of perinatal anxiety and/or depression (PAD) were systematically reviewed with the aim of guiding researchers and commissioners of perinatal mental health services towards potentially cost-effective strategies.MethodsElectronic searches were conducted on the MEDLINE, PsycINFO and NHS Economic Evaluation and Health Technology Assessment databases in September 2017 to identify relevant economic evaluations published since January 2000. Two stages of screening were used with prespecified inclusion/exclusion criteria. A data extraction form was designed prior to the literature search to capture key data. A published checklist was used to assess the quality of publications identified.ResultsOf the 168 non-duplicate citations identified, 8 studies met the inclusion criteria for the review; all but one focussing solely on postnatal depression in mothers. Interventions included prevention (3/8), treatment (3/8) or identification plus treatment (2/8). Two interventions were likely to be cost-effective, both incorporated identification plus treatment. Where the cost per quality-adjusted life year (QALY) gained was reported, interventions ranged from being dominant (cheaper and more effective than usual care) to costing £39 875/QALY.ConclusionsUncertainty and heterogeneity across studies in terms of setting and design make it difficult to make direct comparisons or draw strong conclusions. However, the two interventions incorporating identification plus treatment of perinatal depression were both likely to be cost-effective. Many gaps were identified in the economic evidence, such as the cost-effectiveness of interventions for perinatal anxiety, antenatal depression or interventions for fathers.PROSPERO registration numberCRD42016051133.