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Background To estimate excess mortality for care home residents during the COVID-19 pandemic in England, exploring associations with care home characteristics. Methods Daily number of deaths in all residential and nursing homes in England notified to the Care Quality Commission (CQC) from 1 January 2017 to 7 August 2020. Care home-level data linked with CQC care home register to identify home characteristics: client type (over 65s/children and adults), ownership status (for-profit/not-for-profit; branded/independent) and size (small/medium/large). Excess deaths computed as the difference between observed and predicted deaths using local authority fixed-effect Poisson regressions on pre-pandemic data. Fixed-effect logistic regressions were used to model odds of experiencing COVID-19 suspected/confirmed deaths. Results Up to 7 August 2020, there were 29,542 (95% CI 25,176 to 33,908) excess deaths in all care homes. Excess deaths represented 6.5% (95% CI 5.5 to 7.4%) of all care home beds, higher in nursing (8.4%) than residential (4.6%) homes. 64.7% (95% CI 56.4 to 76.0%) of the excess deaths were confirmed/suspected COVID-19. Almost all excess deaths were recorded in the quarter (27.4%) of homes with any COVID-19 fatalities. The odds of experiencing COVID-19 attributable deaths were higher in homes providing nursing services (OR 1.8, 95% CI 1.6 to 2.0), to older people and/or with dementia (OR 5.5, 95% CI 4.4 to 6.8), amongst larger (vs. small) homes (OR 13.3, 95% CI 11.5 to 15.4) and belonging to a large provider/brand (OR 1.2, 95% CI 1.1 to 1.3). There was no significant association with for-profit status of providers. Conclusions To limit excess mortality, policy should be targeted at care homes to minimise the risk of ingress of disease and limit subsequent transmission. Our findings provide specific characteristic targets for further research on mechanisms and policy priority.

Internal validity is often the primary concern for health technology assessment agencies when assessing comparative effectiveness evidence. However, the increasing use of real-world data from countries other than a health technology assessment agency’s target population in effectiveness research has increased concerns over the external validity, or “transportability”, of this evidence, and has led to a preference for local data. Methods have been developed to enable a lack of transportability to be addressed, for example by accounting for cross-country differences in disease characteristics, but their consideration in health technology assessments is limited. This may be because of limited knowledge of the methods and/or uncertainties in how best to utilise them within existing health technology assessment frameworks. This article aims to provide an introduction to transportability, including a summary of its assumptions and the methods available for identifying and adjusting for a lack of transportability, before discussing important considerations relating to their use in health technology assessment settings, including guidance on the identification of effect modifiers, guidance on the choice of target population, estimand, study sample and methods, and how evaluations of transportability can be integrated into health technology assessment submission and decision processes.

In this analysis of the long-term effect of a pay-for-performance program introduced in England in 2008, in-hospital 30-day mortality for conditions linked to program incentives was reduced during the first 18 months, but the reduction was not sustained at 42 months. Pay-for-performance initiatives, which explicitly link financial incentives to the performance of health care providers, have been adopted in several countries in recent years. 1 , 2 These programs aim to improve the quality of care provided, which should result in better patient outcomes. However, evidence that improvements in health are realized in practice is currently lacking. 3 – 5 Few programs have been subjected to robust evaluation. Programs that have been evaluated show modest and short-term improvements at best on measures of processes related to financial incentives. 6 , 7 There is particular concern about the long-term effects of pay-for-performance initiatives, since initial improvements in measures . . .

In this analysis of the long-term effect of a pay-for-performance program introduced in England in 2008, in-hospital 30-day mortality for conditions linked to program incentives was reduced during the first 18 months, but the reduction was not sustained at 42 months. Pay-for-performance initiatives, which explicitly link financial incentives to the performance of health care providers, have been adopted in several countries in recent years. 1 , 2 These programs aim to improve the quality of care provided, which should result in better patient outcomes. However, evidence that improvements in health are realized in practice is currently lacking. 3 – 5 Few programs have been subjected to robust evaluation. Programs that have been evaluated show modest and short-term improvements at best on measures of processes related to financial incentives. 6 , 7 There is particular concern about the long-term effects of pay-for-performance initiatives, since initial improvements in measures . . .

Background Non-pharmaceutical interventions have been implemented around the world to control Covid-19 transmission. Their general effect on reducing virus transmission is proven, but they can also be negative to mental health and economies, and transmission behaviours can also change voluntarily, without mandated interventions. Their relative impact on Covid-19 attributed mortality, enabling policy selection for maximal benefit with minimal disruption, is not well established due to a lack of definitive methods. Methods We examined variations in timing and strictness of nine non-pharmaceutical interventions implemented in 130 countries and recorded by the Oxford COVID-19 Government Response Tracker (OxCGRT): 1) School closing; 2) Workplace closing; 3) Cancelled public events; 4) Restrictions on gatherings; 5) Closing public transport; 6) Stay at home requirements (‘Lockdown’); 7) Restrictions on internal movement; 8) International travel controls; 9) Public information campaigns. We used two time periods in the first wave of Covid-19, chosen to limit reverse causality, and fixed country policies to those implemented: i) prior to first Covid-19 death (when policymakers could not possibly be reacting to deaths in their own country); and, ii) 14-days-post first Covid-19 death (when deaths were still low, so reactive policymaking still likely to be minimal). We then examined associations with daily deaths per million in each subsequent 24-day period, which could only be affected by the intervention period, using linear and non-linear multivariable regression models. This method, therefore, exploited the known biological lag between virus transmission (which is what the policies can affect) and mortality for statistical inference. Results After adjusting, earlier and stricter school (− 1.23 daily deaths per million, 95% CI − 2.20 to − 0.27) and workplace closures (− 0.26, 95% CI − 0.46 to − 0.05) were associated with lower Covid-19 mortality rates. Other interventions were not significantly associated with differences in mortality rates across countries. Findings were robust across multiple statistical approaches. Conclusions Focusing on ‘compulsory’, particularly school closing, not ‘voluntary’ reduction of social interactions with mandated interventions appears to have been the most effective strategy to mitigate early, wave one, Covid-19 mortality. Within ‘compulsory’ settings, such as schools and workplaces, less damaging interventions than closing might also be considered in future waves/epidemics.

Background School-based social and emotional learning interventions can improve wellbeing and educational attainment in childhood. However, there is no evidence on their effects on health-related quality of life (HRQoL) or on their cost effectiveness. Objective Our objective was to evaluate the cost effectiveness of the Promoting Alternative Thinking Strategies (PATHS) curriculum. Methods A prospective economic evaluation was conducted alongside a cluster-randomised controlled trial of the PATHS curriculum implemented in the Greater Manchester area of England. In total, 23 schools ( n  = 2676 children) were randomised to receive PATHS, and 22 schools ( n  = 2542 children) were randomised to continue with usual practice. A UK health service perspective and a 2-year time horizon were used. HRQoL data were collected prospectively from all children in the trial via the Child Health Utility Nine-Dimension questionnaire. Micro-costing was undertaken to estimate the intervention costs. Missing data were imputed using multiple imputation. Results The mean incremental cost of the PATHS curriculum compared with usual practice was £32.01 per child, and mean incremental quality-adjusted life-years (QALYs) were positive (0.0019; 95% confidence interval [CI] 0.0009–0.0029). Assuming a willingness-to-pay threshold of £20,000 per QALY, the expected incremental net benefit of introducing the PATHS curriculum was £5.56 per child (95% CI − 14.68 to 25.81), and the probability of cost effectiveness was 84%. However, this probability fell to 0% when intervention costs included teacher’s salary costs. Conclusion The PATHS curriculum has the potential to be cost effective at standard UK willingness-to-pay thresholds. However, the sensitivity of the cost-effectiveness estimates to key assumptions means decision makers should seek further information before allocating scarce public resources. Trial registration number ISRCTN85087674.

Introduction The EQ-5D-3L (3L) and EQ-5D-5L (5L) are both frequently used measures of health status. Previous studies have found the EQ-5D-5L to have superior measurement properties but no study has compared the two measures in a large general population survey using matched respondents. Methods Using data from the GP Patient Survey, coarsened exact matching was used to match individuals completing the 3L in 2011 with those completing the 5L in 2012. Measurement properties were assessed for a general population and multimorbid population (chronic conditions ≥ 2), with ceiling effects, informativity and distribution of response compared. Changes in the direction of response, as well as the impact on utility distributions, were quantified. Results Matching resulted in a cohort of 1,023,218 respondents (2011: 511,609; 2012: 511,609) for analysis. Ceiling effects for the 5L were lower than the 3L (43.8% vs. 54.4%). The 5L had improved informativity and broader spread of responses than the 3L (5L top 50 profiles: 77.4% vs. 3L: 98.8%). Overall, there was an upwards shift in utility values for the 5L versus the 3L as respondents using the 5L reported ill health more frequently but with less severity. Measurement improvements and effects on utility values were more pronounced for the multimorbid population. Conclusion The 5L had superior measurement properties than the 3L and should be preferred in general population surveys and for use in individuals with multimorbidity. At increasing levels of morbidity, the 5L is currently associated with higher utility values than the 3L.

BackgroundOver the past decade, targeting acute kidney injury (AKI) has become a priority to improve patient safety and health outcomes. Illness complicated by AKI is common and is associated with adverse outcomes including high rates of unplanned hospital readmission. Through national patient safety directives, NHS England has mandated the implementation of an AKI clinical decision support system in hospitals. In order to improve care following AKI, hospitals have also been incentivised to improve discharge summaries and general practices are recommended to establish registers of people who have had an episode of illness complicated by AKI. However, to date, there is limited evidence surrounding the development and impact of interventions following AKI.DesignWe conducted a quality improvement project in primary care aiming to improve the management of patients following an episode of hospital care complicated by AKI. All 31 general practices within a single NHS Clinical Commissioning Group were incentivised by a locally commissioned service to engage in audit and feedback, education training and to develop an action plan at each practice to improve management of AKI.ResultsAKI coding in general practice increased from 28% of cases in 2015/2016 to 50% in 2017/2018. Coding of AKI was associated with significant improvements in downstream patient management in terms of conducting a medication review within 1 month of hospital discharge, monitoring kidney function within 3 months and providing written information about AKI to patients. However, there was no effect on unplanned hospitalisation and mortality.ConclusionThe findings suggest that the quality improvement intervention successfully engaged a primary care workforce in AKI-related care, but that a higher intensity intervention is likely to be required to improve health outcomes. Development of a real-time audit tool is necessary to better understand and minimise the impact of the high mortality rate following AKI.

Presenting the results of new research on the monasteries of Wearmouth and Jarrow-among the most sophisticated centers of learning and artistic culture in 7th- and 8th-century Europe, and the home of Bede-and their churches, this study examines the long-lasting effect of their buildings and estates on the surrounding region from the Anglo-Saxon period to the present day. The authors trace these relationships through time with new studies of the changing landscape, the monastery precincts, and the surviving structures themselves, detailing how the historical archaeology of the sites reveals how the churches and their communities were rooted in the landscapes of Northumbria but flourished through their links with other parts of Britain and Europe. Researchers from many different backgrounds contributed to the project, using aerial, geophysical, geoarchaeological, and palaeoenvironmental surveys and digital mapping to examine the monasteries and surrounding lands. This book reveals not only the link between the churches and the region's political and economic history, but also demonstrates how their cultural significance for local people in northeast England has changed over time.

BackgroundDuring the COVID-19 pandemic, concerns surrounding safety in the home have been highlighted, as parents have had to manage additional challenges including working from home while simultaneously providing childcare and education. The peak age for accidental insertion of objects or liquids is between 6 months and 3 years of age, and it has been hypothesised that given the additional roles parents have taken on, there may be rise in such incidents due to a reduction in structure and supervision. We therefore reviewed attendances with these complaints over a 6 month period in order to determine whether this occurred, and to prioritise public health and safety messaging from our Children’s Emergency Department (CED).ObjectivesTo describe the epidemiology of presentations with accidental insertion of foreign bodies and hazardous liquids, including demographics, and type of hazard. The secondary objective was to evaluate the possibility of any increase in presentations compared to the previous year.MethodsRetrospective chart review study of patients attending a tertiary urban CED between 23rd March and 23rd September 2020. Patients were identified, and data abstracted, using electronic tracking systems and hand searches of notes. Data abstracted included characteristics of the patients, and the objects ingested/inserted, clinical pathway, and outcomes. Results are provided using descriptive statistics. A secondary analysis compared the frequency of attendance with nasal/aural insertions between 1st June – 31st August 2019, and 2020.ResultsWe identified 330 eligible attendances; 166 (50.3%) were male, median age was 3 years 8 months (IQR 26–69 months). There was no difference in attendance between days of the week, and the time of incident was equally split between 0800–1559, and 1600–2359. Median CED length of stay was 90 minutes (IQR 45–145 minutes), and 254 (77%) were discharged from CED with no follow up. 22 (1.6%) were had pre-existing social care involvement.Ingestion accounted for 153 (55.4%) presentations, with solid objects most commonly metal (67; 23.3%), food (40; 13.9%) and toys/lego (32; 11.1%). Button batteries and magnets were ingested by 35 (12.2%). Liquids were ingested by 42 (13%), with the most common liquid ingested being liquitabs (8; 20%). Insertions accounted for 122 (44.4%) attendances, most commonly in a single nostril (72; 25.3%) or ear (39; 13.7%). Eight (3.7%) families were provided with advice on preventing recurrence of ingestion/insertion at discharge.The total number of aural/nasal insertions between 1st June-31st August 2020 was 59, compared to 65 in 2019. The insertion location and offending object were similar between years.ConclusionsWe demonstrated no change in frequency of aural/nasal insertions between 2019 and 2020, though comparison between years for ingestions was not possible. We have highlighted areas for improvement in communicating safety messages to families as part of a wider programme of discharge advice, and public health messaging. A significant minority had ingested very hazardous materials, and almost one-quarter required hospital admission or follow-up. These offer particular focus for strengthened messaging to reduce serious injury through prevention.