Moving upstream: SEWAHSP and Public Health

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Moving upstreamSEWAHSP and Public Health
Moving upstreamSEWAHSP and Public Health

• Laurence Moore
• DECIPHer
• Schools of Social Sciences and Medicine
• Cardiff University

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• Why move upstream?
• Action outside NHS to support NHS needs
• How to more forward
• Local excellence
• Future potential

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Upstream-Downstream
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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.

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Top 10 Public Health Achievements

• Increased average lifespan
• 1900 49 years
• 1999 75 years
• Sanitation and water
• Vaccination
• Control of Infectious Disease
• Safer Workplaces

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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
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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!

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Nice in theory

• Health promotion doesnt work
• No evidence base"

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Nice in theory

• Health promotion doesnt work
• No evidence base"

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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
  cost-effective.

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Cost-effective solutions often lie outside the NHS

• As with infectious disease..
• environmental health.
• effective preventative actions lie outside the NHS

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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?

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SEWTU

• 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

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• Sample subheading sample heading

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Knowledge Exchange Cycle
Front line Innovation Local focus
Ivory towers REF / RAE Agenda Publications
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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

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• Stemming the tide of antibiotic
• resistance (STAR). A blended learning
• programme addressing appropriate
• antibiotic prescribing in general practice.

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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

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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.

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Method

• The study is a randomized controlled trial with
  general practices as the unit of randomization
  and analysis.
• Process evaluation.
• Cost effectiveness evaluation

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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

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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.

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4 year follow-up data

• After controlling for baseline dispensing rate,
  there was a 6.2 (95 CI1.7, 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).

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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

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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

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A peer-led social network based smoking
prevention intervention for adolescents findings
from a randomised trial in UK schools (The
ASSIST study)
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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 Kellys (1997) sexual health gay
  hero / Popular Opinion Leader in US mid-west

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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

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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

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What evidence do we have that it is
effective?Campbell R et al. Lancet
200837115951602
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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

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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

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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