Internationally there are significant challenges to improving and protecting population health through effective prevention. In this novel analysis, we integrate public health evidence, ethics, and economics to argue that current health resourcing strategies neglect prevention, underestimate the social determinants of health, and fail to engage with the ethical dimensions of economic decision-making. We highlight the risk that overreliance on economic evidence may marginalize underserved populations, where data are limited, thereby deepening health inequalities. We conclude that improving population health and reducing disparities requires reframing prevention through both ethical and economic lenses. Investing in community-based, equity-oriented interventions can deliver sustained health and economic gains and support a more inclusive and resilient health system.

Climate change poses a concern globally, as it adversely affects planetary and population health. Extreme heat is one of the largest weather-related causes of mortality, projected to cause severe heatwaves and droughts globally. Current research has focused on the effects of outdoor heat exposure on population health risks, leaving a gap in knowledge regarding indoor exposure to extreme heat. This paper presents evidence for the effects of extreme heat, both indoors and outdoors, on non-communicable diseases (NCDs) in the United Kingdom. This study applies a systematic review methodology to identify, quality appraise, extract, and summarize findings from studies reporting on the associations between extreme heat and population health risk of NCDs. The literature search was conducted across six electronic databases. `There were 244 studies identified. Twenty-three studies met the inclusion criteria, of these 16 studies met the quality benchmark. Fourteen studies examined the links between heat exposure and mortality, while the remaining studies focused on emergency hospital admissions and years of life lost. The review highlights a consistent association between exposure to extreme heat and increased risk of mortality. Further research is needed to explore the effects of indoor extreme heat on the incidence of NCDs and related outcomes.

Chronic Kidney Disease (CKD) patients often require long-term care, and while Hemodialysis (HD) is the standard treatment, Comprehensive Conservative Care (CCC) is gaining popularity as an alternative. Economic evaluations comparing their cost-effectiveness are crucial. This study aims to perform a cost-utility analysis comparing HD and CCC using the EQ-5D-5L and ICECAP-O instruments to assessing healthcare interventions in CKD patients. This short-term economic evaluation involved 183 participants (105 HD, 76 CCC) and collected data on demographics, comorbidities, laboratory results, treatment costs, and HRQoL measured by ICECAP-O and EQ-5D-5L. Incremental Cost-Effectiveness Ratios (ICERs) and Net Monetary Benefit (NMB) were calculated separately for each instrument, and Probabilistic Sensitivity Analysis (PSA) assessed uncertainty. CCC demonstrated significantly lower costs (mean difference 8,544.52) compared to HD. Both EQ-5D-5L and ICECAP-O indicated higher Quality-Adjusted Life Years (QALYs) for both groups, but the difference was not statistically significant (p > 0.05). CCC dominated HD in terms of HRQoL measures, with ICERs of -141,742.67 (EQ-5D-5L) and -4,272.26 (ICECAP-O). NMB was positive for CCC and negative for HD, highlighting its economic feasibility. CCC proves a preferable and more cost-effective treatment option than HD for CKD patients aged 65 and above, regardless of the quality-of-life measure used for QALY calculations. Both EQ-5D-5L and ICECAP-O showed similar results in cost-utility analysis.

Decision making about breast reconstruction (BR) is complex. The Patients' Ex-pectations and Goals: Assisting Shared Understanding of Surgery (PEGASUS) intervention aims to support shared decision making by helping women and clinicians clarify and discuss their expectations around reconstructive surgery. We conducted a multi-centred sequential trial comparing PEGASUS ( n = 52) with usual care (UC) ( n = 86) in women considering reconstruction, who completed outcome measures at base-line, and 3, 6 and 12 months post-surgery. The primary outcome was BR-specific quality of life (Breast-Q) 6 months post-intervention. Secondary outcomes were health-related quality of life (EQ-5D-5L), capabilities (ICECAP-A) and decisional regret, compared using t-tests and Cohen's d .Comparative analyses revealed no significant differences between groups in Breast-Q scores at any time point, except for a favourable effect for UC on psychological well-being at 3 months ( t =-2.41, p = .019, d =-0.59). Intervention participants reported significantly higher, there-fore improved, ICECAP-A ( t =-2.13, p = .037, d =-0.45) and EQ VAS ( t =-2.28, p = .026, d =-0.49) scores at 12 months compared to UC. Decisional regret was significantly lower in the & nbsp;PEGASUS group compared to the UC group at 6 months ( t = 2.06, p = . 044, d =-0.51), but this was not sustained at 12 months. In conclusion, the PEGASUS intervention offers some benefits to women considering BR. At times, women experienced less decisional regret, improved health-related quality of life and capability well-being. Findings are discussed in the light of fidelity testing and embedding PEGASUS into practice.(c) 2021 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. This is an open access article under the CC BY-NC-ND license ( http://creativecommons.org/licenses/by-nc-nd/4.0/ )

Many women choose to have breast reconstruction after mastectomy; however, decision-making can be difficult and expectations are often unmet. The PEGASUS intervention (Patient Expectations and Goals: Assisting Shared Understanding of Surgery) was developed to support shared decision-making by helping women and healthcare professionals to clarify and discuss their individual expectations around surgery. This study aimed to explore patients’ and health professionals’ experiences of using the intervention and its implementation. Forty interviews were conducted with participants in a large scale, multi-site trial of the effectiveness of PEGASUS, from ‘intervention’ (n=16) and ‘usual care’ groups (n=11), and healthcare professionals (n=13). Data were analysed using thematic analysis. ‘Usual care’ participants described feeling overwhelmed in decision-making (‘bombarded’), often using their own research to break down information (‘process of elimination’). In contrast, intervention group participants described PEGASUS providing focus (‘focus amongst the frenetic’), and increased connection with clinicians (‘more than a number’). Healthcare professionals described increased focus on patient priorities (‘shifting focus’), but stressed the need for whole team buy-in (‘collective commitment’). The PEGASUS intervention offered a qualitatively different experience to individuals considering breast reconstruction, with potential to enhance patients’ and healthcare professionals’ feelings of shared decision-making and patient-centred care. Trial registration: ISRCTN 18000391 ( https://doi.org/10.1186/ISRCTN18000391 ) 27/01/2016.

We examined the effect of parathyroid hormone and various signaling molecules on collagen synthesis and chloramphenicol acetyltransferase activity in cultured transgenic mouse calvariae carrying fusion genes of the rat Col1a1 promoter and the chloramphenicol acetyltransferase reporter. After 48 h of culture, parathyroid hormone, forskolin, dibutyryl cAMP, 8-bromo cAMP, and phorbol myristate acetate inhibited transgene activity, while the calcium ionophore ionomycin had no effect. Pretreatment of calvariae with the phosphodiesterase inhibitor isobutylmethylxanthine potentiated the inhibitory effect of 1 nM parathyroid hormone on transgene activity and collagen synthesis. Parathyroid hormone further inhibited transgene activity and collagen synthesis in the presence of phorbol myristate acetate. Parathyroid hormone inhibition of transgene activity and collagen synthesis was not affected by indomethacin or interleukin-6. After 48 h of culture, parathyroid hormone inhibited chloramphenicol acetyltransferase activity by 50-85% in cultured calvariae carrying transgenes having progressive 5' upstream deletions of promoter DNA down to -1683 bp. These data show that the inhibitory effect of parathyroid hormone on Col1a1 expression in mouse calvariae is mediated mainly by the cAMP signaling pathway. Prostaglandins and IL-6 are not local mediators of the parathyroid hormone response in this model. Finally, regions of the Col1a1 promoter downstream of -1683 bp are sufficient for parathyroid hormone inhibition of the Col1a1 promoter. J. Cell. Biochem. 77:149-158, 2000. (C) 2000 Wiley-Liss, Inc.

Abstract Purpose Total hip arthroplasty (THA) is highly successful but some patients will require later revision surgery. This pilot study evaluates the effects of long‐term follow‐up for patients undergoing revision hip replacement. Methods Consecutive patients undergoing aseptic revision of THA were recruited from a large orthopaedic unit to a single centre, observational study. Primary outcomes were changes in patient‐reported scores from pre‐revision to 12 months post‐surgery. Secondary outcomes were costs during hospital stay up to 6 months post‐revision. Participants were retrospectively allocated to two groups—those with regular orthopaedic review prior to revision (Planned revision) or those without (Unplanned revision). Results 52 patients were recruited, 7 were unrevised, one incomplete baseline questionnaires. There were 25 planned and 19 unplanned revisions with no significant differences between groups at baseline. At 12 months, 34 complete data sets were available for analysis, 17 in each group. Change scores were analysed with Mann–Whitney U test; none reached statistical significance. There was a significant difference for length of stay: Planned group 5 days (2–22), Unplanned 11 days (3–86) (Mann–Whitney U test, p = 0.023). No significant differences found for theatre time or component costs. Resource costs post‐revision surgery are presented. Conclusion This pilot study indicates that some change in methods would be required for future work. The results show that there may be some financial benefit from providing long‐term follow‐up of THA but a larger study is needed to explore these findings and to discuss the impact on recommended guidelines.

Introduction: High quality evaluations of new walking and cycling routes are scarce and understanding contextual mechanisms influencing outcomes is limited. Using different types of data we investigate how context is associated with change in use of new and upgraded walking and cycling infrastructure, and the association between infrastructure use and overall physical activity. Methods: We conducted repeat cross-sectional pre-post analysis of monitoring data from a variety of walking and cycling routes built in 84 locations across the United Kingdom (the Connect2 programme, 2009?2013), using four-day user counts (pre n = 189,250; post n = 319,531), nextto-pass surveys of route users (pre n = 15,641; post n = 20,253), and automatic counter data that generated estimates of total annual users. Using multivariable logistic regression, we identified contextual features associated with 50% increase and doubling of pedestrians, cyclists, and subgroups of users. We combined insights from monitoring data with longitudinal cohort data (the iConnect study) from residents living near three Connect2 schemes. Residents were surveyed by post at baseline, one-year (n = 1853) and two-year follow-up (n = 1524) to investigate associations between use of the new infrastructure and meeting physical activity guidelines. Results: The routes were associated with increased use (median increase in cyclists 52%, pedestrians 38%; p < 0.001). Large relative increases were associated with low baseline levels (e.g. odds of doubling cycling were halved for each additional 10,000 annual cyclists at baseline: OR 0.52, 95% CI 0.31, 0.77). Use was associated with meeting physical activity guidelines in both repeat cross-sectional and longitudinal analyses (users vs. non-users after one year, OR 2.07, 95% CI 1.37, 3.21; after two years, OR 2.00, 95% CI 1.37, 2.96). Conclusions: This examination of use, users, benefit-cost ratios, and physical activity associated with new walking and cycling infrastructure across contexts, using multiple types of data, suggests that building walking and cycling infrastructure could improve population health and reduce inequalities.

This chapter begins with a consideration of the technical processes used for conducting health needs assessment. The relationship between health needs assessment and health economics is then examined and the philosophy of utilitarianism and its influence on health economics is explored. Cost utility analysis and its links to studies of quality of life are described and the important relationships between equity and efficiency are considered. The chapter then proceeds to explore the political and philosophical issues attaching to health needs assessment. This leads to an elaboration of the concept of justice derived from the work of Sen. Using ideas about the importance of human capabilities an argument is developed about the relational approach to understanding justice. The relational as against the individualistic position is found to provide a novel and useful way of describing health need and of attempting to meet that need. It also provides a set of precepts about the ways that services might be configured.

Data sharing is not applicable to this article as no new data were created or analysed in this study.

Purpose The purpose of this paper is to describe the possible impact of normalisation on the perceptions of quality of life (QoL) and the impact of this association on the research to date. This commentary reflects on the implications of limiting QoL research to autistic people who are perceived to be “more able”. Design/methodology/approach This commentary discusses the implications of undertaking QoL research in the field of autism. Findings This commentary argues for further consideration of the autistic voice in QoL research. Researcher epistemology and life experience, including experience of autistic people, is examined in terms of how QoL might be perceived and attributed. Further participatory research in the field of quality of life of autistic people, including those with a learning disability and engagement with a variety of autistic people, is called for. Originality/value This commentary suggests that the existing definitions of QoL, founded on principles of normalisation, may not be completely applicable to autistic people, and that new ways of both defining and measuring QoL might be needed.

Background: Survival rates after out-of-hospital cardiac arrest (OHCA) remain low in the UK. A possible way to improve outcomes is to send a prehospital critical care team to OHCA. These teams consist of doctors/and or paramedics with extended training and skills, required to deal with critically ill patients. However, there is little evidence to support that prehospital critical care improves outcomes following OHCA, when compared to the current standard of care, Advanced Life Support (ALS) by paramedics.

Older adults from Black and Minority Ethnic (BME) groups experience a relatively higher burden of physical inactivity compared with their counterparts from non-BME groups. Despite the increasing number of qualitative studies investigating the barriers and facilitators of physical activity among older adults from BME backgrounds in the UK, there is very limited review-level evidence. The aim of this review is to undertake a synthesis of existing qualitative studies, using a meta-ethnographic approach, to explore the barriers and opportunities for physical activity among adults and older adults from BME communities in the UK. Studies conducted between January 2007 and July 2017 were eligible if they met the following criteria: employed any qualitative method; included participants identified as being BME, aged 50 and above, and living in the UK. In total, 1036 studies were identified from a structured search of six electronic databases combined with hand searching of reference bibliographies. Ten studies met the inclusion criteria for the review and were included. Six key themes emerged from the data: awareness of the links between physical activity and health, interaction and engagement with health professionals, cultural expectations and social responsibilities, suitable environment for physical activity, religious fatalism and practical challenges. There was a substantial gap in research among Black African groups. Interventions aimed at improving physical activity participation among older adults should be acceptable and accessible to minority groups. Further research is needed to investigate the barriers and facilitators of physical activity among older adults from African backgrounds.

Hip arthroplasty surveillance: Is it really needed? Summary of presentation for Topic in Focus Within the orthopaedic community, long-term follow up of joint replacement is recommended, a summary of which was included in the NICE guidelines in 2017 (due for update 2020). However, there has been evidence of the disinvestment in this practice, as shown by an audit of orthopaedic units in 2013, only 43% of which were continuing any follow up beyond 5 years. Within these units, 86% of the services were delivered by arthroplasty practitioners as part of the orthopaedic team. A systematic literature review was conducted to explore evidence of the clinical or cost effectiveness of long-term hip arthroplasty surveillance. After reviewing over 4000 titles and abstracts, and including 114 studies, we were not able to find quantitative evidence to address the research question, but qualitative techniques were used to draw out the expert opinions contained within the studies. The main findings were that follow up was specifically recommended by these authors to monitor change, such as asymptomatic loosening, or when the outcomes of a joint construct are unknown, and for several patient subgroups. The next question in which we were interested was: does long-term follow-up offer any benefit to patients around the time of revision surgery? We conducted a pilot observational study of a cohort of patients undergoing revision hip arthroplasty, collected baseline PROMS and repeated them 12 months after surgery, and collected data on health resources used in the first 6 months after surgery. The results indicate that those with follow up report a statistically significant better view of their general health (EQ-VAS) than those without 12 months after surgery, and that less health resources are used in the group with follow-up. The next study was a survey of health professionals to find out their views on long-term follow-up. A survey of 172 participants at BASK and BHS in 2018 was conducted by questionnaire and showed that 87% were in favour of some form of follow-up, although 33% of the participants emphasised that some change was needed in the intervals and methods of delivery. Finally, we conducted three focus groups to find out the patient view on long-term follow-up after hip arthroplasty. A range of patients were included and the key themes that have emerged relate to WHO, WHAT, WHEN, HOW follow up might be conducted. They stated that there should be no exclusions, as age is not determinant of health and that questionnaires can act as a self-exclusion tool – if not returned, no x-ray is ordered. They preferred that questionnaires were based on everyday life and functional activities, and wanted an x-ray, preferably locally. With regard to frequency, annually is too much; more than 3 years is too little. They repeatedly stated that they like to know they are still ‘in the system’. All were happy to receive a postal questionnaire, local x-ray and a letter to state results, but would want periodic review with orthopaedic personnel of at least senior registrar level or equivalent. Plus, all wanted telephone access to orthopaedic team, not their GP. Lindsay K. Smith 26 February 2019

This report provides insight into the impact of community business-related approaches to health and social care on users’ outcomes, in particular exploring how effective they are in delivering outcomes for users. Community businesses are rooted within a particular area, trade for the benefit of the local community, are accountable to and led by the local community and demonstrate broad community impact. In recent years community businesses have emerged in the wider health and social care market to address factors in local communities that may benefit or harm health and wellbeing. Moreover, publications focused on the evaluation of health and wellbeing benefits of community businesses have also increased within the last four years.

Many children are not sufficiently physically active. We conducted a cluster-randomised feasibility trial of a revised after-school physical activity (PA) programme delivered by trained teaching assistants (TAs) to assess the potential evidence of promise for increasing moderate-to-vigorous physical activity (MVPA). Participants (n = 335) aged 8–10 years were recruited from 12 primary schools in South West England. Six schools were randomised to receive the intervention and six acted as non-intervention controls. In intervention schools, TAs were trained to deliver an after-school programme for 15 weeks. The difference in mean accelerometer-assessed MVPA between intervention and control schools was assessed at follow-up (T1). The cost of programme delivery was estimated. Two schools did not deliver the intervention, meaning four intervention and six control schools were analysed at T1. There was no evidence for a difference in MVPA at T1 between intervention and control groups. Programme delivery cost was estimated at £2.06 per pupil per session. Existing provision in the 12 schools cost £5.91 per pupil per session. Action 3:30 was feasible to deliver and considerably cheaper than existing after-school provision. No difference in weekday MVPA was observed at T1 between the two groups, thus progression to a full trial is not warranted.

Numerous interventions to increase children’s physical activity levels are published, yet, few studies report indicators of external validity. Process evaluations are critical for assessing intervention implementation, sustainability and effectiveness. A mixed-methods process evaluation, using the RE-AIM framework, was conducted to evaluate the internal and external validity of Action 3:30R, a revised teaching assistant-led after-school intervention which aimed to increase physical activity in children aged 8–10 years and was underpinned by Self-determination Theory (SDT). Data were collected and reported in line with the five components of RE-AIM (Reach, Effectiveness, Adoption, Implementation and Maintenance). Quantitative measures included logbooks, registers and self-reported teaching-efficacy, autonomy support, child enjoyment and perceived exertion questionnaires. Questionnaire data were collected at three points throughout the 15-week intervention. Observations by trained researchers were also conducted to assess fidelity to the intervention manual and its underpinning theory. Post-intervention focus groups with pupils and interviews with teaching assistants (TAs), school staff and external stakeholders explored the implementation and potential sustainability of Action 3:30R from stakeholders’ perspectives. Action 3:30R appealed to a broad range of pupils, including girls and less-active pupils. The Action 3:30R TA training was implemented as intended and was perceived as valuable professional development. Releasing staff for training was a barrier in two of the six intervention schools, which were unable to deliver the intervention as a result. Pupils enjoyed the intervention, and the Action 3:30R core principles underpinned by SDT were implemented with high fidelity, as was the intervention itself. Scheduling conflicts with other clubs and lack of parental support were perceived as the main barriers to recruitment and attendance. Lack of space and season were cited as the main barriers affecting the quality of delivery. The study shows evidence of maintenance, as one intervention school decided to continue Action 3:30R beyond the study. Funding and continued TA training were suggested as factors which may affect the maintenance of Action 3:30R. Action 3:30R is an enjoyable, autonomy-supportive after-school programme, which engages a range of pupils and offers TAs valuable training. RE-AIM provided helpful structure and is recommended for intervention evaluations. ISRCTN34001941 . Prospectively registered 01/12/2016.

Objectives This research aimed to answer the following questions: What are the costs of prehospital advanced life support (ALS) and prehospital critical care for out-of-hospital cardiac arrest (OHCA)? What is the cost-effectiveness of prehospital ALS? What improvement in survival rates from OHCA would prehospital critical care need to achieve in order to be cost-effective? Setting A single National Health Service ambulance service and a charity-funded prehospital critical care service in England. Participants The patient population is adult, non-traumatic OHCA. Methods We combined data from previously published research with data provided by a regional ambulance service and air ambulance charity to create a decision tree model, coupled with a Markov model, of costs and outcomes following OHCA. We compared no treatment for OHCA to the current standard of care of prehospital ALS, and prehospital ALS to prehospital critical care. To reflect the uncertainty in the underlying data, we used probabilistic and two-way sensitivity analyses. Results Costs of prehospital ALS and prehospital critical care were £347 and £1711 per patient, respectively. When costs and outcomes of prehospital, in-hospital and postdischarge phase of OHCA care were combined, prehospital ALS was estimated to be cost-effective at £11 407/quality-adjusted life year. In order to be cost-effective in addition to ALS, prehospital critical care for OHCA would need to achieve a minimally economically important difference (MEID) in survival to hospital discharge of 3%–5%. Conclusion This is the first economic analysis to address the question of cost-effectiveness of prehospital critical care following OHCA. While costs of either prehospital ALS and/or critical care per patient with OHCA are relatively low, significant costs are incurred during hospital treatment and after discharge in patients who survive. Knowledge of the MEID for prehospital critical care can guide future research in this field. Trial registration number ISRCTN18375201