Author Archives: Niroshan Siriwardena

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CaHRU/LIH seminar: Economic methods used in Health Technology Assessment

murraysmith1This month’s CaHRU/LIH Improvement Science and Research Methods seminar was presented by Dr. Murray Smith, senior research fellow in econometrics and health economics based in CaHRU on 28 November 2017. His topic was a general introduction to health technology assessment, with the overall aim of seeking to establish whether or not a new health technology is cost effective relative to its comparator.

Murray gave a backround to the principles of health economics and the main approaches to evaluation including cost minimisation, cost effectiveness, cost utility and cost benefit analysis. He described the concept of the incremental economic analysis, demonstrated how to calculate an incremental cost effectiveness ratio (ICER) and described the role that incremental economic methods provide in helping to answer the question of whether or not a new treatment is cost effective relative existing health technologies.

CaHRU_logotypeIn the second half of the presentation, Murray gave examples of assessments undertaken by the National Institute for Health and Care Excellence (NICE), the UK health assessment agency, contrasting their regulatory decisions arrived at through cost effectiveness considerations with other management approaches taken by key stakeholder agencies such as NHS England and the now defunct Cancer Drugs Fund.

[su_document url=”https://communityandhealth.dev.lincoln.ac.uk/files/2017/12/CaHRU-Seminar_MDSmith_28Nov2017.pdf” responsive=”no”]Multi-morbidity, goal-oriented care, the community and equity[/su_document]

By Dr. Murray Smith

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CaHRU/LIH Research methods seminar: Realist evaluation with Dr Paul Leighton

WP_20170124_12_05_46_RichThe latest in the CAHRU/LIH research methods seminars was given by Dr Paul Leighton on 24 October 2017 on the subject of ‘Realist evaluation in health services research’. Paul Leighton is a senior research fellow at the University of Nottingham, deputy director of the NIHR Research Design Service for the East Midlands and an expert in health services research, qualitative methods and process evaluation. The presentation covered the philosophy of critical realism and how this related to realist methods, described a practical example of a realist evaluation and finished with concluding thoughts and comment on the method.

Critical realism was described as a philosophical approach developed by Roy Bhaskar that adopts an ontological position of being in which: the actual world is independent of the human mind and the mind is capable of perceiving the empirical world, but unable to directly perceive unseen forces in the real world. Gravity and social class were cited as examples of unseen forces in the real world.

WordItOut-word-cloud-2565294“Realist” or “realistic evaluation” was described as a form of primary research methodology derived from critical realist philosophy, by Ray Pawson and Nick Tilley, which acknowledges the potential for unseen forces and accepts that interventions will not always work or work in the same way because of local contextual factors will influence how an intervention works and the impact it has. Realistic evaluation was summed up as “What works, for whom, in what circumstances?”

The process of realistic evaluation involves developing a programme theory, which theorises what should happen and how it might happen. This so-called mid-range theory is tested using qualitative and/or quantitative methods to explore the context, mechanisms (often hidden) and outcomes (C+M=O), revised iteratively and tested again, leading to a refined mid-range theory.

This was illustrated using the Falls in Care Homes (FinCH) study and summarised by concluding that interventions will not work all the time in all settings, but will work differently in different contexts.

[su_document url=”https://communityandhealth.dev.lincoln.ac.uk/files/2017/11/lincoln-realist-oct17.pdf” responsive=”no”]Multi-morbidity, goal-oriented care, the community and equity[/su_document]

A. N. Siriwardena

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CaHRU brings together Lincoln sleep researchers for LIH seminar

Professor Niro Siriwardena led the recent Lincoln Institute for Health (LIH) research development seminar entitled, ‘Things that go bump in the night’: exploring the problem of tinnitus and sleep.

This seminar brought together researchers at the University of Lincoln with a common interest in sleep research to explore interdisciplinary research into insomnia. Several research centres, groups and experts from a number of disciplines are members of the LIH and each have a record of funded studies investigating sleep and insomnia in a variety of conditions. The work builds on the University of Lincoln’s 4* impact case study on insomnia from REF2014.

 

The seminar focused on how to combine different research approaches to explore how the team might improve the management of insomnia linked to tinnitus. This began with presentations from each participant on their experience and current work in this field:

  • Niro, who is professor of primary and prehospital care, began by describing CaHRU’s translational research focus, seeking to improve health care processes and outcomes. A key area has been in primary care for people with insomnia which includes systematic reviews, qualitative studies and the development and evaluation of psychological interventions for insomnia.
  • WordItOut-word-cloud-2565244Prof Alina Rodriguez, professor in psychology, presented her approach combining methodological strategies including psychological, epidemiological, and molecular to understand the development of behavioural, cognitive, emotional or physical problems across the lifespan, seeking to identify factors amenable to change that can be translated into public health policy or interventions.
  • Prof Graham Law is professor in medical statistics and has worked extensively in epidemiology and medical statistics, focussing on sleep and the consequences of good and poor sleep on metabolic and cardiovascular health.
  • Dr Simon Durrant, senior lecturer in psychology, initially trained as a musician (counter tenor) before developing his expertise in the cognitive neuroscience of sleep. He leads the sleep lab at Lincoln using techniques such as polysomnography, EEG and actigraphy to understand the physiological basis of sleep and its disorders.

The group then discussed, together and with other academics present, the problem of tinnitus (noise generated internally in the body) which affects around 10% of adults and is associated with insomnia in over three-quarters of those with the condition, particularly causing difficulty getting off to sleep (so-called sleep latency). There followed an exploration of potential ways to investigate the problem of insomnia linked to tinnitus (e.g. using evidence synthesis, analysis of large datasets, and qualitative designs) together with the potential for intervention develop (e.g. using CBT for insomnia together with CBT for tinnitus) and evaluation of these.

The seminar ended with suggestions and proposals for how to take this work forward.

[su_document url=”https://communityandhealth.dev.lincoln.ac.uk/files/2017/11/Tinnitus_insomnia_finalrevised.pdf” responsive=”no”]Multi-morbidity, goal-oriented care, the community and equity[/su_document]

A. N. Siriwardena

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‘Tribulations and trials in primary care insomnia’ at BSS 2017

brighton_metropole This year’s British Sleep Society (BSS) conference, held in Brighton at the Hilton Metropole, featured an invited presentation from Prof Niro Siriwardena, director of CaHRU, entitled ‘Tribulations and trials in primary care insomnia’.

After a welcome to the conference by Professor Mary Morell, President of the BSS, the opening keynote was given by Professor Franco Cappuccio, from the University of Warwick on the topic of ‘Healthy sleep’. This was followed by the opening session of the conference on ‘Sleep and health’ chaired by Professor Graham Law, secretary of the BSS and a member of CaHRU. This session included three presentations. The first was on ‘Sleep and chronic pain: moving from association to causation?’ give by Dr John brighton_peopleMcBeth, Reader at the University of Manchester. He described the bidirectional relationship between chronic pain and sleep, with pain giving rise to insomnia and sleep disturbance exacerbating or even causing pain. Studies had shown that treating insomnia in people with chronic pain, for example due to fibromyalgia led to improvements in wellbeing and quality of life but no improvement in pain.

Prof Siriwardena next talked about how he had initially developed an interest in the problem of insomnia through initial research into use of sleeping tablets by general practitioners. ‘Tribulations and trials in primary care insomnia’ went on to describe the studies that showed that hypnotic drugs like benzodiazepines and z-drugs though often prescribed for insomnia did more harm than good, and that primary care trials of cognitive behavioural therapy for insomnia (CBT-I) showed positive effects. He went on to describe the work on the Resources for Effective Sleep Treatment (REST) project, a quality improvement project which successfully implemented CBT-I in general practice which led to reduced hypnotic prescribing in those practices. Because of the low uptake of CBT-I in primary care, there was increasing evidence that online or self-help CBT-I was effective with similar effect sizes to face-to-face individual or group therapy. Finally he presented the evidence on short behavioural therapies such as sleep restriction therapy including a forthcoming HTA funded trial led by Oxford University’s Simon Kyle and involving the Universities of Manchester (Peter Bower) and Lincoln (Niro Siriwardena).

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The final talk in the session was Dr Eleanor Scott, Senior Lecturer at Leeds University and Consultant Diabetologist at Leeds Teaching Hospitals, who spoke on Sleep and metabolic health, describing the relationship between insomnia and diabetes, obesity and cardiovascular disease. This was followed by Dr Jason Rihel,of University College London discussing his work on sleep in zebrafish and Dr Claire Sexton of Oxford University on her work on sleep related to dementia. Brighton was an excellent setting for a well-attended BSS conference.

By Niro Siriwardena

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Viet-Hai Phung presents at Emergency Medicine Congress, Lisbon

vhp2Viet-Hai Phung presented his work on the perceptions and experiences of Community First Responders (CFRs) in Lincolnshire at the recent Mediterranean Emergency Medicine Congress (MEMC). The Congress, organised by the American Academy of Emergency Medicine (AAEM), took place in the very smart surroundings of the Corinthia Hotel in Lisbon, Portugal from 8-10 September 2017. Despite the title of the Congress, this was a truly international conference, with delegates from North America, the Middle East, Africa and Australasia presenting.

Professor Lee Alan Wallis, Head of Emergency Medicine for the Western Cape Government, was the keynote speaker at the opening ceremony. He talked about the particular challenges of lisbon1emergency medicine provision in southern Africa, where in some countries the infrastructure is extremely basic. Other plenary speakers included: Professor James Ducharme from McMaster University in Toronto, who talked about the complex relationship between pain relief, patient satisfaction and addiction and Dr Eveline Hitti from the American University in Beirut, who spoke about the glass ceiling for women working in emergency medicine.

Viet-Hai presented the interview study that has been undertaken with colleagues Prof Niro Siriwardena, Ian Trueman and Prof Roderick Ørner on the first morning of the conference. The presentation was well-received with only minor points of clarification from the audience concerning the extent of their use in the UK and the levels of training they undertake.

What was interesting about the conference was the sharing of best practice from around the world on many salient problems in emergency medicine, such as alleviating patient overcrowding in the emergency department. All this within the setting of the wonderful city of seven hills, Lisbon.

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By Viet-Hai Phung