Increasing uptake of National Health Service Health Checks in primary care: a pragmatic randomized controlled trial of enhanced invitation letters in Northamptonshire, England

Can uptake of childhood influenza immunisation through schools and GP practices be increased through behaviourally-informed invitation letters and reminders: two pragmatic randomized controlled trials

BACKGROUND

The UK is rolling out a national childhood influenza immunisation programme for children, delivered through primary care and schools. Behaviourally-informed letters and reminders have been successful at increasing uptake of other public health interventions. Therefore, we investigated the effects of a behaviourally-informed letter on uptake of the vaccine at GP practices, and of a letter and a reminder (SMS/ email) on uptake at schools.

METHODS AND RESULTS

Study 1 was a cluster-randomised parallel trial of 21,786 two- and three-year olds in 250 GP practices, conducted during flu season (September to January inclusive) 2016/7. The intervention was a centrally-sent behaviourally-informed invitation letter, control was usual care. The proportion of two- and three-year olds in each practice who received a vaccination by 31st January 2017 was 23.4% in the control group compared to 37.1% in the intervention group (OR = 1.93; 95% CI = 1.82, 2.05, p <  0.001). Study 2 was a 2 (behavioural letter vs standard letter) × 2 (reminder vs no reminder) factorial trial of 1108 primary schools which included 3010 school years 1-3. Letters were sent to parents from providers, and reminders sent to parents from the schools. In the standard-letter-no-reminder arm, an average of 61.6% of eligible children in each school year were vaccinated, compared to 61.9% in the behavioural-letter-no-reminder arm, 63.5% in the standard-letter-plus-reminder arm, and 62.9% in the behavioural-letter-plus reminder condition, F(3, 2990) = 2.68, p = 0.046. In a multi-level model, with demographic variables as fixed effects, the proportion of eligible students in the school year who were vaccinated increased with the reminder, β = 0.086 (0.041), p <  0.036, but there was no effect of the letter nor any interaction effect.

CONCLUSION

Sending a behaviourally informed invitation letter can increase uptake of childhood influenza vaccines at the GP surgery compared to usual practice. A reminder SMS or email can increase uptake of the influenza vaccine in schools, but the effect size was minimal.

TRIAL REGISTRATION

Study 1: Trial registration: ClinicalTrials.gov Identifier: NCT02921633. Study 2: Trial registration: ClinicalTrials.gov Identifier: NCT02883972.

Introducing multi-component cardiovascular health screening into existing Abdominal Aortic Aneurysm (AAA) screening programmes in the UK: a qualitative study of programme staff views

BACKGROUND

Cardiovascular disease is a major contributor to poor health in the UK and the leading cause of death in England. Peripheral arterial disease and high blood pressure are conditions that identify individuals at high cardiovascular disease risk, likely to benefit from cardiovascular risk management. Both conditions remain considerably underdiagnosed and untreated. The National Health Service abdominal aortic aneurysm (AAA) screening programmes represent an opportunity to screen for these conditions with potentially minimal additional effort or cost. We explored AAA screening programme staff views on the proposed introduction of such additional screening within AAA screening.

METHODS

Nine focus groups and seven follow-on interviews were undertaken with 38 AAA screening staff. Our study methods were oriented broadly towards a grounded theory methodology, and data were analysed using thematic analysis.

RESULTS

Three themes were identified: (i) 'Perceptions of patient experience and health-related outcomes', (ii) 'Opportunities and challenges for programme staff', and (iii) 'Maintaining and improving programme standards'. Staff talked about the high uptake of AAA screening, staff experience and skills in their role, and the programme's high quality standards as both opportunities and potential challenges linked to the proposed additions to AAA screening. While positive about the potential to improve patients' health outcomes, participants had questions about the practicalities of incorporating additional procedures within their time- and resource-constrained context, and how this may reconfigure work processes, roles and relationships.

CONCLUSIONS

The proposed additions to the programme require taking staff's views into account. Key areas that need to be addressed relate to ensuring follow-up support for patients, clarity around staff responsibilities, and availability of sufficient resources for the programme.

Postal reminder with reduced burden of clinic information seeking for equitable participation in general health check-ups: A randomized controlled trial

High participation rate and low inequality in participation are key to the program success of general health check-ups in Japan. This study examined the effectiveness of a postal reminder including nearest clinic information, compared to the standard postal reminder including details of all local clinics, on participation rate and income-based participation rate in general health checks. This was a single-blind, two-arm, prospective, randomized controlled study conducted at the Fukuoka Branch of Japan Health Insurance Association. Dependents (family members) of insured persons aged 40-69 years were randomly assigned (1:1) to the intervention group that received a tailored postal reminder intervention (showing information on the nearest clinic from each participant's address) or to the control group that received an original template postal reminder (containing just the URL of the website listing all available clinics). Allocation was concealed from participants and service providers of general health check-up. The primary outcome was participation in general health check-ups within 1 month of intervention. Between February 1 and February 10, 2017, 21,017 were randomly assigned to the intervention (n = 10,474) or control (n = 10,543) group. The participation rate in the intervention group was higher than control group (3.2% vs. 2.1%; OR: 1.55, 95% CI: 1.31-1.85, P < 0.001). The intervention effect was estimated to decrease as the income category increased (P for interaction = 0.037). Tailored postal reminders with information on the nearest clinic were able to improve the overall participation rate and reduce income-based inequality in participation for general health check-ups in Japan. Trial registration: UMIN-CTR, UMIN000042509, Registered 26 November 2020 - Retrospectively registered.

Increasing uptake of NHS Health Checks: a randomised controlled trial using GP computer prompts

Background

Public Health England wants to increase the uptake of the NHS Health Check (NHSHC), a cardiovascular disease prevention programme. Most invitations are sent by letter, but opportunistic invitations may be issued and verbal invitations have a higher rate of uptake. Prompting staff to issue opportunistic invitations might increase uptake.

Aim

To assess the effect on uptake of automated prompts to clinical staff to invite patients to NHSHC, delivered via primary care computer systems.

Design and setting

Pseudo-randomised controlled trial of patients eligible for the NHSHC attending GP practices in Southwark, London.

Method

Eligible patients were allocated into one of two conditions, (a) Prompt and (b) No Prompt, to clinical staff. The primary outcome was attendance at an NHSHC.

Results

Fifteen of 43 (34.88%) practices in Southwark were recruited; 7564 patients were eligible for an NHSHC, 3778 (49.95%) in the control and 3786 (50.05%) in the intervention. Attendance in the intervention arm was 454 (12.09%) compared with 280 (7.41%) in the control group, a total increase of 4.58% (OR = 2.28; 95% CI = 1.46 to 3.55; P<0.001). Regressions found an interaction between intervention and sex (OR = 0.65; 95% CI = 0.44 to 0.86, P = 0.004), with the intervention primarily effective on males. Comparing the probabilities of attendance for each age category across intervention and control suggests that the intervention was primarily effective for younger patients.

Conclusion

Prompts on computer systems in general practice were effective at improving the uptake of the NHSHC, especially for males and younger patients.

Modelling tool to support decision-making in the NHS Health Check programme: workshops, systematic review and co-production with users

BACKGROUND

Local authorities in England commission the NHS Health Check programme to invite everyone aged 40-74 years without pre-existing conditions for risk assessment and eventual intervention, if needed. However, the programme's effectiveness, cost-effectiveness and equity impact remain uncertain.

AIM

To develop a validated open-access flexible web-based model that enables local commissioners to quantify the cost-effectiveness and potential for equitable population health gain of the NHS Health Check programme.

OBJECTIVES

The objectives were as follows: (1) co-produce with stakeholders the desirable features of the user-friendly model; (2) update the evidence base to support model and scenario development; (3) further develop our computational model to allow for developments and changes to the NHS Health Check programme and the diseases it addresses; (4) assess the effectiveness, cost-effectiveness and equity of alternative strategies for implementation to illustrate the use of the tool; and (5) propose a sustainability and implementation plan to deploy our user-friendly computational model at the local level.

DESIGN

Co-production workshops surveying the best-performing local authorities and a systematic literature review of strategies to increase uptake of screening programmes informed model use and development. We then co-produced the workHORSE (working Health Outcomes Research Simulation Environment) model to estimate the health, economic and equity impact of different NHS Health Check programme implementations, using illustrative-use cases.

SETTING

Local authorities in England.

PARTICIPANTS

Stakeholders from local authorities, Public Health England, the NHS, the British Heart Foundation, academia and other organisations participated in the workshops. For the local authorities survey, we invited 16 of the best-performing local authorities in England.

INTERVENTIONS

The user interface allows users to vary key parameters that represent programme activities (i.e. invitation, uptake, prescriptions and referrals). Scenarios can be compared with each other.

MAIN OUTCOME MEASURES

Disease cases and case-years prevented or postponed, incremental cost-effectiveness ratios, net monetary benefit and change in slope index of inequality.

RESULTS

The survey of best-performing local authorities revealed a diversity of effective approaches to maximise the coverage and uptake of NHS Health Check programme, with no distinct 'best buy'. The umbrella literature review identified a range of effective single interventions. However, these generally need to be combined to maximally improve uptake and health gains. A validated dynamic, stochastic microsimulation model, built on robust epidemiology, enabled service options analysis. Analyses of three contrasting illustrative cases estimated the health, economic and equity impact of optimising the Health Checks, and the added value of obtaining detailed local data. Optimising the programme in Liverpool can become cost-effective and equitable, but simply changing the invitation method will require other programme changes to improve its performance. Detailed data inputs can benefit local analysis.

LIMITATIONS

Although the approach is extremely flexible, it is complex and requires substantial amounts of data, alongside expertise to both maintain and run.

CONCLUSIONS

Our project showed that the workHORSE model could be used to estimate the health, economic and equity impact comprehensively at local authority level. It has the potential for further development as a commissioning tool and to stimulate broader discussions on the role of these tools in real-world decision-making.

FUTURE WORK

Future work should focus on improving user interactions with the model, modelling simulation standards, and adapting workHORSE for evaluation, design and implementation support.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42019132087.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 35. See the NIHR Journals Library website for further project information.

NHS Health Check programme: a protocol for a realist review

INTRODUCTION

The NHS Health Check aims to identify individuals at increased risk of cardiovascular diseases (CVDs) among the adult population in England. The Health Check includes calculation of CVD risk and discussion of pharmacological and lifestyle approaches to manage risk, including referral to lifestyle support services. The programme is commissioned by Local Authorities (LAs) and is delivered by a range of different providers in different settings. There is significant variation in activity, with uptake ranging from 25% to 85% in different areas, and clear evidence of variation in implementation and delivery practice.

METHODS AND ANALYSIS

We aim to understand how the NHS Health Check programme works in different settings, for different groups, so that we can recommend improvements to maximise intended outcomes. To do so, we will undertake a realist review and a survey of LA public health teams. Our review will follow Pawson's five iterative stages: (1) locate existing theories, (2) search for evidence, (3) article selection, (4) extract and organise data and (5) synthesise evidence and draw conclusions. Our review will include documents describing local implementation alongside published research studies. We will recruit a stakeholder group (including Public Health England, commissioners and providers of Health Checks, plus members of the public and patients) to advise us throughout. Our survey will be sent to all 152 LAs in England to gather detailed information on programme delivery (including COVID-19-related changes) and available referral services. This will enable us to map delivery across England and relate these data to programme outcomes.

ETHICS AND DISSEMINATION

Ethical approval is not required for this review. For the survey, we have received approval from the University of Kent Research Ethics Committee. Our findings will be used to develop recommendations on tailoring, implementation and design strategies to improve delivery of the NHS Health Check in different settings, for different groups.

PROSPERO REGISTRATION NUMBER

CRD42020163822.

A systematic review of factors influencing NHS health check uptake: invitation methods, patient characteristics, and the impact of interventions

Background

The NHS Health Check (NHSHC) is a risk assessment for those aged 40–74 without a pre-existing condition in England, with the aim of preventing stroke, kidney disease, heart disease, type 2 diabetes and dementia. Uptake has been lower than anticipated. Ensuring that a high percentage of eligible patients receive a NHSHC is key to optimising the clinical and cost effectiveness of the programme. The aim of this systematic review is to highlight interventions and invitation methods that increase the uptake of NHSHCs, and to identify whether the effectiveness of these interact with broader patient and contextual factors.

Method

A systematic review was conducted according to the PRISMA checklist. Papers were eligible if they explored the impact of at least one of (i) interventions, (ii) invitation methods or (iii) broader factors on NHSHC uptake. Ten databases were searched in January 2016 and seven were searched in March 2018. Nine-hundred-and-forty-five papers were identified, 238 were screened and 64 full texts were assessed for eligibility. Nine studies were included in the review.

Results

The nine studies were all from peer reviewed journals. They included two randomised controlled trials, one observational cohort and six cross-sectional studies. Different invitation methods may be more effective for different groups of patients based on their ethnicity and gender. One intervention to enhance invitation letters effectively increased uptake but another did not. In addition, individual patient characteristics (such as age, gender, ethnicity and risk level) were found to influence uptake. This review also finds that uptake varies significantly by GP practice, which could be due either to unidentified practice-level factors or deprivation.

Conclusions

Further research is needed to assess the effectiveness of different invitation methods for different population groups. Research should examine how existing invitation methods can be enhanced to drive uptake whilst reducing health inequalities.

Trial registration

This systematic review was registered with PROSPERO on 22.02.2016. Registration number CRD42016035626.

Applying behavioural science to increase uptake of the NHS Health Check: a randomised controlled trial of gain- and loss-framed messaging in the national patient information leaflet

BACKGROUND

The NHS Health Check (NHSHC) is a national programme for the prevention of non-communicable diseases. Patients aged 40-74 without an existing cardiovascular-related condition should be invited quinquennially. Uptake is lower than anticipated. We assessed the impact on uptake of two new behaviourally-enhanced leaflets (with the current national leaflet as a control), enclosed with the invitation letter: the first trial on the leaflet.

METHODS

A double-blind three-armed randomized controlled trial was conducted. The new leaflets were shorter (two pages, instead of four); one was loss-framed ('don't miss out') and the other was gain-framed ('make the most of life'). The participants were patients from 39 practices in Lewisham and 17 practices in NE Lincolnshire, who were allocated to interventions using a random-number generator and received one of the leaflets with their invitation letter from April-September 2018. The outcome measure was uptake of an NHSHC by November 2018. The trial was powered to detect a 2% effect.

RESULTS

Uptake was 17.6% in the control condition (n = 3677), 17.4% in the loss-framed condition (n = 3664), and 18.2% in the gain-framed condition (n = 3697). Leaflet type was not a significant predictor of NHSHC uptake in a logistic regression that controlled for demographic variables, with GP practice as a random effect. Statistically significant predictors of uptake included location (higher uptake in Lewisham), age (increased age was associated with increased attendance) and sex (higher uptake in females). The Bayes Factor comparing the null to a hypothesis of differences between conditions was 416, which is extreme evidence in favour of the null hypothesis.

CONCLUSION

There was no evidence for a meaningful effect of either a loss-framed or gain-framed behaviourally-informed leaflet type on uptake, which is surprising, given that behaviourally informed letters have improved uptake of NHSHCs. It is possible that people do not pay attention to leaflets that are enclosed with letters, or that the leaflet continues to support informed decision-making but this does not affect uptake.

TRIAL REGISTRATION

Clinicaltrials.gov, NCT03524131. Registered May 14, 2018. Retrospectively registered.