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preserveAspectRatio="none"><path fill="none" stroke="#000" stroke-width="36" stroke-linecap="round" style="fill:#FFF" d="m320,350a153,153 0 1,0-2,2l170,170m-91-117 110,110-26,26-110-110"></path></svg></a><a id="jr-fip-done" class="wsprkl btn" title="Dismiss find">✘</a></nav><nav id="jr-fip-info-p"><a id="jr-fip-prev" class="wsprkl btn" title="Jump to previuos match">◀</a><button id="jr-fip-matches">no matches yet</button><a id="jr-fip-next" class="wsprkl btn" title="Jump to next match">▶</a></nav></nav></div><div id="jr-epub-interstitial" class="hidden"></div><div id="jr-content"><article data-type="main"><div class="main-content lit-style"><div class="fm-sec bkr_bottom_sep"><div class="bkr_thumb"><a href="https://www.nice.org.uk" title="National Institute for Health and Care Excellence (NICE)" class="img_link icnblk_img" ref="pagearea=logo&targetsite=external&targetcat=link&targettype=publisher"><img class="source-thumb" src="/corehtml/pmc/pmcgifs/bookshelf/thumbs/th-niceng220er2-lrg.png" alt="Cover of Evidence reviews for coordination of care: the role of MS nurse specialists and other healthcare professionals" /></a></div><div class="bkr_bib"><h1 id="_NBK585276_"><span itemprop="name">Evidence reviews for coordination of care: the role of MS nurse specialists and other healthcare professionals</span></h1><div class="subtitle">Multiple sclerosis in adults: management</div><p><b>Evidence review B</b></p><p><i>NICE Guideline, No. 220</i></p><div class="half_rhythm">London: <a href="https://www.nice.org.uk" ref="pagearea=meta&targetsite=external&targetcat=link&targettype=publisher"><span itemprop="publisher">National Institute for Health and Care Excellence (NICE)</span></a>; <span itemprop="datePublished">2022 Jun</span>.<div class="small">ISBN-13: <span itemprop="isbn">978-1-4731-4607-5</span></div></div><div><a href="/books/about/copyright/">Copyright</a> © NICE 2022.</div></div><div class="bkr_clear"></div></div><div id="niceng220er2.s1"><h2 id="_niceng220er2_s1_">1. Coordination of care: the role of MS nurse specialists and other healthcare professionals</h2><div id="niceng220er2.s1.1"><h3>1.1. Review question</h3><p><b>Effectiveness:</b> What is the clinical and cost effectiveness of processes of care, including the role of MS specialist nurses and other healthcare professionals, to improve care coordination and health outcomes in adults with MS?</p><p><b>Qualitative:</b> What information, education and support do adults with MS (themes relating to coordination of care only) and their families and carers find most useful?</p><div id="niceng220er2.s1.1.1"><h4>1.1.1. Introduction</h4><p>People with MS face a variety of symptoms and disabilities that arise unpredictably and change over time. Their physical, emotional and social needs may therefore require action from more than one health professional at any time and it’s important that these interventions are timely and co-ordinated.</p><p>A variety of models have been developed to address this need, but it’s recognised some people with MS still find it difficult to access treatment, advice and support from the right people when they need it most.</p><p>The importance of adequately co-ordinated, appropriate and comprehensive care is widely acknowledged and is a function for many people with MS undertaken by a MS Specialist Nurse or other health care professional, but guidance is still needed on the processes or roles that would deliver this most effectively.</p></div><div id="niceng220er2.s1.1.2"><h4>1.1.2. Summary of the protocol</h4><p>For full details see the review protocol in <a href="#niceng220er2.appa">Appendix A</a>.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab1"><a href="/books/NBK585276/table/niceng220er2.tab1/?report=objectonly" target="object" title="Table 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab1" rid-ob="figobniceng220er2tab1"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab1/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab1/?report=previmg" alt="Table 1. PICO characteristics of effectiveness review question." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab1"><a href="/books/NBK585276/table/niceng220er2.tab1/?report=objectonly" target="object" rid-ob="figobniceng220er2tab1">Table 1</a></h4><p class="float-caption no_bottom_margin">PICO characteristics of effectiveness review question. </p></div></div><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab2"><a href="/books/NBK585276/table/niceng220er2.tab2/?report=objectonly" target="object" title="Table 2" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab2" rid-ob="figobniceng220er2tab2"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab2/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab2/?report=previmg" alt="Table 2. PICO characteristics of qualitative review question." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab2"><a href="/books/NBK585276/table/niceng220er2.tab2/?report=objectonly" target="object" rid-ob="figobniceng220er2tab2">Table 2</a></h4><p class="float-caption no_bottom_margin">PICO characteristics of qualitative review question. </p></div></div></div><div id="niceng220er2.s1.1.3"><h4>1.1.3. Methods and process</h4><p>This evidence review was developed using the methods and process described in <a href="https://www.nice.org.uk/process/pmg20/chapter/introduction-and-overview" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Developing NICE guidelines: the manual</a>. Methods specific to this review question are described in the review protocol in <a href="#niceng220er2.appa">appendix A</a> and the methods document.</p><p>Declarations of interest were recorded according to <a href="https://www.nice.org.uk/about/who-we-are/policies-and-procedures" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">NICE’s conflicts of interest policy</a>.</p><p>The evidence from the qualitative review on information and support was combined with this evidence review after the protocol was drafted. The qualitative evidence review was conducted to provide further detail of how coordinated care could be delivered. For details of the search strategy and evidence tables for the qualitative review see evidence review A.</p><p>A number of studies have been identified that report on the value of the MS specialist nurse (Mynors 2012, Mynors 2015, Bowen 2016, Willmington 2017, Leary 2015, Hannan 2018, Punshon 2021, Hopper 2020)<a class="bibr" href="#niceng220er2.ref3" rid="niceng220er2.ref3"><sup>3</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref13" rid="niceng220er2.ref13"><sup>13</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref14" rid="niceng220er2.ref14"><sup>14</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref20" rid="niceng220er2.ref20"><sup>20</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref27" rid="niceng220er2.ref27"><sup>27</sup></a><sup>–</sup><a class="bibr" href="#niceng220er2.ref29" rid="niceng220er2.ref29"><sup>29</sup></a><sup>, </sup><a class="bibr" href="#niceng220er2.ref36" rid="niceng220er2.ref36"><sup>36</sup></a>. These were identified through a review of the evidence or the call for evidence (see <a href="#niceng220er2.s1.1.4.2">section 1.1.4.2</a>). None of these studies were included mainly due to the absence of a comparator. For full details of exclusion see <a href="#niceng220er2.appj">Appendix J</a>.</p></div><div id="niceng220er2.s1.1.4"><h4>1.1.4. Effectiveness evidence</h4><div id="niceng220er2.s1.1.4.1"><h5>1.1.4.1. Included studies</h5><p>Two non-randomised studies were included. One compared standard clinical service at 4 MS centres, each involving an MS nurse, to standard clinical service at 2 centres not involving an MS specialist nurse<a class="bibr" href="#niceng220er2.ref10" rid="niceng220er2.ref10"><sup>10</sup></a> and the other study compared a multidisciplinary MS care protocol to ‘traditional’ care<a class="bibr" href="#niceng220er2.ref16" rid="niceng220er2.ref16"><sup>16</sup></a>.</p><p>These studies are summarised in <a class="figpopup" href="/books/NBK585276/table/niceng220er2.tab2/?report=objectonly" target="object" rid-figpopup="figniceng220er2tab2" rid-ob="figobniceng220er2tab2">Table 2</a> below. Evidence from these studies is summarised in <a href="#niceng220er2.s1.1.6">section 1.1.6</a> on the summary of effectiveness evidence section.</p><p>See also the study selection flow chart in <a href="#niceng220er2.appc">Appendix C</a> and study evidence tables in <a href="#niceng220er2.appd">Appendix D</a>.</p><div id="niceng220er2.s1.1.4.1.1"><h5>Call for evidence</h5><p>The committee identified coordination of care as an area of the scope with limited published evidence. The committee were aware of reports and studies assessing the role of the MS nurse specialist that are currently being conducted but not published or completed but not published. As this review is of high priority for health economic modelling and is a topic where there is limited published evidence, the committee proposed a call for evidence to identify any relevant literature not identified in the searches. The committee agreed to consider a wider variety of evidence to inform their decision making including non-randomised trials, reports, audits and surveys and included these in the call for evidence. Submissions were received from 18 separate organisations or individuals consisting of a variety of reports, commissioned audits or references to publications. All documents and references were checked for relevance to the review question according to the quantitative clinical review protocol. No relevant clinical evidence was obtained that matched the quantitative review protocol, but four reports were summarised as part of the health economic evidence section (see <a href="#niceng220er2.s1.1.10">1.1.10 Summary of health economic studies included in the qualitative evidence</a>). Some references to qualitative studies were submitted and these had already been identified in the search for the information and support for patients (evidence review A). See excluded studies from the call for evidence in Table 20 in <a href="#niceng220er2.appj">Appendix J</a>.</p></div><div id="niceng220er2.s1.1.4.1.2"><h5>Qualitative evidence</h5><p>Qualitative evidence on patient and carer views and their perceptions on coordination of care have been included as part of the review on the information and support needs for patients, families and carers. Themes identified relevant to coordination of care have been included in this review document, but evidence tables and other information such as clinical evidence selection is provided in evidence review A. The committee considered the evidence from both the quantitative evidence and qualitative evidence reviews together when making their recommendations. The quantitative evidence review was used to inform recommendations on the clinical and cost effectiveness of different ways of delivering co-ordinated care. The qualitative review was used to add further detail to these recommendations, for example what roles and functions and health professional may have to fulfil. The findings from these two reviews are therefore presented together in this evidence review. Included studies and findings from this qualitative evidence is presented in this report.</p><p>In the qualitative review, four studies were questionnaire-based but had a qualitative component (for example, open questions where qualitative responses were required) that was analysed qualitatively and these were included alongside the other included studies which were interview-based (sixteen studies), focus group-based (three studies) or involved a mixture of focus groups and interviews (two studies).</p><p>See evidence review A for evidence tables for qualitative evidence.</p></div></div><div id="niceng220er2.s1.1.4.2"><h5>1.1.4.2. Excluded studies</h5><div id="niceng220er2.s1.1.4.2.1"><h5>Differences to the review on coordination of care in CG186</h5><p>This question has a different approach to the review on coordination of care in the previous NICE guideline (2014) (CG186), and the following studies were excluded from this review; Kirker 1995<a class="bibr" href="#niceng220er2.ref18" rid="niceng220er2.ref18"><sup>18</sup></a>, Wilson 1998<a class="bibr" href="#niceng220er2.ref43" rid="niceng220er2.ref43"><sup>43</sup></a> and Johnson 2003<a class="bibr" href="#niceng220er2.ref17" rid="niceng220er2.ref17"><sup>17</sup></a> were excluded because they were non comparative studies, Warner 2005<a class="bibr" href="#niceng220er2.ref41" rid="niceng220er2.ref41"><sup>41</sup></a> was specific to MS nurses administering IV methylprednisolone, and Pozzilli 2002<a class="bibr" href="#niceng220er2.ref35" rid="niceng220er2.ref35"><sup>35</sup></a> compared home-based MDT to usual care. This study did include a co-ordinating single point of contact, but it was a telephone operator and not an HCP.</p><p>See the excluded studies list in <a href="#niceng220er2.appj">Appendix J</a>.</p></div></div></div><div id="niceng220er2.s1.1.5"><h4>1.1.5. Summary of studies included in the effectiveness evidence</h4><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab3"><a href="/books/NBK585276/table/niceng220er2.tab3/?report=objectonly" target="object" title="Table 3" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab3" rid-ob="figobniceng220er2tab3"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab3/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab3/?report=previmg" alt="Table 3. Summary of studies included in the evidence review." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab3"><a href="/books/NBK585276/table/niceng220er2.tab3/?report=objectonly" target="object" rid-ob="figobniceng220er2tab3">Table 3</a></h4><p class="float-caption no_bottom_margin">Summary of studies included in the evidence review. </p></div></div></div><div id="niceng220er2.s1.1.6"><h4>1.1.6. Summary of the effectiveness evidence</h4><p>A meta-analysis of the data was not appropriate due significant differences in interventions, comparators, populations, study designs as well as reporting of the data. Therefore, a narrative summary including summary tables are presented separately for each study.</p><div id="niceng220er2.s1.1.6.1"><h5>Forbes 2006</h5><p>This study compared clinical service at 4 MS centres with established MS nurse specialist programme, to clinical service at 2 centres where an MS specialist nurse role had not been established.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab4"><a href="/books/NBK585276/table/niceng220er2.tab4/?report=objectonly" target="object" title="Table 4" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab4" rid-ob="figobniceng220er2tab4"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab4/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab4/?report=previmg" alt="Table 4. Differences in resource utilisation and care processes in groups involving an MS nurse and adults with MS in groups not involving an MS nurse." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab4"><a href="/books/NBK585276/table/niceng220er2.tab4/?report=objectonly" target="object" rid-ob="figobniceng220er2tab4">Table 4</a></h4><p class="float-caption no_bottom_margin">Differences in resource utilisation and care processes in groups involving an MS nurse and adults with MS in groups not involving an MS nurse. </p></div></div><p>Quality of life and function at 24 months were generally poorer in the MS nurse group than the groups without an MS nurse after adjustment for baseline values. The uncertainty of the direction of the effect was high, except for SF36 general health and SF 36 energy vitality, where a clear effect favouring the group without MS nurses was observed. <a class="figpopup" href="/books/NBK585276/table/niceng220er2.tab5/?report=objectonly" target="object" rid-figpopup="figniceng220er2tab5" rid-ob="figobniceng220er2tab5">Table 5</a> and <a class="figpopup" href="/books/NBK585276/table/niceng220er2.tab6/?report=objectonly" target="object" rid-figpopup="figniceng220er2tab6" rid-ob="figobniceng220er2tab6">Table 6</a> summarise this information:</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab5"><a href="/books/NBK585276/table/niceng220er2.tab5/?report=objectonly" target="object" title="Table 5" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab5" rid-ob="figobniceng220er2tab5"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab5/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab5/?report=previmg" alt="Table 5. Difference in quality of life between adults with MS in groups involving an MS nurse and adults with MS in groups not invo ving an MS nurse." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab5"><a href="/books/NBK585276/table/niceng220er2.tab5/?report=objectonly" target="object" rid-ob="figobniceng220er2tab5">Table 5</a></h4><p class="float-caption no_bottom_margin">Difference in quality of life between adults with MS in groups involving an MS nurse and adults with MS in groups not invo ving an MS nurse. </p></div></div><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab6"><a href="/books/NBK585276/table/niceng220er2.tab6/?report=objectonly" target="object" title="Table 6" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab6" rid-ob="figobniceng220er2tab6"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab6/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab6/?report=previmg" alt="Table 6. Difference in function between adults with MS in groups involving an MS nurse and adults with MS in groups not involving an MS nurse." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab6"><a href="/books/NBK585276/table/niceng220er2.tab6/?report=objectonly" target="object" rid-ob="figobniceng220er2tab6">Table 6</a></h4><p class="float-caption no_bottom_margin">Difference in function between adults with MS in groups involving an MS nurse and adults with MS in groups not involving an MS nurse. </p></div></div></div><div id="niceng220er2.s1.1.6.2"><h5>Jansen 2006</h5><p>This prospective cohort study compared a multidisciplinary MS care protocol to ‘traditional’ care. Data were not reported but both groups were reported to have similar judgements of co-ordination of care at follow up.</p><p>In terms of healthcare use, there were differences at baseline between groups for use of rehab specialist, nurse specialist and physical therapist but no adjustments were made for these differences. Therefore, it is possible that ten-month findings were confounded by these baseline differences.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab7"><a href="/books/NBK585276/table/niceng220er2.tab7/?report=objectonly" target="object" title="Table 7" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab7" rid-ob="figobniceng220er2tab7"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab7/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab7/?report=previmg" alt="Table 7. Healthcare use in the multidisciplinary and traditional care groups." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab7"><a href="/books/NBK585276/table/niceng220er2.tab7/?report=objectonly" target="object" rid-ob="figobniceng220er2tab7">Table 7</a></h4><p class="float-caption no_bottom_margin">Healthcare use in the multidisciplinary and traditional care groups. </p></div></div><p>The multidisciplinary care group people experienced better quality of life at 10 months in terms of feeling more energetic and vital, and showing fewer changes in general health. It is unclear, however, whether these changes in general health were adverse changes or not. This analysis was adjusted for baseline differences in quality of life (<a class="figpopup" href="/books/NBK585276/table/niceng220er2.tab8/?report=objectonly" target="object" rid-figpopup="figniceng220er2tab8" rid-ob="figobniceng220er2tab8">Table 8</a>).</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab8"><a href="/books/NBK585276/table/niceng220er2.tab8/?report=objectonly" target="object" title="Table 8" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab8" rid-ob="figobniceng220er2tab8"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab8/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab8/?report=previmg" alt="Table 8. Quality of life in the multidisciplinary and traditional care groups." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab8"><a href="/books/NBK585276/table/niceng220er2.tab8/?report=objectonly" target="object" rid-ob="figobniceng220er2tab8">Table 8</a></h4><p class="float-caption no_bottom_margin">Quality of life in the multidisciplinary and traditional care groups. </p></div></div></div></div><div id="niceng220er2.s1.1.7"><h4>1.1.7. Qualitative evidence</h4><div id="niceng220er2.s1.1.7.1"><h5>1.1.7.1. Included studies</h5><div id="niceng220er2.s1.1.7.1.1"><h5>General MS population – coordination of care-related themes</h5><p>The qualitative review on information and support included twenty-six studies (from twenty-seven papers) that covered some themes relevant to coordination of care in the general MS population. The studies included in this section varied in terms of the population and aims. Some focused specifically on coordination of care areas (for example, getting opinions on specific roles such as MS or neurological nurses) and others had more general aims but contained some discussion of coordination of care issues. All but three of the studies were themes reported solely from the perspective of the person with MS or condition; of the remaining three studies, one reported family/carer perspectives only while the other two reported perspectives of both people with MS and family/informal caregivers. Most studies were small, with <100 people included; the exceptions were three studies (n=445–757) where the qualitative component was only through free-text responses to questionnaire, rather than using formal qualitative methods such as interviews or focus groups. One study<a class="bibr" href="#niceng220er2.ref1" rid="niceng220er2.ref1"><sup>1</sup></a> that was included aimed to identify experiences of people with long-term neurological conditions and the roles of neurological nurses in their care, which included a proportion of people with MS. Despite being a mixed population, this study was judged by the committee to be relevant to include but there were minor concerns about relevance. Studies that were not based in the UK<a class="bibr" href="#niceng220er2.ref9" rid="niceng220er2.ref9"><sup>9</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref12" rid="niceng220er2.ref12"><sup>12</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref19" rid="niceng220er2.ref19"><sup>19</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref21" rid="niceng220er2.ref21"><sup>21</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref23" rid="niceng220er2.ref23"><sup>23</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref24" rid="niceng220er2.ref24"><sup>24</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref32" rid="niceng220er2.ref32"><sup>32</sup></a><sup>–</sup><a class="bibr" href="#niceng220er2.ref34" rid="niceng220er2.ref34"><sup>34</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref37" rid="niceng220er2.ref37"><sup>37</sup></a><sup>–</sup><a class="bibr" href="#niceng220er2.ref39" rid="niceng220er2.ref39"><sup>39</sup></a> were also considered to have minor concerns about relevance for this section of the review, given that coordination of care may vary across countries and experiences may therefore differ. Additionally, one study<a class="bibr" href="#niceng220er2.ref18" rid="niceng220er2.ref18"><sup>18</sup></a> looking at the effect of a single MS nurse was considered to have moderate concerns about relevance as it was published in 1995 and roles and experiences may have changed substantially since that time.</p></div></div></div><div id="niceng220er2.s1.1.8"><h4>1.1.8. Summary of studies included in the qualitative evidence</h4><p>Included studies tables are presented below. See <a href="#niceng220er2.appd">Appendix D</a> in evidence review A for full evidence tables.</p><div id="niceng220er2.s1.1.8.1"><h5>General MS population – coordination of care themes</h5><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab9"><a href="/books/NBK585276/table/niceng220er2.tab9/?report=objectonly" target="object" title="Table 9" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab9" rid-ob="figobniceng220er2tab9"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab9/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab9/?report=previmg" alt="Table 9. Summary of studies included in the evidence review." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab9"><a href="/books/NBK585276/table/niceng220er2.tab9/?report=objectonly" target="object" rid-ob="figobniceng220er2tab9">Table 9</a></h4><p class="float-caption no_bottom_margin">Summary of studies included in the evidence review. </p></div></div></div></div><div id="niceng220er2.s1.1.9"><h4>1.1.9. Summary of qualitative evidence</h4><p>Interpretations and explanations from the included studies were synthesised to gain an insight into themes present across the body of evidence as a whole. The main concepts found in each individual study which were relevant to our review question were drawn together to inform understanding of overarching themes, with subthemes identified within some of these main findings.</p><div id="niceng220er2.s1.1.9.1"><h5>General MS population – coordination of care themes</h5><div id="niceng220er2.s1.1.9.1.1"><h5>Narrative summary of review findings</h5><p>See <a href="#niceng220er2.appf">Appendix F</a> for full GRADE-CERQual tables.</p></div></div><div id="niceng220er2.s1.1.9.2"><h5>Review finding (theme) 1: Organisation of care and individuals with a central coordination role</h5><p>Organisation of care and individuals with a central coordination role was identified as an important theme across studies. Various subthemes contribute to the main finding as they feed into the idea that organisation of care is an important factor to patients and carers, with some reporting how they would like care to be improved and others reporting positive aspects of someone with a central treatment coordination role, usually MS nurses. Subthemes contributing to this main finding included the perceived benefit of having care delivered by as few individuals as possible, the importance of developing a consistent and personal relationship and the ability of clinicians to respond to changing needs of the person, the role of health care professionals in supporting, educating, guiding and helping to access services, coordination and communication across levels of care, allowing people with MS and carers to maintain usual activities and relationships and promoting self-confidence and the ability to cope, as well as the importance of the patient or carer knowing who to contact. These are discussed in more detail below under separate headings.</p></div><div id="niceng220er2.s1.1.9.3"><h5>Subtheme – Care delivered by fewer professionals and developing a consistent and personal relationship – eight studies</h5><p>A common statement across studies was the preference for care to be delivered by as few healthcare professionals as possible. Reasons for this were most commonly the fact that people felt it frustrating to have to repeat themselves to multiple different professionals and it was also difficult to juggle multiple appointments with different individuals. The frustration of repeating oneself was mentioned in terms of repeating the situation to different types of clinician and also in the context of being assigned a new clinician when the previous one leaves. The latter is unavoidable in terms of organising care but further contributes to the finding that people prefer to be in contact with the same individuals and want to avoid repeating themselves as much as possible, meaning care delivered by as few professionals as possible is ideal. Consistent professional relationships were also reported to increase trust and reassurance among people with MS, meaning they felt able to talk more freely and openly. One study where people had access to a neurological nurse specialist reported the importance of these individuals in reducing the number of professionals required to deliver care and also the number of appointments they needed to attend based on the specialist advice they could provide themselves. Multiple studies where people had access to a neurological or MS nurse specialist or contact with a single professional valued this and reported reassurance, trust and the ability to discuss their condition freely.</p><p><b><u>Explanation of quality assessment:</u></b> There was a judgement of moderate confidence in this finding due to concerns about methodological limitations and possibly relevance, but the fairly large number of studies identified contributing to this theme meant moderate confidence was thought to be appropriate.</p></div><div id="niceng220er2.s1.1.9.4"><h5>Subtheme – Knowing who to contact – fifteen studies (from sixteen papers)</h5><p>The need for people with MS and their carers to have a known point of contact was evident across multiple studies. Evidence for this comes directly from some studies reporting positive experiences of having a single point of contact and also indirectly from others where frustration and confusion about having to facilitate communication between services and not knowing which professional is responsible for specific symptoms of MS was reported. Positive experiences of neurological nurse specialists or MS nurse specialists were described, which included how their role as a point of contact and source of support was reassuring - just the knowledge that they had access to them via email or telephone if needed provided reassurance, even if they never needed to use the service. Others found it easier and quicker to contact the nurse rather than other professionals and also did not want to waste the time of other professionals. Having a well-defined support network of professionals and knowing who to contact was felt to have improved experiences of care and confidence in accessing services for some and the role of a single point of contact in advising and organising appointments and treatment sessions was clear across multiple studies. However, one study where MS nurses were available indicated that there may still be issues for some in terms of accessing relevant information, as they reported that in many cases information was obtained by chance rather than through professionals, though it was unclear whether they had actively asked a point of contact about any of the areas they felt information was lacking on.</p><p>Other studies where there did not appear to be a single point of contact available or where this was unclear also highlighted the potential need for a single point of contact. A lack of clarity about who was responsible for specific symptoms suggested uncertainty about who the person should contact and there was a desire for increased coordination of care and a single point of contact to help guide people with MS to the correct services. It was also highlighted that determining how and when to seek care appropriate for their health concern required work and knowledge on the part of people. Some people from one study stated that the choice of service often depended on ease of access, meaning they defaulted to services that were easiest to access such as emergency departments or walk-in clinics. Some people specifically expressed a need for a point of contact that could be accessed 24 hours a day, while others indirectly suggested this need as they described limited opportunity to discuss issues with neurologists due to limited time and number of appointments, something which a point of contact in between these appointments may improve.</p><p>Often, the reason for wanting or appreciating a point of contact in between appointments was due to the limited number of appointments with neurologists each year and also limited time within these appointments to discuss all concerns. Some were also concerned about wasting the time of other professionals and a point of contact to discuss concerns with initially may alleviate these concerns. As previously mentioned, another key reason for wanting a point of contact was to navigate services and make sure they were referred to the correct service as and when needed, as it was sometimes unclear who was responsible for which symptoms.</p><p><b><u>Explanation of quality assessment:</u></b> There was a judgement of moderate confidence in this finding due to concerns about methodological limitations and possibly relevance, but the fairly large number of studies identified contributing to this theme meant moderate confidence was thought to be appropriate.</p></div><div id="niceng220er2.s1.1.9.5"><h5>Subtheme – Roles of those with a central coordination role</h5><p>Experiences of those that had access to someone with a coordination role, which was a neurology or MS nurse in most cases, highlighted the roles and benefits of these individuals for people with MS and are explained separately below under five different themes. In addition to studies where there was experience of someone involved in coordination, others where this may not have been the case and where issues with any of the themes occurred are also included as someone involved in coordination of care may have improved the experiences of these people with MS and their carers.</p><div id="niceng220er2.s1.1.9.5.1"><h5>Subtheme within ‘Roles of those with a central coordination role’ subtheme – Supporting, educating, guiding and accessing services – twenty-one studies</h5><p>Responses from people that had experience of a neurology or MS nurse involved in their care indicated that these professionals had a large and important role in providing support, educating people with MS, as well as their family and carers. They also in helped people to navigate and access services. People highlighted the importance of advice about disease management such as medication regimes and ways of managing their condition and identifying exacerbations. This allowed proactive care and for issues to be dealt with before they became major issues. People also highlighted that they were key in providing additional types of information and support, such as advice about planning for the future in terms of barriers at work, education, social and leisure activities, and being put in touch with voluntary organisations which allowed access to further information and the opportunity to join peer support groups. Some people also sought emotional support primarily through MS nurses, although others felt that the emotional and mental health side of MS was neglected by services in general and was not addressed enough by MS nurses. One study based in Iran suggested that nurses did not provide sufficient information across different elements of the condition (for example diet), but it was unclear whether this was referring to general nurses or MS nurses and unclear if their role included coordination of care. However, these described limitations in terms of information and support in some studies still highlight how someone with a coordination role may help to improve these experiences by putting people in touch with the correct services or organisations.</p><p>People often commented that support from neurology or MS nurses was ‘invaluable’ and they were often considered to be the first port of call when support or advice was needed. The flexible way in which they provided support, by being just a telephone call away, allowed people fears to be allayed. In addition, fears could be addressed as and when they arose, highlighting the importance of having a point of contact that is accessible as soon as possible.</p><p>GPs were also highlighted by some as being important sources of support due to them being closer in terms of geography to people and relatively easy to access. One study demonstrated that people saw neurologists as well placed to accompany patients through progression of their disease and as an important source of information, education, support and reassurance. Examples include information about research and emerging treatments and the availability of aids to improve quality of life, as well as psychological support and reassurance about their condition. Positive descriptions of healthcare professionals included those who took responsibility for the responsiveness of care and continued contact with a single professional was valued. It was reassuring as they knew they would be able to access services if they knew there was someone to contact that could help them navigate services.</p><p>For groups of people where it was unclear if there was access to an MS nurse or another professional coordinating care, a lack of knowledge around the current healthcare service and the ability to navigate these services effectively was highlighted. Some people expressed the sense of having to fight for services, aids and benefits and a lack of information about what was available to them in terms of care and other elements of life such as financial support. Navigating the systems was described as exhausting by some people, with some choosing to use services that were most easily accessible to them such as emergency departments and walk-in clinics as other services were difficult to gain access to. Some people specifically wanted the provision of or increased access to an MS nurse. In the context of bladder symptoms, this meant that people with MS were self-managing without advice from professionals as they did not know who to talk to about this symptom. Having someone with a coordination role could benefit these people with MS by advising them where possible and helping them to access the right services for their symptoms, though it was unclear whether they already had someone in a coordination role already. Others highlighted the limited time available to discuss issues at appointments with those treating them, suggesting a point of contact in between appointments for support and advice would be an improvement for these people.</p><p><b><u>Explanation of quality assessment:</u></b> There was a judgement of moderate confidence in this finding due to concerns about methodological limitations and possibly relevance. However, the fairly large number of studies identified contributing to this theme meant moderate confidence was thought to be appropriate.</p></div><div id="niceng220er2.s1.1.9.5.2"><h5>Subtheme within ‘Roles of those with a central coordination role’ subtheme – Coordinating and aiding communication across care – thirteen studies (from fourteen papers)</h5><p>For those that had access to a neurology or MS nurse, coordination of services and facilitating and improving communication between different levels of care was described as one of their roles by many people. Compared to other services from which people were discharged once an issue was resolved, neurology nurse specialists kept people with MS on their lists permanently, which allowed support to be ongoing and meant that interruptions in long-term care could be picked up and other professionals kept informed about changes in health of each person with MS in their role as a coordinator. Their knowledge in forward-planning allowed them to coordinate care and meant that the most appropriate professionals were involved in a person’s care at any one time. Their role in coordinating services and information reduced the need for people to have to repeat themselves to different professionals, which was highlighted as a frustration for many. These roles helped to bridge the gap between primary and secondary care for some people and resolve problems with communication and coordination across services. Many felt that without this support it would have been difficult to navigate services and facilitate communication.</p><p>For those where they did not appear to have access to an MS nurse or another professional coordinating care, a desire for increased coordination of their healthcare was common. Frustration at the compartmentalisation of departments and having to facilitate communication between services themselves was expressed. The lack of communication and coordination sometimes meant that issues raised in one service were not resolved. Some people also felt that when specific problems arose, there should be an easier referral to different specialists. Issues with being given conflicting information or treatments from different providers were also described by some, also caused by poor communication. One carer that initially struggled to coordinate care themselves expressed relief when they were provided with help with this by a social worker and others described healthcare professionals that took responsibility for the responsiveness of care positively. Some commented that compartmentalisation was still an issue even when they had access to MS nurses, suggesting that they may not always have a role in coordinating care currently. However, this still highlights how improved coordination and communication between services through a care coordinator, regardless of who this is provided by, may improve patient experience.</p><p><b><u>Explanation of quality assessment:</u></b> There was a judgement of moderate confidence in this finding due to concerns about methodological limitations and possibly relevance, but the fairly large number of studies identified contributing to this theme meant moderate confidence was thought to be appropriate.</p></div><div id="niceng220er2.s1.1.9.5.3"><h5>Subtheme within ‘Roles of those with a central coordination role’ subtheme – Responding to changing needs – five studies</h5><p>Respondents that had access to an MS or neurological nurse described how the long-term relationship they established and the flexibility in which they were able to provide services, information and support was valuable in terms of responding to the changing needs of people with MS which, as a long-term condition, often involved changing needs for example when experiencing relapses or new issues emerging. People reported that the long-term relationship and increased time for nurses to listen to them compared to other professionals, as well as their increased expertise in the condition, allowed them to understand the person as well as the condition and subsequently offer bespoke services and information in response to the person’s needs at that particular time-point. People valued ongoing access to services as and when they needed it and praised the flexibility in which nurses were able to provide support. This included the knowledge and support available at any time as well as the option of nurses visiting them at home rather than having to attend hospital to see them, which could be more difficult at times depending on the condition of the person. The knowledge of this flexibility in response to their needs was also reassuring for some when concerns about the future and whether they would be well enough to attend appointments arose, as they knew they would still be able to have access to services, and some also felt more comfortable discussing more sensitive issues at home with a nurse rather than in a hospital.</p><p>For those where it was unclear whether they had access to an MS nurse or another point of contact, comments were made reflecting the need for improved referral to different specialists when specific problems arose and the fact that the fast onset and severe disability caused by MS relapses meant services needed to be highly responsive to minimise distress and disability. People also expressed the need to stay “in the loop” and maintain contact with services in order to access information and emergency treatment and sometimes felt abandoned without regular follow-up, although the extent of this differed depending on the severity of MS and options for treatments. People also highlighted the importance of healthcare providers taking a patient-centred approach, which involves viewing patients as a whole and actively communicating with patients in order to deliver shared decision making between providers and patients, taking into account the person’s lived experience with MS. The patient-centred approach was described as being associated with improved functioning, participation and independence, while when this approach was not taken feelings of being invalidated and left with concerns that had not been addressed were described.</p><p>These observations highlight the importance of services and support being responsive to the changing and specific needs of each individual and their carers, which may be improved through having flexible access to a single point of contact and more coordinated care.</p><p><b><u>Explanation of quality assessment:</u></b> There was a judgement of low confidence in this finding due to concerns about methodological limitations, adequacy and possibly relevance.</p></div><div id="niceng220er2.s1.1.9.5.4"><h5>Subtheme within ‘Roles of those with a central coordination role’ subtheme – Promoting self-confidence and the ability to cope – three studies</h5><p>Another advantage reported by people that had access to a neurological or MS nurse was that the regular review and follow-up, and the flexible way in which support could be provided, led to people feeling better supported, having some control over service use and therefore able to cope. Nurses helped people and their families to learn coping mechanisms and improve their confidence in self-managing the condition as people with MS were aware that if they did need help, they would be able to access it quickly via their nurse, giving them increased personal agency as well as choice and control.</p><p>For a group where it was unclear if a point of contact and care coordinator was available, they reported a general lack of information concerning bladder symptoms and difficulty navigating services. This lack of support could have contributed to the difficulties they also described in effectively self-managing their condition and symptoms as people with MS were unable to get sufficient advice, something which may be improved if a point of contact involved in coordination of care was available to guide them to the right resources or professional, reducing the need for them to try to cope alone without professional input.</p><p><b><u>Explanation of quality assessment:</u></b> There was a judgement of low confidence in this finding due to concerns about methodological limitations, adequacy and possibly relevance.</p></div><div id="niceng220er2.s1.1.9.5.5"><h5>Subtheme within ‘Roles of those with a central coordination role’ subtheme – Helping maintain usual activities and relationships – one study</h5><p>Respondents from one study that had access to a neurological nurse specialist described how the flexible nature of the service helped them to maintain preferred social and personal relationships and allowed them to participate in activities that maintained or enhanced their quality of life. Examples given included assistance with taking invasive medications at home rather than travelling to the hospital multiple times to receive the treatment, which was beneficial for some in terms of working commitments and minimising disruption to family life. This highlights how someone acting as a point of contact with a role in coordinating care could help to adapt services and care to the needs of those receiving care and allow important relationships and roles to be maintained.</p><p><b><u>Explanation of quality assessment:</u></b> There was a judgement of low confidence in this finding due to concerns about methodological limitations, adequacy and relevance.</p></div></div><div id="niceng220er2.s1.1.9.6"><h5>Review finding (theme) 2: Knowledge of MS for those delivering care was important - thirteen studies (from fourteen papers)</h5><p>For those with access to a neurological or MS nurse specialist, their expertise and increased knowledge of MS was valued and considered reassuring when asking for information and support. In addition to providing reassurance, nurse expertise meant that they could provide advice about medication and management and be proactive in terms of providing care to avoid issues becoming major issues and in some cases reduce the requirement for interventions from other professionals. People compared MS nurses with GPs in terms of their knowledge of MS and the feeling that GPs had limited understanding of MS was common among people, sometimes leading to them feeling unsupported. The increased understanding MS nurses had of the condition meant they were considered to be a lifeline. Some considered MS nurses to have an increased understanding of their condition compared to multiple other professionals, including GPs, neurologists, physiotherapists and occupational therapists, and preferred to contact them for that reason.</p><p>Other studies that did not specifically report on direct experiences of MS nurses also highlighted the importance of having access to a point of contact with increased knowledge of MS, as many people commented on the perceived lack of knowledge GPs had about MS, the services and support available and the skills involved in its management. Although many expressed an understanding that as general practitioners, they would not have in-depth knowledge and appreciated the support they did receive, they still wanted support from someone that did have an increased understanding as this could lead to a feeling of being poorly understood and isolated. People described experiences of feeling invalidated or dismissed by providers, noting the provider’s knowledge of MS. For example, issues would be immediately ascribed to MS without consideration of other possibilities or MS not considered as a contributing factor for a certain health concern. Some expressed a wish to have increased access to or provision of an MS nurse specifically, while others stated that they preferred care from an MS specialist or neurologist but due to permeability barriers they were often reliant on general practitioners. Some also found occupational therapists, physiotherapists and community nurses to be quite knowledgeable. It was also noted by some that though specialists might be very knowledgeable about the condition, they sometimes lacked the ‘lived’ experience of MS.</p><p><b><u>Explanation of quality assessment:</u></b> There was a judgement of moderate confidence in this finding due to concerns about methodological limitations.</p><div class="iconblock whole_rhythm clearfix ten_col fig" id="figniceng220er2fig1" co-legend-rid="figlgndniceng220er2fig1"><a href="/books/NBK585276/figure/niceng220er2.fig1/?report=objectonly" target="object" title="Figure 1" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2fig1" rid-ob="figobniceng220er2fig1"><img class="small-thumb" src="/books/NBK585276/bin/niceng220er2f1.gif" src-large="/books/NBK585276/bin/niceng220er2f1.jpg" alt="Figure 1. Main review findings and details – coordination of care in general MS population." /></a><div class="icnblk_cntnt" id="figlgndniceng220er2fig1"><h4 id="niceng220er2.fig1"><a href="/books/NBK585276/figure/niceng220er2.fig1/?report=objectonly" target="object" rid-ob="figobniceng220er2fig1">Figure 1</a></h4><p class="float-caption no_bottom_margin">Main review findings and details – coordination of care in general MS population. </p></div></div></div></div><div id="niceng220er2.s1.1.10"><h4>1.1.10. Summary of health economic studies included in the qualitative evidence</h4><div id="niceng220er2.s1.1.10.1"><h5>1.1.10.1. Included studies</h5><p>No health economic studies were included.</p></div><div id="niceng220er2.s1.1.10.2"><h5>1.1.10.2. Excluded studies</h5><p>No relevant health economic studies were excluded due to assessment of limited applicability or methodological limitations.</p><p>A number of studies have been identified that report on the value of the MS specialist nurse (Mynors 2012, Mynors 2015, Bowen 2016, Willmington 2017, Leary 2015, Hannan 2018, Punshon 2021, Hopper 2020)<a class="bibr" href="#niceng220er2.ref3" rid="niceng220er2.ref3"><sup>3</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref13" rid="niceng220er2.ref13"><sup>13</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref14" rid="niceng220er2.ref14"><sup>14</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref20" rid="niceng220er2.ref20"><sup>20</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref27" rid="niceng220er2.ref27"><sup>27</sup></a><sup>–</sup><a class="bibr" href="#niceng220er2.ref29" rid="niceng220er2.ref29"><sup>29</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref36" rid="niceng220er2.ref36"><sup>36</sup></a>. None of these studies met our criteria for assessment of applicability or methodology as they were not economic evaluations and/or did not include a comparator, therefore they have not been added to the included or excluded study lists. In the absence of evidence, a summary of their findings is included in the unit cost section of this report.</p><p>See also the health economic study selection flow chart in <a href="#niceng220er2.appg">Appendix G</a>.</p></div></div><div id="niceng220er2.s1.1.11"><h4>1.1.11. Unit costs</h4><p>Relevant unit costs are provided below to aid consideration of cost effectiveness.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab10"><a href="/books/NBK585276/table/niceng220er2.tab10/?report=objectonly" target="object" title="Table 10" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab10" rid-ob="figobniceng220er2tab10"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab10/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab10/?report=previmg" alt="Table 10. Unit cost of health care professionals." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab10"><a href="/books/NBK585276/table/niceng220er2.tab10/?report=objectonly" target="object" rid-ob="figobniceng220er2tab10">Table 10</a></h4><p class="float-caption no_bottom_margin">Unit cost of health care professionals. </p></div></div><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab11"><a href="/books/NBK585276/table/niceng220er2.tab11/?report=objectonly" target="object" title="Table 11" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab11" rid-ob="figobniceng220er2tab11"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab11/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab11/?report=previmg" alt="Table 11. Unit costs of health care professional visits and hospital admissions." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab11"><a href="/books/NBK585276/table/niceng220er2.tab11/?report=objectonly" target="object" rid-ob="figobniceng220er2tab11">Table 11</a></h4><p class="float-caption no_bottom_margin">Unit costs of health care professional visits and hospital admissions. </p></div></div><div id="niceng220er2.s1.1.11.1"><h5>Summary of literature reporting on the value of an MS nurse</h5><div id="niceng220er2.s1.1.11.1.1"><h5>Mynors 2012</h5><p>The first paper, a report by Mynors 2012<a class="bibr" href="#niceng220er2.ref28" rid="niceng220er2.ref28"><sup>28</sup></a>, provided illustrative costs and savings associated with a new MS specialist nurse post using the MS Society cost calculator (2011 edition). This tool is an excel spread sheet which can be used to calculate the actual cost of employing a MS specialist nurse against the cost savings from avoided admissions and other attendances, based on national tariff. The total annual cost (excluding cost savings) for one MS specialist nurse post was estimated to be £63,980 (2011 UK pounds). The cost components considered in the analysis were salary, overheads, telephone, mileage, computer, shared clinic receptionist, clinic room and secretarial support (see <a class="figpopup" href="/books/NBK585276/table/niceng220er2.tab12/?report=objectonly" target="object" rid-figpopup="figniceng220er2tab12" rid-ob="figobniceng220er2tab12">Table 12</a>).</p><p>The report also considered the potential cost savings in terms of saved outpatient appointments and emergency admissions associated with one MS specialist nurse post. These were illustrative figures which assumed a saving of 300 outpatient appointments and 40 emergency admissions were attributed to the creation of one MS specialist nurse post. Using the national tariff, the authors calculated the expected cost savings to commissioners. The total estimated cost saving was £54,000 for each post (see <a class="figpopup" href="/books/NBK585276/table/niceng220er2.tab13/?report=objectonly" target="object" rid-figpopup="figniceng220er2tab13" rid-ob="figobniceng220er2tab13">Table 13</a>). In addition, the report calculated that to breakeven, one MS specialist nurse would need to save 199 outpatient appointments and 21 emergency admissions (see <a class="figpopup" href="/books/NBK585276/table/niceng220er2.tab14/?report=objectonly" target="object" rid-figpopup="figniceng220er2tab14" rid-ob="figobniceng220er2tab14">Table 14</a>). Two case studies estimating savings associated with an MS specialist nurse were presented in the report, the figures differed from the cost analysis summarised below.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab12"><a href="/books/NBK585276/table/niceng220er2.tab12/?report=objectonly" target="object" title="Table 12" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab12" rid-ob="figobniceng220er2tab12"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab12/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab12/?report=previmg" alt="Table 12. Costs associated with a new MS specialist nurse post ." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab12"><a href="/books/NBK585276/table/niceng220er2.tab12/?report=objectonly" target="object" rid-ob="figobniceng220er2tab12">Table 12</a></h4><p class="float-caption no_bottom_margin">Costs associated with a new MS specialist nurse post . </p></div></div><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab13"><a href="/books/NBK585276/table/niceng220er2.tab13/?report=objectonly" target="object" title="Table 13" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab13" rid-ob="figobniceng220er2tab13"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab13/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab13/?report=previmg" alt="Table 13. Illustrative cash releasing savings ." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab13"><a href="/books/NBK585276/table/niceng220er2.tab13/?report=objectonly" target="object" rid-ob="figobniceng220er2tab13">Table 13</a></h4><p class="float-caption no_bottom_margin">Illustrative cash releasing savings . </p></div></div><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab14"><a href="/books/NBK585276/table/niceng220er2.tab14/?report=objectonly" target="object" title="Table 14" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab14" rid-ob="figobniceng220er2tab14"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab14/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab14/?report=previmg" alt="Table 14. Breakeven assumptions ." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab14"><a href="/books/NBK585276/table/niceng220er2.tab14/?report=objectonly" target="object" rid-ob="figobniceng220er2tab14">Table 14</a></h4><p class="float-caption no_bottom_margin">Breakeven assumptions . </p></div></div></div><div id="niceng220er2.s1.1.11.1.2"><h5>GEMSS 2015</h5><p>GEMSS (Generating Evidence in Multiple Sclerosis Services) reported on the findings of their MS specialist nurse evaluation project (Mynors 2015, Bowen 2016<a class="bibr" href="#niceng220er2.ref3" rid="niceng220er2.ref3"><sup>3</sup></a><sup>,</sup>
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<a class="bibr" href="#niceng220er2.ref29" rid="niceng220er2.ref29"><sup>29</sup></a>). The findings of GEMSS are based on the data collected during 2014/5 by 34 MS specialist nurses working across 15 services in England and Scotland.</p><p>Included in the report is a cost-consequence analysis of employing an MS specialist nurse. Of note the outcomes of people with access to an MS nurse are not compared to people without access to an MS nurse as there was no control group in GEMSS. The results of the GEMSS patient and healthcare professional surveys suggests that MS specialist nurse input for people with MS can save money elsewhere in the health system by:
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<ul><li class="half_rhythm"><div>Preventing hospital admissions and unscheduled care by undertaking early assessment and treatment of relapses, infections and other symptoms.</div></li><li class="half_rhythm"><div>Undertaking patient education on self-management and routine preventative work, to prevent symptoms becoming problematic and complications arising.</div></li><li class="half_rhythm"><div>Reducing the need for people with MS (pwMS) to see other, more costly professionals, such as GPs and neurologists.</div></li></ul></p><p>These savings were estimated by asking patients what they would have done if they had not had an MS specialist nurse in the past year. More than a third of respondents said that they would have struggled on their own, with the associated risk that complications of MS would potentially not be dealt with until they were at the point of crisis, requiring unscheduled care. However, nearly half the respondents said that they would have made more use of other services: GPs, neurologists and Accident and Emergency (A&E).</p><p>Based on these results, an estimate of the cost for ambulatory care which would have been necessary, had the MS specialist nurse services not been available was presented (using conservative assumptions). They assumed that each person who said they would have seen their GP ‘more’ or gone to A&E would have done so only once during the year, and we have not made any assumption that the A&E visits would have resulted in a hospital admission.</p><p>For additional neurology appointments, only 19% of pwMS said that they would have needed to see their neurologist more if the MS specialist nurse had not been there, but the authors note that this is an underestimate. In order to comply with the NICE CG186 recommendations, the authors state that everyone with MS would need to see a neurologist once a year in the absence of an MS specialist nurse, for a comprehensive, specialist annual review. They also assumed (conservatively) that people taking oral or self-injected DMDs would need two neurologist appointments in a year, and those on IV DMDs would need four. When compared to current neurologist contact measured by the GEMSS patient survey (an average of 0.74 consultations with a neurologist per year per pwMS), they calculate that, without an MS nurse, each person on the caseload on average would need an additional 0.68 neurologist consultations each year.</p><p>The authors note that even on this very conservative basis, applying these results across a ‘sustainable’ caseload of 358 pwMS, each whole time equivalent (WTE) nurse would have saved the NHS £53.6K in these ambulatory care costs, as shown in <a class="figpopup" href="/books/NBK585276/table/niceng220er2.tab15/?report=objectonly" target="object" rid-figpopup="figniceng220er2tab15" rid-ob="figobniceng220er2tab15">Table 15</a>. Across the average caseload per WTE of the participating GEMSS nurses, which is 511 pwMS per WTE nurse, the saving per WTE nurse rises to £77.4K.</p><div class="iconblock whole_rhythm clearfix ten_col table-wrap" id="figniceng220er2tab15"><a href="/books/NBK585276/table/niceng220er2.tab15/?report=objectonly" target="object" title="Table 15" class="img_link icnblk_img figpopup" rid-figpopup="figniceng220er2tab15" rid-ob="figobniceng220er2tab15"><img class="small-thumb" src="/books/NBK585276/table/niceng220er2.tab15/?report=thumb" src-large="/books/NBK585276/table/niceng220er2.tab15/?report=previmg" alt="Table 15. Conservative modelling of outpatient health service costs saved by MS specialist nurse services." /></a><div class="icnblk_cntnt"><h4 id="niceng220er2.tab15"><a href="/books/NBK585276/table/niceng220er2.tab15/?report=objectonly" target="object" rid-ob="figobniceng220er2tab15">Table 15</a></h4><p class="float-caption no_bottom_margin">Conservative modelling of outpatient health service costs saved by MS specialist nurse services. </p></div></div><p>The GEMSS patient survey also asked pwMS whether they were admitted to hospital in the past year and whether they thought it was related to their MS. The study found that the number of hospital admissions in this cohort seemed low (9.5%) compared to Public Health England data (17%). The authors noted that one explanation could be that those who have been admitted are less likely to have responded to the survey due to ill health (or ongoing hospitalisation), but another possible explanation is the preventative work carried out by MS specialist nurses and other members of the multidisciplinary team. The GEMSS MS specialist nurses recorded the number of times they responded to pwMS contacting their services about an acute deterioration of their symptoms, including suspected relapses, infections, bladder and bowel symptoms and crises relating to their home situation. These amounted to an average of 157 such contacts per WTE MS specialist nurse during the year. The authors note that if only a relatively small share of such interventions result in a prevented admission (estimated cost of an emergency admission £1,820), the savings are considerable.</p><p>Finally, the authors highlight that there are wider societal benefits of MS specialist nurse services. The GEMSS patient survey reported that 5.9% of respondents said that the MS specialist nurse service had helped them stay in employment.</p><p><b>Leary 2015</b><a class="bibr" href="#niceng220er2.ref20" rid="niceng220er2.ref20"><sup>20</sup></a> is a retrospective service evaluation of an established UK MS nursing service. The case study reports on the impact of the introduction of proactive nurse-led management and a rapid response service on rates of emergency presentation, hospital admission, and bed use. The proactive management included the appointment of an extra 6 MS specialist nurse hours per week and the reallocation of some administrative work to allow more time to be spent on proactive as opposed to reactive case management and a rapid response service to emergency physical and psychosocial issues. During a 10-year period, moving from reactive management to proactive management demonstrated an increase in complex specialist nursing interventions and led to a decrease in emergency presentation and bed use at the local acute-care centre. Reduction in utilisation was from a mean of 2,700 bed-days per year (2002–2006) to a mean of 198 bed-days per year (2007–2013).</p><p><b>Willmington Healthcare and the MS trust 2017</b><a class="bibr" href="#niceng220er2.ref27" rid="niceng220er2.ref27"><sup>27</sup></a> published analyses of English Hospital Episode Statistics (HES) from 2015/16, showing there were 26,679 emergency hospital admissions for people with MS in England compared to 23,665 in 2013/14, and this cost the NHS a total of £46m. The report found that nearly one in five of the 89,030 people living with MS in England were admitted to hospital as an emergency in 2015/16. The average cost per admission was £1,733 and the average length of stay was 8.2 days.</p><p>The authors note the most common reasons for emergency MS admissions are often preventable with proactive care: infections (urinary tract and respiratory), bowel problems including constipation, and MS itself (including MS relapse). The report found that urinary tract infections accounted for 14 percent of emergency admissions for MS in 2015/16 and they cost £2,639 per patient. In addition, emergency admissions in people with MS for respiratory issues cost the NHS a total of £5.4m and for bladder and bowel related issues a total of £10.4m (£2,512 per admission).</p><p>A business case by <b>Hopper 2020</b><a class="bibr" href="#niceng220er2.ref14" rid="niceng220er2.ref14"><sup>14</sup></a> reports survey results around the variability of MS nurse service provision in Hampshire for people with MS. The survey found trends suggesting that patients with the lowest engagement with an MS specialist nurse had the highest percentage attendance at GP, district nurse and NHS walk-ins. Similarly, these patients were more likely to have hospital admissions. The author clarifies that the survey does not prove that an MS specialist nurse would affect admissions to NHS facilities, but the data presented shows that there may be an association between the MS specialist nurse system and admissions to NHS facilities.</p><p><b>Hannan 2018</b><a class="bibr" href="#niceng220er2.ref13" rid="niceng220er2.ref13"><sup>13</sup></a> is a report of the 2018 MS Trust Nurse Mapping Survey. It provides a summary of the current provision of MS specialist nurses in the UK. The survey found that the number of whole time equivalent (WTE) MS specialist nurses in the UK has increased from 241.2 in 2016 to 250.32 in 2018. This gives an average of one nurse per 379 people with MS. The MS trust suggests that a sustainable caseload for one MS nurse is 315. The authors therefore conclude that the increase in MS specialist nurses has not been rapid enough to counteract the lower sustainable caseload figure and increase in the number of people with MS. They suggested that an additional 61 and 105 new MS specialist nurses (depending on which MS prevalence figure is used) are required to ensure the caseload is sustainable for MS specialist nurses.</p><p><b>Punshon 2021</b><a class="bibr" href="#niceng220er2.ref36" rid="niceng220er2.ref36"><sup>36</sup></a> is an MS trust funded study to look into the sustainable caseload for an MS nurse. In this study they suggest a new sustainable caseload of 315 per whole time equivalent MS specialist nurse. This is reduced from the current caseload of 358. The authors report factors such as travel time, complexity of caseload, changing drug therapies and societal issues such as the benefits system contributed to driving demand/workload.</p><p>Finally, in the clinical review, one paper<a class="bibr" href="#niceng220er2.ref10" rid="niceng220er2.ref10"><sup>10</sup></a> reported quality of life differences between groups with an MS nurse compared to groups without an MS nurse. Quality of life and function at 24 months were generally poorer in the MS nurse groups than the groups without an MS nurse after adjustment for baseline values. Furthermore, there was no significant reduction in the hospital admission rate in the past 12 months in the groups with MS nurses relative to the groups without MS nurses. This contradicts the findings from the papers above. Together, the decreased quality of life and lack of reduction in hospital admissions would indicate that an MS nurse would not be cost-effective.</p></div></div></div><div id="niceng220er2.s1.1.12"><h4>1.1.12. Evidence statements</h4><div id="niceng220er2.s1.1.12.1"><h5>Effectiveness/Qualitative</h5><p>One non-randomised study (n=753) reported on statistical significance only with no other data provided. Results showed that there is a statistically significant increase in the availability of a contact person when an MS nurse was introduced. The only significant finding in relation to MS complications was a reduction in the incidence of pressure ulcers in the intervention sites. The evidence was rated as low quality.</p><p>One non-randomised study (n=173) reported on the proportion of patients accessing health care professionals showing an increase in the MS nurse group for a rehabilitation therapist, a nurse specialist and physical therapist. Statistical significance was reported only for quality of life and showed a difference in favour of the intervention group for energy and vitality. The evidence was rated as ‘Very Low’ quality.</p><p>For qualitative evidence on coordination of care themes, all evidence is summarised in GRADE-CERQual tables in <a href="#niceng220er2.appf">Appendix F</a></p></div><div id="niceng220er2.s1.1.12.2"><h5>Economic</h5><ul><li class="half_rhythm"><div>No relevant economic evaluations were identified.</div></li></ul></div></div><div id="niceng220er2.s1.1.13"><h4>1.1.13. The committee’s discussion and interpretation of the evidence</h4><p>The committee discussed the evidence for this review alongside the findings from the review on information and support for patients (Evidence review A) and this is noted where relevant.</p><p>The focus of the question has changed since the last guideline from the effectiveness of general processes of care such as regular review and centralised or electronic records to the effectiveness of the role of a health care professional (HCP) who is central to the process. This role includes the provision of advice and support to manage symptoms and relapses, care planning and directing to appropriate services. Although this role may be carried out by an MS nurse specialist, at scope consultation stakeholders noted that this role is also being carried out by other health care professionals such as physiotherapists and occupational therapists.</p><div id="niceng220er2.s1.1.13.1"><h5>1.1.13.1. The outcomes that matter most</h5><p>The committee acknowledged that co-ordination of care by a specific healthcare professional is difficult to measure. Studies on multidisciplinary teams (MDTs) are usually designed to examine overall changes as a result of implementing a team rather than the effects of specific roles within those teams. Therefore, the impact of particular roles within MDTs may be lost within the multiple interactions occurring during the course of provision of care. The committee agreed that in principle, having a single point of contact within an MDT should help reduce healthcare needs such as hospital admissions, additional GP or consultant appointments and improve quality of life. Therefore, the following outcomes were prioritised for this review: reduction or prevention of unplanned hospital admissions, reduction in consultant or GP appointments, treatment adherence, relapse rates, improvement in mental health, patient or carer satisfaction, functional scales that quantify level of disability, Health-related Quality of Life and impact on patients and carers. These outcomes were considered to be of equal importance the committees decision-making.</p><p>Due to the inherent difficulties in conducting research in this field and the sparsity of published studies, the committee wished to consider a wider variety of evidence to inform their decision making. A call for evidence was conducted to seek further evidence from stakeholders including non-randomised trials, reports, audits and surveys. In addition, the committee agreed that the patient perspective was particularly important to consider in this review question and wished to seek evidence on patient experience and perceptions of coordination of care by conducting a qualitative review on co-ordination of care in the general MS population. This qualitative review was a sub-question in a review on information and support needs (the remainder of the review is presented in evidence review A).</p></div><div id="niceng220er2.s1.1.13.2"><h5>1.1.13.2. The quality of the evidence</h5><div id="niceng220er2.s1.1.13.2.1"><h5>Review of the clinical effectiveness</h5><p>A literature search was conducted to look for randomised and non-randomised comparative studies on processes of care which include a single point of contact compared to processes of care where there is no single point of contact. No new studies that had been published since the last MS guideline were identified. A call for evidence did not identify any additional studies that had not already been identified or had already been considered for inclusion in the review.</p><p>Two non-randomised studies were included, with all outcomes being assessed as very low quality. One compared standard clinical service at 4 MS centres, each involving an MS nurse, to standard clinical service at 2 centres not involving an MS specialist nurse; and the other study compared a multidisciplinary MS care protocol to ‘traditional’ care. Both of these were already included in the previous guideline. Both studies were rated as very low quality primarily due to the lack of adjustment for differences in potential confounders.</p><p>The committee noted the difficulties of assessing the implementation of a MS nurse on outcomes including resource utilisation. For example, the role often changes throughout the trial duration, is multifaceted and is not uniform across services. Furthermore, interventions – in order to be successful – may need to include changes to clinician behaviour, changes to how practices are organised, enhanced information systems and providing education and support to people with MS and their carers.</p></div><div id="niceng220er2.s1.1.13.2.2"><h5>Qualitative review of relating to the information and support needs of people with MS to the coordination of care</h5><p>A total of twenty-six qualitative studies (from twenty-seven papers) were included in the review that covered coordination of care-related themes in the general MS population. The majority (seventeen studies) were interview-based, three were focus group-based, two (from three papers) involved a mixture of interviews and focus groups and four involved qualitative components of a questionnaire. In terms of setting, fourteen studies were UK-based, with the others being set in Canada (five studies), USA (four studies), Ireland (one study), Spain (one study) and Iran (one study).</p><div id="niceng220er2.s1.1.13.2.2.1"><h5>General MS population – themes related to coordination of care only</h5><p>A total of twenty-six qualitative studies (from twenty-seven papers) were included in the review that covered coordination of care-related themes in the general MS population. The majority (seventeen studies) were interview-based, three were focus group-based, two (from three papers) involved a mixture of interviews and focus groups and four involved qualitative components of a questionnaire. In terms of setting, fourteen studies were UK-based, with the others being set in Canada (five studies), USA (four studies), Ireland (one study), Spain (one study) and Iran (one study).</p><p>Of the eight findings that were identified and presented, moderate confidence was present for five of the findings and low confidence for three of the findings based on GRADE CERQual, which reflects downgrading of quality by one and two increments, respectively. Concerns about methodological limitations, either minor or moderate depending on the finding, was one factor contributing to downgrading of evidence quality. Common factors contributing to methodological limitations were a lack of consideration and/or discussion of the role of the researcher and how this may have affected study design and subsequent results, no mention of whether and how results were validated and no mention of data saturation. For those where the confidence in the finding was low, this was because fewer studies reported on that finding, meaning that in addition to methodological concerns there were also concerns about adequacy and there was less confidence in the finding compared to those where there were no concerns about adequacy. For all findings, there were no concerns about coherence.</p><p>There were also some minor concerns about relevance for seven of the eight findings identified. This was because there were concerns about relevance for almost half, half or the majority of the studies contributing to the finding. The most common reason for concerns about relevance in studies was being non-UK based, as coordination of care is likely to differ across countries and may be different to the system in the UK. Additionally, one study involved a mixed population of people with different types of long-term neurological conditions, of which MS made up ∼27%, and was therefore indirectly applicable to the population the review focused on. There were concerns about a further study as although it was UK-based and aimed to assess the workload and benefits of a single MS liaison nurse, it was published in 1995 and practice and roles of MS nurses may have changed substantially since then. However, it was not thought to be appropriate to use minor concerns about relevance as a reason to downgrade findings another increment and instead confidence in the finding was primarily based on methodological limitations and adequacy, with relevance concerns considered alongside this.</p></div></div></div><div id="niceng220er2.s1.1.13.3"><h5>1.1.13.3. Benefits and harms</h5><div id="niceng220er2.s1.1.13.3.1"><h5>Review of the clinical effectiveness</h5><p>Forbes 2006 showed that the implementation of MS nurses led to an increase in the availability of a contact person compared to the comparison group. There was limited impact on MS complications. There was a small but statistically significant worsening of physical and symptoms scales of thee SF36 compared to the comparison group.</p><p>Jansen 2006 reported that more MS patients from the intervention group (involving a multidisciplinary care model facilitating cooperation among healthcare professionals, with a nurse acting as case manager and biannual assessments by a multidisciplinary team) consulted specialists than people in the comparison group (traditional care, no clear definition provided but mentions that in the Netherlands care for people with MS is usually provided by GPs or neurologists) and had more healthcare needs. There were no reported differences in judgements of continuity of care of health-related quality of life.</p></div><div id="niceng220er2.s1.1.13.3.2"><h5>Qualitative review of relating to the information and support needs of people with MS to the coordination of care</h5><p>Within the qualitative review, themes of care delivered by fewer professionals and developing a consistent and personal relationship; knowing who to contact; roles related to coordination of care that may improve the experience of people with MS and their carers (supporting, educating, guiding and accessing services; coordinating and aiding communication across levels of care; responding to changing needs; promoting self-confidence and the ability to cope; and helping maintain usual activities and relationships); and knowledge of MS for those delivering care were identified.</p><p>These findings about roles of those coordinating care were useful in highlighting how having a point of contact and someone coordinating care could improve the experience of people with MS and their carers. The evidence highlighted either that people with access to someone coordinating care felt these were benefits or reported issues with these areas in those where it was not clear whether someone was coordinating care. They represent possible ways in which having a point of contact involved in care coordination could improve experiences of services. The theme ‘knowing who to contact’ also highlighted the direct importance of a point of contact coordinating care. This was already covered by an existing recommendation that involved provision of a point of contact that could coordinate care and help people to access services.</p><p>Based on a further finding in the qualitative review which emphasised the importance of MS knowledge in healthcare professionals communicating with people with MS and their carers, the committee amended the existing recommendation to emphasise that the point of contact should have access to appropriate healthcare professionals, such as an MS nurse.</p><p>Because the available clinical and health economic evidence was limited, the committee were not able to specify that the point of contact should have knowledge of MS as this may represent a change in practice and a resource impact. Instead, a point of contact with knowledge of MS services, which would include the point of contact having access to appropriate healthcare professionals, was included as this also covers systems where the point of contact may not currently have knowledge of MS but who is able to get the relevant healthcare professional to contact the person with MS in order to respond to concerns. The committee noted that although MS nurses are a point of contact for many people with MS, there is still variation in practice and specifying this role in a recommendation would have a resource impact. The committee made a research recommendation for comparative studies to be conducted looking at patient and carer outcomes as well as resource utilisation (see <a href="#niceng220er2.appk">Appendix K</a>). In addition to the limited clinical and health economic evidence, there were also concerns that specifying that the point of contact should be an MS nurse or another professional with MS knowledge could mean that they would be inundated with requests for basic information such as date of next appointments if all queries were to go through them which would have a negative effect on their ability to complete other tasks and see patients.</p><p>The remaining finding, which there was moderate confidence in, was care being delivered by fewer professionals and developing consistent and personal relationships. This issue is not specifically covered by a recommendation under coordination of care but the statement that professionals who can best meet the needs of the person with MS should be involved and the fact that care should be coordinated suggests that the most appropriate professionals should be involved in the person’s care at any single time-point. Many of the comments about developing consistent relationships from the evidence were related to specific healthcare professionals leaving and being replaced by new professionals, which is something that could not be addressed by a recommendation. The patient experience guideline contains recommendations on continuity of care and relationships in terms of assessing the need for this on an individual level and how this will be achieved and a reference to this guideline was made.</p><div id="niceng220er2.s1.1.13.3.2.1"><h5>Overall</h5><p>Taking into account the limited evidence and the low quality of the evidence of the quantitative review the committee were unable to recommend a specific model for how care should be coordinated but emphasised how important it is for people with MS and their carers. A comprehensive model of care involves many health professionals from the community and hospital and from health and social care. The committee acknowledged that different health professionals are able to coordinate care and highlighted that in a number of different services this is provided by MS nurses.</p><p>The committee considered that it was not appropriate both on the current evidence base and on their knowledge of differing service organisation, to recommend one model for coordination of care. They did consider that due to the complexity and low prevalence of MS, every person with the disease should be able to access healthcare professionals who are knowledgeable. The committee did not think there was evidence that first point of contact and professional with responsibility for co-ordination had to be carried out by a specified health professional.</p><p>The committee considered that while it might be possible to define a core multi-disciplinary team of people who are involved in patient care for example, a neurologist, MS nurse, physiotherapist, occupational therapist and neuropharmacist/specialist MS pharmacist (new addition to the recommendation), individual patients might have more need of management from other health care professionals and edited the existing recommendation. A multidisciplinary team approach should encompass all these perspectives as well as those of patient and family. They noted that the MDT may be supported by administrative support for example a pathway coordinator.</p><p>The committee made a research recommendation emphasising the importance of conducting comparative intervention studies so that the benefits and resource savings of a service to coordinate care can be evaluated.</p></div></div></div><div id="niceng220er2.s1.1.13.4"><h5>1.1.13.4. Cost effectiveness and resource use</h5><p>No relevant health economic evaluation studies comparing interventions to improve coordination of care were included in the evidence review. Several studies were identified that reported on the value of the MS specialist nurse, however, none of these studies met the criteria for assessment of applicability or methodology as they were not economic evaluations and/or did not include a comparator, therefore they have not been added to the included or excluded study lists. Instead, a summary of their findings was presented to the committee to aid consideration of cost-effectiveness.</p><p>The first analysis (Mynors, 2012) was a report for the MS Trust which produced illustrative figures suggesting that a new MS nurse post could yield a saving to commissioners of £54,000 if they could save 300 outpatient appointments and 40 emergency admissions. This was done using the MS Society cost calculator. The committee were informed that it would be challenging to update these calculations using current unit costs as the MS Society cost calculator is no longer published and it is unclear which Health Resource Group (HRG) codes were used to estimate neurology and other emergency admissions. The GEMSS (Generating Evidence in Multiple Sclerosis Services) 2015 report included a cost-consequence analysis of employing an MS specialist nurse. This was done using the results from the GEMSS patient and healthcare professional surveys, which asked patients what they would have done if they had not had an MS nurse in the past year. The report estimated that when the survey results, alongside a number of conservative assumptions, were applied across a ‘sustainable’ caseload of 358 people with MS, each whole time equivalent (WTE) nurse would have saved the NHS £53.6K in ambulatory care costs. Leary (2015) was a retrospective service evaluation of an established UK MS nursing service and although it did not adequately address the clinical question for this review, it did report that moving from reactive to proactive MS specialist nurse-led management resulted in a reduction in health care resource utilisation from a mean of 2,700 bed-days per year (2002–2006) to a mean of 198 bed-days per year (2007–2013). Similarly, a report from Willmington Healthcare and the MS trust (2017) did not directly address the review question but rather suggested where savings could be made if MS nurses, or other HCP provided proactive care. The authors noted that the most common reasons for emergency MS admissions are often preventable with proactive care, as the report found that UTIs accounted for 14% of emergency admissions for MS from 2015 to 2016 at a typical cost of £2,639 per patient.</p><p>Survey data by Hopper (2020) showed a potential association between the MS specialist nurse system and admissions to NHS facilities, as the results reported trends suggesting that patients with the lowest engagement with an MS specialist nurse had the highest percentage of attendance at GP, district nurse and NHS walk-ins, and that these patients are more likely to have hospital admissions. A couple of papers specifically reported on the caseloads of MS nurses in the UK. Hannan (2018) reported results from the MS Trust nurse mapping survey and found an average of one WTE MS nurse per 379 people with MS in the UK. The MS trust suggests that a sustainable caseload for one MS nurse is 315. The authors concluded that the increase in MS specialist nurses has not been rapid enough to counteract the lower sustainable caseload figure and increase in the number of people with MS. Likewise, Punshon (2021) found that the current recommended UK caseload of 358 people with MS per full-time equivalent appears to be too high, with a considerable amount of work left undone. The authors reported factors such as travel time, complexity of caseload, changing drug therapies and societal issues such as the benefits system contributed to driving demand and workload. Finally, in the clinical review, one paper (Forbes, 2006) reported decreased quality of life and function at 24 months, as well as a lack of reduction in hospital admissions in the past 12 months in groups with an MS nurse groups compared to groups without an MS nurse, after adjustment for baseline values. This contradicts the findings from the papers above and would indicate that an MS nurse would not be cost-effective.</p><p>Unit cost tables were also presented to the committee. The tables included the costs associated with staff providing coordination of care to people with MS, according to the studies previously mentioned, as well as the cost of professional visits and hospital admissions. Due to lack the clinical data it was not possible to undertake any further health economic analyses. Based on their clinical experience, the committee suggested that MS nurses may realise some of the savings suggested in the reports summarised above, but they acknowledged that none of these reports provide robust economic evidence upon which to base a recommendation. Therefore, taking into consideration the limitations of current clinical and health economic evidence the committee agreed that little change could be made from the previous guideline. As noted in the ‘<a href="#niceng220er2.s1.1.13.3">benefits and harms</a>’ section, based on the qualitative review, the committee amended the existing recommendation to emphasise that the point of contact should have access to appropriate healthcare professionals. There was insufficient evidence to enable the committee to name any specific healthcare professionals as the first point of contact or co-ordinators. They did specify however that the point of contact should have knowledge of MS services. The amendment of this recommendation should not result in a large change in practice and therefore will not have a significant resource impact. The committee also expanded on which healthcare professionals may be included in the multidisciplinary team. This was based on committee experience and opinion. Finally, the committee made a research recommendation emphasising the importance of conducting comparative intervention studies so that the benefits and resource savings of a service to coordinate care can be evaluated.</p></div></div><div id="niceng220er2.s1.1.14"><h4>1.1.14. Recommendations supported by this evidence review</h4><p>This evidence review supports recommendations 1.3.1 to 1.3.2 and the research recommendation on coordination of care.</p></div></div></div><div id="niceng220er2.rl.r1"><h2 id="_niceng220er2_rl_r1_">1.1.15. References</h2><dl class="temp-labeled-list"><dl class="bkr_refwrap"><dt>1.</dt><dd><div class="bk_ref" id="niceng220er2.ref1">Aspinal
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F, Gridley
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K, Bernard
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S, Parker
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G. Promoting continuity of care for people with long-term neurological conditions: the role of the neurology nurse specialist. Journal of Advanced Nursing. 2012; 68(10):2309–2319 [<a href="https://pubmed.ncbi.nlm.nih.gov/22276700" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22276700</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>2.</dt><dd><div class="bk_ref" id="niceng220er2.ref2">Blundell Jones
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J, Walsh
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S, Isaac
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C. "Putting one foot in front of the other": A qualitative study of emotional experiences and help-seeking in women with multiple sclerosis. Journal of Clinical Psychology in Medical Settings. 2014; 21(4):356–373 [<a href="https://pubmed.ncbi.nlm.nih.gov/25217970" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25217970</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>3.</dt><dd><div class="bk_ref" id="niceng220er2.ref3">Bowen
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A, Mynors
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G, Suppiah
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J, Suppiah
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M. Enabling specialist nurses to prove their value. Nursing Times. 2016; 112(14):16–19 [<a href="https://pubmed.ncbi.nlm.nih.gov/27214969" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27214969</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>4.</dt><dd><div class="bk_ref" id="niceng220er2.ref4">Browne
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C, Salmon
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N, Kehoe
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M. Bladder dysfunction and quality of life for people with multiple sclerosis. Disability and Rehabilitation. 2015; 37(25):2350–2358 [<a href="https://pubmed.ncbi.nlm.nih.gov/25801920" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25801920</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>5.</dt><dd><div class="bk_ref" id="niceng220er2.ref5">Curtis
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L, Burns
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A. Unit costs of health and social care 2015. Canterbury, England. Personal Social Services Research Unit University of Kent, 2015. Available from: <a href="http://www.pssru.ac.uk/project-pages/unit-costs/2015/" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">http://www<wbr style="display:inline-block"></wbr>​.pssru.ac.uk<wbr style="display:inline-block"></wbr>​/project-pages/unit-costs/2015/</a></div></dd></dl><dl class="bkr_refwrap"><dt>6.</dt><dd><div class="bk_ref" id="niceng220er2.ref6">Curtis
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L, Burns
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A. Unit Costs of Health and Social Care
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2020. Canterbury, England. Personal Social Services Research Unit University of Kent, 2020. Available from: <a href="https://www.pssru.ac.uk/project-pages/unit-costs/unit-costs-2020/" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://www<wbr style="display:inline-block"></wbr>​.pssru.ac<wbr style="display:inline-block"></wbr>​.uk/project-pages/unit-costs<wbr style="display:inline-block"></wbr>​/unit-costs-2020/</a></div></dd></dl><dl class="bkr_refwrap"><dt>7.</dt><dd><div class="bk_ref" id="niceng220er2.ref7">Defriez
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M, Millett
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C, Narendra Thakrar
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D, Winterbotham
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M. The perception of the current provision of care for multiple sclerosis sufferers in the community. Primary Health Care Research & Development. 2003; 4(3):233–243</div></dd></dl><dl class="bkr_refwrap"><dt>8.</dt><dd><div class="bk_ref" id="niceng220er2.ref8">Edmonds
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P, Vivat
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B, Burman
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R, Silber
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E, Higginson
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IJ. ‘Fighting for everything’: service experiences of people severely affected by multiple sclerosis. Multiple Sclerosis. 2007; 13(5):660–667 [<a href="https://pubmed.ncbi.nlm.nih.gov/17548447" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17548447</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>9.</dt><dd><div class="bk_ref" id="niceng220er2.ref9">Falet
|
|
JR, Deshmukh
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|
S, Al-Jassim
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A, Sigler
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G, Babinski
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M, Moore
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F. The neurologisťs role in disabling multiple sclerosis: A qualitative study of patient and care provider perspectives. Multiple Sclerosis. 2020; 26(7):837–842 [<a href="https://pubmed.ncbi.nlm.nih.gov/31074683" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 31074683</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>10.</dt><dd><div class="bk_ref" id="niceng220er2.ref10">Forbes
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L, Griffiths
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P. Evaluation of a MS specialist nurse programme. International Journal of Nursing Studies. 2006; 43(8):985–1000 [<a href="https://pubmed.ncbi.nlm.nih.gov/16412443" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16412443</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>11.</dt><dd><div class="bk_ref" id="niceng220er2.ref11">Forbes
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A, While
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M. What people with multiple sclerosis perceive to be important to meeting their needs. Journal of Advanced Nursing. 2007; 58(1):11–22 [<a href="https://pubmed.ncbi.nlm.nih.gov/17394612" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17394612</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>12.</dt><dd><div class="bk_ref" id="niceng220er2.ref12">Goicochea Briceno
|
|
H, Higueras Hernandez
|
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Y, Fontan Vela
|
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M, Sierra Marticorena
|
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J, Funes Molina
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C, Meldana Rivera
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Focus group on the experience of patients and family members in the multiple sclerosis unit of a tertiary hospital. Revista Cientifica de la Sociedad Espanola de Enfermeria Neurologica. 2021:<a href="https://doi.org/10.1016/j.sedeng.2020.1007.1003" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://doi<wbr style="display:inline-block"></wbr>​.org/10.1016/j<wbr style="display:inline-block"></wbr>​.sedeng.2020.1007.1003</a></div></dd></dl><dl class="bkr_refwrap"><dt>13.</dt><dd><div class="bk_ref" id="niceng220er2.ref13">Hannan
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G, Sopala
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J, Roberts
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M. MS specialist nursing in the UK 2018: Results from the 2018 MS Trust nurse mapping survey. Letchworth Garden City, England. Multiple Sclerosis Trust, 2018. Available from: <a href="https://mstrust.org.uk/health-professionals/resources/service-development/ms-nurse-mapping-2018" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://mstrust<wbr style="display:inline-block"></wbr>​.org.uk<wbr style="display:inline-block"></wbr>​/health-professionals<wbr style="display:inline-block"></wbr>​/resources/service-development<wbr style="display:inline-block"></wbr>​/ms-nurse-mapping-2018</a></div></dd></dl><dl class="bkr_refwrap"><dt>14.</dt><dd><div class="bk_ref" id="niceng220er2.ref14">Hopper
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|
M, Irving
|
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S, Irving
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E. New Forest MSSN business case project: survey and analysis phases. MS Hampshire Collaborative Working Group MS Society, 2021.</div></dd></dl><dl class="bkr_refwrap"><dt>15.</dt><dd><div class="bk_ref" id="niceng220er2.ref15">Hunter
|
|
R, Parry
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B, Thomas
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C. Fears for the future: A qualitative exploration of the experiences of individuals living with multiple sclerosis, and its impact upon the family from the perspective of the person with MS. British Journal of Health Psychology. 2021; 26(2):464–481 [<a href="https://pubmed.ncbi.nlm.nih.gov/33340208" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33340208</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>16.</dt><dd><div class="bk_ref" id="niceng220er2.ref16">Jansen
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DE, Krol
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B, Groothoff
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JW, Post
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D. Evaluation of a transmural care model for multiple sclerosis patients. Journal of Neuroscience Nursing. 2006; 38(5):384–389 [<a href="https://pubmed.ncbi.nlm.nih.gov/17069269" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 17069269</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>17.</dt><dd><div class="bk_ref" id="niceng220er2.ref17">Johnson
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J.
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On receiving the diagnosis of multiple sclerosis: managing the transition. Multiple Sclerosis. 2003; 9(1):82–88 [<a href="https://pubmed.ncbi.nlm.nih.gov/12617273" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12617273</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>18.</dt><dd><div class="bk_ref" id="niceng220er2.ref18">Kirker
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|
SG B, Young
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|
E, Warlow
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CP. An evaluation of a multiple sclerosis liaison nurse. Clinical Rehabilitation. 1995; 9(3):219–226</div></dd></dl><dl class="bkr_refwrap"><dt>19.</dt><dd><div class="bk_ref" id="niceng220er2.ref19">Learmonth
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|
YC, Adamson
|
|
BC, Balto
|
|
JM, Chiu
|
|
CY, Molina-Guzman
|
|
I, Finlayson
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M
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Multiple sclerosis patients need and want information on exercise promotion from healthcare providers: a qualitative study. Health Expectations. 2017; 20(4):574–583 [<a href="/pmc/articles/PMC5513010/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC5513010</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/27436592" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27436592</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>20.</dt><dd><div class="bk_ref" id="niceng220er2.ref20">Leary
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|
A, Quinn
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|
D, Bowen
|
|
A. Impact of proactive case management by multiple sclerosis specialist nurses on use of unscheduled care and emergency presentation in multiple sclerosis: A case study. International Journal of MS Care. 2015; 17(4):159–163 [<a href="/pmc/articles/PMC4542710/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4542710</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/26300701" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26300701</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>21.</dt><dd><div class="bk_ref" id="niceng220er2.ref21">Lowden
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D, Lee
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|
V, Ritchie
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JA. Redefining self: patients’ decision making about treatment for multiple sclerosis. The Journal of Neuroscience Nursing. 2014; 46(4):E14–24 [<a href="https://pubmed.ncbi.nlm.nih.gov/24875289" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 24875289</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>22.</dt><dd><div class="bk_ref" id="niceng220er2.ref22">Markwick
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R, Singleton
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C, Conduit
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J. The perceptions of people with multiple sclerosis about the NHS provision of physiotherapy services. Disability and Rehabilitation. 2014; 36(2):131–135 [<a href="https://pubmed.ncbi.nlm.nih.gov/23651127" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23651127</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>23.</dt><dd><div class="bk_ref" id="niceng220er2.ref23">Masoudi
|
|
R, Abedi
|
|
H, Abedi
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|
P, Mohammadianinejad
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SE. The perspectives of Iranian patients with multiple sclerosis on continuity of care: a qualitative study. Journal of Nursing Research. 2015; 23(2):145–152 [<a href="https://pubmed.ncbi.nlm.nih.gov/25967645" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25967645</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>24.</dt><dd><div class="bk_ref" id="niceng220er2.ref24">McCurry
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MK. An exploratory study of decision making by informal caregivers of individuals with multiple sclerosis. The Journal of Neuroscience Nursing. 2013; 45(1):52–60 [<a href="https://pubmed.ncbi.nlm.nih.gov/23291872" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23291872</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>25.</dt><dd><div class="bk_ref" id="niceng220er2.ref25">Methley
|
|
A, Campbell
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S, Cheraghi-Sohi
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S, Chew-Graham
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C. Meeting the mental health needs of people with multiple sclerosis: a qualitative study of patients and professionals. Disability and Rehabilitation. 2017; 39(11):1097–1105 [<a href="https://pubmed.ncbi.nlm.nih.gov/27269657" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27269657</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>26.</dt><dd><div class="bk_ref" id="niceng220er2.ref26">Methley
|
|
AM, Chew-Graham
|
|
CA, Cheraghi-Sohi
|
|
S, Campbell
|
|
SM. A qualitative study of patient and professional perspectives of healthcare services for multiple sclerosis: implications for service development and policy. Health & Social Care in the Community. 2017; 25(3):848–857 [<a href="https://pubmed.ncbi.nlm.nih.gov/27396582" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 27396582</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>27.</dt><dd><div class="bk_ref" id="niceng220er2.ref27">Multiple Sclerosis Trust. Multiple sclerosis emergency admissions in 2015/16 infographic. Letchworth Garden City, England. Multiple Sclerosis Trust, 2017. Available from: <a href="https://mstrust.org.uk/ms-admissions" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://mstrust<wbr style="display:inline-block"></wbr>​.org.uk/ms-admissions</a></div></dd></dl><dl class="bkr_refwrap"><dt>28.</dt><dd><div class="bk_ref" id="niceng220er2.ref28">Mynors
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G, Perman
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S, Morse
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M. Defining the value of MS specialist nurses. Letchworth Garden City, England. Multiple Sclerosis Trust, 2012. Available from: <a href="https://mstrust.org.uk/health-professionals/resources/service-development/defining-value-ms-specialist-nurses" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://mstrust<wbr style="display:inline-block"></wbr>​.org.uk<wbr style="display:inline-block"></wbr>​/health-professionals<wbr style="display:inline-block"></wbr>​/resources/service-development<wbr style="display:inline-block"></wbr>​/defining-value-ms-specialist-nurses</a></div></dd></dl><dl class="bkr_refwrap"><dt>29.</dt><dd><div class="bk_ref" id="niceng220er2.ref29">Mynors
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G, Suppiah
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J, Bowen
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A. Evidence for MS specialist services: Findings from the GEMSS MS specialist nurse evaluation project. Letchworth Garden City, England. Multiple Sclerosis Trust, 2015. Available from: <a href="https://mstrust.org.uk/health-professionals/resources/service-development/generating-evidence-ms-services-gemss" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://mstrust<wbr style="display:inline-block"></wbr>​.org.uk<wbr style="display:inline-block"></wbr>​/health-professionals<wbr style="display:inline-block"></wbr>​/resources/service-development<wbr style="display:inline-block"></wbr>​/generating-evidence-ms-services-gemss</a></div></dd></dl><dl class="bkr_refwrap"><dt>30.</dt><dd><div class="bk_ref" id="niceng220er2.ref30">National Institute for Health and Care Excellence. Developing NICE guidelines: the manual [updated 2020]. London. National Institute for Health and Care Excellence, 2014. Available from: <a href="http://www.nice.org.uk/article/PMG20/chapter/1%20Introduction%20and%20overview" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">http://www<wbr style="display:inline-block"></wbr>​.nice.org.uk<wbr style="display:inline-block"></wbr>​/article/PMG20/chapter<wbr style="display:inline-block"></wbr>​/1%20Introduction%20and%20overview</a> [<a href="https://pubmed.ncbi.nlm.nih.gov/26677490" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 26677490</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>31.</dt><dd><div class="bk_ref" id="niceng220er2.ref31">NHS England and NHS Improvement. 2019/20 National Cost Collection Data Publication. 2021. Available from: <a href="https://www.england.nhs.uk/publication/2019-20-national-cost-collection-data-publication/" ref="pagearea=cite-ref&targetsite=external&targetcat=link&targettype=uri">https://www<wbr style="display:inline-block"></wbr>​.england.nhs<wbr style="display:inline-block"></wbr>​.uk/publication/2019-20-national-cost-collection-data-publication/</a> Last accessed: 04 October 2021.</div></dd></dl><dl class="bkr_refwrap"><dt>32.</dt><dd><div class="bk_ref" id="niceng220er2.ref32">Pearce
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AR, Meyer
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SB. Patient perspectives on managing uncertainty living with multiple sclerosis. Journal of Communication in Healthcare. 2020; 13(2):111–118</div></dd></dl><dl class="bkr_refwrap"><dt>33.</dt><dd><div class="bk_ref" id="niceng220er2.ref33">Pétrin
|
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J, Donnelly
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C, McColl
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MA, Finlayson
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M. Is it worth it?: The experiences of persons with multiple sclerosis as they access health care to manage their condition. Health Expectations. 2020; 23(5):1269–1279 [<a href="/pmc/articles/PMC7696118/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7696118</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/33145866" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33145866</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>34.</dt><dd><div class="bk_ref" id="niceng220er2.ref34">Pétrin
|
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J, Finlayson
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M, Donnelly
|
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C, McColl
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MA. Healthcare access experiences of persons with MS explored through the Candidacy Framework. Health & Social Care in the Community. 2021; 29(3):789–799 [<a href="https://pubmed.ncbi.nlm.nih.gov/33606904" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33606904</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>35.</dt><dd><div class="bk_ref" id="niceng220er2.ref35">Pozzilli
|
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C, Brunetti
|
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M, Amicosante
|
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A, Gasperini
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C, Ristori
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G, Palmisano
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L
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et al
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Home based management in multiple sclerosis: results of a randomised controlled trial. Journal of Neurology, Neurosurgery and Psychiatry. 2002; 73(3):250–255 [<a href="/pmc/articles/PMC1738043/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC1738043</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/12185154" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 12185154</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>36.</dt><dd><div class="bk_ref" id="niceng220er2.ref36">Punshon
|
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G, Sopala
|
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J, Hannan
|
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G, Roberts
|
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M, Vernon
|
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K, Pearce
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A
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et al
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Modeling the multiple sclerosis specialist nurse workforce by determination of optimum caseloads in the United Kingdom. International Journal of MS Care. 2021; 23(1):1–7 [<a href="/pmc/articles/PMC7906027/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC7906027</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/33658899" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 33658899</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>37.</dt><dd><div class="bk_ref" id="niceng220er2.ref37">Rintell
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DJ, Frankel
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D, Minden
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SL, Glanz
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BI. Patients’ perspectives on quality of mental health care for people with MS. General Hospital Psychiatry. 2012; 34(6):604–610 [<a href="https://pubmed.ncbi.nlm.nih.gov/22591813" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 22591813</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>38.</dt><dd><div class="bk_ref" id="niceng220er2.ref38">Senders
|
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A, Sando
|
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K, Wahbeh
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H, Peterson Hiller
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A, Shinto
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L. Managing psychological stress in the multiple sclerosis medical visit: Patient perspectives and unmet needs. Journal of Health Psychology. 2016; 21(8):1676–1687 [<a href="/pmc/articles/PMC4474779/" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pmc">PMC free article<span class="bk_prnt">: PMC4474779</span></a>] [<a href="https://pubmed.ncbi.nlm.nih.gov/25527612" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 25527612</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>39.</dt><dd><div class="bk_ref" id="niceng220er2.ref39">Sweet
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SN, Perrier M-
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J, Podzyhun
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C, Latimer-Cheung
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AE. Identifying physical activity information needs and preferred methods of delivery of people with multiple sclerosis. Disability and Rehabilitation. 2013; 35(24):2056–2063 [<a href="https://pubmed.ncbi.nlm.nih.gov/23763468" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 23763468</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>40.</dt><dd><div class="bk_ref" id="niceng220er2.ref40">Ward-Abel
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N, Mutch
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K, Huseyin
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H. Demonstrating that multiple sclerosis specialist nurses make a difference to patient care. British Journal of Neuroscience Nursing. 2010; 6(7):319–324</div></dd></dl><dl class="bkr_refwrap"><dt>41.</dt><dd><div class="bk_ref" id="niceng220er2.ref41">Warner
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R, Thomas
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D, Martin
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R. Improving service delivery for relapse management in multiple sclerosis. British Journal of Nursing. 2005; 14(14):746–753 [<a href="https://pubmed.ncbi.nlm.nih.gov/16116378" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 16116378</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>42.</dt><dd><div class="bk_ref" id="niceng220er2.ref42">While
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A, Forbes
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A, Ullman
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R, Mathes
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L. The role of specialist and general nurses working with people with multiple sclerosis. Journal of Clinical Nursing. 2009; 18(18):2635–2648 [<a href="https://pubmed.ncbi.nlm.nih.gov/19017369" ref="pagearea=cite-ref&targetsite=entrez&targetcat=link&targettype=pubmed">PubMed<span class="bk_prnt">: 19017369</span></a>]</div></dd></dl><dl class="bkr_refwrap"><dt>43.</dt><dd><div class="bk_ref" id="niceng220er2.ref43">Wilson
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R.
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The multiple sclerosis partnership programme. International MS Journal. 1998; 5(1):30–34</div></dd></dl></dl></div><div id="apendixesappgroup1"><h2 id="_apendixesappgroup1_">Appendices</h2><div id="niceng220er2.appa"><h3>Appendix A. Review protocols</h3><p id="niceng220er2.appa.et1"><a href="/books/NBK585276/bin/niceng220er2-appa-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (340K)</span></p></div><div id="niceng220er2.appb"><h3>Appendix B. Literature search strategies</h3><p>This literature search strategy was used for the following review:
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<ul><li class="half_rhythm"><div>The clinical and cost effectiveness of processes of care, including the role of MS specialist nurses and other healthcare professionals, to improve care coordination and health outcomes in adults with MS</div></li></ul></p><p>The literature searches for this review are detailed below and complied with the methodology outlined in Developing NICE guidelines: the manual.<a class="bibr" href="#niceng220er2.ref30" rid="niceng220er2.ref30"><sup>30</sup></a></p><p>For more information, please see the Methodology review published as part of the accompanying documents for this guideline.</p><p id="niceng220er2.appb.et1"><a href="/books/NBK585276/bin/niceng220er2-appb-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">B.1. Clinical search literature search strategy</a><span class="small"> (PDF, 316K)</span></p><p id="niceng220er2.appb.et2"><a href="/books/NBK585276/bin/niceng220er2-appb-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">B.2. Health Economics literature search strategy</a><span class="small"> (PDF, 195K)</span></p></div><div id="niceng220er2.appc"><h3>Appendix C. Effectiveness evidence study selection</h3><p id="niceng220er2.appc.et1"><a href="/books/NBK585276/bin/niceng220er2-appc-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (110K)</span></p></div><div id="niceng220er2.appd"><h3>Appendix D. Effectiveness evidence</h3><p id="niceng220er2.appd.et1"><a href="/books/NBK585276/bin/niceng220er2-appd-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (233K)</span></p></div><div id="niceng220er2.appe"><h3>Appendix E. Forest plots</h3><p>None.</p></div><div id="niceng220er2.appf"><h3>Appendix F. GRADE or GRADE-CERQual tables</h3><p id="niceng220er2.appf.et1"><a href="/books/NBK585276/bin/niceng220er2-appf-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (169K)</span></p></div><div id="niceng220er2.appg"><h3>Appendix G. Economic evidence study selection</h3><p id="niceng220er2.appg.et1"><a href="/books/NBK585276/bin/niceng220er2-appg-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (131K)</span></p></div><div id="niceng220er2.apph"><h3>Appendix H. Economic evidence tables</h3><p>None.</p></div><div id="niceng220er2.appi"><h3>Appendix I. Health economic model</h3><p>No original economic modelling undertaken.</p></div><div id="niceng220er2.appj"><h3>Appendix J. Excluded studies</h3><p id="niceng220er2.appj.et1"><a href="/books/NBK585276/bin/niceng220er2-appj-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (531K)</span></p></div><div id="niceng220er2.appk"><h3>Appendix K. Research recommendations – full details</h3><div id="niceng220er2.appk.s1"><h4>K.1. Research recommendation</h4><p>What is the clinical and cost effectiveness of processes of care, including the role of MS specialist nurses and other healthcare professionals, to improve care coordination and health outcomes in adults with MS?</p><div id="niceng220er2.appk.s1.1"><h5>K.1.1. Why this is important</h5><p>People with MS face a variety of symptoms and disabilities that arise unpredictably and change over time. Their physical, emotional and social needs may therefore require action from more than one health professional at any time and it’s important that these interventions are timely and co-ordinated.</p><p>A variety of models have developed to address this need, but it’s recognised some people with MS still find it difficult to access treatment, advice and support from the right people when they need it most.</p><p>The importance of adequately co-ordinated, appropriate and comprehensive care is widely acknowledged and is a function for many people with MS undertaken by a MS Specialist Nurse or other health care professional, but research is still needed on the processes or roles that would deliver this most effectively.</p></div><div id="niceng220er2.appk.s1.2"><h5>K.1.2. Rationale for research recommendation</h5><p id="niceng220er2.appk.et1"><a href="/books/NBK585276/bin/niceng220er2-appk-et1.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (171K)</span></p></div><div id="niceng220er2.appk.s1.3"><h5>K.1.3. Modified PICO table</h5><p id="niceng220er2.appk.et2"><a href="/books/NBK585276/bin/niceng220er2-appk-et2.pdf" class="bk_dwnld_icn bk_dwnld_pdf">Download PDF</a><span class="small"> (167K)</span></p></div></div></div></div></div><div class="fm-sec"><div><p>Final version</p></div><div><p>Evidence reviews underpinning recommendations 1.3.1 to 1.3.2 and research recommendations in the NICE guideline</p><p>These evidence reviews were developed by the Guideline Development Team NGC</p></div><div><p><b>Disclaimer</b>: The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The recommendations in this guideline are not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.</p><p>Local commissioners and/or providers have a responsibility to enable the guideline to be applied when individual health professionals and their patients or service users wish to use it. They should do so in the context of local and national priorities for funding and developing services, and in light of their duties to have due regard to the need to eliminate unlawful discrimination, to advance equality of opportunity and to reduce health inequalities. Nothing in this guideline should be interpreted in a way that would be inconsistent with compliance with those duties.</p><p>NICE guidelines cover health and care in England. Decisions on how they apply in other UK countries are made by ministers in the <a href="http://wales.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Welsh Government</a>, <a href="http://www.scotland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Scottish Government</a>, and <a href="http://www.northernireland.gov.uk/" ref="pagearea=body&targetsite=external&targetcat=link&targettype=uri">Northern Ireland Executive</a>. All NICE guidance is subject to regular review and may be updated or withdrawn.</p></div><div class="half_rhythm"><a href="/books/about/copyright/">Copyright</a> © NICE 2022.</div><div class="small"><span class="label">Bookshelf ID: NBK585276</span><span class="label">PMID: <a href="https://pubmed.ncbi.nlm.nih.gov/36279385" title="PubMed record of this title" ref="pagearea=meta&targetsite=entrez&targetcat=link&targettype=pubmed">36279385</a></span></div></div><div class="small-screen-prev"></div><div class="small-screen-next"></div></article><article data-type="table-wrap" id="figobniceng220er2tab1"><div id="niceng220er2.tab1" class="table"><h3><span class="label">Table 1</span><span class="title">PICO characteristics of effectiveness review question</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab1/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab1_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng220er2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><td headers="hd_b_niceng220er2.tab1_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Adults (≥18 years) with MS, including people receiving palliative care.</td></tr><tr><th id="hd_b_niceng220er2.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Interventions</th><td headers="hd_b_niceng220er2.tab1_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">A process of care where an individual healthcare professional (HCP) or group of HCPs are central to coordination of care and the single point of contact such as:<ul><li class="half_rhythm"><div>MS nurse specialists</div></li><li class="half_rhythm"><div>Physiotherapists</div></li><li class="half_rhythm"><div>Occupational therapists</div></li><li class="half_rhythm"><div>Key workers</div></li><li class="half_rhythm"><div>Social prescribers</div></li><li class="half_rhythm"><div>MDT where the single point of contact is shared, not specified or changes</div></li></ul></td></tr><tr><th id="hd_b_niceng220er2.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comparisons</th><td headers="hd_b_niceng220er2.tab1_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Compared to each other</div></li><li class="half_rhythm"><div>Usual care (where there is no single point of contact)</div></li></ul>
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</td></tr><tr><th id="hd_b_niceng220er2.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcomes</th><td headers="hd_b_niceng220er2.tab1_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Reduction of hospital admissions for:<ul class="circle"><li class="half_rhythm"><div>UTI</div></li><li class="half_rhythm"><div>Pressure sores</div></li><li class="half_rhythm"><div>Falls</div></li><li class="half_rhythm"><div>Respiratory infections</div></li></ul></div></li><li class="half_rhythm"><div>Reduction/prevention of unplanned hospital admissions</div></li><li class="half_rhythm"><div>Reduction in consultant or GP appointments</div></li><li class="half_rhythm"><div>Treatment adherence</div></li><li class="half_rhythm"><div>Relapse rates</div></li><li class="half_rhythm"><div>Improvement in mental health</div></li><li class="half_rhythm"><div>Patient / carer satisfaction</div></li><li class="half_rhythm"><div>Functional scales that quantify level of disability, such as the Expanded Disability Status Scale (EDSS), the Multiple Sclerosis Functional Composite (MSFC), the Cambridge Multiple Sclerosis Basic Score (CAMBS), the Functional Assessment of Multiple Sclerosis (FAMS)</div></li><li class="half_rhythm"><div>Health-related Quality of Life, for example EQ-5D, SF-36, Leeds MS quality of life scale, MS Impact Scale.</div></li><li class="half_rhythm"><div>Impact on patients and carers (formal and informal).</div></li></ul>
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<p>Follow up:<ul><li class="half_rhythm"><div>3–12 months (minimum of 3 months but can include 1–3 months and downgrade)</div></li><li class="half_rhythm"><div>>12 months (data from >12 months follow up may be included but will be downgraded as at >12 months it is more likely that other factors such as progression may occur, which would make it more difficult to be sure any effects on outcome are due to healthcare professionals and care coordination)</div></li></ul></p>
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</td></tr><tr><th id="hd_b_niceng220er2.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study design</th><td headers="hd_b_niceng220er2.tab1_1_1_5_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<ul><li class="half_rhythm"><div>Systematic review/meta-analyses of RCT or cohort studies</div></li><li class="half_rhythm"><div>RCT</div></li><li class="half_rhythm"><div>Non-randomised or quasi-randomised studies</div></li><li class="half_rhythm"><div>Prospective/retrospective cohort studies (comparative only) that have adjusted for relevant confounders (for example age and severity of disease)</div></li><li class="half_rhythm"><div>Audits / service evaluations</div></li></ul>
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</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab2"><div id="niceng220er2.tab2" class="table"><h3><span class="label">Table 2</span><span class="title">PICO characteristics of qualitative review question</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab2/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab2_lrgtbl__"><table><tbody><tr><th id="hd_b_niceng220er2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Objective</th><td headers="hd_b_niceng220er2.tab2_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore perceptions and experiences of patients with MS, their families and carers in order to determine their information and support needs.</td></tr><tr><th id="hd_b_niceng220er2.tab2_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population and setting</th><td headers="hd_b_niceng220er2.tab2_1_1_2_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Inclusion:</p>
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<p>Adults (≥18 years) with MS</p>
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<p>Exclusion:</p>
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<p>Children and young people (≤18 years)</p>
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</td></tr><tr><th id="hd_b_niceng220er2.tab2_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Context</th><td headers="hd_b_niceng220er2.tab2_1_1_3_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Perceptions and experiences of adults with MS (themes relating to coordination of care only) their families and carers regarding the information, education and support they find most useful.</p>
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<p>Themes may include:<ul><li class="half_rhythm"><div>Preferred format of information provision (e.g. face-to-face discussion, remotely, paper, electronic, who gives the information)</div></li><li class="half_rhythm"><div>Content of information (e.g., symptom reduction, timing of intervention)</div></li><li class="half_rhythm"><div>Information sources other than healthcare professionals (e.g. support groups, online resources, telephone helpline, Apps)</div></li><li class="half_rhythm"><div>The need for consistency in the information that is provided (especially when provided from more than one source)</div></li><li class="half_rhythm"><div>Information needs for carers to be considered independently from the needs of the person they care for</div></li><li class="half_rhythm"><div>Timing of information (timely, repeated when necessary, adapted to change in progression)</div></li><li class="half_rhythm"><div>Decision making (sometimes being vague and euphemistic so that people with MS and their families and carers go away unable to plan</div></li><li class="half_rhythm"><div>Greater understanding of own condition</div></li><li class="half_rhythm"><div>Confidence in self-management</div></li><li class="half_rhythm"><div>Impact of treatment on lifestyle and lifestyle on treatment</div></li><li class="half_rhythm"><div>Impact on family</div></li><li class="half_rhythm"><div>Impact on sexual function</div></li><li class="half_rhythm"><div>Impact on cognition</div></li><li class="half_rhythm"><div>Psychological support (e.g., for support with anxiety, fear, confidence)</div></li><li class="half_rhythm"><div>Delivery of support (e.g. patient’s GP, specialist nurse, peer groups)</div></li><li class="half_rhythm"><div>Speed of response from nurse, consultant etc.</div></li><li class="half_rhythm"><div>Transition from relapsing remitting to progressive</div></li><li class="half_rhythm"><div>Role of the MS nurse or health care professional central to coordination of care and their impact on patient experience</div></li><li class="half_rhythm"><div>Information needs for adults with MS who may become pregnant</div></li></ul></p>
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</td></tr><tr><th id="hd_b_niceng220er2.tab2_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Review strategy</th><td headers="hd_b_niceng220er2.tab2_1_1_4_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Synthesis of qualitative research. Results presented in narrative, diagram and table format. Quality of the evidence will be assessed by a GRADE CerQual approach for each review finding.</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab3"><div id="niceng220er2.tab3" class="table"><h3><span class="label">Table 3</span><span class="title">Summary of studies included in the evidence review</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab3/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab3_lrgtbl__"><table><thead><tr><th id="hd_h_niceng220er2.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Study</th><th id="hd_h_niceng220er2.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Intervention and comparison</th><th id="hd_h_niceng220er2.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Population</th><th id="hd_h_niceng220er2.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Outcomes</th><th id="hd_h_niceng220er2.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Comments</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Forbes 2006<a class="bibr" href="#niceng220er2.ref10" rid="niceng220er2.ref10"><sup>10</sup></a></p>
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<p>N=616</p>
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<p>Non-randomised controlled trial</p>
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<p>UK</p>
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</td><td headers="hd_h_niceng220er2.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<b>Clinical service including specialist MS nurse</b>
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</p>
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<p>n=293</p>
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<p>A programme including an MS specialist nurse as a central point of contact which was established to focus on implementing national standards for MS was evaluated across 4 centres. The role of the MS nurse included psychological, social and physical assessments and interventions, coordination and care management and education and support.</p>
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<p>
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<b>Clinical service without a specialist MS nurse (control)</b>
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</p>
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<p>n=323</p>
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<p>Two centres where there was low to moderate specialist MS resources and did not have an established MS nurse role. Care provided mainly by neurologists.</p>
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</td><td headers="hd_h_niceng220er2.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Adults with MS</p>
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<p>mostly progressive MS</p>
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<p>MS nurse group</p>
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<p>Mean age (SD): 47.5 (10.8)</p>
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<p>Type of MS: Relapsing remitting 82 (32%), progressive 163 (56%), other 31 (12%)</p>
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<p>Control group:</p>
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<p>Mean age (SD): 50.7 (10.3)</p>
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<p>Type of MS: Relapsing remitting 89 (30%), progressive 181 (56%), other 38 (14%)</p>
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</td><td headers="hd_h_niceng220er2.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Reduction in hospital admissions in past 12 months</p>
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<p>Experience and severity of MS related problems (surrogate outcome)</p>
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<p>Impact of care process (surrogate outcome)</p>
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<p>Quality of life (SF-36 short form health survey, MSIS-29)</p>
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</td><td headers="hd_h_niceng220er2.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Included in the previous guideline LOW (GRADE) Non RCT, and serious indirectness 50% response rate with no analysis of non-responders. Complex intervention which involved changing a number of factors at the same time.</td></tr><tr><td headers="hd_h_niceng220er2.tab3_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Jansen 2006<a class="bibr" href="#niceng220er2.ref16" rid="niceng220er2.ref16"><sup>16</sup></a></p>
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<p>N=173</p>
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<p>Prospective cohort</p>
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<p>Holland</p>
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</td><td headers="hd_h_niceng220er2.tab3_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>
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<b>Transmural care model for MS (TCMMS)</b>
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</p>
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<p>n=80</p>
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<p>Multidisciplinary (MD) care protocol that facilitates cooperation among healthcare professionals in various settings such as primary care, hospitals and rehabilitation centres. A nurse acts as the case manager and biannual assessments are made by a MD team, leading to an integrated care pathway being formulated.</p>
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<p>
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<b>Traditional care</b>
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</p>
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<p>n=96</p>
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<p>Authors do not report a clear explanation of what traditional care entails but mention that in the Netherlands, care for people with MS is usually provided by their GP or Neurologist and that they receive only a few healthcare services.</p>
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</td><td headers="hd_h_niceng220er2.tab3_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Adults with MS</p>
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<p>TCMMS group</p>
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<p>Mean age (SD): 51 (9.7) years</p>
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<p>Disease duration: 12 years</p>
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<p>Tradition care group</p>
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<p>Mean age (SD): 45 (NR)</p>
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<p>Disease duration: 9 years</p>
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<p>Type of MS: not reported</p>
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</td><td headers="hd_h_niceng220er2.tab3_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Use of healthcare in past 10 months</p>
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<p>Healthcare needs – based on international classification of impairments, disabilities and handicap (ICIDH).</p>
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<p>Continuity of care (Dutch questionnaire covering supply of health care services, cooperation among healthcare professionals and continuity of care when in transition to another healthcare professional) (surrogate outcome)</p>
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<p>Quality of life (RAND 36)</p>
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</td><td headers="hd_h_niceng220er2.tab3_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Included in the previous guideline</p>
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<p>VERY LOW (GRADE)</p>
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<p>Non-randomised comparison study.</p>
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<p>Significant differences in baseline characteristics between groups for use of rehab specialist, nurse specialist and physical therapist. Limited recording of baseline demographic details so unable to assess comparability of groups. >25% dropout with no analysis of people who did not complete the study.</p>
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</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab4"><div id="niceng220er2.tab4" class="table"><h3><span class="label">Table 4</span><span class="title">Differences in resource utilisation and care processes in groups involving an MS nurse and adults with MS in groups not involving an MS nurse</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab4/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab4_lrgtbl__"><table><thead><tr><th id="hd_h_niceng220er2.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Outcome</th><th id="hd_h_niceng220er2.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">P value</th><th id="hd_h_niceng220er2.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Quality</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Hospital admission 12 months</td><td headers="hd_h_niceng220er2.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Chi square p=0.26</td><td headers="hd_h_niceng220er2.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Availability of a contact person</td><td headers="hd_h_niceng220er2.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Group × time interaction p<0.001</td><td headers="hd_h_niceng220er2.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Availability of help in an emergency</td><td headers="hd_h_niceng220er2.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Group × time p=0.1</td><td headers="hd_h_niceng220er2.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Help with urinary problems</td><td headers="hd_h_niceng220er2.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Group × time p=0.3</td><td headers="hd_h_niceng220er2.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Help with fatigue</td><td headers="hd_h_niceng220er2.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Group × time p=0.71</td><td headers="hd_h_niceng220er2.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Help with bowel problems</td><td headers="hd_h_niceng220er2.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Group × time p=0.5</td><td headers="hd_h_niceng220er2.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab4_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Help with pressure sores</td><td headers="hd_h_niceng220er2.tab4_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Group × time p=0.001</td><td headers="hd_h_niceng220er2.tab4_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab5"><div id="niceng220er2.tab5" class="table"><h3><span class="label">Table 5</span><span class="title">Difference in quality of life between adults with MS in groups involving an MS nurse and adults with MS in groups not invo ving an MS nurse</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab5/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab5_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng220er2.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Quality of life</th><th id="hd_h_niceng220er2.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Mean difference (intervention – control at 24 month follow up, adjusted for baseline values). Negative values indicate a worse outcome for the MS nurse groups</th><th id="hd_h_niceng220er2.tab5_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
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<i>p values</i>
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</th><th id="hd_h_niceng220er2.tab5_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<i>Quality</i>
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</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 physical function</td><td headers="hd_h_niceng220er2.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−2.81 (−5.45 to 10.1)</td><td headers="hd_h_niceng220er2.tab5_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.04</td><td headers="hd_h_niceng220er2.tab5_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 role physical</td><td headers="hd_h_niceng220er2.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−2.21(−5.8 to 1.4)</td><td headers="hd_h_niceng220er2.tab5_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.22</td><td headers="hd_h_niceng220er2.tab5_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 mental health</td><td headers="hd_h_niceng220er2.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">1.32 (−1.2 to 3.8)</td><td headers="hd_h_niceng220er2.tab5_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.31</td><td headers="hd_h_niceng220er2.tab5_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 social functioning</td><td headers="hd_h_niceng220er2.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−1.61(−6.3 to 1.6)</td><td headers="hd_h_niceng220er2.tab5_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.67</td><td headers="hd_h_niceng220er2.tab5_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 bodily pain</td><td headers="hd_h_niceng220er2.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−4.09(−7.2 to 0.9)</td><td headers="hd_h_niceng220er2.tab5_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.01</td><td headers="hd_h_niceng220er2.tab5_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 general health</td><td headers="hd_h_niceng220er2.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−5.35(−8.1 to −2.5)</td><td headers="hd_h_niceng220er2.tab5_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><0.001<sup>*</sup></td><td headers="hd_h_niceng220er2.tab5_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab5_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 energy vitality</td><td headers="hd_h_niceng220er2.tab5_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−2.82 (−5.5 to −0.1)</td><td headers="hd_h_niceng220er2.tab5_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.04<sup>*</sup></td><td headers="hd_h_niceng220er2.tab5_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>*</dt><dd><div id="niceng220er2.tab5_1"><p class="no_margin">Statistically significant difference between groups and certainty in direction of effect</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab6"><div id="niceng220er2.tab6" class="table"><h3><span class="label">Table 6</span><span class="title">Difference in function between adults with MS in groups involving an MS nurse and adults with MS in groups not involving an MS nurse</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab6/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab6_lrgtbl__"><table><thead><tr><th id="hd_h_niceng220er2.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Function</th><th id="hd_h_niceng220er2.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">MD (95% CIs) [Intervention – control] at follow up – adjusted for baseline inequality. Negative values indicate a worse outcome for the intervention group.</th><th id="hd_h_niceng220er2.tab6_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
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<i>p values</i>
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</th><th id="hd_h_niceng220er2.tab6_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<i>Quality</i>
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</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">MSIS psychological</td><td headers="hd_h_niceng220er2.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−2.38(−5.2 to 0.4)</td><td headers="hd_h_niceng220er2.tab6_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.09</td><td headers="hd_h_niceng220er2.tab6_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab6_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">MSIS physical</td><td headers="hd_h_niceng220er2.tab6_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−1.83(−4.2 to 0.5)</td><td headers="hd_h_niceng220er2.tab6_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.13</td><td headers="hd_h_niceng220er2.tab6_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab7"><div id="niceng220er2.tab7" class="table"><h3><span class="label">Table 7</span><span class="title">Healthcare use in the multidisciplinary and traditional care groups</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab7/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab7_lrgtbl__"><table><thead><tr><th id="hd_h_niceng220er2.tab7_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Healthcare professional</th><th id="hd_h_niceng220er2.tab7_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Multidisciplinary group at 10 months (%)</th><th id="hd_h_niceng220er2.tab7_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Control group at 10 months (%)</th><th id="hd_h_niceng220er2.tab7_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Between group p</th><th id="hd_h_niceng220er2.tab7_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Baseline equivalence?</th><th id="hd_h_niceng220er2.tab7_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Quality</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab7_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Neurologist</td><td headers="hd_h_niceng220er2.tab7_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">64/80 (80)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">47/96 (49)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"><0.001</td><td headers="hd_h_niceng220er2.tab7_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Y</td><td headers="hd_h_niceng220er2.tab7_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab7_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">GP</td><td headers="hd_h_niceng220er2.tab7_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">59/80 (74)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">51/96 (53)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.01</td><td headers="hd_h_niceng220er2.tab7_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Y</td><td headers="hd_h_niceng220er2.tab7_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab7_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Rehab specialist</td><td headers="hd_h_niceng220er2.tab7_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">17/80 (21)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">11/96 (12)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">NS</td><td headers="hd_h_niceng220er2.tab7_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">N – strongly favouring study group</td><td headers="hd_h_niceng220er2.tab7_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab7_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Nurse specialist</td><td headers="hd_h_niceng220er2.tab7_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">40/80 (50)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">29/96 (30)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.01</td><td headers="hd_h_niceng220er2.tab7_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">N – favouring comparison group [NB the baseline bias goes against the 10-month effect direction so the direction of effect favouring study group at 10 months can be taken as valid]</td><td headers="hd_h_niceng220er2.tab7_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab7_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Physical therapist</td><td headers="hd_h_niceng220er2.tab7_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">45/80 (56)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">37/96 (39)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.02</td><td headers="hd_h_niceng220er2.tab7_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">N – favouring study group</td><td headers="hd_h_niceng220er2.tab7_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab7_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Occupational therapist</td><td headers="hd_h_niceng220er2.tab7_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">15/80 (19)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">9/96 (9)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">NS</td><td headers="hd_h_niceng220er2.tab7_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Y</td><td headers="hd_h_niceng220er2.tab7_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab7_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Social worker</td><td headers="hd_h_niceng220er2.tab7_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">12/80 (15)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">8/96 (8)</td><td headers="hd_h_niceng220er2.tab7_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">NS</td><td headers="hd_h_niceng220er2.tab7_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Y</td><td headers="hd_h_niceng220er2.tab7_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab8"><div id="niceng220er2.tab8" class="table"><h3><span class="label">Table 8</span><span class="title">Quality of life in the multidisciplinary and traditional care groups</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab8/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab8_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng220er2.tab8_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Quality of life variable</th><th id="hd_h_niceng220er2.tab8_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">Standardised regression co-efficient (95% confidence interval). This co-efficient, adjusted for baseline values, refers to the increase in the SF36 variable in the multidisciplinary group compared to the traditional care group. Hence a positive value indicates a benefit for the multidisciplinary group.</th><th id="hd_h_niceng220er2.tab8_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:middle;">
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<i>p</i>
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</th><th id="hd_h_niceng220er2.tab8_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<i>Quality</i>
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</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab8_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 Physical functioning</td><td headers="hd_h_niceng220er2.tab8_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−1.662 (−6.099 to 2.856)</td><td headers="hd_h_niceng220er2.tab8_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.476</td><td headers="hd_h_niceng220er2.tab8_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab8_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 Social function</td><td headers="hd_h_niceng220er2.tab8_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">2.532 (−3.836 to 8.901)</td><td headers="hd_h_niceng220er2.tab8_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.434</td><td headers="hd_h_niceng220er2.tab8_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab8_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 role limitations (physical)</td><td headers="hd_h_niceng220er2.tab8_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">6.053 (−4.283 to 16.389)</td><td headers="hd_h_niceng220er2.tab8_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.249</td><td headers="hd_h_niceng220er2.tab8_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab8_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 role limitations (emotional)</td><td headers="hd_h_niceng220er2.tab8_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">7.602 (−4.426 to 19.632)</td><td headers="hd_h_niceng220er2.tab8_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.214</td><td headers="hd_h_niceng220er2.tab8_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab8_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 Mental health</td><td headers="hd_h_niceng220er2.tab8_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−0.037 (−4.313 to 4.239)</td><td headers="hd_h_niceng220er2.tab8_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.986</td><td headers="hd_h_niceng220er2.tab8_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab8_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 Energy and vitality</td><td headers="hd_h_niceng220er2.tab8_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">4.698 (0.423 to 8.973)</td><td headers="hd_h_niceng220er2.tab8_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.031<sup>*</sup></td><td headers="hd_h_niceng220er2.tab8_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab8_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 Bodily pain</td><td headers="hd_h_niceng220er2.tab8_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.497 (−5.869 to 6.863)</td><td headers="hd_h_niceng220er2.tab8_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.878</td><td headers="hd_h_niceng220er2.tab8_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr><tr><td headers="hd_h_niceng220er2.tab8_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">SF36 General health</td><td headers="hd_h_niceng220er2.tab8_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">−0.537 (−5.094 to 4.019)</td><td headers="hd_h_niceng220er2.tab8_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.816</td><td headers="hd_h_niceng220er2.tab8_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Very low</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>*</dt><dd><div id="niceng220er2.tab8_1"><p class="no_margin">Statistically significant difference between groups</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab9"><div id="niceng220er2.tab9" class="table"><h3><span class="label">Table 9</span><span class="title">Summary of studies included in the evidence review</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab9/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab9_lrgtbl__"><table><thead><tr><th id="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Study</th><th id="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Design</th><th id="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Population</th><th id="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Research aim</th><th id="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Comments</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Aspinal 2012<a class="bibr" href="#niceng220er2.ref1" rid="niceng220er2.ref1"><sup>1</sup></a></p>
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<p>UK</p>
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<p>N=71 (19 with MS)</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">In-depth telephone or face-to-face interviews with analysis using Framework method.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with long-term neurological conditions (19/71 had MS)</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To assess the effect of English National Service Framework on integrated services on integrated services and continuity of care</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor concerns about relevance - indirect population as includes people with various types of long-term neurological conditions</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Blundell Jones 2014<a class="bibr" href="#niceng220er2.ref2" rid="niceng220er2.ref2"><sup>2</sup></a></p>
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<p>UK</p>
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<p>N=10</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews with analysis using interpretative phenomenological approach.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Women with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore how women with MS coped with their emotions.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Browne 2015<a class="bibr" href="#niceng220er2.ref4" rid="niceng220er2.ref4"><sup>4</sup></a></p>
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<p>Ireland</p>
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<p>N=19</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews with thematic analysis.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS and bladder dysfunction</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore in depth how bladder dysfunction interferes with quality of life for people with MS.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Defriez 2003<a class="bibr" href="#niceng220er2.ref7" rid="niceng220er2.ref7"><sup>7</sup></a></p>
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<p>UK</p>
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<p>N=18</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews with thematic analysis.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore the patients’ perception of their current care provision and unmet needs</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Edmonds 2007<a class="bibr" href="#niceng220er2.ref8" rid="niceng220er2.ref8"><sup>8</sup></a></p>
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<p>UK</p>
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<p>N=32</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews with thematic analysis using constant comparative approach.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with severe MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore the needs of those people severely affected by MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Falet 2020<a class="bibr" href="#niceng220er2.ref9" rid="niceng220er2.ref9"><sup>9</sup></a></p>
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<p>Canada</p>
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<p>N=29</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews with inductive thematic analysis</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with severe MS and their informal care providers</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To better understand patient and care provider perspectives on the optimal role of their neurologist.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">No concerns about relevance despite being non-UK based as topics covered are not related to structure of care and may be relevant across countries</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Forbes 2007<a class="bibr" href="#niceng220er2.ref11" rid="niceng220er2.ref11"><sup>11</sup></a></p>
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<p>UK</p>
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<p>N=445 people responded to a qualitative component of a questionnaire</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Postal questionnaire with a qualitative component asking about one thing that would be most helpful in meeting their current needs, with specific method of analysis for qualitative component unclear</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To identify what people with multiple sclerosis perceive to be important to meeting their needs</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Goicochea Briceno 2021<a class="bibr" href="#niceng220er2.ref12" rid="niceng220er2.ref12"><sup>12</sup></a></p>
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<p>Spain</p>
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<p>N=26 (16 people with MS and 10 family/carers)</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Focus groups with analysis performed through phenomenological approach.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS and their family/caregivers</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To learn the experience of patients and their caregivers of the medical care received in the Gregorio Maranon Hospital Demyelinating Unit</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Hunter 2021<a class="bibr" href="#niceng220er2.ref15" rid="niceng220er2.ref15"><sup>15</sup></a></p>
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<p>UK</p>
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<p>N=14</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews with thematic analysis.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To develop an in-depth understanding of the experiences of individuals living with MS and its impact upon the family system from the perspective of the person with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Johnson, 2003<a class="bibr" href="#niceng220er2.ref17" rid="niceng220er2.ref17"><sup>17</sup></a></p>
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<p>UK</p>
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<p>N=24</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">In-depth interviews with thematic analysis.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To gain insight into MS specialist nurse roles</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Kirker 1995<a class="bibr" href="#niceng220er2.ref18" rid="niceng220er2.ref18"><sup>18</sup></a></p>
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<p>UK</p>
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<p>N=71</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Interviews, with type of analysis not described, but appears to just be a summary of main results and no formal qualitative methods.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To assess the workload and benefits of an MS liaison nurse</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Moderate concerns about relevance due to the study being fairly old and possibly less representative of practice now</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Learmonth, 2017<a class="bibr" href="#niceng220er2.ref19" rid="niceng220er2.ref19"><sup>19</sup></a></p>
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<p>USA</p>
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<p>N=50</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews with thematic analysis.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore the needs and wants of patients with MS regarding exercise promotion through healthcare providers</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor concerns about relevance due to the study being non-UK based and it being unclear how relevant it is to UK practice in terms of coordination of care.</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Lowden, 2014<a class="bibr" href="#niceng220er2.ref21" rid="niceng220er2.ref21"><sup>21</sup></a></p>
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<p>Canada</p>
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<p>N=9</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews with analysis using phenomenological approach.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with relapsing-remitting MS with at least 2 relapses in the past 2 years</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore the lived experience of making a first decision about treatment with disease-modifying therapies for relapsing-remitting MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor concerns about relevance due to the study being non-UK based and it being unclear how relevant it is to UK practice in terms of coordination of care.</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Markwick, 2014<a class="bibr" href="#niceng220er2.ref22" rid="niceng220er2.ref22"><sup>22</sup></a></p>
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<p>UK</p>
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<p>N=757 included a free-text comment</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Electronic questionnaire with a qualitative component asking about MS services, with content analysis performed</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To perform content analysis on the views of people with MS about MS services, focussing on physiotherapy provision</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Masoudi, 2015<a class="bibr" href="#niceng220er2.ref23" rid="niceng220er2.ref23"><sup>23</sup></a></p>
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<p>Iran</p>
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<p>N=23</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">In-depth, unstructured interviews with inductive thematic analysis</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To identify continuity of care from the experience and perspective of patients with MS at two teaching hospitals and the MS Society in Ahvaz, Iran</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor concerns about relevance due to the study being non-UK based and it being unclear how relevant it is to UK practice in terms of coordination of care.</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>McCurry 2013<a class="bibr" href="#niceng220er2.ref24" rid="niceng220er2.ref24"><sup>24</sup></a></p>
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<p>USA</p>
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<p>N=6</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">In-depth interviews with thematic content analysis</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Family caregivers of those with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore the decisions made by informal caregivers of multiple sclerosis care recipients and the resources they use to inform those decisions.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor concerns about relevance due to the study being non-UK based and it being unclear how relevant it is to UK practice in terms of coordination of care.</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Methley 2017<a class="bibr" href="#niceng220er2.ref26" rid="niceng220er2.ref26"><sup>26</sup></a></p>
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<p>UK</p>
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<p>N-24</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews with thematic analysis by constant comparative analysis method</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore perspectives and experiences of people with MS and healthcare professionals of UK healthcare services for MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Methley 2017<a class="bibr" href="#niceng220er2.ref25" rid="niceng220er2.ref25"><sup>25</sup></a></p>
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<p>UK</p>
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<p>N=24</p>
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|
</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews with thematic analysis by constant comparative analysis method</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore perspectives and experiences of people with multiple sclerosis and health care professionals of mental health support for MS in the UK</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Pearce 2020<a class="bibr" href="#niceng220er2.ref32" rid="niceng220er2.ref32"><sup>32</sup></a></p>
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<p>Canada</p>
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<p>N=16</p>
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</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">In-depth interviews with convergent methods (questions added or removed as interview process progressed) and thematic analysis</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To explore patient experiences with the uncertainty that MS introduces to their lives and the role of communication with their physicians for managing uncertainty</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor concerns about relevance due to the study being non-UK based and it being unclear how relevant it is to UK practice in terms of coordination of care.</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Petrin 2020<a class="bibr" href="#niceng220er2.ref33" rid="niceng220er2.ref33"><sup>33</sup></a> and Petrin 2021<a class="bibr" href="#niceng220er2.ref34" rid="niceng220er2.ref34"><sup>34</sup></a></p>
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<p>Canada</p>
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<p>N=48</p>
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|
</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Focus groups (n=38) or semi-structured interviews (n=10), with analysis through constant comparison analysis.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To investigate the health-care access experiences of Ontarians with MS as they manage their condition.</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor concerns about relevance due to the study being non-UK based and it being unclear how relevant it is to UK practice in terms of coordination of care.</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Rintell 2012<a class="bibr" href="#niceng220er2.ref37" rid="niceng220er2.ref37"><sup>37</sup></a></p>
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<p>USA</p>
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|
<p>N=54</p>
|
|
</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured focus groups with thematic analysis</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To obtain multiple sclerosis patients’ report on their experience receiving mental health care</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor concerns about relevance due to the study being non-UK based and it being unclear how relevant it is to UK practice in terms of coordination of care.</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Senders 2016<a class="bibr" href="#niceng220er2.ref38" rid="niceng220er2.ref38"><sup>38</sup></a></p>
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<p>USA</p>
|
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<p>N=34</p>
|
|
</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured focus groups with inductive thematic analysis</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To further understand how stress is addressed in the MS medical visit</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor concerns about relevance due to the study being non-UK based and it being unclear how relevant it is to UK practice in terms of coordination of care.</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Sweet 2013<a class="bibr" href="#niceng220er2.ref39" rid="niceng220er2.ref39"><sup>39</sup></a></p>
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<p>Canada</p>
|
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<p>N=21</p>
|
|
</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Semi-structured interviews (n=14) or focus groups (n=7), with analysis by direct content analysis</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To examine the preferred sources and methods for acquiring physical activity information of individuals with multiple sclerosis</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Minor concerns about relevance due to the study being non-UK based and it being unclear how relevant it is to UK practice in terms of coordination of care.</td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Ward-Abel 2010<a class="bibr" href="#niceng220er2.ref40" rid="niceng220er2.ref40"><sup>40</sup></a></p>
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<p>UK</p>
|
|
<p>N=750 questionnaires returned but proportion with free-text response unclear</p>
|
|
</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Postal questionnaire with a qualitative component asking about MS nurse experience, with analysis method unclear and appear to just summarise the findings</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To perform an audit of patient experiences of the MS nurse role</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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|
<p>Warner 2005<a class="bibr" href="#niceng220er2.ref41" rid="niceng220er2.ref41"><sup>41</sup></a></p>
|
|
<p>UK</p>
|
|
<p>N= unclear</p>
|
|
</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Structured interviews focusing on patient satisfaction across themes associated with service delivery, with qualitative methods mentioned but details not provided</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To perform an audit of patient pathway into treatment following a relapse</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab9_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>While 2009<a class="bibr" href="#niceng220er2.ref42" rid="niceng220er2.ref42"><sup>42</sup></a></p>
|
|
<p>UK</p>
|
|
<p>N=65</p>
|
|
</td><td headers="hd_h_niceng220er2.tab9_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Questionnaire with a qualitative component asking about MS nurse role, with thematic analysis using content analysis</td><td headers="hd_h_niceng220er2.tab9_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">People with MS</td><td headers="hd_h_niceng220er2.tab9_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">To describe the perceived role of nurses and other MS carers from perspective of different stakeholders</td><td headers="hd_h_niceng220er2.tab9_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr></tbody></table></div></div></article><article data-type="fig" id="figobniceng220er2fig1"><div id="niceng220er2.fig1" class="figure bk_fig"><div class="graphic"><a href="/core/lw/2.0/html/tileshop_pmc/tileshop_pmc_inline.html?title=Figure%201.%20Main%20review%20findings%20and%20details%20%02013%20coordination%20of%20care%20in%20general%20MS%20population.&p=BOOKS&id=585276_niceng220er2f1.jpg" target="tileshopwindow" class="inline_block pmc_inline_block ts_canvas img_link" title="Click on image to zoom"><div class="ts_bar small" title="Click on image to zoom"></div><img data-src="/books/NBK585276/bin/niceng220er2f1.jpg" alt="Figure 1. Main review findings and details – coordination of care in general MS population." class="tileshop" title="Click on image to zoom" /></a></div><h3><span class="label">Figure 1</span><span class="title">Main review findings and details – coordination of care in general MS population</span></h3></div></article><article data-type="table-wrap" id="figobniceng220er2tab10"><div id="niceng220er2.tab10" class="table"><h3><span class="label">Table 10</span><span class="title">Unit cost of health care professionals</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab10/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab10_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng220er2.tab10_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Resource</th><th id="hd_h_niceng220er2.tab10_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Unit costs (per working hour, including qualifications) <sup>(a)</sup></th><th id="hd_h_niceng220er2.tab10_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Total annual cost</th><th id="hd_h_niceng220er2.tab10_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Source</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab10_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">MS specialist Nurse (band 6/7)</td><td headers="hd_h_niceng220er2.tab10_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£52 / £61</td><td headers="hd_h_niceng220er2.tab10_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£77,471 / £92,234</td><td headers="hd_h_niceng220er2.tab10_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">PSSRU 2020<a class="bibr" href="#niceng220er2.ref6" rid="niceng220er2.ref6"><sup>6</sup></a></td></tr><tr><td headers="hd_h_niceng220er2.tab10_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">MS specialist pharmacist (band 7/8a)</td><td headers="hd_h_niceng220er2.tab10_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£64 / £74</td><td headers="hd_h_niceng220er2.tab10_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£93,501 / £109,786</td><td headers="hd_h_niceng220er2.tab10_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">PSSRU 2020<a class="bibr" href="#niceng220er2.ref6" rid="niceng220er2.ref6"><sup>6</sup></a>, hospital-based pharmacist</td></tr><tr><td headers="hd_h_niceng220er2.tab10_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Hospital Occupational therapist (OT) (band 6/7)</td><td headers="hd_h_niceng220er2.tab10_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£52 / £62</td><td headers="hd_h_niceng220er2.tab10_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£80,485 / £97,342</td><td headers="hd_h_niceng220er2.tab10_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">PSSRU 2020<a class="bibr" href="#niceng220er2.ref6" rid="niceng220er2.ref6"><sup>6</sup></a>, Hospital-based OT</td></tr><tr><td headers="hd_h_niceng220er2.tab10_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Community Occupational therapist (OT) (band 6/7)</td><td headers="hd_h_niceng220er2.tab10_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£50 / £60</td><td headers="hd_h_niceng220er2.tab10_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£77,109 / £93,501</td><td headers="hd_h_niceng220er2.tab10_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">PSSRU 2020<a class="bibr" href="#niceng220er2.ref6" rid="niceng220er2.ref6"><sup>6</sup></a>, Community-based OT</td></tr><tr><td headers="hd_h_niceng220er2.tab10_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">GP</td><td headers="hd_h_niceng220er2.tab10_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£153</td><td headers="hd_h_niceng220er2.tab10_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£278,759</td><td headers="hd_h_niceng220er2.tab10_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">PSSRU 2020<a class="bibr" href="#niceng220er2.ref6" rid="niceng220er2.ref6"><sup>6</sup></a></td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>(a)</dt><dd><div id="niceng220er2.tab10_1"><p class="no_margin">Note: Costs per working hour include salary, salary oncosts, overheads (management and other non-care staff costs including administration and estates staff), capital overheads and qualification costs (with individual and productivity costs excluded)</p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab11"><div id="niceng220er2.tab11" class="table"><h3><span class="label">Table 11</span><span class="title">Unit costs of health care professional visits and hospital admissions</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab11/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab11_lrgtbl__"><table><thead><tr><th id="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Visit or hospital admission type</th><th id="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Unit costs</th><th id="hd_h_niceng220er2.tab11_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Source</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1 hd_h_niceng220er2.tab11_1_1_1_2 hd_h_niceng220er2.tab11_1_1_1_3" colspan="3" rowspan="1" style="text-align:left;vertical-align:top;">Visits</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Neurology: non-admitted face to face attendance, follow up</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£169</td><td headers="hd_h_niceng220er2.tab11_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>HRG code: WF01A</p>
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<p>NHS reference costs 2018/2019<a class="bibr" href="#niceng220er2.ref31" rid="niceng220er2.ref31"><sup>31</sup></a></p>
|
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</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">A&E: weighted average of admitted and non-admitted A&E attendances</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£166</td><td headers="hd_h_niceng220er2.tab11_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>HRG code: VB01Z to VB11Z</p>
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<p>NHS reference costs 2018/2019<a class="bibr" href="#niceng220er2.ref31" rid="niceng220er2.ref31"><sup>31</sup></a></p>
|
|
</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">MS specialist Nurse (band 6/7) surgery appointment (15min)</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£13 / £15</td><td headers="hd_h_niceng220er2.tab11_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<p>Surgery consultation time by a clinical nurse specialist from PSSRU 2015<a class="bibr" href="#niceng220er2.ref5" rid="niceng220er2.ref5"><sup>5</sup></a>, Page 175.</p>
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<p>Unit costs from PSSRU 2020<a class="bibr" href="#niceng220er2.ref6" rid="niceng220er2.ref6"><sup>6</sup></a>.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">MS specialist Nurse (band 6/7) home visit (25 min)</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£22 / £25</td><td headers="hd_h_niceng220er2.tab11_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Home consultation time by a clinical nurse specialist from PSSRU 2015<a class="bibr" href="#niceng220er2.ref5" rid="niceng220er2.ref5"><sup>5</sup></a>, Page 175.</p>
|
|
<p>Unit costs from PSSRU 2020<a class="bibr" href="#niceng220er2.ref6" rid="niceng220er2.ref6"><sup>6</sup></a>.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">MS specialist Nurse (band 6/7) telephone (6 min)</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£5 / £6</td><td headers="hd_h_niceng220er2.tab11_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>Telephone appointment time by a clinical nurse specialist from PSSRU 2015<a class="bibr" href="#niceng220er2.ref5" rid="niceng220er2.ref5"><sup>5</sup></a>, Page 175.</p>
|
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<p>Unit costs from PSSRU 2020<a class="bibr" href="#niceng220er2.ref6" rid="niceng220er2.ref6"><sup>6</sup></a>.</p>
|
|
</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">GP: 9.22 min consultation</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£37</td><td headers="hd_h_niceng220er2.tab11_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Unit cost and duration from PSSRU 2020<a class="bibr" href="#niceng220er2.ref6" rid="niceng220er2.ref6"><sup>6</sup></a></td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1 hd_h_niceng220er2.tab11_1_1_1_2 hd_h_niceng220er2.tab11_1_1_1_3" colspan="3" rowspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>Hospital admissions</b>
|
|
</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Kidney or urinary tract infections – short stay (non-elected)</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£452</td><td headers="hd_h_niceng220er2.tab11_1_1_1_3" rowspan="3" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>HRG code: LA04H to LA04S</p>
|
|
<p>NHS reference costs 2018/2019<a class="bibr" href="#niceng220er2.ref31" rid="niceng220er2.ref31"><sup>31</sup></a></p>
|
|
</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Kidney or urinary tract infections – long stay (non-elected)</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£2,652</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Kidney or urinary tract infections – elective inpatient</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£2,533</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Kidney or urinary tract infections – day case</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£273</td><td headers="hd_h_niceng220er2.tab11_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>HRG code: LA04P to LA04S</p>
|
|
<p>NHS reference costs 2018/2019<a class="bibr" href="#niceng220er2.ref31" rid="niceng220er2.ref31"><sup>31</sup></a></p>
|
|
</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Medical care of patients with MS – short stay (non-elected)</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£512</td><td headers="hd_h_niceng220er2.tab11_1_1_1_3" rowspan="4" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<p>HRG code: AA30C to AA30F</p>
|
|
<p>NHS reference costs 2018/2019<a class="bibr" href="#niceng220er2.ref31" rid="niceng220er2.ref31"><sup>31</sup></a></p>
|
|
</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Medical care of patients with MS – long stay (non-elected)</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£4,018</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Medical care of patients with MS – elective inpatient</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£2,742</td></tr><tr><td headers="hd_h_niceng220er2.tab11_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Medical care of patients with MS – day case</td><td headers="hd_h_niceng220er2.tab11_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£612</td></tr></tbody></table></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab12"><div id="niceng220er2.tab12" class="table"><h3><span class="label">Table 12</span><span class="title">Costs associated with a new MS specialist nurse post <sup>(a)</sup></span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab12/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab12_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng220er2.tab12_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Breakdown</th><th id="hd_h_niceng220er2.tab12_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Unit cost (£, 2011)</th><th id="hd_h_niceng220er2.tab12_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Assumptions (2011)</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab12_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Salary</td><td headers="hd_h_niceng220er2.tab12_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">35,000</td><td headers="hd_h_niceng220er2.tab12_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Band 7 mid-point</td></tr><tr><td headers="hd_h_niceng220er2.tab12_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">On-costs</td><td headers="hd_h_niceng220er2.tab12_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">5,950</td><td headers="hd_h_niceng220er2.tab12_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">17% of salary</td></tr><tr><td headers="hd_h_niceng220er2.tab12_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Telephone</td><td headers="hd_h_niceng220er2.tab12_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">480</td><td headers="hd_h_niceng220er2.tab12_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£40 per month</td></tr><tr><td headers="hd_h_niceng220er2.tab12_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Mileage</td><td headers="hd_h_niceng220er2.tab12_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">791</td><td headers="hd_h_niceng220er2.tab12_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">40 miles per week, 46 weeks per year</td></tr><tr><td headers="hd_h_niceng220er2.tab12_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Computer</td><td headers="hd_h_niceng220er2.tab12_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">500</td><td headers="hd_h_niceng220er2.tab12_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab12_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Clinic receptionist (shared)</td><td headers="hd_h_niceng220er2.tab12_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">5,888</td><td headers="hd_h_niceng220er2.tab12_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">4 clinics per week, £36 per clinic</td></tr><tr><td headers="hd_h_niceng220er2.tab12_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Clinic room cost</td><td headers="hd_h_niceng220er2.tab12_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">7,360</td><td headers="hd_h_niceng220er2.tab12_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">4 clinics per week, £40 per clinic</td></tr><tr><td headers="hd_h_niceng220er2.tab12_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Secretarial support</td><td headers="hd_h_niceng220er2.tab12_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">8,011</td><td headers="hd_h_niceng220er2.tab12_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr><tr><td headers="hd_h_niceng220er2.tab12_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>Total Cost</b>
|
|
</td><td headers="hd_h_niceng220er2.tab12_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>63,980</b>
|
|
</td><td headers="hd_h_niceng220er2.tab12_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>(a)</dt><dd><div id="niceng220er2.tab12_1"><p class="no_margin">Mynors 2012<a class="bibr" href="#niceng220er2.ref28" rid="niceng220er2.ref28"><sup>28</sup></a></p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab13"><div id="niceng220er2.tab13" class="table"><h3><span class="label">Table 13</span><span class="title">Illustrative cash releasing savings <sup>(a)</sup></span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab13/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab13_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng220er2.tab13_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;"></th><th id="hd_h_niceng220er2.tab13_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Number saved</th><th id="hd_h_niceng220er2.tab13_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Unit cost (£, 2011)</th><th id="hd_h_niceng220er2.tab13_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Total saving (£, 2011)</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab13_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Neurology follow up outpatient appointment</td><td headers="hd_h_niceng220er2.tab13_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">300</td><td headers="hd_h_niceng220er2.tab13_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">91</td><td headers="hd_h_niceng220er2.tab13_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">27,300</td></tr><tr><td headers="hd_h_niceng220er2.tab13_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Neurology emergency admissions</td><td headers="hd_h_niceng220er2.tab13_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">30</td><td headers="hd_h_niceng220er2.tab13_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">2,331</td><td headers="hd_h_niceng220er2.tab13_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">69,930</td></tr><tr><td headers="hd_h_niceng220er2.tab13_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Other emergency admissions (e.g. UTI)</td><td headers="hd_h_niceng220er2.tab13_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">10</td><td headers="hd_h_niceng220er2.tab13_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">2,056</td><td headers="hd_h_niceng220er2.tab13_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">20,560</td></tr><tr><td headers="hd_h_niceng220er2.tab13_1_1_1_1 hd_h_niceng220er2.tab13_1_1_1_2 hd_h_niceng220er2.tab13_1_1_1_3" colspan="3" rowspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>TOTAL SAVING</b>
|
|
</td><td headers="hd_h_niceng220er2.tab13_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>117,790</b>
|
|
</td></tr><tr><td headers="hd_h_niceng220er2.tab13_1_1_1_1 hd_h_niceng220er2.tab13_1_1_1_2 hd_h_niceng220er2.tab13_1_1_1_3" colspan="3" rowspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>NET CASH RELEASING SAVING TO COMMISSIONER</b>
|
|
</td><td headers="hd_h_niceng220er2.tab13_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>53,810</b>
|
|
</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>(a)</dt><dd><div id="niceng220er2.tab13_1"><p class="no_margin">Source: Mynors 2012<a class="bibr" href="#niceng220er2.ref28" rid="niceng220er2.ref28"><sup>28</sup></a></p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab14"><div id="niceng220er2.tab14" class="table"><h3><span class="label">Table 14</span><span class="title">Breakeven assumptions <sup>(a)</sup></span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab14/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab14_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng220er2.tab14_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;"></th><th id="hd_h_niceng220er2.tab14_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Number saved</th><th id="hd_h_niceng220er2.tab14_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Unit cost (£, 2011)</th><th id="hd_h_niceng220er2.tab14_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Total saving (£, 2011)</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab14_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Neurology follow up outpatient appointment</td><td headers="hd_h_niceng220er2.tab14_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">199</td><td headers="hd_h_niceng220er2.tab14_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">91</td><td headers="hd_h_niceng220er2.tab14_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">18,109</td></tr><tr><td headers="hd_h_niceng220er2.tab14_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Neurology emergency admissions</td><td headers="hd_h_niceng220er2.tab14_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">10</td><td headers="hd_h_niceng220er2.tab14_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">2,331</td><td headers="hd_h_niceng220er2.tab14_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">23,310</td></tr><tr><td headers="hd_h_niceng220er2.tab14_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Other emergency admissions (e.g. UTI)</td><td headers="hd_h_niceng220er2.tab14_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">11</td><td headers="hd_h_niceng220er2.tab14_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">2,056</td><td headers="hd_h_niceng220er2.tab14_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">22,616</td></tr><tr><td headers="hd_h_niceng220er2.tab14_1_1_1_1 hd_h_niceng220er2.tab14_1_1_1_2 hd_h_niceng220er2.tab14_1_1_1_3" colspan="3" rowspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>TOTAL SAVING</b>
|
|
</td><td headers="hd_h_niceng220er2.tab14_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
|
|
<b>64,035</b>
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</td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt>(a)</dt><dd><div id="niceng220er2.tab14_1"><p class="no_margin">Source: Mynors 2012<a class="bibr" href="#niceng220er2.ref28" rid="niceng220er2.ref28"><sup>28</sup></a></p></div></dd></dl></dl></div></div></div></article><article data-type="table-wrap" id="figobniceng220er2tab15"><div id="niceng220er2.tab15" class="table"><h3><span class="label">Table 15</span><span class="title">Conservative modelling of outpatient health service costs saved by MS specialist nurse services</span></h3><p class="large-table-link" style="display:none"><span class="right"><a href="/books/NBK585276/table/niceng220er2.tab15/?report=objectonly" target="object">View in own window</a></span></p><div class="large_tbl" id="__niceng220er2.tab15_lrgtbl__"><table class="no_bottom_margin"><thead><tr><th id="hd_h_niceng220er2.tab15_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;"></th><th id="hd_h_niceng220er2.tab15_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Additional required per year per person on caseload without the MSSN service</th><th id="hd_h_niceng220er2.tab15_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Number avoided (based on caseload of 358 pwMS)</th><th id="hd_h_niceng220er2.tab15_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Unit cost</th><th id="hd_h_niceng220er2.tab15_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Cost avoided</th><th id="hd_h_niceng220er2.tab15_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:bottom;">Source for cost data</th></tr></thead><tbody><tr><td headers="hd_h_niceng220er2.tab15_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">Neurologist consultations</td><td headers="hd_h_niceng220er2.tab15_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.68</td><td headers="hd_h_niceng220er2.tab15_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">243</td><td headers="hd_h_niceng220er2.tab15_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£174</td><td headers="hd_h_niceng220er2.tab15_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£42,359</td><td headers="hd_h_niceng220er2.tab15_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">NHS reference costs 2012–13</td></tr><tr><td headers="hd_h_niceng220er2.tab15_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">A&E visits</td><td headers="hd_h_niceng220er2.tab15_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.05</td><td headers="hd_h_niceng220er2.tab15_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">18</td><td headers="hd_h_niceng220er2.tab15_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£114</td><td headers="hd_h_niceng220er2.tab15_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£2,041</td><td headers="hd_h_niceng220er2.tab15_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">NHS reference costs 2012–13</td></tr><tr><td headers="hd_h_niceng220er2.tab15_1_1_1_1" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">GP visits</td><td headers="hd_h_niceng220er2.tab15_1_1_1_2" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">0.39</td><td headers="hd_h_niceng220er2.tab15_1_1_1_3" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">140</td><td headers="hd_h_niceng220er2.tab15_1_1_1_4" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£66</td><td headers="hd_h_niceng220er2.tab15_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">£9,215</td><td headers="hd_h_niceng220er2.tab15_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">PSSRU unit costs of health and social care 2013, 17.2 minute consultation</td></tr><tr><td headers="hd_h_niceng220er2.tab15_1_1_1_1 hd_h_niceng220er2.tab15_1_1_1_2 hd_h_niceng220er2.tab15_1_1_1_3 hd_h_niceng220er2.tab15_1_1_1_4" colspan="4" rowspan="1" style="text-align:left;vertical-align:top;">
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<b>Total ambulatory care costs avoided</b>
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</td><td headers="hd_h_niceng220er2.tab15_1_1_1_5" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;">
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<b>£53,614</b>
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</td><td headers="hd_h_niceng220er2.tab15_1_1_1_6" rowspan="1" colspan="1" style="text-align:left;vertical-align:top;"></td></tr></tbody></table></div><div class="tblwrap-foot"><div><dl class="temp-labeled-list small"><dl class="bkr_refwrap"><dt></dt><dd><div><p class="no_margin">Mynors 2015<a class="bibr" href="#niceng220er2.ref29" rid="niceng220er2.ref29"><sup>29</sup></a></p></div></dd></dl></dl></div></div></div></article></div><div id="jr-scripts"><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/libs.min.js"> </script><script src="/corehtml/pmc/jatsreader/ptpmc_3.22/js/jr.min.js"> </script></div></div>
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