Title: The Effectiveness and Cost-Effectiveness of a Clinical Violence Prevention Team Based in the Emergency Department
Funder: Health and Care Research Wales (Welsh Government)

Abstract: Aim_x000D_ _x000D_ People who are seriously injured due to violence often go straight to A&E for treatment. Organisations, such as the police, are not aware of these patients. There are over 170,00 such visits each year in England and Wales, and up to 60% of these patients will return to A&E within two years. This highlights the cost of violence to the NHS. There are many reasons why people are exposed to violence. Some are victims of ongoing domestic violence, some misuse alcohol, or drugs, and some are children living in chaotic households. To stop people becoming involved in violence, we need to address these underlying causes and not just treat their injuries. Police-led nursing teams in A&E are well-placed to do this. In this research, we aim to understand whether a dedicated team in A&E can identify patients’ needs, refer them into services able to support them, and if this approach reduces these patients’ subsequent use of emergency healthcare. _x000D_ _x000D_ Background_x000D_ _x000D_ There are several schemes based in A&Es that refer patients with violence-related injuries to services that offer support. Those who are victims of domestic violence can be referred to Domestic Violence Advocates who can offer support. However, there is little support those most likely to visit A&E because of violence - young men. Violence Prevention Teams are funded by, and work closely with the police. It is run by a nurse familiar with A&E. They approach all those attending A&E with injuries due to violence, irrespective of their age and gender, and work with them to identify the support that they need. This collaboration between the police and clinical staff is unique across the UK and we wish to understand if it reduces later emergency healthcare use in those offered support._x000D_ _x000D_ Design and Methods_x000D_ _x000D_ We will identify patients who have been supported by the Violence Prevention Teams in Cardiff (from October 2019) and Swansea (from January 2022) and, using a Secure Anonymised Information Linkage facility, access their routinely collected healthcare records. For children, we can also access their school records. We can also do the same with other A&E patients across Wales who have no contact with a Violence Prevention Team but attended their local A&E with violence-related injury. In this way we can see whether the approach in Cardiff and Swansea means patients are less likely to access emergency healthcare due to the support from the Violence Prevention Team. _x000D_ _x000D_ Patient and Public Involvement_x000D_ _x000D_ Patients and the public have commented on the proposal and their suggestions have been incorporated. We will further arrange focus groups with a broad range of people, including those who have experience of emergency healthcare because of their drug and alcohol use, and survivors of domestic violence. The research team includes two co-applicants experienced in providing PPI support. One promotes the involvement of patients and the public in research, and the other has experience of equality and diversity. _x000D_ _x000D_ Dissemination_x000D_ _x000D_ Little research has looked at how A&E staff can refer patients for support beyond their immediate health needs. The UK Government has invested money to tackle violence and it is likely that our research will be of general interest. We will engage with local and national government, police forces, practitioners, and the public through regular newsletters. We will also publish our findings in academic journals and present this research at international conferences.

Lay abstract: Research question_x000D_ _x000D_ Does an Emergency Department (ED) based violence intervention programme reduce future emergency healthcare utilisation?_x000D_ _x000D_ Background_x000D_ _x000D_ Assault-related attendance (ARA), and resulting emergency healthcare utilisation, is symptomatic of chronic vulnerabilities, including alcohol and illicit substance abuse. Police-funded ED-based violence prevention initiatives can support and refer patients to services able to address these vulnerabilities, thus reducing the likelihood of repeat unscheduled ED attendance and violence recidivism. Since October 2019, a Violence Prevention Team (VPT) has been operational in Cardiff ED; a second VPT will start in Swansea Oct 2021. Comprising a nurse and an advocate, VPTs work with the clinical team, who can be reluctant to explore reasons for injuries with patients, to identify and refer patients according to need._x000D_ _x000D_ Aims & objectives_x000D_ _x000D_ We aim to assess the effectiveness and cost-effectiveness of the VPTs:_x000D_ _x000D_ Q1 Does involvement with a VPT reduce the likelihood of unscheduled ED re-attendance?_x000D_ Q2 From an NHS perspective, do VPTs represent value for money?_x000D_ Q3 Does the presence of the VPT improve ascertainment of ARAs in ED attendances?_x000D_ _x000D_ We consider outcomes by patients’ age, gender, ethnicity, and socio-economic status, and include data on other residents in these households. We will also explore a range of societal outcomes, using GP mental health data, referrals from ED to elsewhere in the NHS, attendance and attainment in young persons’ education, and police data on Public Protection Notices._x000D_ _x000D_ Method_x000D_ _x000D_ Patients 11 years and older, with an ARA in Welsh EDs and with a minimum 12-month follow-up period available are eligible. Individual-level data are accessed through the Secure Anonymised Information Linkage databank. Intervention patients will be propensity score matched to control patients using age, gender, and location (urban/rural)._x000D_ _x000D_ Q1 Intention-to-treat recurrent event analysis for ED unscheduled reattendance following an ARA, comparing case to control hazard rates. Data will be right-side censored using death or end of analysis period. _x000D_ Q2 The component costs of the VPT and unscheduled healthcare utilisation, complementing Q1 with modelling to estimate value for money over a 10-year period. Health impacts on individuals will be measured in terms of life years and quality adjusted life years, with the latter estimated from health-related quality of life decrements associated with ED attendances._x000D_ Q3 Time series on weekly proportion of injury attendances identified as an ARA in Welsh EDs (for seven years, including the two VPT introduction dates) analysed using interrupted time series analysis._x000D_ _x000D_ Further analyses will be exploratory and developed through further close Public and Patient Involvement and consultation with collaborators._x000D_ _x000D_ Timelines for delivery_x000D_ _x000D_ The evaluation can begin in February 2022 and run for 30 months._x000D_ _x000D_ Anticipated impact and dissemination_x000D_ _x000D_ The UK Government continues to invest significant resources into activities designed to challenge the causes of violence. ED-based violence prevention initiatives are a significant innovation but are yet to be rigorously evaluated in the UK. We expect outputs from the study to have immediate and considerable impact on policy in this area. We have been asked to consider criteria prognostic of ARA, in particular education-related measures, which we will published in interim analyses.

Research activity codes: 3.1 PRIMARY PREVENTION INTERVENTIONS TO MODIFY BEHAVIOURS OR PROMOTE WELL-BEING
Health categories: GENERIC HEALTH RELEVANCE