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Mintz HP, Dosanjh A, Parsons HM, Hughes A, Jakeman A, Pope AM, Bryan RT, James ND, Patel P. Development and validation of a follow-up methodology for a randomised controlled trial, utilising routine clinical data as an alternative to traditional designs: a pilot study to assess the feasibility of use for the BladderPath trial. Pilot Feasibility Stud 2020; 6:165. [PMID: 33292682 PMCID: PMC7599120 DOI: 10.1186/s40814-020-00713-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/20/2020] [Indexed: 01/19/2023] Open
Abstract
Background Bladder cancer outcomes have not changed significantly in 30 years; the BladderPath trial (Image Directed Redesign of Bladder Cancer Treatment Pathway, ISRCTN35296862) proposes to evaluate a modified pathway for diagnosis and treatment ensuring appropriate pathways are undertaken earlier to improve outcomes. We are piloting a novel data collection technique based on routine National Health Service (NHS) data, with no traditional patient-Health Care Professional contact after recruitment, where trial data are traditionally collected on case report forms. Data will be collected from routine administrative sources and validated via data queries to sites. We report here the feasibility and pre-trial methodological development and validation of the schema proposed for BladderPath. Methods Locally treated patient cohorts were utilised for routine data validation (hospital interactions data (HID) and administrative radiotherapy department data (RTD)). Single site events of interest were algorithmically extracted from the 2008–2018 HID and validated against reference datasets to determine detection sensitivity. Survival analysis was performed using RTD and HID data. Hazard ratios and survival statistics were calculated estimating treatment effects and further validating and assessing the scope of routine data. Results Overall, 829/1042 (sensitivity 0.80) events of interest were identified in the HID, with varying levels of sensitivity; identifying, 202/206 (sensitivity 0.98; PPV 0.96) surgical events but only 391/568 (sensitivity 0.69; PPV 0.95) radiotherapy regimens. An overall temporal quality improvement trend was present: detecting 41/117 events (35%) in 2011 to 104/109 (95%) in 2017 (all event types). Using the RTD, 5-year survival rates were 43% (95% CI 25–59%) in the chemoradiotherapy group and 30% (95% CI 23–36%) in the radiotherapy group; using the HID, the 5-year radical cystectomy survival rate was 57% (95% CI 50–63%). Conclusions Routine data are a feasible method for trial data collection. As long as events of interest are pre-validated, very high sensitivities for trial conduct can be achieved and further improved with targeted data queries. Outcomes can also be produced comparable to clinical trial and national dataset results. Given the real-time, obligatory nature of the HID, which forms the Hospital Episode Statistics (HES) data, alongside other datasets, we believe routine data extraction and validation is a robust way of rapidly collecting datasets for trials. Supplementary Information Supplementary information accompanies this paper at 10.1186/s40814-020-00713-y.
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Affiliation(s)
- Harriet P Mintz
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK.,University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW, UK
| | - Amandeep Dosanjh
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW, UK.,Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Helen M Parsons
- Warwick Medical School, University of Warwick, Coventry, CV4 7AL, UK
| | - Ana Hughes
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Alicia Jakeman
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW, UK
| | - Ann M Pope
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | - Richard T Bryan
- Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK
| | | | - Nicholas D James
- The Institute of Cancer Research, 237 Fulham Road, London, SW3 6JB, UK.,The Royal Marsden NHS foundation Trust, Fulham Road, Chelsea, London, SW3 6JJ, UK
| | - Prashant Patel
- University Hospitals Birmingham NHS Foundation Trust, Edgbaston, Birmingham, B15 2GW, UK. .,Institute of Cancer and Genomic Sciences, University of Birmingham, Edgbaston, Birmingham, B15 2TT, UK.
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Abstract
The mission of the Cochrane Nursing Care Field (CNCF) is to improve health outcomes through increasing the use of the Cochrane Library and supporting Cochrane's role by providing an evidence base for nurses and healthcare professionals who deliver, lead or research nursing care. The CNCF produces Cochrane Corner columns, summaries of recent nursing-care-relevant Cochrane Reviews that are regularly published in collaborating nursing-related journals. Information on the processes CNCF has developed can be accessed at: cncf.cochrane.org/evidence-transfer-program-review-summaries. This is a Cochrane review summary of: Smith SM, Fahey T, Smucny J et al (2017) Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews. Issue 6. CD000245. doi: 10.1002/14651858.CD000245.pub4.
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Affiliation(s)
- Melanie Tanner
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, England, and member of the Cochrane Nursing Care Field
| | - Jennifer Karen Roddis
- School of Health Sciences and Social Work, University of Portsmouth, Portsmouth, England, and member of the Cochrane Nursing Care Field
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Julious SA, Horspool MJ, Davis S, Bradburn M, Norman P, Shephard N, Cooper CL, Smithson WH, Boote J, Elphick H, Loban A, Franklin M, Kua WS, May R, Campbell J, Williams R, Rex S, Bortolami O. PLEASANT: Preventing and Lessening Exacerbations of Asthma in School-age children Associated with a New Term - a cluster randomised controlled trial and economic evaluation. Health Technol Assess 2018; 20:1-154. [PMID: 28005003 DOI: 10.3310/hta20930] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Asthma episodes and deaths are known to be seasonal. A number of reports have shown peaks in asthma episodes in school-aged children associated with the return to school following the summer vacation. A fall in prescription collection in the month of August has been observed, and was associated with an increase in the number of unscheduled contacts after the return to school in September. OBJECTIVE The primary objective of the study was to assess whether or not a NHS-delivered public health intervention reduces the September peak in unscheduled medical contacts. DESIGN Cluster randomised trial, with the unit of randomisation being 142 NHS general practices, and trial-based economic evaluation. SETTING Primary care. INTERVENTION A letter sent (n = 70 practices) in July from their general practitioner (GP) to parents/carers of school-aged children with asthma to remind them of the importance of taking their medication, and to ensure that they have sufficient medication prior to the start of the new school year in September. The control group received usual care. MAIN OUTCOME MEASURES The primary outcome measure was the proportion of children aged 5-16 years who had an unscheduled medical contact in September 2013. Supporting end points included the proportion of children who collected prescriptions in August 2013 and unscheduled contacts through the following 12 months. Economic end points were quality-adjusted life-years (QALYs) gained and costs from an NHS and Personal Social Services perspective. RESULTS There is no evidence of effect in terms of unscheduled contacts in September. Among children aged 5-16 years, the odds ratio (OR) was 1.09 [95% confidence interval (CI) 0.96 to 1.25] against the intervention. The intervention did increase the proportion of children collecting a prescription in August (OR 1.43, 95% CI 1.24 to 1.64) as well as scheduled contacts in the same month (OR 1.13, 95% CI 0.84 to 1.52). For the wider time intervals (September-December 2013 and September-August 2014), there is weak evidence of the intervention reducing unscheduled contacts. The intervention did not reduce unscheduled care in September, although it succeeded in increasing the proportion of children collecting prescriptions in August as well as having scheduled contacts in the same month. These unscheduled contacts in September could be a result of the intervention, as GPs may have wanted to see patients before issuing a prescription. The economic analysis estimated a high probability that the intervention was cost-saving, for baseline-adjusted costs, across both base-case and sensitivity analyses. There was no increase in QALYs. LIMITATION The use of routine data led to uncertainty in the coding of medical contacts. The uncertainty was mitigated by advice from a GP adjudication panel. CONCLUSIONS The intervention did not reduce unscheduled care in September, although it succeeded in increasing the proportion of children both collecting prescriptions and having scheduled contacts in August. After September there is weak evidence in favour of the intervention. The intervention had a favourable impact on costs but did not demonstrate any impact on QALYs. The results of the trial indicate that further work is required on assessing and understanding adherence, both in terms of using routine data to make quantitative assessments, and through additional qualitative interviews with key stakeholders such as practice nurses, GPs and a wider group of children with asthma. TRIAL REGISTRATION Current Controlled Trials ISRCTN03000938. FUNDING DETAILS This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 93. See the HTA programme website for further project information.
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Affiliation(s)
- Steven A Julious
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Michelle J Horspool
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Sarah Davis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Mike Bradburn
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Paul Norman
- Department of Psychology, University of Sheffield, Sheffield, UK
| | - Neil Shephard
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Cindy L Cooper
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - W Henry Smithson
- Department of Clinical Practice, University of Cork, Cork, Ireland
| | - Jonathan Boote
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Heather Elphick
- Respiratory Department, Sheffield Children's Hospital, Sheffield, UK
| | - Amanda Loban
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Matthew Franklin
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Wei Sun Kua
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Robin May
- Clinical Practice Research Datalink, London, UK
| | | | | | - Saleema Rex
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Oscar Bortolami
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
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Abstract
BACKGROUND The benefits and risks of antibiotics for acute bronchitis remain unclear despite it being one of the most common illnesses seen in primary care. OBJECTIVES To assess the effects of antibiotics in improving outcomes and to assess adverse effects of antibiotic therapy for people with a clinical diagnosis of acute bronchitis. SEARCH METHODS We searched CENTRAL 2016, Issue 11 (accessed 13 January 2017), MEDLINE (1966 to January week 1, 2017), Embase (1974 to 13 January 2017), and LILACS (1982 to 13 January 2017). We searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 5 April 2017. SELECTION CRITERIA Randomised controlled trials comparing any antibiotic therapy with placebo or no treatment in acute bronchitis or acute productive cough, in people without underlying pulmonary disease. DATA COLLECTION AND ANALYSIS At least two review authors extracted data and assessed trial quality. MAIN RESULTS We did not identify any new trials for inclusion in this 2017 update. We included 17 trials with 5099 participants in the primary analysis. The quality of trials was generally good. At follow-up there was no difference in participants described as being clinically improved between the antibiotic and placebo groups (11 studies with 3841 participants, risk ratio (RR) 1.07, 95% confidence interval (CI) 0.99 to 1.15). Participants given antibiotics were less likely to have a cough (4 studies with 275 participants, RR 0.64, 95% CI 0.49 to 0.85; number needed to treat for an additional beneficial outcome (NNTB) 6) and a night cough (4 studies with 538 participants, RR 0.67, 95% CI 0.54 to 0.83; NNTB 7). Participants given antibiotics had a shorter mean cough duration (7 studies with 2776 participants, mean difference (MD) -0.46 days, 95% CI -0.87 to -0.04). The differences in presence of a productive cough at follow-up and MD of productive cough did not reach statistical significance.Antibiotic-treated participants were more likely to be improved according to clinician's global assessment (6 studies with 891 participants, RR 0.61, 95% CI 0.48 to 0.79; NNTB 11) and were less likely to have an abnormal lung exam (5 studies with 613 participants, RR 0.54, 95% CI 0.41 to 0.70; NNTB 6). Antibiotic-treated participants also had a reduction in days feeling ill (5 studies with 809 participants, MD -0.64 days, 95% CI -1.16 to -0.13) and days with impaired activity (6 studies with 767 participants, MD -0.49 days, 95% CI -0.94 to -0.04). The differences in proportions with activity limitations at follow-up did not reach statistical significance. There was a significant trend towards an increase in adverse effects in the antibiotic group (12 studies with 3496 participants, RR 1.20, 95% CI 1.05 to 1.36; NNT for an additional harmful outcome 24). AUTHORS' CONCLUSIONS There is limited evidence of clinical benefit to support the use of antibiotics in acute bronchitis. Antibiotics may have a modest beneficial effect in some patients such as frail, elderly people with multimorbidity who may not have been included in trials to date. However, the magnitude of this benefit needs to be considered in the broader context of potential side effects, medicalisation for a self limiting condition, increased resistance to respiratory pathogens, and cost of antibiotic treatment.
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Affiliation(s)
- Susan M Smith
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St Stephens GreenDublin 2Ireland
| | - Tom Fahey
- RCSI Medical SchoolHRB Centre for Primary Care Research, Department of General Practice123 St Stephens GreenDublin 2Ireland
| | - John Smucny
- Palo Alto Medical Foundation, Dublin CenterDublinCaliforniaUSA
| | - Lorne A Becker
- SUNY Upstate Medical UniversityDepartment of Family Medicine475 Irving AveSuite 200SyracuseNew YorkUSA13210
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Juszczyk D, Charlton J, McDermott L, Soames J, Sultana K, Ashworth M, Fox R, Hay AD, Little P, Moore MV, Yardley L, Prevost AT, Gulliford MC. Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records-REDUCE Trial study original protocol. BMJ Open 2016; 6:e010892. [PMID: 27491663 PMCID: PMC4985802 DOI: 10.1136/bmjopen-2015-010892] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices. METHODS AND ANALYSIS 2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practice's antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms. ETHICS AND DISSEMINATION Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact. TRIAL REGISTRATION NUMBER ISRCTN95232781; Pre-results.
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Affiliation(s)
- Dorota Juszczyk
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Judith Charlton
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
| | - A Toby Prevost
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
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Gordon CL, Weng C. Combining expert knowledge and knowledge automatically acquired from electronic data sources for continued ontology evaluation and improvement. J Biomed Inform 2015. [PMID: 26212414 DOI: 10.1016/j.jbi.2015.07.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
INTRODUCTION A common bottleneck during ontology evaluation is knowledge acquisition from domain experts for gold standard creation. This paper contributes a novel semi-automated method for evaluating the concept coverage and accuracy of biomedical ontologies by complementing expert knowledge with knowledge automatically extracted from clinical practice guidelines and electronic health records, which minimizes reliance on expensive domain expertise for gold standards generation. METHODS We developed a bacterial clinical infectious diseases ontology (BCIDO) to assist clinical infectious disease treatment decision support. Using a semi-automated method we integrated diverse knowledge sources, including publically available infectious disease guidelines from international repositories, electronic health records, and expert-generated infectious disease case scenarios, to generate a compendium of infectious disease knowledge and use it to evaluate the accuracy and coverage of BCIDO. RESULTS BCIDO has three classes (i.e., infectious disease, antibiotic, bacteria) containing 593 distinct concepts and 2345 distinct concept relationships. Our semi-automated method generated an ID knowledge compendium consisting of 637 concepts and 1554 concept relationships. Overall, BCIDO covered 79% (504/637) of the concepts and 89% (1378/1554) of the concept relationships in the ID compendium. BCIDO coverage of ID compendium concepts was 92% (121/131) for antibiotic, 80% (205/257) for infectious disease, and 72% (178/249) for bacteria. The low coverage of bacterial concepts in BCIDO was due to a difference in concept granularity between BCIDO and infectious disease guidelines. Guidelines and expert generated scenarios were the richest source of ID concepts and relationships while patient records provided relatively fewer concepts and relationships. CONCLUSIONS Our semi-automated method was cost-effective for generating a useful knowledge compendium with minimal reliance on domain experts. This method can be useful for continued development and evaluation of biomedical ontologies for better accuracy and coverage.
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Affiliation(s)
- Claire L Gordon
- Department of Medicine, Columbia University Medical Center, 630 West 168th Street, New York, USA; Department of Biomedical Informatics, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA; Department of Medicine, University of Melbourne, Melbourne, VIC 3010, Australia
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University Medical Center, 622 West 168th Street, New York, NY 10032, USA.
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Elkhenini HF, Davis KJ, Stein ND, New JP, Delderfield MR, Gibson M, Vestbo J, Woodcock A, Bakerly ND. Using an electronic medical record (EMR) to conduct clinical trials: Salford Lung Study feasibility. BMC Med Inform Decis Mak 2015; 15:8. [PMID: 25880660 PMCID: PMC4331140 DOI: 10.1186/s12911-015-0132-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2013] [Accepted: 01/15/2015] [Indexed: 11/10/2022] Open
Abstract
Background Real-world data on the benefit/risk profile of medicines is needed, particularly in patients who are ineligible for randomised controlled trials conducted for registration purposes. This paper describes the methodology and source data verification which enables the conduct of pre-licensing clinical trials of COPD and asthma in the community using the electronic medical record (EMR), NorthWest EHealth linked database (NWEH-LDB) and alert systems. Methods Dual verification of extracts into NWEH-LDB was performed using two independent data sources (Salford Integrated Record [SIR] and Apollo database) from one primary care practice in Salford (N = 3504). A feasibility study was conducted to test the reliability of the NWEH-LDB to support longitudinal data analysis and pragmatic clinical trials in asthma and COPD. This involved a retrospective extraction of data from all registered practices in Salford to identify a cohort of patients with a diagnosis of asthma (aged ≥18) and/or COPD (aged ≥40) and ≥2 prescriptions for inhaled bronchodilators during 2008. Health care resource utilisation (HRU) outcomes during 2009 were assessed. Exacerbations were defined as: prescription for oral corticosteroids (OCS) in asthma and prescription of OCS or antibiotics in COPD; and/or hospitalisation for a respiratory cause. Results Dual verification demonstrated consistency between SIR and Apollo data sources: 3453 (98.6%) patients were common to both systems; 99.9% of prescription records were matched and of 29,830 diagnosis records, one record was missing from Apollo and 272 (0.9%) from SIR. Identified COPD patients were also highly concordant (Kappa coefficient = 0.98). A total of 7981 asthma patients and 4478 COPD patients were identified within the NWEH-LDB. Cohort analyses enumerated the most commonly prescribed respiratory medication classes to be: inhaled corticosteroids (ICS) (42%) and ICS plus long-acting β2-agonist (LABA) (40%) in asthma; ICS plus LABA (55%) and long-acting muscarinic antagonists (36%) in COPD. During 2009 HRU was greater in the COPD versus asthma cohorts, and exacerbation rates in 2009 were higher in patients who had ≥2 exacerbations versus ≤1 exacerbation in 2008 for both asthma (137.5 vs. 20.3 per 100 person-years, respectively) and COPD (144.6 vs. 41.0, respectively). Conclusion Apollo and SIR data extracts into NWEH-LDB showed a high level of concordance for asthma and COPD patients. Longitudinal data analysis characterized the COPD and asthma populations in Salford including medications prescribed and health care utilisation outcomes suitable for clinical trial planning.
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Affiliation(s)
- Hanaa F Elkhenini
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK. .,NorthWest EHealth, Salford Royal NHS Foundation Trust, Salford, UK.
| | - Kourtney J Davis
- GlaxoSmithKline R&D, Worldwide Epidemiology, Wavre, Belgium.,GlaxoSmithKline R&D, Worldwide Epidemiology, Uxbridge, UK
| | - Norman D Stein
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,NorthWest EHealth, Salford Royal NHS Foundation Trust, Salford, UK
| | - John P New
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,NorthWest EHealth, Salford Royal NHS Foundation Trust, Salford, UK
| | - Mark R Delderfield
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,NorthWest EHealth, Salford Royal NHS Foundation Trust, Salford, UK
| | - Martin Gibson
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,NorthWest EHealth, Salford Royal NHS Foundation Trust, Salford, UK
| | - Jorgen Vestbo
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,University Hospital South Manchester, Manchester, UK
| | - Ashley Woodcock
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,University Hospital South Manchester, Manchester, UK
| | - Nawar Diar Bakerly
- Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.,NorthWest EHealth, Salford Royal NHS Foundation Trust, Salford, UK
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McDermott L, Yardley L, Little P, van Staa T, Dregan A, McCann G, Ashworth M, Gulliford M. Process evaluation of a point-of-care cluster randomised trial using a computer-delivered intervention to reduce antibiotic prescribing in primary care. BMC Health Serv Res 2014; 14:594. [PMID: 25700144 PMCID: PMC4260184 DOI: 10.1186/s12913-014-0594-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 11/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The study aimed to conduct a process evaluation for a cluster randomised trial of a computer-delivered, point-of-care intervention to reduce antibiotic prescribing in primary care. The study aimed to evaluate both the intervention and implementation of the trial. METHODS The intervention comprised a set of electronic educational and decision support tools that were remotely installed and activated during consultations with patients with acute respiratory infections over a 12 month intervention period. A mixed method evaluation was conducted with 103 general practitioners (GPs) who participated in the trial. Semi-structured telephone interviews were conducted with 20 GPs who had been in the intervention group of the trial and 4 members of the implementation staff. Questionnaires, consisting of both intervention evaluation and theory-based measures, were self-administered to 83 GPs (56 control group and 27 intervention group). RESULTS Interviews suggested that a key factor influencing GPs' use of the intervention appeared to be their awareness of the implementation of the system into their practice. GPs who were aware of the implementation of the intervention reported feeling confident in using it if they chose to and understood the purpose of the intervention screens. However, GPs who were unaware that the intervention would be appearing often reported feeling confused when they saw the messages appear on the screen and not fully understanding what they were for or how they could be used. Intervention evaluation questionnaires indicated that GPs were satisfied with the usability of the prompts, and theory-based measures revealed that intervention group GPs reported higher levels of self-efficacy in managing RTI patients according to recommended guidelines compared to GPs in the control group. CONCLUSIONS Remote installation of a computer-delivered intervention for use at the point-of-care was feasible and acceptable. Additional measures to promote awareness of the intervention may be required to promote health care professionals' utilisation of the intervention and these might sometimes compromise the pragmatic intention of a trial. TRIAL REGISTRATION ISRCTN47558792 (registered on 17 March 2010).
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Affiliation(s)
- Lisa McDermott
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - Lucy Yardley
- />Department of Psychology, University of Southampton, Shakleton Building, Highfield, Southampton, UK
| | - Paul Little
- />Aldermoor Health Centre, School of Primary Care and Population Sciences, University of Southampton, Aldermoor Close, Southampton, UK
| | - Tjeerd van Staa
- />The Clinical Practice Research Datalink Group, The Medicines and Healthcare products Regulatory Agency, 5th Floor, 151 Buckingham Palace Road, London, Victoria UK
| | - Alex Dregan
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - Gerard McCann
- />The Clinical Practice Research Datalink Group, The Medicines and Healthcare products Regulatory Agency, 5th Floor, 151 Buckingham Palace Road, London, Victoria UK
| | - Mark Ashworth
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - Martin Gulliford
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - The eCRT research team
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
- />Department of Psychology, University of Southampton, Shakleton Building, Highfield, Southampton, UK
- />Aldermoor Health Centre, School of Primary Care and Population Sciences, University of Southampton, Aldermoor Close, Southampton, UK
- />The Clinical Practice Research Datalink Group, The Medicines and Healthcare products Regulatory Agency, 5th Floor, 151 Buckingham Palace Road, London, Victoria UK
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9
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Gulliford MC, Dregan A, Moore MV, Ashworth M, van Staa T, McCann G, Charlton J, Yardley L, Little P, McDermott L. Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices. BMJ Open 2014; 4:e006245. [PMID: 25348424 PMCID: PMC4212213 DOI: 10.1136/bmjopen-2014-006245] [Citation(s) in RCA: 172] [Impact Index Per Article: 17.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2014] [Revised: 09/18/2014] [Accepted: 10/07/2014] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Overutilisation of antibiotics may contribute to the emergence of antimicrobial drug resistance, a growing international concern. This study aimed to analyse the performance of UK general practices with respect to antibiotic prescribing for respiratory tract infections (RTIs) among young and middle-aged adults. SETTING Data are reported for 568 UK general practices contributing to the Clinical Practice Research Datalink. PARTICIPANTS Participants were adults aged 18-59 years. Consultations were identified for acute upper RTIs including colds, cough, otitis-media, rhino-sinusitis and sore throat. PRIMARY AND SECONDARY OUTCOME MEASURES For each consultation, we identified whether an antibiotic was prescribed. The proportion of RTI consultations with antibiotics prescribed was estimated. RESULTS There were 568 general practices analysed. The median general practice prescribed antibiotics at 54% of RTI consultations. At the highest prescribing 10% of practices, antibiotics were prescribed at 69% of RTI consultations. At the lowest prescribing 10% of practices, antibiotics were prescribed at 39% RTI consultations. The median practice prescribed antibiotics at 38% of consultations for 'colds and upper RTIs', 48% for 'cough and bronchitis', 60% for 'sore throat', 60% for 'otitis-media' and 91% for 'rhino-sinusitis'. The highest prescribing 10% of practices issued antibiotic prescriptions at 72% of consultations for 'colds', 67% for 'cough', 78% for 'sore throat', 90% for 'otitis-media' and 100% for 'rhino-sinusitis'. CONCLUSIONS Most UK general practices prescribe antibiotics to young and middle-aged adults with respiratory infections at rates that are considerably in excess of what is clinically justified. This will fuel antibiotic resistance.
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Affiliation(s)
- Martin C Gulliford
- King's College London, Primary Care and Public Health Sciences, London, UK
| | - Alex Dregan
- King's College London, Primary Care and Public Health Sciences, London, UK
| | - Michael V Moore
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Mark Ashworth
- King's College London, Primary Care and Public Health Sciences, London, UK
| | - Tjeerd van Staa
- Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, UK
- Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, London, UK
| | - Gerard McCann
- Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Judith Charlton
- King's College London, Primary Care and Public Health Sciences, London, UK
| | - Lucy Yardley
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Paul Little
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Lisa McDermott
- King's College London, Primary Care and Public Health Sciences, London, UK
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Howell LP, MacDonald S, Jones J, Tancredi DJ, Melnikow J. Can automated alerts within computerized physician order entry improve compliance with laboratory practice guidelines for ordering Pap tests? J Pathol Inform 2014; 5:37. [PMID: 25337434 PMCID: PMC4204299 DOI: 10.4103/2153-3539.141994] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2014] [Accepted: 08/28/2014] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND The electronic health record (EHR) provides opportunity to improve health and enhance appropriate test utilization through decision support. Electronic alerts in the order entry system can guide test use. Few published reports have assessed the impact of automated alerts on compliance of Pap ordering with published screening guidelines. METHODS Programming rules for Pap test ordering were developed within the EHR (Epic, Madison, WI) of the University of California, Davis Health System using American College of Obstetrics and Gynecology's 2009 guidelines and implemented in primary care clinics in 2010. Alerts discouraged Pap orders in women <21 and >71 years and displayed when an order was initiated. Providers were not prevented from placing an order. Results were measured during four calendar periods: (1) pre-alert (baseline) (July 2010 to June 2011), (2) post alert (alerts on) (July 2011 to December 2011), (3) inadvertent alert turn-off ("glitch") (January 2012 to December 2012), (5) post-glitch (alerts re-instated) (1/2013-7/2013). Metrics used to measure alert impact were between time and period seasonally adjusted relative frequency ratios. RESULTS Alerts were most effective in the <21 year old age group. During the baseline period 2.7 Pap tests were order in patients less than age 21 for every 100 Paps in those 21-71 years of age. This relative frequency decreased to 1.7 in the post-alert period and 1.4 during the glitch, with an even greater decline to 0.8 post-glitch when alerts were reinstated. Less impact was observed in the >70 year old group where the baseline relative frequency was 2.4 and declined to 2.1 post-alert, remained stable at 2.0 during the glitch period, and declined again to 1.7 post-glitch when alerts were reinstated. This likely reflects inclusion of women with a history of abnormal Pap tests for whom continued Pap testing is indicated, as well as reluctance by providers and patients to accept discontinuation of Pap testing for women with a history of normal Pap results. In both age groups, decreases in ordering were greatest when the alerts were functioning, indicating that the alerts had an effect beyond the influences of the environment. CONCLUSIONS Discouraging alerts can impact ordering of Pap tests and improve compliance with established guidelines, thus avoiding unnecessary follow-up tests that can create potential patient harm and unnecessary expense. Alerts represent a potential model to address utilization of other lab tests. Longer study intervals are necessary to determine if provider compliance is maintained.
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Affiliation(s)
- Lydia Pleotis Howell
- Department of Pathology and Laboratory Medicine, University of California Davis Health System, Sacramento, California, United States
| | - Scott MacDonald
- Department of Internal Medicine, University of California Davis Health System, Sacramento, California, United States
| | - Jacqueline Jones
- Department of Clinical Information Systems/Knowledge Management, University of California Davis Health System, Sacramento, California, United States
| | - Daniel J Tancredi
- Department of Pediatrics, University of California Davis Health System, Sacramento, California, United States
| | - Joy Melnikow
- Department of Family and Community Medicine, University of California Davis Health System, Sacramento, California, United States
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11
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Williams T, van Staa T, Puri S, Eaton S. Recent advances in the utility and use of the General Practice Research Database as an example of a UK Primary Care Data resource. Ther Adv Drug Saf 2014; 3:89-99. [PMID: 25083228 DOI: 10.1177/2042098611435911] [Citation(s) in RCA: 242] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Since its inception in the mid-1980s, the General Practice Research Database (GPRD) has undergone many changes but remains the largest validated and most utilised primary care database in the UK. Its use in pharmacoepidemiology stretches back many years with now over 800 original research papers. Administered by the Medicines and Healthcare products Regulatory Agency since 2001, the last 5 years have seen a rebuild of the database processing system enhancing access to the data, and a concomitant push towards broadening the applications of the database. New methodologies including real-world harm-benefit assessment, pharmacogenetic studies and pragmatic randomised controlled trials within the database are being implemented. A substantive and unique linkage program (using a trusted third party) has enabled access to secondary care data and disease-specific registry data as well as socio-economic data and death registration data. The utility of anonymised free text accessed in a safe and appropriate manner is being explored using simple and more complex techniques such as natural language processing.
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Gulliford MC, van Staa T, Dregan A, McDermott L, McCann G, Ashworth M, Charlton J, Little P, Moore MV, Yardley L. Electronic health records for intervention research: a cluster randomized trial to reduce antibiotic prescribing in primary care (eCRT study). Ann Fam Med 2014; 12:344-51. [PMID: 25024243 PMCID: PMC4096472 DOI: 10.1370/afm.1659] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 03/04/2014] [Accepted: 03/29/2014] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This study aimed to implement a point-of-care cluster randomized trial using electronic health records. We evaluated the effectiveness of electronically delivered decision support tools at reducing antibiotic prescribing for respiratory tract infections in primary care. METHODS Family practices from England and Scotland participating in the Clinical Practice Research Datalink (CPRD) were included in the trial; 53 family practices were allocated to intervention and 51 practices were allocated to usual care. Patients aged 18 to 59 years consulting for respiratory tract infections were eligible. The intervention was through remotely installed, computer-delivered decision support tools accessed during the consultations. Control practices provided usual care. The primary outcome was the proportion of consultations for respiratory tract infections with an antibiotic prescribed based on electronic health records. Family practice-specific proportions were included in a cluster-level analysis. RESULTS Data were analyzed for 603,409 patients: 317,717 at intervention practices and 285,692 at control practices. Use of the intervention was less than anticipated, varying among practices. There was a reduction in proportion of consultations with antibiotics prescribed of 1.85% (95% CI, 0.10%-3.59%, P=.038) and in the rate of antibiotic prescribing for respiratory tract infections (9.69%; 95% CI, 0.75%-18.63%, fewer prescriptions per 1,000 patient-years, P=.034). There were no adverse events. CONCLUSIONS Cluster randomized trials may be implemented efficiently in large samples from routine care settings by using primary care electronic health records. Future studies should develop and test multicomponent methods for remotely delivered intervention.
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Affiliation(s)
- Martin C Gulliford
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Tjeerd van Staa
- Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, United Kingdom London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alex Dregan
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Lisa McDermott
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
| | - Gerard McCann
- Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, United Kingdom
| | - Mark Ashworth
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Judith Charlton
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Paul Little
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
| | - Michael V Moore
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
| | - Lucy Yardley
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
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13
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Gulliford MC, van Staa TP, McDermott L, McCann G, Charlton J, Dregan A. Cluster randomized trials utilizing primary care electronic health records: methodological issues in design, conduct, and analysis (eCRT Study). Trials 2014; 15:220. [PMID: 24919485 PMCID: PMC4062282 DOI: 10.1186/1745-6215-15-220] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/22/2014] [Indexed: 11/10/2022] Open
Abstract
Background There is growing interest in conducting clinical and cluster randomized trials through electronic health records. This paper reports on the methodological issues identified during the implementation of two cluster randomized trials using the electronic health records of the Clinical Practice Research Datalink (CPRD). Methods Two trials were completed in primary care: one aimed to reduce inappropriate antibiotic prescribing for acute respiratory infection; the other aimed to increase physician adherence with secondary prevention interventions after first stroke. The paper draws on documentary records and trial datasets to report on the methodological experience with respect to research ethics and research governance approval, general practice recruitment and allocation, sample size calculation and power, intervention implementation, and trial analysis. Results We obtained research governance approvals from more than 150 primary care organizations in England, Wales, and Scotland. There were 104 CPRD general practices recruited to the antibiotic trial and 106 to the stroke trial, with the target number of practices being recruited within six months. Interventions were installed into practice information systems remotely over the internet. The mean number of participants per practice was 5,588 in the antibiotic trial and 110 in the stroke trial, with the coefficient of variation of practice sizes being 0.53 and 0.56 respectively. Outcome measures showed substantial correlations between the 12 months before, and after intervention, with coefficients ranging from 0.42 for diastolic blood pressure to 0.91 for proportion of consultations with antibiotics prescribed, defining practice and participant eligibility for analysis requires careful consideration. Conclusions Cluster randomized trials may be performed efficiently in large samples from UK general practices using the electronic health records of a primary care database. The geographical dispersal of trial sites presents a difficulty for research governance approval and intervention implementation. Pretrial data analyses should inform trial design and analysis plans. Trial registration Current Controlled Trials ISRCTN 47558792 and ISRCTN 35701810 (both registered on 17 March 2010).
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Affiliation(s)
- Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, Capital House, 42 Weston St, London SE1 3QD, UK.
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14
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van Staa TP, Klungel O, Smeeth L. Use of electronic healthcare records in large-scale simple randomized trials at the point of care for the documentation of value-based medicine. J Intern Med 2014; 275:562-9. [PMID: 24635449 DOI: 10.1111/joim.12211] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A solid foundation of evidence of the effects of an intervention is a prerequisite of evidence-based medicine. The best source of such evidence is considered to be randomized trials, which are able to avoid confounding. However, they may not always estimate effectiveness in clinical practice. Databases that collate anonymized electronic health records (EHRs) from different clinical centres have been widely used for many years in observational studies. Randomized point-of-care trials have been initiated recently to recruit and follow patients using the data from EHR databases. In this review, we describe how EHR databases can be used for conducting large-scale simple trials and discuss the advantages and disadvantages of their use.
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Affiliation(s)
- T-P van Staa
- Utrecht Institute for Pharmaceutical Sciences, Utrecht University, Utrecht, the Netherlands; London School of Hygiene and Tropical Medicine, London, UK
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Wolfe CDA, Rudd AG, McKevitt C. Modelling, evaluating and implementing cost-effective services to reduce the impact of stroke. PROGRAMME GRANTS FOR APPLIED RESEARCH 2014. [DOI: 10.3310/pgfar02020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BackgroundStroke is a leading cause of death and disability but there is little information on the longer-term needs of patients and those of different ethnic groups.ObjectivesTo estimate risk of stroke, longer-term needs and outcomes, risk of recurrence, trends and predictors of effective care, to model cost-effective configurations of care, to understand stakeholders’ perspectives of services and to develop proposals to underpin policy.DesignPopulation-based stroke register, univariate and multivariate analyses, Markov and discrete event simulation, and qualitative methods for stakeholder perspectives of care and outcome.SettingSouth London, UK, with modelling for estimates of cost-effectiveness.ParticipantsInner-city population of 271,817 with first stroke in lifetime between 1995 and 2012.Outcome measuresStroke incidence rates and trends, recurrence, survival, activities of daily living, anxiety, depression, quality of life, appropriateness and cost-effectiveness of care, and qualitative narratives of perspectives.Data sourcesSouth London Stroke Register (SLSR), qualitative data, group discussions.ResultsStroke incidence has decreased since 1995, particularly in the white population, but with a higher stroke risk in black groups. There are variations in risk factors and types of stroke between ethnic groups and a large number of strokes occurred in people with untreated risk factors with no improvement in detection observed over time. A total of 30% of survivors have a poor range of outcomes up to 10 years after stroke with differences in outcomes by sociodemographic group. Depression affects over half of all stroke patients and the prevalence of cognitive impairment remains 22%. Survival has improved significantly, particularly in the older black groups, and the cumulative risk of recurrence at 10 years is 24.5%. The proportion of patients receiving effective acute stroke care has significantly improved, yet inequalities of provision remain. Using register data, the National Audit Office (NAO) compared the levels of stroke care in the UK in 2010 with previous provision levels and demonstrated that improvements have been cost-effective. The treatment of, and productivity loss arising from, stroke results in total societal costs of £8.9B a year and 5% of UK NHS costs. Stroke unit care followed by early supported discharge is a cost-effective strategy, with the main gain being years of life saved. Half of stroke survivors report unmet long-term needs. Needs change over time, but may not be stroke specific. Analysis of patient journeys suggests that provision of care is also influenced by structural, social and personal characteristics.Conclusions/recommendationsThe SLSR has been a platform for a range of health services research activities of international relevance. The programme has produced data to inform policy and practice with estimates of need for stroke prevention and care services, identification of persistent sociodemographic inequalities in risk and care despite a reduction in stroke risk, quantification of the effectiveness and cost-effectiveness of care and development of models to simulate configurations of care. Stroke is a long-term condition with significant social impact and the data on need and economic modelling have been utilised by the Department of Health, the NAO and Healthcare for London to assess need and model cost-effective options for stroke care. Novel approaches are now required to ensure that such information is used effectively to improve population and patient outcomes.FundingThe National Institute for Health Research Programme Grants for Applied Research programme and the Department of Health via the National Institute for Health Research Biomedical Research Centre award to Guy’s and St Thomas’ NHS Foundation Trust in partnership with King’s College London.
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Affiliation(s)
- Charles DA Wolfe
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, School of Medicine, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
| | - Anthony G Rudd
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, School of Medicine, King’s College London, London, UK
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Christopher McKevitt
- Department of Primary Care and Public Health Sciences, Division of Health and Social Care Research, School of Medicine, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust and King’s College London, London, UK
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Affiliation(s)
- Sara Muller
- Research Institute for Primary Care & Health Sciences, Keele University, Keele, UK
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17
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Abstract
BACKGROUND The benefits and risks of antibiotics for acute bronchitis remain unclear despite it being one of the most common illnesses seen in primary care. OBJECTIVES To assess the effects of antibiotics in improving outcomes and assess adverse effects of antibiotic therapy for patients with a clinical diagnosis of acute bronchitis. SEARCH METHODS We searched CENTRAL 2013, Issue 12, MEDLINE (1966 to January week 1, 2014), EMBASE (1974 to January 2014) and LILACS (1982 to January 2014). SELECTION CRITERIA Randomised controlled trials (RCTs) comparing any antibiotic therapy with placebo or no treatment in acute bronchitis or acute productive cough, in patients without underlying pulmonary disease. DATA COLLECTION AND ANALYSIS At least two review authors extracted data and assessed trial quality. MAIN RESULTS Seventeen trials with 3936 participants were included in the primary analysis. The quality of trials was generally good. There was limited evidence to support the use of antibiotics in acute bronchitis. At follow-up, there was no difference in participants described as being clinically improved between antibiotic and placebo groups (11 studies with 3841 participants, risk ratio (RR) 1.07, 95% confidence interval (CI) 0.99 to 1.15; number needed to treat for an additional beneficial outcome (NNTB) 22. Participants given antibiotics were less likely to have a cough (four studies with 275 participants, RR 0.64, 95% CI 0.49 to 0.85; NNTB 6); have a night cough (four studies with 538 participants, RR 0.67, 95% CI 0.54 to 0.83; NNTB 7) and a shorter mean cough duration (seven studies with 2776 participants, mean difference (MD) -0.46 days, 95% CI -0.87 to -0.04). The differences in presence of a productive cough at follow-up and MD of productive cough did not reach statistical significance.Antibiotic-treated patients were more likely to be unimproved according to clinician's global assessment (six studies with 891 participants, RR 0.61, 95% CI 0.48 to 0.79; NNTB 25); have an abnormal lung exam (five studies with 613 participants, RR 0.54, 95% CI 0.41 to 0.70; NNTB 6); have a reduction in days feeling ill (five studies with 809 participants, MD -0.64 days, 95% CI -1.16 to -0.13) and a reduction in days with limited activity (six studies with 767 participants MD -0.49 days, 95% CI -0.94 to -0.04). The differences in proportions with activity limitations at follow-up did not reach statistical significance. There was a significant trend towards an increase in adverse effects in the antibiotic group (12 studies with 3496 participants) (RR 1.20, 95% CI 1.05 to 1.36; NNT for an additional adverse effect 5). AUTHORS' CONCLUSIONS There is limited evidence to support the use of antibiotics in acute bronchitis. Antibiotics may have a modest beneficial effect in some patients such as frail, elderly people with multimorbidity who may not have been included in trials to date. However, the magnitude of this benefit needs to be considered in the broader context of potential side effects, medicalisation for a self-limiting condition, increased resistance to respiratory pathogens and cost of antibiotic treatment.
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Affiliation(s)
- Susan M Smith
- Department of General Practice, Royal College of Surgeons, Beaux Lane House, Mercer St, Dublin, Ireland, 2
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Gordon CL, Pouch S, Cowell LG, Boland MR, Platt HL, Goldfain A, Weng C. Design and evaluation of a bacterial clinical infectious diseases ontology. AMIA ... ANNUAL SYMPOSIUM PROCEEDINGS. AMIA SYMPOSIUM 2013; 2013:502-511. [PMID: 24551353 PMCID: PMC3900194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
With antimicrobial resistance increasing worldwide, there is a great need to use automated antimicrobial decision support systems (ADSSs) to lower antimicrobial resistance rates by promoting appropriate antimicrobial use. However, they are infrequently used mostly because of their poor interoperability with different health information technologies. Ontologies can augment portable ADSSs by providing an explicit knowledge representation for biomedical entities and their relationships, helping to standardize and integrate heterogeneous data resources. We developed a bacterial clinical infectious diseases ontology (BCIDO) using Protégé-OWL. BCIDO defines a controlled terminology for clinical infectious diseases along with domain knowledge commonly used in hospital settings for clinical infectious disease treatment decision-making. BCIDO has 599 classes and 2355 object properties. Terms were imported from or mapped to Systematized Nomenclature of Medicine, Unified Medical Language System, RxNorm and National Center for Bitechnology Information Organismal Classification where possible. Domain expert evaluation using the "laddering" technique, ontology visualization, and clinical notes and scenarios, confirmed the correctness and potential usefulness of BCIDO.
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Affiliation(s)
- Claire L Gordon
- Department of Biomedical Informatics, Columbia University, New York ; Division of Infectious Diseases, Department of Medicine, Columbia University, New York ; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Stephanie Pouch
- Division of Infectious Diseases, Department of Medicine, Columbia University, New York
| | - Lindsay G Cowell
- Department of Clinical Sciences, University of Texas Southwestern Medical Center, Dallas
| | | | - Heather L Platt
- Division of Infectious Diseases, Department of Medicine, Columbia University, New York
| | | | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, New York
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Horspool MJ, Julious SA, Boote J, Bradburn MJ, Cooper CL, Davis S, Elphick H, Norman P, Smithson WH, vanStaa T. Preventing and lessening exacerbations of asthma in school-age children associated with a new term (PLEASANT): study protocol for a cluster randomised control trial. Trials 2013; 14:297. [PMID: 24041259 PMCID: PMC4016495 DOI: 10.1186/1745-6215-14-297] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2013] [Accepted: 09/04/2013] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND Within the UK, during September, there is a pronounced increase in the number of unscheduled medical contacts by school-aged children (4-16 years) with asthma. It is thought that that this might be caused by the return back to school after the summer holidays, suddenly mixing with other children again and picking up viruses which could affect their asthma. There is also a drop in the number of prescriptions administered in August. It is possible therefore that children might not be taking their medication as they should during the summer contributing to them becoming ill when they return to school.It is hoped that a simple intervention from the GP to parents of children with asthma at the start of the summer holiday period, highlighting the importance of maintaining asthma medication can help prevent increased asthma exacerbation, and unscheduled NHS appointments, following return to school in September. METHODS/DESIGN PLEASANT is a cluster randomised trial. A total of 140 General Practices (GPs) will be recruited into the trial; 70 GPs randomised to the intervention and 70 control practices of "usual care". An average practice is expected to have approximately 100 children (aged 4-16 with a diagnosis of asthma) hence observational data will be collected on around 14000 children over a 24-month period. The Clinical Practice Research Datalink will collect all data required for the study which includes diagnostic, prescription and referral data. DISCUSSION The trial will assess whether the intervention can reduce exacerbation of asthma and unscheduled medical contacts in school-aged children associated with the return to school after the summer holidays. It has the potential to benefit the health and quality of life of children with asthma while also improving the effectiveness of NHS services by reducing NHS use in one of the busiest months of the year.An exploratory health economic analysis will gauge any cost saving associated with the intervention and subsequent impacts on quality of life. If results for the intervention are positive it is hoped that this could be adopted as part of routine care management of childhood asthma in general practice. TRIAL REGISTRATION Current controlled trials: ISRCTN03000938 (assigned 19/10/12) http://www.controlled-trials.com/ISRCTN03000938/. UKCRN ID 13572.
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Affiliation(s)
- Michelle J Horspool
- Clinical Trials Research Unit, University of Sheffield, School of Health and Related Research, 30 Regent Street, Sheffield S1 4DA, UK
| | - Steven A Julious
- Medical Statistics Group, University of Sheffield, School of Health and Related Research, 30 Regent Street, Sheffield S1 4DA, UK
| | - Jonathan Boote
- Design, Trials and Statistics, University of Sheffield, School of Health and Related Research, 30 Regent Street, Sheffield S1 4DA, UK
| | - Mike J Bradburn
- Clinical Trials Research Unit, University of Sheffield, School of Health and Related Research, 30 Regent Street, Sheffield S1 4DA, UK
| | - Cindy L Cooper
- Clinical Trials Research Unit, University of Sheffield, School of Health and Related Research, 30 Regent Street, Sheffield S1 4DA, UK
| | - Sarah Davis
- Health Economics and Decision Science, University of Sheffield, School of Health and Related Research, 30 Regent Street, Sheffield S1 4DA, UK
| | - Heather Elphick
- Department of Paediatric Respiratory Medicine, Sheffield Children’s Hospital, Western Bank, Sheffield S10 2TH, UK
| | - Paul Norman
- Department of Psychology, University of Sheffield, Western Bank, Sheffield S10 2TP, UK
| | - W Henry Smithson
- Academic Unit of Primary Medical Care, University of Sheffield, Samuel Fox House, Northern General Hospital, Herries Road, Sheffield S5 7AU, UK
| | - Tjeerd vanStaa
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, 5th Floor, 151 Buckingham Palace Road, Victoria, London SW1W 9SZ, UK
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Herrett E, Shah AD, Boggon R, Denaxas S, Smeeth L, van Staa T, Timmis A, Hemingway H. Completeness and diagnostic validity of recording acute myocardial infarction events in primary care, hospital care, disease registry, and national mortality records: cohort study. BMJ 2013; 346:f2350. [PMID: 23692896 PMCID: PMC3898411 DOI: 10.1136/bmj.f2350] [Citation(s) in RCA: 264] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/26/2013] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To determine the completeness and diagnostic validity of myocardial infarction recording across four national health record sources in primary care, hospital care, a disease registry, and mortality register. DESIGN Cohort study. PARTICIPANTS 21 482 patients with acute myocardial infarction in England between January 2003 and March 2009, identified in four prospectively collected, linked electronic health record sources: Clinical Practice Research Datalink (primary care data), Hospital Episode Statistics (hospital admissions), the disease registry MINAP (Myocardial Ischaemia National Audit Project), and the Office for National Statistics mortality register (cause specific mortality data). SETTING One country (England) with one health system (the National Health Service). MAIN OUTCOME MEASURES Recording of acute myocardial infarction, incidence, all cause mortality within one year of acute myocardial infarction, and diagnostic validity of acute myocardial infarction compared with electrocardiographic and troponin findings in the disease registry (gold standard). RESULTS Risk factors and non-cardiovascular coexisting conditions were similar across patients identified in primary care, hospital admission, and registry sources. Immediate all cause mortality was highest among patients with acute myocardial infarction recorded in primary care, which (unlike hospital admission and disease registry sources) included patients who did not reach hospital, but at one year mortality rates in cohorts from each source were similar. 5561 (31.0%) patients with non-fatal acute myocardial infarction were recorded in all three sources and 11 482 (63.9%) in at least two sources. The crude incidence of acute myocardial infarction was underestimated by 25-50% using one source compared with using all three sources. Compared with acute myocardial infarction defined in the disease registry, the positive predictive value of acute myocardial infarction recorded in primary care was 92.2% (95% confidence interval 91.6% to 92.8%) and in hospital admissions was 91.5% (90.8% to 92.1%). CONCLUSION Each data source missed a substantial proportion (25-50%) of myocardial infarction events. Failure to use linked electronic health records from primary care, hospital care, disease registry, and death certificates may lead to biased estimates of the incidence and outcome of myocardial infarction. TRIAL REGISTRATION NCT01569139 clinicaltrials.gov.
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Affiliation(s)
- Emily Herrett
- London School of Hygiene and Tropical Medicine, London WC1E 7HT, UK.
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Dregan A, van Staa T, McDermott L, McCann G, Ashworth M, Charlton J, Wolfe C, Rudd A, Yardley L, Gulliford M. Cluster randomized trial in the general practice research database: 2. Secondary prevention after first stroke (eCRT study): study protocol for a randomized controlled trial. Trials 2012; 13:181. [PMID: 23034059 PMCID: PMC3570277 DOI: 10.1186/1745-6215-13-181] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 09/26/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this research is to develop and evaluate methods for conducting pragmatic cluster randomized trials in a primary care electronic database. The proposal describes one application, in a less frequent chronic condition of public health importance, secondary prevention of stroke. A related protocol in antibiotic prescribing was reported previously. METHODS/DESIGN The study aims to implement a cluster randomized trial (CRT) using the electronic patient records of the General Practice Research Database (GPRD) as a sampling frame and data source. The specific objective of the trial is to evaluate the effectiveness of a computer-delivered intervention at enhancing the delivery of stroke secondary prevention in primary care. GPRD family practices will be allocated to the intervention or usual care. The intervention promotes the use of electronic prompts to support adherence with the recommendations of the UK Intercollegiate Stroke Working Party and NICE guidelines for the secondary prevention of stroke in primary care. Primary outcome measure will be the difference in systolic blood pressure between intervention and control trial arms at 12-month follow-up. Secondary outcomes will be differences in serum cholesterol, prescribing of antihypertensive drugs, statins, and antiplatelet therapy. The intervention will continue for 12 months. Information on the utilization of the decision-support tools will also be analyzed. DISCUSSION The CRT will investigate the effectiveness of using a computer-delivered intervention to reduce the risk of stroke recurrence following a first stroke event. The study will provide methodological guidance on the implementation of CRTs in electronic databases in primary care. TRIAL REGISTRATION Current Controlled Trials ISRCTN35701810.
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Affiliation(s)
- Alex Dregan
- Department of Primary Care and Public Health Sciences, King's College, London, UK.
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Zipkin DA, Greenblatt L, Kushinka JT. Evidence-Based Medicine and Primary Care: Keeping Up Is Hard to Do. ACTA ACUST UNITED AC 2012; 79:545-54. [DOI: 10.1002/msj.21337] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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Staa TPV, Goldacre B, Gulliford M, Cassell J, Pirmohamed M, Taweel A, Delaney B, Smeeth L. Pragmatic randomised trials using routine electronic health records: putting them to the test. BMJ 2012; 344:e55. [PMID: 22315246 PMCID: PMC3934788 DOI: 10.1136/bmj.e55] [Citation(s) in RCA: 121] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/23/2011] [Indexed: 11/28/2022]
Affiliation(s)
- Tjeerd-Pieter van Staa
- General Practice Research Database, Medicines and Healthcare products Regulatory Agency, 151 Buckingham Palace Road, London SW1W 9SZ, UK.
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Abstract
BACKGROUND Antibiotic treatment of acute bronchitis, which is one of the most common illnesses seen in primary care, is controversial. Most clinicians prescribe antibiotics in spite of expert recommendations against this practice. OBJECTIVES The objective of this review was to assess the effects of antibiotic treatment for patients with a clinical diagnosis of acute bronchitis. SEARCH STRATEGY In this updated review, we searched the Cochrane Central Register of Controlled trials (CENTRAL) (The Cochrane Library Issue 2, 2004); MEDLINE (January 1966 to March 2004); EMBASE (January 2000 to December 2003); SciSearch from 1989 to 2004; reference lists of articles and the authors' personal collections up to 1996, and also wrote to study authors and drug manufacturers. EMBASE has previously been searched from 1974 to 2000). SELECTION CRITERIA Randomised controlled trials comparing any antibiotic therapy with placebo in acute bronchitis or acute productive cough without other obvious cause in patients without underlying pulmonary disease. DATA COLLECTION AND ANALYSIS At least two reviewers extracted data and assessed trial quality. Authors were contacted for missing data. MAIN RESULTS Nine trials involving over 750 patients aged eight to over 65 and including smokers and non-smokers were included in the primary analysis. The quality of the trials was variable. A variety of outcome measures were assessed. Overall, patients receiving antibiotics had better outcomes than did those receiving placebo. At a follow-up visit, they were less likely to have a cough (relative risk (RR) 0.64, 95% confidence interval (CI) 0.49 to 0.85; number-needed-to-treat (NNT) 5; 95% CI 3 to 14), show no improvement on physician assessment (RR 0.52; 95% CI 0.31 to 0.87; NNT 14; 95% CI 8 to 50), or have abnormal lung findings (RR 0.48; 95% CI 0.26 to 0.89; NNT 11; 95% CI 6 to 50); and had shorter durations of cough (weighted mean difference 0.58 days; 95% CI 0.01 to 1.16 days), productive cough (weighted mean difference (WMD) 0.52 days; 95% CI 0.01 to 1.03 days), and feeling ill (WMD 0.58 days; 95% CI 0.00 to 1.16 days). There were no significant differences regarding the presence of night cough, productive cough, or activity limitations at follow up, or in the mean duration of activity limitations. The benefits of antibiotics were less apparent in a sensitivity analysis that included data from two other studies of patients with upper respiratory tract infections with productive cough. There was a non significant trend towards an increase in adverse effects in the antibiotic group, relative risk (RR) 1.22 (95% CI 0.94 to 1.58). REVIEWERS' CONCLUSIONS Overall, antibiotics appear to have a modest beneficial effect in patients who are diagnosed with acute bronchitis. The magnitude of this benefit, however, is similar to that of the detriment from potential adverse effects.
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