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Dhanda A, Andrade J, Allende H, Allgar V, Bailey M, Callaghan L, Cocking L, Goodwin E, Hawton A, Hayward C, Hudson B, Ingram W, Jeffery A, King A, Lavers V, Lomax J, McCune CA, Musicha C, Parker R, Rollinson C, Wilks J, Creanor ES. Mental Imagery to Reduce Alcohol-related harm in patients with alcohol use disorder and alcohol-related liver damaGE: the MIRAGE randomised pilot trial results. BMJ Open Gastroenterol 2024; 11:e001267. [PMID: 38286518 PMCID: PMC10870787 DOI: 10.1136/bmjgast-2023-001267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/04/2024] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE The healthcare burden of alcohol-related liver disease (ARLD) is increasing. ARLD and alcohol use disorder (AUD) is best managed by reduction or cessation of alcohol use, but effective treatments are lacking. We tested whether people with ARLD and AUD admitted to hospital could be recruited to and retained in a trial of Functional Imagery Training (FIT), a psychological therapy that uses mental imagery to reduce alcohol craving. We conducted a multicentre randomised pilot trial of treatment as usual (TAU) versus FIT+TAU in people admitted to hospital with ARLD and AUD. DESIGN Participants were randomised to TAU (a single session of brief intervention) or FIT+TAU (TAU with one hospital-based FIT session then eight telephone sessions over 6 months). Pilot outcomes included recruitment rate and retention at day 180. Secondary outcomes included fidelity of FIT delivery, alcohol use, and severity of alcohol dependence. RESULTS Fifty-four participants (mean age 49; 63% male) were recruited and randomised, 28 to TAU and 26 to FIT+TAU. The retention rate at day 180 was 43%. FIT was delivered adequately by most alcohol nurses. 50% of intervention participants completed FIT sessions 1 and 2. There were no differences in alcohol use or severity of alcohol dependence between treatment groups at day 180. CONCLUSION Participants with ARLD and AUD could be recruited to a trial of FIT versus FIT+TAU. However, retention at day 180 was suboptimal. Before conducting a definitive trial of FIT in this patient group, modifications in the intervention and recruitment/retention strategy must be tested. TRIAL REGISTRATION NUMBER ISRCTN41353774.
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Affiliation(s)
- Ashwin Dhanda
- Faculty of Health, University of Plymouth, Plymouth, UK
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | - Hannah Allende
- Research, Development and Innovation, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | | | | | | | - Laura Cocking
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Annie Hawton
- Medical School, University of Exeter, Exeter, UK
| | | | - Ben Hudson
- Royal Devon University Hospital Foundation NHS Trust, Exeter, UK
| | - Wendy Ingram
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Angela King
- Faculty of Health, University of Plymouth, Plymouth, UK
| | | | - Joe Lomax
- Faculty of Health, University of Plymouth, Plymouth, UK
| | - C Anne McCune
- Department of Liver Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | | | - Richard Parker
- Leeds Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher Rollinson
- Research, Development and Innovation, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jonny Wilks
- Faculty of Health, University of Plymouth, Plymouth, UK
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Stevens KN, Creanor S, Jeffery A, Whone A, Zajicek J, Foggo A, Jones B, Chapman R, Cocking L, Wilks J, Webb D, Carroll C, Inches J, Underwood D, Frost J, James A, Schofield C, James R, O’Reilly C, Sheridan R, Statton S, Goff A, Russell T, Whitcher A, Craw S, Lewis A, Sophia R, Amar K, Hernandez R, Pitcher A, Carvey S, Hamlin R, Lyell V, Aubry L, Carey G, Coebergh J, Mojela I, Molloy S, Berceruelo Bergaz Y, Camera B, Campbell P, Morris H, Samakomva T, Schrag A, Fuller S, Misbahuddin A, Parker L, Visentin E, Gallehawk S, Rudd J, Singh S, Wilson S, Creven J, Croucher Y, Tluk S, Watts P, Hargreaves S, Johnson D, Worboys L, Worth P, Brooke J, Kobylecki C, Parker V, Johnson L, Joseph R, Melville J, Raw J, Birt J, Hare M, Shaik S, Alty J, Cosgrove J, Burn D, Green A, McNichol A, Pavese N, Pilkington H, Price M, Walker K, Chaudhuri R, Podlewska A, Reddy P, Trivedi D, Bandmann O, Clegg R, Cole G, Emery A, Dostal V, Graham J, Keshet-Price J, Mamutse G, Miller-Fik A, Wiltshire A, Wright C, Dixon K, Abdelhafiz A, Rose J. Evaluation of Simvastatin as a Disease-Modifying Treatment for Patients With Parkinson Disease: A Randomized Clinical Trial. JAMA Neurol 2022; 79:1232-1241. [PMID: 36315128 PMCID: PMC9623477 DOI: 10.1001/jamaneurol.2022.3718] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Importance Current treatments manage symptoms of Parkinson disease (PD), but no known treatment slows disease progression. Preclinical and epidemiological studies support the potential use of statins as disease-modifying therapy. Objective To determine whether simvastatin has potential as a disease-modifying treatment for patients with moderate PD. Design, Setting, and Participants This randomized clinical trial, a double-blind, parallel-group, placebo-controlled futility trial, was conducted between March 2016 and May 2020 within 23 National Health Service Trusts in England. Participants aged 40 to 90 years with a diagnosis of idiopathic PD, with a modified Hoehn and Yahr stage of 3.0 or less while taking medication, and taking dopaminergic medication with wearing-off phenomenon were included. Data were analyzed from May 2020 to September 2020, with additional analysis in February 2021. Interventions Participants were allocated 1:1 to simvastatin or matched placebo via a computer-generated random sequence, stratified by site and Hoehn and Yahr stage. In the simvastatin arm, participants entered a 1-month phase of simvastatin, 40 mg daily, followed by 23 months of simvastatin, 80 mg daily, before a 2-month washout period. Main Outcomes and Measures The prespecified primary outcome was 24-month change in Movement Disorder Society Unified Parkinson Disease Rating Scale (MDS-UPDRS) part III score measured while not taking medication (high scores indicate worse outcome). The primary futility analysis included participants who commenced the 80-mg phase and had valid primary outcome data. The safety analysis included all participants who commenced trial treatment and is reported by dose at time of event. Results Of 332 patients assessed for eligibility, 32 declined and 65 were ineligible. Of 235 recruited participants, 97 (41%) were female, 233 (99%) were White, and the mean (SD) age was 65.4 (9.4) years. A total of 216 patients progressed to the 80-mg dose. Primary outcome analysis (n = 178) indicated the simvastatin group had an additional deterioration in MDS-UPDRS III score while not taking medication at 24 months compared with the placebo group (1.52 points; 2-sided 80% CI, -0.77 to 3.80; 1-sided futility test P = .006). A total of 37 serious adverse events (AEs), including 3 deaths, and 171 AEs were reported for participants receiving 0-mg simvastatin; 37 serious AEs and 150 AEs were reported for participants taking 40 mg or 80 mg of simvastatin. Four participants withdrew from the trial because of an AE. Conclusions and Relevance In this randomized clinical trial, simvastatin was futile as a disease-modifying therapy in patients with PD of moderate severity, providing no evidence to support proceeding to a phase 3 trial. Trial Registration ISRCTN Identifier: 16108482.
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Affiliation(s)
- Kara N. Stevens
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom,Exploristics Ltd, Belfast, United Kingdom
| | - Siobhan Creanor
- College of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Alison Jeffery
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Alan Whone
- Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - John Zajicek
- School of Medicine, Medical and Biological Sciences, University of St Andrews, St Andrews, United Kingdom
| | - Andy Foggo
- School of Biological and Marine Sciences, Faculty of Science and Engineering, University of Plymouth, Plymouth, United Kingdom
| | - Ben Jones
- College of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Rebecca Chapman
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Laura Cocking
- NIHR BioResource, University of Cambridge, Cambridge, United Kingdom
| | - Jonny Wilks
- MAC Clinical Research, Blackpool, United Kingdom
| | - Doug Webb
- Bristol Trials Centre, University of Bristol, Bristol, United Kingdom
| | - Camille Carroll
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
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Kehagia AA, North TK, Grose J, Jeffery AN, Cocking L, Chapman R, Carroll C. Enhancing Trial Delivery in Parkinson’s Disease: Qualitative Insights from PD STAT. JPD 2022; 12:1591-1604. [PMID: 35466952 PMCID: PMC9398073 DOI: 10.3233/jpd-212987] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background: Recruitment and retention of participants in clinical trials for Parkinson’s disease (PD) is challenging. A qualitative study embedded in the PD STAT multi-centre randomised controlled trial of simvastatin for neuroprotection in PD explored the motivators, barriers and challenges of participants, care partners and research staff. Objective: To outline a set of considerations informing a patient-centred approach to trial recruitment, retention, and delivery. Method: We performed semi-structured interviews and focus groups with a subset of trial participants and their care partners. Quantitative and qualitative data were obtained through surveys circulated among the 235 participants across 23 UK sites at the beginning, middle and end of the 2-year trial. We also interviewed and surveyed research staff at trial closure. Results: Twenty-seven people with PD, 6 care partners and 9 researchers participated in interviews and focus groups. A total of 463 trial participant survey datasets were obtained across three timepoints, and 53 staff survey datasets at trial closure. Trial participants discussed the physical and psychological challenges they faced, especially in the context of OFF state assessments, relationships, and communication with research staff. Care partners shared their insights into OFF state challenges, and the value of being heard by research teams. Research staff echoed many concerns with suggestions on flexible, person-centred approaches to maximising convenience, comfort, and privacy. Conclusion: These considerations, in favour of person-centred research protocols informed by the variable needs of participants, care partners and staff, could be developed into a set of recommendations for future trials.
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Affiliation(s)
- Angie A. Kehagia
- University College Hospital, University London Hospitals NHS Trust, London, UK
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
| | - Tracie K. North
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
| | - Jane Grose
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
| | | | - Laura Cocking
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
| | - Rebecca Chapman
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
| | - Camille Carroll
- University of Plymouth, Faculty of Health, Plymouth, Devon, UK
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Rapson R, Marsden J, Latour J, Ingram W, Stevens KN, Cocking L, Carter B. Multicentre, randomised controlled feasibility study to compare a 10-week physiotherapy programme using an interactive exercise training device to improve walking and balance, to usual care of children with cerebral palsy aged 4-18 years: the ACCEPT study protocol. BMJ Open 2022; 12:e058916. [PMID: 35636794 PMCID: PMC9152930 DOI: 10.1136/bmjopen-2021-058916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Children with cerebral palsy (CP) frequently undertake physiotherapy programmes to improve walking and balance. They often require adult support to exercise in a functional position. A novel interactive exercise trainer has been devised to enable children to exercise with against resistance in a functional position, but its efficacy has yet to be proved. A novel protocol has been developed to determine whether a randomised controlled trial (RCT) is feasible. AIM To establish whether it is feasible to conduct an RCT to assess the effectiveness of a 10-week physiotherapy intervention using an interactive trainer in children with CP. METHODS AND ANALYSIS This study is multicentre randomised controlled feasibility trial with an embedded qualitative study. Forty children with CP, Gross Motor Function Classification System (GMFCS) I-III will be recruited from community paediatric physiotherapy caseloads. Participants will be randomised to 10 weeks of training with the interactive training device or to usual physiotherapy care. The mediolateral motion of the centre of mass estimate and Paediatric Balance Scale will be explored as potential primary outcomes measures, tested at baseline, 10 weeks and follow-up at 20 weeks. The views of child participants, their parents and physiotherapists will be gained through e-diaries and qualitative interviews.Feasibility will be determined by examining recruitment and retention rates, completeness of, adherence to the intervention, appropriateness of outcome measures and effectiveness of blinding. Results will be reported in accordance to Consolidated Standards of Reporting Trials (CONSORT) guidelines. ETHICS AND DISSEMINATION Physiotherapists, children and parents have informed trial design and information leaflets. Results will be disseminated via publications, conferences and to families. This study has approval from North of Scotland Research Ethics Committee (20/NS/0018). TRIAL REGISTRATION NUMBER ISRCTN80878394.
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Affiliation(s)
- Rachel Rapson
- Physiotherapy, Children and Family Health Devon, Torbay and South Devon National Health Service Foundation Trust, Torquay, UK
- Faculty of Health and human Sciences, University of Plymouth, Plymouth, UK
| | - Jonathan Marsden
- University of Plymouth Faculty of Health and Human Sciences, Plymouth, UK
| | - Jos Latour
- University of Plymouth School of Nursing and Midwifery, Plymouth, UK
| | - Wendy Ingram
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | - Laura Cocking
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), University of Plymouth, Plymouth, UK
| | - Bernie Carter
- Faculty of Health and Social Care, Edge Hill University, Ormskirk, UK
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Dhanda AD, Allende H, Allgar V, Andrade J, Bailey MP, Callaghan L, Cocking L, Goodwin E, Hawton A, Hayward C, Hudson B, Jeffery A, King A, Lavers V, Lomax J, McCune CA, Parker R, Rollinson C, Wilks J, Creanor ES. Mental Imagery to Reduce Alcohol-related harm in patients with alcohol dependence and alcohol-related liver damaGE: the MIRAGE pilot trial protocol. BMJ Open 2022; 12:e060498. [PMID: 35584873 PMCID: PMC9119183 DOI: 10.1136/bmjopen-2021-060498] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION In the UK, alcohol use is the main driver of chronic liver disease and each year results in over 1 million unplanned hospital admissions and over 25 000 deaths from alcohol-related liver disease (ArLD). The only effective treatment to prevent progression of liver damage is reducing or ceasing alcohol consumption. Psychological and pharmacological therapies for alcohol misuse are ineffective in patients with ArLD. Functional imagery training (FIT) is a novel psychological therapy that builds on motivational interviewing techniques with multisensory imagery. This pilot trial aims to test the feasibility of training alcohol liaison nurses to deliver FIT therapy and of recruiting and retaining patients with ArLD and alcohol dependence to a randomised trial of FIT and treatment as usual (TAU) versus TAU alone. METHODS AND ANALYSIS This is a randomised pilot trial of FIT and TAU versus TAU alone in 90 patients with ArLD and alcohol dependence admitted to one of four UK centres. The primary objectives are to estimate rates of screening, recruitment, randomisation, retention, adherence to FIT/TAU and a preliminary assessment of the FIT intervention in the ArLD population. Data from the pilot study will be used to finalise the design of a definitive randomised controlled trial to assess the effectiveness and cost-effectiveness of FIT. The proposed primary outcome measure for the definitive trial is self-reported alcohol use assessed using timeline follow-back. ETHICS AND DISSEMINATION Research ethics approval was given by the Yorkshire and Humber-Bradford Leeds Research Ethics Committee (reference: 21/YH/0044). Eligible patients will be approached and written informed consent obtained prior to participation. Results will be disseminated through peer-reviewed open access journals, international conferences and a lay summary published on the Trials Unit website and made available to patient groups. TRIAL REGISTRATION NUMBER ISRCTN41353774.
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Affiliation(s)
- Ashwin D Dhanda
- South West Liver Unit, University Hospitals Plymouth NHS Trust, Plymouth, UK
- Peninsula Medical School, University of Plymouth, Plymouth, UK
| | - Hannah Allende
- Research, Development and Innovation, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Victoria Allgar
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - Jackie Andrade
- School of Psychology, University of Plymouth, Plymouth, UK
| | | | - Lynne Callaghan
- NIHR Peninsula ARC (PenARC), Peninsula Medical School, Plymouth, UK
| | - Laura Cocking
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - Elizabeth Goodwin
- Health Economics Group, University of Exeter Medical School, Exeter, UK
| | - Annie Hawton
- Health Economics Group, University of Exeter Medical School, Exeter, UK
| | | | - Ben Hudson
- Department of Hepatology, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Alison Jeffery
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - Angela King
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | | | - Joe Lomax
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - C Anne McCune
- Department of Liver Medicine, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Richard Parker
- Liver Unit, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher Rollinson
- Research, Development and Innovation, University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Jonny Wilks
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
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Rockett M, Creanor S, Squire R, Barton A, Benger J, Cocking L, Ewings P, Eyre V, Smith JE. The impact of emergency department patient-controlled analgesia (PCA) on the incidence of chronic pain following trauma and non-traumatic abdominal pain. Anaesthesia 2018; 74:69-73. [PMID: 30367688 PMCID: PMC6587467 DOI: 10.1111/anae.14476] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/25/2018] [Indexed: 12/19/2022]
Abstract
The effect of patient-controlled analgesia during the emergency phase of care on the prevalence of persistent pain is unkown. We studied individuals with traumatic injuries or abdominal pain 6 months after hospital admission via the emergency department using an opportunistic observational study design. This was conducted using postal questionnaires that were sent to participants recruited to the multi-centre pain solutions in the emergency setting study. Patients with prior chronic pain states or opioid use were not studied. Questionnaires included the EQ5D, the Brief Pain Inventory and the Hospital Anxiety and Depression scale. Overall, 141 out of 286 (49% 95%CI 44-56%) patients were included in this follow-up study. Participants presenting with trauma were more likely to develop persistent pain than those presenting with abdominal pain, 45 out of 64 (70%) vs. 24 out of 77 (31%); 95%CI 24-54%, p < 0.001. There were no statistically significant associations between persistent pain and analgesic modality during hospital admission, age or sex. Across both abdominal pain and traumatic injury groups, participants with persistent pain had lower EQ5D mobility scores, worse overall health and higher anxiety and depression scores (p < 0.05). In the abdominal pain group, 13 out of 50 (26%) patients using patient-controlled analgesia developed persistent pain vs. 11 out of 27 (41%) of those with usual treatment; 95%CI for difference (control - patient-controlled analgesia) -8 to 39%, p = 0.183. Acute pain scores at the time of hospital admission were higher in participants who developed persistent pain; 95%CI 0.7-23.6, p = 0.039. For traumatic pain, 25 out of 35 (71%) patients given patient-controlled analgesia developed persistent pain vs. 20 out of 29 (69%) patients with usual treatment; 95%CI -30 to 24%, p = 0.830. Persistent pain is common 6 months after hospital admission, particularly following trauma. The study findings suggest that it may be possible to reduce persistent pain (at least in patients with abdominal pain) by delivering better acute pain management. Further research is needed to confirm this hypothesis.
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Affiliation(s)
- M Rockett
- Anaesthesia and Pain Medicine, Plymouth University Hospitals NHS Trust, Plymouth, UK
| | - S Creanor
- Clinical Trials and Medical Statistics, University of Plymouth, UK
| | - R Squire
- Plymouth University Hospitals NHS Trust, Plymouth, UK
| | - A Barton
- NIHR Research Design Service South West, London, UK
| | - J Benger
- Emergency Care, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | | | - P Ewings
- NIHR Research Design Service South West, London, UK
| | - V Eyre
- Re:Cognition Health Ltd, Plymouth, UK
| | - J E Smith
- Emergency Medicine, Plymouth University Hospitals NHS Trust, Plymouth, UK
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Gabbay MB, Ring A, Byng R, Anderson P, Taylor RS, Matthews C, Harris T, Berry V, Byrne P, Carter E, Clarke P, Cocking L, Edwards S, Emsley R, Fornasiero M, Frith L, Harris S, Huxley P, Jones S, Kinderman P, King M, Kosnes L, Marshall D, Mercer D, May C, Nolan D, Phillips C, Rawcliffe T, Sardani AV, Shaw E, Thompson S, Vickery J, Wainman B, Warner M. Debt Counselling for Depression in Primary Care: an adaptive randomised controlled pilot trial (DeCoDer study). Health Technol Assess 2018. [PMID: 28648148 DOI: 10.3310/hta21350] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Depression and debt are common in the UK. Debt Counselling for Depression in Primary Care: an adaptive randomised controlled pilot trial (DeCoDer) aimed to assess the clinical effectiveness and cost-effectiveness of the addition of a primary care debt counselling advice service to usual care for patients with depression and debt. However, the study was terminated early during the internal pilot trial phase because of recruitment delays. This report describes the rationale, methods and findings of the pilot study, and implications for future research. OBJECTIVES The overarching aim of the internal pilot was to identify and resolve problems, thereby assessing the feasibility of the main trial. The specific objectives were to confirm methods for practice recruitment and the ability to recruit patients via the proposed approaches; to determine the acceptability of the study interventions and outcome measures; to assess contamination; to confirm the randomisation method for main trial and the level of participant attrition; and to check the robustness of data collection systems. DESIGN An adaptive, parallel, two-group multicentre randomised controlled pilot trial with a nested mixed-methods process and economic evaluation. Both individual- and cluster (general practice)-level were was used in the pilot phase to assign participants to intervention or control groups. SETTING General practices in England and Wales. PARTICIPANTS Individuals were included who were aged ≥ 18 years, scored ≥ 14 on the Beck Depression Inventory II and self-identified as having debt worries. The main exclusion criteria were being actively suicidal or psychotic and/or severely depressed and unresponsive to treatment; having a severe addiction to alcohol/illicit drugs; being unable/unwilling to give written informed consent; currently participating in other research including follow-up phases; having received Citizens Advice Bureau (CAB) debt advice in the past year; and not wanting debt advice via a general practice. INTERVENTIONS The participants in the intervention group were given debt advice provided by the CAB and shared biopsychosocial assessment, in addition to treatment as usual (TAU) and two debt advice leaflets. The participants in the control group were given advice leaflets provided by the general practitioner and TAU only. MAIN OUTCOME MEASURES (1) Outcomes of the pilot trial - the proportion of eligible patients who consented, the number of participants recruited compared with target, assessment of contamination, and assessment of patient satisfaction with intervention and outcome measures. (2) Participant outcomes - primary - Beck Depression Inventory II; secondary - psychological well-being, health and social care utilisation, service satisfaction, substance misuse, record of priority/non-priority debts, life events and difficulties, and explanatory measures. Outcomes were assessed at baseline (pre-randomisation) and at 4 months post randomisation. Other data sources - qualitative interviews were conducted with participants, clinicians and CAB advisors. RESULTS Of the 238 expressions of interest screened, 61 participants (26%) were recruited and randomised (32 in the intervention group and 29 in the control group). All participants provided baseline outcomes and 52 provided the primary outcome at 4 months' follow-up (14.7% dropout). Seventeen participants allocated to the intervention saw a CAB advisor. Descriptive statistics are reported for participants with complete outcomes at baseline and 4 months' follow-up. Our qualitative findings suggest that the relationship between debt and depression is complex, and the impact of each on the other is compounded by other psychological, social and contextual influences. CONCLUSIONS As a result of low recruitment, this trial was terminated at the internal pilot phase and was too small for inferential statistical analysis. We recommend ways to reduce this risk when conducting complex trials among vulnerable populations recruited in community settings. These cover trial design, the design and delivery of interventions, recruitment strategies and support for sites. TRIAL REGISTRATION Current Controlled Trials ISRCTN79705874. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 35. See the NIHR Journals Library website for further project information. Mark Gabbay and Adele Ring are part-funded by NIHR Collaborations for Leadership in Applied Health Research and Care (CLAHRC) North West Coast and Richard Byng and Rod S Taylor, Vashti Berry and Elizabeth Shaw part-funded by NIHR CLAHRC South West Peninsula.
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Affiliation(s)
- Mark B Gabbay
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Adele Ring
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Richard Byng
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Pippa Anderson
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Rod S Taylor
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | | | - Tirril Harris
- Department of Health Service and Population Research, King's College London, London, UK
| | - Vashti Berry
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Paula Byrne
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Elliot Carter
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Pam Clarke
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Laura Cocking
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Suzanne Edwards
- Swansea University Medical School, Swansea University, Swansea, UK
| | - Richard Emsley
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Mauro Fornasiero
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Lucy Frith
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Shaun Harris
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Peter Huxley
- Centre for Mental Health and Society, School of Social Sciences, Bangor University, Bangor, UK
| | - Siw Jones
- Citizens Advice Bureau, Liverpool, UK
| | - Peter Kinderman
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Michael King
- Division of Psychiatry, University College London, London, UK
| | - Liv Kosnes
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Daniel Marshall
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Dave Mercer
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Carl May
- Faculty of Life Sciences, University of Southampton, Southampton, UK
| | | | - Ceri Phillips
- Swansea Centre for Health Economics, Swansea University, Swansea, UK
| | - Tim Rawcliffe
- Lancashire Care NHS Foundation Trust, Lancashire, UK
| | | | - Elizabeth Shaw
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Sam Thompson
- Department of Health Services Research, Institute of Psychology, Health and Society, University of Liverpool, Liverpool, UK
| | - Jane Vickery
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Brian Wainman
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Mark Warner
- Institute of Translational and Stratified Medicine, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
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Fortnum H, Ukoumunne OC, Hyde C, Taylor RS, Ozolins M, Errington S, Zhelev Z, Pritchard C, Benton C, Moody J, Cocking L, Watson J, Roberts S. A programme of studies including assessment of diagnostic accuracy of school hearing screening tests and a cost-effectiveness model of school entry hearing screening programmes. Health Technol Assess 2018; 20:1-178. [PMID: 27169435 DOI: 10.3310/hta20360] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Identification of permanent hearing impairment at the earliest possible age is crucial to maximise the development of speech and language. Universal newborn hearing screening identifies the majority of the 1 in 1000 children born with a hearing impairment, but later onset can occur at any time and there is no optimum time for further screening. A universal but non-standardised school entry screening (SES) programme is in place in many parts of the UK but its value is questioned. OBJECTIVES To evaluate the diagnostic accuracy of hearing screening tests and the cost-effectiveness of the SES programme in the UK. DESIGN Systematic review, case-control diagnostic accuracy study, comparison of routinely collected data for services with and without a SES programme, parental questionnaires, observation of practical implementation and cost-effectiveness modelling. SETTING Second- and third-tier audiology services; community. PARTICIPANTS Children aged 4-6 years and their parents. MAIN OUTCOME MEASURES Diagnostic accuracy of two hearing screening devices, referral rate and source, yield, age at referral and cost per quality-adjusted life-year. RESULTS The review of diagnostic accuracy studies concluded that research to date demonstrates marked variability in the design, methodological quality and results. The pure-tone screen (PTS) (Amplivox, Eynsham, UK) and HearCheck (HC) screener (Siemens, Frimley, UK) devices had high sensitivity (PTS ≥ 89%, HC ≥ 83%) and specificity (PTS ≥ 78%, HC ≥ 83%) for identifying hearing impairment. The rate of referral for hearing problems was 36% lower with SES (Nottingham) relative to no SES (Cambridge) [rate ratio 0.64, 95% confidence interval (CI) 0.59 to 0.69; p < 0.001]. The yield of confirmed cases did not differ between areas with and without SES (rate ratio 0.82, 95% CI 0.63 to 1.06; p = 0.12). The mean age of referral did not differ between areas with and without SES for all referrals but children with confirmed hearing impairment were older at referral in the site with SES (mean age difference 0.47 years, 95% CI 0.24 to 0.70 years; p < 0.001). Parental responses revealed that the consequences to the family of the referral process are minor. A SES programme is unlikely to be cost-effective and, using base-case assumptions, is dominated by a no screening strategy. A SES programme could be cost-effective if there are fewer referrals associated with SES programmes or if referrals occur more quickly with SES programmes. CONCLUSIONS A SES programme using the PTS or HC screener is unlikely to be effective in increasing the identified number of cases with hearing impairment and lowering the average age at identification and is therefore unlikely to represent good value for money. This finding is, however, critically dependent on the results of the observational study comparing Nottingham and Cambridge, which has limitations. The following are suggested: systematic reviews of the accuracy of devices used to measure hearing at school entry; characterisation and measurement of the cost-effectiveness of different approaches to the ad-hoc referral system; examination of programme specificity as opposed to test specificity; further observational comparative studies of different programmes; and opportunistic trials of withdrawal of SES programmes. TRIAL REGISTRATION Current Controlled Trials ISRCTN61668996. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 36. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Heather Fortnum
- National Institute for Health Research, Nottingham Hearing Biomedical Research Unit, Hearing and Otology Group, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Obioha C Ukoumunne
- National Institute for Health Research, Collaborations for Leadership in Applied Health Research and Care South West Peninsula, University of Exeter Medical School, Exeter, UK
| | - Chris Hyde
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Rod S Taylor
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Mara Ozolins
- National Institute for Health Research, Nottingham Hearing Biomedical Research Unit, Hearing and Otology Group, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sam Errington
- National Institute for Health Research, Nottingham Hearing Biomedical Research Unit, Hearing and Otology Group, Division of Clinical Neuroscience, School of Medicine, University of Nottingham, Nottingham, UK
| | - Zhivko Zhelev
- National Institute for Health Research, Collaborations for Leadership in Applied Health Research and Care South West Peninsula, University of Exeter Medical School, Exeter, UK
| | | | - Claire Benton
- Nottingham Audiology Services, Nottingham University Hospitals, Nottingham, UK
| | - Joanne Moody
- Cambridgeshire Community Services, Community Child Health, Ida Darwin Hospital, Fulbourn, Cambridge, UK
| | - Laura Cocking
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
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Ukoumunne OC, Hyde C, Ozolins M, Zhelev Z, Errington S, Taylor RS, Benton C, Moody J, Cocking L, Watson J, Fortnum H. A directly comparative two-gate case-control diagnostic accuracy study of the pure tone screen and HearCheck screener tests for identifying hearing impairment in school children. BMJ Open 2017; 7:e017258. [PMID: 28701413 PMCID: PMC5541595 DOI: 10.1136/bmjopen-2017-017258] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES This study directly compared the accuracy of two audiometry-based tests for screening school children for hearing impairment: the currently used test, pure tone screen and a device newly applied to children, HearCheck Screener. DESIGN Two-gate case-control diagnostic test accuracy study. SETTING AND PARTICIPANTS Hearing impaired children ('intended cases') aged 4-6 years were recruited between February 2013 and August 2014 from collaborating audiology services. Children with no previously identified impairment ('intended controls') were recruited from Foundation and Year 1 of schools between February 2013 and June 2014 in central England. The reference standard was pure tone audiometry. Tests were administered at Nottingham Hearing Biomedical Research Unit or, for some intended cases only, in the participant's home. MAIN OUTCOME MEASURES Sensitivity and specificity of the pure tone screen and HearCheck tests based on pure tone audiometry result as reference standard. RESULTS 315 children (630 ears) were recruited; 75 from audiology services and 240 from schools. Full test and reference standard data were obtained for 600 ears; 155 ears were classified as truly impaired and 445 as truly hearing based on the pure tone audiometry assessment. Sensitivity was estimated to be 94.2% (95% CI 89.0% to 97.0%) for pure tone screen and 89.0% (95% CI 82.9% to 93.1%) for HearCheck (difference=5.2% favouring pure tone screen; 95% CI 0.2% to 10.1%; p=0.02). Estimates for specificity were 82.2% (95% CI 77.7% to 86.0%) for pure tone screen and 86.5% (95% CI 82.5% to 89.8%) for HearCheck (difference=4.3% favouring HearCheck; 95% CI0.4% to 8.2%; p=0.02). CONCLUSION Pure tone screen was better than HearCheck with respect to sensitivity but inferior with respect to specificity. As avoiding missed cases is arguably of greater importance for school entry screening, pure tone screen is probably preferable in this context. STUDY REGISTRATION NUMBER Current controlled trials: ISRCTN61668996.
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Affiliation(s)
- Obioha C Ukoumunne
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter, UK
| | - Chris Hyde
- Institute of Health Research, University of Exeter Medical School Luke’s Campus, Exeter, UK
| | - Mara Ozolins
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Zhivko Zhelev
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, South Cloisters, St Luke’s Campus, Exeter, UK
| | - Sam Errington
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Rod S Taylor
- Institute of Health Research, University of Exeter Medical School Luke’s Campus, Exeter, UK
| | - Claire Benton
- Nottingham Audiology Services, Nottingham University Hospitals, Nottingham, UK
| | - Joanne Moody
- Community Child Health, Ida Darwin Hospital, Fulbourn, Cambridge, UK
| | - Laura Cocking
- Peninsula Clinical Trials Unit at Plymouth University (PenCTU), Plymouth University, Plymouth, UK
| | | | - Heather Fortnum
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
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Pritchard C, Smith JE, Creanor S, Squire R, Barton A, Benger J, Cocking L, Ewings P, Rockett M. The cost-effectiveness of patient-controlled analgesia vs. standard care in patients presenting to the Emergency Department in pain, who are subsequently admitted to hospital. Anaesthesia 2017; 72:953-960. [PMID: 28547753 DOI: 10.1111/anae.13932] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/11/2017] [Indexed: 11/30/2022]
Abstract
The clinical effectiveness of patient-controlled analgesia has been demonstrated in a variety of settings. However, patient-controlled analgesia is rarely utilised in the Emergency Department. The aim of this study was to compare the cost-effectiveness of patient-controlled analgesia vs. standard care in participants admitted to hospital from the Emergency Department with pain due to traumatic injury or non-traumatic abdominal pain. Pain scores were measured hourly for 12 h using a visual analogue scale. Cost-effectiveness was measured as the additional cost per hour in moderate to severe pain avoided by using patient-controlled analgesia rather than standard care (the incremental cost-effectiveness ratio). Sampling variation was estimated using bootstrap methods and the effects of parameter uncertainty explored in a sensitivity analysis. The cost per hour in moderate or severe pain averted was estimated as £24.77 (€29.05, US$30.80) (bootstrap estimated 95%CI £8.72 to £89.17) for participants suffering pain from traumatic injuries and £15.17 (€17.79, US$18.86) (bootstrap estimate 95%CI £9.03 to £46.00) for participants with non-traumatic abdominal pain. Overall costs were higher with patient-controlled analgesia than standard care in both groups: pain from traumatic injuries incurred an additional £18.58 (€21.79 US$23.10) (95%CI £15.81 to £21.35) per 12 h; and non-traumatic abdominal pain an additional £20.18 (€23.67 US$25.09) (95%CI £19.45 to £20.84) per 12 h.
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Affiliation(s)
- C Pritchard
- NIHR Research Design Service, South West, UK
| | - J E Smith
- Department of Anaesthesia, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
| | - S Creanor
- Department of Medical Statistics, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - R Squire
- Emergency Department, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
| | - A Barton
- NIHR Research Design Service, South West, UK
| | - J Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - L Cocking
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - P Ewings
- NIHR Research Design Service, South West, UK
| | - M Rockett
- Department of Anaesthesia, Critical Care and Pain Medicine, Derriford Hospital, Plymouth, UK
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Smith JE, Squire R, Pritchard C, Ewings P, Barton A, Rockett M, Creanor S, Hayward C, Eyre V, Cocking L, Benger J. THE COST-EFFECTIVENESS OF PATIENT CONTROLLED ANALGESIA VERSUS ROUTINE CARE IN PATIENTS PRESENTING TO THE EMERGENCY DEPARTMENT IN PAIN, WHO ARE SUBSEQUENTLY ADMITTED TO HOSPITAL. Arch Emerg Med 2016. [DOI: 10.1136/emermed-2016-206402.19] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Smith JE, Rockett M, Creanor S, Squire R, Hayward C, Ewings P, Barton A, Pritchard C, Eyre V, Cocking L, Benger J. PAin SoluTions In the Emergency Setting (PASTIES)--patient controlled analgesia versus routine care in emergency department patients with non-traumatic abdominal pain: randomised trial. BMJ 2015; 350:h3147. [PMID: 26094712 PMCID: PMC4476026 DOI: 10.1136/bmj.h3147] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine whether patient controlled analgesia (PCA) is better than routine care in providing effective analgesia for patients presenting to emergency departments with moderate to severe non-traumatic abdominal pain. DESIGN Pragmatic, multicentre, parallel group, randomised controlled trial SETTING Five English hospitals. PARTICIPANTS 200 adults (66% (n=130) female), aged 18 to 75 years, who presented to the emergency department requiring intravenous opioid analgesia for the treatment of moderate to severe non-traumatic abdominal pain and were expected to be admitted to hospital for at least 12 hours. INTERVENTIONS Patient controlled analgesia or nurse titrated analgesia (treatment as usual). MAIN OUTCOME MEASURES The primary outcome was total pain experienced over the 12 hour study period, derived by standardised area under the curve (scaled from 0 to 100) of each participant's hourly pain scores, captured using a visual analogue scale. Pre-specified secondary outcomes included total morphine use, percentage of study period in moderate or severe pain, percentage of study period asleep, length of hospital stay, and satisfaction with pain management. RESULTS 196 participants were included in the primary analyses (99 allocated to PCA and 97 to treatment as usual). Mean total pain experienced was 35.3 (SD 25.8) in the PCA group compared with 47.3 (24.7) in the treatment as usual group. The adjusted between group difference was 6.3 (95% confidence interval 0.7 to 11.9). Participants in the PCA group received significantly more morphine (mean 36.1 (SD 22.4) v 23.6 (13.1) mg; mean difference 12.3 (95% confidence interval 7.2 to 17.4) mg), spent less of the study period in moderate or severe pain (32.6% v 46.9%; mean difference 14.5% (5.6% to 23.5%)), and were more likely to be perfectly or very satisfied with the management of their pain (83% (73/88) v 66% (57/87); adjusted odds ratio 2.56 (1.25 to 5.23)) in comparison with participants in the treatment as usual group. CONCLUSIONS Significant reductions in pain can be achieved by PCA compared with treatment as usual in patients presenting to the emergency department with non-traumatic abdominal pain. Trial registration European Clinical Trials Database EudraCT2011-000194-31; Current Controlled Trials ISRCTN25343280.
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Affiliation(s)
- Jason E Smith
- Derriford Hospital, Plymouth PL6 8DH, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Medical Directorate, Birmingham, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Mark Rockett
- Derriford Hospital, Plymouth PL6 8DH, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Siobhan Creanor
- Centre for Biostatistics, Bioinformatics and Biomarkers, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | - Chris Hayward
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | | | | | - Victoria Eyre
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Laura Cocking
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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Smith JE, Rockett M, S SC, Squire R, Hayward C, Ewings P, Barton A, Pritchard C, Eyre V, Cocking L, Benger J. PAin SoluTions In the Emergency Setting (PASTIES)--patient controlled analgesia versus routine care in emergency department patients with pain from traumatic injuries: randomised trial. BMJ 2015; 350:h2988. [PMID: 26094763 PMCID: PMC4476025 DOI: 10.1136/bmj.h2988] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVE To determine whether patient controlled analgesia (PCA) is better than routine care in patients presenting to emergency departments with moderate to severe pain from traumatic injuries. DESIGN Pragmatic, multicentre, parallel group, randomised controlled trial. SETTING Five English hospitals. PARTICIPANTS 200 adults (71% (n = 142) male), aged 18 to 75 years, who presented to the emergency department requiring intravenous opioid analgesia for the treatment of moderate to severe pain from traumatic injuries and were expected to be admitted to hospital for at least 12 hours. INTERVENTIONS PCA (n = 99) or nurse titrated analgesia (treatment as usual; n = 101). MAIN OUTCOME MEASURES The primary outcome was total pain experienced over the 12 hour study period, derived by standardised area under the curve (scaled from 0 to 100) of each participant's hourly pain scores, captured using a visual analogue scale. Pre-specified secondary outcomes included total morphine use, percentage of study period in moderate/severe pain, percentage of study period asleep, length of hospital stay, and satisfaction with pain management. RESULTS 200 participants were included in the primary analyses. Mean total pain experienced was 47.2 (SD 21.9) for the treatment as usual group and 44.0 (24.0) for the PCA group. Adjusted analyses indicated slightly (but not statistically significantly) lower total pain experienced in the PCA group than in the routine care group (mean difference 2.7, 95% confidence interval -2.4 to 7.8). Participants allocated to PCA used more morphine in total than did participants in the treatment as usual group (mean 44.3 (23.2) v 27.2 (18.2) mg; mean difference 17.0, 11.3 to 22.7). PCA participants spent, on average, less time in moderate/severe pain (36.2% (31.0) v 44.1% (31.6)), but the difference was not statistically significant. A higher proportion of PCA participants reported being perfectly or very satisfied compared with the treatment as usual group (86% (78/91) v 76% (74/98)), but this was also not statistically significant. CONCLUSIONS PCA provided no statistically significant reduction in pain compared with routine care for emergency department patients with traumatic injuries. Trial registration European Clinical Trials Database EudraCT2011-000194-31; Current Controlled Trials ISRCTN25343280.
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Affiliation(s)
- Jason E Smith
- Derriford Hospital, Plymouth PL6 8DH, UK Academic Department of Military Emergency Medicine, Royal Centre for Defence Medicine (Research and Academia), Medical Directorate, Birmingham, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Mark Rockett
- Derriford Hospital, Plymouth PL6 8DH, UK Centre for Clinical Trials and Population Studies, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Siobhan Creanor S
- Centre for Biostatistics, Bioinformatics and Biomarkers, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | - Chris Hayward
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | | | | | | | - Victoria Eyre
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Laura Cocking
- Peninsula Clinical Trials Unit, Plymouth University Peninsula Schools of Medicine and Dentistry, Plymouth, UK
| | - Jonathan Benger
- Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
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