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Golder S, Jefferson L, McHugh E, Essex H, Heathcote C, Castro Avila A, Dale V, Van Der Feltz-Cornelis C, Bloor K. General practitioners' wellbeing during the COVID-19 pandemic: Novel methods with social media data. Health Info Libr J 2023; 40:400-416. [PMID: 36416221 DOI: 10.1111/hir.12466] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 07/14/2022] [Accepted: 11/02/2022] [Indexed: 11/24/2022]
Abstract
BACKGROUND It is difficult to engage busy healthcare professionals in research. Yet during the COVID-19 pandemic, gaining their perspectives has never been more important. OBJECTIVE To explore social media data for insights into the wellbeing of UK General Practitioners (GPs) during the Covid-19 pandemic. METHODS We used a combination of search approaches to identify 381 practising UK NHS GPs on Twitter. Using a two stage social media analysis, we firstly searched for key themes from 91,034 retrieved tweets (before and during the pandemic). Following this we used qualitative content analysis to provide in-depth insights from 7145 tweets related to wellbeing. RESULTS Social media proved a useful tool to identify a cohort of UK GPs; following their tweets longitudinally to explore key themes and trends in issues related to GP wellbeing during the pandemic. These predominately related to support, resources and public perceptions and fluctuations were identified at key timepoints during the pandemic, all achieved without burdening busy GPs. CONCLUSION Social media data can be searched to identify a cohort of GPs to explore their wellbeing and changes over time.
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Affiliation(s)
- Su Golder
- Department of Health Sciences, University of York, York, UK
| | | | | | - Holly Essex
- Department of Health Sciences, University of York, York, UK
| | | | | | - Veronica Dale
- Department of Health Sciences, University of York, York, UK
| | | | - Karen Bloor
- Department of Health Sciences, University of York, York, UK
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Jefferson L, Golder S, Essex H, Dale V, Bloor K. Exploring gender differences in uptake of GP partnership roles: a qualitative mixed-methods study. Br J Gen Pract 2023; 73:e545-e555. [PMID: 37365008 PMCID: PMC10325588 DOI: 10.3399/bjgp.2022.0544] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2022] [Revised: 12/02/2022] [Accepted: 03/05/2023] [Indexed: 06/28/2023] Open
Abstract
BACKGROUND The unadjusted gender pay gap in general practice is reported to be 33.5%. This reflects partly the differential rate at which women become partners, but evidence exploring gender differences in GPs' career progression is sparse. AIM To explore factors affecting uptake of partnership roles, focusing particularly on gender differences. DESIGN AND SETTING Convergent mixed-methods research design using data from UK GPs. METHOD Secondary analysis of qualitative interviews and social media analysis of UK GPs' Twitter commentaries, which informed the conduct of asynchronous online focus groups. Findings were combined using methodological triangulation. RESULTS The sample comprised 40 GP interviews, 232 GPs tweeting about GP partnership roles, and seven focus groups with 50 GPs. Factors at individual, organisational, and national levels influence partnership uptake and career decisions of both men and women GPs. Desire for work-family balance (particularly childcare responsibilities) presented the greatest barrier, for both men and women, as well as workload, responsibility, financial investment, and risk. Greater challenges were, however, reported by women, particularly regarding balancing work-family lives, as well as prohibitive working conditions (including maternity and sickness pay) and discriminatory practices perceived to favour men and full-time GPs. CONCLUSION There are some long-standing gendered barriers that continue to affect the career decisions of women GPs. The relative attractiveness of salaried, locum, or private roles in general practice appears to discourage both men and women from partnerships presently. Promoting positive workplace cultures through strong role models, improved flexibility in roles, and skills training could potentially encourage greater uptake.
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Affiliation(s)
| | - Su Golder
- Department of Health Sciences, University of York, York
| | - Holly Essex
- Department of Health Sciences, University of York, York
| | - Veronica Dale
- Department of Health Sciences, University of York, York
| | - Karen Bloor
- Department of Health Sciences, University of York, York
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Jefferson L, Heathcote C, Bloor K. General practitioner well-being during the COVID-19 pandemic: a qualitative interview study. BMJ Open 2023; 13:e061531. [PMID: 36813497 PMCID: PMC9950583 DOI: 10.1136/bmjopen-2022-061531] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023] Open
Abstract
OBJECTIVES The COVID-19 pandemic presented new challenges for general practitioners' (GPs') mental health and well-being, with growing international evidence of its negative impact. While there has been a wide UK commentary on this topic, research evidence from a UK setting is lacking. This study sought to explore the lived experience of UK GPs during COVID-19, and the pandemic's impact on their psychological well-being. DESIGN AND SETTING In-depth qualitative interviews, conducted remotely by telephone or video call, with UK National Health Service GPs. PARTICIPANTS GPs were sampled purposively across three career stages (early career, established and late career or retired GPs) with variation in other key demographics. A comprehensive recruitment strategy used multiple channels. Data were analysed thematically using Framework Analysis. RESULTS We interviewed 40 GPs; most described generally negative sentiment and many displayed signs of psychological distress and burnout. Causes of stress and anxiety related to personal risk, workload, practice changes, public perceptions and leadership, team working and wider collaboration and personal challenges. GPs described potential facilitators of their well-being, including sources of support and plans to reduce clinical hours or change career path, and some described the pandemic as offering a catalyst for positive change. CONCLUSIONS A range of factors detrimentally affected the well-being of GPs during the pandemic and we highlight the potential impact of this on workforce retention and quality of care. As the pandemic progresses and general practice faces continued challenges, urgent policy measures are now needed.
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Affiliation(s)
- Laura Jefferson
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Claire Heathcote
- Department of Health Sciences, University of York, York, North Yorkshire, UK
| | - Karen Bloor
- Department of Health Sciences, University of York, York, North Yorkshire, UK
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Dias J, Brealey S, Cook L, Fairhurst C, Hinde S, Leighton P, Choudhary S, Costa M, Hewitt C, Hodgson S, Jefferson L, Jeyapalan K, Keding A, Northgraves M, Palmer J, Rangan A, Richardson G, Taub N, Tew G, Thompson J, Torgerson D. Surgical fixation compared with cast immobilisation for adults with a bicortical fracture of the scaphoid waist: the SWIFFT RCT. Health Technol Assess 2021; 24:1-234. [PMID: 33109331 DOI: 10.3310/hta24520] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. Immediate surgical fixation of this fracture has increased. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of surgical fixation with cast treatment and early fixation in adults with scaphoid waist fractures that fail to unite. DESIGN Multicentre, pragmatic, open-label, parallel two-arm randomised controlled trial with an economic evaluation and a nested qualitative study. SETTING Orthopaedic departments of 31 hospitals in England and Wales recruited from July 2013, with final follow-up in September 2017. PARTICIPANTS Adults (aged ≥ 16 years) presenting within 2 weeks of injury with a clear, bicortical fracture of the scaphoid waist on plain radiographs. INTERVENTIONS Early surgical fixation using Conformité Européenne-marked headless compression screws. Below-elbow cast immobilisation for 6-10 weeks and urgent fixation of confirmed non-union. MAIN OUTCOME MEASURES The primary outcome and end point was the Patient-Rated Wrist Evaluation total score at 52 weeks, with a clinically relevant difference of 6 points. Secondary outcomes included Patient-Rated Wrist Evaluation pain and function subscales, Short Form questionnaire 12-items, bone union, range of movement, grip strength, complications and return to work. RESULTS The mean age of 439 participants was 33 years; 363 participants were male (83%) and 269 participants had an undisplaced fracture (61%). The primary analysis was on 408 participants with valid Patient-Rated Wrist Evaluation outcome data for at least one post-randomisation time point (surgery, n = 203 of 219; cast, n = 205 of 220). There was no clinically relevant difference in the Patient-Rated Wrist Evaluation total score at 52 weeks: the mean score in the cast group was 14.0 (95% confidence interval 11.3 to 16.6) and in the surgery group was 11.9 (95% confidence interval 9.2 to 14.5), with an adjusted mean difference of -2.1 in favour of surgery (95% confidence interval -5.8 to 1.6; p = 0.27). The non-union rate was low (surgery group, n = 1; cast group, n = 4). Eight participants in the surgery group had a total of 11 reoperations and one participant in the cast group required a reoperation for non-union. The base-case economic analysis at 52 weeks found that surgery cost £1295 per patient more (95% confidence interval £1084 to £1504) than cast treatment. The base-case analysis of a lifetime-extrapolated model confirmed that the cast treatment pathway was more cost-effective. The nested qualitative study identified patients' desire to have a 'sense of recovering', which surgeons should address at the outset. LIMITATION There were 17 participants who had initial cast treatment and surgery for confirmed non-union, which in 14 cases was within 6 months from randomisation and in three cases was after 6 months. Three of the four participants in the cast group who had a non-union at 52 weeks were not offered surgery. CONCLUSIONS Adult patients with an undisplaced or minimally displaced scaphoid waist fracture should have cast immobilisation and suspected non-unions immediately confirmed and urgently fixed. Patients should be followed up at 5 years to investigate the effect of partial union, degenerative arthritis, malunion and screw problems on their quality of life. TRIAL REGISTRATION Current Controlled Trials ISRCTN67901257. 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. 24, No. 52. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Joseph Dias
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Stephen Brealey
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Liz Cook
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Caroline Fairhurst
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | | | - Paul Leighton
- School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Surabhi Choudhary
- Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Matthew Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK.,Kadoorie Centre, John Radcliffe Hospital, Oxford, UK
| | - Catherine Hewitt
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Stephen Hodgson
- Department of Orthopaedic Surgery, Bolton NHS Foundation Trust, Royal Bolton Hospital, Bolton, UK
| | - Laura Jefferson
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK.,Department of Health Sciences, University of York, York, UK
| | | | - Ada Keding
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Matthew Northgraves
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
| | - Jared Palmer
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Amar Rangan
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK.,Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | | | - Nicholas Taub
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Garry Tew
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK.,Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, UK
| | - John Thompson
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - David Torgerson
- Alcuin Research Resource Centre Building, Department of Health Sciences, University of York, York, UK
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5
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Castro-Avila AC, Jefferson L, Dale V, Bloor K. Support and follow-up needs of patients discharged from intensive care after severe COVID-19: a mixed-methods study of the views of UK general practitioners and intensive care staff during the pandemic's first wave. BMJ Open 2021; 11:e048392. [PMID: 33980533 PMCID: PMC8117472 DOI: 10.1136/bmjopen-2020-048392] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
OBJECTIVES To identify follow-up services planned for patients with COVID-19 discharged from intensive care unit (ICU) and to explore the views of ICU staff and general practitioners (GPs) regarding these patients' future needs and care coordination. DESIGN This is a sequential mixed-methods study using online surveys and semistructured interviews. Interview data were inductively coded and thematically analysed. Survey data were descriptively analysed. SETTING GP surgeries and acute National Health Service Trusts in the UK. PARTICIPANTS GPs and clinicians leading care for patients discharged from ICU. PRIMARY AND SECONDARY OUTCOMES Usual follow-up practice after ICU discharge, changes in follow-up during the pandemic, and GP awareness of follow-up and support needs of patients discharged from ICU. RESULTS We obtained 170 survey responses and conducted 23 interviews. Over 60% of GPs were unaware of the follow-up services generally provided by their local hospitals and whether or not these were functioning during the pandemic. Eighty per cent of ICUs reported some form of follow-up services, with 25% of these suspending provision during the peak of the pandemic and over half modifying their provision (usually to provide the service remotely). Common themes relating to barriers to provision of follow-up were funding complexities, remit and expertise, and communication between ICU and community services. Discharge documentation was described as poor and lacking key information. Both groups mentioned difficulties accessing services in the community and lack of clarity about who was responsible for referrals and follow-up. CONCLUSIONS The pandemic has highlighted long-standing issues of continuity of care and complex funding streams for post-ICU follow-up care. The large cohort of ICU patients admitted due to COVID-19 highlights the need for improved follow-up services and communication between specialists and GPs, not only for patients with COVID-19, but for all those discharged from ICU.
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Affiliation(s)
- Ana Cristina Castro-Avila
- Department of Health Sciences, University of York, York, UK
- Carrera de Kinesiología, Universidad del Desarrollo Facultad de Medicina Clínica Alemana, Santiago, Chile
| | | | - Veronica Dale
- Department of Health Sciences, University of York, York, UK
| | - Karen Bloor
- Department of Health Sciences, University of York, York, UK
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6
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Dias JJ, Brealey SD, Fairhurst C, Amirfeyz R, Bhowal B, Blewitt N, Brewster M, Brown D, Choudhary S, Coapes C, Cook L, Costa M, Davis T, Di Mascio L, Giddins G, Hedley H, Hewitt C, Hinde S, Hobby J, Hodgson S, Jefferson L, Jeyapalan K, Johnston P, Jones J, Keding A, Leighton P, Logan A, Mason W, McAndrew A, McNab I, Muir L, Nicholl J, Northgraves M, Palmer J, Poulter R, Rahimtoola Z, Rangan A, Richards S, Richardson G, Stuart P, Taub N, Tavakkolizadeh A, Tew G, Thompson J, Torgerson D, Warwick D. Surgery versus cast immobilisation for adults with a bicortical fracture of the scaphoid waist (SWIFFT): a pragmatic, multicentre, open-label, randomised superiority trial. Lancet 2020; 396:390-401. [PMID: 32771106 DOI: 10.1016/s0140-6736(20)30931-4] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2020] [Revised: 04/02/2020] [Accepted: 04/16/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Scaphoid fractures account for 90% of carpal fractures and occur predominantly in young men. The use of immediate surgical fixation to manage this type of fracture has increased, despite insufficient evidence of improved outcomes over non-surgical management. The SWIFFT trial compared the clinical effectiveness of surgical fixation with cast immobilisation and early fixation of fractures that fail to unite in adults with scaphoid waist fractures displaced by 2 mm or less. METHODS This pragmatic, parallel-group, multicentre, open-label, two-arm, randomised superiority trial included adults (aged 16 years or older) who presented to orthopaedic departments of 31 hospitals in England and Wales with a clear bicortical fracture of the scaphoid waist on radiographs. An independent remote randomisation service used a computer-generated allocation sequence with randomly varying block sizes to randomly assign participants (1:1) to receive either early surgical fixation (surgery group) or below-elbow cast immobilisation followed by immediate fixation if non-union of the fracture was confirmed (cast immobilisation group). Randomisation was stratified by whether or not there was displacement of either a step or a gap of 1-2 mm inclusive on any radiographic view. The primary outcome was the total patient-rated wrist evaluation (PRWE) score at 52 weeks after randomisation, and it was analysed on an available case intention-to-treat basis. This trial is registered with the ISRCTN registry, ISRCTN67901257, and is no longer recruiting, but long-term follow-up is ongoing. FINDINGS Between July 23, 2013, and July 26, 2016, 439 (42%) of 1047 assessed patients (mean age 33 years; 363 [83%] men) were randomly assigned to the surgery group (n=219) or to the cast immobilisation group (n=220). Of these, 408 (93%) participants were included in the primary analysis (203 participants in the surgery group and 205 participants in the cast immobilisation group). 16 participants in the surgery group and 15 participants in the cast immobilisation group were excluded because of either withdrawal, no response, or no follow-up data at 6, 12, 26, or 52 weeks. There was no significant difference in mean PRWE scores at 52 weeks between the surgery group (adjusted mean 11·9 [95% CI 9·2-14·5]) and the cast immobilisation group (14·0 [11·3 to 16·6]; adjusted mean difference -2·1 [95% CI -5·8 to 1·6], p=0·27). More participants in the surgery group (31 [14%] of 219 participants) had a potentially serious complication from surgery than in the cast immobilisation group (three [1%] of 220 participants), but fewer participants in the surgery group (five [2%]) had cast-related complications than in the cast immobilisation group (40 [18%]). The number of participants who had a medical complication was similar between the two groups (four [2%] in the surgery group and five [2%] in the cast immobilisation group). INTERPRETATION Adult patients with scaphoid waist fractures displaced by 2 mm or less should have initial cast immobilisation, and any suspected non-unions should be confirmed and immediately fixed with surgery. This treatment strategy will help to avoid the risks of surgery and mostly limit the use of surgery to fixing fractures that fail to unite. FUNDING National Institute for Health Research Health Technology Assessment Programme.
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Affiliation(s)
- Joseph J Dias
- Leicester General Hospital, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, UK.
| | - Stephen D Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Caroline Fairhurst
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Rouin Amirfeyz
- University Hospitals Bristol NHS Foundation Trust, Bristol Royal Infirmary, Bristol, UK
| | - Bhaskar Bhowal
- Leicester General Hospital, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, UK
| | - Neil Blewitt
- North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Mark Brewster
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Daniel Brown
- The Royal Liverpool and Broadgreen University Hospitals NHS Trust, Royal Liverpool University Hospital, Liverpool, UK
| | - Surabhi Choudhary
- University Hospitals Birmingham NHS Foundation Trust, Queen Elizabeth Hospital, Birmingham, UK
| | - Christopher Coapes
- South Tees Hospitals NHS Foundation Trust, The James Cook University Hospital, Middlesbrough, UK
| | - Liz Cook
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Matthew Costa
- The Kadoorie Centre, John Radcliffe Hospital, Oxford, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford, UK
| | - Tim Davis
- Nottingham University Hospitals NHS Trust, Queen's Medical Centre Campus, Nottingham, UK
| | - Livio Di Mascio
- Barts Health NHS Trust, The Royal London Hospital, London, UK
| | - Grey Giddins
- Royal United Hospital Bath NHS Trust, Royal United Hospital, Bath, UK
| | - Helen Hedley
- University Hospitals Coventry and Warwickshire NHS Trust, University Hospital, Coventry, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Jonathan Hobby
- Hampshire Hospitals NHS Foundation Trust, Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | - Stephen Hodgson
- Bolton NHS Foundation Trust, Royal Bolton Hospital, Bolton, UK
| | | | - Kanagaratnam Jeyapalan
- Leicester General Hospital, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, UK
| | - Phillip Johnston
- Cambridge University Hospitals NHS Foundation Trust, Addenbrooke's Hospital, Cambridge, UK
| | - Jonathon Jones
- Peterborough and Stamford Hospitals NHS Foundation Trust, Peterborough City Hospital, Peterborough, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Paul Leighton
- School of Medicine, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Andrew Logan
- Cardiff and Vale University of Health Board, University Hospital of Wales, Cardiff, UK
| | - Will Mason
- Gloucestershire Hospitals NHS Foundation Trust, Gloucestershire Royal Hospital, Gloucester, UK
| | - Andrew McAndrew
- Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, Reading, UK
| | - Ian McNab
- Oxford University Hospitals NHS Trust, Nuffield Orthopaedic Centre, Oxford, UK
| | - Lindsay Muir
- Salford Royal Hospital NHS Foundation Trust, Salford, UK
| | - James Nicholl
- Maidstone and Tunbridge Wells NHS Trust, Tunbridge Wells, Kent, UK
| | | | - Jared Palmer
- Leicester General Hospital, University Hospitals of Leicester National Health Service (NHS) Trust, Leicester, UK
| | - Rob Poulter
- Royal Cornwall Hospitals NHS Trust, Royal Cornwall Hospital, Truro, Cornwall, UK
| | - Zulfi Rahimtoola
- Royal Berkshire NHS Foundation Trust, Royal Berkshire Hospital, Reading, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, York, UK; Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Nuffield Orthopaedic Centre, Oxford, UK
| | | | | | - Paul Stuart
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Nicholas Taub
- Department of Health Sciences, University of Leicester, George Davies Centre, Leicester, UK
| | - Adel Tavakkolizadeh
- King's College Hospital NHS Foundation Trust, King's College Hospital, Brixton, London, UK
| | - Garry Tew
- Department of Sport, Exercise and Rehabilitation, Northumbria University, Newcastle upon Tyne, UK
| | - John Thompson
- Department of Health Sciences, University of Leicester, George Davies Centre, Leicester, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - David Warwick
- University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK
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Johnson MJ, Cockayne S, Currow DC, Bell K, Hicks K, Fairhurst C, Gabe R, Torgerson D, Jefferson L, Oxberry S, Ghosh J, Hogg KJ, Murphy J, Allgar V, Cleland JG, Clark AL. Oral modified release morphine for breathlessness in chronic heart failure: a randomized placebo-controlled trial. ESC Heart Fail 2019; 6:1149-1160. [PMID: 31389157 PMCID: PMC6989293 DOI: 10.1002/ehf2.12498] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [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] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 05/19/2019] [Accepted: 06/18/2019] [Indexed: 02/03/2023] Open
Abstract
AIMS Morphine is shown to relieve chronic breathlessness in chronic obstructive pulmonary disease. There are no definitive data in people with heart failure. We aimed to determine the effectiveness and cost-effectiveness of 12 weeks morphine therapy for the relief of chronic breathlessness in people with chronic heart failure compared with placebo. METHODS AND RESULTS Parallel group, double-blind, randomized, placebo-controlled, phase III trial of 20 mg daily oral modified release morphine was conducted in 13 sites in England and Scotland: hospital/community cardiology or palliative care outpatients. The primary analysis compared between-group numerical rating scale average breathlessness/24 hours at week 4 using a covariance pattern linear mixed model. Secondary outcomes included treatment-emergent harms (worse or new). The trial closed early due to slow recruitment, randomizing 45 participants [average age 72 (range 39-89) years; 84% men; 98% New York Heart Association class III]. For the primary analysis, the adjusted mean difference was 0.26 (95% confidence interval, -0.86 to 1.37) in favour of placebo. All other breathlessness measures improved in both groups (week 4 change-from-baseline) but by more in those assigned to morphine. Neither group was excessively drowsy at baseline or week 4. There were no between-group differences in quality of life (Kansas) or cognition (Montreal) at any time point. There was no exercise-related desaturation and no change between baseline and week 4 in either group. There was no change in vital signs at week 4. The natriuretic peptide measures fell in both groups but by more in the morphine group [morphine 2169 (1092, 3851) pg/mL vs. placebo 2851 (1694, 5437)] pg/mL. There was no excess serious adverse events in the morphine group. Treatment-emergent harms during the first week were more common in the morphine group; all apart from 1 were ≤ grade 2. CONCLUSIONS We could not answer our primary objectives due to inadequate power. However, we provide novel placebo-controlled medium-term benefit and safety data useful for clinical practice and future trial design. Morphine should only be prescribed in this population when other measures are unhelpful and with early management of side effects.
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Affiliation(s)
- Miriam J. Johnson
- Wolfson Palliative Care Research CentreUniversity of HullHullHU6 7RXUK
| | | | - David C. Currow
- Wolfson Palliative Care Research CentreUniversity of HullHullHU6 7RXUK
- IMPACCT, Faculty of HealthUniversity of Technology SydneyUltimoNSWAustralia
| | - Kerry Bell
- York Trials UnitUniversity of YorkYorkUK
| | - Kate Hicks
- York Trials UnitUniversity of YorkYorkUK
| | | | - Rhian Gabe
- Hull York Medical School and York Trials UnitUniversity of YorkYorkUK
| | | | | | - Stephen Oxberry
- Calderdale & Huddersfield Foundation TrustHuddersfield Royal InfirmaryHuddersfieldUK
| | - Justin Ghosh
- Department of CardiologyScarborough HospitalScarboroughUK
| | - Karen J. Hogg
- Department of CardiologyGlasgow Royal Infirmary, University of GlasgowGlasgowUK
| | - Jeremy Murphy
- Department of CardiologyDarlington Memorial HospitalDarlingtonUK
| | - Victoria Allgar
- Hull York Medical School and Department of Health SciencesUniversity of YorkYorkUK
| | - John G.F. Cleland
- Robertson Centre for Biostatistics & Clinical Trials, Institute of Health & Well‐beingUniversity of GlasgowGlasgowUK
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Jefferson L, Atkin K, Sheridan R, Oliver S, Macleod U, Hall G, Forbes S, Green T, Allgar V, Knapp P. Non-attendance at urgent referral appointments for suspected cancer: a qualitative study to gain understanding from patients and GPs. Br J Gen Pract 2019:bjgp1919X706625. [PMID: 31740457 DOI: 10.3399/bjgp1919x706625] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Accepted: 08/20/2019] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND The 2-week-wait urgent referral policy in the UK has sought to improve cancer outcomes by accelerating diagnosis and treatment. However, around 5-7% of symptomatic referred patients cancel or do not attend their hospital appointment. While subsequent cancer diagnosis was less likely in non-attenders, those with a diagnosis had worse early mortality outcomes. AIM To examine how interpersonal, communication, social, and organisational factors influence a patient's non-attendance. DESIGN AND SETTING Qualitative study in GP practices in one Northern English city. METHOD In-depth, individual interviews were undertaken face-to-face or by telephone between December 2016 and May 2018, followed by thematic framework analysis. RESULTS In this study 21 GPs, and 24 patients who did not attend or had cancelled their appointment were interviewed, deriving a range of potential explanations for non-attendance, including: system flaws; GP difficulties with booking appointments; patient difficulties with navigating the appointment system, particularly older patients and those from more deprived areas; patients leading 'difficult lives'; and patients' expectations of the referral, informed by their beliefs, circumstances, priorities, and the perceived prognosis. GPs recognised the importance of communication with the patient, particularly the need to tailor communication to perceived patient understanding and anxiety. GPs and practices varied in their responses to patient non-attendance, influenced by time pressures and perceptions of patient responsibility. CONCLUSION Failure to be seen within 2 weeks of urgent referral resulted from a number of patient and provider factors. The urgent referral process in general practice and cancer services should accommodate patient perceptions and responses, facilitate referral and attendance, and enable responses to patient non-attendance.
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Affiliation(s)
| | | | | | - Steven Oliver
- University of York, Hull York Medical School, Hull and York
| | - Una Macleod
- University of Hull, Hull York Medical School, Hull and York
| | - Geoff Hall
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds
| | | | - Trish Green
- University of Hull, Hull York Medical School, Hull and York
| | | | - Peter Knapp
- University of York, Hull York Medical School, Hull and York
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Keding A, Handoll H, Brealey S, Jefferson L, Hewitt C, Corbacho B, Torgerson D, Rangan A. The impact of surgeon and patient treatment preferences in an orthopaedic trauma surgery trial. Trials 2019; 20:570. [PMID: 31533863 PMCID: PMC6751812 DOI: 10.1186/s13063-019-3631-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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] [Received: 10/31/2018] [Accepted: 08/07/2019] [Indexed: 12/12/2022] Open
Abstract
Background Surgeon and patient treatment preferences are important threats to the internal and external validity of surgical trials such as PROFHER, which compared surgical versus non-surgical treatment for displaced fractures of the proximal humerus in adults. We explored the treatment preferences expressed by surgeons and patients in the trial and how these impacted on patient selection, trial conduct and patient outcome. Methods A series of exploratory secondary analyses of the PROFHER trial data were undertaken. We reviewed the extent of surgeon and patient treatment preferences (surgery or not surgery) at screening (n = 1250) as well as prior preference (including no preference) of randomised patients (n = 250), and assessed their impact on recruitment and adherence to follow-up and rehabilitation. Changes in treatment after 2 years’ follow-up were explored. Patient preference and characteristics associated with trial inclusion or treatment preference (t test, chi-squared test, Wilcoxon rank-sum test) were included as treatment interaction terms in the primary trial analysis of shoulder functioning (Oxford Shoulder Score, OSS). Results Surgeons excluded 17% of otherwise eligible patients based on lack of equipoise; these patients had less complex fractures (p < 0.001) and tended to be older (p = 0.062). Surgeons were more likely to recommend surgery for patients under 65 years of age (p = 0.059) and who had injured their right shoulder (p = 0.052). Over half of eligible patients (56%) did not consent to take part in the trial; these patients tended to be older (p = 0.022), with a preference for not surgery (74%; which was associated with older age, p = 0.039). There were no differential treatment effects (p value of interaction) for shoulder functioning (OSS) based on subgroups of patient preference (p = 0.751), age group (p = 0.264), fracture type (p = 0.954) and shoulder dominance (p = 0.850). Patients who were randomised to their preferred treatment had better follow-up rates (94 vs 84% at 2 years) and treatment adherence (90 vs 83% reported completing home exercises). Patients who were not randomised to their preferred treatment were more likely to change their treatment preference at 24 months (60 vs 26%). Conclusions The robustness of the PROFHER trial findings was confirmed against possible bias introduced by surgeon and patient preferences. The importance of collecting preference data is highlighted. Trial registration ISRCTN50850043. Registered on 25 March 2008.
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Affiliation(s)
- Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK.
| | - Helen Handoll
- School of Health and Social Care, Teesside University, Middlesbrough, Tees Valley, TS1 3BA, UK
| | - Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK
| | - Laura Jefferson
- Department of Health Sciences, University of York, Heslington, YO10 5DD, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK
| | - Belen Corbacho
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK
| | - Amar Rangan
- York Trials Unit, Department of Health Sciences, University of York, Heslington, YO10 5DD, UK.,Department of Trauma and Orthopaedics, James Cook University Hospital, South Tees Hospitals NHS Trust, Marton Road, Middlesbrough, TS4 3BW, UK
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Affiliation(s)
- G. A. Zentmyer
- Department of Plant Pathology, University of California, Riverside 92502
| | - Laura Jefferson
- Department of Plant Pathology, University of California, Riverside 92502
| | - C. J. Hickman
- Department of Plant Sciences, University of Western Ontario, London 72, Canada
| | - Yung Chang-Ho
- Department of Plant Sciences, University of Western Ontario, London 72, Canada
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11
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Jefferson L, Fairhurst C, Brealey S, Coleman E, Cook L, Hewitt C, Keding A, Northgraves M, Rangan A, Tew GA, Torgerson DJ, Dias J. Remote or on-site visits were feasible for the initial setup meetings with hospitals in a multicenter surgical trial: an embedded randomized trial. J Clin Epidemiol 2018; 100:13-21. [PMID: 29679748 DOI: 10.1016/j.jclinepi.2018.04.011] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Revised: 04/07/2018] [Accepted: 04/11/2018] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To investigate the effects, costs, and feasibility of providing on-site compared with remote meetings to set up hospital sites in a multicenter, surgical randomized controlled trial. STUDY DESIGN AND SETTING Hospitals were randomized to receive the initial trial setup meetings on-site (i.e., face-to-face) or remotely (i.e., via teleconference). Data were collected on site setup, recruitment, follow-up, and costs for the two methods. The hospital staff experience of trial setup was also surveyed. RESULTS Thirty-nine sites were randomized and 33 sites set up to recruit (19 on-site and 14 remote). For sites randomized to an on-site meeting compared with remote meeting respectively, the time from first contact to the first recruit was a median of 246 days (interquartile range [IQR] 196-346] vs. 212 days (IQR 154-266), mean recruitment was 10 participants (median 10, IQR 2-17) vs. 11 participants (median 6, IQR 5-23), and participant follow-up at 12 months was 81% vs. 82%. Sites allocated to an initial on-site visit cost on average £289.83 more to setup. CONCLUSION Remote or on-site visits are feasible for the initial setup meetings with hospitals in a multicenter surgical trial. This embedded trial should be replicated to improve generalizability and increase statistical power using meta-analysis. ISRCTN78899574.
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Affiliation(s)
- Laura Jefferson
- Department of Health Sciences, University of York, Area 4, Seebohm Rowntree Building, Heslington, York YO10 5DD, United Kingdom
| | - Caroline Fairhurst
- Department of Health Sciences, University of York, York Trials Unit, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, United Kingdom
| | - Stephen Brealey
- Department of Health Sciences, University of York, York Trials Unit, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, United Kingdom.
| | - Elizabeth Coleman
- Department of Health Sciences, University of York, York Trials Unit, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, United Kingdom
| | - Liz Cook
- Department of Health Sciences, University of York, York Trials Unit, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, United Kingdom
| | - Catherine Hewitt
- Department of Health Sciences, University of York, York Trials Unit, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, United Kingdom
| | - Ada Keding
- Department of Health Sciences, University of York, York Trials Unit, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, United Kingdom
| | - Matthew Northgraves
- Department of Health Sciences, University of York, York Trials Unit, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, United Kingdom
| | - Amar Rangan
- Department of Health Sciences, University of York, York Trials Unit, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, United Kingdom
| | - Garry A Tew
- Department of Health Sciences, University of York, York Trials Unit, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, United Kingdom
| | - David J Torgerson
- Department of Health Sciences, University of York, York Trials Unit, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, United Kingdom
| | - Joseph Dias
- AToMS-Academic Team of Musculoskeletal Surgery, University Hospitals of Leicester NHS Trust, Leicester General Hospital, Undercroft (nr Ward 28), Gwendolen Road, Leicester LE5 4PW, United Kingdom
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12
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Littlewood E, Ali S, Dyson L, Keding A, Ansell P, Bailey D, Bates D, Baxter C, Beresford-Dent J, Clarke A, Gascoyne S, Gray C, Hackney L, Hewitt C, Hutchinson D, Jefferson L, Mann R, Marshall D, McMillan D, North A, Nutbrown S, Peckham E, Pervin J, Richardson Z, Swan K, Taylor H, Waterhouse B, Wills L, Woodhouse R, Gilbody S. Identifying perinatal depression with case-finding instruments: a mixed-methods study (BaBY PaNDA – Born and Bred in Yorkshire PeriNatal Depression Diagnostic Accuracy). Health Serv Deliv Res 2018. [DOI: 10.3310/hsdr06060] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background
Perinatal depression is well recognised as a mental health condition but < 50% of cases are identified in routine practice. A case-finding strategy using the Whooley questions is currently recommended by the National Institute for Health and Care Excellence.
Objectives
To determine the diagnostic accuracy, acceptability and cost-effectiveness of the Whooley questions and the Edinburgh Postnatal Depression Scale (EPDS) to identify perinatal depression.
Design
A prospective diagnostic accuracy cohort study, with concurrent qualitative and economic evaluations.
Setting
Maternity services in England.
Participants
A total of 391 pregnant women.
Main outcome measures
Women completed the Whooley questions, EPDS and a diagnostic reference standard (Clinical Interview Schedule – Revised) during pregnancy (20 weeks) and postnatally (3–4 months). Qualitative interviews were conducted with health professionals (HPs) and a subsample of women.
Results
Diagnostic accuracy results: depression prevalence rates were 10.3% during pregnancy and 10.5% postnatally. The Whooley questions and EPDS (cut-off point of ≥ 10) performed reasonably well, with comparable sensitivity [pregnancy: Whooley questions 85.0%, 95% confidence interval (CI) 70.2% to 94.3%; EPDS 82.5%, 95% CI 67.2% to 92.7%; postnatally: Whooley questions 85.7%, 95% CI 69.7% to 95.2%; EPDS 82.9%, 95% CI 66.4% to 93.4%] and specificity (pregnancy: Whooley questions 83.7%, 95% CI 79.4% to 87.4%; EPDS 86.6%, 95% CI 82.5% to 90.0%; postnatally: Whooley questions 80.6%, 95% CI 75.7% to 84.9%; EPDS 87.6%, 95% CI 83.3% to 91.1%). Diagnostic accuracy of the EPDS (cut-off point of ≥ 13) was poor at both time points (pregnancy: sensitivity 45%, 95% CI 29.3% to 61.5%, and specificity 95.7%, 95% CI 93.0% to 97.6%; postnatally: sensitivity 62.9%, 95% CI 44.9% to 78.5%, and specificity 95.7%, 95% CI 92.7% to 97.7%). Qualitative evaluation: women and HPs were supportive of screening/case-finding for perinatal depression. The EPDS was preferred to the Whooley questions by women and HPs, mainly because of its ‘softer’ wording. Whooley question 1 was thought to be less acceptable, largely because of the terms ‘depressed’ and ‘hopeless’, leading to women not revealing their depressive symptoms. HPs identified a ‘patient-centred’ environment that focused on the mother and baby to promote discussion about mental health. Cost-effectiveness results: screening/case-finding using the Whooley questions or the EPDS alone was not the most cost-effective strategy. A two-stage strategy, ‘Whooley questions followed by the Patient Health Questionnaire’ (a measure assessing depression symptomatology), was the most cost-effective strategy in the range between £20,000 and £30,000 per quality-adjusted life-year in both the prenatal and postnatal decision models.
Limitations
Perinatal depression diagnosis was not cross-referenced with women’s medical records so the proportion of new cases identified is unknown. The clinical effectiveness and cost-effectiveness of screening/case-finding strategies was not assessed as part of a randomised controlled trial.
Conclusions
The Whooley questions and EPDS had acceptable sensitivity and specificity, but their use in practice might be limited by low predictive value and variation in their acceptability. A two-stage strategy was more cost-effective than single-stage strategies. Neither case-finding instrument met National Screening Committee criteria.
Future work
The yield of screening/case-finding should be established with reference to health-care records. The clinical effectiveness and cost-effectiveness of screening/case-finding for perinatal depression needs to be tested in a randomised controlled trial.
Funding
The National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Elizabeth Littlewood
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Shehzad Ali
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Lisa Dyson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Pat Ansell
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Della Bailey
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Debrah Bates
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe General Hospital, Scunthorpe, UK
| | - Catherine Baxter
- Leeds and York Partnership NHS Foundation Trust, Bootham Park Hospital, York, UK
| | - Jules Beresford-Dent
- Leeds and York Partnership NHS Foundation Trust, Bootham Park Hospital, York, UK
| | - Arabella Clarke
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Samantha Gascoyne
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Carol Gray
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe General Hospital, Scunthorpe, UK
| | - Lisa Hackney
- Leeds and York Partnership NHS Foundation Trust, Bootham Park Hospital, York, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Dorothy Hutchinson
- Northern Lincolnshire and Goole NHS Foundation Trust, Scunthorpe General Hospital, Scunthorpe, UK
| | - Laura Jefferson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Rachel Mann
- Department of Health Sciences, University of York, York, UK
| | - David Marshall
- Leeds and York Partnership NHS Foundation Trust, Bootham Park Hospital, York, UK
| | - Dean McMillan
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
- Hull York Medical School, York, UK
| | - Alice North
- Patient and public involvement representative, York, UK
| | - Sarah Nutbrown
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Emily Peckham
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Jodi Pervin
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Zoe Richardson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Kelly Swan
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Holly Taylor
- Leeds and York Partnership NHS Foundation Trust, Bootham Park Hospital, York, UK
| | - Bev Waterhouse
- Epidemiology and Cancer Statistics Group, Department of Health Sciences, University of York, York, UK
| | - Louise Wills
- Harrogate and District NHS Foundation Trust, Harrogate District Hospital, Harrogate, UK
| | - Rebecca Woodhouse
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
| | - Simon Gilbody
- Mental Health and Addiction Research Group, Department of Health Sciences, University of York, York, UK
- Hull York Medical School, York, UK
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Jefferson L, Brealey S, Handoll H, Keding A, Kottam L, Sbizzera I, Rangan A. Impact of the PROFHER trial findings on surgeons' clinical practice: An online questionnaire survey. Bone Joint Res 2017; 6:590-599. [PMID: 29066532 PMCID: PMC5670363 DOI: 10.1302/2046-3758.610.bjr-2017-0170] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2017] [Accepted: 08/25/2017] [Indexed: 11/26/2022] Open
Abstract
Objectives To explore whether orthopaedic surgeons have adopted the Proximal Fracture of the Humerus: Evaluation by Randomisation (PROFHER) trial results routinely into clinical practice. Methods A questionnaire was piloted with six orthopaedic surgeons using a ‘think aloud’ process. The final questionnaire contained 29 items and was distributed online to surgeon members of the British Orthopaedic Association and British Elbow and Shoulder Society. Descriptive statistics summarised the sample characteristics and fracture treatment of respondents overall, and grouped them by whether they changed practice based on PROFHER trial findings. Free-text responses were analysed qualitatively for emerging themes using Framework Analysis principles. Results There were complete responses from 265 orthopaedic and trauma surgeons who treat patients with proximal humeral fractures. Around half (137) had changed practice to various extents because of PROFHER, by operating on fewer PROFHER-eligible fractures. A third (43) of the 128 respondents who had not changed practice were already managing patients non-operatively. Those who changed practice were more likely to be younger, work in a trauma unit rather than a major trauma centre, be specialist shoulder surgeons and treat fewer PROFHER-eligible fractures surgically. This group gave higher scores when assessing validity and applicability of PROFHER. In contrast, a quarter of the non-changers were critical, sometimes emphatically, of PROFHER. The strongest theme that emerged overall was the endorsement of evidence-based practice. Conclusion PROFHER has had an impact on surgeons’ clinical practice, both through changing it, and through underpinning existing non-operative practice. Although some respondents expressed reservations about the trial, evidence from such trials was found to be the most important influence on surgeons’ decisions to change practice. Cite this article: L. Jefferson, S. Brealey, H. Handoll, A. Keding, L. Kottam, I. Sbizzera, A. Rangan. Impact of the PROFHER trial findings on surgeons’ clinical practice: An online questionnaire survey. Bone Joint Res 2017;6:590–599. DOI: 10.1302/2046-3758.610.BJR-2017-0170.
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Affiliation(s)
- L Jefferson
- Department of Health Sciences, University of York, Heslington, York YO10 5DD, UK
| | - S Brealey
- York Trials Unit, University of York, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, UK
| | - H Handoll
- School of Health and Social Care, Teesside University, Middlesbrough, Tees Valley TS1 3BA, UK
| | - A Keding
- York Trials Unit, University of York, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, UK
| | - L Kottam
- Department of Trauma and Orthopaedics, South Tees Hospitals NHS Trust, James Cook University Hospital, Marton Road, Middlesborough, Tees Valley TS4 3BW, UK
| | - I Sbizzera
- York Trials Unit, University of York, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, UK
| | - A Rangan
- York Trials Unit, University of York, Lower Ground Floor, ARRC Building, Heslington, York YO10 5DD, UK and School of Health and Social Care, Middlesbrough, Tees Valley TS1 3BA, UK and South Tees Hospitals NHS Trust, Marton Road, Middlesborough TS4 3BW, UK
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Arundel C, Jefferson L, Bailey M, Cockayne S, Hicks K, Loughrey L, Rodgers S, Torgerson DJ. A randomized, embedded trial of pre-notification of trial participation did not increase recruitment rates to a falls prevention trial. J Eval Clin Pract 2017; 23:73-78. [PMID: 27320133 DOI: 10.1111/jep.12576] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 05/06/2016] [Accepted: 05/09/2016] [Indexed: 11/27/2022]
Abstract
OBJECTIVES To design and evaluate the effectiveness of a pre-notification leaflet about research to increase recruitment to a randomized controlled trial (RCT). METHODS A methodological, two-arm, RCT was conducted, embedded within an existing cohort RCT (REFORM). Participants were randomized for the embedded trial, using a 1:2 ratio (intervention : control) before being randomized for REFORM. Controls received a trial recruitment pack. The intervention group received an additional pre-notification leaflet 2-3 weeks before the recruitment pack. Primary and secondary analyses were conducted using relative risk, the Cox proportional hazards model and incremental cost-effectiveness ratios. RESULTS Of the 1436 intervention group participants, 73 (5.1%) were randomized into the REFORM trial compared with 126 (4.4%) of the 2878 control group participants. The associated relative risk (1.16) was not statistically significant [95% confidence interval (CI) 0.88-1.56]. Return rate was not significantly increased (relative risk 1.10, 95% CI 0.92-1.28) nor time to return decreased (hazard ratio: 1.11, 95% CI 0.93-1.33). Incremental cost-effectiveness ratios indicated the intervention may be cost-effective if the true estimate of effect was close to the upper bound of the associated 95% CI. CONCLUSION Pre-notification for potential trial participants demonstrated a small difference to randomization (0.7% difference) and return rates (1.1% difference) in favour of the intervention. Results should however be interpreted with caution as CIs for these estimates cross the point of no effect. Nevertheless, this research enhances existing evidence for pre-notification to increase recruitment rates, with further development and assessment of this potentially cost-effective intervention being recommended.
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Affiliation(s)
- Catherine Arundel
- York Trials Unit - Department of Health Sciences, The University of York, York, UK
| | - Laura Jefferson
- York Trials Unit - Department of Health Sciences, The University of York, York, UK
| | - Matthew Bailey
- York Trials Unit - Department of Health Sciences, The University of York, York, UK
| | - Sarah Cockayne
- York Trials Unit - Department of Health Sciences, The University of York, York, UK
| | - Kate Hicks
- York Trials Unit - Department of Health Sciences, The University of York, York, UK
| | - Lorraine Loughrey
- York Trials Unit - Department of Health Sciences, The University of York, York, UK
| | - Sara Rodgers
- York Trials Unit - Department of Health Sciences, The University of York, York, UK
| | - David J Torgerson
- York Trials Unit - Department of Health Sciences, The University of York, York, UK
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- York Trials Unit - Department of Health Sciences, The University of York, York, UK
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15
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Jefferson L, Fairhurst C, Cooper E, Hewitt C, Torgerson T, Cook L, Tharmanathan P, Cockayne S, Torgerson D. No difference found in time to publication by statistical significance of trial results: a methodological review. JRSM Open 2016; 7:2054270416649283. [PMID: 27757242 PMCID: PMC5052771 DOI: 10.1177/2054270416649283] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [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] [Indexed: 12/22/2022] Open
Abstract
Objective Time-lag from study completion to publication is a potential source of publication bias in randomised controlled trials. This study sought to update the evidence base by identifying the effect of the statistical significance of research findings on time to publication of trial results. Design Literature searches were carried out in four general medical journals from June 2013 to June 2014 inclusive (BMJ, JAMA, the Lancet and the New England Journal of Medicine). Setting Methodological review of four general medical journals. Participants Original research articles presenting the primary analyses from phase 2, 3 and 4 parallel-group randomised controlled trials were included. Main outcome measures Time from trial completion to publication. Results The median time from trial completion to publication was 431 days (n = 208, interquartile range 278–618). A multivariable adjusted Cox model found no statistically significant difference in time to publication for trials reporting positive or negative results (hazard ratio: 0.86, 95% CI 0.64 to 1.16, p = 0.32). Conclusion In contrast to previous studies, this review did not demonstrate the presence of time-lag bias in time to publication. This may be a result of these articles being published in four high-impact general medical journals that may be more inclined to publish rapidly, whatever the findings. Further research is needed to explore the presence of time-lag bias in lower quality studies and lower impact journals.
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Affiliation(s)
- L Jefferson
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - C Fairhurst
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - E Cooper
- Elderly medicine, York Hospital, York YO31 8HE, UK
| | - C Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - T Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - L Cook
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - P Tharmanathan
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - S Cockayne
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
| | - D Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York YO10 5DD, UK
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Handoll HHG, Brealey SD, Jefferson L, Keding A, Brooksbank AJ, Johnstone AJ, Candal-Couto JJ, Rangan A. Defining the fracture population in a pragmatic multicentre randomised controlled trial: PROFHER and the Neer classification of proximal humeral fractures. Bone Joint Res 2016; 5:481-489. [PMID: 27756739 PMCID: PMC5086839 DOI: 10.1302/2046-3758.510.bjr-2016-0132.r1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Accepted: 08/24/2016] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVES Accurate characterisation of fractures is essential in fracture management trials. However, this is often hampered by poor inter-observer agreement. This article describes the practicalities of defining the fracture population, based on the Neer classification, within a pragmatic multicentre randomised controlled trial in which surgical treatment was compared with non-surgical treatment in adults with displaced fractures of the proximal humerus involving the surgical neck. METHODS The trial manual illustrated the Neer classification of proximal humeral fractures. However, in addition to surgical neck displacement, surgeons assessing patient eligibility reported on whether either or both of the tuberosities were involved. Anonymised electronic versions of baseline radiographs were sought for all 250 trial participants. A protocol, data collection tool and training presentation were developed and tested in a pilot study. These were then used in a formal assessment and classification of the trial fractures by two independent senior orthopaedic shoulder trauma surgeons. RESULTS Two or more baseline radiographic views were obtained for each participant. The independent raters confirmed that all fractures would have been considered for surgery in contemporaneous practice. A full description of the fracture population based on the Neer classification was obtained. The agreement between the categorisation at baseline (tuberosity involvement) and Neer classification as assessed by the two raters was only fair (kappa 0.29). However, this disparity did not appear to affect trial findings, specifically in terms of influencing the effect of treatment on the primary outcome of the trial. CONCLUSIONS A key reporting requirement, namely the description of the fracture population, was achieved within the context of a pragmatic multicentre randomised clinical trial. This article provides important guidance for researchers designing similar trials on fracture management.Cite this article: H. H. G. Handoll, S. D. Brealey, L. Jefferson, A. Keding, A. J. Brooksbank, A. J. Johnstone, J. J. Candal-Couto, A. Rangan. Defining the fracture population in a pragmatic multicentre randomised controlled trial: PROFHER and the Neer classification of proximal humeral fractures.Bone Joint Res 2016;5:481-489. DOI: 10.1302/2046-3758.510.BJR-2016-0132.R1.
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Affiliation(s)
- H H G Handoll
- Health and Social Care Institute, School of Health and Social Care, Teesside University, Middlesbrough, Tees Valley, TS1 3BA, UK
| | - S D Brealey
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - L Jefferson
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - A Keding
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - A J Brooksbank
- Department of Orthopaedics and Trauma, Glasgow Royal Infirmary, 84 Castle Street, Glasgow, G4 0SF, UK
| | - A J Johnstone
- Orthopaedic Trauma Unit, Aberdeen Royal Infirmary, Foresterhill, Aberdeen, AB25 2ZN, UK
| | - J J Candal-Couto
- Northumbria Healthcare NHS Trust, Wansbeck General Hospital, Woodhorn Lane, Ashington, Northumberland, NE63 9JJ, UK
| | - A Rangan
- Department of Trauma and Orthopaedics, James Cook University Hospital, South Tees Hospitals NHS Trust, Marton Road, Middlesbrough, TS4 3BW, UK
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Dias J, Brealey S, Choudhary S, Cook L, Costa M, Fairhurst C, Hewitt C, Hodgson S, Jefferson L, Jeyapalan K, Keding A, Leighton P, Rangan A, Richardson G, Rothery C, Taub N, Thompson J, Torgerson D. Scaphoid Waist Internal Fixation for Fractures Trial (SWIFFT) protocol: a pragmatic multi-centre randomised controlled trial of cast treatment versus surgical fixation for the treatment of bi-cortical, minimally displaced fractures of the scaphoid waist in adults. BMC Musculoskelet Disord 2016; 17:248. [PMID: 27260639 PMCID: PMC4893284 DOI: 10.1186/s12891-016-1107-7] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 05/28/2016] [Indexed: 12/22/2022] Open
Abstract
Background A scaphoid fracture is the most common type of carpal fracture affecting young active people. The optimal management of this fracture is uncertain. When treated with a cast, 88 to 90 % of these fractures unite; however, for the remaining 10-12 % the non-union almost invariably leads to arthritis. The alternative is surgery to fix the scaphoid with a screw at the outset. Methods/Design We will conduct a randomised controlled trial (RCT) of 438 adult patients with a “clear” and “bicortical” scaphoid waist fracture on plain radiographs to evaluate the clinical effectiveness and cost-effectiveness of plaster cast treatment (with fixation of those that fail to unite) versus early surgical fixation. The plaster cast treatment will be immobilisation in a below elbow cast for 6 to 10 weeks followed by mobilisation. If non-union is confirmed on plain radiographs and/or Computerised Tomogram at 6 to 12 weeks, then urgent surgical fixation will be performed. This is being compared with immediate surgical fixation with surgeons using their preferred technique and implant. These treatments will be undertaken in trauma units across the United Kingdom. The primary outcome and end-point will be the Patient Rated Wrist Evaluation (a patient self-reported assessment of wrist pain and function) at 52 weeks and also measured at 6, 12, 26 weeks and 5 years. Secondary outcomes include an assessment of radiological union of the fracture; quality of life; recovery of wrist range and strength; and complications. We will also qualitatively investigate patient experiences of their treatment. Discussion Scaphoid fractures are an important public health problem as they predominantly affect young active individuals in the more productive working years of their lives. Non-union, if untreated, can lead to arthritis which can disable patients at a very young age. There is a rapidly increasing trend for immediate surgical fixation of these fractures but there is insufficient evidence from existing RCTs to support this. The SWIFFT Trial is a rigorously designed and adequately powered study which aims to contribute to the evidence-base to inform clinical decisions for the treatment of this common fracture in adults. Trial registration The trial is registered with the International Standard Randomised Controlled Trial Register (ISRCTN67901257). Date registration assigned was 13/02/2013.
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Affiliation(s)
- Joseph Dias
- AToMS - Academic Team of Musculoskeletal Surgery, Undercroft (nr Ward 28), University Hospitals of Leicester NHS Trust, Leicester General Hospital, Gwendolen Road, Leicester, LE5 4PW, UK.
| | - Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Surabhi Choudhary
- Department of Radiology, University Hospital Birmingham, Mindelsohn Way, Edgbaston, Birmingham, B15 2WB, UK
| | - Liz Cook
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Matthew Costa
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, The Kadoorie Centre, John Radcliffe Hospital, Oxford, OX3 9DU, UK
| | - Caroline Fairhurst
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Catherine Hewitt
- York Trials Unit and NIHR RDS YH, Department of Health Sciences, Faculty of Science, University of York, ARRC Building, Heslington, York, YO10 5DD, UK
| | - Stephen Hodgson
- Bolton NHS Foundation Trust, Trust HQ, Royal Bolton Hospital, 1st Floor, Minerva Road, Farnworth, Bolton, BL4 0JR, UK
| | - Laura Jefferson
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Kanagaratnam Jeyapalan
- Department of Diagnostic Radiology, University Hospitals of Leicester, The Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, Heslington, York, YO10 5DD, UK
| | - Paul Leighton
- School of Medicine, University of Nottingham, Nottingham Health Science Partners, C-Floor South Block, Queens Medical Centre, Nottingham, NG7 2UH, UK
| | - Amar Rangan
- South Tees Hospitals NHS Foundation Trust, The James Cook University Hospital, Marton Road, Middlesbrough, TS4 3BW, UK
| | - Gerry Richardson
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
| | - Claire Rothery
- Centre for Health Economics, University of York, Heslington, York, YO10 5DD, UK
| | - Nicholas Taub
- Department of Health Sciences & NIHR Research Design Service for the East Midlands, University of Leicester, Centre for Medicine, University Road, Leicester, LE1 7RH, UK
| | - John Thompson
- Department of Health Sciences, College of Medicine, Biological Sciences and Psychology, University of Leicester, Centre for Medicine, University Road, Leicester, LE1 7RH, UK
| | - David Torgerson
- York Trials Unit and NIHR RDS YH, Department of Health Sciences, Faculty of Science, University of York, ARRC Building, Heslington, York, YO10 5DD, UK
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Corbacho B, Duarte A, Keding A, Handoll H, Chuang LH, Torgerson D, Brealey S, Jefferson L, Hewitt C, Rangan A. Cost effectiveness of surgical versus non-surgical treatment of adults with displaced fractures of the proximal humerus. Bone Joint J 2016; 98-B:152-9. [DOI: 10.1302/0301-620x.98b2.36614] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
Aims A pragmatic multicentre randomised controlled trial (PROFHER) was conducted in United Kingdom National Health Service (NHS) hospitals to evaluate the clinical effectiveness and cost effectiveness of surgery compared with non-surgical treatment for displaced fractures of the proximal humerus involving the surgical neck in adults. Methods A cost utility analysis from the NHS perspective was performed. Differences between surgical and non-surgical treatment groups in costs and quality adjusted life years (QALYs) at two years were used to derive an estimate of the cost effectiveness of surgery using regression methods. Results Patients randomised to receive surgical intervention accumulated mean greater costs and marginally lower QALYs than patients randomised to non-surgery. The surgical intervention cost a mean of £1758 more per patient (95% confidence intervals (CI) £1126 to £2389). Total QALYs for the surgical group were smaller than those for non-surgery -0.0101 (95% CI -0.13 to 0.11). The probability of surgery being cost effective was less than 10% given the current NICE willingness to pay at a threshold of £20 000 for an additional QALY. The results were robust to sensitivity analyses. Discussion The results suggest that current surgical treatment is not cost effective for the majority of displaced fractures of the proximal humerus involving the surgical neck in the United Kingdom’s NHS. Take home message: The results of this trial do not support the trend of increased surgical treatment for patients with displaced fractures of the proximal humerus involving the surgical neck within the United Kingdom NHS. Cite this article: Bone Joint J 2016;98-B:152–9.
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Affiliation(s)
- B. Corbacho
- University of York, Heslington, York, YO10
5DD, UK
| | - A. Duarte
- Centre for Health Economics, University
of York, Alcuin Block A, University
of York, York, YO10 5DD, UK
| | - A. Keding
- University of York, Heslington, York, YO10
5DD, UK
| | - H. Handoll
- Teesside University, Middlesbrough, Tees
Valley, TS1 3BA, UK
| | - L. H. Chuang
- Pharmerit Europe, Marten
Meesweg 107, 3068 AV Rotterdam, The
Netherlands
| | - D. Torgerson
- University of York, Heslington, York, YO10
5DD, UK
| | - S. Brealey
- University of York, Heslington, York, YO10
5DD, UK
| | - L. Jefferson
- University of York, Heslington, York, YO10
5DD, UK
| | - C. Hewitt
- University of York, Heslington, York, YO10
5DD, UK
| | - A. Rangan
- James
Cook University Hospital, Marton Road, Middlesbrough, TS4
3BW, UK
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Jefferson L, Cook L, Keding A, Brealey S, Handoll H, Rangan A. "Away Days" in multicenter randomized controlled trials: a questionnaire survey of their use and a case study on the effect of one Away Day on patient recruitment. J Evid Based Med 2016; 9:24-31. [PMID: 26549433 DOI: 10.1111/jebm.12180] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2014] [Accepted: 10/27/2015] [Indexed: 01/11/2023]
Abstract
OBJECTIVE "Away Days" (trial promotion and training events for trial site personnel) are a well-established method used by trialists to encourage engagement of research sites in the recruitment of patients to multicenter randomized controlled trials (RCTs). We explored the use of Away Days in multicenter RCTs and analyzed the effect on patient recruitment in a case study. METHODS Members of the United Kingdom Trial Managers' Network were surveyed in June 2013 to investigate their experiences in the design and conduct of Away Days in RCTs. We used data from a multicenter pragmatic surgical trial to explore the effects of an Away Day on the screening and recruitment of patients. RESULTS A total of 94 people responded to the survey. The majority (78%), who confirmed had organized an Away Day previously, found them to be useful. This is despite their costs. There was no evidence, however, from the analysis of data from a surgical trial that attendance at an Away Day increased the number of patients screened or recruited at participating sites. CONCLUSIONS Although those responsible for managing RCTs in the UK tend to believe that trial Away Days are beneficial, evidence from a multicenter surgical trial shows no improvement on a key indicator of trial success. This points to the need to carefully consider the aims, design, and conduct of Away Days. Further more rigorous research nested within RCTs would be valuable to evaluate the design and conduct of Away Days.
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Affiliation(s)
- Laura Jefferson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Liz Cook
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Helen Handoll
- School of Health and Social Care, Health and Social Care Institute, Teesside University, Middlesbrough, UK
| | - Amar Rangan
- The James Cook University Hospital, Middlesbrough, UK
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Handoll H, Brealey S, Rangan A, Keding A, Corbacho B, Jefferson L, Chuang LH, Goodchild L, Hewitt C, Torgerson D. The ProFHER (PROximal Fracture of the Humerus: Evaluation by Randomisation) trial - a pragmatic multicentre randomised controlled trial evaluating the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment for proximal fracture of the humerus in adults. Health Technol Assess 2015; 19:1-280. [PMID: 25822598 DOI: 10.3310/hta19240] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND Proximal humeral fractures account for 5-6% of all fractures in adults. There is considerable variation in whether or not surgery is used in the management of displaced fractures involving the surgical neck. OBJECTIVE To evaluate the clinical effectiveness and cost-effectiveness of surgical compared with non-surgical treatment of the majority of displaced fractures of the proximal humerus involving the surgical neck in adults. DESIGN A pragmatic parallel-group multicentre randomised controlled trial with an economic evaluation. Follow-up was for 2 years. SETTING Recruitment was undertaken in the orthopaedic departments of 33 acute NHS hospitals in the UK. Patient care pathways included outpatient and community-based rehabilitation. PARTICIPANTS Adults (aged ≥ 16 years) presenting within 3 weeks of their injury with a displaced fracture of the proximal humerus involving the surgical neck. INTERVENTIONS The choice of surgical intervention was left to the treating surgeons, who used techniques with which they were experienced. Non-surgical treatment was initial sling immobilisation followed by active rehabilitation. Provision of rehabilitation was comparable in both groups. MAIN OUTCOME MEASURES The primary outcome was the Oxford Shoulder Score (OSS) assessed at 6, 12 and 24 months. Secondary outcomes were the 12-item Short Form health survey, surgical and other shoulder fracture-related complications, secondary surgery to the shoulder or increased/new shoulder-related therapy, medical complications during inpatient stay and mortality. European Quality of Life-5 Dimensions data and treatment costs were also collected. RESULTS The mean age of the 250 trial participants was 66 years and 192 (77%) were female. Independent assessment using the Neer classification identified 18 one-part fractures, 128 two-part fractures and 104 three- or four-part fractures. OSS data were available for 215 participants at 2 years. We found no statistically or clinically significant differences in OSS scores between the two treatment groups (scale 0-48, with a higher score indicating a better outcome) over the 2-year period [difference of 0.75 points in favour of the surgery group, 95% confidence interval (CI) -1.33 to 2.84; p = 0.479; data from 114 surgery and 117 non-surgery participants] or at individual time points. We found no statistically significant differences between surgical and non-surgical group participants in SF-12 physical or mental component summary scores; surgical or shoulder fracture-related complications (30 vs. 23 respectively); those undergoing further shoulder-related therapy, either surgery (11 vs. 11 respectively) or other therapy (seven vs. four respectively); or mortality (nine vs. five respectively). The base-case economic analysis showed that, at 2 years, the cost of surgical intervention was, on average, £1780.73 more per patient (95% CI £1152.71 to £2408.75) than the cost of non-surgical intervention. It was also slightly less beneficial in terms of utilities, although this difference was not statistically significant. The net monetary benefit associated with surgery is negative. There was only a 5% probability of surgery achieving the criterion of costing < £20,000 to gain a quality-adjusted life-year, which was confirmed by extensive sensitivity analyses. CONCLUSIONS Current surgical practice does not result in a better outcome for most patients with displaced fractures of the proximal humerus involving the surgical neck and is not cost-effective in the UK setting. Two areas for future work are the setting up of a national database of these fractures, including the collection of patient-reported outcomes, and research on the best ways of informing patients with these and other upper limb fractures about initial self-care. TRIAL REGISTRATION Current Controlled Trials ISRCTN50850043. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 24. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Helen Handoll
- Health and Social Care Institute, School of Health and Social Care, Teesside University, Middlesbrough, UK
| | - Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Amar Rangan
- Department of Trauma and Orthopaedics, James Cook University Hospital, Middlesbrough, UK
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Belen Corbacho
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - Laura Jefferson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | | | - Lorna Goodchild
- Department of Rehabilitation, James Cook University Hospital, Middlesbrough, UK
| | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, UK
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, UK
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Abstract
INTRODUCTION Women now outnumber men in British medical schools. This paper charts the history of women in medicine and provides current demographic trends. SOURCES OF DATA A historical literature review and routinely collected data from Department of Health and the Health and Social Care Information Centre. AREAS OF AGREEMENT Clear gender differences are apparent in working practices, including greater likelihood of working part time and specializing in certain areas of medicine. AREAS OF CONTROVERSY The increasing need to increase activity among the existing medical workforce is timely amidst a changing workforce demographic. GROWING POINTS Workforce planners, policymakers and Royal Colleges should continue to develop interventions that may reduce disparities in career choices, as well as considering ways to increase participation and activity. AREAS TIMELY FOR DEVELOPING RESEARCH Further research is needed to explore the cost-effectiveness of existing and future interventions in this field.
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Affiliation(s)
- Laura Jefferson
- Department of Health Sciences, The University of York, York, UK
| | - Karen Bloor
- Department of Health Sciences, The University of York, York, UK
| | - Alan Maynard
- Department of Health Sciences, The University of York, York, UK
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Rangan A, Handoll H, Brealey S, Jefferson L, Keding A, Martin BC, Goodchild L, Chuang LH, Hewitt C, Torgerson D. Surgical vs nonsurgical treatment of adults with displaced fractures of the proximal humerus: the PROFHER randomized clinical trial. JAMA 2015; 313:1037-47. [PMID: 25756440 DOI: 10.1001/jama.2015.1629] [Citation(s) in RCA: 306] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE The need for surgery for the majority of patients with displaced proximal humeral fractures is unclear, but its use is increasing. OBJECTIVE To evaluate the clinical effectiveness of surgical vs nonsurgical treatment for adults with displaced fractures of the proximal humerus involving the surgical neck. DESIGN, SETTING, AND PARTICIPANTS A pragmatic, multicenter, parallel-group, randomized clinical trial, the Proximal Fracture of the Humerus Evaluation by Randomization (PROFHER) trial, recruited 250 patients aged 16 years or older (mean age, 66 years [range, 24-92 years]; 192 [77%] were female; and 249 [99.6%] were white) who presented at the orthopedic departments of 32 acute UK National Health Service hospitals between September 2008 and April 2011 within 3 weeks after sustaining a displaced fracture of the proximal humerus involving the surgical neck. Patients were followed up for 2 years (up to April 2013) and 215 had complete follow-up data. The data for 231 patients (114 in surgical group and 117 in nonsurgical group) were included in the primary analysis. INTERVENTIONS Fracture fixation or humeral head replacement were performed by surgeons experienced in these techniques. Nonsurgical treatment was sling immobilization. Standardized outpatient and community-based rehabilitation was provided to both groups. MAIN OUTCOMES AND MEASURES Primary outcome was the Oxford Shoulder Score (range, 0-48; higher scores indicate better outcomes) assessed during a 2-year period, with assessment and data collection at 6, 12, and 24 months. Sample size was based on a minimal clinically important difference of 5 points for the Oxford Shoulder Score. Secondary outcomes were the Short-Form 12 (SF-12), complications, subsequent therapy, and mortality. RESULTS There was no significant mean treatment group difference in the Oxford Shoulder Score averaged over 2 years (39.07 points for the surgical group vs 38.32 points for the nonsurgical group; difference of 0.75 points [95% CI, -1.33 to 2.84 points]; P = .48) or at individual time points. There were also no significant between-group differences over 2 years in the mean SF-12 physical component score (surgical group: 1.77 points higher [95% CI, -0.84 to 4.39 points]; P = .18); the mean SF-12 mental component score (surgical group: 1.28 points lower [95% CI, -3.80 to 1.23 points]; P = .32); complications related to surgery or shoulder fracture (30 patients in surgical group vs 23 patients in nonsurgical group; P = .28), requiring secondary surgery to the shoulder (11 patients in both groups), and increased or new shoulder-related therapy (7 patients vs 4 patients, respectively; P = .58); and mortality (9 patients vs 5 patients; P = .27). Ten medical complications (2 cardiovascular events, 2 respiratory events, 2 gastrointestinal events, and 4 others) occurred in the surgical group during the postoperative hospital stay. CONCLUSIONS AND RELEVANCE Among patients with displaced proximal humeral fractures involving the surgical neck, there was no significant difference between surgical treatment compared with nonsurgical treatment in patient-reported clinical outcomes over 2 years following fracture occurrence. These results do not support the trend of increased surgery for patients with displaced fractures of the proximal humerus. TRIAL REGISTRATION isrctn.com Identifier: ISRCTN50850043.
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Affiliation(s)
- Amar Rangan
- James Cook University Hospital, Middlesbrough, England
| | - Helen Handoll
- Health and Social Care Institute, School of Health and Social Care, Teesside University, Middlesbrough, England
| | - Stephen Brealey
- York Trials Unit, Department of Health Sciences, University of York, York, England
| | - Laura Jefferson
- York Trials Unit, Department of Health Sciences, University of York, York, England
| | - Ada Keding
- York Trials Unit, Department of Health Sciences, University of York, York, England
| | | | | | | | - Catherine Hewitt
- York Trials Unit, Department of Health Sciences, University of York, York, England
| | - David Torgerson
- York Trials Unit, Department of Health Sciences, University of York, York, England
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Jefferson L, Bloor K, Hewitt C. The effect of physician gender on length of patient consultations: observational findings from the UK hospital setting and synthesis with existing studies. J R Soc Med 2015; 108:136-41. [PMID: 25567769 DOI: 10.1177/0141076814558522] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVES To investigate the effect of physician gender on consultation length in UK hospital outpatient clinics and compare this, through meta-analysis, with previous studies outside the UK. DESIGN Observational data on clinic times were analysed and findings were combined in a meta-analysis with existing studies investigating the effect of physician gender on consultation length. SETTING UK hospital practice. PARTICIPANTS A total of 174 observations of outpatient consultations with 10 hospital specialists (consultants) from different specialties in two UK hospital trusts. MAIN OUTCOME MEASURES Clinic times were recorded and analysis of consultation length was undertaken with physician gender as a covariate. Data were then synthesised through meta-analysis with 10 existing studies in this field. RESULTS No statistically significant difference was found in the length of consultations for male and female doctors in these UK hospital settings. When pooled with existing studies, consultations with women doctors were found to be approximately two minutes longer than with men (p = 0.01). CONCLUSIONS Findings from this analysis of clinic consultations in the UK National Health Service do not support previous studies, which were undertaken predominantly in North America and primary care settings. Overall, meta-analysis suggests doctors' gender may influence consultation length. Gender differences in communication should be considered in training clinicians and in overall clinical practice.
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Affiliation(s)
- Laura Jefferson
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Karen Bloor
- Department of Health Sciences, University of York, York, YO10 5DD, UK
| | - Catherine Hewitt
- Department of Health Sciences, University of York, York, YO10 5DD, UK
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Abstract
OBJECTIVE Internationally, increasing numbers of women are practising medicine. Gender differences in doctors' working hours, specialty choices and communication styles are well documented, but studies often neglect contextual factors such as the role of socialised gender expectations on behaviours in the workplace and the medical profession. These may be important as recent studies have reported gender differences in doctors' activity rates that cannot be explained by specialty or contracted hours, suggesting other sources of variation. This study sought to explore the working lives of hospital doctors and how their work is negotiated according to gender and context. DESIGN Gender differences in the day-to-day work of hospital specialists (consultants) in the NHS were investigated using a qualitative approach, including observation and interview methods. Data were analysed inductively using qualitative observation and interview methods. SETTING Two NHS hospital trusts in England. PARTICIPANTS Data were collected from 13 participants working in a variety of specialties and in a range of clinical and non-clinical settings. MAIN OUTCOME MEASURES Various behaviours, attitudes and experiences were explored, such as doctor-patient communication, interactions with colleagues and workload. RESULTS Influences at both individual and situational levels, appear to affect differentially the work of male and female doctors. Female consultants described awareness of the impact of behaviours on relationships with colleagues, and their interactions appeared to be more carefully performed. Nurses and other colleagues tend to demonstrate less cooperation with female consultants. Gender differences also exist in patient communication, feelings of work-family conflict and barriers to career progression. CONCLUSIONS These variations in hospital consultants' work may have implications for both the quantity and quality of care provided by male and female consultants. This is timely and of importance to the medical workforce as the gender composition approaches parity.
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Affiliation(s)
- Laura Jefferson
- Department of Health Sciences, University of York, York Trials Unit, University of York, York YO10 5DD, UK
| | - Karen Bloor
- Department of Health Sciences, University of York, York Trials Unit, University of York, York YO10 5DD, UK
| | - Karen Spilsbury
- Department of Health Sciences, University of York, York Trials Unit, University of York, York YO10 5DD, UK
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Handoll HHG, Goodchild L, Brealey SD, Hanchard NCA, Jefferson L, Keding A, Rangan A. Developing, delivering and documenting rehabilitation in a multi-centre randomised controlled surgical trial: experiences from the ProFHER trial. Bone Joint Res 2014; 3:335-40. [PMID: 25519445 PMCID: PMC4286698 DOI: 10.1302/2046-3758.312.2000364] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
Objectives A rigorous approach to developing, delivering and documenting
rehabilitation within randomised controlled trials of surgical interventions
is required to underpin the generation of reliable and usable evidence.
This article describes the key processes used to ensure provision
of good quality and comparable rehabilitation to all participants
of a multi-centre randomised controlled trial comparing surgery
with conservative treatment of proximal humeral fractures in adults. Methods These processes included the development of a patient information
leaflet on self-care during sling immobilisation, the development
of a basic treatment physiotherapy protocol that received input
and endorsement by specialist physiotherapists providing patient
care, and establishing an expectation for the provision of home
exercises. Specially designed forms were also developed to facilitate
reliable reporting of the physiotherapy care that patients received. Results All three initiatives were successfully implemented, alongside
the measures to optimise the documentation of physiotherapy. Thus,
all participating sites that recruited patients provided the sling
immobilisation leaflet, all adhered to the physiotherapy protocol
and all provided home exercises. There was exemplary completion
of the physiotherapy forms that often reflected a complex patient
care pathway. These data demonstrated equal and high access to and
implementation of physiotherapy between groups, including the performance
of home exercises. Conclusion In order to increase the validity and relevance of the evidence
from trials of surgical interventions and meet international reporting
standards, careful attention to study design, conduct and reporting
of the intrinsic rehabilitation components is required. The involvement
of rehabilitation specialists is crucial to achieving this. Cite this article: Bone Joint Res 2014;3:335–40.
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Affiliation(s)
- H H G Handoll
- Health and Social Care Institute, School of Health and Social Care, Teesside University, Middlesbrough TS1 3BA, UK
| | - L Goodchild
- James Cook University Hospital, South Tees Hospitals NHS Trust, Marton Road, Middlesbrough TS4 3BW, UK
| | - S D Brealey
- York Trials Unit, Lower Ground Floor, ARRC Building, Department of Health Sciences, University of York, Heslington, York YO10 5DD, UK
| | - N C A Hanchard
- Health and Social Care Institute, School of Health and Social Care, Teesside University, Middlesbrough TS1 3BA, UK
| | - L Jefferson
- York Trials Unit, Lower Ground Floor, ARRC Building, Department of Health Sciences, University of York, Heslington, York YO10 5DD, UK
| | - A Keding
- York Trials Unit, Lower Ground Floor, ARRC Building, Department of Health Sciences, University of York, Heslington, York YO10 5DD, UK
| | - A Rangan
- James Cook University Hospital, South Tees Hospitals NHS Trust, Marton Road, Middlesbrough TS4 3BW, UK
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Abstract
The aim of this study was to review the role
of clinical trial networks in orthopaedic surgery. A total of two
electronic databases (MEDLINE and EMBASE) were searched from inception
to September 2013 with no language restrictions. Articles related
to randomised controlled trials (RCTs), research networks and orthopaedic
research, were identified and reviewed. The usefulness of trainee-led
research collaborations is reported and our knowledge of current
clinical trial infrastructure further supplements the review. Searching
yielded 818 titles and abstracts, of which 12 were suitable for
this review. Results are summarised and presented narratively under
the following headings: 1) identifying clinically relevant research
questions; 2) education and training; 3) conduct of multicentre
RCTs and 4) dissemination and adoption of trial results. This review
confirms growing international awareness of the important role research
networks play in supporting trials in orthopaedic surgery. Multidisciplinary
collaboration and adequate investment in trial infrastructure are crucial
for successful delivery of RCTs. Cite this article: Bone Joint Res 2014;3:169–74.
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Affiliation(s)
- A Rangan
- The James Cook University Hospital, Marton Road, Middlesborough, TS4 3BW, UK
| | - L Jefferson
- University of York, York Trials Unit, Department of Health Sciences, York, YO10 5DD, UK
| | - P Baker
- The James Cook University Hospital, Marton Road, Middlesborough, TS4 3BW, UK
| | - L Cook
- University of York, York Trials Unit, Department of Health Sciences, York, YO10 5DD, UK
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Rodgers S, Brealey S, Jefferson L, McDaid C, Maund E, Hanchard N, Goodchild L, Spencer S. Exploring the outcomes in studies of primary frozen shoulder: is there a need for a core outcome set? Qual Life Res 2014; 23:2495-504. [PMID: 24817317 DOI: 10.1007/s11136-014-0708-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/28/2014] [Indexed: 01/28/2023]
Abstract
PURPOSE In our study we explored the need to define a core outcome set for primary frozen shoulder. METHODS We investigated the outcomes used by studies included in a systematic review of the management of primary frozen shoulder; surveyed which primary outcome measures health care professionals considered important; and re-examined papers previously obtained for a systematic review of patients' views of interventions for frozen shoulder to investigate their views on outcomes. RESULTS Thirty-one studies investigated the outcomes range of movement (28 studies), pain (22), function and disability (22), adverse events (13), quality of life (7) and other outcomes (5). Many different types of pain and ranges of movement were measured. Function and disability was measured using fifteen instruments, the content of which varied considerably. Function and disability, pain and range of movement (132, 108 and 104 respondents, respectively) were most often cited by health care professionals as the primary outcome measure that should be used. Searches identified one paper that included patients' views. Outcomes of importance to patients were pain at night, general pain, reduced mobility (resulting in modification of activities) and the emotional impact of frozen shoulder. CONCLUSIONS We identified a diverse range of outcomes that have been used or are considered to be important. The development of a core outcome set would improve the design and reporting of studies and availability of data for evidence synthesis. Methods used to develop a core outcome set should be robust, transparent and reflect the views of all stakeholders.
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Affiliation(s)
- Sara Rodgers
- York Trials Unit, Alcuin Research Resource Centre, University of York, York, YO10 5DD, UK,
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Arundel C, Torgerson D, Jefferson L, Cockayne S. A nested randomised controlled trial of a leaflet, containing information on research, to increase the recruitment rate of reform (reducing falls with orthoses and a multifaceted podiatry) trial participants. Trials 2013. [PMCID: PMC3981119 DOI: 10.1186/1745-6215-14-s1-o109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
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Jefferson L, Bloor K, Birks Y, Hewitt C, Bland M. Effect of physicians’ gender on communication and consultation length: a systematic review and meta-analysis. J Health Serv Res Policy 2013; 18:242-8. [DOI: 10.1177/1355819613486465] [Citation(s) in RCA: 93] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective Physician gender may be a source of differences in communication between physicians and their patients, which may in turn contribute to patient satisfaction and other outcomes. Our aim was to review systematically research on gender differences in the length, style and content of communication with patients. Methods Seven electronic databases were searched from inception to September 2010 with no language restrictions (included MEDLINE; PsychINFO; EMBASE; CINAHL; Health Management Information Consortium; Web of Science; and ASSIA). ‘Grey’ literature was also searched. Data extraction and quality assessment was carried out in accordance with Cochrane Collaboration guidelines by at least two reviewers. The review uses mainly narrative synthesis due to the heterogeneous nature of the studies, with only data on consultation length being pooled in a random effects generic inverse variance meta-analysis. Results Searches yielded 6412 articles, of which 33 studies fulfilled the inclusion criteria. Studies were heterogenous and of mixed quality. Conflicting results are reported for many communication variables. There is some evidence that female physicians adopt a more partnership building style and spend on average 2.24 min longer with patients per consultation (95% CI 0.62–3.86) than their male colleagues. Conclusions Greater patient engagement by female doctors may reflect a more patient-centred approach, but their longer consultation times will limit the number of consultations they can provide. This has implications for planning and managing services.
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Affiliation(s)
- Laura Jefferson
- Research Fellow, Department of Health Sciences, University of York, UK
| | - Karen Bloor
- Professor of Health Economics and Policy, Department of Health Sciences, University of York, UK
| | - Yvonne Birks
- Senior Research Fellow, Department of Health Sciences, University of York, UK
| | - Catherine Hewitt
- Senior Research Fellow, Department of Health Sciences, University of York, UK
| | - Martin Bland
- Professor of Health Statistics, Department of Health Sciences, University of York, UK
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Cheng HW, Jefferson L. Different Behavioral and Physiological Responses in Two Genetic Lines of Laying Hens After Transportation. Poult Sci 2008; 87:885-92. [DOI: 10.3382/ps.2007-00482] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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31
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Martin B, Cheli CD, Lifsey D, Ward M, Pollard S, Jefferson L, Thiel RP, Rayford W. Complexed PSA performance for prostate cancer detection in an African-American population. Urology 2003; 62:835-9. [PMID: 14624904 DOI: 10.1016/s0090-4295(03)00675-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Complexed prostate-specific antigen (cPSA) has been shown to improve the differentiation of benign and malignant disease compared with total PSA (tPSA) in studies evaluating predominantly white populations of men. We sought to evaluate the diagnostic performance of cPSA relative to tPSA in a population of African-American men. METHODS Consecutive African-American men scheduled for prostate biopsy were enrolled prospectively at the Louisiana State University Medical Center, New Orleans. Serum was collected before the biopsy procedure and tested with the Immuno 1 tPSA and cPSA methods. Receiver operating characteristic curve analysis was performed and the area under the curve was calculated for tPSA and cPSA. RESULTS A total of 156 patients were evaluated, 51 (32.7%) of whom were diagnosed with prostate cancer. The median PSA value for men with prostate cancer was 4.96 ng/mL and for those with benign disease was 3.93 ng/mL. The receiver operating characteristic analysis indicated that the area under the curve for cPSA (0.679) was statistically greater than that achieved for tPSA (0.642, P = 0.004). Using cutoff values for cPSA of 2.3 ng/mL and for tPSA of 2.85 ng/mL provided a specificity of 31.4% and 26.7%, respectively, at a sensitivity for prostate cancer detection of 95%. This was not statistically significant (P = 0.18). CONCLUSIONS cPSA offers modest improvement in prostate cancer detection compared with tPSA in African-American men, but not at the clinically relevant 95% sensitivity level. Additional work is needed to improve prostate cancer detection in this high-risk cohort of patients.
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Affiliation(s)
- B Martin
- Louisiana State University Medical Center, New Orleans, Louisiana 70112, USA
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32
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Ren J, Natavio M, Jefferson L, Pavlik ML, Brown RA. Loss of cardiac contractile response to tetrahydropapaveroline with advanced age and hypertension. Cell Mol Biol (Noisy-le-grand) 2002; 47 Online Pub:OL15-22. [PMID: 11936862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
Tetrahydropapaveroline (THP), a condensation product of ethanol-derived acetaldehyde, potentiates cardiac function through beta-adrenoceptor. We have recently shown that THP-induced cardiac contractile action is likely due to its action at the single myocyte level, and is markedly diminished during early hypertension. Cardiac function alters with advanced age reminiscent of hypertension. This study was to examine cardiac contractile response to THP with advanced age and hypertension. Left ventricular papillary muscles and myocytes were isolated from normotensive (WKY) or hypertensive (SHR) rats, and stimulated to contract at 0.5 Hz. Mechanical parameters evaluated include: peak tension developed (PTD)/peak shortening (PS), time-to-PTD/PS (TPT/TPS), time-to-90% relaxation/relengthening (RT90/TR90), and maximal velocities of contraction/relaxation (+/- VT/+/- dLdt). Intracellular Ca2+ transients were measured as fura-2 fluorescence intensity changes (AFFI). THP (0.1-100 microM) increased PTD in 10- but not 36-wk-old WKY rat myocardium. THP elicited positive, negative or no response on PS in myocytes from 10-wk WKY, 36-wk WKY, and 36-wk SHR groups, respectively. Interestingly, THP elicited discrepant response on intracellular Ca2+ transient compared with that of myocyte shortening. THP increased AFFI in 10-wk WKY and 36-wk SHR myocytes while exhibiting a significant inhibiting action in 36-wk WKY myocytes. Lastly, THP shortened TPT/TPS, RT90/TR90 and increased +VT in all animal groups. These results indicate that the THP-induced myocardial contractile response is altered in advanced age and hypertension, in a manner similar to early stage of hypertension. It is possible that altered intracellular Ca2+ responsiveness may be involved in THP-induced action.
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Affiliation(s)
- J Ren
- Department of Pharmacology, Physiology, and Therapeutics, University of North Dakota, School of Medicine and Health Sciences, Grand Forks 58203, USA.
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33
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Fontaine KR, Cheskin LJ, Carriero NJ, Jefferson L, Finley CJ, Gorelick DA. Body mass index and effects of refeeding on liver tests in drug-dependent adults in a residential research unit. J Am Diet Assoc 2001; 101:1467-9. [PMID: 11762745 DOI: 10.1016/s0002-8223(01)00354-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- K R Fontaine
- Department of Medicine, Johns Hopkins Bayview Medical Center Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Ren J, Walsh MF, Jefferson L, Natavio M, Ilg KJ, Sowers JR, Brown RA. Basal and ethanol-induced cardiac contractile response in lean and obese Zucker rat hearts. J Biomed Sci 2000; 7:390-400. [PMID: 10971137 DOI: 10.1007/bf02255814] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Obesity plays a pivotal role in metabolic and cardiovascular diseases. Certain types of obesity may be related to alcohol ingestion, which itself leads to impaired cardiac function. This study analyzed basal and ethanol-induced cardiac contractile response using left-ventricular papillary muscles and myocytes from lean and obese Zucker rats. Contractile properties analyzed include: peak tension development (PTD), peak shortening amplitude (PS), time to PTD/PS (TPT/TPS), time to 90% relaxation/relengthening (RT(90)/TR(90)) and maximal velocities of contraction/shortening and relaxation/relengthening (+/-VT and +/-dL/dt). Intracellular Ca(2+) transients were measured as fura-2 fluorescence intensity (DeltaFFI) changes and fluorescence decay time (FDT). In papillary muscles from obese rats, the baseline TPT and RT(90) were significantly prolonged accompanied with low to normal PTD and +/-VT compared to those in lean rats. Muscles from obese hearts also exhibited reduced responsiveness to postrest potentiation, increase in extracellular Ca(2+) concentration, and norepinephrine. By contrast, in isolated myocytes, obesity reduced PS associated with a significant prolonged TR(90), normal TPS and +/-dL/dt. Intracellular Ca(2+) recording revealed decreased resting Ca(2+) levels and prolonged FDT. Acute ethanol exposure (80-640 mg/dl) caused comparable concentration-dependent inhibitions of PTD/PS and DeltaFFI, associated with reduced +/-VT in both groups. Collectively, these results suggest altered cardiac contractile function and unchanged ethanol-induced depression in obesity.
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Affiliation(s)
- J Ren
- Department of Pharmacology, Physiology, and Therapeutics, University of North Dakota School of Medicine, Grand Forks, ND 58203, USA.
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Ren J, Jefferson L, Sowers JR, Brown RA. Influence of age on contractile response to insulin-like growth factor 1 in ventricular myocytes from spontaneously hypertensive rats. Hypertension 1999; 34:1215-22. [PMID: 10601121 DOI: 10.1161/01.hyp.34.6.1215] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Evidence suggests a pathophysiological role of insulin-like growth factor 1 (IGF-1) in hypertension. Cardiac function is altered with advanced age, similar to hypertension. Accordingly, the effects of IGF-1 on cardiac myocyte shortening and intracellular Ca(2+) were evaluated in hypertension at different ages. Ventricular myocytes were isolated from Wistar-Kyoto rats (WKY) and spontaneously hypertensive rats (SHR), aged 12 and 36 weeks. Mechanical and intracellular Ca(2+) properties were examined by edge-detection and fluorescence microscopy. At 12 weeks, IGF-1 (1 to 500 ng/mL) increased peak twitch amplitude (PTA) and FFI changes (DeltaFFI) in a dose-dependent manner in WKY myocytes, with maximal increases of 27.5% and 35.2%, respectively. However, IGF-1 failed to exert any action on PTA and DeltaFFI in the age-matched SHR myocytes. Interestingly, at 36 weeks, IGF-1 failed to exert any response in WKY myocytes but depressed both PTA and DeltaFFI in a dose-dependent manner in SHR myocytes, with maximal inhibitions of 40.5% and 16.1%, respectively. Myocytes from SHR or 36-week WKY were less sensitive to norepinephrine (1 micromol/L) and KCl (30 mmol/L). Pretreatment with nitric oxide synthase inhibitor N(omega)-nitro-L-arginine methyl ester (L-NAME, 100 micromol/L) did not alter the IGF-1-induced response in 12-week WKY myocytes but unmasked a positive action in 12-week SHR and 36-week WKY myocytes. L-NAME also significantly attenuated IGF-1-induced depression in 36-week SHR myocytes. In addition, the Ca(2+) channel opener Bay K8644 (1 micromol/L) abolished IGF-1-induced cardiac depression in 36-week SHR myocytes. Collectively, these results suggest that the IGF-1-induced cardiac contractile response was reduced with advanced age as well as with hypertension. Alterations in nitric oxide and intracellular Ca(2+) modulation may underlie, in part, the resistance to IGF-1 in hypertension and advanced age.
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Affiliation(s)
- J Ren
- Department of Physiology, University of North Dakota, Grand Forks, USA
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Brown RA, Jefferson L, Sudan N, Lloyd TC, Ren J. Acetaldehyde depresses myocardial contraction and cardiac myocyte shortening in spontaneously hypertensive rats: role of intracellular Ca2+. Cell Mol Biol (Noisy-le-grand) 1999; 45:453-65. [PMID: 10432192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Abstract
Acetaldehyde (ACA), the major metabolite of ethanol, exerts both stimulatory and depressive actions on myocardial tissue. We have recently shown that ACA depresses myocardial contraction, cardiac myocyte shortening and intracellular Ca2+ transients in normal rat heart. The purpose of the present study was to determine the influence of hypertension on ACA-induced myocardial actions. Mechanical properties of left ventricular papillary muscles and ventricular myocytes isolated from both 25-week-old normotensive Wistar-Kyoto (WKY) and spontaneously hypertensive rats (SHR) were evaluated using force-transducer and video edge-detection, respectively. Papillary muscles and cardiac myocytes were electrically stimulated to contract at 0.5 Hz. Contractile properties analyzed include: peak tension development (PTD), peak twitch amplitude (PTA), time-to-PTD/PTA (TPT/TPS), time-to-90% relaxation/relengthening (RT90/TR90) and maximal velocities of contraction/shortening and relaxation/relengthening (+/-VT/+/-dL/dt). Intracellular Ca2+ transients were measured as fura-2 fluorescence intensity (FFI) changes. ACA (1-30 mM) depressed PTD without affecting other mechanical indices in both WKY and SHR myocardium, with maximal inhibition of 64 and 69%, respectively. SHR myocytes exhibited increased cell dimension, baseline PTA and resting intracellular Ca2+ levels, compared to WKY counterparts. ACA (0.03-30 mM) depressed PTA without affecting TPT, TR90 and +/-dL/dt. The maximal inhibitions were 31 and 36% in WKY and SHR groups, respectively. Interestingly, ACA exerted a biphasic effect on FFI, displaying potentiation at lower doses (<3 mM) and inhibition at higher doses (>3 mM). The maximal increase in FFI changes were 19 and 22% at 0.3 mM and the maximal decreases were 37 and 29% at 30 mM ACA, in WKY and SHR myocytes, respectively. Neither resting intracellular Ca2+ levels (FFI) nor fluorescence decay time (FDT) were affected by ACA. The increase in FFI was attenuated by propranolol (1 microM), whereas the decrease in FFI was reversed by BayK 8644 (1 microM). These results suggest that hypertension does not appear to alter ACA-induced myocardial depression. The mechanism underlying ACA-induced myocardial actions may involve increased beta-adrenergic activity at low doses and reduced Ca2+ entry and/or release at high doses.
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Affiliation(s)
- R A Brown
- Department of Physiology, Wayne State University School of Medicine, Detroit, MI 48201, USA.
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Jefferson L. Telemedicine: saving lives & costs in the Lone Star State. Healthc Inform 1994; 11:40-2, 44, 46. [PMID: 10138392] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
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Zentmyer GA, Jefferson L. Studies of Phytophthora citricola, isolated from Persea americana. Mycologia 1974; 66:830-45. [PMID: 4437579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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