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Armitage KF, Porter CE, Ahmed S, Cook J, Boards J, Bongard E, Butler CC, Corfield K, Davoudianfar M, Galal U, Howard P, Mujica-Mota R, Saman R, Santillo M, Savic S, Shinkins B, Tonkin-Crine S, Wanat M, West RM, Yu LM, Pavitt S, Sandoe JAT. Penicillin allergy status and its effect on antibiotic prescribing, patient outcomes and antimicrobial resistance (ALABAMA): protocol for a multicentre, parallel-arm, open-label, randomised pragmatic trial. BMJ Open 2023; 13:e072253. [PMID: 37666558 PMCID: PMC10481831 DOI: 10.1136/bmjopen-2023-072253] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 07/07/2023] [Indexed: 09/06/2023] Open
Abstract
INTRODUCTION Incorrect penicillin allergy records are recognised as an important barrier to the safe treatment of infection and affect an estimated 2.7 million people in England. Penicillin allergy records are associated with worse health outcome and antimicrobial resistance. The ALlergy AntiBiotics And Microbial resistAnce (ALABAMA) trial aims to determine if an intervention package, centred around a penicillin allergy assessment pathway (PAAP) initiated in primary care, is safe and effective in improving patient health outcomes and antibiotic prescribing. METHODS AND ANALYSIS The ALABAMA trial is a multicentre, parallel-arm, open-label, randomised pragmatic trial with a nested pilot study. Adults (≥18 years) with a penicillin allergy record and who have received antibiotics in the previous 24 months will be eligible for participation. Between 1592 and 2090 participants will be recruited from participating National Health Service general practices in England. Participants will be randomised to either usual care or intervention to undergo a pre-emptive PAAP using a 1:1 allocation ratio. The primary outcome measure is the percentage of treatment response failures within 28 days of an index prescription. 2090 and 1592 participants are estimated to provide 90% and 80% power, respectively, to detect a clinically important absolute difference of 7.9% in primary outcome at 1 year between groups. The trial includes a mixed-methods process evaluation and cost-effectiveness evaluation. ETHICS AND DISSEMINATION This trial has been approved by London Bridge Research Ethics Committee (ref: 19/LO/0176). It will be conducted in compliance with Good Clinical Practice guidelines according to the Declaration of Helsinki. Informed consent will be obtained from all subjects involved in the study. The primary trial results will be submitted for publication to an international, peer-reviewed journal. TRIAL REGISTRATION ISRCTN20579216.
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Affiliation(s)
- Kelsey Fiona Armitage
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Catherine E Porter
- Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, West Yorkshire, UK
| | - Shadia Ahmed
- Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
- Leeds Institute of Medical Research, School of Medicine, University of Leeds, Leeds, UK
| | - Johanna Cook
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Jenny Boards
- Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Kate Corfield
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Ushma Galal
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Philip Howard
- School of Healthcare, University of Leeds, Leeds, UK
- NHS England, Leeds, UK
| | - Ruben Mujica-Mota
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Razan Saman
- Leeds Teaching Hospitals NHS Trust, Leeds, Leeds, UK
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Sinisa Savic
- Clinical Immunology and Allergy, University of Leeds Leeds Institute of Medical Research at St James's, Leeds, UK
| | - Bethany Shinkins
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Robert M West
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, Clinical Trials Unit, University of Oxford, Oxford, UK
| | - Sue Pavitt
- Dental Translational and Clinical Research Unit, School of Dentistry, University of Leeds, Leeds, West Yorkshire, UK
| | - Jonathan A T Sandoe
- Leeds Institute of Medical Research, School of Medicine, University of Leeds, Leeds, UK
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Wanat M, Santillo M, Galal U, Davoudianfar M, Bongard E, Savic S, Savic L, Porter C, Fielding J, Butler CC, Pavitt S, Sandoe J, Tonkin-Crine S. Mixed-methods evaluation of a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice. BMJ Open 2022; 12:e057471. [PMID: 36691248 PMCID: PMC9171226 DOI: 10.1136/bmjopen-2021-057471] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 05/11/2022] [Indexed: 01/27/2023] Open
Abstract
OBJECTIVES About 6% of the UK general practice population has a record of a penicillin allergy but fewer than 10% of these are likely to be truly allergic. In the ALABAMA (Allergy Antibiotics and Microbial resistance) feasibility trial, primary care patients with penicillin allergy were randomised to penicillin allergy assessment pathway or usual care to assess the effect on health outcomes. A behavioural intervention package was developed to aid delabelling. This study aimed to investigate patients' and clinicians' views of penicillin allergy testing (PAT). DESIGN We conducted a mixed-methods process evaluation embedded within the ALABAMA trial, which included a clinician survey, a patient survey (at baseline and follow-up) and semistructured interviews with patients and clinicians. SETTINGS The study was conducted in primary care, as part of the feasibility stage of the ALABAMA trial. PARTICIPANTS Patients and primary care clinicians. RESULTS Clinicians (N=53; 52.2%) were positive about PAT and its potential value but did not have previous experience of referring patients for a PAT and were unsure whether patients would take penicillin after a negative allergy test. Patients (N=36; 46%) were unsure whether they were severely allergic to penicillin and did not fear a severe allergic reaction to penicillin. Clinician interviews showed that they were already aware of the benefit of PAT. Interviews with patients suggested the importance of safety as patients valued having numerous opportunities to address their concerns about safety of the test. CONCLUSIONS This study highlights the positive effects of the ALABAMA behavioural intervention for both patients and clinicians. TRIAL REGISTRATION NUMBER NCT04108637; ISRCTN20579216; Pre-results.
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Affiliation(s)
- Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Ushma Galal
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sinisa Savic
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Faculty of Medicine and Health, Leeds, UK
| | - Louise Savic
- University of Leeds and Leeds Teaching Hospitals NHS Trust, Faculty of Medicine and Health, Leeds, UK
| | - Catherine Porter
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Joanne Fielding
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sue Pavitt
- Dental Translational and Clinical Research Unit, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Jonathan Sandoe
- Healthcare Associated Infection Group, University of Leeds and Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
- National Institute for Health Research (NIHR) Health Protection Research Unit (HPRU) in Healthcare Associated Infections and Antimicrobial Resistance, University of Oxford, Oxford, UK
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Santillo M, Wanat M, Davoudianfar M, Bongard E, Savic S, Savic L, Porter C, Fielding J, Butler CC, Pavitt S, Sandoe J, Tonkin-Crine S. Developing a behavioural intervention package to identify and amend incorrect penicillin allergy records in UK general practice and subsequently change antibiotic use. BMJ Open 2020; 10:e035793. [PMID: 33004384 PMCID: PMC7534681 DOI: 10.1136/bmjopen-2019-035793] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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] [Received: 11/18/2019] [Revised: 07/29/2020] [Accepted: 08/14/2020] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES To develop a behavioural intervention package to support clinicians and patients to amend incorrect penicillin allergy records in general practice. The intervention aimed to: (1) support clinicians to refer patients for penicillin allergy testing (PAT), (2) support patients to attend for PAT and (3) support clinicians and patients to prescribe or consume penicillin, when indicated, following a negative PAT result. METHODS Theory-based, evidence-based and person-based approaches were used in the intervention development. We used evidence from a rapid review, two qualitative studies, and expert consultations with the clinical research team to identify the intervention 'guiding principles' and develop an intervention plan. Barriers and facilitators to the target behaviours were mapped to behaviour change theory in order to describe the proposed mechanisms of change. In the final stage, think-aloud interviews were conducted to optimise intervention materials. RESULTS The collated evidence showed that the key barriers to referral of patients by clinicians were limited experience of referral and limited knowledge of referral criteria and PAT. Barriers for patients attending PAT were lack of knowledge of the benefits of testing and lack of motivation to get tested. The key barriers to the prescription and consumption of first-line penicillin following a negative test result were patient and clinician beliefs about the accuracy of PAT and whether taking penicillin was safe. Intervention materials were designed and developed to address these barriers. CONCLUSIONS We present a novel behavioural intervention package designed to address the multiple barriers to uptake of PAT in general practice by clinicians and patients. The intervention development details how behaviour change techniques have been incorporated to hypothesise how the intervention is likely to work to help amend incorrect penicillin allergy records. The intervention will go on to be tested in a feasibility trial and randomised controlled trial in England.
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Affiliation(s)
- Marta Santillo
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Marta Wanat
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Emily Bongard
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | - Sinisa Savic
- Faculty of Medicine and Health, University of Leeds, Leeds, Leeds, UK
| | - Louise Savic
- Faculty of Medicine and Health, University of Leeds, Leeds, Leeds, UK
| | - Catherine Porter
- Healthcare Associated Infection Group, University of Leeds, Leeds, West Yorkshire, UK
| | - Joanne Fielding
- Healthcare Associated Infection Group, University of Leeds, Leeds, West Yorkshire, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
| | | | - Jonathan Sandoe
- Healthcare Associated Infection Group, University of Leeds, Leeds, West Yorkshire, UK
| | - Sarah Tonkin-Crine
- Nuffield Department of Primary Care Health Sciences, Oxford University, Oxford, UK
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Butler CC, Lau M, Gillespie D, Owen-Jones E, Lown M, Wootton M, Calder PC, Bayer AJ, Moore M, Little P, Davies J, Edwards A, Shepherd V, Hood K, Hobbs FDR, Davoudianfar M, Rutter H, Stanton H, Lowe R, Fuller R, Francis NA. Effect of Probiotic Use on Antibiotic Administration Among Care Home Residents: A Randomized Clinical Trial. JAMA 2020; 324:47-56. [PMID: 32633801 PMCID: PMC7341173 DOI: 10.1001/jama.2020.8556] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [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: 12/15/2022]
Abstract
IMPORTANCE Probiotics are frequently used by residents in care homes (residential homes or nursing homes that provide residents with 24-hour support for personal care or nursing care), although the evidence on whether probiotics prevent infections and reduce antibiotic use in these settings is limited. OBJECTIVE To determine whether a daily oral probiotic combination of Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp lactis BB-12 compared with placebo reduces antibiotic administration in care home residents. DESIGN, SETTING, AND PARTICIPANTS Placebo-controlled randomized clinical trial of 310 care home residents, aged 65 years and older, recruited from 23 care homes in the United Kingdom between December 2016 and May 2018, with last follow-up on October 31, 2018. INTERVENTIONS Study participants were randomized to receive a daily capsule containing a probiotic combination of Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp lactis BB-12 (total cell count per capsule, 1.3 × 1010 to 1.6 × 1010) (n = 155), or daily matched placebo (n = 155), for up to 1 year. MAIN OUTCOMES AND MEASURES The primary outcome was cumulative antibiotic administration days for all-cause infections measured from randomization for up to 1 year. RESULTS Among 310 randomized care home residents (mean age, 85.3 years; 66.8% women), 195 (62.9%) remained alive and completed the trial. Participant diary data (daily data including study product use, antibiotic administration, and signs of infection) were available for 98.7% randomized to the probiotic group and 97.4% randomized to placebo. Care home residents randomized to the probiotic group had a mean of 12.9 cumulative systemic antibiotic administration days (95% CI, 0 to 18.05), and residents randomized to placebo had a mean of 12.0 days (95% CI, 0 to 16.95) (absolute difference, 0.9 days [95% CI, -3.25 to 5.05]; adjusted incidence rate ratio, 1.13 [95% CI, 0.79 to 1.63]; P = .50). A total of 120 care home residents experienced 283 adverse events (150 adverse events in the probiotic group and 133 in the placebo group). Hospitalizations accounted for 94 of the events in probiotic group and 78 events in the placebo group, and deaths accounted for 33 of the events in the probiotic group and 32 of the events in the placebo group. CONCLUSIONS AND RELEVANCE Among care home residents in the United Kingdom, a daily dose of a probiotic combination of Lactobacillus rhamnosus GG and Bifidobacterium animalis subsp lactis BB-12 did not significantly reduce antibiotic administration for all-cause infections. These findings do not support the use of probiotics in this setting. TRIAL REGISTRATION ISRCTN Identifier:16392920.
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Affiliation(s)
- Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Bldg, University of Oxford, Oxford, United Kingdom
| | - Mandy Lau
- Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - David Gillespie
- Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - Eleri Owen-Jones
- Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - Mark Lown
- Primary Care and Population Sciences Unit, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology, University Hospital of Wales, Heath Park, Cardiff, United Kingdom
| | - Philip C. Calder
- NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, United Kingdom
| | - Antony J. Bayer
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Cardiff University, Cardiff, United Kingdom
| | - Michael Moore
- Primary Care and Population Sciences Unit, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom
| | - Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom
| | - Jane Davies
- Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - Alison Edwards
- Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - Victoria Shepherd
- Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - F. D. Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Bldg, University of Oxford, Oxford, United Kingdom
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Bldg, University of Oxford, Oxford, United Kingdom
| | - Heather Rutter
- Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Bldg, University of Oxford, Oxford, United Kingdom
| | - Helen Stanton
- Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - Rachel Lowe
- Centre for Trials Research, Cardiff University, Heath Park, Cardiff, United Kingdom
| | - Richard Fuller
- Primary Care and Population Sciences Unit, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom
| | - Nick A. Francis
- Primary Care and Population Sciences Unit, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, United Kingdom
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Powell J, Williams V, Atherton H, Bennett K, Yang Y, Davoudianfar M, Hellsing A, Martin A, Mollison J, Shanyinde M, Yu LM, Griffiths KM. Effectiveness and Cost-Effectiveness of a Self-Guided Internet Intervention for Social Anxiety Symptoms in a General Population Sample: Randomized Controlled Trial. J Med Internet Res 2020; 22:e16804. [PMID: 31821151 PMCID: PMC6996778 DOI: 10.2196/16804] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2019] [Revised: 11/22/2019] [Accepted: 12/10/2019] [Indexed: 11/13/2022] Open
Abstract
Background Many people are accessing digital self-help for mental health problems, often with little evidence of effectiveness. Social anxiety is one of the most common sources of mental distress in the population, and many people with symptoms do not seek help for what represents a significant public health problem. Objective This study aimed to evaluate the effectiveness of a self-guided cognitive behavioral internet intervention for people with social anxiety symptoms in the general population. Methods We conducted a two-group randomized controlled trial in England between May 11, 2016, and June 27, 2018. Adults with social anxiety symptoms who were not receiving treatment for social anxiety were recruited using online advertisements. All participants had unrestricted access to usual care and were randomized in a 1:1 ratio to either a Web-based unguided self-help intervention based on cognitive behavioral principles or a waiting list control group. All outcomes were collected through self-report online questionnaires. The primary outcome was the change in 17-item Social Phobia Inventory (SPIN-17) score from baseline to 6 weeks using a linear mixed-effect model that used data from all time points (6 weeks, 3 months, 6 months, and 12 months). Results A total of 2122 participants were randomized, and 6 were excluded from analyses because they were ineligible. Of the 2116 eligible randomized participants (mean age 37 years; 80.24%, 1698/2116 women), 70.13% (1484/2116) had follow-up data available for analysis, and 56.95% (1205/2116) had data on the primary outcome, although attrition was higher in the intervention arm. At 6 weeks, the mean (95% CI) adjusted difference in change in SPIN-17 score in the intervention group compared with control was −1.94 (−3.13 to −0.75; P=.001), a standardized mean difference effect size of 0.2. The improvement was maintained at 12 months. Given the high dropout rate, sensitivity analyses explored missing data assumptions, with results that were consistent with those of the primary analysis. The economic evaluation demonstrated cost-effectiveness with a small health status benefit and a reduction in health service utilization. Conclusions For people with social anxiety symptoms who are not receiving other forms of help, this study suggests that the use of an online self-help tool based on cognitive behavioral principles can provide a small improvement in social anxiety symptoms compared with no intervention, although dropout rates were high. Trial Registration ClinicalTrials.gov NCT02451878; https://clinicaltrials.gov/ct2/show/NCT02451878
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Affiliation(s)
- John Powell
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Veronika Williams
- School of Nursing, Faculty of Education and Professional Studies, Nipissing University, North Bay, ON, Canada
| | - Helen Atherton
- Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | | | - Yaling Yang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Annika Hellsing
- Research School of Psychology, Australian National University, Canberra, Australia
| | - Angela Martin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Jill Mollison
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Milensu Shanyinde
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
| | - Kathleen M Griffiths
- Research School of Psychology, Australian National University, Canberra, Australia
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Owen-Jones E, Lowe R, Lown M, Gillespie D, Addison K, Bayer T, Calder PC, Davies J, Davoudianfar M, Downs J, Edwards A, Francis NA, Fuller R, Hobbs R, Hood K, Lau M, Little P, Moore M, Shepherd V, Stanton H, Toghill A, Wootton M, Butler CC. Protocol for a double-blind placebo-controlled trial to evaluate the efficacy of probiotics in reducing antibiotics for infection in care home residents: the Probiotics to Reduce Infections iN CarE home reSidentS (PRINCESS) trial. BMJ Open 2019; 9:e027513. [PMID: 31227535 PMCID: PMC6596947 DOI: 10.1136/bmjopen-2018-027513] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 12/15/2022] Open
Abstract
INTRODUCTION Care home residents are at increased risk of infections and antibiotic prescription. Reduced antibiotic use from fewer infections would improve quality of life. The Probiotics to Reduce Infections iN CarE home reSidentS (PRINCESS) trial aims to determine the efficacy and investigate mechanisms of daily probiotics on antibiotic use and incidence of infections in care home residents. METHODS AND ANALYSIS PRINCESS is a double-blind, individually randomised, placebo-controlled trial that will assess the effect of a daily oral probiotic combination of Lactobacillus rhamnosus, GG (LGG) and Bifidobacterium animalis subsp. lactis, BB-12 (BB-12) on cumulative antibiotic administration days (CAADs) (primary outcome) for infection in up to 330 care home residents aged ≥65 years over up to 12 months. Secondary outcomes include: Infection: Total number of days of antibiotic administration for each infection type (respiratory tract infection, urinary tract infection, gastrointestinal infection, unexplained fever and other); number, site, duration of infection; estimation of incidence and duration of diarrhoea and antibiotic-associated diarrhoea; Stool microbiology: Clostridium difficile infection; Gram-negative Enterobacteriaceae and vancomycin-resistant enterococci; LGG and BB-12. Oral microbiology: Candida spp. Health and well-being: Self and/or proxy health-related quality of life EQ5D (5 L); self-and/or proxy-reported ICEpop CAPability measure for older people. Hospitalisations: number and duration of all-cause hospital stays. Mortality: deaths. Mechanistic immunology outcomes: influenza vaccine efficacy (haemagglutination inhibition assay and antibody titres); full blood count and immune cell phenotypes, plasma cytokines and chemokines; cytokine and chemokine response in whole blood stimulated ex vivo by toll-like receptor 2 and 4 agonists; monocyte and neutrophil phagocytosis of Escherichia coli; serum vitamin D. ETHICS AND DISSEMINATION Ethics approval is from the Wales Research Ethics Committee 3. Findings will be disseminated through peer-reviewed journals and conferences; results will be of interest to patient and policy stakeholders. TRIAL REGISTRATION NUMBER ISRCTN16392920; Pre-results.
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Affiliation(s)
| | - Rachel Lowe
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mark Lown
- Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | | | - Katy Addison
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Tony Bayer
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Cardiff University, Cardiff, UK
| | - Philip C Calder
- Human Development & Health, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Jane Davies
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mina Davoudianfar
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Alison Edwards
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Nick A Francis
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Cardiff University, Cardiff, UK
| | - Richard Fuller
- Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Richard Hobbs
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mandy Lau
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Michael Moore
- Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Victoria Shepherd
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Cardiff University, Cardiff, UK
| | - Helen Stanton
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital of Wales, Cardiff, UK
| | - Chris C Butler
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Little P, Stuart B, Hobbs FR, Kelly J, Smith ER, Bradbury KJ, Hughes S, Smith PW, Moore MV, Lean ME, Margetts BM, Byrne CD, Griffin S, Davoudianfar M, Hooper J, Yao G, Zhu S, Raftery J, Yardley L. Randomised controlled trial and economic analysis of an internet-based weight management programme: POWeR+ (Positive Online Weight Reduction). Health Technol Assess 2018; 21:1-62. [PMID: 28122658 DOI: 10.3310/hta21040] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Behavioural counselling with intensive follow-up for obesity is effective, but in resource-constrained primary care settings briefer approaches are needed. OBJECTIVES To estimate the clinical effectiveness and cost-effectiveness of an internet-based behavioural intervention with regular face-to-face or remote support in primary care, compared with brief advice. DESIGN Individually randomised three-arm parallel trial with health economic evaluation and nested qualitative interviews. SETTING Primary care general practices in the UK. PARTICIPANTS Patients with a body mass index of ≥ 30 kg/m2 (or ≥ 28 kg/m2 with risk factors) identified from general practice records, recruited by postal invitation. INTERVENTIONS Positive Online Weight Reduction (POWeR+) is a 24-session, web-based weight management intervention completed over 6 months. Following online registration, the website randomly allocated participants using computer-generated random numbers to (1) the control intervention (n = 279), which had previously been demonstrated to be clinically effective (brief web-based information that minimised pressure to cut down foods, instead encouraging swaps to healthier choices and increasing fruit and vegetables, plus 6-monthly nurse weighing); (2) POWeR+F (n = 269), POWeR+ supplemented by face-to-face nurse support (up to seven contacts); or (3) POWeR+R (n = 270), POWeR+ supplemented by remote nurse support (up to five e-mails or brief telephone calls). MAIN OUTCOME MEASURES The primary outcome was a modelled estimate of average weight reduction over 12 months, assessed blind to group where possible, using multiple imputation for missing data. The secondary outcome was the number of participants maintaining a 5% weight reduction at 12 months. RESULTS A total of 818 eligible individuals were randomised using computer-generated random numbers. Weight change, averaged over 12 months, was documented in 666 out of 818 participants (81%; control, n = 227; POWeR+F, n = 221; POWeR+R, n = 218). The control group maintained nearly 3 kg of weight loss per person (mean weight per person: baseline, 104.4 kg; 6 months, 101.9 kg; 12 months, 101.7 kg). Compared with the control group, the estimated additional weight reduction with POWeR+F was 1.5 kg [95% confidence interval (CI) 0.6 to 2.4 kg; p = 0.001] and with POWeR+R was 1.3 kg (95% CI 0.34 to 2.2 kg; p = 0.007). By 12 months the mean weight loss was not statistically significantly different between groups, but 20.8% of control participants, 29.2% of POWeR+F participants (risk ratio 1.56, 95% CI 0.96 to 2.51; p = 0.070) and 32.4% of POWeR+R participants (risk ratio 1.82, 95% CI 1.31 to 2.74; p = 0.004) maintained a clinically significant 5% weight reduction. The POWeR+R group had fewer individuals who reported doing another activity to help lose weight [control, 47.1% (64/136); POWeR+F, 37.2% (51/137); POWeR+R, 26.7% (40/150)]. The incremental cost to the health service per kilogram weight lost, compared with the control group, was £18 (95% CI -£129 to £195) for POWeR+F and -£25 (95% CI -£268 to £157) for POWeR+R. The probability of being cost-effective at a threshold of £100 per kilogram was 88% and 98% for POWeR+F and POWeR+R, respectively. POWeR+R was dominant compared with the control group. No harms were reported and participants using POWeR+ felt more enabled in managing their weight. The qualitative studies documented that POWeR+ was viewed positively by patients and that health-care professionals generally enjoyed supporting patients using POWeR+. STUDY LIMITATIONS Maintenance of weight loss after 1 year is unknown. FUTURE WORK Identifying strategies for longer-term engagement, impact in community settings and increasing physical activity. CONCLUSION Clinically valuable weight loss (> 5%) is maintained in 20% of individuals using novel written materials with brief follow-up. A web-based behavioural programme and brief support results in greater mean weight loss and 10% more participants maintain valuable weight loss; it achieves greater enablement and fewer participants undertaking other weight-loss activities; and it is likely to be cost-effective. TRIAL REGISTRATION Current Controlled Trials ISRCTN21244703. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Beth Stuart
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jo Kelly
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Emily R Smith
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
| | - Katherine J Bradbury
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
| | - Stephanie Hughes
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Peter Wf Smith
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Mike Ej Lean
- Human Nutrition, School of Medicine, University of Glasgow, Glasgow, UK
| | - Barrie M Margetts
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Christopher D Byrne
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre, University Hospital Southampton, Southampton, UK
| | - Simon Griffin
- Medical Research Council (MRC) Epidemiology Unit, University of Cambridge School of Clinical Medicine, Institute of Metabolic Science, Cambridge Biomedical Campus, Cambridge, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julie Hooper
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Guiqing Yao
- Health Economic Analyses Team (HEAT), Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Shihua Zhu
- Health Economic Analyses Team (HEAT), Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - James Raftery
- Health Economic Analyses Team (HEAT), Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
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Powell J, Atherton H, Williams V, Martin A, Bennett K, Bennett A, Mollison J, Yu LM, Yang Y, Locock L, Davoudianfar M, Griffiths KM. Effectiveness and cost-effectiveness of a fully self-guided internet-based intervention for sub-clinical social anxiety symptoms: Protocol for a randomised controlled trial. Digit Health 2017; 3:2055207617702272. [PMID: 29942591 PMCID: PMC6001207 DOI: 10.1177/2055207617702272] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2016] [Accepted: 02/16/2017] [Indexed: 11/17/2022] Open
Abstract
Design and objective This paper describes the protocol for a large-scale pragmatic, randomised controlled trial and economic evaluation to investigate the effectiveness and cost-effectiveness of the self-directed E-Couch social anxiety module versus a waiting list control condition, for reducing sub-clinical social anxiety symptoms in the general population. Study population Community-based adults (aged 18+) with social anxiety symptoms that do not meet the criteria for social anxiety disorder recruited via a direct-to-consumer advertisement on national websites. Intervention and control Intervention is the self-guided E-Couch social anxiety module. Control group participants are placed on a waiting list to receive the intervention at the end of the trial. Both groups receive email and text message reminders. Outcome measures The primary outcome will be change in self-reported social anxiety score using the Social Phobia Inventory (SPIN). Secondary outcomes will be the changes in the following self-report measures: Brief Fear of Negative Evaluation scale (BFNE-S); depression (CES-D); mental wellbeing (SWEMWEBS); health status (SF36); use of health services; safety events; and adherence, retention, and attrition rates. All measures will be administered at baseline, 6 weeks, and 3, 6 and 12 months. Analysis A mixed effects model will be used to analyse the effect of the intervention on the primary and secondary outcomes (intention to treat analysis). Secondary analyses will explore moderators and mediators of effect. A prospective economic evaluation, conducted from a NHS and social care perspective, will provide estimates of cost utility and cost-effectiveness. An interview study will be conducted with 20 participants to explore issues including acceptability, adherence, retention and attrition. Trial registration numbers NCT02451878 and ISRCTN15819951
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Affiliation(s)
- John Powell
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | | | - Veronika Williams
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Angela Martin
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Kylie Bennett
- National Institute for Mental Health Research, Australian National University, Australia
| | - Anthony Bennett
- National Institute for Mental Health Research, Australian National University, Australia
| | - Jill Mollison
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Ly-Mee Yu
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Yaling Yang
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Louise Locock
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Kathleen M Griffiths
- National Institute for Mental Health Research, Australian National University, Australia
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Newhouse N, Martin A, Jawad S, Yu LM, Davoudianfar M, Locock L, Ziebland S, Powell J. Randomised feasibility study of a novel experience-based internet intervention to support self-management in chronic asthma. BMJ Open 2016; 6:e013401. [PMID: 28031210 PMCID: PMC5223671 DOI: 10.1136/bmjopen-2016-013401] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2016] [Revised: 10/11/2016] [Accepted: 10/21/2016] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVE To determine the feasibility of a randomised controlled trial (RCT) assessing the effects of an experience-based website as a resource for the self-management of chronic asthma. DESIGN AND SETTING Feasibility, single-blind RCT in 2 regions of England. Randomisation used computer-generated random number sequence in a 1:1 ratio, after baseline data collection, to website access for 2 weeks. PARTICIPANTS Adults (age ≥18 years), with clinically diagnosed asthma as coded in their primary care electronic record, prescribed inhaled corticosteroids for at least 3 months in the previous year, were recruited from 9 general practices. INTERVENTION The EXPERT asthma intervention is an interactive PC/laptop/tablet/smartphone compatible website designed with extensive input from adults with asthma. It provides experience-based information and aims to support subjective perception of self-efficacy, self-management and improve health status. OUTCOME MEASURES Primary outcomes were consent/recruitment, website usage and completion of outcome measures. Secondary outcomes included Partners in Health (PIH) questionnaire, the Chronic Disease Self-Efficacy Scale, the SF36 and the E-Health Impact Questionnaire. Participant blinding postrandomisation was not possible. The analysis was blind to allocation. RESULTS Recruitment target exceeded. 148 participants randomised (73 intervention group). Age range 19-84 years; 59% female. 121 of 148 (84%; 62 intervention group) followed up. The median number of logins was 2 (IQR 2-3, range 1-48). Minimal differences of change from baseline between groups; both showed improvement in health state or management of their condition with no significant differences between arms. No adverse events. CONCLUSIONS Recruitment and retention confirmed feasibility. The trends towards improved outcomes suggest that further research on digital interventions based on exposure to others' personal experiences may be of value in the self-management of chronic asthma. TRIAL REGISTRATION NUMBER ISRCTN29549695; Results.
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Affiliation(s)
- Nikki Newhouse
- Nuffield Department of Primary Care Health Sciences, Health Experiences Research Group, University of Oxford, Oxford, UK
| | - Angela Martin
- Nuffield Department of Primary Care Health Sciences, Health Experiences Research Group, University of Oxford, Oxford, UK
| | - Sena Jawad
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mina Davoudianfar
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louise Locock
- Nuffield Department of Primary Care Health Sciences, Health Experiences Research Group, University of Oxford, Oxford, UK
| | - Sue Ziebland
- Nuffield Department of Primary Care Health Sciences, Health Experiences Research Group, University of Oxford, Oxford, UK
| | - John Powell
- Nuffield Department of Primary Care Health Sciences, Health Experiences Research Group, University of Oxford, Oxford, UK
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Powell J, Newhouse N, Martin A, Jawad S, Yu LM, Davoudianfar M, Locock L, Ziebland S. A novel experience-based internet intervention for smoking cessation: feasibility randomised controlled trial. BMC Public Health 2016; 16:1156. [PMID: 27835953 PMCID: PMC5106834 DOI: 10.1186/s12889-016-3821-3] [Citation(s) in RCA: 7] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2016] [Accepted: 11/04/2016] [Indexed: 12/04/2022] Open
Abstract
Background The internet is frequently used to share experiences of health and illness, but this phenomenon has not been harnessed as an intervention to achieve health behaviour change. The aim of this study was to determine the feasibility of a randomised trial assessing the effects of a novel, experience-based website as a smoking cessation intervention. The secondary aim was to measure the potential impact on smoking behaviour of both the intervention and a comparator website. Methods A feasibility randomised controlled single-blind trial assessed a novel, experience-based website containing personal accounts of quitting smoking as a cessation intervention, and a comparator website providing factual information. Feasibility measures including recruitment, and usage of the interventions were recorded, and the following participant-reported outcomes were also measured: Smoking Abstinence Self-Efficacy Questionnaire, the single-item Motivation to Stop Scale, self-reported abstinence, quit attempts and health status outcomes. Eligible smokers from two English regions were entered into the trial and given access to their allocated website for two weeks. Results Eighty-seven smokers were randomised, 65 completed follow-up (75 %). Median usage was 15 min for the intervention, and 5 min for the comparator (range 0.5–213 min). Median logins for both sites was 2 (range 1–20). All participant-reported outcomes were similar between groups. Conclusions It was technically feasible to deliver a novel intervention harnessing the online sharing of personal experiences as a tool for smoking cessation, but recruitment was slow and actual use was relatively low, with attrition from the trial. Future work needs to maximize engagement and to understand how best to assess the value of such interventions in everyday use, rather than as an isolated ‘dose of information’. Trial registration ISRCTN29549695 DOI 10.1186/ISRCTN29549695. Registered 17/05/2013.
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Affiliation(s)
- John Powell
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.
| | - Nikki Newhouse
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Angela Martin
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sena Jawad
- Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ly-Mee Yu
- Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mina Davoudianfar
- Primary Care Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Louise Locock
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Sue Ziebland
- Health Experiences Research Group, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Little P, Stuart B, Hobbs FR, Kelly J, Smith ER, Bradbury KJ, Hughes S, Smith PWF, Moore MV, Lean MEJ, Margetts BM, Byrne CD, Griffin S, Davoudianfar M, Hooper J, Yao G, Zhu S, Raftery J, Yardley L. An internet-based intervention with brief nurse support to manage obesity in primary care (POWeR+): a pragmatic, parallel-group, randomised controlled trial. Lancet Diabetes Endocrinol 2016; 4:821-8. [PMID: 27474214 DOI: 10.1016/s2213-8587(16)30099-7] [Citation(s) in RCA: 118] [Impact Index Per Article: 14.8] [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] [Received: 04/05/2016] [Revised: 05/16/2016] [Accepted: 05/17/2016] [Indexed: 11/21/2022]
Abstract
BACKGROUND The obesity epidemic has major public health consequences. Expert dietetic and behavioural counselling with intensive follow-up is effective, but resource requirements severely restrict widespread implementation in primary care, where most patients are managed. We aimed to estimate the effectiveness and cost-effectiveness of an internet-based behavioural intervention (POWeR+) combined with brief practice nurse support in primary care. METHODS We did this pragmatic, parallel-group, randomised controlled trial at 56 primary care practices in central and south England. Eligible adults aged 18 years or older with a BMI of 30 kg/m(2) or more (or ≥28 kg/m(2) with hypertension, hypercholesterolaemia, or diabetes) registered online with POWeR+-a 24 session, web-based, weight management intervention lasting 6 months. After registration, the website automatically randomly assigned patients (1:1:1), via computer-generated random numbers, to receive evidence-based dietetic advice to swap foods for similar, but healthier, choices and increase fruit and vegetable intake, in addition to 6 monthly nurse follow-up (control group); web-based intervention and face-to-face nurse support (POWeR+Face-to-face [POWeR+F]; up to seven nurse contacts over 6 months); or web-based intervention and remote nurse support (POWeR+Remote [POWeR+R]; up to five emails or brief phone calls over 6 months). Participants and investigators were masked to group allocation at the point of randomisation; masking of participants was not possible after randomisation. The primary outcome was weight loss averaged over 12 months. We did a secondary analysis of weight to measure maintenance of 5% weight loss at months 6 and 12. We modelled the cost-effectiveness of each intervention. We did analysis by intention to treat, with multiple imputation for missing data. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN21244703. FINDINGS Between Jan 30, 2013, and March 20, 2014, 818 participants were randomly assigned to the control group (n=279), the POWeR+F group (n=269), or the POWeR+R group (n=270). Weight loss averaged over 12 months was recorded in 666 (81%) participants. The control group lost almost 3 kg over 12 months (crude mean weight: baseline 104·38 kg [SD 21·11; n=279], 6 months 101·91 kg [19·35; n=136], 12 months 101·74 kg [19·57; n=227]). The primary imputed analysis showed that compared with the control group, patients in the POWeR+F group achieved an additional weight reduction of 1·5 kg (95% CI 0·6-2·4; p=0·001) averaged over 12 months, and patients in the POWeR+R group achieved an additional 1·3 kg (0·34-2·2; p=0·007). 21% of patients in the control group had maintained a clinically important 5% weight reduction at month 12, compared with 29% of patients in the POWeR+F group (risk ratio 1·56, 0·96-2·51; p=0·070) and 32% of patients in the POWeR+R group (1·82, 1·31-2·74; p=0·004). The incremental overall cost to the health service per kg weight lost with the POWeR+ interventions versus the control strategy was £18 (95% CI -129 to 195) for POWeR+F and -£25 (-268 to 157) for POWeR+R; the probability of being cost-effective at a threshold of £100 per kg lost was 88% and 98%, respectively. No adverse events were reported. INTERPRETATION Weight loss can be maintained in some individuals by use of novel written material with occasional brief nurse follow-up. However, more people can maintain clinically important weight reductions with a web-based behavioural program and brief remote follow-up, with no increase in health service costs. Future research should assess the extent to which clinically important weight loss can be maintained beyond 1 year. FUNDING Health Technology Assessment Programme of the National Institute for Health Research.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK.
| | - Beth Stuart
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Fd Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jo Kelly
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Emily R Smith
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
| | - Katherine J Bradbury
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
| | - Stephanie Hughes
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Peter W F Smith
- Southampton Statistical Sciences Research Institute, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Mike E J Lean
- Human Nutrition, School of Medicine, University of Glasgow, Glasgow, UK
| | - Barrie M Margetts
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Chris D Byrne
- Southampton National Institute for Health Research (NIHR) Biomedical Research Centre, University Hospital Southampton and University of Southampton, Southampton, UK
| | - Simon Griffin
- Cambridge Medical Research Council Epidemiology Unit, Institute of Metabolic Science, Cambridge Biomedical Campus, University of Cambridge School of Clinical Medicine, Cambridge, UK
| | - Mina Davoudianfar
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Julie Hooper
- Primary Care and Population Sciences Unit, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Guiqing Yao
- Health Economic Analyses Team (HEAT), Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Shihua Zhu
- Health Economic Analyses Team (HEAT), Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - James Raftery
- Health Economic Analyses Team (HEAT), Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Centre for Applications of Health Psychology (CAHP), Faculty of Social and Human Sciences, University of Southampton, Southampton, UK
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Dutton SJ, Ferry DR, Blazeby JM, Abbas H, Dahle-Smith A, Mansoor W, Thompson J, Harrison M, Chatterjee A, Falk S, Garcia-Alonso A, Fyfe DW, Hubner RA, Gamble T, Peachey L, Davoudianfar M, Pearson SR, Julier P, Jankowski J, Kerr R, Petty RD. Gefitinib for oesophageal cancer progressing after chemotherapy (COG): a phase 3, multicentre, double-blind, placebo-controlled randomised trial. Lancet Oncol 2014; 15:894-904. [PMID: 24950987 DOI: 10.1016/s1470-2045(14)70024-5] [Citation(s) in RCA: 234] [Impact Index Per Article: 23.4] [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: 02/07/2023]
Abstract
BACKGROUND Evidence is scarce for the effectiveness of therapies for oesophageal cancer progressing after chemotherapy, and no randomised trials have been reported. We aimed to compare gefitinib with placebo in previously treated advanced oesophageal cancer. METHODS For this phase 3, parallel, randomised, placebo-controlled trial, eligible patients were adults with advanced oesophageal cancer or type I/II Siewert junctional tumours, histologically confirmed squamous-cell carcinoma or adenocarcinoma, who had progressed after chemotherapy, with WHO performance status 0-2, and with measurable or evaluable disease on CT scan. Participants were recruited from 48 UK centres and randomly assigned (1:1) to gefitinib (500 mg) or matching placebo by simple randomisation with no stratification factors. Patients, clinicians, and trial office staff were masked to treatment allocation. Treatment continued until disease progression, unacceptable toxicity, or patient choice. The primary outcome was overall survival, analysed by intention to treat. This trial is registered, number ISRCTN29580179. FINDINGS Between March 30, 2009, and Nov 18, 2011, 450 patients were randomly assigned to treatment groups (one patient withdrew consent; 224 patients allocated gefitinib and 225 allocated placebo included in analyses). Overall survival did not differ between groups (median 3·73 months, 95% CI 3·23-4·50, for gefitinib vs 3·67 months, 95% CI 2·97-4·37, for placebo; hazard ratio [HR] 0·90, 95% CI 0·74-1·09, p=0·29). Among the prespecified patient-reported outcomes (110 patients on gefitinib and 121 on placebo completed both baseline and 4 week questionnaires and were included in analyses), odynophagia was significantly better in the gefitinib group (adjusted mean difference -8·61, 95% CI -14·49 to -2·73; n=227; p=0·004), whereas the other outcomes were not significantly improved compared with placebo: global quality of life (2·69, 95% CI -2·33 to 7·72, n=231, p=0·293), dysphagia (-3·18, 95% CI -8·36 to 2·00, n=231, p=0·228), and eating (-4·11, 95% CI -9·96 to 1·75, n=229, p=0·168). Median progression-free survival was marginally longer with gefitinib than it was with placebo (1·57 months, 95% CI 1·23-1·90 in the gefitinib group vs 1·17 months, 95% CI 1·07-1·37 in the placebo group; HR 0·80, 95% CI 0·66-0·96, p=0·020). The most common toxicities were diarrhoea (36 [16%] of 224 patients on gefitinib vs six [3%] of 225 on placebo) and skin toxicity (46 [21%] vs two [1%]), both mostly grade 2. The commonest grade 3-4 toxicities were fatigue (24 [11%] vs 13 [6%] patients) and diarrhoea (13 [6%] vs two [1%]). Serious adverse events were reported in 109 (49%) of 224 patients assigned to gefitinib and 101 (45%) of 225 on placebo. 54 (24%) of patients in the gefitinib group achieved disease control at 8 weeks, as did 35 (16%) of patients on placebo (p=0·023). INTERPRETATION The use of gefitinib as a second-line treatment in oesophageal cancer in unselected patients does not improve overall survival, but has palliative benefits in a subgroup of these difficult-to-treat patients with short life expectancy. Future research should focus on identification of predictive biomarkers to identify this subgroup of benefiting patients. FUNDING Cancer Research UK.
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Affiliation(s)
- Susan J Dutton
- Oxford Clinical Trials Research Unit and Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Botnar Research Centre, Oxford, UK.
| | - David R Ferry
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK; Lilly UK, Erl Wood Manor, Windlesham, UK
| | - Jane M Blazeby
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK; School of Social and Community Medicine, University of Bristol Senate House, Bristol, UK
| | - Haider Abbas
- Royal Wolverhampton Hospitals NHS Trust, Wolverhampton, UK
| | - Asa Dahle-Smith
- University of Aberdeen, Institute of Medical Sciences, Aberdeen, UK
| | - Wasat Mansoor
- Christie Hospital NHS Foundation Trust, Manchester, UK
| | | | | | | | - Stephen Falk
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - David W Fyfe
- University Hospitals of Morecombe Bay, Furness General Hospital, Barrow-in-Furness, UK
| | | | - Tina Gamble
- Birmingham Heartlands Hospital, Birmingham, UK
| | - Lynnda Peachey
- Oncology Clinical Trials Office, University of Oxford, Department of Oncology, Old Road Campus Research Building, University of Oxford, Old Road Campus, Oxford, UK
| | - Mina Davoudianfar
- Oncology Clinical Trials Office, University of Oxford, Department of Oncology, Old Road Campus Research Building, University of Oxford, Old Road Campus, Oxford, UK
| | - Sarah R Pearson
- Oncology Clinical Trials Office, University of Oxford, Department of Oncology, Old Road Campus Research Building, University of Oxford, Old Road Campus, Oxford, UK
| | - Patrick Julier
- Oncology Clinical Trials Office, University of Oxford, Department of Oncology, Old Road Campus Research Building, University of Oxford, Old Road Campus, Oxford, UK
| | | | - Rachel Kerr
- Oncology Clinical Trials Office, University of Oxford, Department of Oncology, Old Road Campus Research Building, University of Oxford, Old Road Campus, Oxford, UK
| | - Russell D Petty
- University of Aberdeen, Institute of Medical Sciences, Aberdeen, UK
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