Understanding Measurement of postural hypotension: a nationwide survey of primary care practice in England

BACKGROUND

Postural hypotension (PH), the drop in blood pressure (BP) on standing, is associated with falls, all-cause mortality and cognitive decline. PH diagnostic criteria require lying-to-standing BP measurements. PH Prevalence in older adults is 20%, however, it is infrequently recorded in primary care records, suggesting PH testing and/or recording is under-utilised in this setting.

AIM

To understand current PH measurement and management by primary care practitioners in England.

METHOD

Clinical Research Networks circulated an online survey to primary care clinicians involved in measurement of BP. Demographics and responses were summarised as percentages, or median and inter-quartile ranges (IQR), as appropriate. The survey remains open until 30 November 2022; full results will be presented at the conference.

RESULTS

To date, there are 669 replies (341 doctors, 179 nurses, 70 healthcare assistants, 23 pharmacists, 56 other roles); median age 45 (IQR 38 to 53), 72% female. Overall, 597 (89%) responders check for PH, predominantly when symptoms are present (98%). Less common reasons to check include patients being over 80 (24%), Parkinson's disease (21%), hypertension reviews (18%), medication reviews (12%) or diabetes reviews (11%). Sitting-to-standing BP measurements are common (77%); only 22% use lying-to-standing. Only 64% ensure a rest period before sitting or lying BP measurement and only 1 (IQR 1 to 2) standing BP measurement is made, usually (66%) within the first minute of standing.

CONCLUSION

Interim findings suggest that most PH assessments in primary care do not meet current guideline criteria. Full findings from this survey are expected to inform and influence future national guidelines.

Systematic approach to outcome assessment from coded electronic healthcare records in the DaRe2THINK NHS-embedded randomized trial. Eur Heart J Digit Health 2022;3:426-436. [PMID: 36712153 PMCID: PMC9708037 DOI: 10.1093/ehjdh/ztac046]

Aims

Improving the efficiency of clinical trials is key to their continued importance in directing evidence-based patient care. Digital innovations, in particular the use of electronic healthcare records (EHRs), allow for large-scale screening and follow up of participants. However, it is critical these developments are accompanied by robust and transparent methods that can support high-quality and high clinical value research.

Methods and results

The DaRe2THINK trial includes a series of novel processes, including nationwide pseudonymized pre screening of the primary-care EHR across England, digital enrolment, remote e-consent, and 'no-visit' follow up by linking all primary- and secondary-care health data with patient-reported outcomes. DaRe2THINK is a pragmatic, healthcare-embedded randomized trial testing whether earlier use of direct oral anticoagulants in patients with prior or current atrial fibrillation can prevent thromboembolic events and cognitive decline (www.birmingham.ac.uk/dare2think). This study outlines the systematic approach and methodology employed to define patient information and outcome events. This includes transparency on all medical code lists and phenotypes used in the trial across a variety of national data sources, including Clinical Practice Research Datalink Aurum (primary care), Hospital Episode Statistics (secondary care), and the Office for National Statistics (mortality).

Conclusion

Co-designed by a patient and public involvement team, DaRe2THINK presents an opportunity to transform the approach to randomized trials in the setting of routine healthcare, providing high-quality evidence generation in populations representative of the community at risk.

Early Impacts of COVID-19 on Select Hospices: Operations, Care Delivery, and Service Utilization

Objective

The COVID-19 public health emergency (PHE) has important implications for health care service delivery. Little is understood about how the PHE impacted community-based hospice providers and service delivery to hospice-eligible beneficiaries. The aim of this study was to describe hospice response to the PHE and correlated impacts on beneficiary receipt of hospice support services delivered to hospice-eligible beneficiaries participating in the Centers for Medicare & Medicaid Services (CMS) Medicare Care Choices Model (MCCM), a national model testing the provision of certain hospice-like supportive services with concurrent usual care among seriously ill, community-residing Medicare beneficiaries that have not elected to receive hospice care.

Methods

We employed descriptive analysis using concurrent qualitative and quantitative data sources, consisting of provider surveys, beneficiary-level encounter data submitted by hospices, and Medicare administrative claims describing beneficiary service utilization. The sample included both hospice providers (N = 82) and beneficiaries (N = 2294) voluntarily participating in MCCM.

Results

Nearly all participating MCCM hospices adopted operational changes to address their staff and beneficiaries’ safety during the COVID-19 PHE. We report changes to service delivery, including declines in total encounters as well as service modality, and the types of services provided.

Conclusions

While the analyses reported indicate that seriously ill Medicare beneficiaries participating in MCCM were directly impacted by the PHE, we are still unclear whether changes in the service modality and encounters by provider type and the decline in average service counts per beneficiary are driven more by hospices or by beneficiary decisions to minimize exposure. Future research should attempt to disentangle these factors.

Effect of moderate to high intensity aerobic exercise on blood pressure in young adults: The TEPHRA open, two-arm, parallel superiority randomized clinical trial

BACKGROUND

Exercise is advised for young adults with elevated blood pressure, but no trials have investigated efficacy at this age. We aimed to determine whether aerobic exercise, self-monitoring and motivational coaching lowers blood pressure in this group.

METHODS

The study was a single-centre, open, two-arm, parallel superiority randomized clinical trial with open community-based recruitment of physically-inactive 18-35 year old adults with awake 24 h blood pressure 115/75mmHg-159/99 mmHg and BMI<35 kg/m². The study took place in the Cardiovascular Clinical Research Facility, John Radcliffe Hospital, Oxford, UK. Participants were randomized (1:1) with minimisation factors sex, age (<24, 24-29, 30-35 years) and gestational age at birth (<32, 32-37, >37 weeks) to the intervention group, who received 16-weeks aerobic exercise training (three aerobic training sessions per week of 60 min per session at 60-80% peak heart rate, physical activity self-monitoring with encouragement to do 10,000 steps per day and motivational coaching to maintain physical activity upon completion of the intervention. The control group were sign-posted to educational materials on hypertension and recommended lifestyle behaviours. Investigators performing statistical analyses were blinded to group allocation. The primary outcome was 24 h awake ambulatory blood pressure (systolic and diastolic) change from baseline to 16-weeks on an intention-to-treat basis. Clinicaltrials.gov registered on March 30, 2016 (NCT02723552).

FINDINGS

Enrolment occurred between 30/06/2016-26/10/2018. Amongst the 203 randomized young adults (n = 102 in the intervention group; n = 101 in the control group), 178 (88%; n = 76 intervention group, n = 84 control group) completed 16-week follow-up and 160 (79%; n = 68 intervention group, n = 69 control group) completed 52-weeks follow-up. There were no group differences in awake systolic (0·0 mmHg [95%CI, -2·9 to 2·8]; P = 0·98) or awake diastolic ambulatory blood pressure (0·6 mmHg [95%CI, -1·4. to 2·6]; P = 0·58). Aerobic training increased peak oxygen uptake (2·8 ml/kg/min [95%CI, 1·6 to 4·0]) and peak wattage (14·2watts [95%CI, 7·6 to 20·9]) at 16-weeks. There were no intervention effects at 52-weeks follow-up.

INTEPRETATION

These results do not support the exclusive use of moderate to high intensity aerobic exercise training for blood pressure control in young adults.

FUNDING

Wellcome Trust, British Heart Foundation, National Institute for Health Research, Oxford Biomedical Research Centre.

Comparative accuracies of automated and manual office blood pressure measurements in a Chinese population

We aimed to assess the difference in the accuracy of readings from automated office blood pressure machines with each other or with manual office blood pressure measurements in Chinese individuals. We collected awake 48-h ambulatory blood pressure monitoring, two automated office blood pressure device (BpTRU and WatchBP) readings, and manual office blood pressure measurements in Chinese patients (n = 135) with hypertension in a randomized sequence. Differences were compared using paired t-tests and Bland-Altman plots. The sensitivity and specificity of the techniques for detecting elevated blood pressure were calculated using awake ambulatory blood pressure monitoring as the reference standard. The WatchBP device's and awake ambulatory blood pressure readings were similar. The BpTRU device provided significantly lower mean systolic (P < 0.001) and diastolic (P < 0.001) blood pressure readings, while manual office BP provided significantly higher mean systolic (P = 0.008) and diastolic (P < 0.001) blood pressure readings than the awake automated office blood pressure readings. Automated and manual office blood pressure measurements showed similar sensitivity, specificity, and 95% limits of agreement as based on Bland-Altman plots. The mean systolic (P < 0.001) and diastolic (P < 0.02) blood pressure readings of WatchBP and BpTRU differed, and their diagnostic performances were not superior than those of manual office blood pressure measurements in Chinese patients. Therefore, automated office blood pressure measurements cannot be routinely recommended for Chinese individuals in clinical practice. More studies are needed to confirm these results.

Preoperative polymicrobial urine culture: An analysis of the risk of perioperative urinary tract infection

PURPOSE

To report our management of preoperative polymicrobial urine culture and to determine its correlation with the risk of postoperative urinary tract infection (UTI).

PATIENTS AND METHODS

We retrospectively identified all patients with preoperative polymicrobial urine culture in our center between January 2017 and October 2019. Preoperative urine cultures were collected 5 to 8 days before the surgery. No antibiotic prophylaxis was administered preoperatively in the absence of pyuria. Patients with pyuria (≥10 leukocytes/mm³) were treated preoperatively with Ceftriaxone. In case of beta-lactam allergy, the choice between other antibiotic therapies was left to the surgeon's discretion. A second urine culture was collected the day before surgery. The primary endpoint was the occurrence of UTI within 15 days following surgery.

RESULTS

In all, 690 patients were included in the study. In line with our protocol, patients had Ceftriaxone, Fluoroquinolones, another antibiotic or no antibiotic prophylaxis in 492 cases (71.3%), 22 cases (3.2%), 31 cases (4.5%), and 145 cases (21%), respectively. The overall sterilization rate of 40.4% was similar between each treatment arm (P=0.54). Postoperative UTI occurred in 68 cases (10.5%). In multivariate analysis, a sterile urine culture the day before surgery was the only factor decreasing the risk of postoperative UTI (OR 0.39, 95%CI, 0.17-0.84; P=0.022).

CONCLUSIONS

Our findings suggest that empirical antibiotic therapy for the treatment of preoperative polymicrobial urine culture is no longer adequate. Further evaluation of organisms isolated may provide the necessary antibiograms for initiation of susceptibility based antibiotic therapy that could decrease postoperative UTI rates.

LEVEL OF EVIDENCE

3.

Age-stratified and blood-pressure-stratified effects of blood-pressure-lowering pharmacotherapy for the prevention of cardiovascular disease and death: an individual participant-level data meta-analysis

BACKGROUND

The effects of pharmacological blood-pressure-lowering on cardiovascular outcomes in individuals aged 70 years and older, particularly when blood pressure is not substantially increased, is uncertain. We compared the effects of blood-pressure-lowering treatment on the risk of major cardiovascular events in groups of patients stratified by age and blood pressure at baseline.

METHODS

We did a meta-analysis using individual participant-level data from randomised controlled trials of pharmacological blood-pressure-lowering versus placebo or other classes of blood-pressure-lowering medications, or between more versus less intensive treatment strategies, which had at least 1000 persons-years of follow-up in each treatment group. Participants with previous history of heart failure were excluded. Data were obtained from the Blood Pressure Lowering Treatment Triallists' Collaboration. We pooled the data and categorised participants into baseline age groups (<55 years, 55-64 years, 65-74 years, 75-84 years, and ≥85 years) and blood pressure categories (in 10 mm Hg increments from <120 mm Hg to ≥170 mm Hg systolic blood pressure and from <70 mm Hg to ≥110 mm Hg diastolic). We used a fixed effects one-stage approach and applied Cox proportional hazard models, stratified by trial, to analyse the data. The primary outcome was defined as either a composite of fatal or non-fatal stroke, fatal or non-fatal myocardial infarction or ischaemic heart disease, or heart failure causing death or requiring hospital admission.

FINDINGS

We included data from 358 707 participants from 51 randomised clinical trials. The age of participants at randomisation ranged from 21 years to 105 years (median 65 years [IQR 59-75]), with 42 960 (12·0%) participants younger than 55 years, 128 437 (35·8%) aged 55-64 years, 128 506 (35·8%) 65-74 years, 54 016 (15·1%) 75-84 years, and 4788 (1·3%) 85 years and older. The hazard ratios for the risk of major cardiovascular events per 5 mm Hg reduction in systolic blood pressure for each age group were 0·82 (95% CI 0·76-0·88) in individuals younger than 55 years, 0·91 (0·88-0·95) in those aged 55-64 years, 0·91 (0·88-0·95) in those aged 65-74 years, 0·91 (0·87-0·96) in those aged 75-84 years, and 0·99 (0·87-1·12) in those aged 85 years and older (adjusted pinteraction=0·050). Similar patterns of proportional risk reductions were observed for a 3 mm Hg reduction in diastolic blood pressure. Absolute risk reductions for major cardiovascular events varied by age and were larger in older groups (adjusted pinteraction=0·024). We did not find evidence for any clinically meaningful heterogeneity of relative treatment effects across different baseline blood pressure categories in any age group.

INTERPRETATION

Pharmacological blood pressure reduction is effective into old age, with no evidence that relative risk reductions for prevention of major cardiovascular events vary by systolic or diastolic blood pressure levels at randomisation, down to less than 120/70 mm Hg. Pharmacological blood pressure reduction should, therefore, be considered an important treatment option regardless of age, with the removal of age-related blood-pressure thresholds from international guidelines.

FUNDING

British Heart Foundation, National Institute of Health Research Oxford Biomedical Research Centre, Oxford Martin School.

Predictors of Frailty Change in Home and Community-Based Services Populations

OBJECTIVES

With unprecedented demand for Medicaid long-term services and supports, states are seeking to allocate resources in the most efficient way. Understanding the prevalence of frailty and how it varies across home and community-based services (HCBS) populations can assist states with more precise identification of individuals most in need of services. Early identification of individuals more likely to experience frailty changes could allow for enhanced care planning to prevent or slow the progression of decline.

DESIGN

Longitudinal study.

SETTING AND PARTICIPANTS

Data from Connecticut's assessment tool (based on interRAI-HC) were analyzed at 2 time points for 16,309 individuals receiving HCBS. The sample included assessments completed between November 1, 2017 and July 15, 2020 across 4 groups: older adults 65+ years old meeting nursing facility level of care (NF LOC), older adults 65+ years old not meeting NF LOC, individuals with acquired brain injury, and individuals <65 years old with physical disability.

METHODS

We measured frailty using the Frailty Index (FI) and examined change in FI between baseline and follow-up. A change in FI score of at least ±0.03 was classified as a clinically meaningful change. We compared predictors of clinically meaningful decline or improvement using multivariate logistic regression.

RESULTS

In our sample, 54% of individuals experienced a clinically meaningful change: 42% declined and 12% improved. Individuals receiving in-home care services had lower odds of improvement across all HCBS groups and multiple frailty categories with odds ratios ranging from 0.35 to 0.68. Frail older adults 65+ years old meeting nursing facility level of care receiving physical therapy were 21% less likely to experience decline and 1.4 times more likely to improve.

CONCLUSIONS AND IMPLICATIONS

The nature of HCBS support provided can impact changes in frailty status. More reactive services such as in-home care may contribute to frailty decline while rehabilitative services such as physical therapy may protect against decline.

Rates, risks and routes to reduce vascular dementia (R4vad), a UK-wide multicentre prospective observational cohort study of cognition after stroke: Protocol

BACKGROUND

Stroke commonly affects cognition and, by definition, much vascular dementia follows stroke. However, there are fundamental limitations in our understanding of vascular cognitive impairment, restricting understanding of prevalence, trajectories, mechanisms, prevention, treatment and patient-service needs.

AIMS

Rates, Risks and Routes to Reduce Vascular Dementia (R4VaD) is an observational cohort study of post-stroke cognition. We aim to recruit a wide range of patients with stroke, presenting to geographically diverse UK hospitals, into a longitudinal study to determine rates of, and risk factors for, cognitive and related impairments after stroke, to assess potential mechanisms and improve prediction models.

METHODS

We will recruit at least 2000 patients within six weeks of stroke with or without capacity to consent and collect baseline demographic, clinical, socioeconomic, lifestyle, cognitive, neuropsychiatric and informant data using streamlined patient-centred methods appropriate to the stage after stroke. We will obtain more detailed assessments at four to eight weeks after the baseline assessment and follow-up by phone and post yearly to at least two years. We will assess diagnostic neuroimaging in all and high-sensitivity inflammatory markers, genetics, blood pressure and diffusion tensor imaging in mechanistic sub-studies.Planned outputs: R4VaD will provide reliable data on long-term cognitive function after stroke, stratified by prior cognition, stroke- and patient-related variables and improved risk prediction. It will create a platform enabling sharing of data, imaging and samples. Participants will be consented for re-contact, facilitating future clinical trials and providing a resource for the stroke and dementia research communities.

Trial of exercise to prevent HypeRtension in young adults (TEPHRA) a randomized controlled trial: study protocol

Background

Hypertension prevalence in young adults has increased and is associated with increased incidence of cerebrovascular and cardiovascular events in middle age. However, there is significant debate regards how to effectively manage young adult hypertension with recommendation to target lifestyle intervention. Surprisingly, no trials have investigated whether lifestyle advice developed for blood pressure control in older adults is effective in these younger populations.

Methods/Design

TEPHRA is an open label, parallel arm, randomised controlled trial in young adults with high normal and elevated blood pressure. The study will compare a supervised physical activity intervention consisting of 16 weeks structured exercise, physical activity self-monitoring and motivational coaching with a control group receiving usual care/minimal intervention. Two hundred young adults aged 18–35 years, including a subgroup of preterm born participants will be recruited through open recruitment and direct invitation. Participants will be randomised in a ratio of 1:1 to either the exercise intervention group or control group. Primary outcome will be ambulatory blood pressure monitoring at 16 weeks with measure of sustained effect at 12 months. Study measures include multimodal cardiovascular assessments; peripheral vascular measures, blood sampling, microvascular assessment, echocardiography, objective physical activity monitoring and a subgroup will complete multi-organ magnetic resonance imaging.

Discussion

The results of this trial will deliver a novel, randomised control trial that reports the effect of physical activity intervention on blood pressure integrated with detailed cardiovascular phenotyping in young adults. The results will support the development of future research and expand the evidence-based management of blood pressure in young adult populations.

Trial Registration

Clinicaltrials.gov registration number NCT02723552, registered on 30 March, 2016.

A universal standard for the validation of blood pressure measuring devices: Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Collaboration Statement

: In the last 30 years, several organizations, such as the US Association for the Advancement of Medical Instrumentation (AAMI), the British Hypertension Society, the European Society of Hypertension (ESH) Working Group on Blood Pressure (BP) Monitoring and the International Organization for Standardization (ISO) have developed protocols for clinical validation of BP measuring devices. However, it is recognized that science, as well as patients, consumers and manufacturers would be best served if all BP measuring devices were assessed for accuracy according to an agreed single validation protocol that had global acceptance. Therefore, an international initiative was taken by AAMI, ESH and ISO experts who agreed to develop a universal standard for device validation. This statement presents the key aspects of a validation procedure, which were agreed by the AAMI, ESH and ISO representatives as the basis for a single universal validation protocol. As soon as the AAMI/ESH/ISO standard is fully developed, this will be regarded as the single universal standard and will replace all other previous standards/protocols.

A Universal Standard for the Validation of Blood Pressure Measuring Devices: Association for the Advancement of Medical Instrumentation/European Society of Hypertension/International Organization for Standardization (AAMI/ESH/ISO) Collaboration Statement

In the past 30 years, several organizations, such as the US Association for the Advancement of Medical Instrumentation (AAMI), the British Hypertension Society, the European Society of Hypertension (ESH) Working Group on Blood Pressure (BP) Monitoring, and the International Organization for Standardization (ISO), have developed protocols for clinical validation of BP measuring devices. However, it is recognized that science, as well as patients, consumers, and manufacturers, would be best served if all BP measuring devices were assessed for accuracy according to an agreed single validation protocol that had global acceptance. Therefore, an international initiative was taken by the AAMI, ESH, and ISO experts who agreed to develop a universal standard for device validation. This statement presents the key aspects of a validation procedure, which were agreed by the AAMI, ESH, and ISO representatives as the basis for a single universal validation protocol. As soon as the AAMI/ESH/ISO standard is fully developed, this will be regarded as the single universal standard and will replace all other previous standards/protocols.

Translating Healthy Living Messages to Postpartum Women and Their Partners After Gestational Diabetes (GDM): Body Habitus, A1C, Lifestyle Habits, and Program Engagement Results From the Families Defeating Diabetes (FDD) Randomized Trial

PURPOSE

The Families Defeating Diabetes intervention evaluated a postpartum healthy living program for women with recent gestational diabetes mellitus (GDM).

DESIGN

Randomized controlled trial.

SETTING

Tertiary centers in London, Calgary, and Victoria, Canada.

PARTICIPANTS

Women with GDM and partners; 46% of eligible maternal participants agreed to participate.

INTERVENTION

Interventional (INT) participants received a healthy living seminar at 3 months; access to a walking group/Website; biweekly e-mails. Control (CON) participants received a contemporary postpartum diabetes prevention handout.

MEASURES

Maternal, partner, and offspring demographics at baseline, 3, and 12 months.

ANALYSIS

Percentages of women losing ≥7% of postpartum weight were compared by χ² testing; body habitus comparisons by analysis of covariance (ANCOVA); maternal A1C comparisons by unpaired t tests; participant outcome associations by Pearson correlation coefficients.

RESULTS

Maternal participants were 170 (89 INT and 81 CON) with 63 partners (30 INT and 33 CON); 103 (73 maternal; 30 partners) were lost to follow-up; 57% of maternal participants completed 12 months; 33% INT women (n = 50) lost ≥7% weight versus 25% CON women (n = 47), P = .43. Interventional participant results did not correlate with accession of study elements. Maternal completion was significantly associated with partner involvement, breastfeeding, higher income, and education. Paternal weights correlated significantly with maternal and offspring weights.

CONCLUSION

Families Defeating Diabetes outcomes were not significantly different for INT maternal or paternal participants versus CON participants. Secondary outcomes of future value included statistically significant positive associations between paternal participation, socioeconomic indicators, and maternal study completion, significant correlations between maternal, paternal, and offspring weights as well as insights into study component engagement.

Race and place differences in patients hospitalized with an acute coronary syndrome: Is there double jeopardy? Findings from TRACE-CORE

The objectives of this longitudinal study were to examine differences between whites and blacks, and across two geographical regions, in the socio-demographic, clinical, and psychosocial characteristics, hospital treatment practices, and post-discharge mortality for hospital survivors of an acute coronary syndrome (ACS). In this prospective cohort study, we performed in-person interviews and medical record abstractions for patients discharged from the hospital after an ACS at participating sites in Central Massachusetts and Central Georgia during 2011–2013. Among the 1143 whites in Central Massachusetts, 514 whites in Central Georgia, and 277 blacks in Central Georgia, we observed a gradient of socioeconomic position with whites in Central Massachusetts being the most privileged, followed by whites and then blacks from Central Georgia; similar gradients pertained to psychosocial vulnerability (e.g., 10.7%, 25.1%, and 49.1% had cognitive impairment, respectively) and to the hospital receipt of all 4 evidence-based cardiac medications (35.5%, 18.1%, and 14.4%, respectively) used in the acute management of patients hospitalized with an ACS. Multivariable adjusted odds ratios (95% confidence intervals) for the receipt of a percutaneous coronary intervention for whites and blacks in Georgia vs. whites in Massachusetts were 0.57 (0.46–0.71) and 0.40(0.30–0.52), respectively. Thirty-day and one-year mortality risks exhibited a similar gradient.

The results of this contemporary clinical/epidemiologic study in a diverse patient cohort suggest that racial and geographic disparities continue to exist for patients hospitalized with an ACS.

•

We observed a gradient of socio-economic position, treatment practices, and dying.

•

Interplay of race and place with treatment practices and post discharge outcomes.

•

Racial and geographic disparities continue to exist for patients after an ACS.

Understanding how primary care practitioners perceive an online intervention for the management of hypertension

BACKGROUND

In order to achieve successful implementation an intervention needs to be acceptable and feasible to its users and must overcome barriers to behaviour change. The Person-Based Approach can help intervention developers to improve their interventions to ensure more successful implementation. This study provides an example of using the Person-Based Approach to refine a digital intervention for hypertension (HOME BP).

METHODS

Our Person-Based Approach involved conducting qualitative focus groups with practice staff to explore their perceptions of HOME BP and to identify any potential barriers to implementation of the HOME BP procedures. We took an iterative approach moving between data collection, analysis and modifications to the HOME BP intervention, followed by further data collection. The data was analysed using thematic analysis.

RESULTS

Many aspects of HOME BP appeared to be acceptable, persuasive and feasible to implement. Practitioners perceived benefits in using HOME BP, including that it could empower patients to self-manage their health, potentially overcome clinical inertia around prescribing medication and save both the patient and practitioner time. However, practitioners also had some concerns. Some practitioners were concerned about the accuracy of patients' home blood pressure readings, or the potential for home monitoring to cause patients anxiety and therefore increase consultations. Some GPs lacked confidence in choosing multiple medication changes, or had concerns about unanticipated drug interactions. A few nurses were concerned that the model of patient support they were asked to provide was not consistent with their perceived role. Modifications were made to the intervention based on this feedback, which appeared to help overcome practitioners' concerns and improve the acceptability and feasibility of the intervention.

CONCLUSIONS

This paper provides a detailed example of using the Person-Based Approach to refine HOME BP, demonstrating how we improved the acceptability and feasibility of HOME BP based on feedback from practice staff. This demonstration may be useful to others developing digital interventions.

Choice of statistical model for cost-effectiveness analysis and covariate adjustment: empirical application of prominent models and assessment of their results

CONTEXT

Statistical models employed in analysing patient-level cost and effectiveness data need to be flexible enough to adjust for any imbalanced covariates, account for correlations between key parameters, and accommodate potential skewed distributions of costs and/or effects. We compare prominent statistical models for cost-effectiveness analysis alongside randomised controlled trials (RCTs) and covariate adjustment to assess their performance and accuracy using data from a large RCT.

METHOD

Seemingly unrelated regressions, linear regression of net monetary benefits, and Bayesian generalized linear models with various distributional assumptions were used to analyse data from the TASMINH2 trial. Each model adjusted for covariates prognostic of costs and outcomes.

RESULTS

Cost-effectiveness results were notably sensitive to model choice. Models assuming normally distributed costs and effects provided a poor fit to the data, and potentially misleading inference. Allowing for a beta distribution captured the true incremental difference in effects and changed the decision as to which treatment is preferable.

CONCLUSIONS

Our findings suggest that Bayesian generalized linear models which allow for non-normality in estimation offer an attractive tool for researchers undertaking cost-effectiveness analyses. The flexibility provided by such methods allows the researcher to analyse patient-level data which are not necessarily normally distributed, while at the same time it enables assessing the effect of various baseline covariates on cost-effectiveness results.

The Stroke Prevention Programme: a programme of research to inform optimal stroke prevention in primary care

Background

The management of cardiovascular (CV) risk factors in community populations is suboptimal. The aim of this programme was to explore the role of three approaches [use of a ‘polypill’; self-management of hypertension; and more intensive targets for blood pressure (BP) lowering after stroke] to improve prevention of CV disease (CVD) in the community.

Research questions

(1) Is it more cost-effective to titrate treatments to target levels of cholesterol and BP or to use fixed doses of statins and BP-lowering agents (polypill strategy)? (2) Will telemonitoring and self-management improve BP control in people on treatment for hypertension or with a history of stroke/transient ischaemic attack (TIA) in primary care and are they cost-effective? (3) In people with a history of stroke/TIA, can intensive BP-lowering targets be achieved in a primary care setting and what impact will this have on health outcomes and cost-effectiveness?

Design

Mixed methods, comprising three randomised controlled trials (RCTs); five cost-effectiveness analyses; qualitative studies; analysis of electronic general practice data; a screening study; a systematic review; and a questionnaire study.

Setting

UK general practices, predominantly from the West Midlands and the east of England.

Participants

Adults registered with participating general practices. Inclusion criteria varied from study to study.

Interventions

A polypill – a fixed-dose combination pill containing three antihypertensive medicines and simvastatin – compared with current practice and with optimal implementation of national guidelines; self-monitoring of BP with self-titration of medication, compared with usual care; and an intensive target for systolic BP of < 130 mmHg or a 10 mmHg reduction if baseline BP is < 140 mmHg, compared with a target of < 140 mmHg.

Results

For patients known to be at high risk of CVD, treatment as per guidelines was the most cost-effective strategy. For people with unknown CV risk aged ≥ 50 years, offering a polypill is cost-effective [incremental cost-effectiveness ratio (ICER) of £8115 per quality-adjusted life-year (QALY)] compared with a strategy of screening and treating according to national guidelines. Both results were sensitive to the cost of the polypill. Self-management in people with uncontrolled hypertension led to a 5.4 mmHg [95% confidence interval (CI) 2.4 to 8.5 mmHg] reduction in systolic BP at 1 year, compared with usual care. It was cost-effective for men (ICER of £1624 per QALY) and women (ICER of £4923 per QALY). In people with stroke and other high-risk groups, self-management led to a 9.2 mmHg (95% CI 5.7 to 12.7 mmHg) reduction in systolic BP at 1 year compared with usual care and dominated (lower cost and better outcome) usual care. Aiming for the more intensive BP target after stroke led to a 2.9 mmHg (95% CI 0.2 to 5.7 mmHg) greater reduction in BP and dominated the 140 mmHg target.

Conclusions

Potential for a polypill needs to be further explored in RCTs. Self-management should be offered to people with poorly controlled BP. Management of BP in the post-stroke population should focus on achieving a < 140 mmHg target.

Trial registration

Current Controlled Trials ISRCTN17585681, ISRCTN87171227 and ISRCTN29062286.

Funding

The National Institute for Health Research (NIHR) Programme Grants for Applied Research programme. Additional funding was provided by the NIHR National School for Primary Care Research, the NIHR Career Development Fellowship and the Department of Health Policy Research Programme.

Characteristics of contemporary patients discharged from the hospital after an acute coronary syndrome

BACKGROUND

Limited contemporary data compare the clinical and psychosocial characteristics and acute management of patients hospitalized with an initial vs a recurrent episode of acute coronary disease. We describe these factors in a cohort of patients recruited from 6 hospitals in Massachusetts and Georgia after an acute coronary syndrome.

MATERIALS AND METHODS

We performed structured baseline in-person interviews and medical record abstractions for 2174 eligible and consenting patients surviving hospitalization for an acute coronary syndrome between April 2011 and May 2013.

RESULTS

The average patient age was 61 years, 64% were men, and 47% had a high school education or less; 29% had a low general quality of life, and 1 in 5 were cognitively impaired. Patients with a recurrent coronary episode had a greater burden of previously diagnosed comorbidities. Overall, psychosocial burden was high, and more so in those with a recurrent vs those with an initial episode. Patients with an initial coronary episode were as likely to have been treated with all 4 effective cardiac medications (51.6%) as patients with a recurrent episode (52.3%), but were significantly more likely to have undergone cardiac catheterization (97.9% vs 92.9%) and a percutaneous coronary intervention (73.7% vs 60.9%) (P < .001) during their index hospitalization.

CONCLUSIONS

Patients with a first episode of acute coronary artery disease have a more favorable psychosocial profile, less comorbidity, and receive more invasive procedures but similar medical management, than patients with previously diagnosed coronary disease. Implications of the high psychosocial burden on various patient-related outcomes require investigation.

Abstract 329: Change in Cognitive Status in the Month Following Hospitalization for an Acute Coronary Syndrome: findings from TRACE-CORE

Background: Cognitive impairment (CI) during hospitalization is associated with poor long-term outcomes but little is known about changes in cognitive status soon after discharge.

Methods: Adults (n=1,545) without dementia or delirium were interviewed during hospitalization for an Acute Coronary Syndrome (ACS) and at 1-month post-discharge as part of the ongoing Transitions, Risks and Actions in Coronary Events - Center for Cardiovascular Outcomes Research and Education (TRACE-CORE) study. CI was indicated by a score ≤28 on the Telephone Interview of Cognitive Status (TICS; range: 0-41). Patients reported demographic characteristics, anxiety (GAD7), depression (PHQ9), and stress (PSS4). Factors associated with cognitive change categories (consistently impaired, transiently impaired, newly impaired versus not impaired) were examined using adjusted multinomial logistic regression (Table).

Results: Participants were 66% male, 83% non-Hispanic white, and aged 62±11 years. Of those with CI during hospitalization (16%; n=245), 53% remediated by 1-month. Among the remaining 1300 patients, with normal cognitive function during hospitalization, 5% (n=67) had developed cognitive impairment by 1-month post discharge. Women had higher odds of becoming newly impaired (Table). Low education, health literacy, and numeracy were associated with persistent, transient, and new impairment. Compared to those who lived with a spouse, patients who lived alone were more likely to be transiently impaired, and those who lived with others were more like to become newly impaired. High stress and low social support were associated with persistent impairment.

Conclusions: For many patients with ACS, cognitive status changes during the transition from hospital to home; thus, assessing cognition both in-hospital and post-discharge is important for detecting patients who could benefit from tailored transitional care, because they are at high risk for decline, or early follow-up for booster discharge instructions and secondary prevention, because there is a good chance of their improving.

Abstract 126: In-hospital Depression Predicts Early Hospital Readmission after an Acute Coronary Syndrome: Preliminary Data from TRACE-CORE

Background: Hospital systems, patients and providers seek to avert rehospitalizations within 30 days for patients admitted with an acute coronary syndrome (ACS). Rehospitalizations within 30 days of discharge are often considered preventable and to reflect poor in-hospital management or discharge practices. However, independent associations of psychosocial factors with early rehospitalization in patients admitted with an ACS have not been examined.

Methods: A multi-racial cohort of 1,540 patients admitted with an ACS reported psychosocial factors via standardized questionnaires in an in-hospital interview. One month following discharge, patients were interviewed via phone and reported hospital readmissions. We used logistic regression models to estimate odds ratios (ORs) and 95% confidence intervals (CIs) of the association between in-hospital psychosocial characteristics (depression, anxiety, and perceived stress), health literacy and numeracy, and cognitive status, with self-reported readmission within 30 days.

Results: Participants were 34% female and 17% non-white, with a mean age of 62 years and a mean length of stay of 4.1 days. Rehospitalization was reported for 14% (n=208) of participants, 77% of which were due to CVD. In univariate analyses, in-hospital severe depression, anxiety, and high stress were associated with higher odds of early readmission, whereas low health numeracy was associated with lower odds of early readmission (Table 1). Severe depression remained associated with higher odds and low health numeracy remained associated with lower odds of early readmission in a multivariable model including covariates associated on univariate testing with rehospitalization.

Conclusions: Early readmission after hospitalization for an ACS was common and associated with in-hospital depression and health numeracy. Notably, depression and health numeracy were the only predictors independently associated with readmission in multivariable analyses. We speculate that the lower likelihood of readmission for those with low numeracy may be related to less engagement with the healthcare system. In-hospital screening for depression and characterization of health numeracy may help stratify risk for early rehospitalization after an ACS.

Benefits of Aldosterone Receptor Antagonism in Chronic Kidney Disease (BARACK D) trial-a multi-centre, prospective, randomised, open, blinded end-point, 36-month study of 2,616 patients within primary care with stage 3b chronic kidney disease to compare the efficacy of spironolactone 25 mg once daily in addition to routine care on mortality and cardiovascular outcomes versus routine care alone: study protocol for a randomized controlled trial

BACKGROUND

Chronic kidney disease (CKD) is common and increasing in prevalence. Cardiovascular disease (CVD) is a major cause of morbidity and death in CKD, though of a different phenotype to the general CVD population. Few therapies have proved effective in modifying the increased CVD risk or rate of renal decline in CKD. There are accumulating data that aldosterone receptor antagonists (ARA) may offer cardio-protection and delay renal impairment in patients with the CV phenotype in CKD. The use of ARA in CKD has therefore been increasingly advocated. However, no large study of ARA with renal or CVD outcomes is underway.

METHODS

The study is a prospective randomised open blinded endpoint (PROBE) trial set in primary care where patients will mainly be identified by their GPs or from existing CKD lists. They will be invited if they have been formally diagnosed with CKD stage 3b or there is evidence of stage 3b CKD from blood results (eGFR 30-44 mL/min/1.73 m2) and fulfil the other inclusion/exclusion criteria. Patients will be randomised to either spironolactone 25 mg once daily in addition to routine care or routine care alone and followed-up for 36 months.

DISCUSSION

BARACK D is a PROBE trial to determine the effect of ARA on mortality and cardiovascular outcomes (onset or progression of CVD) in patients with stage 3b CKD.

TRIAL REGISTRATION

EudraCT: 2012-002672-13ISRTN: ISRCTN44522369.

The Oxford Renal (OxRen) cross-sectional study of chronic kidney disease in the UK

INTRODUCTION

Chronic kidney disease (CKD) diagnosed with objective measures of kidney damage and function has been recognised as a major public health burden. Independent of age, sex, ethnicity and comorbidity, strong associations exist between cardiovascular disease, mortality, morbidity and CKD, defined by reduced glomerular filtration rate and increased urinary albumin excretion. Detection of CKD within the population is therefore a priority for health systems.

METHODS AND ANALYSIS

15 000 patients aged 60 years or over meeting the inclusion criteria will be invited to the study. Recruitment will be stratified to represent the distribution of socioeconomic position in the UK general population. Patients will be excluded if terminally ill (expected survival <1 year), or if they have received a solid organ transplant. Patients will attend up to two screening visits, to determine if they have CKD, followed by an assessment visit where demographic and physiological parameters will be recorded alongside questionnaires on exercise, diet, cognitive assessment and quality of life. Blood and urine specimens will be taken for immediate routine assays as well as for freezing pending peptide and genetic studies. Patients will have office and home blood pressure measurements as well as pulse wave velocity assessment. Healthcare costs of screening and subsequent monitoring will be calculated.

ETHICS AND DISSEMINATION

The protocol and related documents have been approved by NRES Committee South Central-Oxford B-Reference 13/SC/0020.

NHS arm's length bodies and regulatory networks in England: quantitative analysis

Health regulation is an area of English public policy that involves a plethora of different bodies operating independently of one another with the purported aim of monitoring standards, ensuring minimum standards are met and providing assurance for the public and government. The purpose of this research is to ascertain as well as possible whether regulation generally is having a positive effect on service provision as well as what the relationship between the data collected by these bodies is. The rationale for testing whether the effect of regulation is positive is obvious; it costs money, time and effort, so does it work? The rationale for testing the relationships is that providers who score well on quality measures should also be experiencing fewer deaths compared with what would be expected. They should also be the providers who are performing well in terms of finances and governance. If there is no relationship between these data sets, then surely something is going wrong; that is, does the various regulatory monitoring and scrutiny actually measure what it sets out to measure?

Clinical score and rapid antigen detection test to guide antibiotic use for sore throats: randomised controlled trial of PRISM (primary care streptococcal management)

OBJECTIVE

To determine the effect of clinical scores that predict streptococcal infection or rapid streptococcal antigen detection tests compared with delayed antibiotic prescribing.

DESIGN

Open adaptive pragmatic parallel group randomised controlled trial.

SETTING

Primary care in United Kingdom.

PATIENTS

Patients aged ≥ 3 with acute sore throat.

INTERVENTION

An internet programme randomised patients to targeted antibiotic use according to: delayed antibiotics (the comparator group for analyses), clinical score, or antigen test used according to clinical score. During the trial a preliminary streptococcal score (score 1, n=1129) was replaced by a more consistent score (score 2, n=631; features: fever during previous 24 hours; purulence; attends rapidly (within three days after onset of symptoms); inflamed tonsils; no cough/coryza (acronym FeverPAIN).

OUTCOMES

Symptom severity reported by patients on a 7 point Likert scale (mean severity of sore throat/difficulty swallowing for days two to four after the consultation (primary outcome)), duration of symptoms, use of antibiotics.

RESULTS

For score 1 there were no significant differences between groups. For score 2, symptom severity was documented in 80% (168/207 (81%) in delayed antibiotics group; 168/211 (80%) in clinical score group; 166/213 (78%) in antigen test group). Reported severity of symptoms was lower in the clinical score group (-0.33, 95% confidence interval -0.64 to -0.02; P=0.04), equivalent to one in three rating sore throat a slight versus moderate problem, with a similar reduction for the antigen test group (-0.30, -0.61 to -0.00; P=0.05). Symptoms rated moderately bad or worse resolved significantly faster in the clinical score group (hazard ratio 1.30, 95% confidence interval 1.03 to 1.63) but not the antigen test group (1.11, 0.88 to 1.40). In the delayed antibiotics group, 75/164 (46%) used antibiotics. Use of antibiotics in the clinical score group (60/161) was 29% lower (adjusted risk ratio 0.71, 95% confidence interval 0.50 to 0.95; P=0.02) and in the antigen test group (58/164) was 27% lower (0.73, 0.52 to 0.98; P=0.03). There were no significant differences in complications or reconsultations.

CONCLUSION

Targeted use of antibiotics for acute sore throat with a clinical score improves reported symptoms and reduces antibiotic use. Antigen tests used according to a clinical score provide similar benefits but with no clear advantages over a clinical score alone.

TRIAL REGISTRATION

ISRCTN32027234.

RApid Primary care Initiation of Drug treatment for Transient Ischaemic Attack (RAPID-TIA): study protocol for a pilot randomised controlled trial

Background

People who have a transient ischaemic attack (TIA) or minor stroke are at high risk of a recurrent stroke, particularly in the first week after the event. Early initiation of secondary prevention drugs is associated with an 80% reduction in risk of stroke recurrence. This raises the question as to whether these drugs should be given before being seen by a specialist – that is, in primary care or in the emergency department. The aims of the RAPID-TIA pilot trial are to determine the feasibility of a randomised controlled trial, to analyse cost effectiveness and to ask: Should general practitioners and emergency doctors (primary care physicians) initiate secondary preventative measures in addition to aspirin in people they see with suspected TIA or minor stroke at the time of referral to a specialist?

Methods/Design

This is a pilot randomised controlled trial with a sub-study of accuracy of primary care physician diagnosis of TIA. In the pilot trial, we aim to recruit 100 patients from 30 general practices (including out-of-hours general practice centres) and 1 emergency department whom the primary care physician diagnoses with TIA or minor stroke and randomly assign them to usual care (that is, initiation of aspirin and referral to a TIA clinic) or usual care plus additional early initiation of secondary prevention drugs (a blood-pressure lowering protocol, simvastatin 40 mg and dipyridamole 200 mg m/r bd). The primary outcome of the main study will be the number of strokes at 90 days. The diagnostic accuracy sub-study will include these 100 patients and an additional 70 patients in whom the primary care physician thinks the diagnosis of TIA is possible, rather than probable. For the pilot trial, we will report recruitment rate, follow-up rate, a preliminary estimate of the primary event rate and occurrence of any adverse events. For the diagnostic study, we will calculate sensitivity and specificity of primary care physician diagnosis using the final TIA clinic diagnosis as the reference standard.

Discussion

This pilot study will be used to estimate key parameters that are needed to design the main study and to estimate the accuracy of primary care diagnosis of TIA. The planned follow-on trial will have important implications for the initial management of people with suspected TIA.

Trial registration

ISRCTN62019087