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Mok J, Adeleke MO, Brown A, Magee CG, Firman C, Makahamadze C, Jassil FC, Marvasti P, Carnemolla A, Devalia K, Fakih N, Elkalaawy M, Pucci A, Jenkinson A, Adamo M, Omar RZ, Batterham RL, Makaronidis J. Safety and Efficacy of Liraglutide, 3.0 mg, Once Daily vs Placebo in Patients With Poor Weight Loss Following Metabolic Surgery: The BARI-OPTIMISE Randomized Clinical Trial. JAMA Surg 2023; 158:1003-1011. [PMID: 37494014 PMCID: PMC10372755 DOI: 10.1001/jamasurg.2023.2930] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Accepted: 05/08/2023] [Indexed: 07/27/2023]
Abstract
Importance Metabolic surgery leads to weight loss and improved health, but these outcomes are highly variable. Poor weight loss is associated with lower circulating levels of glucagon-like peptide-1 (GLP-1). Objective To assess the efficacy and safety of the GLP-1 receptor agonist, liraglutide, 3.0 mg, on percentage body weight reduction in patients with poor weight loss and suboptimal GLP-1 response after metabolic surgery. Design, Setting, and Participants The Evaluation of Liraglutide 3.0 mg in Patients With Poor Weight Loss and a Suboptimal Glucagon-Like Peptide-1 Response (BARI-OPTIMISE) randomized placebo-controlled trial recruited adult patients at least 1 year after metabolic surgery who had experienced 20% or less body weight loss from the day of surgery and a suboptimal nutrient-stimulated GLP-1 response from 2 hospitals in London, United Kingdom, between October 2018 and November 2019. Key exclusion criteria were type 1 diabetes; severe concomitant psychiatric, gastrointestinal, cardiac, kidney or metabolic disease; and use of insulin, GLP-1 receptor analogues, and medication that can affect weight. The study period was 24 weeks followed by a 4-week follow-up period. Last participant follow-up was completed in June 2020. All participants and clinical study personnel were blinded to treatment allocation. Of 154 assessed for eligibility, 70 met trial criteria and were included in the study, and 57 completed follow-up. Interventions Liraglutide, 3.0 mg, once daily or placebo as an adjunct to lifestyle intervention with a 500-kcal daily energy deficit for 24 weeks, on a 1:1 allocation by computer-generated randomization sequence, stratified by surgery type (Roux-en-Y gastric bypass [RYGB] or sleeve gastrectomy [SG]) and type 2 diabetes status. Main Outcome and Measures The primary outcome was change in percentage body weight from baseline to the end of the 24-week study period based on an intention-to-treat analysis. Participant safety was assessed through monitoring of biochemical parameters, including kidney and liver function, physical examination, and assessment for adverse events. Results A total of 70 participants (mean [SD] age, 47.6 [10.7] years; 52 [74%] female) with a poor weight loss response following RYGB or SG were randomized to receive 3.0-mg liraglutide (n = 35) or placebo (n = 35). All participants received at least 1 dose of the trial drug. Eight participants discontinued treatment (4 per group), and 2 in the 3.0-mg liraglutide group and 1 in the placebo group were lost to follow-up. Due to COVID-19 restrictions, 3 participants in the 3.0-mg liraglutide group and 7 in the placebo group were unable to attend their final in-person assessment. Estimated change in mean (SD) percentage body weight from baseline to week 24 was -8.82 (4.94) with liraglutide, 3.0 mg (n = 31), vs -0.54 (3.32) with placebo (n = 26). The mean difference in percentage body weight change for liraglutide, 3.0 mg, vs placebo was -8.03 (95% CI, -10.39 to -5.66; P < .001). Adverse events, predominantly gastrointestinal, were more frequent with liraglutide, 3.0 mg (28 events [80%]), than placebo (20 events [57%]). There were no serious adverse events and no treatment-related deaths. Conclusion and Relevance These findings support the use of adjuvant liraglutide, 3.0 mg, for weight management in patients with poor weight loss and suboptimal GLP-1 response after metabolic surgery. Trial Registration ClinicalTrials.gov Identifier: NCT03341429.
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Affiliation(s)
- Jessica Mok
- Division of Medicine, University College London Centre for Obesity Research, Rayne Institute, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
- National Institute for Health and Care Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Mariam O. Adeleke
- Department of Statistical Science, University College London, London, United Kingdom
| | - Adrian Brown
- Division of Medicine, University College London Centre for Obesity Research, Rayne Institute, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
- National Institute for Health and Care Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Cormac G. Magee
- Division of Medicine, University College London Centre for Obesity Research, Rayne Institute, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
- National Institute for Health and Care Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Chloe Firman
- Division of Medicine, University College London Centre for Obesity Research, Rayne Institute, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
- National Institute for Health and Care Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Christwishes Makahamadze
- Division of Medicine, University College London Centre for Obesity Research, Rayne Institute, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
| | - Friedrich C. Jassil
- Division of Medicine, University College London Centre for Obesity Research, Rayne Institute, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
| | - Parastou Marvasti
- Division of Medicine, University College London Centre for Obesity Research, Rayne Institute, London, United Kingdom
- National Institute for Health and Care Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Alisia Carnemolla
- Division of Medicine, University College London Centre for Obesity Research, Rayne Institute, London, United Kingdom
| | - Kalpana Devalia
- Bariatric Surgery Department Homerton University Hospital National Health Service Trust, London, United Kingdom
| | - Naim Fakih
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
| | - Mohamed Elkalaawy
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
| | - Andrea Pucci
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
| | - Andrew Jenkinson
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
| | - Marco Adamo
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
| | - Rumana Z. Omar
- Department of Statistical Science, University College London, London, United Kingdom
| | - Rachel L. Batterham
- Division of Medicine, University College London Centre for Obesity Research, Rayne Institute, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
- National Institute for Health and Care Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom
| | - Janine Makaronidis
- Division of Medicine, University College London Centre for Obesity Research, Rayne Institute, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospitals, National Health Service Foundation Trust, London, United Kingdom
- National Institute for Health and Care Research, University College London Hospitals Biomedical Research Centre, London, United Kingdom
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2
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Pavlou M, Ambler G, Omar RZ, Goodwin AT, Trivedi U, Ludman P, de Belder M. Outlier identification and monitoring of institutional or clinician performance: an overview of statistical methods and application to national audit data. BMC Health Serv Res 2023; 23:23. [PMID: 36627627 PMCID: PMC9832645 DOI: 10.1186/s12913-022-08995-z] [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] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2022] [Accepted: 12/20/2022] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Institutions or clinicians (units) are often compared according to a performance indicator such as in-hospital mortality. Several approaches have been proposed for the detection of outlying units, whose performance deviates from the overall performance. METHODS We provide an overview of three approaches commonly used to monitor institutional performances for outlier detection. These are the common-mean model, the 'Normal-Poisson' random effects model and the 'Logistic' random effects model. For the latter we also propose a visualisation technique. The common-mean model assumes that the underlying true performance of all units is equal and that any observed variation between units is due to chance. Even after applying case-mix adjustment, this assumption is often violated due to overdispersion and a post-hoc correction may need to be applied. The random effects models relax this assumption and explicitly allow the true performance to differ between units, thus offering a more flexible approach. We discuss the strengths and weaknesses of each approach and illustrate their application using audit data from England and Wales on Adult Cardiac Surgery (ACS) and Percutaneous Coronary Intervention (PCI). RESULTS In general, the overdispersion-corrected common-mean model and the random effects approaches produced similar p-values for the detection of outliers. For the ACS dataset (41 hospitals) three outliers were identified in total but only one was identified by all methods above. For the PCI dataset (88 hospitals), seven outliers were identified in total but only two were identified by all methods. The common-mean model uncorrected for overdispersion produced several more outliers. The reason for observing similar p-values for all three approaches could be attributed to the fact that the between-hospital variance was relatively small in both datasets, resulting only in a mild violation of the common-mean assumption; in this situation, the overdispersion correction worked well. CONCLUSION If the common-mean assumption is likely to hold, all three methods are appropriate to use for outlier detection and their results should be similar. Random effect methods may be the preferred approach when the common-mean assumption is likely to be violated.
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Affiliation(s)
| | | | | | - Andrew T. Goodwin
- grid.440194.c0000 0004 4647 6776Department of Cardiothoracic Surgery, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK ,grid.139534.90000 0001 0372 5777National Institute for Cardiovascular Outcomes Research (NICOR), Barts Health NHS Trust, London, UK
| | - Uday Trivedi
- Department of Cardiac Surgery, University Hospital Sussex NHS Foundation Trust, Brighton, UK
| | - Peter Ludman
- grid.139534.90000 0001 0372 5777National Institute for Cardiovascular Outcomes Research (NICOR), Barts Health NHS Trust, London, UK ,grid.6572.60000 0004 1936 7486Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Mark de Belder
- grid.139534.90000 0001 0372 5777National Institute for Cardiovascular Outcomes Research (NICOR), Barts Health NHS Trust, London, UK
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3
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Norrish G, Ding T, Field E, Cervi E, Ziółkowska L, Olivotto I, Khraiche D, Limongelli G, Anastasakis A, Weintraub R, Biagini E, Ragni L, Prendiville T, Duignan S, McLeod K, Ilina M, Fernández A, Marrone C, Bökenkamp R, Baban A, Kubus P, Daubeney PEF, Sarquella-Brugada G, Cesar S, Klaassen S, Ojala TH, Bhole V, Medrano C, Uzun O, Brown E, Gran F, Sinagra G, Castro FJ, Stuart G, Vignati G, Yamazawa H, Barriales-Villa R, Garcia-Guereta L, Adwani S, Linter K, Bharucha T, Garcia-Pavia P, Siles A, Rasmussen TB, Calcagnino M, Jones CB, De Wilde H, Kubo T, Felice T, Popoiu A, Mogensen J, Mathur S, Centeno F, Reinhardt Z, Schouvey S, O'Mahony C, Omar RZ, Elliott PM, Kaski JP. Relationship Between Maximal Left Ventricular Wall Thickness and Sudden Cardiac Death in Childhood Onset Hypertrophic Cardiomyopathy. Circ Arrhythm Electrophysiol 2022; 15:e010075. [PMID: 35491873 PMCID: PMC7612749 DOI: 10.1161/circep.121.010075] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
BACKGROUND Maximal left ventricular wall thickness (MLVWT) is a risk factor for sudden cardiac death (SCD) in hypertrophic cardiomyopathy (HCM). In adults, the severity of left ventricular hypertrophy has a nonlinear relationship with SCD, but it is not known whether the same complex relationship is seen in childhood. The aim of this study was to describe the relationship between left ventricular hypertrophy and SCD risk in a large international pediatric HCM cohort. METHODS The study cohort comprised 1075 children (mean age, 10.2 years [±4.4]) diagnosed with HCM (1-16 years) from the International Paediatric Hypertrophic Cardiomyopathy Consortium. Anonymized, noninvasive clinical data were collected from baseline evaluation and follow-up, and 5-year estimated SCD risk was calculated (HCM Risk-Kids). RESULTS MLVWT Z score was <10 in 598 (58.1%), ≥10 to <20 in 334 (31.1%), and ≥20 in 143 (13.3%). Higher MLVWT Z scores were associated with heart failure symptoms, unexplained syncope, left ventricular outflow tract obstruction, left atrial dilatation, and nonsustained ventricular tachycardia. One hundred twenty-two patients (71.3%) with MLVWT Z score ≥20 had coexisting risk factors for SCD. Over a median follow-up of 4.9 years (interquartile range, 2.3-9.3), 115 (10.7%) had an SCD event. Freedom from SCD event at 5 years for those with MLVWT Z scores <10, ≥10 to <20, and ≥20 was 95.6%, 87.4%, and 86.0, respectively. The estimated SCD risk at 5 years had a nonlinear, inverted U-shaped relationship with MLVWT Z score, peaking at Z score +23. The presence of coexisting risk factors had a summative effect on risk. CONCLUSIONS In children with HCM, an inverted U-shaped relationship exists between left ventricular hypertrophy and estimated SCD risk. The presence of additional risk factors has a summative effect on risk. While MLVWT is important for risk stratification, it should not be used either as a binary variable or in isolation to guide implantable cardioverter defibrillator implantation decisions in children with HCM.
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Affiliation(s)
- Gabrielle Norrish
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom (G.N., E.F., E.C., J.P.K.).,Institute of Cardiovascular Sciences (G.N., C.O., P.M.E., J.P.K.), University College London, United Kingdom
| | - Tao Ding
- Department of Statistical Science (T.D., R.Z.O.), University College London, United Kingdom
| | - Ella Field
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom (G.N., E.F., E.C., J.P.K.)
| | - Elena Cervi
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom (G.N., E.F., E.C., J.P.K.)
| | | | | | | | | | | | | | - Elena Biagini
- Cardiology Unit, S. Orsola-Malpighi Hospital, IRCCS Azienda Ospedalierao-Universitaria di Bologna, Italy (E.B., L.R.)
| | - Luca Ragni
- Cardiology Unit, S. Orsola-Malpighi Hospital, IRCCS Azienda Ospedalierao-Universitaria di Bologna, Italy (E.B., L.R.)
| | | | - Sophie Duignan
- Royal Hospital for Children, Glasgow, United Kingdom (K.M., M.I.)
| | - Karen McLeod
- Royal Hospital for Children, Glasgow, United Kingdom (K.M., M.I.)
| | - Maria Ilina
- Royal Hospital for Children, Glasgow, United Kingdom (K.M., M.I.)
| | - Adrián Fernández
- Fundación Favaloro University Hospital, Buenos Aires, Argentina (A.F.)
| | | | | | | | - Peter Kubus
- University Hospital Motol, Prague, Czech Republic (P.K.)
| | - Piers E F Daubeney
- Royal Brompton and Harefield NHS Trust, London, United Kingdom (P.E.F.D.)
| | | | - Sergi Cesar
- Sant Joan de Deu, Barcelona, Spain (G.S.-B., S.C.)
| | - Sabine Klaassen
- Department of Pediatric Cardiology (S.K.), Charite-Universitatsmedizin Berlin, Germany.,Experimental and Clinical Research Center, a joint cooperation between the Charité Medical Faculty and the Max-Delbrück-Center for Molecular Medicine (S.K.), Charite-Universitatsmedizin Berlin, Germany.,German Centre for Cardiovascular Research, Partner Site Berlin, Germany (S.K.)
| | - Tiina H Ojala
- Department of Pediatric Cardiology, Pediatric Research Center, New Children's Hospital, University of Helsinki, Finland (T.H.O.)
| | - Vinay Bhole
- Birmingham Children's Hospital, United Kingdom (V.B.)
| | - Constancio Medrano
- Fondazione Toscana G. Monasterio, Massa-Pisa, Italy (C.M.).,Hospital General Universitario Gregorio Marañón, Madrid, Spain (C.M.)
| | - Orhan Uzun
- University Hospital of Wales, Cardiff (O.U.)
| | | | - Ferran Gran
- Val d'Hebron University Hospital, Barcelona, Spain (F.G.)
| | - Gianfranco Sinagra
- Heart Muscle Disease Registry Trieste, University of Trieste, Italy (G.S.)
| | | | - Graham Stuart
- Bristol Royal Hospital for Children, United Kingdom (G.S.)
| | | | - Hirokuni Yamazawa
- Department of Pediatrics, Faculty of Medicine and Graduate School of Medicine, Hokkaido University Hospital, Sapporo, Japan (H.Y.)
| | | | | | | | | | - Tara Bharucha
- Southampton General Hospital, Southampton, United Kingdom (T.B.)
| | - Pablo Garcia-Pavia
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain (P.G.-P., A.S.)
| | - Ana Siles
- Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain (P.G.-P., A.S.)
| | | | - Margherita Calcagnino
- Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico Milano, Dept di Medicina Interna, UOC Cardiologica, Milano, Italy (M.C.)
| | - Caroline B Jones
- Alder Hey Children's Hospital, Liverpool, United Kingdom (C.B.J.)
| | | | - Toru Kubo
- Kochi Medical School Hospital, Japan (T.K.)
| | | | - Anca Popoiu
- Department of Pediatrics, University of Medicine and Pharmacy "Victor Babes" Timisoara, Children's Hospital 'Louis Turcanu,' Romania (A.P.)
| | | | - Sujeev Mathur
- Evelina Children's Hospital, London, United Kingdom (S.M.)
| | | | | | | | - Costas O'Mahony
- Institute of Cardiovascular Sciences (G.N., C.O., P.M.E., J.P.K.), University College London, United Kingdom.,St Bartholomew's Centre for Inherited Cardiovascular Diseases, St Bartholomew's Hospital, West Smithfield, London, United Kingdom (C.O., P.M.E.)
| | - Rumana Z Omar
- Department of Statistical Science (T.D., R.Z.O.), University College London, United Kingdom
| | - Perry M Elliott
- Institute of Cardiovascular Sciences (G.N., C.O., P.M.E., J.P.K.), University College London, United Kingdom.,St Bartholomew's Centre for Inherited Cardiovascular Diseases, St Bartholomew's Hospital, West Smithfield, London, United Kingdom (C.O., P.M.E.)
| | - Juan Pablo Kaski
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London, United Kingdom (G.N., E.F., E.C., J.P.K.).,Institute of Cardiovascular Sciences (G.N., C.O., P.M.E., J.P.K.), University College London, United Kingdom
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4
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Stone PC, Chu C, Todd C, Griffiths J, Kalpakidou A, Keeley V, Omar RZ, Vickerstaff V. The accuracy of clinician predictions of survival in the Prognosis in Palliative care Study II (PiPS2): A prospective observational study. PLoS One 2022; 17:e0267050. [PMID: 35421168 PMCID: PMC9009717 DOI: 10.1371/journal.pone.0267050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 03/31/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Prognostic information is important for patients with cancer, their families, and clinicians. In practice, survival predictions are made by clinicians based on their experience, judgement, and intuition. Previous studies have reported that clinicians' survival predictions are often inaccurate. This study reports a secondary analysis of data from the Prognosis in Palliative care Study II (PiPS2) to assess the accuracy of survival estimates made by doctors and nurses. METHODS AND FINDINGS Adult patients (n = 1833) with incurable, locally advanced or metastatic cancer, recently referred to palliative care services (community teams, hospital teams, and inpatient palliative care units) were recruited. Doctors (n = 431) and nurses (n = 777) provided independent prognostic predictions and an agreed multi-professional prediction for each patient. Clinicians provided prognostic estimates in several formats including predictions about length of survival and probability of surviving to certain time points. There was a minimum follow up of three months or until death (whichever was sooner; maximum follow-up 783 days). Agreed multi-professional predictions about whether patients would survive for days, weeks or months+ were accurate on 61.9% of occasions. The positive predictive value of clinicians' predictions about imminent death (within one week) was 77% for doctors and 79% for nurses. The sensitivity of these predictions was low (37% and 35% respectively). Specific predictions about how many weeks patients would survive were not very accurate but showed good discrimination (patients estimated to survive for shorted periods had worse outcomes). The accuracy of clinicians' probabilistic predictions (assessed using Brier's scores) was consistently better than chance, improved with proximity to death and showed good discrimination between groups of patients with different survival outcomes. CONCLUSIONS Using a variety of different approaches, this study found that clinicians predictions of survival show good discrimination and accuracy, regardless of whether the predictions are about how long or how likely patients are to survive. Accuracy improves with proximity to death. Although the positive predictive value of estimates of imminent death are relatively high, the sensitivity of such predictions is relatively low. Despite limitations, the clinical prediction of survival should remain the benchmark against which any innovations in prognostication are judged. STUDY REGISTRATION ISRCTN13688211. http://www.isrctn.com/ISRCTN13688211.
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Affiliation(s)
- Patrick C. Stone
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London (UCL), London, United Kingdom
- * E-mail:
| | - Christina Chu
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London (UCL), London, United Kingdom
| | - Chris Todd
- Faculty of Biology, School of Health Sciences, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
- Manchester University NHS Foundation Trust, Manchester, United Kingdom
| | - Jane Griffiths
- Faculty of Biology, School of Health Sciences, Medicine and Health, The University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Anastasia Kalpakidou
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London (UCL), London, United Kingdom
| | - Vaughan Keeley
- Palliative Medicine Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom
| | - Rumana Z. Omar
- Department of Statistical Science, University College London (UCL), London, United Kingdom
| | - Victoria Vickerstaff
- Division of Psychiatry, Marie Curie Palliative Care Research Department, University College London (UCL), London, United Kingdom
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5
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Norrish G, Qu C, Field E, Cervi E, Khraiche D, Klaassen S, Ojala TH, Sinagra G, Yamazawa H, Marrone C, Popoiu A, Centeno F, Schouvey S, Olivotto I, Day SM, Colan S, Rossano J, Wittekind SG, Saberi S, Russell M, Helms A, Ingles J, Semsarian C, Elliott PM, Ho CY, Omar RZ, Kaski JP. External validation of the HCM Risk-Kids model for predicting sudden cardiac death in childhood hypertrophic cardiomyopathy. Eur J Prev Cardiol 2022; 29:678-686. [PMID: 34718528 PMCID: PMC8967478 DOI: 10.1093/eurjpc/zwab181] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [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] [Received: 08/06/2021] [Revised: 09/22/2021] [Indexed: 11/24/2022]
Abstract
AIMS Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM). The newly developed HCM Risk-Kids model provides clinicians with individualized estimates of risk. The aim of this study was to externally validate the model in a large independent, multi-centre patient cohort. METHODS AND RESULTS A retrospective, longitudinal cohort of 421 patients diagnosed with HCM aged 1-16 years independent of the HCM Risk-Kids development and internal validation cohort was studied. Data on HCM Risk-Kids predictor variables (unexplained syncope, non-sustained ventricular tachycardia, maximal left ventricular wall thickness, left atrial diameter, and left ventricular outflow tract gradient) were collected from the time of baseline clinical evaluation. The performance of the HCM Risk-Kids model in predicting risk at 5 years was assessed. Twenty-three patients (5.4%) met the SCD end-point within 5 years, with an overall incidence rate of 2.03 per 100 patient-years [95% confidence interval (CI) 1.48-2.78]. Model validation showed a Harrell's C-index of 0.745 (95% CI 0.52-0.97) and Uno's C-index 0.714 (95% 0.58-0.85) with a calibration slope of 1.15 (95% 0.51-1.80). A 5-year predicted risk threshold of ≥6% identified 17 (73.9%) SCD events with a corresponding C-statistic of 0.702 (95% CI 0.60-0.81). CONCLUSIONS This study reports the first external validation of the HCM Risk-Kids model in a large and geographically diverse patient population. A 5-year predicted risk of ≥6% identified over 70% of events, confirming that HCM Risk-Kids provides a method for individualized risk predictions and shared decision-making in children with HCM.
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Affiliation(s)
- Gabrielle Norrish
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Chen Qu
- Department of Statistical Science, University College London, London, UK
| | - Ella Field
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK
- Institute of Cardiovascular Sciences, University College London, London, UK
| | - Elena Cervi
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK
| | | | - Sabine Klaassen
- Department of Paediatric Cardiology, Charite – Universitatsmedizin Berlin, Berlin, Germany
- Experimental and Clinical Research Centre (ECRC), a joint cooperation between the Charité Medical Faculty and the Max-Delbrück-Centre for Molecular Medicine (MDC), Charite – Universitatsmedizin Berlin, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Tiina H Ojala
- Department of Paediatric Cardiology, New Children’s Hospital, University of Helsinki, Helsinki, Finland
| | - Gianfranco Sinagra
- Heart Muscle Disease Registry Trieste, University of Trieste, Trieste, Italy
| | - Hirokuni Yamazawa
- Department of Paediatrics, Faculty of Medicine and Graduate school of Medicine, Hokkaido University Hospital, Sapporo, Japan
| | | | - Anca Popoiu
- Department of Paediatrics, Children’s Hospital ‘Louis Turcanu’, University of Medicine and Pharmacy “Victor Babes” Timisoara, Timisoara, Romania
| | | | | | - Iacopo Olivotto
- Cardiomyopathy Unit, Careggi University Hospital, Florence, Italy
| | - Sharlene M Day
- Department of Internal Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Steve Colan
- Boston Children’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Joseph Rossano
- Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Samuel G Wittekind
- Cincinnati Children's Hospital Medical Center, Heart Institute, Cincinnati, OH, USA
| | - Sara Saberi
- Department of Internal Medicine-Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Mark Russell
- Department of Internal Medicine-Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Adam Helms
- Department of Internal Medicine-Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Jodie Ingles
- Cardio Genomics Program at Centenary Institute, The University of Sydney, Sydney, Australia
| | - Christopher Semsarian
- Agnes Ginges Centre for Molecular Cardiology, Centenary Institute, The University of Sydney, Sydney, Australia
| | - Perry M Elliott
- Institute of Cardiovascular Sciences, University College London, London, UK
- St Bartholomew’s Centre for Inherited Cardiovascular Diseases, St Bartholomew’s Hospital, West Smithfield, London, UK
| | - Carolyn Y Ho
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Juan P Kaski
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, London WC1N 3JH, UK
- Institute of Cardiovascular Sciences, University College London, London, UK
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Beeken RJ, Leurent B, Vickerstaff V, Wilson R, Croker H, Morris S, Omar RZ, Nazareth I, Wardle J. Correction to: A brief intervention for weight control based on habit-formation theory delivered through primary care: results from a randomised controlled trial. Int J Obes (Lond) 2021; 45:2137-2138. [PMID: 34099843 PMCID: PMC8380537 DOI: 10.1038/s41366-021-00862-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- R J Beeken
- Department of Epidemiology and Public Health, University College London, London, UK.
| | - B Leurent
- Department of Primary Care and Population Health, University College London, London, UK
| | - V Vickerstaff
- Department of Primary Care and Population Health, University College London, London, UK
| | - R Wilson
- Department of Epidemiology and Public Health, University College London, London, UK
| | - H Croker
- Department of Epidemiology and Public Health, University College London, London, UK
| | - S Morris
- Department of Epidemiology and Public Health, University College London, London, UK
| | - R Z Omar
- Department of Statistical Science, University College London, London, UK
| | - I Nazareth
- Department of Primary Care and Population Health, University College London, London, UK
| | - J Wardle
- Department of Epidemiology and Public Health, University College London, London, UK
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Pavlou M, Ambler G, Omar RZ. Risk prediction in multicentre studies when there is confounding by cluster or informative cluster size. BMC Med Res Methodol 2021; 21:135. [PMID: 34218793 PMCID: PMC8254921 DOI: 10.1186/s12874-021-01321-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 05/19/2021] [Indexed: 12/04/2022] Open
Abstract
Background Clustered data arise in research when patients are clustered within larger units. Generalised Estimating Equations (GEE) and Generalised Linear Models (GLMM) can be used to provide marginal and cluster-specific inference and predictions, respectively. Methods Confounding by Cluster (CBC) and Informative cluster size (ICS) are two complications that may arise when modelling clustered data. CBC can arise when the distribution of a predictor variable (termed ‘exposure’), varies between clusters causing confounding of the exposure-outcome relationship. ICS means that the cluster size conditional on covariates is not independent of the outcome. In both situations, standard GEE and GLMM may provide biased or misleading inference, and modifications have been proposed. However, both CBC and ICS are routinely overlooked in the context of risk prediction, and their impact on the predictive ability of the models has been little explored. We study the effect of CBC and ICS on the predictive ability of risk models for binary outcomes when GEE and GLMM are used. We examine whether two simple approaches to handle CBC and ICS, which involve adjusting for the cluster mean of the exposure and the cluster size, respectively, can improve the accuracy of predictions. Results Both CBC and ICS can be viewed as violations of the assumptions in the standard GLMM; the random effects are correlated with exposure for CBC and cluster size for ICS. Based on these principles, we simulated data subject to CBC/ICS. The simulation studies suggested that the predictive ability of models derived from using standard GLMM and GEE ignoring CBC/ICS was affected. Marginal predictions were found to be mis-calibrated. Adjusting for the cluster-mean of the exposure or the cluster size improved calibration, discrimination and the overall predictive accuracy of marginal predictions, by explaining part of the between cluster variability. The presence of CBC/ICS did not affect the accuracy of conditional predictions. We illustrate these concepts using real data from a multicentre study with potential CBC. Conclusion Ignoring CBC and ICS when developing prediction models for clustered data can affect the accuracy of marginal predictions. Adjusting for the cluster mean of the exposure or the cluster size can improve the predictive accuracy of marginal predictions. Supplementary Information The online version contains supplementary material available at 10.1186/s12874-021-01321-x.
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Kalpakidou AK, Todd C, Omar RZ, Keeley V, Griffiths J, Spencer K, Vickerstaff V, Christidoulides K, Perry R, Katsampa D, Stone P. Study recruitment factors in advanced cancer: the Prognosis in Palliative care Study II (PiPS2) - a multicentre, prospective, observational cohort project. BMJ Support Palliat Care 2021:bmjspcare-2020-002670. [PMID: 33952580 DOI: 10.1136/bmjspcare-2020-002670] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 03/22/2021] [Accepted: 03/26/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVES The Prognosis in Palliative care Study II (PiPS2) was a large multicentre observational study validating prognostic tools in patients with advanced cancer. Many palliative care studies fail to reach their recruitment target. To inform future studies, PiPS2 rigorously monitored and identified any potential recruitment barriers. METHODS Key recruitment stages (ie, whether patients were eligible for the study, approached by the researchers and whether consent was obtained for enrolment) were monitored via comprehensive screening logs at participating sites (inpatient hospices, hospitals and community palliative care teams). The reasons for patients' ineligibility, inaccessibility or decision not to consent were documented. RESULTS 17 014 patients were screened across 27 participating sites over a 20-month recruitment period. Of those, 4642 (27%) were ineligible for participation in the study primarily due to non-cancer diagnoses. Of 12 372 eligible patients, 9073 (73%) were not approached, the most common reason being a clinical decision not to do so. Other reasons included patients' death or discharge before they were approached by the researchers. Of the 3299 approached patients, 1458 (44%) declined participation mainly because of feeling too unwell, experiencing severe distress or having other competing priorities. 11% (n=1841/17 014) of patients screened were enrolled in the study, representing 15% (n=1841/12 372) of eligible patients. Different recruitment patterns were observed across inpatient hospice, hospital and community palliative care teams. CONCLUSIONS The main barrier to recruitment was 'accessing' potentially eligible patients. Monitoring key recruitment stages may help to identify barriers and facilitators to enrolment and allow results to be put into better context. TRIAL REGISTRATION NUMBER ISRCTN13688211.
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Affiliation(s)
| | - Chris Todd
- Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Vaughan Keeley
- Palliative Medicine Department, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Jane Griffiths
- Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | - Karen Spencer
- Faculty of Biology, Medicine and Health, The University of Manchester School of Health Sciences, Manchester, UK
| | | | | | - Rachel Perry
- Marie Curie Hospice Solihull, Solihull, West Midlands, UK
| | - Dafni Katsampa
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, University College London, London, UK
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Stone P, Kalpakidou A, Todd C, Griffiths J, Keeley V, Spencer K, Buckle P, Finlay DA, Vickerstaff V, Omar RZ. Prognostic models of survival in patients with advanced incurable cancer: the PiPS2 observational study. Health Technol Assess 2021; 25:1-118. [PMID: 34018486 DOI: 10.3310/hta25280] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND The Prognosis in Palliative care Study (PiPS) prognostic survival models predict survival in patients with incurable cancer. PiPS-A (Prognosis in Palliative care Study - All), which involved clinical observations only, and PiPS-B (Prognosis in Palliative care Study - Blood), which additionally required blood test results, consist of 14- and 56-day models that combine to create survival risk categories: 'days', 'weeks' and 'months+'. OBJECTIVES The primary objectives were to compare PIPS-B risk categories against agreed multiprofessional estimates of survival and to validate PiPS-A and PiPS-B. The secondary objectives were to validate other prognostic models, to assess the acceptability of the models to patients, carers and health-care professionals and to identify barriers to and facilitators of clinical use. DESIGN This was a national, multicentre, prospective, observational, cohort study with a nested qualitative substudy using interviews with patients, carers and health-care professionals. SETTING Community, hospital and hospice palliative care services across England and Wales. PARTICIPANTS For the validation study, the participants were adults with incurable cancer, with or without capacity to consent, who had been recently referred to palliative care services and had sufficient English language. For the qualitative substudy, a subset of participants in the validation study took part, along with informal carers, patients who declined to participate in the main study and health-care professionals. MAIN OUTCOME MEASURES For the validation study, the primary outcomes were survival, clinical prediction of survival and PiPS-B risk category predictions. The secondary outcomes were predictions of PiPS-A and other prognostic models. For the qualitative substudy, the main outcomes were participants' views about prognostication and the use of prognostic models. RESULTS For the validation study, 1833 participants were recruited. PiPS-B risk categories were as accurate as agreed multiprofessional estimates of survival (61%; p = 0.851). Discrimination of the PiPS-B 14-day model (c-statistic 0.837, 95% confidence interval 0.810 to 0.863) and the PiPS-B 56-day model (c-statistic 0.810, 95% confidence interval 0.788 to 0.832) was excellent. The PiPS-B 14-day model showed some overfitting (calibration in the large -0.202, 95% confidence interval -0.364 to -0.039; calibration slope 0.840, 95% confidence interval 0.730 to 0.950). The PiPS-B 56-day model was well-calibrated (calibration in the large 0.152, 95% confidence interval 0.030 to 0.273; calibration slope 0.914, 95% confidence interval 0.808 to 1.02). PiPS-A risk categories were less accurate than agreed multiprofessional estimates of survival (p < 0.001). The PiPS-A 14-day model (c-statistic 0.825, 95% confidence interval 0.803 to 0.848; calibration in the large -0.037, 95% confidence interval -0.168 to 0.095; calibration slope 0.981, 95% confidence interval 0.872 to 1.09) and the PiPS-A 56-day model (c-statistic 0.776, 95% confidence interval 0.755 to 0.797; calibration in the large 0.109, 95% confidence interval 0.002 to 0.215; calibration slope 0.946, 95% confidence interval 0.842 to 1.05) had excellent or reasonably good discrimination and calibration. Other prognostic models were also validated. Where comparisons were possible, the other prognostic models performed less well than PiPS-B. For the qualitative substudy, 32 health-care professionals, 29 patients and 20 carers were interviewed. The majority of patients and carers expressed a desire for prognostic information and said that PiPS could be helpful. Health-care professionals said that PiPS was user friendly and may be helpful for decision-making and care-planning. The need for a blood test for PiPS-B was considered a limitation. LIMITATIONS The results may not be generalisable to other populations. CONCLUSIONS PiPS-B risk categories are as accurate as agreed multiprofessional estimates of survival. PiPS-A categories are less accurate. Patients, carers and health-care professionals regard PiPS as potentially helpful in clinical practice. FUTURE WORK A study to evaluate the impact of introducing PiPS into routine clinical practice is needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN13688211. 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. 25, No. 28. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Anastasia Kalpakidou
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Chris Todd
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Jane Griffiths
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Vaughan Keeley
- Palliative Medicine Department, Derby Teaching Hospitals NHS Foundation Trust, Derby, UK
| | - Karen Spencer
- School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Peter Buckle
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Dori-Anne Finlay
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
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Pavlou M, Qu C, Omar RZ, Seaman SR, Steyerberg EW, White IR, Ambler G. Estimation of required sample size for external validation of risk models for binary outcomes. Stat Methods Med Res 2021; 30:2187-2206. [PMID: 33881369 PMCID: PMC8529102 DOI: 10.1177/09622802211007522] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Risk-prediction models for health outcomes are used in practice as part of
clinical decision-making, and it is essential that their performance be
externally validated. An important aspect in the design of a validation study is
choosing an adequate sample size. In this paper, we investigate the sample size
requirements for validation studies with binary outcomes to estimate measures of
predictive performance (C-statistic for discrimination and calibration slope and
calibration in the large). We aim for sufficient precision in the estimated
measures. In addition, we investigate the sample size to achieve sufficient
power to detect a difference from a target value. Under normality assumptions on
the distribution of the linear predictor, we obtain simple estimators for sample
size calculations based on the measures above. Simulation studies show that the
estimators perform well for common values of the C-statistic and outcome
prevalence when the linear predictor is marginally Normal. Their performance
deteriorates only slightly when the normality assumptions are violated. We also
propose estimators which do not require normality assumptions but require
specification of the marginal distribution of the linear predictor and require
the use of numerical integration. These estimators were also seen to perform
very well under marginal normality. Our sample size equations require a
specified standard error (SE) and the anticipated C-statistic and outcome
prevalence. The sample size requirement varies according to the prognostic
strength of the model, outcome prevalence, choice of the performance measure and
study objective. For example, to achieve an SE < 0.025 for the C-statistic,
60–170 events are required if the true C-statistic and outcome prevalence are
between 0.64–0.85 and 0.05–0.3, respectively. For the calibration slope and
calibration in the large, achieving SE < 0.15 would require 40–280 and 50–100 events, respectively. Our
estimators may also be used for survival outcomes when the proportion of
censored observations is high.
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Affiliation(s)
- Menelaos Pavlou
- Department of Statistical Science, University College London, UK
| | - Chen Qu
- Department of Statistical Science, University College London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, UK
| | - Shaun R Seaman
- MRC Biostatistics Unit, Institute of Public Health, University of Cambridge, Cambridge, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Ian R White
- MRC Clinical Trials Unit, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, UK
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Norrish G, Topriceanu C, Qu C, Field E, Walsh H, Ziółkowska L, Olivotto I, Passantino S, Favilli S, Anastasakis A, Vlagkouli V, Weintraub R, King I, Biagini E, Ragni L, Prendiville T, Duignan S, McLeod K, Ilina M, Fernández A, Bökenkamp R, Baban A, Drago F, Kubuš P, Daubeney PEF, Chivers S, Sarquella-Brugada G, Cesar S, Marrone C, Medrano C, Alvarez Garcia-Roves R, Uzun O, Gran F, Castro FJ, Gimeno JR, Barriales-Villa R, Rueda F, Adwani S, Searle J, Bharucha T, Siles A, Usano A, Rasmussen TB, Jones CB, Kubo T, Mogensen J, Reinhardt Z, Cervi E, Elliott PM, Omar RZ, Kaski JP. The role of the electrocardiographic phenotype in risk stratification for sudden cardiac death in childhood hypertrophic cardiomyopathy. Eur J Prev Cardiol 2021; 29:645-653. [PMID: 33772274 PMCID: PMC8967480 DOI: 10.1093/eurjpc/zwab046] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 02/25/2021] [Accepted: 03/09/2021] [Indexed: 11/13/2022]
Abstract
AIMS The 12-lead electrocardiogram (ECG) is routinely performed in children with hypertrophic cardiomyopathy (HCM). An ECG risk score has been suggested as a useful tool for risk stratification, but this has not been independently validated. This aim of this study was to describe the ECG phenotype of childhood HCM in a large, international, multi-centre cohort and investigate its role in risk prediction for arrhythmic events. METHODS AND RESULTS Data from 356 childhood HCM patients with a mean age of 10.1 years (±4.5) were collected from a retrospective, multi-centre international cohort. Three hundred and forty-seven (97.5%) patients had ECG abnormalities at baseline, most commonly repolarization abnormalities (n = 277, 77.8%); left ventricular hypertrophy (n = 240, 67.7%); abnormal QRS axis (n = 126, 35.4%); or QT prolongation (n = 131, 36.8%). Over a median follow-up of 3.9 years (interquartile range 2.0-7.7), 25 (7%) had an arrhythmic event, with an overall annual event rate of 1.38 (95% CI 0.93-2.04). No ECG variables were associated with 5-year arrhythmic event on univariable or multivariable analysis. The ECG risk score threshold of >5 had modest discriminatory ability [C-index 0.60 (95% CI 0.484-0.715)], with corresponding negative and positive predictive values of 96.7% and 6.7. CONCLUSION In a large, international, multi-centre cohort of childhood HCM, ECG abnormalities were common and varied. No ECG characteristic, either in isolation or combined in the previously described ECG risk score, was associated with 5-year sudden cardiac death risk. This suggests that the role of baseline ECG phenotype in improving risk stratification in childhood HCM is limited.
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Affiliation(s)
- Gabrielle Norrish
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.,Institute of Cardiovascular Sciences, University College London, London, UK
| | | | - Chen Qu
- Department of Statistical Science, University College London, London, UK
| | - Ella Field
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.,Institute of Cardiovascular Sciences, University College London, London, UK
| | - Helen Walsh
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK
| | - Lidia Ziółkowska
- Department of Cardiology, The Children's Memorial Health Institute, Warsaw, Poland
| | | | | | - Silvia Favilli
- Cardiology Unit, A Meyer Pediatric Hospital, Florence, Italy
| | | | | | - Robert Weintraub
- The Royal Children's Hospital, Melbourne, Australia.,The Murdoch Children's Research Institute.,University of Melbourne, Australia
| | | | | | - Luca Ragni
- S. Orsola-Malpighi Hospital, Bologna, Italy
| | | | | | | | | | - Adrian Fernández
- Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | | | | | | | - Peter Kubuš
- University Hospital Motol, Prague, Czech Republic
| | | | - Sian Chivers
- Royal Brompton and Harefield NHS Trust, London, UK
| | - Georgia Sarquella-Brugada
- Arrhythmia and Inherited Cardiac Diseases Unit, Hospital Sant Joan de Déu, University of Barcelona, Spain.,Medical Sciences Department, School of Medicine, University of Girona
| | - Sergi Cesar
- Arrhythmia and Inherited Cardiac Diseases Unit, Hospital Sant Joan de Déu, University of Barcelona, Spain
| | | | | | | | - Orhan Uzun
- University Hospital of Wales, Cardiff, UK
| | - Ferran Gran
- Val d'Hebron University Hospital, Barcelona, Spain
| | | | - Juan R Gimeno
- University Hospital Virgen de la Arrixaca, Murcia, Spain
| | | | - Fernando Rueda
- Complexo Hospitalario Universitario A Coruña, CIBERCV, A Coruña, Spain
| | | | | | | | - Ana Siles
- Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV, Madrid, Spain.,University Francisco de Vitoria, Pozuelo de Alarcon, Spain
| | - Ana Usano
- Hospital Universitario Puerta de Hierro Majadahonda, CIBERCV, Madrid, Spain.,University Francisco de Vitoria, Pozuelo de Alarcon, Spain
| | | | | | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Japan
| | | | | | - Elena Cervi
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.,Institute of Cardiovascular Sciences, University College London, London, UK
| | - Perry M Elliott
- Institute of Cardiovascular Sciences, University College London, London, UK.,St Bartholomew's Centre for Inherited Cardiovascular Diseases, St Bartholomew's Hospital, West Smithfield, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Juan P Kaski
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, Great Ormond Street, London WC1N 3JH, UK.,Institute of Cardiovascular Sciences, University College London, London, UK
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12
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Wenborn J, O’Keeffe AG, Mountain G, Moniz-Cook E, King M, Omar RZ, Mundy J, Burgess J, Poland F, Morris S, Pizzo E, Vernooij-Dassen M, Challis D, Michie S, Russell I, Sackley C, Graff M, Swinson T, Crellin N, Hynes S, Stansfeld J, Orrell M. Community Occupational Therapy for people with dementia and family carers (COTiD-UK) versus treatment as usual (Valuing Active Life in Dementia [VALID]) study: A single-blind, randomised controlled trial. PLoS Med 2021; 18:e1003433. [PMID: 33395437 PMCID: PMC7781374 DOI: 10.1371/journal.pmed.1003433] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Accepted: 11/24/2020] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND We aimed to estimate the clinical effectiveness of Community Occupational Therapy for people with dementia and family carers-UK version (Community Occupational Therapy in Dementia-UK version [COTiD-UK]) relative to treatment as usual (TAU). We hypothesised that COTiD-UK would improve the ability of people with dementia to perform activities of daily living (ADL), and family carers' sense of competence, compared with TAU. METHODS AND FINDINGS The study design was a multicentre, 2-arm, parallel-group, assessor-masked, individually randomised controlled trial (RCT) with internal pilot. It was conducted in 15 sites across England from September 2014 to January 2018. People with a diagnosis of mild to moderate dementia living in their own home were recruited in pairs with a family carer who provided domestic or personal support for at least 4 hours per week. Pairs were randomised to either receive COTiD-UK, which comprised 10 hours of occupational therapy delivered over 10 weeks in the person with dementia's home or TAU, which comprised the usual local service provision that may or may not include standard occupational therapy. The primary outcome was the Bristol Activities of Daily Living Scale (BADLS) score at 26 weeks. Secondary outcomes for the person with dementia included the following: the BADLS scores at 52 and 78 weeks, cognition, quality of life, and mood; and for the family carer: sense of competence and mood; plus the number of social contacts and leisure activities for both partners. Participants were analysed by treatment allocated. A total of 468 pairs were recruited: people with dementia ranged from 55 to 97 years with a mean age of 78.6 and family carers ranged from 29 to 94 with a mean of 69.1 years. Of the people with dementia, 74.8% were married and 19.2% lived alone. Of the family carers, 72.6% were spouses, and 22.2% were adult children. On randomisation, 249 pairs were assigned to COTiD-UK (62% people with dementia and 23% carers were male) and 219 to TAU (52% people with dementia and 32% carers were male). At the 26 weeks follow-up, data were available for 364 pairs (77.8%). The BADLS score at 26 weeks did not differ significantly between groups (adjusted mean difference estimate 0.35, 95% CI -0.81 to 1.51; p = 0.55). Secondary outcomes did not differ between the groups. In total, 91% of the activity-based goals set by the pairs taking part in the COTiD-UK intervention were fully or partially achieved by the final COTiD-UK session. Study limitations include the following: Intervention fidelity was moderate but varied across and within sites, and the reliance on primarily proxy data focused on measuring the level of functional or cognitive impairment which may not truly reflect the actual performance and views of the person living with dementia. CONCLUSIONS Providing community occupational therapy as delivered in this study did not improve ADL performance, cognition, quality of life, or mood in people with dementia nor sense of competence or mood in family carers. Future research should consider measuring person-centred outcomes that are more meaningful and closely aligned to participants' priorities, such as goal achievement or the quantity and quality of activity engagement and participation. TRIAL REGISTRATION Current Controlled Trials ISRCTN10748953.
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Affiliation(s)
- Jennifer Wenborn
- Division of Psychiatry, University College London, London, United Kingdom
- Research & Development Department, North East London NHS Foundation Trust, London, United Kingdom
- * E-mail:
| | - Aidan G. O’Keeffe
- Department of Statistical Science, University College London, London, United Kingdom
- Priment Clinical Trials Unit, University College London, London, United Kingdom
| | - Gail Mountain
- School of Health and Related Research (ScHARR), The University of Sheffield, Sheffield, United Kingdom
- Centre for Applied Dementia Studies, Faculty of Health Studies, University of Bradford, Bradford, United Kingdom
| | - Esme Moniz-Cook
- Faculty of Health Sciences, School of Health & Social Care, University of Hull, Hull, United Kingdom
| | - Michael King
- Division of Psychiatry, University College London, London, United Kingdom
- Priment Clinical Trials Unit, University College London, London, United Kingdom
| | - Rumana Z. Omar
- Department of Statistical Science, University College London, London, United Kingdom
- Priment Clinical Trials Unit, University College London, London, United Kingdom
| | - Jacqueline Mundy
- Essex Stroke Hub Team, North East London NHS Foundation Trust, London, United Kingdom
| | - Jane Burgess
- Research & Development Department, North East London NHS Foundation Trust, London, United Kingdom
| | - Fiona Poland
- School of Health Sciences, University of East Anglia, Norwich, United Kingdom
| | - Stephen Morris
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, United Kingdom
| | - Elena Pizzo
- Department of Applied Health Research, University College London, London, United Kingdom
| | - Myrra Vernooij-Dassen
- Faculty of Medical Sciences, Radboud University Medical Center (Radboudumc), Nijmegen, the Netherlands
| | - David Challis
- Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom
| | - Susan Michie
- UCL Centre for Behaviour Change, Department of Clinical, Educational and Health Psychology, University College London, London, United Kingdom
| | - Ian Russell
- Medical School, Swansea University, Swansea, United Kingdom
| | - Catherine Sackley
- Department of Public Health Sciences, King’s College London, London, United Kingdom
| | - Maud Graff
- Faculty of Medical Sciences, Radboud University Medical Center (Radboudumc), Nijmegen, the Netherlands
| | - Tom Swinson
- East Herts and Broxbourne Adult Disability Team, Hertfordshire County Council, Stevenage, United Kingdom
| | - Nadia Crellin
- Research & Development Department, North East London NHS Foundation Trust, London, United Kingdom
| | - Sinéad Hynes
- School of Health Sciences, National University of Ireland, Galway, Ireland
| | - Jacki Stansfeld
- Division of Psychiatry, University College London, London, United Kingdom
- Research & Development Department, North East London NHS Foundation Trust, London, United Kingdom
| | - Martin Orrell
- Institute of Mental Health, University of Nottingham, Nottingham, United Kingdom
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Vickerstaff V, Ambler G, Omar RZ. A comparison of methods for analysing multiple outcome measures in randomised controlled trials using a simulation study. Biom J 2020; 63:599-615. [PMID: 33314364 PMCID: PMC7984364 DOI: 10.1002/bimj.201900040] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Revised: 04/23/2020] [Accepted: 05/25/2020] [Indexed: 11/08/2022]
Abstract
Multiple primary outcomes are sometimes collected and analysed in randomised controlled trials (RCTs), and are used in favour of a single outcome. By collecting multiple primary outcomes, it is possible to fully evaluate the effect that an intervention has for a given disease process. A simple approach to analysing multiple outcomes is to consider each outcome separately, however, this approach does not account for any pairwise correlations between the outcomes. Any cases with missing values must be ignored, unless an additional imputation step is performed. Alternatively, multivariate methods that explicitly model the pairwise correlations between the outcomes may be more efficient when some of the outcomes have missing values. In this paper, we present an overview of relevant methods that can be used to analyse multiple outcome measures in RCTs, including methods based on multivariate multilevel (MM) models. We perform simulation studies to evaluate the bias in the estimates of the intervention effects and the power of detecting true intervention effects observed when using selected methods. Different simulation scenarios were constructed by varying the number of outcomes, the type of outcomes, the degree of correlations between the outcomes and the proportions and mechanisms of missing data. We compare multivariate methods to univariate methods with and without multiple imputation. When there are strong correlations between the outcome measures (ρ > .4), our simulation studies suggest that there are small power gains when using the MM model when compared to analysing the outcome measures separately. In contrast, when there are weak correlations (ρ < .4), the power is reduced when using univariate methods with multiple imputation when compared to analysing the outcome measures separately.
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Affiliation(s)
- Victoria Vickerstaff
- Division of Psychiatry, University College London, London, UK.,Department of Statistical Science, University College London, London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
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14
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Norrish G, Ding T, Field E, McLeod K, Ilina M, Stuart G, Bhole V, Uzun O, Brown E, Daubeney PEF, Lota A, Linter K, Mathur S, Bharucha T, Kok KL, Adwani S, Jones CB, Reinhardt Z, Omar RZ, Kaski JP. A validation study of the European Society of Cardiology guidelines for risk stratification of sudden cardiac death in childhood hypertrophic cardiomyopathy. Europace 2020; 21:1559-1565. [PMID: 31155643 PMCID: PMC6788212 DOI: 10.1093/europace/euz118] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 04/05/2019] [Indexed: 01/15/2023] Open
Abstract
AIMS Sudden cardiac death (SCD) is the most common cause of death in children with hypertrophic cardiomyopathy (HCM). The European Society of Cardiology (ESC) recommends consideration of an implantable cardioverter-defibrillator (ICD) if two or more clinical risk factors (RFs) are present, but this approach to risk stratification has not been formally validated. METHODS AND RESULTS Four hundred and eleven paediatric HCM patients were assessed for four clinical RFs in accordance with current ESC recommendations: severe left ventricular hypertrophy, unexplained syncope, non-sustained ventricular tachycardia, and family history of SCD. The primary endpoint was a composite outcome of SCD or an equivalent event (aborted cardiac arrest, appropriate ICD therapy, or sustained ventricular tachycardia), defined as a major arrhythmic cardiac event (MACE). Over a follow-up period of 2890 patient years (median 5.5 years), MACE occurred in 21 patients (7.5%) with 0 RFs, 19 (16.8%) with 1 RFs, and 3 (18.8%) with 2 or more RFs. Corresponding incidence rates were 1.13 [95% confidence interval (CI) 0.7-1.73], 2.07 (95% CI 1.25-3.23), and 2.52 (95% CI 0.53-7.35) per 100 patient years at risk. Patients with two or more RFs did not have a higher incidence of MACE (log-rank test P = 0.34), with a positive and negative predictive value of 19% and 90%, respectively. The C-statistic was 0.62 (95% CI 0.52-0.72) at 5 years. CONCLUSIONS The incidence of MACE is higher for patients with increasing numbers of clinical RFs. However, the current ESC guidelines have a low ability to discriminate between high- and low-risk individuals.
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Affiliation(s)
- Gabrielle Norrish
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, Great Ormond Street, London, UK.,Institute of Cardiovascular Sciences University College London, London, UK.,ERN GUARD-HEART (European Reference Network for Rare and Complex Diseases of the Heart)
| | - Tao Ding
- Department of Statistical Science, University College London, London, UK
| | - Ella Field
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, Great Ormond Street, London, UK.,Institute of Cardiovascular Sciences University College London, London, UK.,ERN GUARD-HEART (European Reference Network for Rare and Complex Diseases of the Heart)
| | - Karen McLeod
- Department of Paediatric Cardiology, Royal Hospital for Children, Glasgow, UK
| | - Maria Ilina
- Department of Paediatric Cardiology, Royal Hospital for Children, Glasgow, UK
| | - Graham Stuart
- Department of Paediatric Cardiology, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Vinay Bhole
- Department of Paediatric Cardiology, Birmingham Women and Children's NHS Foundation Trust, Birmingham, UK
| | - Orhan Uzun
- Department of Paediatric Cardiology, University Hospital of Wales, Cardiff, UK
| | - Elspeth Brown
- Department of Paediatric Cardiology, Leeds Teaching Hospital NHS Trust, Leeds, UK
| | - Piers E F Daubeney
- Department of Paediatric Cardiology, Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, London, UK
| | - Amrit Lota
- Department of Paediatric Cardiology, Royal Brompton Hospital, National Heart and Lung Institute, Imperial College London, London, UK
| | - Katie Linter
- Department of Paediatric Cardiology, University Hospitals of Leicester, Leicester, UK
| | - Sujeev Mathur
- Department of Paediatric Cardiology, Evelina London Children's Hospital, Guys and St Thomas' NHS Foundation Trust, London, UK
| | - Tara Bharucha
- Department of Paediatric Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Khoon Li Kok
- Department of Paediatric Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Satish Adwani
- Department of Paediatric Cardiology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Caroline B Jones
- Department of Paediatric Cardiology, Alder Hey Children's Hospital, Liverpool, UK
| | - Zdenka Reinhardt
- Department of Paediatric Cardiology, The Freeman Hospital, Newcastle, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Juan Pablo Kaski
- Centre for Inherited Cardiovascular Diseases, Great Ormond Street Hospital, Great Ormond Street, London, UK.,Institute of Cardiovascular Sciences University College London, London, UK.,ERN GUARD-HEART (European Reference Network for Rare and Complex Diseases of the Heart)
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15
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Johnson S, Rains LS, Marwaha S, Strang J, Craig T, Weaver T, McCrone P, King M, Fowler D, Pilling S, Marston L, Omar RZ, Craig M, Spencer J, Hinton M. A contingency management intervention to reduce cannabis use and time to relapse in early psychosis: the CIRCLE RCT. Health Technol Assess 2020; 23:1-108. [PMID: 31460865 DOI: 10.3310/hta23450] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Cannabis is the most prevalent illicit substance among people with psychosis, and its use is associated with poorer clinical and social outcomes. However, so far, there has been limited evidence that any treatment is effective for reducing use. Contingency management (CM) is an incentive-based intervention for substance misuse that has a substantial evidence base across a range of substances and cohorts. However, to date there have been no randomised controlled trials (RCTs) of CM as a treatment for cannabis use specifically in psychosis. OBJECTIVE To conduct a RCT investigating the clinical effectiveness and cost-effectiveness of CM in reducing cannabis use among Early Intervention in Psychosis (EIP) service users. DESIGN The CIRCLE (Contingency Intervention for Reduction of Cannabis in Early Psychosis) trial was a rater-blinded, multicentre RCT with two arms. Participants were randomised 1 : 1 to either an CM arm, in which participants received CM for cannabis use alongside an optimised treatment-as-usual programme including structured psychoeducation, or a control arm in which participants received the treatment as usual only. SETTING EIP services across the Midlands and the south-east of England. PARTICIPANTS The main eligibility criteria were EIP service users with a history of psychosis, aged 18-36 years, and having used cannabis at least once per week during 12 of the previous 24 weeks. INTERVENTION The CM intervention offered financial incentives (i.e. shopping vouchers) for cannabis abstinence over 12 once-weekly sessions, confirmed using urinalysis. The maximum value in vouchers that participants could receive was £240. MAIN OUTCOME MEASURES The main outcome was time to relapse, operationalised as admission to an acute mental health service or hospital. The primary outcome was assessed at 18 months post inclusion using electronic patient records. Secondary outcomes assessed the clinical effectiveness and cost-effectiveness of the intervention, for which data were collected at 3 and 18 months. RESULTS A total of 278 participants were randomised to the CM arm and 273 were randomised to the control arm. In total, 530 (96%) participants were followed up for the primary outcome. There was no significant difference in time to admission between trial arms by 18 months following consent (hazard ratio 1.03, 95% confidence interval 0.76 to 1.40). There were no statistically significant differences in most secondary outcomes, including cannabis use, at either follow-up assessment. There were 58 serious adverse events, comprising 52 inpatient episodes, five deaths and one arrest. LIMITATIONS Participant retention was low at 18 months, limiting the assessment of secondary outcomes. A different CM intervention design or reward level may have been effective. CONCLUSIONS The CM intervention did not appear to be effective in reducing cannabis use and acute relapse among people with early psychosis and problematic cannabis use. FUTURE WORK Cannabis use is still a significant clinical concern in this population. A pressing need remains to identify suitable treatments. A wider perspective on the social circumstances of young people with psychosis may be needed for a successful intervention to be found. TRIAL REGISTRATION Current Controlled Trials ISRCTN33576045. 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. 23, No. 45. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | | | - Steven Marwaha
- Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - John Strang
- Addictions Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Thomas Craig
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Tim Weaver
- Mental Health, Social Work and Interprofessional Learning, Middlesex University, London, UK
| | - Paul McCrone
- Department of Health Service and Population Research, King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Michael King
- Division of Psychiatry, University College London, London, UK
| | - David Fowler
- Department of Psychology, University of Sussex, Brighton, UK
| | - Stephen Pilling
- Clinical Psychology and Clinical Effectiveness, University College London, London, UK
| | - Louise Marston
- Department of Primary Care and Population Health and PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Meghan Craig
- Division of Psychiatry, University College London, London, UK
| | - Jonathan Spencer
- Health Service and Population Research Department, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Mark Hinton
- Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, VIC, Australia
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16
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Makaronidis J, Mok J, Balogun N, Magee CG, Omar RZ, Carnemolla A, Batterham RL. Seroprevalence of SARS-CoV-2 antibodies in people with an acute loss in their sense of smell and/or taste in a community-based population in London, UK: An observational cohort study. PLoS Med 2020; 17:e1003358. [PMID: 33001967 PMCID: PMC7529306 DOI: 10.1371/journal.pmed.1003358] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/26/2020] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Loss of smell and taste are commonly reported symptoms associated with coronavirus disease 2019 (COVID-19); however, the seroprevalence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) antibodies in people with acute loss of smell and/or taste is unknown. The study aimed to determine the seroprevalence of SARS-CoV-2 antibodies in a community-based population with acute loss of smell and/or taste and to compare the frequency of COVID-19 associated symptoms in participants with and without SARS-CoV-2 antibodies. It also evaluated whether smell or taste loss are indicative of COVID-19 infection. METHODS AND FINDINGS Text messages, sent via primary care centers in London, United Kingdom, invited people with loss of smell and/or taste in the preceding month, to participate. Recruitment took place between 23 April 2020 and 14 May 2020. A total of 590 participants enrolled via a web-based platform and responded to questions about loss of smell and taste and other COVID-19-related symptoms. Mean age was 39.4 years (SD ± 12.0) and 69.1% (n = 392) of participants were female. A total of 567 (96.1%) had a telemedicine consultation during which their COVID-19-related symptoms were verified and a lateral flow immunoassay test that detected SARS-CoV-2 immunoglobulin G (IgG) and immunoglobulin M (IgM) antibodies was undertaken under medical supervision. A total of 77.6% of 567 participants with acute smell and/or taste loss had SARS-CoV-2 antibodies; of these, 39.8% (n = 175) had neither cough nor fever. New loss of smell was more prevalent in participants with SARS-CoV-2 antibodies, compared with those without antibodies (93.4% versus 78.7%, p < 0.001), whereas taste loss was equally prevalent (90.2% versus 89.0%, p = 0.738). Seropositivity for SARS-CoV-2 was 3 times more likely in participants with smell loss (OR 2.86; 95% CI 1.27-6.36; p < 0.001) compared with those with taste loss. The limitations of this study are the lack of a general population control group, the self-reported nature of the smell and taste changes, and the fact our methodology does not take into account the possibility that a population subset may not seroconvert to develop SARS-CoV-2 antibodies post-COVID-19. CONCLUSIONS Our findings suggest that recent loss of smell is a highly specific COVID-19 symptom and should be considered more generally in guiding case isolation, testing, and treatment of COVID-19. TRIALS REGISTRATION ClinicalTrials.gov NCT04377815.
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Affiliation(s)
- Janine Makaronidis
- UCL Centre for Obesity Research, Division of Medicine, University College London, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital, London, United Kingdom
- National Institute of Health Research, UCLH Biomedical Research Centre, London, United Kingdom
| | - Jessica Mok
- UCL Centre for Obesity Research, Division of Medicine, University College London, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital, London, United Kingdom
- National Institute of Health Research, UCLH Biomedical Research Centre, London, United Kingdom
| | - Nyaladzi Balogun
- UCL Centre for Obesity Research, Division of Medicine, University College London, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital, London, United Kingdom
- National Institute of Health Research, UCLH Biomedical Research Centre, London, United Kingdom
| | - Cormac G. Magee
- UCL Centre for Obesity Research, Division of Medicine, University College London, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital, London, United Kingdom
- National Institute of Health Research, UCLH Biomedical Research Centre, London, United Kingdom
| | - Rumana Z. Omar
- Department of Statistical Science, University College London, London, United Kingdom
| | - Alisia Carnemolla
- UCL Centre for Obesity Research, Division of Medicine, University College London, London, United Kingdom
- National Institute of Health Research, UCLH Biomedical Research Centre, London, United Kingdom
| | - Rachel L. Batterham
- UCL Centre for Obesity Research, Division of Medicine, University College London, London, United Kingdom
- Bariatric Centre for Weight Management and Metabolic Surgery, University College London Hospital, London, United Kingdom
- National Institute of Health Research, UCLH Biomedical Research Centre, London, United Kingdom
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17
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Sampson EL, Anderson JE, Candy B, Davies N, Ellis-Smith C, Gola A, Harding R, Kenten C, Kupeli N, Mead S, Moore KJ, Omar RZ, Sleeman KE, Stewart R, Ward J, Warren JD, Evans CJ. Empowering Better End-of-Life Dementia Care (EMBED-Care): A mixed methods protocol to achieve integrated person-centred care across settings. Int J Geriatr Psychiatry 2020; 35:820-832. [PMID: 31854477 DOI: 10.1002/gps.5251] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Accepted: 12/07/2019] [Indexed: 12/12/2022]
Abstract
OBJECTIVES Globally, the number of people with dementia who have palliative care needs will increase fourfold over the next 40 years. The Empowering Better End-of-Life Dementia Care (EMBED-Care) Programme aims to deliver a step change in care through a large sequential study, spanning multiple work streams. METHODS We will use mixed methods across settings where people with dementia live and die: their own homes, care homes, and hospitals. Beginning with policy syntheses and reviews of interventions, we will develop a conceptual framework and underpinning theory of change. We will use linked data sets to explore current service use, care transitions, and inequalities and predict future need for end-of-life dementia care. Longitudinal cohort studies of people with dementia (including young onset and prion dementias) and their carers will describe care transitions, quality of life, symptoms, formal and informal care provision, and costs. Data will be synthesised, underpinned by the Knowledge-to-Action Implementation Framework, to design a novel complex intervention to support assessment, decision making, and communication between patients, carers, and inter-professional teams. This will be feasibility and pilot tested in UK settings. Patient and public involvement and engagement, innovative work with artists, policymakers, and third sector organisations are embedded to drive impact. We will build research capacity and develop an international network for excellence in dementia palliative care. CONCLUSIONS EMBED-Care will help us understand current and future need, develop novel cost-effective care innovations, build research capacity, and promote international collaborations in research and practice to ensure people live and die well with dementia.
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Affiliation(s)
- Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
| | - Janet E Anderson
- Department of Adult Nursing, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nathan Davies
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,Centre for Population Ageing Studies, Research Department of Primary Care and Population Health, University College London, London, UK
| | - Clare Ellis-Smith
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Anna Gola
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Richard Harding
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Charlotte Kenten
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Simon Mead
- National Prion Clinic, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Foundation Trust, London, UK.,MRC Prion Unit at UCL, Institute of Prion Diseases, UCL, London, UK
| | - Kirsten J Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Katherine E Sleeman
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK
| | - Robert Stewart
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK.,South London and Maudsley NHS Foundation Trust, London, UK
| | - Jane Ward
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Jason D Warren
- Dementia Research Centre, UCL Queen Square Institute of Neurology, University College London, London, UK
| | - Catherine J Evans
- Cicely Saunders Institute of Palliative Care, Policy & Rehabilitation, Florence Nightingale Faculty of Nursing, Midwifery and Palliative Care, King's College London, London, UK.,Sussex Community NHS Foundation Trust, Brighton, UK
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18
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Norrish G, Ding T, Field E, O'mahony C, Elliott PM, Omar RZ, Kaski JP. 227A novel risk prediction model for sudden cardiac death in childhood hypertrophic cardiomyopathy (HCM Risk-Kids). Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz747.0062] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM) but there is no validated algorithm to identify those at highest risk. This study sought to develop and validate a SCD risk prediction model that provides individualized risk estimates.
Methods
A prognostic model was derived from an international, retrospective, multi-center longitudinal cohort study of 1024 consecutively evaluated patients aged ≤16 years. The model was developed using pre-selected predictor variables [unexplained syncope, maximal left ventricular (LV) wall thickness (MWT), left atrial diameter (LAD), LV outflow tract (LVOT) gradient and non-sustained ventricular tachycardia (NSVT)] identified from the literature and internally validated using bootstrapping.
Results
Over a median follow up of 5.3 years (IQR 2.6, 8.2, total patient years 5984), 89 (8.7%) patients died suddenly or had an equivalent event [annual event rate 1.49 (95% CI 1.15–1.92)]. The pediatric model was developed using pre-selected variables to predict the risk of SCD. The model's ability to predict risk at 5 years was validated; C-statistic was 0.69 (95% CI 0.66–0.72) and the calibration slope was 0.98 (95% CI 0.58–1.38). For every 10 ICDs implanted in patients with ≥6% 5-year SCD risk, potentially 1 patient will be saved from SCD at 5 years.
Conclusions
This new validated risk stratification model for SCD in childhood HCM provides accurate individualized estimates of risk at 5 years using readily obtained clinical risk factors.
Acknowledgement/Funding
British Heart Foundation
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Affiliation(s)
- G Norrish
- University College London, London, United Kingdom
| | - T Ding
- University College London, London, United Kingdom
| | - E Field
- Great Ormond Street Hospital for Children, Inherited Cardiovascular Diseases Unit, London, United Kingdom
| | - C O'mahony
- University College London, London, United Kingdom
| | - P M Elliott
- University College London, London, United Kingdom
| | - R Z Omar
- University College London, London, United Kingdom
| | - J P Kaski
- University College London, London, United Kingdom
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19
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Norrish G, Ding T, Field E, Ziółkowska L, Olivotto I, Limongelli G, Anastasakis A, Weintraub R, Biagini E, Ragni L, Prendiville T, Duignan S, McLeod K, Ilina M, Fernández A, Bökenkamp R, Baban A, Kubuš P, Daubeney PEF, Sarquella-Brugada G, Cesar S, Marrone C, Bhole V, Medrano C, Uzun O, Brown E, Gran F, Castro FJ, Stuart G, Vignati G, Barriales-Villa R, Guereta LG, Adwani S, Linter K, Bharucha T, Garcia-Pavia P, Rasmussen TB, Calcagnino MM, Jones CB, De Wilde H, Toru-Kubo J, Felice T, Mogensen J, Mathur S, Reinhardt Z, O’Mahony C, Elliott PM, Omar RZ, Kaski JP. Development of a Novel Risk Prediction Model for Sudden Cardiac Death in Childhood Hypertrophic Cardiomyopathy (HCM Risk-Kids). JAMA Cardiol 2019; 4:918-927. [PMID: 31411652 PMCID: PMC6694401 DOI: 10.1001/jamacardio.2019.2861] [Citation(s) in RCA: 131] [Impact Index Per Article: 26.2] [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: 04/29/2019] [Accepted: 06/19/2019] [Indexed: 12/16/2022]
Abstract
Importance Sudden cardiac death (SCD) is the most common mode of death in childhood hypertrophic cardiomyopathy (HCM), but there is no validated algorithm to identify those at highest risk. Objective To develop and validate an SCD risk prediction model that provides individualized risk estimates. Design, Setting, and Participants A prognostic model was developed from a retrospective, multicenter, longitudinal cohort study of 1024 consecutively evaluated patients aged 16 years or younger with HCM. The study was conducted from January 1, 1970, to December 31, 2017. Exposures The model was developed using preselected predictor variables (unexplained syncope, maximal left-ventricular wall thickness, left atrial diameter, left-ventricular outflow tract gradient, and nonsustained ventricular tachycardia) identified from the literature and internally validated using bootstrapping. Main Outcomes and Measures A composite outcome of SCD or an equivalent event (aborted cardiac arrest, appropriate implantable cardioverter defibrillator therapy, or sustained ventricular tachycardia associated with hemodynamic compromise). Results Of the 1024 patients included in the study, 699 were boys (68.3%); mean (interquartile range [IQR]) age was 11 (7-14) years. Over a median follow-up of 5.3 years (IQR, 2.6-8.3; total patient years, 5984), 89 patients (8.7%) died suddenly or had an equivalent event (annual event rate, 1.49; 95% CI, 1.15-1.92). The pediatric model was developed using preselected variables to predict the risk of SCD. The model's ability to predict risk at 5 years was validated; the C statistic was 0.69 (95% CI, 0.66-0.72), and the calibration slope was 0.98 (95% CI, 0.59-1.38). For every 10 implantable cardioverter defibrillators implanted in patients with 6% or more of a 5-year SCD risk, 1 patient may potentially be saved from SCD at 5 years. Conclusions and Relevance This new, validated risk stratification model for SCD in childhood HCM may provide individualized estimates of risk at 5 years using readily obtained clinical risk factors. External validation studies are required to demonstrate the accuracy of this model's predictions in diverse patient populations.
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Affiliation(s)
- Gabrielle Norrish
- Centre for Inherited Cardiovascular Diseases, Department of Cardiology, Great Ormond Street Hospital, London, United Kingdom
- Institute of Cardiovascular Sciences, University College London, London, United Kingdom
- European Reference Network for Rare and Complex Diseases of the Heart, Amsterdam, the Netherlands
| | - Tao Ding
- Department of Statistical Science, University College London, London, United Kingdom
| | - Ella Field
- Centre for Inherited Cardiovascular Diseases, Department of Cardiology, Great Ormond Street Hospital, London, United Kingdom
- Institute of Cardiovascular Sciences, University College London, London, United Kingdom
- European Reference Network for Rare and Complex Diseases of the Heart, Amsterdam, the Netherlands
| | - Lidia Ziółkowska
- Department of Cardiology, The Children’s Memorial Health Institute, Warsaw, Poland
| | - Iacopo Olivotto
- Cardiothoracovascular Department, Careggi University Hospital, Florence, Italy
| | - Giuseppe Limongelli
- European Reference Network for Rare and Complex Diseases of the Heart, Amsterdam, the Netherlands
- Department of Cardiothoracic Sciences, Monaldi Hospital, Naples, Italy
| | | | - Robert Weintraub
- Department of Cardiology, The Royal Children’s Hospital, Melbourne, Australia
- Department of Clinical Sciences, The Murdoch Children’s Research Institute, Parkville, Australia
- Department of Medical and Health Sciences, University of Melbourne, Melbourne, Australia
| | - Elena Biagini
- Department of Cardiology, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Luca Ragni
- Department of Cardiology, S. Orsola-Malpighi Hospital, Bologna, Italy
| | - Terence Prendiville
- The Children’s Heart Centre, Our Lady’s Children’s Hospital, Dublin, Ireland
| | - Sophie Duignan
- The Children’s Heart Centre, Our Lady’s Children’s Hospital, Dublin, Ireland
| | - Karen McLeod
- Department of Paediatric Cardiology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Maria Ilina
- Department of Paediatric Cardiology, Royal Hospital for Children, Glasgow, United Kingdom
| | - Adrián Fernández
- Department of Ambulatory Cardiology, Favaloro Foundation University Hospital, Buenos Aires, Argentina
| | - Regina Bökenkamp
- Department of Paediatric Cardiology, Leiden University Medical Center, Leiden, the Netherlands
| | - Anwar Baban
- European Reference Network for Rare and Complex Diseases of the Heart, Amsterdam, the Netherlands
- Department of Paediatric Cardiology and Cardiac Surgery, Bambino Gesu Hospital, Rome, Italy
| | - Peter Kubuš
- Children’s Heart Centre, University Hospital Motol, Prague, Czech Republic
| | - Piers E. F. Daubeney
- Department of Paediatric Cardiology, Royal Brompton and Harefield NHS Trust, London, United Kingdom
| | - Georgia Sarquella-Brugada
- European Reference Network for Rare and Complex Diseases of the Heart, Amsterdam, the Netherlands
- Arrhythmia and Inherited Cardiac Diseases Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
- Medical Sciences Department, School of Medicine, University of Girona, Girona, Spain
| | - Sergi Cesar
- European Reference Network for Rare and Complex Diseases of the Heart, Amsterdam, the Netherlands
- Arrhythmia and Inherited Cardiac Diseases Unit, Hospital Sant Joan de Déu, University of Barcelona, Barcelona, Spain
| | - Chiara Marrone
- Department of Paediatric Cardiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Vinay Bhole
- The Heart Unit, Birmingham Children’s Hospital, Birmingham, United Kingdom
| | - Constancio Medrano
- Department of Paediatric Cardiology, Hospital General Universitario Gregorio Marañón, Madrid, Spain
| | - Orhan Uzun
- Children’s Heart Unit, University Hospital of Wales, Cardiff, United Kingdom
| | - Elspeth Brown
- Department of Paediatric Cardiology, Leeds General Infirmary, Leeds, United Kingdom
| | - Ferran Gran
- Paediatric Cardiology Department, Val d’Hebron University Hospital, Barcelona, Spain
| | - Francisco J. Castro
- Department of Cardiology, University Hospital Virgen de la Arrixaca, Murcia, Spain
| | - Graham Stuart
- Department of Paediatric Cardiology, Bristol Royal Hospital for Children, Bristol, United Kingdom
| | | | - Roberto Barriales-Villa
- Department of Cardiology, Complexo Hospitalario Universitario A Coruña, Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, A Coruña, Spain
| | - Luis G. Guereta
- Department of Cardiology, University Hospital La Paz, Madrid, Spain
| | - Satish Adwani
- Department of Paediatric Cardiology, John Radcliffe Hospital, Oxford, United Kingdom
| | - Katie Linter
- Department of Paediatric Cardiology, Glenfield Hospital, Leicester, United Kingdom
| | - Tara Bharucha
- Department of Paediatric Cardiology, Southampton General Hospital, Southampton, United Kingdom
| | - Pablo Garcia-Pavia
- European Reference Network for Rare and Complex Diseases of the Heart, Amsterdam, the Netherlands
- Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Centro de Investigación Biomédica en Red Enfermedades Cardiovasculares, Madrid, Spain
- Department of Cardiology, University Francisco de Vitoria, Pozuelo de Alarcon, Spain
| | | | - Margherita M. Calcagnino
- Department of Cardiology, University Hospitals Parma, Parma, Italy
- Cardiology Unit, IRCCS Ospedale Maggiore Policlinico, Milan, Italy
| | - Caroline B. Jones
- Department of Cardiology, Alder Hey Children’s Hospital, Liverpool, United Kingdom
| | - Hans De Wilde
- Department of Paediatric Cardiology, Ghent University Hospital, Ghent, Belgium
| | - J. Toru-Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kochi, Japan
| | - Tiziana Felice
- Department of Paediatric Cardiology, Mater Dei Hospital, Msida, Malta
| | - Jens Mogensen
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | - Sujeev Mathur
- Children’s Heart Service, Evelina Children’s Hospital, London, United Kingdom
| | - Zdenka Reinhardt
- Department of Paediatric Cardiology, The Freeman Hospital, Newcastle, United Kingdom
| | - Constantinos O’Mahony
- Institute of Cardiovascular Sciences, University College London, London, United Kingdom
- European Reference Network for Rare and Complex Diseases of the Heart, Amsterdam, the Netherlands
- St Bartholomew’s Centre for Inherited Cardiovascular Diseases, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom
| | - Perry M. Elliott
- Institute of Cardiovascular Sciences, University College London, London, United Kingdom
- European Reference Network for Rare and Complex Diseases of the Heart, Amsterdam, the Netherlands
- St Bartholomew’s Centre for Inherited Cardiovascular Diseases, Barts Heart Centre, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom
| | - Rumana Z. Omar
- Department of Statistical Science, University College London, London, United Kingdom
| | - Juan P. Kaski
- Centre for Inherited Cardiovascular Diseases, Department of Cardiology, Great Ormond Street Hospital, London, United Kingdom
- Institute of Cardiovascular Sciences, University College London, London, United Kingdom
- European Reference Network for Rare and Complex Diseases of the Heart, Amsterdam, the Netherlands
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Sheridan Rains L, Marston L, Hinton M, Marwaha S, Craig T, Fowler D, King M, Omar RZ, McCrone P, Spencer J, Taylor J, Colman S, Harder C, Gilbert E, Randhawa A, Labuschagne K, Jones C, Stefanidou T, Christoforou M, Craig M, Strang J, Weaver T, Johnson S. Clinical and cost-effectiveness of contingency management for cannabis use in early psychosis: the CIRCLE randomised clinical trial. BMC Med 2019; 17:161. [PMID: 31412884 PMCID: PMC6694526 DOI: 10.1186/s12916-019-1395-5] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Accepted: 07/22/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cannabis is the most commonly used illicit substance amongst people with psychosis. Continued cannabis use following the onset of psychosis is associated with poorer functional and clinical outcomes. However, finding effective ways of intervening has been very challenging. We examined the clinical and cost-effectiveness of adjunctive contingency management (CM), which involves incentives for abstinence from cannabis use, in people with a recent diagnosis of psychosis. METHODS CIRCLE was a pragmatic multi-centre randomised controlled trial. Participants were recruited via Early Intervention in Psychosis (EIP) services across the Midlands and South East of England. They had had at least one episode of clinically diagnosed psychosis (affective or non-affective); were aged 18 to 36; reported cannabis use in at least 12 out of the previous 24 weeks; and were not currently receiving treatment for cannabis misuse, or subject to a legal requirement for cannabis testing. Participants were randomised via a secure web-based service 1:1 to either an experimental arm, involving 12 weeks of CM plus a six-session psychoeducation package, or a control arm receiving the psychoeducation package only. The total potential voucher reward in the CM intervention was £240. The primary outcome was time to acute psychiatric care, operationalised as admission to an acute mental health service (including community alternatives to admission). Primary outcome data were collected from patient records at 18 months post-consent by assessors masked to allocation. The trial was registered with the ISRCTN registry, number ISRCTN33576045. RESULTS Five hundred fifty-one participants were recruited between June 2012 and April 2016. Primary outcome data were obtained for 272 (98%) in the CM (experimental) group and 259 (95%) in the control group. There was no statistically significant difference in time to acute psychiatric care (the primary outcome) (HR 1.03, 95% CI 0.76, 1.40) between groups. By 18 months, 90 (33%) of participants in the CM group, and 85 (30%) of the control groups had been admitted at least once to an acute psychiatric service. Amongst those who had experienced an acute psychiatric admission, the median time to admission was 196 days (IQR 82, 364) in the CM group and 245 days (IQR 99, 382) in the control group. Cost-effectiveness analyses suggest that there is an 81% likelihood that the intervention was cost-effective, mainly resulting from higher mean inpatient costs for the control group compared with the CM group; however, the cost difference between groups was not statistically significant. There were 58 adverse events, 27 in the CM group and 31 in the control group. CONCLUSIONS Overall, these results suggest that CM is not an effective intervention for improving the time to acute psychiatric admission or reducing cannabis use in psychosis, at least at the level of voucher reward offered.
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Affiliation(s)
| | - Louise Marston
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Mark Hinton
- Camden and Islington NHS Foundation Trust, 4 St Pancras Way, London, NW1 0PE, UK.,Centre for Posttraumatic Mental Health, Department of Psychiatry, University of Melbourne, Melbourne, Australia
| | - Steven Marwaha
- Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK.,Institute for Mental Health, School of Psychology, University of Birmingham, Birmingham, B15 2TT, UK
| | - Thomas Craig
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - David Fowler
- Department of Psychology, University of Sussex, Brighton, UK
| | - Michael King
- Division of Psychiatry, University College London, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Paul McCrone
- Department of Health Services and Population Research, King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London, London, UK
| | - Jonathan Spencer
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Joanne Taylor
- Division of Psychiatry, University College London, London, UK
| | - Sophie Colman
- Division of Psychiatry, University College London, London, UK
| | | | - Eleanor Gilbert
- Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - Amie Randhawa
- Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Charlotte Jones
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | | | | | - Meghan Craig
- Division of Psychiatry, University College London, London, UK
| | - John Strang
- Addictions Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Tim Weaver
- Mental Health Social Work & Inter-professional Learning, Middlesex University London, London, UK
| | - Sonia Johnson
- Division of Psychiatry, University College London, London, UK
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Vickerstaff V, Omar RZ, Ambler G. Correction to: Methods to adjust for multiple comparisons in the analysis and sample size calculation of randomised controlled trials with multiple primary outcomes. BMC Med Res Methodol 2019; 19:158. [PMID: 31331273 PMCID: PMC6643307 DOI: 10.1186/s12874-019-0807-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Affiliation(s)
- Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, Gower Street, London, WC1E 6BT, UK. .,Department of Statistical Science, University College London, Gower Street, London, WC1E 6BT, UK.
| | - Rumana Z Omar
- Department of Statistical Science, University College London, Gower Street, London, WC1E 6BT, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, London, WC1E 6BT, UK
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22
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Vickerstaff V, Omar RZ, Ambler G. Methods to adjust for multiple comparisons in the analysis and sample size calculation of randomised controlled trials with multiple primary outcomes. BMC Med Res Methodol 2019; 19:129. [PMID: 31226934 PMCID: PMC6588937 DOI: 10.1186/s12874-019-0754-4] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [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: 12/04/2018] [Accepted: 05/21/2019] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Multiple primary outcomes may be specified in randomised controlled trials (RCTs). When analysing multiple outcomes it's important to control the family wise error rate (FWER). A popular approach to do this is to adjust the p-values corresponding to each statistical test used to investigate the intervention effects by using the Bonferroni correction. It's also important to consider the power of the trial to detect true intervention effects. In the context of multiple outcomes, depending on the clinical objective, the power can be defined as: 'disjunctive power', the probability of detecting at least one true intervention effect across all the outcomes or 'marginal power' the probability of finding a true intervention effect on a nominated outcome. We provide practical recommendations on which method may be used to adjust for multiple comparisons in the sample size calculation and the analysis of RCTs with multiple primary outcomes. We also discuss the implications on the sample size for obtaining 90% disjunctive power and 90% marginal power. METHODS We use simulation studies to investigate the disjunctive power, marginal power and FWER obtained after applying Bonferroni, Holm, Hochberg, Dubey/Armitage-Parmar and Stepdown-minP adjustment methods. Different simulation scenarios were constructed by varying the number of outcomes, degree of correlation between the outcomes, intervention effect sizes and proportion of missing data. RESULTS The Bonferroni and Holm methods provide the same disjunctive power. The Hochberg and Hommel methods provide power gains for the analysis, albeit small, in comparison to the Bonferroni method. The Stepdown-minP procedure performs well for complete data. However, it removes participants with missing values prior to the analysis resulting in a loss of power when there are missing data. The sample size requirement to achieve the desired disjunctive power may be smaller than that required to achieve the desired marginal power. The choice between whether to specify a disjunctive or marginal power should depend on the clincial objective.
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Affiliation(s)
- Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, Gower Street, London, WC1E 6BT, UK. .,Department of Statistical Science, University College London, Gower Street, London, WC1E 6BT, UK.
| | - Rumana Z Omar
- Department of Statistical Science, University College London, Gower Street, London, WC1E 6BT, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, London, WC1E 6BT, UK
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Serfaty M, Armstrong M, Vickerstaff V, Davis S, Gola A, McNamee P, Omar RZ, King M, Tookman A, Jones L, Low JT. Acceptance and commitment therapy for adults with advanced cancer (CanACT): A feasibility randomised controlled trial. Psychooncology 2018; 28:488-496. [DOI: 10.1002/pon.4960] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Marc Serfaty
- Marie Curie Palliative Care Research Department, Division of Psychiatry; University College London; London UK
| | - Megan Armstrong
- Marie Curie Palliative Care Research Department, Division of Psychiatry; University College London; London UK
- Camden and Islington NHS Foundation Trust, St. Pancras Hospital; London UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry; University College London; London UK
- Department of Primary Care and Population Health; University College London; London UK
| | - Sarah Davis
- Marie Curie Palliative Care Research Department, Division of Psychiatry; University College London; London UK
| | - Anna Gola
- Marie Curie Palliative Care Research Department, Division of Psychiatry; University College London; London UK
| | - Philip McNamee
- Marie Curie Palliative Care Research Department, Division of Psychiatry; University College London; London UK
- Camden and Islington NHS Foundation Trust, St. Pancras Hospital; London UK
| | - Rumana Z. Omar
- Department of Statistical Science; University College London; London UK
| | - Michael King
- Marie Curie Palliative Care Research Department, Division of Psychiatry; University College London; London UK
| | | | - Louise Jones
- Marie Curie Palliative Care Research Department, Division of Psychiatry; University College London; London UK
| | - Joseph T.S. Low
- Marie Curie Palliative Care Research Department, Division of Psychiatry; University College London; London UK
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O'Mahony C, Akhtar MM, Anastasiou Z, Guttmann OP, Vriesendorp PA, Michels M, Magrì D, Autore C, Fernández A, Ochoa JP, Leong KMW, Varnava AM, Monserrat L, Anastasakis A, Garcia-Pavia P, Rapezzi C, Biagini E, Gimeno JR, Limongelli G, Omar RZ, Elliott PM. Effectiveness of the 2014 European Society of Cardiology guideline on sudden cardiac death in hypertrophic cardiomyopathy: a systematic review and meta-analysis. Heart 2018; 105:623-631. [PMID: 30366935 DOI: 10.1136/heartjnl-2018-313700] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2018] [Revised: 09/18/2018] [Accepted: 09/22/2018] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE In 2014, the European Society of Cardiology (ESC) recommended the use of a novel risk prediction model (HCM Risk-SCD) to guide use of implantable cardioverter defibrillators (ICD) for the primary prevention of sudden cardiac death (SCD) in patients with hypertrophic cardiomyopathy (HCM). We sought to determine the performance of HCM Risk-SCD by conducting a systematic review and meta-analysis of articles reporting on the prevalence of SCD within 5 years of evaluation in low, intermediate and high-risk patients as defined by the 2014 guidelines (predicted risk <4%, 4%-<6% and ≥6%, respectively). METHODS The protocol was registered with PROSPERO (registration number: CRD42017064203). MEDLINE and manual searches for papers published from October 2014 to December 2017 were performed. Longitudinal, observational cohorts of unselected adult patients, without history of cardiac arrest were considered. The original HCM Risk-SCD development study was included a priori. Data were pooled using a random effects model. RESULTS Six (0.9%) out of 653 independent publications identified by the initial search were included. The calculated 5-year risk of SCD was reported in 7291 individuals (70% low, 15% intermediate; 15% high risk) with 184 (2.5%) SCD endpoints within 5 years of baseline evaluation. Most SCD endpoints (68%) occurred in patients with an estimated 5-year risk of ≥4% who formed 30% of the total study cohort. Using the random effects method, the pooled prevalence of SCD endpoints was 1.01% (95% CI 0.52 to 1.61) in low-risk patients, 2.43% (95% CI 1.23 to 3.92) in intermediate and 8.4% (95% CI 6.68 to 10.25) in high-risk patients. CONCLUSIONS This meta-analysis demonstrates that HCM Risk-SCD provides accurate risk estimations that can be used to guide ICD therapy in accordance with the 2014 ESC guidelines. REGISTRATION NUMBER PROSPERO CRD42017064203;Pre-results.
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Affiliation(s)
- Constantinos O'Mahony
- The Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,UCL Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, London, UK.,European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-HEART)
| | - Mohammed Majid Akhtar
- The Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-HEART).,UCL Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, London, UK
| | | | - Oliver P Guttmann
- The Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-HEART).,UCL Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, London, UK
| | - Pieter A Vriesendorp
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Michelle Michels
- Department of Cardiology, Thoraxcenter, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Damiano Magrì
- Clinical and Molecular Medicine, University 'La Sapienza', Rome, Italy
| | - Camillo Autore
- Clinical and Molecular Medicine, University 'La Sapienza', Rome, Italy
| | - Adrián Fernández
- Department of Cardiology, Favaloro Foundation University Hospital, Institute of Cardiology and Cardiovascular Surgery, Buenos Aires, Argentina
| | - Juan Pablo Ochoa
- Department of Cardiology, Favaloro Foundation University Hospital, Institute of Cardiology and Cardiovascular Surgery, Buenos Aires, Argentina.,GRINCAR (Cardiovascular Research Group), University of A Coruña, A Coruña, Spain.,Scientific Department, Health In Code, A Coruña, Spain
| | | | | | - Lorenzo Monserrat
- Scientific Department, Health In Code, A Coruña, Spain.,Cardiology Department and Research Unit, A Coruña University Hospital, Galician Health Service, A Coruña, Spain
| | - Aristides Anastasakis
- Unit of Inherited Cardiovascular Diseases, First Department of Cardiology, University of Athens, Athens, Greece
| | - Pablo Garcia-Pavia
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-HEART).,Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain.,University Francisco de Vitoria (UFV), Madrid, Spain.,Centro de Investigacion Biomedica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Claudio Rapezzi
- Department of Specialised, Experimental and Diagnostic Medicine, Institute of Cardiology, University of Bologna, Bologna, Italy
| | - Elena Biagini
- Department of Specialised, Experimental and Diagnostic Medicine, Institute of Cardiology, University of Bologna, Bologna, Italy
| | - Juan Ramon Gimeno
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-HEART).,Cardiac Department, University Hospital Virgen Arrixaca, La Alberca (Murcia), Spain
| | - Giuseppe Limongelli
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-HEART).,Monaldi Hospital, Second University of Naples, Naples, Italy
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Perry M Elliott
- The Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew's Hospital, London, UK.,European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-HEART).,UCL Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, London, UK
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Kalpakidou AK, Todd C, Keeley V, Griffiths J, Spencer K, Vickerstaff V, Omar RZ, Stone P. The Prognosis in Palliative care Study II (PiPS2): study protocol for a multi-centre, prospective, observational, cohort study. BMC Palliat Care 2018; 17:101. [PMID: 30103711 PMCID: PMC6090599 DOI: 10.1186/s12904-018-0352-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [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] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 07/23/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND More accurate methods of prognostication are likely to lead to improvements in the quality of care of patients approaching the ends of their lives. The Prognosis in Palliative care Scales (PiPS) are prognostic models of survival. The scores are calculated using simple clinical data and observations. There are two separate PiPS models; PiPS-A for patients without blood test results and PiPS-B for patients with blood test results. Both models predict whether a patient is likely to live for "days", "weeks" or "months" and have been shown to perform as well as clinicians' estimates of survival. PiPS-B has also been found to be significantly better than doctors' estimates of survival. We report here a protocol for the validation of PiPS and for the evaluation of the accuracy of other prognostic tools in a new, larger cohort of patients with advanced cancer. METHODS This is a national, multi-centre, prospective, observational cohort study, aiming to recruit 1778 patients via palliative care services across England and Wales. Eligible patients have advanced, incurable cancer and have recently been referred to palliative care services. Patients with or without capacity are included in the study. The primary outcome is the accuracy of PiPS predictions and the difference in accuracy between these predictions and the clinicians' estimates of survival; with PiPS-B being the main model of interest. The secondary outcomes include the accuracy of predictions by the Palliative Prognostic Index (PPI), Palliative Performance Scale (PPS), Palliative Prognostic score (PaP) and the Feliu Prognostic Nomogram (FPN) compared with actual patient survival and clinicians' estimates of survival. A nested qualitative sub-study using face-to-face interviews with patients, carers and clinicians is also being undertaken to assess the acceptability of the prognostic models and to identify barriers and facilitators to clinical use. DISCUSSION The study closed to recruitment at the end of April 2018 having exceeded the required sample size of 1778 patients. The qualitative sub-study is nearing completion. This demonstrates the feasibility of recruiting large numbers of participants to a prospective palliative care study. TRIAL REGISTRATION ISRCTN13688211 (registration date: 28/06/2016).
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Affiliation(s)
- Anastasia K. Kalpakidou
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Chris Todd
- The School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, M13 9PL UK
| | - Vaughan Keeley
- Derby Teaching Hospitals NHS Foundation Trust, Derby, DE1 2QY UK
| | - Jane Griffiths
- The School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, M13 9PL UK
| | - Karen Spencer
- The School of Nursing, Midwifery and Social Work, University of Manchester, Manchester, M13 9PL UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Rumana Z. Omar
- Department of Statistical Science, UCL, London, WC1E 7HB UK
| | - Patrick Stone
- Marie Curie Palliative Care Research Department, Division of Psychiatry, UCL, 6th Floor, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
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Patel N, Beeken RJ, Leurent B, Omar RZ, Nazareth I, Morris S. Cost-effectiveness of habit-based advice for weight control versus usual care in general practice in the Ten Top Tips (10TT) trial: economic evaluation based on a randomised controlled trial. BMJ Open 2018; 8:e017511. [PMID: 30104307 PMCID: PMC6091904 DOI: 10.1136/bmjopen-2017-017511] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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] [Indexed: 01/31/2023] Open
Abstract
OBJECTIVE Ten Top Tips (10TT) is a primary care-led behavioural intervention which aims to help adults reduce and manage their weight by following 10 weight loss tips. The intervention promotes habit formation to encourage long-term behavioural changes. The aim of this study was to estimate the cost-effectiveness of 10TT in general practice from the perspective of the UK National Health Service. DESIGN An economic evaluation was conducted alongside an individually randomised controlled trial. SETTING 14 general practitioner practices in England. PARTICIPANTS All patients were aged ≥18 years, with body mass index ≥30 kg/m2. A total of 537 patients were recruited; 270 received the usual care offered by their practices and 267 received the 10TT intervention. OUTCOMES MEASURES Health service use and quality-adjusted life years (QALYs) were measured over 2 years. Analysis was conducted in terms of incremental net monetary benefits (NMBs), using non-parametric bootstrapping and multiple imputation. RESULTS Over a 2-year time horizon, the mean costs and QALYs per patient in the 10TT group were £1889 (95% CI £1522 to £2566) and 1.51 (95% CI 1.44 to 1.58). The mean costs and QALYs for usual care were £1925 (95% CI £1599 to £2251) and 1.51 (95% CI 1.45 to 1.57), respectively. This generated a mean cost difference of -£36 (95% CI -£512 to £441) and a mean QALY difference of 0.001 (95% CI -0.080 to 0.082). The incremental NMB for 10TT versus usual care was £49 (95% CI -£1709 to £1800) at a maximum willingness to pay for a QALY of £20 000. 10TT had a 52% probability of being cost-effective at this threshold. CONCLUSIONS Costs and QALYs for 10TT were not significantly different from usual care and therefore 10TT is as cost-effective as usual care. There was no evidence to recommend nor advice against offering 10TT to obese patients in general practices based on cost-effectiveness considerations. TRIAL REGISTRATION NUMBER ISRCTN16347068; Post-results.
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Affiliation(s)
- Nishma Patel
- Department of Applied Health Research, University College London, London, UK
| | - Rebecca J Beeken
- Department of Behavioural Science and Health, University College London, London, UK
- Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Baptiste Leurent
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, London, UK
| | - Stephen Morris
- Department of Applied Health Research, University College London, London, UK
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Norrish G, Ding T, Field E, O'Mahony C, Elliott PM, Omar RZ, Kaski JP. 403An international validation study of the 2014 european society of cardiology sudden cardiac death risk prediction model in childhood hypertrophic cardiomyopathy. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy564.403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- G Norrish
- Great Ormond Street Hospital for Children, Inherited Cardiovascular Disease, London, United Kingdom
| | - T Ding
- University College London, Department of Statistical Science, London, United Kingdom
| | - E Field
- Great Ormond Street Hospital for Children, Inherited Cardiovascular Disease, London, United Kingdom
| | - C O'Mahony
- Barts Health NHS Trust, London, United Kingdom
| | - P M Elliott
- Barts Health NHS Trust, London, United Kingdom
| | - R Z Omar
- University College London, Department of Statistical Science, London, United Kingdom
| | - J P Kaski
- Great Ormond Street Hospital for Children, Inherited Cardiovascular Disease, London, United Kingdom
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O’Mahony C, Jichi F, Ommen SR, Christiaans I, Arbustini E, Garcia-Pavia P, Cecchi F, Olivotto I, Kitaoka H, Gotsman I, Carr-White G, Mogensen J, Antoniades L, Mohiddin SA, Maurer MS, Tang HC, Geske JB, Siontis KC, Mahmoud KD, Vermeer A, Wilde A, Favalli V, Guttmann OP, Gallego-Delgado M, Dominguez F, Tanini I, Kubo T, Keren A, Bueser T, Waters S, Issa IF, Malcolmson J, Burns T, Sekhri N, Hoeger CW, Omar RZ, Elliott PM. International External Validation Study of the 2014 European Society of Cardiology Guidelines on Sudden Cardiac Death Prevention in Hypertrophic Cardiomyopathy (EVIDENCE-HCM). Circulation 2018; 137:1015-1023. [DOI: 10.1161/circulationaha.117.030437] [Citation(s) in RCA: 116] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2017] [Accepted: 11/06/2017] [Indexed: 11/16/2022]
Abstract
Background:
Identification of people with hypertrophic cardiomyopathy (HCM) who are at risk of sudden cardiac death (SCD) and require a prophylactic implantable cardioverter defibrillator is challenging. In 2014, the European Society of Cardiology proposed a new risk stratification method based on a risk prediction model (HCM Risk-SCD) that estimates the 5-year risk of SCD. The aim was to externally validate the 2014 European Society of Cardiology recommendations in a geographically diverse cohort of patients recruited from the United States, Europe, the Middle East, and Asia.
Methods:
This was an observational, retrospective, longitudinal cohort study.
Results:
The cohort consisted of 3703 patients. Seventy three (2%) patients reached the SCD end point within 5 years of follow-up (5-year incidence, 2.4% [95% confidence interval {CI}, 1.9–3.0]). The validation study revealed a calibration slope of 1.02 (95% CI, 0.93–1.12), C-index of 0.70 (95% CI, 0.68–0.72), and D-statistic of 1.17 (95% CI, 1.05–1.29). In a complete case analysis (n= 2147; 44 SCD end points at 5 years), patients with a predicted 5-year risk of <4% (n=1524; 71%) had an observed 5-year SCD incidence of 1.4% (95% CI, 0.8–2.2); patients with a predicted risk of ≥6% (n=297; 14%) had an observed SCD incidence of 8.9% (95% CI, 5.96–13.1) at 5 years. For every 13 (297/23) implantable cardioverter defibrillator implantations in patients with an estimated 5-year SCD risk ≥6%, 1 patient can potentially be saved from SCD.
Conclusions:
This study confirms that the HCM Risk-SCD model provides accurate prognostic information that can be used to target implantable cardioverter defibrillator therapy in patients at the highest risk of SCD.
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Affiliation(s)
- Constantinos O’Mahony
- St. Bartholomew’s Centre for Inherited Cardiovascular Disease, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom (C.O., S.A.M., O.P.G., J.M., N.S., P.M.E.)
- Centre for Heart Muscle Disease, Institute of Cardiovascular Science (C.O., P.M.E.)
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
| | - Fatima Jichi
- Biostatistics Group, University College London Hospitals/University College London Joint Research Office (F.J.)
| | - Steve R. Ommen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (S.R.O., J.B.G., K.C.S., K.D.M.)
| | - Imke Christiaans
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
- Heart Center, Department of Clinical and Experimental Cardiology (I.C., A.V., A.W.)
- Department of Clinical Genetics (I.C., A.V.)
| | - Eloisa Arbustini
- Academic Medical Center, Amsterdam, Netherlands. Centre for Inherited Cardiovascular Diseases, Transplant Research Area, Istituto di Ricovero e Cura a Carattere Scientifico Foundation, Policlinico San Matteo, Pavia, Italy (E.A., V.F.)
| | - Pablo Garcia-Pavia
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain (P.G.-P., M.G.-D., F.D.)
- Centro de Investigacion Biomedica en Red en Enfermedades Cardiovasculares, Madrid, Spain (P.G.-P.). University Francisco de Vitoria, Pozuelo de Alarcón, Madrid, Spain (P.G.-P.)
| | - Franco Cecchi
- Department of Cardiology, Careggi University Hospital, Florence, Italy (F.C., I.O., I.T.)
| | - Iacopo Olivotto
- Department of Cardiology, Careggi University Hospital, Florence, Italy (F.C., I.O., I.T.)
| | - Hiroaki Kitaoka
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku-shi, Japan (H.K., T.K.)
| | - Israel Gotsman
- Heart Institute, Hadassah University Hospital, Jerusalem, Israel (I.G., A.K.)
| | - Gerald Carr-White
- Guy’s and St. Thomas’ Hospital National Health Service Foundation Trust, London, United Kingdom (G.C.-W., T.B., S.W.)
| | - Jens Mogensen
- London Chest Hospital, United Kingdom (S.A.M., J.M., T.B., N.S.)
| | - Loizos Antoniades
- Inherited Cardiovascular Disease Unit, Department of Cardiology, Nicosia General Hospital, Latsia, Cyprus (L.A.)
| | - Saidi A. Mohiddin
- St. Bartholomew’s Centre for Inherited Cardiovascular Disease, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom (C.O., S.A.M., O.P.G., J.M., N.S., P.M.E.)
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
- London Chest Hospital, United Kingdom (S.A.M., J.M., T.B., N.S.)
| | - Mathew S. Maurer
- Columbia University Medical Center, New York, NY (M.S.M., C.W.H.)
| | - Hak Chiaw Tang
- Department of Cardiology, National Heart Centre Singapore (H.C.T.)
| | - Jeffrey B. Geske
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (S.R.O., J.B.G., K.C.S., K.D.M.)
| | - Konstantinos C. Siontis
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (S.R.O., J.B.G., K.C.S., K.D.M.)
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor (K.C.S.)
| | - Karim D. Mahmoud
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, MN (S.R.O., J.B.G., K.C.S., K.D.M.)
- Thorax Center, Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands (K.D.M.)
| | - Alexa Vermeer
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
- Heart Center, Department of Clinical and Experimental Cardiology (I.C., A.V., A.W.)
- Department of Clinical Genetics (I.C., A.V.)
| | - Arthur Wilde
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
- Heart Center, Department of Clinical and Experimental Cardiology (I.C., A.V., A.W.)
| | - Valentina Favalli
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
- Academic Medical Center, Amsterdam, Netherlands. Centre for Inherited Cardiovascular Diseases, Transplant Research Area, Istituto di Ricovero e Cura a Carattere Scientifico Foundation, Policlinico San Matteo, Pavia, Italy (E.A., V.F.)
| | - Oliver P. Guttmann
- St. Bartholomew’s Centre for Inherited Cardiovascular Disease, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom (C.O., S.A.M., O.P.G., J.M., N.S., P.M.E.)
- The Inherited Cardiac Diseases Unit, The Heart Hospital (O.P.G., P.M.E.)
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
| | - Maria Gallego-Delgado
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain (P.G.-P., M.G.-D., F.D.)
| | - Fernando Dominguez
- Heart Failure and Inherited Cardiac Diseases Unit, Department of Cardiology, Hospital Universitario Puerta de Hierro Majadahonda, Madrid, Spain (P.G.-P., M.G.-D., F.D.)
| | - Ilaria Tanini
- Department of Cardiology, Careggi University Hospital, Florence, Italy (F.C., I.O., I.T.)
| | - Toru Kubo
- Department of Cardiology and Geriatrics, Kochi Medical School, Kochi University, Kohasu, Oko-cho, Nankoku-shi, Japan (H.K., T.K.)
| | - Andre Keren
- Heart Institute, Hadassah University Hospital, Jerusalem, Israel (I.G., A.K.)
- Clalit Health Services Beit Hadfus 20, Jerusalem, Israel (A.K.). Assuta Hospitals, Tel Aviv, Israel (A.K.)
| | - Teofila Bueser
- London Chest Hospital, United Kingdom (S.A.M., J.M., T.B., N.S.)
- King’s College London, United Kingdom (T.B.). St George’s, University of London, United Kingdom (T.B.)
| | - Sarah Waters
- Guy’s and St. Thomas’ Hospital National Health Service Foundation Trust, London, United Kingdom (G.C.-W., T.B., S.W.)
| | - Issa F. Issa
- Department of Cardiology, Odense University Hospital, Denmark (J.M., I.F.I.)
| | - James Malcolmson
- St. Bartholomew’s Centre for Inherited Cardiovascular Disease, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom (C.O., S.A.M., O.P.G., J.M., N.S., P.M.E.)
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
- Department of Cardiology, Odense University Hospital, Denmark (J.M., I.F.I.)
| | - Tom Burns
- Guy’s and St. Thomas’ Hospital National Health Service Foundation Trust, London, United Kingdom (G.C.-W., T.B., S.W.)
| | - Neha Sekhri
- St. Bartholomew’s Centre for Inherited Cardiovascular Disease, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom (C.O., S.A.M., O.P.G., J.M., N.S., P.M.E.)
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
- London Chest Hospital, United Kingdom (S.A.M., J.M., T.B., N.S.)
| | | | | | - Perry M. Elliott
- St. Bartholomew’s Centre for Inherited Cardiovascular Disease, St Bartholomew’s Hospital, West Smithfield, London, United Kingdom (C.O., S.A.M., O.P.G., J.M., N.S., P.M.E.)
- Centre for Heart Muscle Disease, Institute of Cardiovascular Science (C.O., P.M.E.)
- The Inherited Cardiac Diseases Unit, The Heart Hospital (O.P.G., P.M.E.)
- University College London, United Kingdom. European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARDHEART; http://guardheart.ern-net.eu) (C.O., I.C., P.G.-P., S.A.M., A.V., A.W., V.F., O.P.G., J.M., N.S., P.M.E.)
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Sampson EL, Candy B, Davis S, Gola AB, Harrington J, King M, Kupeli N, Leavey G, Moore K, Nazareth I, Omar RZ, Vickerstaff V, Jones L. Living and dying with advanced dementia: A prospective cohort study of symptoms, service use and care at the end of life. Palliat Med 2018; 32:668-681. [PMID: 28922625 PMCID: PMC5987852 DOI: 10.1177/0269216317726443] [Citation(s) in RCA: 105] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Increasing number of people are dying with advanced dementia. Comfort and quality of life are key goals of care. AIMS To describe (1) physical and psychological symptoms, (2) health and social care service utilisation and (3) care at end of life in people with advanced dementia. DESIGN 9-month prospective cohort study. SETTING AND PARTICIPANTS Greater London, England, people with advanced dementia (Functional Assessment Staging Scale 6e and above) from 14 nursing homes or their own homes. MAIN OUTCOME MEASURES At study entry and monthly: prescriptions, Charlson Comorbidity Index, pressure sore risk/severity (Waterlow Scale/Stirling Scale, respectively), acute medical events, pain (Pain Assessment in Advanced Dementia), neuropsychiatric symptoms (Neuropsychiatric Inventory), quality of life (Quality of Life in Late-Stage Dementia Scale), resource use (Resource Utilization in Dementia Questionnaire and Client Services Receipt Inventory), presence/type of advance care plans, interventions, mortality, place of death and comfort (Symptom Management at End of Life in Dementia Scale). RESULTS Of 159 potential participants, 85 were recruited (62% alive at end of follow-up). Pain (11% at rest, 61% on movement) and significant agitation (54%) were common and persistent. Aspiration, dyspnoea, septicaemia and pneumonia were more frequent in those who died. In total, 76% had 'do not resuscitate' statements, less than 40% advance care plans. Most received primary care visits, there was little input from geriatrics or mental health but contact with emergency paramedics was common. CONCLUSION People with advanced dementia lived with distressing symptoms. Service provision was not tailored to their needs. Longitudinal multidisciplinary input could optimise symptom control and quality of life.
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Affiliation(s)
- Elizabeth L Sampson
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,2 Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
| | - Bridget Candy
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Sarah Davis
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Anna Buylova Gola
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Jane Harrington
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Michael King
- 3 Division of Psychiatry, University College London, London, UK
| | - Nuriye Kupeli
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Gerry Leavey
- 4 The Bamford Centre for Mental Health and Wellbeing, Ulster University, Coleraine, UK
| | - Kirsten Moore
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Irwin Nazareth
- 5 Department of Primary Care and Population Health, University College London, London, UK
| | - Rumana Z Omar
- 6 Department of Statistical Science, University College London, London, UK
| | - Victoria Vickerstaff
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK.,5 Department of Primary Care and Population Health, University College London, London, UK
| | - Louise Jones
- 1 Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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Hassiotis A, Poppe M, Strydom A, Vickerstaff V, Hall IS, Crabtree J, Omar RZ, King M, Hunter R, Biswas A, Cooper V, Howie W, Crawford MJ. Clinical outcomes of staff training in positive behaviour support to reduce challenging behaviour in adults with intellectual disability: cluster randomised controlled trial. Br J Psychiatry 2018; 212:161-168. [PMID: 29436314 DOI: 10.1192/bjp.2017.34] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND Staff training in positive behaviour support (PBS) is a widespread treatment approach for challenging behaviour in adults with intellectual disability. Aims To evaluate whether such training is clinically effective in reducing challenging behaviour during routine care (trial registration: NCT01680276). METHOD We carried out a multicentre, cluster randomised controlled trial involving 23 community intellectual disability services in England, randomly allocated to manual-assisted staff training in PBS (n = 11) or treatment as usual (TAU, n = 12). Data were collected from 246 adult participants. RESULTS No treatment effects were found for the primary outcome (challenging behaviour over 12 months, adjusted mean difference = -2.14, 95% CI: -8.79, 4.51) or secondary outcomes. CONCLUSIONS Staff training in PBS, as applied in this study, did not reduce challenging behaviour. Further research should tackle implementation issues and endeavour to identify other interventions that can reduce challenging behaviour. Declaration of interest None.
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Affiliation(s)
- Angela Hassiotis
- University College London Division of Psychiatry,UK and Camden and Islington NHS Foundation Trust,UK
| | | | - Andre Strydom
- King's College London and South London and the Maudsley NHS Foundation Trust,UK
| | | | - Ian S Hall
- Tower Hamlets Community Learning Disability Service,Mile End Hospital,London,UK
| | - Jason Crabtree
- Tower Hamlets Community Learning Disability Service,Mile End Hospital,London,UK
| | - Rumana Z Omar
- Department of Statistical Science,University College London,UK
| | - Michael King
- University College London Division of Psychiatry,UK
| | - Rachael Hunter
- University College London PRIMENT Clinical Trials Unit,UK
| | - Asit Biswas
- Leicestershire Partnership National Health Service Trust,Directorate of Learning Disabilities,Frith Hospital,Leicester,UK
| | | | - William Howie
- Wandsworth Community Mental Health Intellectual Disabilities Team,Springfield Hospital,UK
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Gray J, Millett C, O'Sullivan C, Omar RZ, Majeed A. Association of Age, Sex and Deprivation with Quality Indicators for Diabetes: Population-Based Cross Sectional Survey in Primary Care. J R Soc Med 2017; 99:576-81. [PMID: 17082303 PMCID: PMC1633555 DOI: 10.1177/014107680609901117] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives To determine the quality of diabetes management in primary care after the publication of the National Service Framework and examine the impact of age, gender and deprivation on the achievement of established quality indicators. Design Population-based cross sectional survey using electronic general practice records carried out between June–October 2003. Setting Thirty-four practices in Wandsworth, South-West London, UK. Participants 6035 adult patients (≥18 years) with diabetes from a total registered population of 201 572 patients. Interventions None. Main Outcome Measures Success rates for the diabetes quality indicators within the General Medical Services contract for general practitioners. Results We identified large variations in diabetes management between general practitioner practices with poorer recording of quality care in younger patients (18–44 years). In addition, younger patients had a worse cholesterol and glycaemia profile, although hypertension was more common in older patients. Gender and deprivation did not appear to be important determinants of the quality of care received. Conclusions There are large variations in diabetes management between general practitioner practices, with care seemingly worse for younger adults. Longitudinal studies are required to determine whether current UK quality improvement initiatives have been successful in attenuating existing variations in care and treatment outcomes.
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Affiliation(s)
- Jeremy Gray
- Wandsworth Primary Care Research Centre, London SW11 6HN
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Moore KJ, Candy B, Davis S, Gola A, Harrington J, Kupeli N, Vickerstaff V, King M, Leavey G, Nazareth I, Omar RZ, Jones L, Sampson EL. Implementing the compassion intervention, a model for integrated care for people with advanced dementia towards the end of life in nursing homes: a naturalistic feasibility study. BMJ Open 2017; 7:e015515. [PMID: 28694253 PMCID: PMC5541605 DOI: 10.1136/bmjopen-2016-015515] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Many people with dementia die in nursing homes, but quality of care may be suboptimal. We developed the theory-driven 'Compassion Intervention' to enhance end-of-life care in advanced dementia. OBJECTIVES To (1) understand how the Intervention operated in nursing homes in different health economies; (2) collect preliminary outcome data and costs of an interdisciplinary care leader (ICL) to facilitate the Intervention; (3) check the Intervention caused no harm. DESIGN A naturalistic feasibility study of Intervention implementation for 6 months. SETTINGS Two nursing homes in northern London, UK. PARTICIPANTS Thirty residents with advanced dementia were assessed of whom nine were recruited for data collection; four of these residents' family members were interviewed. Twenty-eight nursing home and external healthcare professionals participated in interviews at 7 (n=19), 11 (n=19) and 15 months (n=10). INTERVENTION An ICL led two core Intervention components: (1) integrated, interdisciplinary assessment and care; (2) education and support for paid and family carers. DATA COLLECTED Process and outcome data were collected. Symptoms were recorded monthly for recruited residents. Semistructured interviews were conducted at 7, 11 and 15 months with nursing home staff and external healthcare professionals and at 7 months with family carers. ICL hours were costed using Department of Health and Health Education England tariffs. RESULTS Contextual differences were identified between sites: nursing home 2 had lower involvement with external healthcare services. Core components were implemented at both sites but multidisciplinary meetings were only established in nursing home 1. The Intervention prompted improvements in advance care planning, pain management and person-centred care; we observed no harm. Six-month ICL costs were £18 255. CONCLUSIONS Implementation was feasible to differing degrees across sites, dependent on context. Our data inform future testing to identify the Intervention's effectiveness in improving end-of-life care in advanced dementia. TRIAL REGISTRATION ClinicalTrials.gov:NCT02840318: Results.
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Affiliation(s)
- Kirsten J Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Sarah Davis
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Anna Gola
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Jane Harrington
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Michael King
- Division of Psychiatry, University College London, London, UK
| | - Gerard Leavey
- Bamford Centre for Mental Health & Wellbeing, University of Ulster, Derry Londonderry, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Louise Jones
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London, London, UK
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Rahman MS, Ambler G, Choodari-Oskooei B, Omar RZ. Review and evaluation of performance measures for survival prediction models in external validation settings. BMC Med Res Methodol 2017; 17:60. [PMID: 28420338 PMCID: PMC5395888 DOI: 10.1186/s12874-017-0336-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2017] [Accepted: 04/03/2017] [Indexed: 01/09/2023] Open
Abstract
Background When developing a prediction model for survival data it is essential to validate its performance in external validation settings using appropriate performance measures. Although a number of such measures have been proposed, there is only limited guidance regarding their use in the context of model validation. This paper reviewed and evaluated a wide range of performance measures to provide some guidelines for their use in practice. Methods An extensive simulation study based on two clinical datasets was conducted to investigate the performance of the measures in external validation settings. Measures were selected from categories that assess the overall performance, discrimination and calibration of a survival prediction model. Some of these have been modified to allow their use with validation data, and a case study is provided to describe how these measures can be estimated in practice. The measures were evaluated with respect to their robustness to censoring and ease of interpretation. All measures are implemented, or are straightforward to implement, in statistical software. Results Most of the performance measures were reasonably robust to moderate levels of censoring. One exception was Harrell’s concordance measure which tended to increase as censoring increased. Conclusions We recommend that Uno’s concordance measure is used to quantify concordance when there are moderate levels of censoring. Alternatively, Gönen and Heller’s measure could be considered, especially if censoring is very high, but we suggest that the prediction model is re-calibrated first. We also recommend that Royston’s D is routinely reported to assess discrimination since it has an appealing interpretation. The calibration slope is useful for both internal and external validation settings and recommended to report routinely. Our recommendation would be to use any of the predictive accuracy measures and provide the corresponding predictive accuracy curves. In addition, we recommend to investigate the characteristics of the validation data such as the level of censoring and the distribution of the prognostic index derived in the validation setting before choosing the performance measures.
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Affiliation(s)
- M Shafiqur Rahman
- Institute of Statistical Research and Training, University of Dhaka, Dhaka, Bangladesh.
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, UK
| | | | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
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Guttmann OP, Pavlou M, O'Mahony C, Monserrat L, Anastasakis A, Rapezzi C, Biagini E, Gimeno JR, Limongelli G, Garcia-Pavia P, McKenna WJ, Omar RZ, Elliott PM. Predictors of atrial fibrillation in hypertrophic cardiomyopathy. Heart 2016; 103:672-678. [DOI: 10.1136/heartjnl-2016-309672] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Revised: 09/05/2016] [Accepted: 10/03/2016] [Indexed: 01/20/2023] Open
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Johnson S, Sheridan Rains L, Marwaha S, Strang J, Craig T, Weaver T, McCrone P, King M, Fowler D, Pilling S, Marston L, Omar RZ, Craig M, Hinton M. A randomised controlled trial of the clinical and cost-effectiveness of a contingency management intervention compared to treatment as usual for reduction of cannabis use and of relapse in early psychosis (CIRCLE): a study protocol for a randomised controlled trial. Trials 2016; 17:515. [PMID: 27770820 PMCID: PMC5075422 DOI: 10.1186/s13063-016-1620-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [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: 04/28/2016] [Accepted: 09/24/2016] [Indexed: 12/22/2022] Open
Abstract
Background Around 35–45 % of people in contact with services for a first episode of psychosis are using cannabis. Cannabis use is associated with delays in remission, poorer clinical outcomes, significant increases in the risk of relapse, and lower engagement in work or education. While there is a clear need for effective interventions, so far only very limited benefits have been achieved from psychological interventions. Contingency management (CM) is a behavioural intervention in which specified desired behavioural change is reinforced through financial rewards. CM is now recognised to have a substantial evidence base in some contexts and its adoption in the UK is advocated by the National Institute for Health and Care Excellence (NICE) guidance as a treatment for substance or alcohol misuse. However, there is currently little published data testing its effectiveness for reducing cannabis use in early psychosis. Methods CIRCLE is a two-arm, rater-blinded randomised controlled trial (RCT) investigating the clinical and cost-effectiveness of a CM intervention for reducing cannabis use among young people receiving treatment from UK Early Intervention in Psychosis (EIP) services. EIP service users (n = 544) with a recent history of cannabis use will be recruited. The experimental group will receive 12 once-weekly CM sessions, and a voucher reward if urinalysis shows that they have not used cannabis in the previous week. Both the experimental and the control groups will be offered an Optimised Treatment as Usual (OTAU) psychoeducational package targeting cannabis use. Assessment interviews will be performed at consent, at 3 months, and at 18 months. The primary outcome is time to relapse, defined as admission to an acute mental health service. Secondary outcomes include proportion of cannabis-free urine samples during the intervention period, severity of positive psychotic symptoms, quality-adjusted life years, and engagement in work or education. Discussion CIRCLE is a RCT of CM for cannabis use in young people with a recent history of psychosis (EIP service users) and recent cannabis use. It is designed to investigate whether the intervention is a clinically and cost-effective treatment for cannabis use. It is intended to inform future treatment delivery, particularly in EIP settings. Trial registration ISRCTN33576045: doi 10.1186/ISRCTN33576045, registered on 28 November 2011.
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Affiliation(s)
- Sonia Johnson
- Division of Psychiatry, University College London, London, UK
| | | | - Steven Marwaha
- Mental Health and Wellbeing, Warwick Medical School, University of Warwick, Coventry, UK
| | - John Strang
- Addictions Department, Institute of Psychiatry, Psychology, and Neuroscience, King's College London, London, UK
| | - Thomas Craig
- Health Service and Population Research Department, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Tim Weaver
- Mental Health Social Work & Interprofessional Learning,, Middlesex University London, London, UK
| | - Paul McCrone
- Department of Health Services and Population Research, King's Health Economics, Institute of Psychiatry, Psychology & Neuroscience, King's College London , London, UK
| | - Michael King
- Division of Psychiatry, University College London, London, UK
| | - David Fowler
- Department of Psychology, University of Sussex, Brighton, UK
| | - Stephen Pilling
- Clinical Psychology and Clinical Effectiveness, University College London, London, UK
| | - Louise Marston
- Department of Primary Care and Population Health and Priment Clinical Trials Unit, University College London, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK
| | - Meghan Craig
- Division of Psychiatry, University College London, London, UK
| | - Mark Hinton
- Division of Psychiatry, University College London, London, UK
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O’Mahony C, Jichi F, Monserrat L, Ortiz-Genga M, Anastasakis A, Rapezzi C, Biagini E, Gimeno JR, Limongelli G, McKenna WJ, Omar RZ, Elliott PM. Inverted U-Shaped Relation Between the Risk of Sudden Cardiac Death and Maximal Left Ventricular Wall Thickness in Hypertrophic Cardiomyopathy. Circ Arrhythm Electrophysiol 2016; 9:CIRCEP.115.003818. [DOI: 10.1161/circep.115.003818] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 04/06/2016] [Indexed: 11/16/2022]
Abstract
Background—
Hypertrophic cardiomyopathy is associated with sudden cardiac death (SCD). Some studies have shown an association between risk of sudden death and left ventricular maximal wall thickness (MWT), but there are few data in patients with extreme hypertrophy. The aim of this study was to determine the relation between MWT and the risk of SCD.
Methods and Results—
This is a multicenter, retrospective, longitudinal cohort study of 3673 adult (≥16 years) patients, previously used to develop and validate a risk prediction model for SCD (HCM Risk-SCD [hypertrophic cardiomyopathy risk-SCD]). There was an inverted U-shaped relation between MWT and the estimated 5-year risk of SCD. In patients with MWT≥35 mm (n=47; mean age, 33 years; 81% men), there was a single SCD end point (annual rate, 0.2%; 95% confidence interval, 0.03–1.60) and 3 additional cardiovascular events during a median follow-up of 9.5 years. Compared with patients with MWT≤14 mm, those with MWT≥35 mm did not have a higher risk for SCD (hazard ratio, 0.22; 95% confidence interval, 0.03–1.65), cardiovascular death (hazard ratio, 0.66; 95% confidence interval, 0.26–1.67), or all-cause mortality (hazard ratio, 0.73; 95% confidence interval, 0.32–1.69).
Conclusions—
The risk of SCD has a complex, nonlinear relationship to MWT. The pathophysiological mechanisms behind this observation require further study but implantable cardioverter defibrillator implantation should not be guided solely on the severity of left ventricular hypertrophy.
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Affiliation(s)
- Constantinos O’Mahony
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - Fatima Jichi
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - Lorenzo Monserrat
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - Martin Ortiz-Genga
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - Aristides Anastasakis
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - Claudio Rapezzi
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - Elena Biagini
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - Juan Ramon Gimeno
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - Giuseppe Limongelli
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - William J. McKenna
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - Rumana Z. Omar
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
| | - Perry M. Elliott
- From the Inherited Cardiac Diseases Unit, Barts Heart Centre, St Bartholomew’s Hospital, London, United Kingdom (C.O’M., W.J.M., P.M.E.); Biostatistics Group, University College London Hospitals/University College London Research Support Centre, London, United Kingdom (F.J., R.Z.O.); Department of Statistical Science, University College London, London, United Kingdom (R.Z.O.); Research Unit, Department of Cardiology, A Coruña University Hospital, and Galician Health Service, A Coruña, Spain (L.M., M
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Killaspy H, Marston L, Green N, Harrison I, Lean M, Holloway F, Craig T, Leavey G, Arbuthnott M, Koeser L, McCrone P, Omar RZ, King M. Clinical outcomes and costs for people with complex psychosis; a naturalistic prospective cohort study of mental health rehabilitation service users in England. BMC Psychiatry 2016; 16:95. [PMID: 27056042 PMCID: PMC4823891 DOI: 10.1186/s12888-016-0797-6] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 03/31/2016] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND Mental health rehabilitation services in England focus on people with complex psychosis. This group tend to have lengthy hospital admissions due to the severity of their problems and, despite representing only 10-20 % of all those with psychosis, they absorb 25-50 % of the total mental health budget. Few studies have investigated the effectiveness of these services and there is little evidence available to guide clinicians working in this area. As part of a programme of research into inpatient mental health rehabilitation services, we carried out a prospective study to investigate longitudinal outcomes and costs for patients of these services and the predictors of better outcome. METHOD Inpatient mental health rehabilitation services across England that scored above average (median) on a standardised quality assessment tool used in a previous national survey were eligible for the study. Unit quality was reassessed and costs of care and patient characteristics rated using standardised tools at recruitment. Multivariable regression modelling was used to investigate the relationship between service quality, patient characteristics and the following clinical outcomes at 12 month follow-up: social function; length of admission in the rehabiliation unit; successful community discharge (without readmission or community placement breakdown) and costs of care. RESULTS Across England, 50 units participated and 329 patients were followed over 12 months (94 % of those recruited). Service quality was not associated with patients' social function or length of admission (median 16 months) at 12 months but most patients were successfully discharged (56 %) or ready for discharge (14 %), with associated reductions in the costs of care. Factors associated with successful discharge were the recovery orientation of the service (OR 1.04, 95 % CI 1.00-1.08), and patients' activity (OR 1.03, 95 % CI 1.01-1.05) and social skills (OR 1.13, 95 % CI 1.04-1.24) at recruitment. CONCLUSION Inpatient mental health rehabilitation services in England are able to successfully discharge over half their patients within 18 months, reducing the costs of care for this complex group. Provision of recovery orientated practice that promotes patients' social skills and activities may further enhance the effectiveness of these services.
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Affiliation(s)
- Helen Killaspy
- Division of Psychiatry, University College London (UCL), Maple House, 149 Tottenham Court Road, London, W1T 7NF, UK. .,Camden and Islington NHS Foundation Trust, London, NW1 OPE, UK.
| | - Louise Marston
- Department of Primary Care and Population Health, UCL, Rowland Hill Street, London, NW3 2PF UK ,UCL PRIMENT Clinical Trials Unit, Research Department of Primary Care & Population Health, Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK
| | - Nicholas Green
- Division of Psychiatry, University College London (UCL), Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Isobel Harrison
- Division of Psychiatry, University College London (UCL), Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Melanie Lean
- Division of Psychiatry, University College London (UCL), Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Frank Holloway
- South London and Maudsley Hospital NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, BR3 3BX UK
| | - Tom Craig
- South London and Maudsley Hospital NHS Foundation Trust, Bethlem Royal Hospital, Monks Orchard Road, Beckenham, BR3 3BX UK ,Health Services Research Department, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, London, SE5 8AF UK
| | - Gerard Leavey
- Bamford Centre for Mental Health and Wellbeing, University of Ulster, Northland Road, Derry, BT48 7JL UK
| | - Maurice Arbuthnott
- North London Service User Research Forum, Division of Psychiatry, UCL, Maple House, 149 Tottenham Court Road, London, W1T 7NF UK
| | - Leonardo Koeser
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, Derry, SE5 8AF UK
| | - Paul McCrone
- Centre for the Economics of Mental and Physical Health, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, De Crespigny Park, Derry, SE5 8AF UK
| | - Rumana Z. Omar
- UCL PRIMENT Clinical Trials Unit, Research Department of Primary Care & Population Health, Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK ,UCL Department of Statistical Science, Gower Street, London, WC1E 6BT UK
| | - Michael King
- Division of Psychiatry, University College London (UCL), Maple House, 149 Tottenham Court Road, London, W1T 7NF UK ,Camden and Islington NHS Foundation Trust, London, NW1 OPE UK ,UCL PRIMENT Clinical Trials Unit, Research Department of Primary Care & Population Health, Royal Free Campus, Rowland Hill Street, London, NW3 2PF UK
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Pavlou M, Ambler G, Seaman S, De Iorio M, Omar RZ. Review and evaluation of penalised regression methods for risk prediction in low-dimensional data with few events. Stat Med 2016; 35:1159-77. [PMID: 26514699 PMCID: PMC4982098 DOI: 10.1002/sim.6782] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [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] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 09/30/2015] [Accepted: 10/06/2015] [Indexed: 12/16/2022]
Abstract
Risk prediction models are used to predict a clinical outcome for patients using a set of predictors. We focus on predicting low-dimensional binary outcomes typically arising in epidemiology, health services and public health research where logistic regression is commonly used. When the number of events is small compared with the number of regression coefficients, model overfitting can be a serious problem. An overfitted model tends to demonstrate poor predictive accuracy when applied to new data. We review frequentist and Bayesian shrinkage methods that may alleviate overfitting by shrinking the regression coefficients towards zero (some methods can also provide more parsimonious models by omitting some predictors). We evaluated their predictive performance in comparison with maximum likelihood estimation using real and simulated data. The simulation study showed that maximum likelihood estimation tends to produce overfitted models with poor predictive performance in scenarios with few events, and penalised methods can offer improvement. Ridge regression performed well, except in scenarios with many noise predictors. Lasso performed better than ridge in scenarios with many noise predictors and worse in the presence of correlated predictors. Elastic net, a hybrid of the two, performed well in all scenarios. Adaptive lasso and smoothly clipped absolute deviation performed best in scenarios with many noise predictors; in other scenarios, their performance was inferior to that of ridge and lasso. Bayesian approaches performed well when the hyperparameters for the priors were chosen carefully. Their use may aid variable selection, and they can be easily extended to clustered-data settings and to incorporate external information.
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Affiliation(s)
- Menelaos Pavlou
- Department of Statistical Science, University College London, London, WC1E 6BT, U.K
| | - Gareth Ambler
- Department of Statistical Science, University College London, London, WC1E 6BT, U.K
| | | | - Maria De Iorio
- Department of Statistical Science, University College London, London, WC1E 6BT, U.K
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, WC1E 6BT, U.K
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Jones L, Candy B, Davis S, Elliott M, Gola A, Harrington J, Kupeli N, Lord K, Moore K, Scott S, Vickerstaff V, Omar RZ, King M, Leavey G, Nazareth I, Sampson EL. Development of a model for integrated care at the end of life in advanced dementia: A whole systems UK-wide approach. Palliat Med 2016; 30:279-95. [PMID: 26354388 PMCID: PMC4766969 DOI: 10.1177/0269216315605447] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
BACKGROUND The prevalence of dementia is rising worldwide and many people will die with the disease. Symptoms towards the end of life may be inadequately managed and informal and professional carers poorly supported. There are few evidence-based interventions to improve end-of-life care in advanced dementia. AIM To develop an integrated, whole systems, evidence-based intervention that is pragmatic and feasible to improve end-of-life care for people with advanced dementia and support those close to them. DESIGN A realist-based approach in which qualitative and quantitative data assisted the development of statements. These were incorporated into the RAND/UCLA appropriateness method to achieve consensus on intervention components. Components were mapped to underlying theory of whole systems change and the intervention described in a detailed manual. SETTING/PARTICIPANTS Data were collected from people with dementia, carers and health and social care professionals in England, from expert opinion and existing literature. Professional stakeholders in all four countries of the United Kingdom contributed to the RAND/UCLA appropriateness method process. RESULTS A total of 29 statements were agreed and mapped to individual, group, organisational and economic/political levels of healthcare systems. The resulting main intervention components are as follows: (1) influencing local service organisation through facilitation of integrated multi-disciplinary care, (2) providing training and support for formal and informal carers and (3) influencing local healthcare commissioning and priorities of service providers. CONCLUSION Use of in-depth data, consensus methods and theoretical understanding of the intervention components produced an evidence-based intervention for further testing in end-of-life care in advanced dementia.
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Affiliation(s)
- Louise Jones
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Bridget Candy
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Sarah Davis
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Margaret Elliott
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Anna Gola
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Jane Harrington
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Nuriye Kupeli
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Kathryn Lord
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Kirsten Moore
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Sharon Scott
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK St Christopher's Hospice, Sydenham, UK
| | - Victoria Vickerstaff
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London (UCL), London, UK
| | - Michael King
- Division of Psychiatry, University College London (UCL), London, UK
| | - Gerard Leavey
- The Bamford Centre for Mental Health and Well Being, University of Ulster, Londonderry, UK
| | - Irwin Nazareth
- Department of Primary Care and Population Health, University College London (UCL), London, UK
| | - Elizabeth L Sampson
- Marie Curie Palliative Care Research Department, Division of Psychiatry, University College London (UCL), London, UK Barnet Enfield and Haringey Mental Health Trust Liaison Psychiatry Team, North Middlesex University Hospital, London, UK
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Walters K, Hardoon S, Petersen I, Iliffe S, Omar RZ, Nazareth I, Rait G. Predicting dementia risk in primary care: development and validation of the Dementia Risk Score using routinely collected data. BMC Med 2016; 14:6. [PMID: 26797096 PMCID: PMC4722622 DOI: 10.1186/s12916-016-0549-y] [Citation(s) in RCA: 76] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/16/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Existing dementia risk scores require collection of additional data from patients, limiting their use in practice. Routinely collected healthcare data have the potential to assess dementia risk without the need to collect further information. Our objective was to develop and validate a 5-year dementia risk score derived from primary healthcare data. METHODS We used data from general practices in The Health Improvement Network (THIN) database from across the UK, randomly selecting 377 practices for a development cohort and identifying 930,395 patients aged 60-95 years without a recording of dementia, cognitive impairment or memory symptoms at baseline. We developed risk algorithm models for two age groups (60-79 and 80-95 years). An external validation was conducted by validating the model on a separate cohort of 264,224 patients from 95 randomly chosen THIN practices that did not contribute to the development cohort. Our main outcome was 5-year risk of first recorded dementia diagnosis. Potential predictors included sociodemographic, cardiovascular, lifestyle and mental health variables. RESULTS Dementia incidence was 1.88 (95% CI, 1.83-1.93) and 16.53 (95% CI, 16.15-16.92) per 1000 PYAR for those aged 60-79 (n = 6017) and 80-95 years (n = 7104), respectively. Predictors for those aged 60-79 included age, sex, social deprivation, smoking, BMI, heavy alcohol use, anti-hypertensive drugs, diabetes, stroke/TIA, atrial fibrillation, aspirin, depression. The discrimination and calibration of the risk algorithm were good for the 60-79 years model; D statistic 2.03 (95% CI, 1.95-2.11), C index 0.84 (95% CI, 0.81-0.87), and calibration slope 0.98 (95% CI, 0.93-1.02). The algorithm had a high negative predictive value, but lower positive predictive value at most risk thresholds. Discrimination and calibration were poor for the 80-95 years model. CONCLUSIONS Routinely collected data predicts 5-year risk of recorded diagnosis of dementia for those aged 60-79, but not those aged 80+. This algorithm can identify higher risk populations for dementia in primary care. The risk score has a high negative predictive value and may be most helpful in 'ruling out' those at very low risk from further testing or intensive preventative activities.
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Affiliation(s)
- K Walters
- Research Department of Primary Care & Population Health, University College London, Rowland Hill St, London, NW3 2PF, UK.
| | - S Hardoon
- Research Department of Primary Care & Population Health, University College London, Rowland Hill St, London, NW3 2PF, UK
| | - I Petersen
- Research Department of Primary Care & Population Health, University College London, Rowland Hill St, London, NW3 2PF, UK
| | - S Iliffe
- Research Department of Primary Care & Population Health, University College London, Rowland Hill St, London, NW3 2PF, UK
| | - R Z Omar
- Department of Statistical Science, University College London, Gower Street, London, WC1E 6BT, UK
| | - I Nazareth
- Research Department of Primary Care & Population Health, University College London, Rowland Hill St, London, NW3 2PF, UK
| | - G Rait
- Research Department of Primary Care & Population Health, University College London, Rowland Hill St, London, NW3 2PF, UK
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Vickerstaff V, Ambler G, Omar RZ. The potential of the multivariate multilevel model for analysing correlated multiple outcomes: a simulation study. Trials 2015. [PMCID: PMC4660172 DOI: 10.1186/1745-6215-16-s2-p151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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Beard E, Lewis JJ, Copas A, Davey C, Osrin D, Baio G, Thompson JA, Fielding KL, Omar RZ, Ononge S, Hargreaves J, Prost A. Stepped wedge randomised controlled trials: systematic review of studies published between 2010 and 2014. Trials 2015; 16:353. [PMID: 26278881 PMCID: PMC4538902 DOI: 10.1186/s13063-015-0839-2] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [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] [Subscribe] [Scholar Register] [Received: 03/01/2015] [Accepted: 07/01/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND In a stepped wedge, cluster randomised trial, clusters receive the intervention at different time points, and the order in which they received it is randomised. Previous systematic reviews of stepped wedge trials have documented a steady rise in their use between 1987 and 2010, which was attributed to the design's perceived logistical and analytical advantages. However, the interventions included in these systematic reviews were often poorly reported and did not adequately describe the analysis and/or methodology used. Since 2010, a number of additional stepped wedge trials have been published. This article aims to update previous systematic reviews, and consider what interventions were tested and the rationale given for using a stepped wedge design. METHODS We searched PubMed, PsychINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Web of Science, the Cochrane Library and the Current Controlled Trials Register for articles published between January 2010 and May 2014. We considered stepped wedge randomised controlled trials in all fields of research. We independently extracted data from retrieved articles and reviewed them. Interventions were then coded using the functions specified by the Behaviour Change Wheel, and for behaviour change techniques using a validated taxonomy. RESULTS Our review identified 37 stepped wedge trials, reported in 10 articles presenting trial results, one conference abstract, 21 protocol or study design articles and five trial registrations. These were mostly conducted in developed countries (n = 30), and within healthcare organisations (n = 28). A total of 33 of the interventions were educationally based, with the most commonly used behaviour change techniques being 'instruction on how to perform a behaviour' (n = 32) and 'persuasive source' (n = 25). Authors gave a wide range of reasons for the use of the stepped wedge trial design, including ethical considerations, logistical, financial and methodological. The adequacy of reporting varied across studies: many did not provide sufficient detail regarding the methodology or calculation of the required sample size. CONCLUSIONS The popularity of stepped wedge trials has increased since 2010, predominantly in high-income countries. However, there is a need for further guidance on their reporting and analysis.
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Affiliation(s)
- Emma Beard
- Department of Clinical, Educational and Health Psychology, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
- Department of Epidemiology and Public Health, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - James J Lewis
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Andrew Copas
- MRC Clinical Trials Unit at University College London, 175 Tottenham Court Road, London, W1T 7NU, UK.
| | - Calum Davey
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - David Osrin
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
| | - Gianluca Baio
- Department of Statistical Science, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Jennifer A Thompson
- MRC Clinical Trials Unit at University College London, 175 Tottenham Court Road, London, W1T 7NU, UK.
- Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Katherine L Fielding
- MRC Tropical Epidemiology Group, Department of Infectious Disease Epidemiology, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Rumana Z Omar
- Department of Statistical Science, University College London, 1-19 Torrington Place, London, WC1E 7HB, UK.
| | - Sam Ononge
- Department of Obstetrics and Gynaecology, Makerere University College of Health Sciences, P.O. Box 7072, Kampala, Uganda.
| | - James Hargreaves
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, WC1E 7HT, UK.
| | - Audrey Prost
- Institute for Global Health, University College London, 30 Guilford Street, London, WC1N 1EH, UK.
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Abstract
BACKGROUND Stepped wedge trials (SWTs) can be considered as a variant of a clustered randomised trial, although in many ways they embed additional complications from the point of view of statistical design and analysis. While the literature is rich for standard parallel or clustered randomised clinical trials (CRTs), it is much less so for SWTs. The specific features of SWTs need to be addressed properly in the sample size calculations to ensure valid estimates of the intervention effect. METHODS We critically review the available literature on analytical methods to perform sample size and power calculations in a SWT. In particular, we highlight the specific assumptions underlying currently used methods and comment on their validity and potential for extensions. Finally, we propose the use of simulation-based methods to overcome some of the limitations of analytical formulae. We performed a simulation exercise in which we compared simulation-based sample size computations with analytical methods and assessed the impact of varying the basic parameters to the resulting sample size/power, in the case of continuous and binary outcomes and assuming both cross-sectional data and the closed cohort design. RESULTS We compared the sample size requirements for a SWT in comparison to CRTs based on comparable number of measurements in each cluster. In line with the existing literature, we found that when the level of correlation within the clusters is relatively high (for example, greater than 0.1), the SWT requires a smaller number of clusters. For low values of the intracluster correlation, the two designs produce more similar requirements in terms of total number of clusters. We validated our simulation-based approach and compared the results of sample size calculations to analytical methods; the simulation-based procedures perform well, producing results that are extremely similar to the analytical methods. We found that usually the SWT is relatively insensitive to variations in the intracluster correlation, and that failure to account for a potential time effect will artificially and grossly overestimate the power of a study. CONCLUSIONS We provide a framework for handling the sample size and power calculations of a SWT and suggest that simulation-based procedures may be more effective, especially in dealing with the specific features of the study at hand. In selected situations and depending on the level of intracluster correlation and the cluster size, SWTs may be more efficient than comparable CRTs. However, the decision about the design to be implemented will be based on a wide range of considerations, including the cost associated with the number of clusters, number of measurements and the trial duration.
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Affiliation(s)
- Gianluca Baio
- Department of Statistical Science, University College London, Gower Street, London, UK.
| | - Andrew Copas
- MRC Clinical Trials Unit at University College London, CC, London, UK.
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, London, UK.
| | - James Hargreaves
- Department of Social and Environmental Health Research, London School of Hygiene and Tropical Medicine, Keppel Street, London, UK.
| | - Emma Beard
- Department of Clinical, Educational and Health Psychology, University College London, Gower Street, London, UK.
- Department of Epidemiology and Public Health, University College London, Gower Street, London, UK.
| | - Rumana Z Omar
- Department of Statistical Science, University College London, Gower Street, London, UK.
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Abstract
When the number of events is low relative to the number of predictors, standard regression could produce overfitted risk models that make inaccurate predictions. Use of penalised regression may improve the accuracy of risk prediction
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Affiliation(s)
- Menelaos Pavlou
- Department of Statistical Science, University College London, WC1E 6BT London, UK
| | - Gareth Ambler
- Department of Statistical Science, University College London, WC1E 6BT London, UK
| | | | - Oliver Guttmann
- School of Life and Medical Sciences, Institute of Cardiovascular Science, University College London
| | - Perry Elliott
- Inherited Cardiac Disease Unit, the Heart Hospital, London
| | - Michael King
- Division of Psychiatry, University College London
| | - Rumana Z Omar
- Department of Statistical Science, University College London, WC1E 6BT London, UK
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Pavlou M, Ambler G, Seaman S, Omar RZ. A note on obtaining correct marginal predictions from a random intercepts model for binary outcomes. BMC Med Res Methodol 2015; 15:59. [PMID: 26242875 PMCID: PMC4525751 DOI: 10.1186/s12874-015-0046-6] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2015] [Accepted: 07/06/2015] [Indexed: 11/29/2022] Open
Abstract
Background Clustered data with binary outcomes are often analysed using random intercepts models or generalised estimating equations (GEE) resulting in cluster-specific or ‘population-average’ inference, respectively. Methods When a random effects model is fitted to clustered data, predictions may be produced for a member of an existing cluster by using estimates of the fixed effects (regression coefficients) and the random effect for the cluster (conditional risk calculation), or for a member of a new cluster (marginal risk calculation). We focus on the second. Marginal risk calculation from a random effects model is obtained by integrating over the distribution of random effects. However, in practice marginal risks are often obtained, incorrectly, using only estimates of the fixed effects (i.e. by effectively setting the random effects to zero). We compare these two approaches to marginal risk calculation in terms of model calibration. Results In simulation studies, it has been seen that use of the incorrect marginal risk calculation from random effects models results in poorly calibrated overall marginal predictions (calibration slope <1 and calibration in the large ≠ 0) with mis-calibration becoming worse with higher degrees of clustering. We clarify that this was due to the incorrect calculation of marginal predictions from a random intercepts model and explain intuitively why this approach is incorrect. We show via simulation that the correct calculation of marginal risks from a random intercepts model results in predictions with excellent calibration. Conclusion The logistic random intercepts model can be used to obtain valid marginal predictions by integrating over the distribution of random effects. Electronic supplementary material The online version of this article (doi:10.1186/s12874-015-0046-6) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Menelaos Pavlou
- Department of Statistical Science, University College London, Gower St., London, WC1E 6BT, UK.
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower St., London, WC1E 6BT, UK
| | | | - Rumana Z Omar
- Department of Statistical Science, University College London, Gower St., London, WC1E 6BT, UK
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Vickerstaff V, Ambler G, King M, Nazareth I, Omar RZ. Are multiple primary outcomes analysed appropriately in randomised controlled trials? A review. Contemp Clin Trials 2015. [PMID: 26215934 DOI: 10.1016/j.cct.2015.07.016] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES To review how multiple primary outcomes are currently considered in the analysis of randomised controlled trials. We briefly describe the methods available to safeguard the inferences and to raise awareness of the potential problems caused by multiple outcomes. METHODS/DESIGN We reviewed randomised controlled trials (RCTs) in neurology and psychiatry disease areas, as these frequently analyse multiple outcomes. We reviewed all published RCTs from July 2011 to June 2014 inclusive in the following high impact journals: The New England Journal of Medicine, The Lancet, The American Journal of Psychiatry, JAMA Psychiatry, The Lancet Neurology and Neurology. We examined the information presented in the abstract and the methods used for sample size calculation and statistical analysis. We recorded the number of primary outcomes, the methods used to account for multiple primary outcomes, the number of outcomes discussed in the abstract and the number of outcomes used in the sample size calculation. RESULTS Of the 209 RCTs that we identified, 60 (29%) analysed multiple primary outcomes. Of these, 45 (75%) did not adjust for multiplicity in their analyses. Had multiplicity been addressed, some of the trial conclusions would have changed. Of the 15 (25%) trials which accounted for multiplicity, Bonferroni's correction was the most commonly used method. CONCLUSIONS Our review shows that trials with multiple primary outcomes are common. However, appropriate steps are not usually taken in most of the analyses to safeguard the inferences against multiplicity. Authors should state their chosen primary outcomes clearly and justify their methods of analysis.
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Affiliation(s)
- Victoria Vickerstaff
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, UK; Department of Statistical Science, University College London, Gower Street, London WC1E 6BT, UK; The Research Department of Primary Care and Population Health, University College London, Rowland Hill Street, London NW3 2PF, UK.
| | - Gareth Ambler
- Department of Statistical Science, University College London, Gower Street, London WC1E 6BT, UK.
| | - Michael King
- Division of Psychiatry, University College London, 6th Floor, Maple House, 149 Tottenham Court Road, London W1T 7NF, UK.
| | - Irwin Nazareth
- The Research Department of Primary Care and Population Health, University College London, Rowland Hill Street, London NW3 2PF, UK.
| | - Rumana Z Omar
- Department of Statistical Science, University College London, Gower Street, London WC1E 6BT, UK.
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Guttmann OP, Pavlou M, O'Mahony C, Monserrat L, Anastasakis A, Rapezzi C, Biagini E, Gimeno JR, Limongelli G, Garcia-Pavia P, McKenna WJ, Omar RZ, Elliott PM. Prediction of thrombo-embolic risk in patients with hypertrophic cardiomyopathy (HCM Risk-CVA). Eur J Heart Fail 2015; 17:837-45. [PMID: 26183688 PMCID: PMC4737264 DOI: 10.1002/ejhf.316] [Citation(s) in RCA: 104] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2015] [Revised: 05/14/2015] [Accepted: 06/04/2015] [Indexed: 11/13/2022] Open
Abstract
Aims Atrial fibrillation (AF) and thrombo‐embolism (TE) are associated with reduced survival in hypertrophic cardiomyopathy (HCM), but the absolute risk of TE in patients with and without AF is unclear. The primary aim of this study was to derive and validate a model for estimating the risk of TE in HCM. Exploratory analyses were performed to determine predictors of TE, the performance of the CHA2DS2‐VASc score, and outcome with vitamin K antagonists (VKAs). Methods and results A retrospective, longitudinal cohort of seven institutions was used to develop multivariable Cox regression models fitted with pre‐selected predictors. Bootstrapping was used for validation. Of 4821 HCM patients recruited between 1986 and 2008, 172 (3.6%) reached the primary endpoint of cerebrovascular accident (CVA), transient ischaemic attack (TIA), or systemic peripheral embolus within 10 years. A total of 27.5% of patients had a CHA2DS2‐VASc score of 0, of whom 9.8% developed TE during follow‐up. Cox regression revealed an association between TE and age, AF, the interaction between age and AF, TE prior to first evaluation, NYHA class, left atrial (LA) diameter, vascular disease, and maximal LV wall thickness. There was a curvilinear relationship between LA size and TE risk. The model predicted TE with a C‐index of 0.75 [95% confidence interval (CI) 0.70–0.80] and the D‐statistic was 1.30 (95% CI 1.05–1.56). VKA treatment was associated with a 54.8% (95% CI 31–97%, P = 0.037) relative risk reduction in HCM patients with AF. Conclusions The study shows that the risk of TE in HCM patients can be identified using a small number of simple clinical features. LA size, in particular, should be monitored closely, and the assessment and treatment of conventional vascular risk factors should be routine practice in older patients. Exploratory analyses show for the first time evidence for a reduction of TE with VKA treatment. The CHA2DS2‐VASc score does not appear to correlate well with the clinical outcome in patients with HCM and should not be used to assess TE risk in this population.
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Affiliation(s)
- Oliver P Guttmann
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, London, UK
| | - Menelaos Pavlou
- Department of Statistical Science, University College London, London, UK
| | - Constantinos O'Mahony
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, London, UK
| | - Lorenzo Monserrat
- Cardiology Department and Research Unit, A Coruña University Hospital, Galician Health Service, Spain
| | - Aristides Anastasakis
- Unit of Inherited Cardiovascular Diseases, 1st Department of Cardiology, University of Athens, Athens, Greece
| | - Claudio Rapezzi
- Institute of Cardiology, Department of Specialised, Experimental and Diagnostic Medicine, University of Bologna, Bologna, Italy
| | - Elena Biagini
- Institute of Cardiology, Department of Specialised, Experimental and Diagnostic Medicine, University of Bologna, Bologna, Italy
| | - Juan Ramon Gimeno
- Cardiac Department, University Hospital Virgen Arrixaca, Murcia-Cartagena s/n, El Palmar, Murcia, Spain
| | | | - Pablo Garcia-Pavia
- Heart Failure and Inherited Cardiac Diseases Unit, Hospital Universitario Puerta del Hierro Majadahonda, Madrid, Spain
| | - William J McKenna
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, London, UK
| | - Rumana Z Omar
- Department of Statistical Science, University College London, London, UK.,Biostatistics Group, University College London Hospitals/University College London Clinical Research Centre, University College London, London, UK
| | - Perry M Elliott
- The Inherited Cardiac Diseases Unit, The Heart Hospital/University College London, London, UK
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Morris S, Patel N, Baio G, Kelly L, Lewis-Holmes E, Omar RZ, Katona C, Cooper C, Livingston G. Monetary costs of agitation in older adults with Alzheimer's disease in the UK: prospective cohort study. BMJ Open 2015; 5:e007382. [PMID: 25770235 PMCID: PMC4360590 DOI: 10.1136/bmjopen-2014-007382] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.1] [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: 11/18/2022] Open
Abstract
OBJECTIVE While nearly half of all people with Alzheimer's disease (AD) have agitation symptoms every month, little is known about the costs of agitation in AD. We calculated the monetary costs associated with agitation in older adults with AD in the UK from a National Health Service and personal social services perspective. DESIGN Prospective cohort study. SETTING London and the South East Region of the UK (LASER-AD study). PARTICIPANTS 224 people with AD recruited between July 2002 and January 2003 and followed up for 54 months. PRIMARY AND SECONDARY OUTCOME MEASURES The primary outcome was health and social care costs, including accommodation costs and costs of contacts with health and social care services. Agitation was assessed using the Neuropsychiatric Inventory (NPI) agitation score. RESULTS After adjustment, health and social care costs varied significantly by agitation, from £29,000 over a 1 year period with no agitation symptoms (NPI agitation score=0) to £57,000 at the most severe levels of agitation (NPI agitation score=12; p=0.01). The mean excess cost associated with agitation per person with AD was £4091 a year, accounting for 12% of the health and social care costs of AD in our data, and equating to £2 billion a year across all people with AD in the UK. CONCLUSIONS Agitation in people with AD represents a substantial monetary burden over and above the costs associated with cognitive impairment.
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Affiliation(s)
- Stephen Morris
- Department of Applied Health Research, University College London, London, UK
| | - Nishma Patel
- Department of Applied Health Research, University College London, London, UK
| | - Gianluca Baio
- Department of Statistical Science and PRIMENT Clinical Trials Unit, University College London, London, UK
| | - Lynsey Kelly
- Division of Psychiatry, University College London, London, UK
| | | | - Rumana Z Omar
- Department of Statistical Science and PRIMENT Clinical Trials Unit, University College London, London, UK
| | | | - Claudia Cooper
- Division of Psychiatry, University College London, London, UK
| | - Gill Livingston
- Division of Psychiatry, University College London, London, UK
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Moore KJ, Elliott M, Kupeli N, Davis S, Harrington J, Vickerstaff V, Gola A, Candy B, King MB, Leavey G, Omar RZ, Morris S, Nazareth I, Sampson EL, Jones L. A QUALITATIVE ANALYSIS OF BARRIERS TO FUTURE CARE DISCUSSIONS WITH FAMILY MEMBERS OF CARE HOME RESIDENTS WITH ADVANCED DEMENTIA. BMJ Support Palliat Care 2015. [DOI: 10.1136/bmjspcare-2014-000838.28] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Kupeli N, Sampson EL, Harrington J, Moore KJ, Elliott M, Davis S, Vickerstaff V, Gola A, Candy B, King MB, Omar RZ, Morris S, Nazareth I, Leavey G, Jones L. WHY IS INTEGRATED CARE NOT WORKING IN END OF LIFE CARE FOR THOSE WITH ADVANCED DEMENTIA? FROM THE HEALTH CARE PROFESSIONAL PERSPECTIVE. BMJ Support Palliat Care 2015. [DOI: 10.1136/bmjspcare-2014-000838.29] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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