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Fairhurst K, Potter S, Blazeby JM, Avery KNL. Recommendations for optimising pilot and feasibility work in surgery. Pilot Feasibility Stud 2024; 10:64. [PMID: 38637818 PMCID: PMC11025276 DOI: 10.1186/s40814-024-01489-1] [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: 11/15/2022] [Accepted: 03/26/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Surgical trials are recognised as inherently challenging. Pilot and feasibility studies (PAFS) are increasingly acknowledged as a key method to optimise the design and conduct of randomised trials but remain limited in surgery. We used a mixed methods approach to develop recommendations for how surgical PAFS could be optimised. METHODS The findings from a quantitative analysis of funded surgical PAFS over a 10-year period and in-depth qualitative interviews with surgeons, methodologists and funders were triangulated and synthesised with available methodological guidance on PAFS. RESULTS The synthesis informed the development of an explanatory model describing root causes and compounding challenges that contribute to how and why surgical PAFS is not currently optimised. The four root causes identified include issues relating to (i) understanding the full scope of PAFS; (ii) design and conduct of PAFS; (iii) reporting of PAFS; and (iv) lack of appreciation of the value of PAFS by all stakeholder groups. Compounding challenges relate to both cultural issues and access to and interpretation of available methodological PAFS guidance. The study findings and explanatory model were used to inform the development of a practical guidance tool for surgeons and study teams to improve research practice. CONCLUSIONS Optimisation of PAFS in surgery requires a cultural shift in research practice amongst funders, academic institutions, regulatory bodies and journal editors, as well as amongst surgeons. Our 'Top Tips' guidance tool offers an accessible framework for surgeons designing PAFS. Adoption and utilisation of these recommendations will optimise surgical PAFS, facilitating successful and efficient future surgical trials.
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Affiliation(s)
- K Fairhurst
- Centre for Surgical Research, Medical Research Council ConDuCT-II Hub for Trials Methodology Research and Biomedical Research Centre, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK.
| | - S Potter
- Centre for Surgical Research, Medical Research Council ConDuCT-II Hub for Trials Methodology Research and Biomedical Research Centre, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
| | - J M Blazeby
- Centre for Surgical Research, Medical Research Council ConDuCT-II Hub for Trials Methodology Research and Biomedical Research Centre, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
| | - K N L Avery
- Centre for Surgical Research, Medical Research Council ConDuCT-II Hub for Trials Methodology Research and Biomedical Research Centre, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Clifton, Bristol, BS8 2PS, UK
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Fairhurst K, Roberts K, Fairbrother P, Potter S. Current use of drains and management of seroma following mastectomy and axillary surgery: results of a United Kingdom national practice survey. Breast Cancer Res Treat 2024; 203:187-196. [PMID: 37878150 PMCID: PMC10787912 DOI: 10.1007/s10549-023-07042-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 07/06/2023] [Indexed: 10/26/2023]
Abstract
PURPOSE Up to 40% of the 56,000 women diagnosed with breast cancer each year in the UK undergo mastectomy. Seroma formation following surgery is common, may delay wound healing, and be uncomfortable or delay the start of adjuvant treatment. Multiple strategies to reduce seroma formation include surgical drains, flap fixation and external compression exist but evidence to support best practice is lacking. We aimed to survey UK breast surgeons to determine current practice to inform the feasibility of undertaking a future trial. METHODS An online survey was developed and circulated to UK breast surgeons via professional and trainee associations and social media to explore current attitudes to drain use and management of post-operative seroma. Simple descriptive statistics were used to summarise the results. RESULTS The majority of surgeons (82/97, 85%) reported using drains either routinely (38, 39%) or in certain circumstances (44, 45%). Other methods for reducing seroma such as flap fixation were less commonly used. Wide variation was reported in the assessment and management of post-operative seromas. Over half (47/91, 52%) of respondents felt there was some uncertainty about drain use after mastectomy and axillary surgery and two-thirds (59/91, 65%) felt that a trial evaluating the use of drains vs no drains after simple breast cancer surgery was needed. CONCLUSIONS There is a need for a large-scale UK-based RCT to determine if, when and in whom drains are necessary following mastectomy and axillary surgery. This work will inform the design and conduct of a future trial.
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Affiliation(s)
- K Fairhurst
- Centre for Surgical Research, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England.
| | - K Roberts
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
| | - P Fairbrother
- Independent Cancer Patient Voice (ICPV), London, England
| | - S Potter
- Centre for Surgical Research, Department of Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, England
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Fairhurst K, Blazeby JM, Potter S, Gamble C, Rowlands C, Avery KNL. Value of surgical pilot and feasibility study protocols. Br J Surg 2019; 106:968-978. [PMID: 31074503 PMCID: PMC6618315 DOI: 10.1002/bjs.11167] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 02/04/2019] [Accepted: 02/12/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND RCTs in surgery are challenging owing to well established methodological issues. Well designed pilot and feasibility studies (PFS) may help overcome such issues to inform successful main trial design and conduct. This study aimed to analyse protocols of UK-funded studies to explore current use of PFS in surgery and identify areas for practice improvement. METHODS PFS of surgical interventions funded by UK National Institute for Health Research programmes from 2005 to 2015 were identified, and original study protocols and associated publications sourced. Data extracted included study design characteristics, reasons for performing the work including perceived uncertainties around conducting a definitive main trial, and whether the studies had been published. RESULTS Thirty-five surgical studies were identified, of which 29 were randomized, and over half (15 of 29) included additional methodological components (such as qualitative work examining recruitment, and participant surveys studying current interventions). Most studies focused on uncertainties around recruitment (32 of 35), with far fewer tackling uncertainties specific to surgery, such as intervention stability, implementation or delivery (10 of 35). Only half (19 of 35) had made their results available publicly, to date. CONCLUSION The full potential of pretrial work to inform and optimize definitive surgical studies is not being realized.
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Affiliation(s)
- K. Fairhurst
- Centre for Surgical Research and Medical Research Council (MRC) ConDuCT‐II Hub for Trials Methodology Research, Department of Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - J. M. Blazeby
- Centre for Surgical Research and Medical Research Council (MRC) ConDuCT‐II Hub for Trials Methodology Research, Department of Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - S. Potter
- Centre for Surgical Research and Medical Research Council (MRC) ConDuCT‐II Hub for Trials Methodology Research, Department of Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - C. Gamble
- MRC North West Hub for Trials Methodology ResearchUniversity of LiverpoolLiverpoolUK
| | - C. Rowlands
- Centre for Surgical Research and Medical Research Council (MRC) ConDuCT‐II Hub for Trials Methodology Research, Department of Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
| | - K. N. L. Avery
- Centre for Surgical Research and Medical Research Council (MRC) ConDuCT‐II Hub for Trials Methodology Research, Department of Population Health Sciences, Bristol Medical SchoolUniversity of BristolBristolUK
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Patel M, Garcea G, Fairhurst K, Dennison AR. Patient perception of laparoscopic versus open mesh repair of inguinal hernia, the hard sell. Hernia 2012; 16:411-5. [DOI: 10.1007/s10029-012-0933-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2011] [Accepted: 06/03/2012] [Indexed: 12/31/2022]
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Kapadia MZ, Warner P, Fairhurst K. SP6-45 Screening for genital chlamydia for young people in community pharmacies: a meta-analysis of chlamydia prevalence. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976q.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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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Kapadia MZ, Warner P, Fairhurst K. P1-29 Using international evidence to develop a conceptual framework of facilitators and barriers of chlamydia screening service in community pharmacies. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976c.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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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Abstract
BACKGROUND Failure to attend appointments compromises health service efficiency. Despite considerable interest in using novel technologies to improve attendance, evidence from rigorously conducted controlled studies is lacking. AIM To evaluate the effectiveness of texting appointment reminders to patients who persistently fail to attend appointments. DESIGN Randomised controlled study. SETTING Inner city general practice in Lothian, Scotland. METHOD We included 415 appointments made by patients (n = 173) who had failed to attend two or more routine appointments in the preceding year. Patients whose appointments were randomised to the intervention group received a text message reminder of the appointment. Patients whose appointments were in the control group received no reminder. Our primary outcome measure was non-attendance rates. We undertook an intention-to-treat analysis and multi-level analysis to take account of the lack of independence of the outcomes of repeated appointments for the same patient. RESULTS Of the 418 appointments originally included in the study, three were excluded due to clerical error; 189 were randomised to the intervention group and 226 to the control group. Twenty-two appointments (12%) were not attended in the intervention group compared with 39 (17%) in the control group. A chi-square analysis, considering the outcome of appointments as independent from one another, gave a non-significant difference of 5% (95% CI of difference -1.1 to 12.3%, p = 0.13). Multilevel analysis applied to the binary outcome data on non-attendance gave an odds ratio for non-attendance in the intervention group compared with the control group of 0.63 (95% CI 0.36 to 1.1, p = 0.11). CONCLUSION Although the intervention showed promise, we failed to demonstrate significant reduction in non-attendance rates, as a result of texting appointment reminders to patients who persistently fail to attend their general practice appointments.
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Affiliation(s)
- K Fairhurst
- Division of Community Health Sciences: GP Section, University of Edinburgh, Edinburgh, UK.
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Abstract
BACKGROUND The idea that the patient is in some way known to the doctor is an important one in general practice. The thrust towards patient-centred medicine, the promotion of open and negotiative consultation skills and the development of a biopsychosocial model of primary care medicine all rely on the patient providing a history composed of more than a list of facts. OBJECTIVE Our aim was to explore the nature and importance of doctors' knowledge about patients. METHODS Fifteen GPs audio-recorded 25-30 consultations with consecutive consenting patients. They scored each consultation according to how satisfying they found it. Semi-structured interviews based on a selection of consultations were conducted to draw out the doctor's views on the factors that were important to their satisfaction. The interviews were transcribed verbatim. Qualitative analysis was inductive and iterative. RESULTS Within doctors' narratives, we found accounts of two ways of 'knowing' the patient. The first was a deductive mode of reasoning derived from facts about the patient. The facts that were known were specific to the context of the general practice consultation and led to biomedical and biographical knowledge. The second was an inductive mode of reasoning derived from a contextual interpretation of the facts about the patient which resulted in knowledge of their behaviour and cognitions. Both modes of reasoning gave the doctor knowledge of the patient and permitted action by the doctor in the consultation but led to different interpretations of the patient and different experiences of the consultation. CONCLUSION 'Knowing the patient' is important to the way GPs attribute meaning to their work. Doctors were more likely to identify as 'known' those patients with whom they adopted an inductive mode of reasoning. In addition, their experience of the consultation was more likely to be positive.
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Affiliation(s)
- K Fairhurst
- Department of Community Health Sciences, General Practice, University of Edinburgh, UK
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Hall R, Adderley N, MacLaren C, McIntyre A, Barker R, Imrie D, Allen C, Glenn J, Fairhurst K, McLaren R. Does intrathecal morphine alter the stress response following coronary artery bypass grafting surgery? Can J Anaesth 2000; 47:463-6. [PMID: 10831205 DOI: 10.1007/bf03018978] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
PURPOSE Intrathecal morphine administered prior to coronary artery revascularization (CABG) surgery was studied to determine its effects on the stress response. METHODS In a single centre, open, randomized clinical trial, first time elective CABG surgery patients, < 75 yr, were studied. Control subjects (n=12) received a standardized anesthetic consisting of fentanyl (maximum cumulative dose of 35 microg x kg(-1)), propofol, and pancuronium. In addition, spinal subjects (n=13) received 1.0 mg (age > 60 yr) or 1.5 mg (age < or = 59 yr) intrathecal morphine prior to induction of anesthesia. Control subjects received continuous i.v. morphine at 2 mg x hr(-1) on arrival in the ICU with i.v. bolus morphine supplementation as required while spinal subjects received bolus i.v. morphine as required. Changes in plasma cortisol and catecholamine concentrations were measured preoperatively, poststernotomy, on admission to ICU, following tracheal extubation, at 0800 hr on the first postoperative day, and 24 and 48 hr after ICU admission. RESULTS No differences between groups were detected for demographic variables. The percent change in cortisol concentration relative to preoperative values (control vs spinal; (38 (87) vs -41 (46)%: P < 0.05)) was lower in the spinal group on admission to ICU. The percent change in plasma epinephrine levels (control vs spinal) on admission to ICU (285 (337) vs -10 (37)%) and 0800 hr after surgery (314 (341) vs -4 (37)%) was also significantly different. CONCLUSION Intrathecal morphine only partially attenuated the postsurgical stress response in CABG surgical patients.
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Affiliation(s)
- R Hall
- Department of Anesthesiology, Dalhousie University and Queen Elizabeth II Health Sciences Centre, Halifax, Nova Scotia, Canada.
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Fairhurst K, Huby G. From trial data to practical knowledge: qualitative study of how general practitioners have accessed and used evidence about statin drugs in their management of hypercholesterolaemia. BMJ 1998; 317:1130-4. [PMID: 9784451 PMCID: PMC28696 DOI: 10.1136/bmj.317.7166.1130] [Citation(s) in RCA: 101] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To explore how general practitioners have accessed and evaluated evidence from trials on the use of statin lipid lowering drugs and incorporated this evidence into their practice. To draw out the practical implications of this study for strategies to integrate clinical evidence into general medical practice. DESIGN Qualitative analysis of semistructured interviews. SETTING General practices in Lothian. SUBJECTS 24 general practitioners selected to obtain a heterogeneous sample. RESULTS Respondents were generally aware of the evidence relating to the use of statins in secondary prevention of coronary heart disease, but they were less clear about the evidence in primary prevention. The benefits of statins in secondary prevention were clearer to them and the social and economic issues less complex than was the case for use in primary prevention. Respondents rarely said they appraised the methods and content of trials, rather they judged the trustworthiness of the source of trial evidence and interpreted it within the context of the economic and social factors which impinge on their practice. Moreover, trial data become relevant for routine practice only when underpinned by a consensus on these issues. CONCLUSION Strategies to promote incorporation of evidence from clinical trials into everyday practice are likely to be effective if they tap into and build on the process of local consensus building. Strategies such as teaching critical appraisal skills and guideline development may have little effect if they are separated from this process.
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Affiliation(s)
- K Fairhurst
- Department of Community Health Sciences (General Practice), University of Edinburgh, Levinson House, Edinburgh EH8 9DX.
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Fairhurst K, Dowrick C. Problems with recruitment in a randomized controlled trial of counselling in general practice: causes and implications. J Health Serv Res Policy 1996; 1:77-80. [PMID: 10180853 DOI: 10.1177/135581969600100205] [Citation(s) in RCA: 119] [Impact Index Per Article: 4.3] [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: 11/17/2022]
Abstract
OBJECTIVES To evaluate the effectiveness of counselling in the management of minor psychiatric morbidity in general practice, and to explore the reasons for difficulties in recruiting patients to such an evaluation. METHODS We attempted to conduct a randomized controlled trial of counselling in eight general practices in one NHS family health services authority area in England. Having experienced significant problems recruiting patients, we conducted semi-structured telephone interviews (n = 8) with participating GPs to explore the reasons for these difficulties. RESULTS Five months after the start of the study only one patient had been recruited. The main reasons identified as contributing to the recruitment problems were: general practitioners' motivation for involvement in the study; their ethical doubts about the randomization process; the perceived lack of a viable non-counselling intervention; and their existing practical commitment to counselling. CONCLUSION Although methodological modification might enhance the potential for success in future studies of this sort, more fundamental difficulties concerning general practitioners' attitudes to research and their professional responsibilities lie at the heart of our recruitment problems.
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Affiliation(s)
- K Fairhurst
- Department of General Practice, University of Edinburgh, Scotland, UK
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Fairhurst K, Blair M, Cutting J, Featherstone M, Hayes B, Howarth M, Rose D, Stanley I. The quality of hospital discharge: a survey of discharge arrangements for the over-65s. Int J Qual Health Care 1996; 8:167-74. [PMID: 8792172 DOI: 10.1093/intqhc/8.2.167] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
A three-phase study comprising semi-structured interviews with patients and/or their carers, follow-up postal questionnaires, and a postal survey of the views of professionals involved in the discharge of participating patients was conducted to assess the quality of arrangements for patients over 65 years of age, discharged from hospitals in Chester and Ellesmere Port in the United Kingdom. A large majority of patients (80%) felt they had been adequately consulted about arrangements for their discharge, but less than 2% of health and social care professionals considered all discharges satisfactory. This apparent disparity between patient and professional views may be explained by low levels of expectation among patients in this aspect of their care and their reluctance to express views which they fear may compromise future care. Continuing difficulties with interprofessional communication and liaison suggest that further attention to discharge management is required if improvements are to be effected.
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Affiliation(s)
- K Fairhurst
- Department of Primary Care, University of Liverpool, UK
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Fairhurst K, Stanley I, Griffiths C. Should medical students learn more about management? Br J Gen Pract 1995; 45:2-3. [PMID: 7779469 PMCID: PMC1239103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
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Pearson T, Levy J, Kilburn D, Fairhurst K. The effect of antigen suicide on numbers of cells binding defined antigenic determinants. J Immunol Methods 1976; 10:99-104. [PMID: 58940 DOI: 10.1016/0022-1759(76)90160-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Lymph node cells from guinea pigs immunized to oxidized ferredoxin (O-Fd) were treated in an antigen suicide procedure designed to inactivate lymphocytes binding the haptenic peptide determinants of the ferredoxin molecule. O-Fd-induced DNA synthesis and cells binding either peptide determinant were examined both before and after allowing suicide. The proliferative response to O-Fd and the number of determinant-binding cells were specifically and markedly decreased after antigen suicide.
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