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Gulliford MC, Charlton J, Boiko O, Winter JR, Rezel-Potts E, Sun X, Burgess C, McDermott L, Bunce C, Shearer J, Curcin V, Fox R, Hay AD, Little P, Moore MV, Ashworth M. Safety of reducing antibiotic prescribing in primary care: a mixed-methods study. Health Serv Deliv Res 2021. [DOI: 10.3310/hsdr09090] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
The threat of antimicrobial resistance has led to intensified efforts to reduce antibiotic utilisation, but serious bacterial infections are increasing in frequency.
Objectives
To estimate the risks of serious bacterial infections in association with lower antibiotic prescribing and understand stakeholder views with respect to safe antibiotic reduction.
Design
Mixed-methods research was undertaken, including a qualitative interview study of patient and prescriber views that informed a cohort study and a decision-analytic model, using primary care electronic health records. These three work packages were used to design an application (app) for primary care prescribers.
Data sources
The Clinical Practice Research Datalink.
Setting
This took place in UK general practices.
Participants
A total of 706 general practices with 66.2 million person-years of follow-up from 2002 to 2017 and antibiotic utilisation evaluated for 671,830 registered patients. The qualitative study included 31 patients and 30 health-care professionals from primary care.
Main outcome measures
Sepsis and localised bacterial infections.
Results
Patients were concerned about antimicrobial resistance and the side effects, as well as the benefits, of antibiotic treatment. Prescribers viewed the onset of sepsis as the most concerning potential outcome of reduced antibiotic prescribing. More than 40% of antibiotic prescriptions in primary care had no coded indication recorded across both Vision® and EMIS® practice systems. Antibiotic prescribing rates varied widely between general practices, but there was no evidence that serious bacterial infections were less frequent at higher prescribing practices (adjusted rate ratio for 20% increase in prescribing 1.03, 95% confidence interval 1.00 to 1.06; p = 0.074). The probability of sepsis was lower if an antibiotic was prescribed at an infection consultation, and the number of antibiotic prescriptions required to prevent one episode of sepsis (i.e. the number needed to treat) decreased with age. For those aged 0–4 years, the number needed to treat was 29,773 (95% uncertainty interval 18,458 to 71,091) in boys and 27,014 (95% uncertainty interval 16,739 to 65,709) in girls. For those aged > 85 years, the number needed to treat was 262 (95% uncertainty interval 236 to 293) in men and 385 (95% uncertainty interval 352 to 421) in women. Frailty was associated with a greater risk of sepsis and a smaller number needed to treat. For severely frail patients aged 55–64 years, the number needed to treat was 247 (95% uncertainty interval 156 to 459) for men and 343 (95% uncertainty interval 234 to 556) for women. At all ages, the probability of sepsis was greatest for urinary tract infection, followed by skin infection and respiratory tract infection. The numbers needed to treat were generally smaller for the period 2014–17, when sepsis was diagnosed more frequently. The results are available using an app that we developed to provide primary care prescribers with stratified risk estimates during infection consultations.
Limitations
Analyses were based on non-randomised comparisons. Infection episodes and antibiotic prescribing are poorly documented in primary care.
Conclusions
Antibiotic treatment is generally associated with lower risks, but the most serious bacterial infections remain infrequent even without antibiotic treatment. This research identifies risk strata in which antibiotic prescribing can be more safely reduced.
Future work
The software developed from this research may be further developed and investigated for antimicrobial stewardship effect.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 9. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Olga Boiko
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Joanne R Winter
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Emma Rezel-Potts
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Xiaohui Sun
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Caroline Burgess
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Catey Bunce
- School of Population Health and Environmental Sciences, King’s College London, London, UK
- National Institute for Health Research Biomedical Research Centre, Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - James Shearer
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, King’s College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King’s College London, London, UK
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McDermott L, Kalluri M, Fox K, Richman-Eisenstat J. Redesigning interstitial lung disease clinic care through interprofessional collaboration. J Interprof Care 2021; 36:64-74. [PMID: 33870830 DOI: 10.1080/13561820.2021.1884051] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Descriptions of how to foster and accomplish interprofessional collaboration (IPC) in practice across different healthcare settings are needed. This paper examines the transformation of a normative interstitial lung disease (ILD) clinic to an IPC delivering person-centric care across an outpatient specialty clinic and the community. It describes how the IPC was started; the actions undertaken to do this; and the processes supporting it within the outpatient clinic, and between it and its community-based partners. Qualitative research methods (participants-as-co-researchers, unstructured interviews, thematic content analysis) were used with the two physicians founding the IPC to understand this transformation process; this is supplemented with preliminary findings of interviews with patients/carers (N = 30) attending the outpatient clinic. Analysis suggests the power of IPC to improve patients' quality of life and death, reduce acute care use and hospitalization, and realize patient preferences for location of death. Despite this, the ILD IPC encounters resistance from larger institutional and political forces.
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Affiliation(s)
- Lisa McDermott
- Faculty of Kinesiology, Sport, & Recreation, Alberta, Canada
| | - Meena Kalluri
- Faculty of Medicine, University of Alberta, Edmonton, Canada
| | - Karen Fox
- Faculty of Kinesiology, Sport, & Recreation, Alberta, Canada
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Gulliford MC, Juszczyk D, Prevost AT, Soames J, McDermott L, Sultana K, Wright M, Fox R, Hay AD, Little P, Moore M, Yardley L, Ashworth M, Charlton J. Electronically delivered interventions to reduce antibiotic prescribing for respiratory infections in primary care: cluster RCT using electronic health records and cohort study. Health Technol Assess 2020; 23:1-70. [PMID: 30900550 DOI: 10.3310/hta23110] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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: 01/26/2023] Open
Abstract
BACKGROUND Unnecessary prescribing of antibiotics in primary care is contributing to the emergence of antimicrobial drug resistance. OBJECTIVES To develop and evaluate a multicomponent intervention for antimicrobial stewardship in primary care, and to evaluate the safety of reducing antibiotic prescribing for self-limiting respiratory infections (RTIs). INTERVENTIONS A multicomponent intervention, developed as part of this study, including a webinar, monthly reports of general practice-specific data for antibiotic prescribing and decision support tools to inform appropriate antibiotic prescribing. DESIGN A parallel-group, cluster randomised controlled trial. SETTING The trial was conducted in 79 general practices in the UK Clinical Practice Research Datalink (CPRD). PARTICIPANTS All registered patients were included. MAIN OUTCOME MEASURES The primary outcome was the rate of antibiotic prescriptions for self-limiting RTIs over the 12-month intervention period. COHORT STUDY A separate population-based cohort study was conducted in 610 CPRD general practices that were not exposed to the trial interventions. Data were analysed to evaluate safety outcomes for registered patients with 45.5 million person-years of follow-up from 2005 to 2014. RESULTS There were 41 intervention trial arm practices (323,155 patient-years) and 38 control trial arm practices (259,520 patient-years). There were 98.7 antibiotic prescriptions for RTIs per 1000 patient-years in the intervention trial arm (31,907 antibiotic prescriptions) and 107.6 per 1000 patient-years in the control arm (27,923 antibiotic prescriptions) [adjusted antibiotic-prescribing rate ratio (RR) 0.88, 95% confidence interval (CI) 0.78 to 0.99; p = 0.040]. There was no evidence of effect in children aged < 15 years (RR 0.96, 95% CI 0.82 to 1.12) or adults aged ≥ 85 years (RR 0.97, 95% CI 0.79 to 1.18). Antibiotic prescribing was reduced in adults aged between 15 and 84 years (RR 0.84, 95% CI 0.75 to 0.95), that is, one antibiotic prescription was avoided for every 62 patients (95% CI 40 to 200 patients) aged 15-84 years per year. Analysis of trial data for 12 safety outcomes, including pneumonia and peritonsillar abscess, showed no evidence that these outcomes might be increased as a result of the intervention. The analysis of data from non-trial practices showed that if a general practice with an average list size of 7000 patients reduces the proportion of RTI consultations with antibiotics prescribed by 10%, then 1.1 (95% CI 0.6 to 1.5) more cases of pneumonia per year and 0.9 (95% CI 0.5 to 1.3) more cases of peritonsillar abscesses per decade may be observed. There was no evidence that mastoiditis, empyema, meningitis, intracranial abscess or Lemierre syndrome were more frequent at low-prescribing practices. LIMITATIONS The research was based on electronic health records that may not always provide complete data. The number of practices included in the trial was smaller than initially intended. CONCLUSIONS This study found evidence that, overall, general practice antibiotic prescribing for RTIs was reduced by this electronically delivered intervention. Antibiotic prescribing rates were reduced for adults aged 15-84 years, but not for children or the senior elderly. FUTURE WORK Strategies for antimicrobial stewardship should employ stratified interventions that are tailored to specific age groups. Further research into the safety of reduced antibiotic prescribing is also needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN95232781. 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. 11. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Dorota Juszczyk
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - A Toby Prevost
- School of Population Health and Environmental Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre, Guy's and St Thomas' NHS Foundation Trust, London, UK.,School of Public Health, Imperial College London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | - Mark Wright
- Clinical Practice Research Datalink, Medicines and Healthcare products Regulatory Agency, London, UK
| | | | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK.,School of Psychological Science, University of Bristol, Bristol, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King's College London, London, UK
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Bahce I, Hashemi S, Fransen M, Veltman J, McDermott L, Hutchins J, Caldwell C, Argyres M, Long B, Wolf J, Thunnissen E. 1390P Impact of adding viagenpumatucel-L to nivolumab in non-small cell lung cancer (NSCLC) patients with low levels of tumour infiltrating lymphocytes. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.1704] [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: 10/23/2022] Open
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Krivtsov AV, Evans K, Gadrey JY, Eschle BK, Hatton C, Uckelmann HJ, Ross KN, Perner F, Olsen SN, Pritchard T, McDermott L, Jones CD, Jing D, Braytee A, Chacon D, Earley E, McKeever BM, Claremon D, Gifford AJ, Lee HJ, Teicher BA, Pimanda JE, Beck D, Perry JA, Smith MA, McGeehan GM, Lock RB, Armstrong SA. A Menin-MLL Inhibitor Induces Specific Chromatin Changes and Eradicates Disease in Models of MLL-Rearranged Leukemia. Cancer Cell 2019; 36:660-673.e11. [PMID: 31821784 PMCID: PMC7227117 DOI: 10.1016/j.ccell.2019.11.001] [Citation(s) in RCA: 212] [Impact Index Per Article: 42.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2019] [Revised: 09/23/2019] [Accepted: 11/04/2019] [Indexed: 12/13/2022]
Abstract
Inhibition of the Menin (MEN1) and MLL (MLL1, KMT2A) interaction is a potential therapeutic strategy for MLL-rearranged (MLL-r) leukemia. Structure-based design yielded the potent, highly selective, and orally bioavailable small-molecule inhibitor VTP50469. Cell lines carrying MLL rearrangements were selectively responsive to VTP50469. VTP50469 displaced Menin from protein complexes and inhibited chromatin occupancy of MLL at select genes. Loss of MLL binding led to changes in gene expression, differentiation, and apoptosis. Patient-derived xenograft (PDX) models derived from patients with either MLL-r acute myeloid leukemia or MLL-r acute lymphoblastic leukemia (ALL) showed dramatic reductions of leukemia burden when treated with VTP50469. Multiple mice engrafted with MLL-r ALL remained disease free for more than 1 year after treatment. These data support rapid translation of this approach to clinical trials.
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Affiliation(s)
- Andrei V Krivtsov
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02215, USA
| | - Kathryn Evans
- Children's Cancer Institute, School of Women's and Children's Health, UNSW, Sydney 2052, Australia
| | - Jayant Y Gadrey
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02215, USA
| | - Benjamin K Eschle
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02215, USA
| | - Charlie Hatton
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02215, USA
| | - Hannah J Uckelmann
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02215, USA
| | - Kenneth N Ross
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02215, USA
| | - Florian Perner
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02215, USA
| | - Sarah N Olsen
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02215, USA
| | - Tara Pritchard
- Children's Cancer Institute, School of Women's and Children's Health, UNSW, Sydney 2052, Australia
| | - Lisa McDermott
- Children's Cancer Institute, School of Women's and Children's Health, UNSW, Sydney 2052, Australia
| | - Connor D Jones
- Children's Cancer Institute, School of Women's and Children's Health, UNSW, Sydney 2052, Australia
| | - Duohui Jing
- Children's Cancer Institute, School of Women's and Children's Health, UNSW, Sydney 2052, Australia
| | - Ali Braytee
- Lowy Cancer Research Centre and the Prince of Wales Clinical School, UNSW, Sydney 2052, Australia; Centre for Health Technologies and the School of Biomedical Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia
| | - Diego Chacon
- Lowy Cancer Research Centre and the Prince of Wales Clinical School, UNSW, Sydney 2052, Australia; Centre for Health Technologies and the School of Biomedical Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia
| | - Eric Earley
- RTI International, Research Triangle Park, NC 27709, USA
| | | | | | - Andrew J Gifford
- Children's Cancer Institute, School of Women's and Children's Health, UNSW, Sydney 2052, Australia; Department of Anatomical Pathology, Prince of Wales Hospital, Sydney, NSW 2031, Australia
| | - Heather J Lee
- School of Biomedical Sciences and Pharmacy, Faculty of Health and Medicine, The University of Newcastle, Callaghan, NSW 2308, Australia
| | | | - John E Pimanda
- Lowy Cancer Research Centre and the Prince of Wales Clinical School, UNSW, Sydney 2052, Australia; Department of Haematology, Prince of Wales Hospital, Sydney, NSW 2210, Australia
| | - Dominik Beck
- Lowy Cancer Research Centre and the Prince of Wales Clinical School, UNSW, Sydney 2052, Australia; Centre for Health Technologies and the School of Biomedical Engineering, University of Technology Sydney, Ultimo, NSW 2007, Australia
| | - Jennifer A Perry
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02215, USA
| | | | | | - Richard B Lock
- Children's Cancer Institute, School of Women's and Children's Health, UNSW, Sydney 2052, Australia
| | - Scott A Armstrong
- Department of Pediatric Oncology, Dana-Farber Cancer Institute, and Division of Hematology/Oncology, Boston Children's Hospital, Boston, MA 02215, USA.
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Evans K, Duan J, Pritchard T, Jones CD, McDermott L, Gu Z, Toscan CE, El-Zein N, Mayoh C, Erickson SW, Guo Y, Meng F, Jung D, Rathi KS, Roberts KG, Mullighan CG, Shia CS, Pearce T, Teicher BA, Smith MA, Lock RB. OBI-3424, a Novel AKR1C3-Activated Prodrug, Exhibits Potent Efficacy against Preclinical Models of T-ALL. Clin Cancer Res 2019; 25:4493-4503. [PMID: 31015346 DOI: 10.1158/1078-0432.ccr-19-0551] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2019] [Revised: 03/19/2019] [Accepted: 04/17/2019] [Indexed: 11/16/2022]
Abstract
PURPOSE OBI-3424 is a highly selective prodrug that is converted by aldo-keto reductase family 1 member C3 (AKR1C3) to a potent DNA-alkylating agent. OBI-3424 has entered clinical testing for hepatocellular carcinoma and castrate-resistant prostate cancer, and it represents a potentially novel treatment for acute lymphoblastic leukemia (ALL). EXPERIMENTAL DESIGN We assessed AKR1C3 expression by RNA-Seq and immunoblotting, and evaluated the in vitro cytotoxicity of OBI-3424. We investigated the pharmacokinetics of OBI-3424 in mice and nonhuman primates, and assessed the in vivo efficacy of OBI-3424 against a large panel of patient-derived xenografts (PDX). RESULTS AKR1C3 mRNA expression was significantly higher in primary T-lineage ALL (T-ALL; n = 264) than B-lineage ALL (B-ALL; n = 1,740; P < 0.0001), and OBI-3424 exerted potent cytotoxicity against T-ALL cell lines and PDXs. In vivo, OBI-3424 significantly prolonged the event-free survival (EFS) of nine of nine ALL PDXs by 17.1-77.8 days (treated/control values 2.5-14.0), and disease regression was observed in eight of nine PDXs. A significant reduction (P < 0.0001) in bone marrow infiltration at day 28 was observed in four of six evaluable T-ALL PDXs. The importance of AKR1C3 in the in vivo response to OBI-3424 was verified using a B-ALL PDX that had been lentivirally transduced to stably overexpress AKR1C3. OBI-3424 combined with nelarabine resulted in prolongation of mouse EFS compared with each single agent alone in two T-ALL PDXs. CONCLUSIONS OBI-3424 exerted profound in vivo efficacy against T-ALL PDXs derived predominantly from aggressive and fatal disease, and therefore may represent a novel treatment for aggressive and chemoresistant T-ALL in an AKR1C3 biomarker-driven clinical trial.
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Affiliation(s)
- Kathryn Evans
- Children's Cancer Institute, School of Women's and Children's Health, UNSW Sydney, Sydney, Australia
| | - JianXin Duan
- Ascentawits Pharmaceuticals, Ltd, Nanshan Shenzhen, China
| | - Tara Pritchard
- Children's Cancer Institute, School of Women's and Children's Health, UNSW Sydney, Sydney, Australia
| | - Connor D Jones
- Children's Cancer Institute, School of Women's and Children's Health, UNSW Sydney, Sydney, Australia
| | - Lisa McDermott
- Children's Cancer Institute, School of Women's and Children's Health, UNSW Sydney, Sydney, Australia
| | - Zhaohui Gu
- Department of Pathology and the Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Cara E Toscan
- Children's Cancer Institute, School of Women's and Children's Health, UNSW Sydney, Sydney, Australia
| | - Narimanne El-Zein
- Children's Cancer Institute, School of Women's and Children's Health, UNSW Sydney, Sydney, Australia
| | - Chelsea Mayoh
- Children's Cancer Institute, School of Women's and Children's Health, UNSW Sydney, Sydney, Australia
| | | | - Yuelong Guo
- RTI International, Research Triangle Park, North Carolina
| | - Fanying Meng
- Ascentawits Pharmaceuticals, Ltd, Nanshan Shenzhen, China
| | - Donald Jung
- Ascentawits Pharmaceuticals, Ltd, Nanshan Shenzhen, China
| | - Komal S Rathi
- Division of Oncology and Center for Childhood Cancer Research, Department of Biomedical and Health Informatics and Center for Data-Driven Discovery in Biomedicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Kathryn G Roberts
- Department of Pathology and the Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Charles G Mullighan
- Department of Pathology and the Hematological Malignancies Program, St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | | | | | | | - Richard B Lock
- Children's Cancer Institute, School of Women's and Children's Health, UNSW Sydney, Sydney, Australia.
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Gulliford MC, Prevost AT, Charlton J, Juszczyk D, Soames J, McDermott L, Sultana K, Wright M, Fox R, Hay AD, Little P, Moore MV, Yardley L, Ashworth M. Effectiveness and safety of electronically delivered prescribing feedback and decision support on antibiotic use for respiratory illness in primary care: REDUCE cluster randomised trial. BMJ 2019; 364:l236. [PMID: 30755451 PMCID: PMC6371944 DOI: 10.1136/bmj.l236] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
OBJECTIVES To evaluate the effectiveness and safety at population scale of electronically delivered prescribing feedback and decision support interventions at reducing antibiotic prescribing for self limiting respiratory tract infections. DESIGN Open label, two arm, cluster randomised controlled trial. SETTING UK general practices in the Clinical Practice Research Datalink, randomised between 11 November 2015 and 9 August 2016, with final follow-up on 9 August 2017. PARTICIPANTS 79 general practices (582 675 patient years) randomised (1:1) to antimicrobial stewardship (AMS) intervention or usual care. INTERVENTIONS AMS intervention comprised a brief training webinar, automated monthly feedback reports of antibiotic prescribing, and electronic decision support tools to inform appropriate prescribing over 12 months. Intervention components were delivered electronically, supported by a local practice champion nominated for the trial. MAIN OUTCOME MEASURES Primary outcome was the rate of antibiotic prescriptions for respiratory tract infections from electronic health records. Serious bacterial complications were evaluated for safety. Analysis was by Poisson regression with general practice as a random effect, adjusting for covariates. Prespecified subgroup analyses by age group were reported. RESULTS The trial included 41 AMS practices (323 155 patient years) and 38 usual care practices (259 520 patient years). Unadjusted and adjusted rate ratios for antibiotic prescribing were 0.89 (95% confidence interval 0.68 to 1.16) and 0.88 (0.78 to 0.99, P=0.04), respectively, with prescribing rates of 98.7 per 1000 patient years for AMS (31 907 prescriptions) and 107.6 per 1000 patient years for usual care (27 923 prescriptions). Antibiotic prescribing was reduced most in adults aged 15-84 years (adjusted rate ratio 0.84, 95% confidence interval 0.75 to 0.95), with one antibiotic prescription per year avoided for every 62 patients (95% confidence interval 40 to 200). There was no evidence of effect for children younger than 15 years (adjusted rate ratio 0.96, 95% confidence interval 0.82 to 1.12) or people aged 85 years and older (0.97, 0.79 to 1.18); there was also no evidence of an increase in serious bacterial complications (0.92, 0.74 to 1.13). CONCLUSIONS Electronically delivered interventions, integrated into practice workflow, result in moderate reductions of antibiotic prescribing for respiratory tract infections in adults, which are likely to be of importance for public health. Antibiotic prescribing to very young or old patients requires further evaluation. TRIAL REGISTRATION ISRCTN95232781.
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Affiliation(s)
- Martin C Gulliford
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, London, UK
| | - A Toby Prevost
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, London, UK
- School of Public Health, Imperial College London, London, UK
| | - Judith Charlton
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
| | - Dorota Juszczyk
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Mark Wright
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Robin Fox
- The Health Centre, Bicester, Oxfordshire, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, Bristol Medical School, Population Health Sciences, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
- School of Psychological Science, University of Bristol, Bristol, UK
| | - Mark Ashworth
- School of Population Health and Environmental Sciences, King's College London, Guy's Campus, King's College London, London, UK
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Alageel S, Gulliford MC, McDermott L, Wright AJ. Implementing multiple health behaviour change interventions for cardiovascular risk reduction in primary care: a qualitative study. BMC Fam Pract 2018; 19:171. [PMID: 30376826 PMCID: PMC6208114 DOI: 10.1186/s12875-018-0860-0] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Accepted: 10/19/2018] [Indexed: 01/17/2023]
Abstract
Background The implementation of multiple health behaviour change interventions for cardiovascular risk reduction in primary care is suboptimal. This study aimed to identify barriers and facilitators to implementing multiple health behaviour change interventions for cardiovascular disease (CVD) risk reduction in primary care. Methods Qualitative study using semi-structured interviews informed by the Theoretical Domains Framework. Interviews were conducted with a purposive sample of healthcare professionals working in the implementation of the NHS Health Check programme in London. Data were analysed using the Framework method. Results Thirty participants were recruited including ten general practitioners, ten practice nurses, seven healthcare assistants and three practice managers from 23 practices. Qualitative analysis identified three main themes: healthcare professionals’ conceptualising health behaviour change; delivering multiple health behaviour change interventions in primary care; and delivering the health check programme. Healthcare professionals generally recognised the importance of health behaviour change for CVD risk reduction but were more sceptical about the potential for successful intervention through primary care. Participants identified the difficulty of sustained behaviour change for patients, the lack of evidence for effective interventions and limited access to appropriate resources in primary care as barriers. Discussing changing multiple health behaviours was perceived to be overwhelming for patients and difficult to implement for healthcare professionals with current primary care resources. The health check programme consists of several components that are difficult to fully complete in limited time. Conclusions Advancing the prevention agenda will require strategies to support the delivery of behaviour change interventions in primary care. Greater emphasis needs to be given to promoting behaviour change through supportive environmental context. Further research is needed to evaluate current external lifestyle services to improve the intervention outcomes. Electronic supplementary material The online version of this article (10.1186/s12875-018-0860-0) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Samah Alageel
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, Addison House, Guy's Campus, London, SE1 1UL, UK.
| | - Martin C Gulliford
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Lisa McDermott
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, Addison House, Guy's Campus, London, SE1 1UL, UK
| | - Alison J Wright
- School of Population Health and Environmental Sciences, Faculty of Life Sciences and Medicine, King's College London, Addison House, Guy's Campus, London, SE1 1UL, UK
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Little P, Hobbs FDR, Moore M, Mant D, Williamson I, McNulty C, Lasseter G, Cheng MYE, Leydon G, McDermott L, Turner D, Pinedo-Villanueva R, Raftery J, Glasziou P, Mullee M. Corrigendum: PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study. Health Technol Assess 2018. [DOI: 10.3310/hta18060-c201810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Abstract
The text in Chapter 4, Results, Main findings, Complications has been replaced with the following text [these data do not alter the economic modelling (which was based on the correct data), nor the inferences from the trial that the FeverPAIN score is the optimal management approach]:
There were very few complications in any trial groups: during the first trial phase there were two cases of otitis media and one case of cellulitis in the clinical score group and one case of cellulitis in the delayed antibiotic group; during the second trial phase (when using the FeverPAIN score) there were two cases of quinsy in the delayed antibiotic group and one case of otitis media in the RADT group.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - FD Richard Hobbs
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Michael Moore
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Mant
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ian Williamson
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Cliodna McNulty
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - Gemma Lasseter
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - MY Edith Cheng
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Lisa McDermott
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Turner
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | | | - James Raftery
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Paul Glasziou
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Mullee
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
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Cornelius VR, McDermott L, Forster AS, Ashworth M, Wright AJ, Gulliford MC. Automated recruitment and randomisation for an efficient randomised controlled trial in primary care. Trials 2018; 19:341. [PMID: 29945656 PMCID: PMC6020316 DOI: 10.1186/s13063-018-2723-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2017] [Accepted: 06/06/2018] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND/AIMS Use of electronic health records and information technology to deliver more efficient clinical trials is attracting the attention of research funders and researchers. We report on methodological issues and data quality for a comparison of 'automated' and manual (or 'in-practice') methods for recruitment and randomisation in a large randomised controlled trial, with individual patient allocation in primary care. METHODS We conducted a three-arm randomised controlled trial in primary care to evaluate interventions to improve the uptake of invited NHS health checks for cardiovascular risk assessment. Eligible participants were identified using a borough-wide health check management information system. An in-practice recruitment and randomisation method used at 12 general practices required the research team to complete monthly visits to each general practice. For the fully automated method, employed for six general practices, randomisation of eligible participants was performed automatically and remotely using a bespoke algorithm embedded in the health check management information system. RESULTS There were 8588 and 4093 participants recruited for the manual and automated methods, respectively. The in-practice method was ready for implementation 3 months sooner than the automated method and the in-practice method allowed for full control and documentation of the randomisation procedure. However the in-practice approach was labour intensive and the requirement for participant records to be stored locally resulted in the loss of data for 10 practice months. No records for participants allocated using the automated method were lost. A fixed-effects meta-analysis showed that effect estimates for the primary outcome were consistent for the two allocation methods. CONCLUSIONS This trial demonstrated the feasibility of automated recruitment and randomisation methods into a randomised controlled trial performed in primary care. Future research should explore the application of these techniques in other clinical contexts and health care settings. TRIAL REGISTRATION Current Controlled Trials, ID: ISRCTN42856343 . Registered on 21 March 2013.
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Affiliation(s)
- Victoria R Cornelius
- Department of Primary Care and Public Health Sciences, King's College, London, UK.
- Imperial Clinical Trials Unit, Imperial College London, 68 Wood Lane, London, W12 7RH, UK.
| | - Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College, London, UK
| | - Alice S Forster
- Department of Primary Care and Public Health Sciences, King's College, London, UK
- Department of Behavioural Science and Health, University College, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College, London, UK
| | - Alison J Wright
- Department of Primary Care and Public Health Sciences, King's College, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital, London, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College, London, UK
- NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital, London, UK
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Gulliford MC, Khoshaba B, McDermott L, Cornelius V, Ashworth M, Fuller F, Miller J, Dodhia H, Wright AJ. Cardiovascular risk at health checks performed opportunistically or following an invitation letter. Cohort study. J Public Health (Oxf) 2018. [PMID: 28633511 PMCID: PMC6053837 DOI: 10.1093/pubmed/fdx068] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background A population-based programme of health checks has been established in England. Participants receive postal invitations through a population-based call–recall system but health check providers may also offer health checks opportunistically. We compared cardiovascular risk scores for ‘invited’ and ‘opportunistic’ health checks. Methods Cohort study of all health checks completed at 18 general practices from July 2013 to June 2015. For each general practice, cardiovascular (CVD) risk scores were compared by source of check and pooled using meta-analysis. Effect estimates were compared by gender, age-group, ethnicity and fifths of deprivation. Results There were 6184 health checks recorded (2280 invited and 3904 opportunistic) with CVD risk scores recorded for 5359 (87%) participants. There were 17.0% of invited checks and 22.2% of opportunistic health checks with CVD risk score ≥10%; a relative increment of 28% (95% confidence interval: 14–44%, P < 0.001). In the most deprived quintile, 15.3% of invited checks and 22.4% of opportunistic checks were associated with elevated CVD risk (adjusted odds ratio: 1.94, 1.37–2.74, P < 0.001). Conclusions Respondents at health checks performed opportunistically are at higher risk of cardiovascular disease than those participating in response to a standard invitation letter, potentially reducing the effect of uptake inequalities.
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Affiliation(s)
- Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital, London, UK
| | - Bernadette Khoshaba
- Department of Primary Care and Public Health Sciences, King's College, London, UK
| | - Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College, London, UK
| | - Victoria Cornelius
- Department of Primary Care and Public Health Sciences, King's College, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College, London, UK
| | - Frances Fuller
- Public Health Directorate, Lewisham Borough Council, London, UK
| | - Jane Miller
- Public Health Directorate, Lewisham Borough Council, London, UK
| | - Hiten Dodhia
- Public Health Directorate, Lambeth Borough Council, London, UK
| | - Alison J Wright
- Department of Primary Care and Public Health Sciences, King's College, London, UK
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McDermott L, Cornelius V, Wright AJ, Burgess C, Forster AS, Ashworth M, Khoshaba B, Clery P, Fuller F, Miller J, Dodhia H, Rudisill C, Conner MT, Gulliford MC. Enhanced Invitations Using the Question-Behavior Effect and Financial Incentives to Promote Health Check Uptake in Primary Care. Ann Behav Med 2018; 52:594-605. [PMID: 29860363 PMCID: PMC6361284 DOI: 10.1093/abm/kax048] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [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] [Indexed: 11/14/2022] Open
Abstract
Background Uptake of health checks for cardiovascular risk assessment in primary care in England is lower than anticipated. The question-behavior effect (QBE) may offer a simple, scalable intervention to increase health check uptake. Purpose The present study aimed to evaluate the effectiveness of enhanced invitation methods employing the QBE, with or without a financial incentive to return the questionnaire, at increasing uptake of health checks. Methods We conducted a three-arm randomized trial including all patients at 18 general practices in two London boroughs, who were invited for health checks from July 2013 to December 2014. Participants were randomized to three trial arms: (i) Standard health check invitation letter only; (ii) QBE questionnaire followed by standard invitation letter; or (iii) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by standard invitation letter. In intention to treat analysis, the primary outcome of completion of health check within 6 months of invitation, was evaluated using a p value of .0167 for significance. Results 12,459 participants were randomized. Health check uptake was evaluated for 12,052 (97%) with outcome data collected. Health check uptake within 6 months of invitation was: standard invitation, 590 / 4,095 (14.41%); QBE questionnaire, 630 / 3,988 (15.80%); QBE questionnaire and financial incentive, 629 / 3,969 (15.85%). Difference following QBE questionnaire, 1.43% (95% confidence interval -0.12 to 2.97%, p = .070); following QBE questionnaire and financial incentive, 1.52% (-0.03 to 3.07%, p = .054). Conclusions Uptake of health checks following a standard invitation was low and not significantly increased through enhanced invitation methods using the QBE.
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Affiliation(s)
- Lisa McDermott
- Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s Campus, London, UK
| | - Victoria Cornelius
- Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s Campus, London, UK
| | - Alison J Wright
- Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s Campus, London, UK
| | - Caroline Burgess
- Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s Campus, London, UK
| | - Alice S Forster
- Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s Campus, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s Campus, London, UK
| | - Bernadette Khoshaba
- Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s Campus, London, UK
| | - Philippa Clery
- Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s Campus, London, UK
| | - Frances Fuller
- Public Health, Community Services Directorate, Lewisham Borough Council, Laurence House, London, UK
| | - Jane Miller
- Public Health, Community Services Directorate, Lewisham Borough Council, Laurence House, London, UK
| | - Hiten Dodhia
- Public Health Directorate, Lambeth Borough Council, Phoenix House, London, UK
| | - Caroline Rudisill
- Department of Social Policy, London School of Economics and Political Science, Houghton St, London, UK
| | - Mark T Conner
- School of Psychology, University of Leeds, Leeds, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King’s College London, Addison House, Guy’s Campus, London, UK
- NIHR Biomedical Research Centre at Guy’s and St Thomas’ Hospital, Guy’s Hospital, London, UK
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13
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McDermott L. SP-0559: For the motion: Until we finally perfect x-ray vision, we need patient specific QA. Radiother Oncol 2018. [DOI: 10.1016/s0167-8140(18)30869-7] [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: 12/01/2022]
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14
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McDermott L, Wright AJ, Cornelius V, Burgess C, Forster AS, Ashworth M, Khoshaba B, Clery P, Fuller F, Miller J, Dodhia H, Rudisill C, Conner MT, Gulliford MC. Enhanced invitation methods and uptake of health checks in primary care: randomised controlled trial and cohort study using electronic health records. Health Technol Assess 2018; 20:1-92. [PMID: 27846927 DOI: 10.3310/hta20840] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND A national programme of health checks to identify risk of cardiovascular disease (CVD) is being rolled out but is encountering difficulties because of low uptake. OBJECTIVE To evaluate the effectiveness of an enhanced invitation method using the question-behaviour effect (QBE), with or without the offer of a financial incentive to return the QBE questionnaire, at increasing the uptake of health checks. The research went on to evaluate the reasons for the low uptake of invitations and compare the case mix for invited and opportunistic health checks. DESIGN Three-arm randomised trial and cohort study. PARTICIPANTS All participants invited for a health check from 18 general practices. Individual participants were randomised. INTERVENTIONS (1) Standard health check invitation only; (2) QBE questionnaire followed by a standard invitation; and (3) QBE questionnaire with offer of a financial incentive to return the questionnaire, followed by a standard invitation. MAIN OUTCOME MEASURES The primary outcome was completion of the health check within 6 months of invitation. A p-value of 0.0167 was used for significance. In the cohort study of all health checks completed during the study period, the case mix was compared for participants responding to invitations and those receiving 'opportunistic' health checks. Participants were not aware that several types of invitation were in use. The research team were blind to trial arm allocation at outcome data extraction. RESULTS In total, 12,459 participants were included in the trial and health check uptake was evaluated for 12,052 participants for whom outcome data were collected. Health check uptake was as follows: standard invitation, 590 out of 4095 (14.41%); QBE questionnaire, 630 out of 3988 (15.80%); QBE questionnaire and financial incentive, 629 out of 3969 (15.85%). The increase in uptake associated with the QBE questionnaire was 1.43% [95% confidence interval (CI) -0.12% to 2.97%; p = 0.070] and the increase in uptake associated with the QBE questionnaire and offer of financial incentive was 1.52% (95% CI -0.03% to 3.07%; p = 0.054). The difference in uptake associated with the offer of an incentive to return the QBE questionnaire was -0.01% (95% CI -1.59% to 1.58%; p = 0.995). During the study period, 58% of health check cardiovascular risk assessments did not follow a trial invitation. People who received an 'opportunistic' health check had greater odds of a ≥ 10% CVD risk than those who received an invited health check (adjusted odds ratio 1.70, 95% CI 1.45 to 1.99; p < 0.001). CONCLUSIONS Uptake of a health check following an invitation letter is low and is not increased through an enhanced invitation method using the QBE. The offer of a £5 incentive did not increase the rate of return of the QBE questionnaire. A high proportion of all health checks are performed opportunistically and not in response to a standard invitation letter. Participants receiving opportunistic checks are at higher risk of CVD than those responding to standard invitations. Future research should aim to increase the accessibility of preventative medical interventions to increase uptake. Research should also explore the wider use of electronic health records in delivering efficient trials. TRIAL REGISTRATION Current Controlled Trials ISRCTN42856343. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 84. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Alison J Wright
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Victoria Cornelius
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Caroline Burgess
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Alice S Forster
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Bernadette Khoshaba
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Philippa Clery
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Frances Fuller
- Public Health Directorate, Lewisham Borough Council, London, UK
| | - Jane Miller
- Public Health Directorate, Lewisham Borough Council, London, UK
| | - Hiten Dodhia
- Public Health Directorate, Lambeth Borough Council, London, UK
| | - Caroline Rudisill
- Department of Social Policy, London School of Economics and Political Science, London, UK
| | - Mark T Conner
- School of Psychology, University of Leeds, Leeds, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' Hospitals, Guy's Hospital, London, UK
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McDermott L, Leydon GM, Halls A, Kelly J, Nagle A, White J, Little P. Qualitative interview study of antibiotics and self-management strategies for respiratory infections in primary care. BMJ Open 2017; 7:e016903. [PMID: 29180593 PMCID: PMC5719297 DOI: 10.1136/bmjopen-2017-016903] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To explore perceptions of illness, the decisions to consult and the acceptability of delayed antibiotic prescriptions and self-help treatments for respiratory tract infections (RTIs). DESIGN Qualitative semistructured interview study. SETTING UK primary care. PARTICIPANTS 20 adult patients who had been participating in the 'PIPS' (Pragmatic Ibuprofen Paracetamol and Steam) trial in the South of England. METHOD Semistructured telephone interviews were conducted with participants to explore their experiences and views on various treatments for RTI. RESULTS Participants had concerns about symptoms that were not clinically serious and were mostly unaware of the natural history of RTIs, but were aware of the limitations of antibiotics and did not expect them with every consultation. Most viewed delayed prescriptions positively and had no strong preference over which technique is used to deliver the delayed antibiotic, but some patients received mixed messages, such as being told their infection was viral then being given an antibiotic, or were sceptical about the rationale. Participants disliked self-help treatments that involved taking medication and were particularly concerned about painkillers in combination. Steam inhalation was viewed as only moderately helpful for mild symptoms. CONCLUSION Delayed prescribing is acceptable no matter how the delay is operationalised, but explanation of the rationale is needed and care taken to minimise mixed messages about the severity of illnesses and causation by viruses or bacteria. Better access is needed to good natural history information, and the signs and symptoms requiring or not requiring general practitioner advice. Significant concerns about paracetamol, ibuprofen and steam inhalation are likely to need careful exploration in the consultation.
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Affiliation(s)
- Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Geraldine M Leydon
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Amy Halls
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jo Kelly
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Amanda Nagle
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Jennifer White
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Paul Little
- Department of Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Southampton, UK
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16
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Leydon GM, McDermott L, Thomas T, Halls A, Holdstock-Brown B, Petley S, Wiseman C, Little P. 'Well, it literally stops me from having a life when it's really bad': a nested qualitative interview study of patient views on the use of self-management treatments for the management of recurrent sinusitis (SNIFS trial). BMJ Open 2017; 7:e017130. [PMID: 29101134 PMCID: PMC5695339 DOI: 10.1136/bmjopen-2017-017130] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To explore the experience and perceptions of illness, the decision to consult a general practitioner and the use of self-management approaches for chronic or recurrent sinusitis. DESIGN Qualitative semistructured interview study. SETTING UK primary care. PARTICIPANTS 32 participants who had been participating in the 'SNIFS' (Steam inhalation and Nasal Irrigation For recurrent Sinusitis) trial in the South of England. METHOD Thematic analysis of semistructured telephone interviews. RESULTS Participants often reported dramatic impact on both activities and their quality of life. Participants were aware of both antibiotic side effects and resistance, but if they had previously been prescribed antibiotics, many patients believed that they would be necessary for the future treatment of sinusitis. Participants used self-help treatments for short and limited periods of time only. In the context of the trial, steam inhalation used for recurrent sinusitis was described as acceptable but is seen as having limited effectiveness. Nasal irrigation was viewed as acceptable and beneficial by more patients. However, some participants reported that they would not use the treatment again due to the uncomfortable side effects they experienced, which outweighed any symptom relief, which may have resulted had they continued. CONCLUSIONS Steam inhalation is acceptable but seen as having limited effectiveness. Nasal irrigation is generally acceptable and beneficial for symptoms, but detailed information on the correct procedure and potential benefits of persisting may increase acceptability and adherence in those patients who find it uncomfortable. TRIAL REGISTRATION NUMBER ISRCTN 88204146.
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Affiliation(s)
- Geraldine M Leydon
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Lisa McDermott
- Primary Care and Public Health Sciences, King's College, 614, 6th Floor, Capital House, 42 Weston Street, London, SE1 3QD, UK
| | - Tammy Thomas
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Amy Halls
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Ben Holdstock-Brown
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Stephen Petley
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Clare Wiseman
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
| | - Paul Little
- Primary Care and Population Sciences, Faculty of Medicine, University of Southampton, Aldermoor Health Centre, Aldermoor Close, Southampton, SO16 5ST, UK
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17
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Alageel S, Gulliford MC, McDermott L, Wright AJ. Multiple health behaviour change interventions for primary prevention of cardiovascular disease in primary care: systematic review and meta-analysis. BMJ Open 2017; 7:e015375. [PMID: 28619779 PMCID: PMC5734412 DOI: 10.1136/bmjopen-2016-015375] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [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: 01/01/2023] Open
Abstract
BACKGROUND It is uncertain whether multiple health behaviour change (MHBC) interventions are effective for the primary prevention of cardiovascular disease (CVD) in primary care. A systematic review and a meta-analysis were performed to evaluate the effectiveness of MHBC interventions on CVD risk and CVD risk factors; the study also evaluated associations of theoretical frameworks and intervention components with intervention effectiveness. METHODS The search included randomised controlled trials of MHBC interventions aimed at reducing CVD risk in primary prevention population up to 2017. Theoretical frameworks and intervention components were evaluated using standardised methods. Meta-analysis with stratification and meta-regression were used to evaluate intervention effects. RESULTS We identified 31 trials (36 484 participants) with a minimum duration of 12 months follow-up. Pooled net change in systolic blood pressure (16 trials) was -1.86 (95% CI -3.17 to -0.55; p=0.01) mm Hg; diastolic blood pressure (15 trials), -1.53 (-2.43 to -0.62; p=0.001) mm Hg; body mass index (14 trials), -0.13 (-0.26 to -0.01; p=0.04) kg/m2; serum total cholesterol (14 trials), -0.13 (-0.19 to -0.07; p<0.001) mmol/L. There was no significant association between interventions with a reported theoretical basis and improved intervention outcomes. No association was observed between intervention intensity (number of sessions and intervention duration) and intervention outcomes. There was significant heterogeneity for some risk factor analyses, leading to uncertain validity of some pooled net changes. CONCLUSIONS MHBC interventions delivered to CVD-free participants in primary care did not appear to have quantitatively important effects on CVD risk factors. Better reporting of interventions' rationale, content and delivery is essential to understanding their effectiveness.
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Affiliation(s)
- Samah Alageel
- Department of Primary Care and Public Health Sciences, King’s College London, London, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King’s College London, London, UK
| | - Lisa McDermott
- Department of Primary Care and Public Health Sciences, King’s College London, London, UK
| | - Alison J Wright
- Department of Primary Care and Public Health Sciences, King’s College London, London, UK
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Ryves R, Eyles C, Moore M, McDermott L, Little P, Leydon GM. Understanding the delayed prescribing of antibiotics for respiratory tract infection in primary care: a qualitative analysis. BMJ Open 2016; 6:e011882. [PMID: 27864242 PMCID: PMC5129131 DOI: 10.1136/bmjopen-2016-011882] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2016] [Revised: 08/10/2016] [Accepted: 08/16/2016] [Indexed: 01/06/2023] Open
Abstract
OBJECTIVE To identify general practitioner (GP) views and understanding on the use of delayed prescribing in primary care. DESIGN Qualitative semistructured telephone interview study. SETTING Primary care general practices in England. PARTICIPANTS 32 GPs from identified high-prescribing and low-prescribing general practices in England. METHOD Semistructured telephone interviews were conducted with GPs identified from practices within clinical commissioning groups with the highest and lowest prescribing rates in England. A thematic analysis of the data was conducted to generate themes. RESULTS All GPs had a good understanding of respiratory tract infection (RTI) management and how the delayed prescribing approach could be used in primary care. However, GPs highlighted factors that were influential as to whether delayed prescribing was successfully carried out during the consultation. These included the increase in evidence of antimicrobial resistance, and GPs' prior experiences of using delayed prescribing during the consultation. The patient-practitioner relationship could also influence treatment outcomes for RTI, and a lack of an agreed prescribing strategy within and between practices was considered to be of significance to GPs. Participants expressed that a lack of feedback on prescribing data at an individual and practice level made it difficult to know if delayed prescribing strategies were successful in reducing unnecessary consumption. GPs agreed that coherent and uniform training and guidelines would be of some benefit to ensure consistent prescribing throughout the UK. CONCLUSIONS Delayed prescribing is encouraged in primary care, but is not always implemented successfully. Greater uniformity within and between practices in the UK is needed to operationalise delayed prescribing, as well as providing feedback on the uptake of antibiotics. Finally, GPs may need further guidance on how to answer the concerns of patients without interpreting these questions as a demand for antibiotics, as well as educating the patient about antimicrobial resistance and supporting a good patient-practitioner relationship.
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Affiliation(s)
- R Ryves
- Department of Primary Care & Population Sciences, University of Southampton, Southampton, UK
| | - C Eyles
- Department of Primary Care & Population Sciences, University of Southampton, Southampton, UK
| | - M Moore
- Department of Primary Care & Population Sciences, University of Southampton, Southampton, UK
| | - L McDermott
- Department of Primary Care & Population Health Sciences, King's College London, London, UK
| | - P Little
- Department of Primary Care & Population Sciences, University of Southampton, Southampton, UK
| | - G M Leydon
- Department of Primary Care & Population Sciences, University of Southampton, Southampton, UK
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Forster AS, Burgess C, Dodhia H, Fuller F, Miller J, McDermott L, Gulliford MC. Do health checks improve risk factor detection in primary care? Matched cohort study using electronic health records. J Public Health (Oxf) 2016; 38:552-559. [PMID: 26350481 PMCID: PMC5072161 DOI: 10.1093/pubmed/fdv119] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND To evaluate the effect of NHS Health Checks on cardiovascular risk factor detection and inequalities. METHODS Matched cohort study in the Clinical Practice Research Datalink, including participants who received a health check in England between 1 April 2010 and 31 March 2013, together with matched control participants, with linked deprivation scores. RESULTS There were 91 618 eligible participants who received a health check, of whom 75 123 (82%) were matched with 182 245 controls. After the health check, 90% of men and 92% of women had complete data for blood pressure, total cholesterol, smoking and body mass index; a net 51% increase (P < 0.001) over controls. After the check, gender and deprivation inequalities in recording of all risk factors were lower than for controls. Net increase in risk factor detection was greater for hypercholesterolaemia (men +33%; women +32%) than for obesity (men +8%; women +4%) and hypertension in men only (+5%) (all P < 0.001). Detection of smoking was 5% lower in health check participants than controls (P < 0.001). Over 4 years, statins were prescribed to 11% of health -check participants and 7.6% controls (hazard ratio 1.58, 95% confidence interval 1.53-1.63, P < 0.001). CONCLUSION NHS Health Checks are associated with increased detection of hypercholesterolaemia, and to a lesser extent obesity and hypertension, but smokers may be under-represented.
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Affiliation(s)
- Alice S Forster
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Caroline Burgess
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Hiten Dodhia
- Public Health Directorate, London Boroughs of Lambeth and Southwark, London, UK
| | - Frances Fuller
- Department of Public Health, London Borough of Lewisham, London, UK
| | - Jane Miller
- Department of Public Health, London Borough of Lewisham, London, UK
| | - Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
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20
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Juszczyk D, Charlton J, McDermott L, Soames J, Sultana K, Ashworth M, Fox R, Hay AD, Little P, Moore MV, Yardley L, Prevost AT, Gulliford MC. Electronically delivered, multicomponent intervention to reduce unnecessary antibiotic prescribing for respiratory infections in primary care: a cluster randomised trial using electronic health records-REDUCE Trial study original protocol. BMJ Open 2016; 6:e010892. [PMID: 27491663 PMCID: PMC4985802 DOI: 10.1136/bmjopen-2015-010892] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION Respiratory tract infections (RTIs) account for about 60% of antibiotics prescribed in primary care. This study aims to test the effectiveness, in a cluster randomised controlled trial, of electronically delivered, multicomponent interventions to reduce unnecessary antibiotic prescribing when patients consult for RTIs in primary care. The research will specifically evaluate the effectiveness of feeding back electronic health records (EHRs) data to general practices. METHODS AND ANALYSIS 2-arm cluster randomised trial using the EHRs of the Clinical Practice Research Datalink (CPRD). General practices in England, Scotland, Wales and Northern Ireland are being recruited and the general population of all ages represents the target population. Control trial arm practices will continue with usual care. Practices in the intervention arm will receive complex multicomponent interventions, delivered remotely to information systems, including (1) feedback of each practice's antibiotic prescribing through monthly antibiotic prescribing reports estimated from CPRD data; (2) delivery of educational and decision support tools; (3) a webinar to explain and promote effective usage of the intervention. The intervention will continue for 12 months. Outcomes will be evaluated from CPRD EHRs. The primary outcome will be the number of antibiotic prescriptions for RTIs per 1000 patient years. Secondary outcomes will be: the RTI consultation rate; the proportion of consultations for RTI with an antibiotic prescribed; subgroups of age; different categories of RTI and quartiles of intervention usage. There will be more than 80% power to detect an absolute reduction in antibiotic prescription for RTI of 12 per 1000 registered patient years. Total healthcare usage will be estimated from CPRD data and compared between trial arms. ETHICS AND DISSEMINATION Trial protocol was approved by the National Research Ethics Service Committee (14/LO/1730). The pragmatic design of the trial will enable subsequent translation of effective interventions at scale in order to achieve population impact. TRIAL REGISTRATION NUMBER ISRCTN95232781; Pre-results.
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Affiliation(s)
- Dorota Juszczyk
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Judith Charlton
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Lisa McDermott
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Jamie Soames
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Kirin Sultana
- Clinical Practice Research Datalink, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Mark Ashworth
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Robin Fox
- Bicester Health Centre, Bicester, UK
| | - Alastair D Hay
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Paul Little
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Michael V Moore
- Primary Care Research Group, University of Southampton, Southampton, UK
| | - Lucy Yardley
- Department of Psychology, University of Southampton, Southampton, UK
| | - A Toby Prevost
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
| | - Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
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21
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Little P, Stuart B, Andreou P, McDermott L, Joseph J, Mullee M, Moore M, Broomfield S, Thomas T, Yardley L. Primary care randomised controlled trial of a tailored interactive website for the self-management of respiratory infections (Internet Doctor). BMJ Open 2016; 6:e009769. [PMID: 27098821 PMCID: PMC4838709 DOI: 10.1136/bmjopen-2015-009769] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [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] [Indexed: 12/02/2022] Open
Abstract
OBJECTIVE To assess an internet-delivered intervention providing advice to manage respiratory tract infections (RTIs). DESIGN Open pragmatic parallel group randomised controlled trial. SETTING Primary care in UK. PARTICIPANTS Adults (aged ≥18) registered with general practitioners, recruited by postal invitation. INTERVENTION Patients were randomised with computer-generated random numbers to access the intervention website (intervention) or not (control). The intervention tailored advice about the diagnosis, natural history, symptom management (particularly paracetamol/ibuprofen use) and when to seek further help. OUTCOMES Primary: National Health Service (NHS) contacts for those reporting RTIs from monthly online questionnaires for 20 weeks. Secondary: hospitalisations; symptom duration/severity. RESULTS Results 3044 participants were recruited. 852 in the intervention group and 920 in the control group reported one or more RTIs, among whom there a modest increase in NHS Direct contacts in the intervention group (intervention 44/1734 (2.5%) versus control 24/1842 (1.3%); multivariate Risk Ratio (RR) 2.53 (95% CI 1.10 to 5.82, p=0.029)). Conversely reduced contact with doctors occurred (283/1734 (16.3%) vs 368/1845 (20.0%); risk ratio 0.71, 0.53 to 0.95, p=0.019). Reduction in contacts occurred despite slightly longer illness duration (11.3 days versus 10.9 days respectively; multivariateestimate 0.48 days longer (-0.16 to 1.12, p=0.141) and more days of illness rated moderately bad or worse illness (0.53 days; 0.12 to 0.94, p=0.012). The estimate of slower symptom resolution in the intervention group was attenuated when controlling for whether individuals had used webpages which advocated ibuprofen use (length of illness 0.22 days, −0.51 to 0.95, p=0.551; moderately bad or worse symptoms 0.36 days, −0.08 to 0.80, p=0.105). There was no evidence of increased hospitalisations (risk ratio 0.13; 0.02 to 1.01; p=0.051). CONCLUSIONS An internet-delivered intervention for the self-management of RTIs modifies help-seeking behaviour, and does not result in more hospital admissions due to delayed help seeking. Advising the use of ibuprofen may not be helpful. TRIAL REGISTRATION NUMBER ISRCTN91518452.
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Affiliation(s)
- Paul Little
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Beth Stuart
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Panayiota Andreou
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Lisa McDermott
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Judith Joseph
- Centre for the Applications of Health Psychology, University of Southampton, Southampton, UK
| | - Mark Mullee
- Research Design Service South Central, Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Mike Moore
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Sue Broomfield
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Tammy Thomas
- Primary Care Group, Primary Care and Population Sciences Unit, University of Southampton,Southampton, UK
| | - Lucy Yardley
- Centre for the Applications of Health Psychology, University of Southampton, Southampton, UK
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22
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Ghoreishi N, Graham T, McDermott L, Gardiner S, walls T. Antimicrobial use in children at a tertiary teaching hospital in New Zealand. Int J Infect Dis 2016. [DOI: 10.1016/j.ijid.2016.02.302] [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: 10/22/2022] Open
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23
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Forster AS, Dregan A, van Staa TP, McDermott L, McCann G, Wolfe CDA, Rudd A, Gulliford MC. Why do electronic health records reveal oral anticoagulant prescription after haemorrhagic stroke? Br J Clin Pharmacol 2016; 79:1037-9. [PMID: 25495586 DOI: 10.1111/bcp.12570] [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] [Subscribe] [Scholar Register] [Received: 10/10/2014] [Accepted: 12/06/2014] [Indexed: 11/29/2022] Open
Affiliation(s)
- Alice S Forster
- Primary Care and Public Health Sciences, King's College London, London, UK
| | - Alex Dregan
- Primary Care and Public Health Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, UK
| | - Tjeerd P van Staa
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, UK.,University of Manchester, Manchester, UK
| | - Lisa McDermott
- Primary Care and Public Health Sciences, King's College London, London, UK
| | - Gerard McCann
- Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Charles D A Wolfe
- Primary Care and Public Health Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, UK
| | - Anthony Rudd
- Primary Care and Public Health Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, UK
| | - Martin C Gulliford
- Primary Care and Public Health Sciences, King's College London, London, UK.,NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, UK
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Warrier K, Cliffe L, McDermott L, Rangaraj S. MEFV mutations - therapeutic guides or red herrings? Pediatr Rheumatol Online J 2015. [PMCID: PMC4599120 DOI: 10.1186/1546-0096-13-s1-p129] [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: 11/23/2022] Open
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25
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Basude S, McDermott L, Newell S, Wreyford B, Denbow M, Hutchinson J, Abdel-Fattah S. Fetal hemivertebra: associations and perinatal outcome. Ultrasound Obstet Gynecol 2015; 45:434-438. [PMID: 24789522 DOI: 10.1002/uog.13401] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/10/2013] [Revised: 03/11/2014] [Accepted: 04/22/2014] [Indexed: 06/03/2023]
Abstract
OBJECTIVES To assess the accuracy of antenatal diagnosis of hemivertebra, to quantify the association with coexisting anomalies and to determine the perinatal outcome. METHOD This was a retrospective observational study of all cases of suspected fetal or neonatal hemivertebra identified via the UK Southwest Congenital Anomaly Register (SWCAR) between 2002 and 2012. RESULTS From a total of 88 cases of hemivertebra identified during the study period, data were obtained for 67 of them: 45 (10 isolated and 35 with coexisting anomalies) cases were suspected antenatally and 22 (10 isolated and 12 with coexisting anomalies) were diagnosed postnatally. Of the cases detected postnatally, five (four with coexisting anomalies) were unsuspected and diagnosed at postmortem examination. The most commonly associated anomalies included additional skeletal abnormalities (n = 16), genitourinary abnormalities (n = 10), VATER/VACTERL association (n = 5), cardiac abnormalities (n = 4) and central nervous system abnormalities (n = 4). In cases with coexisting anomalies there was a 48% fetal/neonatal loss, compared to 19% in cases with isolated hemivertebra. CONCLUSIONS Although antenatal diagnosis of hemivertebra was accurate, a third of the cases were diagnosed only postnatally. These data suggest a difficulty in antenatal diagnosis of the condition. The majority of cases of hemivertebra had coexisting anomalies, and in these cases the rate of perinatal loss was high. These data should be useful in providing additional information for counseling when a diagnosis of hemivertebra is made.
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Affiliation(s)
- S Basude
- Department of Obstetrics and Fetal Medicine, St Michael's Hospital, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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26
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McDermott L, Yardley L, Little P, van Staa T, Dregan A, McCann G, Ashworth M, Gulliford M. Process evaluation of a point-of-care cluster randomised trial using a computer-delivered intervention to reduce antibiotic prescribing in primary care. BMC Health Serv Res 2014; 14:594. [PMID: 25700144 PMCID: PMC4260184 DOI: 10.1186/s12913-014-0594-1] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Accepted: 11/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The study aimed to conduct a process evaluation for a cluster randomised trial of a computer-delivered, point-of-care intervention to reduce antibiotic prescribing in primary care. The study aimed to evaluate both the intervention and implementation of the trial. METHODS The intervention comprised a set of electronic educational and decision support tools that were remotely installed and activated during consultations with patients with acute respiratory infections over a 12 month intervention period. A mixed method evaluation was conducted with 103 general practitioners (GPs) who participated in the trial. Semi-structured telephone interviews were conducted with 20 GPs who had been in the intervention group of the trial and 4 members of the implementation staff. Questionnaires, consisting of both intervention evaluation and theory-based measures, were self-administered to 83 GPs (56 control group and 27 intervention group). RESULTS Interviews suggested that a key factor influencing GPs' use of the intervention appeared to be their awareness of the implementation of the system into their practice. GPs who were aware of the implementation of the intervention reported feeling confident in using it if they chose to and understood the purpose of the intervention screens. However, GPs who were unaware that the intervention would be appearing often reported feeling confused when they saw the messages appear on the screen and not fully understanding what they were for or how they could be used. Intervention evaluation questionnaires indicated that GPs were satisfied with the usability of the prompts, and theory-based measures revealed that intervention group GPs reported higher levels of self-efficacy in managing RTI patients according to recommended guidelines compared to GPs in the control group. CONCLUSIONS Remote installation of a computer-delivered intervention for use at the point-of-care was feasible and acceptable. Additional measures to promote awareness of the intervention may be required to promote health care professionals' utilisation of the intervention and these might sometimes compromise the pragmatic intention of a trial. TRIAL REGISTRATION ISRCTN47558792 (registered on 17 March 2010).
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Affiliation(s)
- Lisa McDermott
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - Lucy Yardley
- />Department of Psychology, University of Southampton, Shakleton Building, Highfield, Southampton, UK
| | - Paul Little
- />Aldermoor Health Centre, School of Primary Care and Population Sciences, University of Southampton, Aldermoor Close, Southampton, UK
| | - Tjeerd van Staa
- />The Clinical Practice Research Datalink Group, The Medicines and Healthcare products Regulatory Agency, 5th Floor, 151 Buckingham Palace Road, London, Victoria UK
| | - Alex Dregan
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - Gerard McCann
- />The Clinical Practice Research Datalink Group, The Medicines and Healthcare products Regulatory Agency, 5th Floor, 151 Buckingham Palace Road, London, Victoria UK
| | - Mark Ashworth
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - Martin Gulliford
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
| | - The eCRT research team
- />Department of Primary Care and Public Health Sciences, King’s College London, Capital House, 42 Weston Street, London, UK
- />Department of Psychology, University of Southampton, Shakleton Building, Highfield, Southampton, UK
- />Aldermoor Health Centre, School of Primary Care and Population Sciences, University of Southampton, Aldermoor Close, Southampton, UK
- />The Clinical Practice Research Datalink Group, The Medicines and Healthcare products Regulatory Agency, 5th Floor, 151 Buckingham Palace Road, London, Victoria UK
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27
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Gulliford MC, Dregan A, Moore MV, Ashworth M, van Staa T, McCann G, Charlton J, Yardley L, Little P, McDermott L. Continued high rates of antibiotic prescribing to adults with respiratory tract infection: survey of 568 UK general practices. BMJ Open 2014; 4:e006245. [PMID: 25348424 PMCID: PMC4212213 DOI: 10.1136/bmjopen-2014-006245] [Citation(s) in RCA: 169] [Impact Index Per Article: 16.9] [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: 08/01/2014] [Revised: 09/18/2014] [Accepted: 10/07/2014] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES Overutilisation of antibiotics may contribute to the emergence of antimicrobial drug resistance, a growing international concern. This study aimed to analyse the performance of UK general practices with respect to antibiotic prescribing for respiratory tract infections (RTIs) among young and middle-aged adults. SETTING Data are reported for 568 UK general practices contributing to the Clinical Practice Research Datalink. PARTICIPANTS Participants were adults aged 18-59 years. Consultations were identified for acute upper RTIs including colds, cough, otitis-media, rhino-sinusitis and sore throat. PRIMARY AND SECONDARY OUTCOME MEASURES For each consultation, we identified whether an antibiotic was prescribed. The proportion of RTI consultations with antibiotics prescribed was estimated. RESULTS There were 568 general practices analysed. The median general practice prescribed antibiotics at 54% of RTI consultations. At the highest prescribing 10% of practices, antibiotics were prescribed at 69% of RTI consultations. At the lowest prescribing 10% of practices, antibiotics were prescribed at 39% RTI consultations. The median practice prescribed antibiotics at 38% of consultations for 'colds and upper RTIs', 48% for 'cough and bronchitis', 60% for 'sore throat', 60% for 'otitis-media' and 91% for 'rhino-sinusitis'. The highest prescribing 10% of practices issued antibiotic prescriptions at 72% of consultations for 'colds', 67% for 'cough', 78% for 'sore throat', 90% for 'otitis-media' and 100% for 'rhino-sinusitis'. CONCLUSIONS Most UK general practices prescribe antibiotics to young and middle-aged adults with respiratory infections at rates that are considerably in excess of what is clinically justified. This will fuel antibiotic resistance.
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Affiliation(s)
- Martin C Gulliford
- King's College London, Primary Care and Public Health Sciences, London, UK
| | - Alex Dregan
- King's College London, Primary Care and Public Health Sciences, London, UK
| | - Michael V Moore
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Mark Ashworth
- King's College London, Primary Care and Public Health Sciences, London, UK
| | - Tjeerd van Staa
- Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, UK
- Health eResearch Centre, Farr Institute for Health Informatics Research, University of Manchester, London, UK
| | - Gerard McCann
- Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, UK
| | - Judith Charlton
- King's College London, Primary Care and Public Health Sciences, London, UK
| | - Lucy Yardley
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Paul Little
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Lisa McDermott
- King's College London, Primary Care and Public Health Sciences, London, UK
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Little P, Hobbs FDR, Moore M, Mant D, Williamson I, McNulty C, Lasseter G, Cheng MYE, Leydon G, McDermott L, Turner D, Pinedo-Villanueva R, Raftery J, Glasziou P, Mullee M. PRImary care Streptococcal Management (PRISM) study: in vitro study, diagnostic cohorts and a pragmatic adaptive randomised controlled trial with nested qualitative study and cost-effectiveness study. Health Technol Assess 2014; 18:vii-xxv, 1-101. [PMID: 24467988 DOI: 10.3310/hta18060] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Antibiotics are still prescribed to most patients attending primary care with acute sore throat, despite evidence that there is modest benefit overall from antibiotics. Targeting antibiotics using either clinical scoring methods or rapid antigen detection tests (RADTs) could help. However, there is debate about which groups of streptococci are important (particularly Lancefield groups C and G), and uncertainty about the variables that most clearly predict the presence of streptococci. OBJECTIVE This study aimed to compare clinical scores or RADTs with delayed antibiotic prescribing. DESIGN The study comprised a RADT in vitro study; two diagnostic cohorts to develop streptococcal scores (score 1; score 2); and, finally, an open pragmatic randomised controlled trial with nested qualitative and cost-effectiveness studies. SETTING The setting was UK primary care general practices. PARTICIPANTS Participants were patients aged ≥ 3 years with acute sore throat. INTERVENTIONS An internet program randomised patients to targeted antibiotic use according to (1) delayed antibiotics (control group), (2) clinical score or (3) RADT used according to clinical score. MAIN OUTCOME MEASURES The main outcome measures were self-reported antibiotic use and symptom duration and severity on seven-point Likert scales (primary outcome: mean sore throat/difficulty swallowing score in the first 2-4 days). RESULTS The IMI TestPack Plus Strep A (Inverness Medical, Bedford, UK) was sensitive, specific and easy to use. Lancefield group A/C/G streptococci were found in 40% of cohort 2 and 34% of cohort 1. A five-point score predicting the presence of A/C/G streptococci [FeverPAIN: Fever; Purulence; Attend rapidly (≤ 3 days); severe Inflammation; and No cough or coryza] had moderate predictive value (bootstrapped estimates of area under receiver operating characteristic curve: 0.73 cohort 1, 0.71 cohort 2) and identified a substantial number of participants at low risk of streptococcal infection. In total, 38% of cohort 1 and 36% of cohort 2 scored ≤ 1 for FeverPAIN, associated with streptococcal percentages of 13% and 18%, respectively. In an adaptive trial design, the preliminary score (score 1; n = 1129) was replaced by FeverPAIN (n = 631). For score 1, there were no significant differences between groups. For FeverPAIN, symptom severity was documented in 80% of patients, and was lower in the clinical score group than in the delayed prescribing group (-0.33; 95% confidence interval -0.64 to -0.02; p = 0.039; equivalent to one in three rating sore throat a slight rather than moderately bad problem), and a similar reduction was observed for the RADT group (-0.30; -0.61 to 0.00; p = 0.053). Moderately bad or worse symptoms resolved significantly faster (30%) in the clinical score group (hazard ratio 1.30; 1.03 to 1.63) but not the RADT group (1.11; 0.88 to 1.40). In the delayed group, 75/164 (46%) used antibiotics, and 29% fewer used antibiotics in the clinical score group (risk ratio 0.71; 0.50 to 0.95; p = 0.018) and 27% fewer in the RADT group (0.73; 0.52 to 0.98; p = 0.033). No significant differences in complications or reconsultations were found. The clinical score group dominated both other groups for both the cost/quality-adjusted life-years and cost/change in symptom severity analyses, being both less costly and more effective, and cost-effectiveness acceptability curves indicated the clinical score to be the most likely to be cost-effective from an NHS perspective. Patients were positive about RADTs. Health professionals' concerns about test validity, the time the test took and medicalising self-limiting illness lessened after using the tests. For both RADTs and clinical scores, there were tensions with established clinical experience. CONCLUSIONS Targeting antibiotics using a clinical score (FeverPAIN) efficiently improves symptoms and reduces antibiotic use. RADTs used in combination with FeverPAIN provide no clear advantages over FeverPAIN alone, and RADTs are unlikely to be incorporated into practice until health professionals' concerns are met and they have experience of using them. Clinical scores also face barriers related to clinicians' perceptions of their utility in the face of experience. This study has demonstrated the limitation of using one data set to develop a clinical score. FeverPAIN, derived from two data sets, appears to be valid and its use improves outcomes, but diagnostic studies to confirm the validity of FeverPAIN in other data sets and settings are needed. Experienced clinicians need to identify barriers to the use of clinical scoring methods. Implementation studies that address perceived barriers in the use of FeverPAIN are needed. TRIAL REGISTRATION Current Controlled Trials ISRCTN32027234. SOURCE OF FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 6. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Paul Little
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - F D Richard Hobbs
- Primary Care Clinical Sciences, University of Birmingham, Birmingham, UK
| | - Michael Moore
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Mant
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Ian Williamson
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Cliodna McNulty
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - Gemma Lasseter
- Public Health England, Primary Care Unit, Microbiology Laboratory, Gloucestershire Royal Hospital, Gloucester, UK
| | - M Y Edith Cheng
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Geraldine Leydon
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Lisa McDermott
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - David Turner
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | | | - James Raftery
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
| | - Paul Glasziou
- Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Mark Mullee
- Primary Care and Population Sciences Unit, University of Southampton, Southampton, UK
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Forster AS, Dodhia H, Booth H, Dregan A, Fuller F, Miller J, Burgess C, McDermott L, Gulliford MC. Estimating the yield of NHS Health Checks in England: a population-based cohort study. J Public Health (Oxf) 2014; 37:234-40. [PMID: 25326192 DOI: 10.1093/pubmed/fdu079] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [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: 11/12/2022] Open
Abstract
BACKGROUND This study aimed to evaluate the yield of the NHS Health Checks programme. METHODS A cohort study, conducted in the Clinical Practice Research Datalink in England. Electronic health records were analysed for patients aged 40-74 receiving an NHS Health Check between 2010 and 2013. RESULTS There were 65 324 men and 75 032 women receiving a health check. For every 1000 men assessed, there were 205 smokers (95% confidence interval 195-215), 355 (340-369) with hypertension (≥140/90 mmHg) and 633 (607-658) with elevated cholesterol (≥5 mmol/l). Among 1000 women, there were 161 (151-171) smokers, 247 (238-257) with hypertension and 668 (646-689) with elevated cholesterol. In the 12 months following the check, statins were prescribed to 18% of men and 21% of women with ≥20% cardiovascular risk and antihypertensive drugs to 11% of men and 16% of women with ≥20% cardiovascular risk. Slight reductions in risk factor values were observed in the minority of participants with follow-up values recorded in the 15 months following the check. CONCLUSIONS A universal primary prevention programme identifies substantial risk factor burden in a population without known cardiovascular disease. Research is needed to monitor interventions, and intermediate- and long-term outcomes, in those identified at high risk.
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Affiliation(s)
| | - Hiten Dodhia
- Lambeth-Southwark Public Health Directorate, London SE1 2QH, UK
| | | | | | | | - Jane Miller
- London Borough of Lewisham, London SE6 4RU, UK
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Forster AS, Burgess C, McDermott L, Wright AJ, Dodhia H, Conner M, Miller J, Rudisill C, Cornelius V, Gulliford MC. Enhanced invitation methods to increase uptake of NHS health checks: study protocol for a randomized controlled trial. Trials 2014; 15:342. [PMID: 25174568 PMCID: PMC4156615 DOI: 10.1186/1745-6215-15-342] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2014] [Accepted: 08/20/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND NHS Health Checks is a new program for primary prevention of heart disease, stroke, diabetes, chronic kidney disease, and vascular dementia in adults aged 40 to 74 years in England. Individuals without existing cardiovascular disease or diabetes are invited for a Health Check every 5 years. Uptake among those invited is lower than anticipated. METHOD The project is a three-arm randomized controlled trial to test the hypothesis that enhanced invitation methods, using the Question-Behaviour Effect (QBE), will increase uptake of NHS Health Checks compared with a standard invitation. Participants comprise individuals eligible for an NHS Health Check registered in two London boroughs. Participants are randomized into one of three arms. Group A receives the standard NHS Health Check invitation letter, information sheet, and reminder letter at 12 weeks for nonattenders. Group B receives a QBE questionnaire 1 week before receiving the standard invitation, information sheet, and reminder letter where appropriate. Group C is the same as Group B, but participants are offered a £5 retail voucher if they return the questionnaire. Participants are randomized in equal proportions, stratified by general practice. The primary outcome is uptake of NHS Health Checks 6 months after invitation from electronic health records. We will estimate the incremental health service cost per additional completed Health Check for trial groups B and C versus trial arm A, as well as evaluating the impact of the QBE questionnaire, and questionnaire plus voucher, on the socioeconomic inequality in uptake of Health Checks.The trial includes a nested comparison of two methods for implementing allocation, one implemented manually at general practices and the other implemented automatically through the information systems used to generate invitations for the Health Check. DISCUSSION The research will provide evidence on whether asking individuals to complete a preliminary questionnaire, by using the QBE, is effective in increasing uptake of Health Checks and whether an incentive alters questionnaire return rates as well as uptake of Health Checks. The trial interventions can be readily translated into routine service delivery if they are shown to be cost-effective. TRIAL REGISTRATION Current Controlled Trials ISRCTN42856343. Date registered: 21.03.2013.
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Gulliford MC, van Staa T, Dregan A, McDermott L, McCann G, Ashworth M, Charlton J, Little P, Moore MV, Yardley L. Electronic health records for intervention research: a cluster randomized trial to reduce antibiotic prescribing in primary care (eCRT study). Ann Fam Med 2014; 12:344-51. [PMID: 25024243 PMCID: PMC4096472 DOI: 10.1370/afm.1659] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 03/04/2014] [Accepted: 03/29/2014] [Indexed: 11/09/2022] Open
Abstract
PURPOSE This study aimed to implement a point-of-care cluster randomized trial using electronic health records. We evaluated the effectiveness of electronically delivered decision support tools at reducing antibiotic prescribing for respiratory tract infections in primary care. METHODS Family practices from England and Scotland participating in the Clinical Practice Research Datalink (CPRD) were included in the trial; 53 family practices were allocated to intervention and 51 practices were allocated to usual care. Patients aged 18 to 59 years consulting for respiratory tract infections were eligible. The intervention was through remotely installed, computer-delivered decision support tools accessed during the consultations. Control practices provided usual care. The primary outcome was the proportion of consultations for respiratory tract infections with an antibiotic prescribed based on electronic health records. Family practice-specific proportions were included in a cluster-level analysis. RESULTS Data were analyzed for 603,409 patients: 317,717 at intervention practices and 285,692 at control practices. Use of the intervention was less than anticipated, varying among practices. There was a reduction in proportion of consultations with antibiotics prescribed of 1.85% (95% CI, 0.10%-3.59%, P=.038) and in the rate of antibiotic prescribing for respiratory tract infections (9.69%; 95% CI, 0.75%-18.63%, fewer prescriptions per 1,000 patient-years, P=.034). There were no adverse events. CONCLUSIONS Cluster randomized trials may be implemented efficiently in large samples from routine care settings by using primary care electronic health records. Future studies should develop and test multicomponent methods for remotely delivered intervention.
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Affiliation(s)
- Martin C Gulliford
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Tjeerd van Staa
- Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, United Kingdom London School of Hygiene & Tropical Medicine, London, United Kingdom
| | - Alex Dregan
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Lisa McDermott
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
| | - Gerard McCann
- Clinical Practice Research Datalink (CPRD) Division, Medicines and Healthcare Products Regulatory Agency, London, United Kingdom
| | - Mark Ashworth
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Judith Charlton
- King's College London, Primary Care and Public Health Sciences, London, United Kingdom
| | - Paul Little
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
| | - Michael V Moore
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
| | - Lucy Yardley
- Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom
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Gulliford MC, van Staa TP, McDermott L, McCann G, Charlton J, Dregan A. Cluster randomized trials utilizing primary care electronic health records: methodological issues in design, conduct, and analysis (eCRT Study). Trials 2014; 15:220. [PMID: 24919485 PMCID: PMC4062282 DOI: 10.1186/1745-6215-15-220] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2014] [Accepted: 05/22/2014] [Indexed: 11/10/2022] Open
Abstract
Background There is growing interest in conducting clinical and cluster randomized trials through electronic health records. This paper reports on the methodological issues identified during the implementation of two cluster randomized trials using the electronic health records of the Clinical Practice Research Datalink (CPRD). Methods Two trials were completed in primary care: one aimed to reduce inappropriate antibiotic prescribing for acute respiratory infection; the other aimed to increase physician adherence with secondary prevention interventions after first stroke. The paper draws on documentary records and trial datasets to report on the methodological experience with respect to research ethics and research governance approval, general practice recruitment and allocation, sample size calculation and power, intervention implementation, and trial analysis. Results We obtained research governance approvals from more than 150 primary care organizations in England, Wales, and Scotland. There were 104 CPRD general practices recruited to the antibiotic trial and 106 to the stroke trial, with the target number of practices being recruited within six months. Interventions were installed into practice information systems remotely over the internet. The mean number of participants per practice was 5,588 in the antibiotic trial and 110 in the stroke trial, with the coefficient of variation of practice sizes being 0.53 and 0.56 respectively. Outcome measures showed substantial correlations between the 12 months before, and after intervention, with coefficients ranging from 0.42 for diastolic blood pressure to 0.91 for proportion of consultations with antibiotics prescribed, defining practice and participant eligibility for analysis requires careful consideration. Conclusions Cluster randomized trials may be performed efficiently in large samples from UK general practices using the electronic health records of a primary care database. The geographical dispersal of trial sites presents a difficulty for research governance approval and intervention implementation. Pretrial data analyses should inform trial design and analysis plans. Trial registration Current Controlled Trials ISRCTN 47558792 and ISRCTN 35701810 (both registered on 17 March 2010).
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Affiliation(s)
- Martin C Gulliford
- Department of Primary Care and Public Health Sciences, King's College London, Capital House, 42 Weston St, London SE1 3QD, UK.
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Dregan A, van Staa TP, McDermott L, McCann G, Ashworth M, Charlton J, Wolfe CDA, Rudd A, Yardley L, Gulliford MC, Trial Steering Committee. Point-of-care cluster randomized trial in stroke secondary prevention using electronic health records. Stroke 2014; 45:2066-71. [PMID: 24903985 DOI: 10.1161/strokeaha.114.005713] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The aim of this study was to evaluate whether the remote introduction of electronic decision support tools into family practices improves risk factor control after first stroke. This study also aimed to develop methods to implement cluster randomized trials in stroke using electronic health records. METHODS Family practices were recruited from the UK Clinical Practice Research Datalink and allocated to intervention and control trial arms by minimization. Remotely installed, electronic decision support tools promoted intensified secondary prevention for 12 months with last measure of systolic blood pressure as the primary outcome. Outcome data from electronic health records were analyzed using marginal models. RESULTS There were 106 Clinical Practice Research Datalink family practices allocated (intervention, 53; control, 53), with 11 391 (control, 5516; intervention, 5875) participants with acute stroke ever diagnosed. Participants at trial practices had similar characteristics as 47,887 patients with stroke at nontrial practices. During the intervention period, blood pressure values were recorded in the electronic health records for 90% and cholesterol values for 84% of participants. After intervention, the latest mean systolic blood pressure was 131.7 (SD, 16.8) mm Hg in the control trial arm and 131.4 (16.7) mm Hg in the intervention trial arm, and adjusted mean difference was -0.56 mm Hg (95% confidence interval, -1.38 to 0.26; P=0.183). The financial cost of the trial was approximately US $22 per participant, or US $2400 per family practice allocated. CONCLUSIONS Large pragmatic intervention studies may be implemented at low cost by using electronic health records. The intervention used in this trial was not found to be effective, and further research is needed to develop more effective intervention strategies. CLINICAL TRIAL REGISTRATION URL http://www.controlled-trials.com. Current Controlled Trials identifier: ISRCTN35701810.
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Affiliation(s)
- Alex Dregan
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Tjeerd P van Staa
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Lisa McDermott
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Gerard McCann
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Mark Ashworth
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Judith Charlton
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Charles D A Wolfe
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Anthony Rudd
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Lucy Yardley
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.)
| | - Martin C Gulliford
- From the Department of Primary Care and Public Health Sciences, King's College London, London, United Kingdom (A.D., L.M., M.A., J.C., C.D.A.W., A.R., M.C.G.); NIHR Biomedical Research Centre at Guy's and St Thomas' Hospital London, London, United Kingdom (A.D., C.D.A.W., A.R., M.C.G.); Clinical Practice Research Datalink (CPRD), Medicines and Healthcare Products Regulatory Agency, London, United Kingdom (T.P.v.S., G.M.); London School of Hygiene & Tropical Medicine, London, United Kingdom (T.P.v.S.); and Division of Community Clinical Sciences, University of Southampton, Southampton, United Kingdom (L.M., L.Y.).
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Franich R, Smith R, Haworth A, Taylor M, McDermott L, Millar J. SU-C-16A-01: In Vivo
Source Position Verification in High Dose Rate (HDR) Prostate Brachytherapy Using a Flat Panel Imager: Initial Clinical Experience. Med Phys 2014. [DOI: 10.1118/1.4889693] [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: 11/07/2022] Open
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Little P, Moore M, Kelly J, Williamson I, Leydon G, McDermott L, Mullee M, Stuart B. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, factorial, randomised controlled trial. BMJ 2014; 348:g1606. [PMID: 24603565 PMCID: PMC3944682 DOI: 10.1136/bmj.g1606] [Citation(s) in RCA: 106] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
Abstract
OBJECTIVE To estimate the effectiveness of different strategies involving delayed antibiotic prescription for acute respiratory tract infections. DESIGN Open, pragmatic, parallel group, factorial, randomised controlled trial. SETTING Primary care in the United Kingdom. PATIENTS 889 patients aged 3 years and over with acute respiratory tract infection, recruited between 3 March 2010 and 28 March 2012 by 53 health professionals in 25 practices. INTERVENTIONS Patients judged not to need immediate antibiotics were randomised to undergo four strategies of delayed prescription: recontact for a prescription, post-dated prescription, collection of the prescription, and be given the prescription (patient led). During the trial, a strategy of no antibiotic prescription was added as another randomised comparison. Analysis was intention to treat. MAIN OUTCOME MEASURES Mean symptom severity (0-6 scale) at days 2-4 (primary outcome), antibiotic use, and patients' beliefs in the effectiveness of antibiotic use. Secondary analysis included comparison with immediate use of antibiotics. RESULTS Mean symptom severity had minimal differences between the strategies involving no prescription and delayed prescription (recontact, post-date, collection, patient led; 1.62, 1.60, 1.82, 1.68, 1.75, respectively; likelihood ratio test χ(2) 2.61, P=0.625). Duration of symptoms rated moderately bad or worse also did not differ between no prescription and delayed prescription strategies combined (median 3 days v 4 days; 4.29, P=0.368). There were modest and non-significant differences in patients very satisfied with the consultation between the randomised groups (79%, 74%, 80%, 88%, 89%, respectively; likelihood ratio test χ(2) 2.38, P=0.667), belief in antibiotics (71%, 74%, 73%, 72%, 66%; 1.62, P=0.805), or antibiotic use (26%, 37%, 37%, 33%, 39%; 4.96, P=0.292). By contrast, most patients given immediate antibiotics used antibiotics (97%) and strongly believed in them (93%), but with no benefit for symptom severity (score 1.76) or duration (median 4 days). CONCLUSION Strategies of no prescription or delayed antibiotic prescription result in fewer than 40% of patients using antibiotics, and are associated with less strong beliefs in antibiotics, and similar symptomatic outcomes to immediate prescription. If clear advice is given to patients, there is probably little to choose between the different strategies of delayed prescription. TRIAL REGISTRATION ISRCTN38551726.
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Affiliation(s)
- Paul Little
- University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
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Everitt H, McDermott L, Leydon G, Yules H, Baldwin D, Little P. GPs' management strategies for patients with insomnia: a survey and qualitative interview study. Br J Gen Pract 2014; 64:e112-9. [PMID: 24567616 PMCID: PMC3905408 DOI: 10.3399/bjgp14x677176] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 09/03/2013] [Accepted: 10/05/2013] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Patients frequently experience sleep problems and present to primary care. However, information is limited regarding the management strategies that GPs employ. AIM To gain an understanding of current GP management strategies for insomnia. DESIGN AND SETTING A postal questionnaire survey and qualitative interviews with GPs in the south of England. METHOD A postal survey of 296 GPs and qualitative interviews were carried out with 23 of the GPs. RESULTS The survey response rate was 56% (166/296). GPs look for signs of depression and anxiety in patients and if present treat these first. 'Sleep hygiene' advice is provided by 88% (147/166) of GPs but often seems insufficient and they feel under pressure to prescribe. Benzodiazepines and Z drugs are prescribed, often reluctantly, for short periods, because of known problems with dependence and tolerance. Many GPs prescribe low-dose amitriptyline for insomnia although it is not licensed for this indication. For insomnia 95% (157/166) of survey responders 'ever prescribe' amitriptyline, with 31% (52/166) stating they do so commonly. Most GPs perceived amitriptyline to be effective and a longer-term option for those with ongoing sleep problems. GPs report a lack of knowledge and confidence in the provision and use of psychological therapies, such as cognitive behavioural therapy (CBT), in the management of insomnia. CONCLUSION GPs often find 'sleep hygiene' advice is insufficient for managing insomnia and report frequently prescribing medication, including amitriptyline (off licence), which is often based on perceived patient pressure for a prescription. Patients are rarely offered psychological therapies such as CBT for insomnia, despite evidence suggesting its potential effectiveness.
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Affiliation(s)
- Hazel Everitt
- Primary Care and Public Health Sciences, Health and Social Care Research, School of Medicine, King's College London
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Abstract
This audit was performed in the obstetrics and gynaecology department of a tertiary referral hospital, to investigate the use and results of TORCH screening. St Michael's Hospital delivers approximately 6,000 women from South Bristol a year and receives tertiary referrals from the South West of England and South Wales. It was found that 739 patients over a 6-year period from April 2006 to January 2012 underwent testing. The majority's indication (21%) was polyhydramnios. Three patients had evidence of primary CMV infection in pregnancy on serology, two for fetal indications (polyhydramnios and echogenic bowel) and one following a miscarriage. There were no confirmed cases of gestational toxoplasma or rubella. Routine testing for toxoplasma and rubella infection as part of the TORCH screening in cases of fetal or obstetric abnormality should thus be discontinued in our population.
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Affiliation(s)
- S Halawa
- Department of Obstetrics and Gynaecology
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Little P, Moore M, Kelly J, Williamson I, Leydon G, McDermott L, Mullee M, Stuart B. Ibuprofen, paracetamol, and steam for patients with respiratory tract infections in primary care: pragmatic randomised factorial trial. BMJ 2013; 347:f6041. [PMID: 24162940 PMCID: PMC3808081 DOI: 10.1136/bmj.f6041] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/23/2013] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To assess strategies for advice on analgesia and steam inhalation for respiratory tract infections. DESIGN Open pragmatic parallel group factorial randomised controlled trial. SETTING Primary care in United Kingdom. PARTICIPANTS Patients aged ≥ 3 with acute respiratory tract infections. INTERVENTION 889 patients were randomised with computer generated random numbers in pre-prepared sealed numbered envelopes to components of advice or comparator advice: advice on analgesia (take paracetamol, ibuprofen, or both), dosing of analgesia (take as required v regularly), and steam inhalation (no inhalation v steam inhalation). OUTCOMES Primary: mean symptom severity on days 2-4; symptoms rated 0 (no problem) to 7 (as bad as it can be). Secondary: temperature, antibiotic use, reconsultations. RESULTS Neither advice on dosing nor on steam inhalation was significantly associated with changes in outcomes. Compared with paracetamol, symptom severity was little different with ibuprofen (adjusted difference 0.04, 95% confidence interval -0.11 to 0.19) or the combination of ibuprofen and paracetamol (0.11, -0.04 to 0.26). There was no evidence for selective benefit with ibuprofen among most subgroups defined before analysis (presence of otalgia; previous duration of symptoms; temperature >37.5 °C; severe symptoms), but there was evidence of reduced symptoms severity benefit in the subgroup with chest infections (ibuprofen -0.40, -0.78 to -0.01; combination -0.47; -0.84 to -0.10), equivalent to almost one in two symptoms rated as a slight rather than a moderately bad problem. Children might also benefit from treatment with ibuprofen (ibuprofen: -0.47, -0.76 to -0.18; combination: -0.04, -0.31 to 0.23). Reconsultations with new/unresolved symptoms or complications were documented in 12% of those advised to take paracetamol, 20% of those advised to take ibuprofen (adjusted risk ratio 1.67, 1.12 to 2.38), and 17% of those advised to take the combination (1.49, 0.98 to 2.18). Mild thermal injury with steam was documented for four patients (2%) who returned full diaries, but no reconsultations with scalding were documented. CONCLUSION Overall advice to use steam inhalation, or ibuprofen rather than paracetamol, does not help control symptoms in patients with acute respiratory tract infections and must be balanced against the possible progression of symptoms during the next month for a minority of patients. Advice to use ibuprofen might help short term control of symptoms in those with chest infections and in children. TRIAL REGISTRATION ISRCTN 38551726.
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Affiliation(s)
- Paul Little
- University of Southampton, Aldermoor Health Centre, Southampton SO16 5ST, UK
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Ashworth M, Charlton J, Little P, Moore M, Yardley L, Gulliford M, Dregan A, Staa TV, McDermott L, McCann G. PP36 Use of Electronic Health Records to Implement a Cluster Randomised Trial in Primary Care. Br J Soc Med 2013. [DOI: 10.1136/jech-2013-203126.135] [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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Leydon GM, McDermott L, Moore M, Williamson I, Hobbs FDR, Lambton T, Cooper R, Henderson H, Little P. A qualitative study of GP, NP and patient views about the use of rapid streptococcal antigen detection tests (RADTs) in primary care: 'swamped with sore throats?'. BMJ Open 2013; 3:e002460. [PMID: 23558734 PMCID: PMC3641470 DOI: 10.1136/bmjopen-2012-002460] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2012] [Accepted: 02/05/2013] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To explore patient and healthcare professionals' (HCP) views of clinical scores and rapid streptococcal antigen detection tests (RADTs) for acute sore throat. DESIGN Qualitative semistructured interview study. SETTING UK primary care. PARTICIPANTS General practitioners (GPs), nurse practitioners (NPs) and patients from general practices across Hampshire, Oxfordshire and the West Midlands who were participating in the Primary Care Streptococcal Management (PRISM) study. METHOD Semistructured, face-to-face and phone interviews were conducted with GPs, NPs and patients from general practices across Hampshire, Oxfordshire and the West Midlands. RESULTS 51 participants took part in the study. Of these, 42 were HCPs (29 GPs and 13 NPs) and 9 were patients. HCPs could see a positive role for RADTs in terms of reassurance, as an educational tool for patients, and for aiding inexperienced practitioners, but also had major concerns about RADT use in clinical practice. Particular concerns included the validity of the tests (the role of other bacteria, and carrier states), the tension and possible disconnect with clinical assessment and intuition, the issues of time and resource use and the potential for medicalisation of self-limiting illness. In contrast, however, experience of using RADTs over time seemed to make some participants more positive about using the tests. Moreover, patients were much more positive about the place of RADTs in providing reassurance and in limiting their antibiotic use. CONCLUSIONS It is unlikely that RADTs will have a (comfortable) place in clinical practice in the near future until health professionals' concerns are met, and they have direct experience of using them. The routine use of clinical scoring systems for acute upper respiratory illness also face important barriers related to clinicians' perceptions of their utility in the face of clinician experience and intuition.
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Affiliation(s)
- Gerry M Leydon
- Department of Primary Care and Population Sciences, University of Southampton, Southampton, UK
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Dregan A, van Staa T, McDermott L, McCann G, Ashworth M, Charlton J, Wolfe C, Rudd A, Yardley L, Gulliford M. Cluster randomized trial in the general practice research database: 2. Secondary prevention after first stroke (eCRT study): study protocol for a randomized controlled trial. Trials 2012; 13:181. [PMID: 23034059 PMCID: PMC3570277 DOI: 10.1186/1745-6215-13-181] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 09/26/2012] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The purpose of this research is to develop and evaluate methods for conducting pragmatic cluster randomized trials in a primary care electronic database. The proposal describes one application, in a less frequent chronic condition of public health importance, secondary prevention of stroke. A related protocol in antibiotic prescribing was reported previously. METHODS/DESIGN The study aims to implement a cluster randomized trial (CRT) using the electronic patient records of the General Practice Research Database (GPRD) as a sampling frame and data source. The specific objective of the trial is to evaluate the effectiveness of a computer-delivered intervention at enhancing the delivery of stroke secondary prevention in primary care. GPRD family practices will be allocated to the intervention or usual care. The intervention promotes the use of electronic prompts to support adherence with the recommendations of the UK Intercollegiate Stroke Working Party and NICE guidelines for the secondary prevention of stroke in primary care. Primary outcome measure will be the difference in systolic blood pressure between intervention and control trial arms at 12-month follow-up. Secondary outcomes will be differences in serum cholesterol, prescribing of antihypertensive drugs, statins, and antiplatelet therapy. The intervention will continue for 12 months. Information on the utilization of the decision-support tools will also be analyzed. DISCUSSION The CRT will investigate the effectiveness of using a computer-delivered intervention to reduce the risk of stroke recurrence following a first stroke event. The study will provide methodological guidance on the implementation of CRTs in electronic databases in primary care. TRIAL REGISTRATION Current Controlled Trials ISRCTN35701810.
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Affiliation(s)
- Alex Dregan
- Department of Primary Care and Public Health Sciences, King's College, London, UK.
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Sexton CE, Le Masurier M, Allan CL, Jenkinson M, McDermott L, Kalu UG, Herrmann LL, Bradley KM, Mackay CE, Ebmeier KP. Magnetic resonance imaging in late-life depression: vascular and glucocorticoid cascade hypotheses. Br J Psychiatry 2012; 201:46-51. [PMID: 22753853 DOI: 10.1192/bjp.bp.111.105361] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [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] [Indexed: 01/02/2023]
Abstract
BACKGROUND Late-life depression is a common and heterogeneous illness, associated with structural abnormalities in both grey and white matter. AIMS To examine the relationship between age at onset and magnetic resonance imaging (MRI) measures of grey and white matter to establish whether they support particular hypotheses regarding the anatomy and aetiology of network disruption in late-life depression. METHOD We studied 36 participants with late-life depression. Grey matter was examined using T(1)-weighted MRI and analysed using voxel-based morphometry. The hippocampus was automatically segmented and volume and shape analysis performed. White matter was examined using diffusion tensor imaging and analysed using tract-based spatial statistics. RESULTS Later age at onset was significantly associated with reduced fractional anisotropy of widespread tracts, in particular the anterior thalamic radiation and superior longitudinal fasciculus. Earlier age at onset was associated with reduced hippocampal volume normalised to whole brain size bilaterally. However, no significant correlations were detected using hippocampal shape analysis or voxel-based morphometry. CONCLUSIONS Overall, the results were compatible with the vascular hypothesis, and provided some support for the glucocorticoid cascade hypothesis.
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Affiliation(s)
- Claire E Sexton
- University Department of Psychiatry, Warneford Hospital, Oxford, UK
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Sexton CE, McDermott L, Kalu UG, Herrmann LL, Bradley KM, Allan CL, Le Masurier M, Mackay CE, Ebmeier KP. Exploring the pattern and neural correlates of neuropsychological impairment in late-life depression. Psychol Med 2012; 42:1195-1202. [PMID: 22030013 DOI: 10.1017/s0033291711002352] [Citation(s) in RCA: 70] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Neuropsychological impairment is a key feature of late-life depression, with deficits observed across multiple domains. However, it is unclear whether deficits in multiple domains represent relatively independent processes with specific neural correlates or whether they can be explained by cognitive deficits in executive function or processing speed. METHOD We examined group differences across five domains (episodic memory; executive function; language skills; processing speed; visuospatial skills) in a sample of 36 depressed participants and 25 control participants, all aged ≥ 60 years. The influence of executive function and processing speed deficits on other neuropsychological domains was also investigated. Magnetic resonance imaging correlates of executive function, processing speed and episodic memory were explored in the late-life depression group. RESULTS Relative to controls, the late-life depression group performed significantly worse in the domains of executive function, processing speed, episodic memory and language skills. Impairments in executive function or processing speed were sufficient to explain differences in episodic memory and language skills. Executive function was correlated with anisotropy of the anterior thalamic radiation and uncinate fasciculus; processing speed was correlated with anisotropy of genu of the corpus callosum. Episodic memory was correlated with anisotropy of the anterior thalamic radiation, the genu and body of the corpus callosum and the fornix. CONCLUSIONS Executive function and processing speed appear to represent important cognitive deficits in late-life depression, which contribute to deficits in other domains, and are related to reductions in anisotropy in frontal tracts.
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Affiliation(s)
- C E Sexton
- Department of Psychiatry, University of Oxford, Oxford, UK
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Dregan A, McDermott L, McCann G, Yardley L, van Staa T, Gulliford M. P1-21 Cluster randomised trials in a healthcare database: utilising electronic patient records for intervention research. Br J Soc Med 2011. [DOI: 10.1136/jech.2011.142976c.15] [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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Gulliford MC, van Staa T, McDermott L, Dregan A, McCann G, Ashworth M, Charlton J, Grieve AP, Little P, Moore MV, Yardley L. Cluster randomised trial in the General Practice Research Database: 1. Electronic decision support to reduce antibiotic prescribing in primary care (eCRT study). Trials 2011; 12:115. [PMID: 21569237 PMCID: PMC3101122 DOI: 10.1186/1745-6215-12-115] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2011] [Accepted: 05/10/2011] [Indexed: 01/17/2023] Open
Abstract
Background The purpose of this research is to develop and evaluate methods for conducting cluster randomised trials in a primary care database that contains electronic patient records for large numbers of family practices. Cluster randomised trials are trials in which the units allocated represent groups of individuals, in this case family practices and their registered patients. Cluster randomised trials often suffer from the limitation that they include too few clusters, leading to problems of insufficient power and only imprecise estimation of the intraclass correlation coefficient, a key design parameter. This difficulty might be overcome by utilising databases that already hold electronic patient records for large numbers of practices. The protocol describes one application: a study of antibiotic prescribing for acute respiratory infection; a second protocol outlines an intervention in a less frequent chronic condition of public health importance, stroke. Methods/Design The objective of the study is to implement a cluster randomised trial to test the effectiveness of an electronic record-based intervention at achieving a reduction in antibiotic prescribing at consultations for respiratory illness in patients aged 18 and 59 years old in intervention family practices as compared with controls. Family practices will be recruited from the practices that presently contribute data to the UK General Practice Research Database (GPRD). Following randomisation, electronic prompts will be installed remotely at intervention practices to promote adherence with evidence-based standards of medical practice. The intervention was developed through qualitative research at non-intervention practices. Data for outcome assessment will be obtained from anonymised electronic patient records that are routinely collected into GPRD. This protocol outlines the proposed study designs, data sources, sample size requirements, analysis methods and dissemination plans. Ethical issues are also discussed. Discussion Results from this study will provide methodological evidence concerning the use of electronic patient records and databases for implementing cluster randomised trials in primary care. The study will also provide substantive findings in respect of electronic record-based interventions to reduce antibiotic prescribing in primary care. Trial Registration Current Controlled Trials ISRCTN 47558792.
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McDermott L, Yardley L, Little P, Ashworth M, Gulliford M. Developing a computer delivered, theory based intervention for guideline implementation in general practice. BMC Fam Pract 2010; 11:90. [PMID: 21087469 PMCID: PMC2995485 DOI: 10.1186/1471-2296-11-90] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/22/2010] [Accepted: 11/18/2010] [Indexed: 11/10/2022]
Abstract
BACKGROUND Non-adherence to clinical guidelines has been identified as a consistent finding in general practice. The purpose of this study was to develop theory-informed, computer-delivered interventions to promote the implementation of guidelines in general practice. Specifically, our aim was to develop computer-delivered prompts to promote guideline adherence for antibiotic prescribing in respiratory tract infections (RTIs), and adherence to recommendations for secondary stroke prevention. METHODS A qualitative design was used involving 33 face-to-face interviews with general practitioners (GPs). The prompts used in the interventions were initially developed using aspects of social cognitive theory, drawing on nationally recommended standards for clinical content. The prompts were then presented to GPs during interviews, and iteratively modified and refined based on interview feedback. Inductive thematic analysis was employed to identify responses to the prompts and factors involved in the decision to use them. RESULTS GPs reported being more likely to use the prompts if they were perceived as offering support and choice, but less likely to use them if they were perceived as being a method of enforcement. Attitudes towards using the prompts were also related to anticipated patient outcomes, individual prescriber differences, accessibility and presentation of prompts and acceptability of guidelines. Comments on the prompts were largely positive after modifying them based on participant feedback. CONCLUSIONS Acceptability and satisfaction with computer-delivered prompts to follow guidelines may be increased by working with practitioners to ensure that the prompts will be perceived as valuable tools that can support GPs' practice.
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Affiliation(s)
- Lisa McDermott
- School of Psychology, University of Southampton, Shakleton Building, Highfield, Southampton, UK.
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Franich R, McDermott L, Wang L, Wilkinson L, Johnston P. VENTILATION-PERFUSION SCANNING TECHNIQUES WITH JOINT HISTOGRAM ANALYSIS FOR THE DETECTION OF LUNG ABNORMALITIES. Radiother Oncol 2009. [DOI: 10.1016/s0167-8140(12)72812-8] [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: 11/29/2022]
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Dunn L, McDermott L, Franich R, Kron T, Johnston P. DEVELOPMENT OF A MOTION REPLICATION TOOL. Radiother Oncol 2009. [DOI: 10.1016/s0167-8140(12)73024-4] [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: 11/27/2022]
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Haworth A, McDermott L, Ebert M, Wiltshire K, Pearse M, Willis D, Sproston C, Thompson A, Kneebone A. DEVELOPMENT OF SOFTWARE TOOLS FOR ANALYSIS OF CLINICAL TRIAL BENCHMARKING EXERCISES. Radiother Oncol 2009. [DOI: 10.1016/s0167-8140(12)73261-9] [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: 11/28/2022]
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