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Cameron CM, Shibl R, Cramb S, McCreanor V, Proper M, Warren J, Smyth T, Carter HE, Vallmuur K, Graves N, Bradford N, Loveday B. Community Opioid Dispensing after Injury (CODI): Cohort characteristics and opioid dispensing patterns. Injury 2024; 55:111216. [PMID: 38000939 DOI: 10.1016/j.injury.2023.111216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 11/02/2023] [Accepted: 11/12/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND Despite a focus of opioid-related research internationally, there is limited understanding of long-term opioid use in adults following injury. We analysed data from the 'Community Opioid Dispensing after Injury' data linkage study. AIMS This paper aims to describe the baseline characteristics of the injured cohort and report opioid dispensing patterns following injury-related hospitalisations. METHODS Retrospective cohort study of adults hospitalised after injury (ICD-10AM: S00-S99, T00-T75) in Queensland, Australia between 1 January 2014 and 31 December 2015, prior to implementation of opioid stewardship programs. Data were person-linked between hospitalisation, community opioid dispensing and mortality collections. Data were extracted for 90-days prior to the index hospital admission, to establish opiate naivety, to 720 days after discharge. Median daily oral morphine equivalents (i.e., dose) were averaged for each 30-day interval. Cumulative duration of dispensing and dose were compared by demographic and clinical characteristics, stratified by drug dependency status. RESULTS Of the 129,684 injured adults, 61.3 % had no opioids dispensed in the 2-year follow-up period. Adults having any opioids dispensed in the community (38.7 %) were more likely older, female, to have fracture injuries and injuries with a higher severity, compared to those with no opioids dispensed. Longer durations and higher doses of opioids were seen for those with pre-injury opioid use, more hospital readmissions and repeat surgeries, as well as those who died in the 2-year follow-up period. Median dispensing duration was 24-days with a median daily end dose of 13 oral morphine equivalents. If dispensing occurred prior to the injury, duration increased 10-fold and oral morphine equivalents doubled. Adults with a documented dependency prior to, or after, the injury had significantly longer durations of use and higher doses than the rest of the cohort receiving opioids. Approximately 7 % of the total cohort continued to be dispensed opioids at 2-years post injury. CONCLUSION This is a novel population-level profile of opioid dispensing patterns following injury-related hospitalisation, described for the time period prior to the implementation of opioid stewardship programs and regulatory changes in Queensland. Detailed understanding of this pre-implementation period is critical for evaluating the impact of these changes moving forward.
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Affiliation(s)
- C M Cameron
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health; Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia.
| | - R Shibl
- School of Science Technology and Engineering, University of the Sunshine Coast, Petrie, QLD, Australia
| | - S Cramb
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health; Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - V McCreanor
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health; Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - M Proper
- Royal Brisbane & Women's Hospital, Metro North Health, Brisbane, Australia
| | - J Warren
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health; Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - T Smyth
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health
| | - H E Carter
- Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - K Vallmuur
- Jamieson Trauma Institute, Royal Brisbane and Women's Hospital, Metro North Health; Australian Centre for Health Services Innovation and Centre for Healthcare Transformation, School of Public Health and Social Work, Faculty of Health, Queensland University of Technology, Brisbane, Australia
| | - N Graves
- Health Services and Systems Research, Duke-NUS Medical School, Singapore
| | - N Bradford
- Centre for Healthcare Transformation, Queensland University of Technology, Brisbane, Australia
| | - B Loveday
- Q-Script Management Unit, Queensland Health, Brisbane, Australia
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Amundsen EJ, Odsbu I, Skurtveit SO, Gjersing L. Patterns of filled prescriptions and the association with risk of drug-induced death. A population-based nested case-control register study. Pharmacoepidemiol Drug Saf 2024; 33:e5763. [PMID: 38357780 DOI: 10.1002/pds.5763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 12/12/2023] [Accepted: 01/18/2024] [Indexed: 02/16/2024]
Abstract
PURPOSE Opioid analgesics (OA) and other pharmaceuticals have been associated with drug-induced deaths. However, there is a lack of knowledge regarding patterns of use of these pharmaceuticals in the population and regarding such associations. We identify and describe subgroups of people with different patterns of filled prescriptions of OA and other relevant pharmaceuticals and examine associations with drug-induced deaths. In addition, we estimate the proportion of drug-induced deaths with a filled OA prescription and OA as cause of death. METHODS A Norwegian population-based nested case-control register study with cases (drug-induced deaths 2010-2018, N = 2388) and population controls matched for age, gender and year of inclusion (N = 21 465). Patterns of filled prescriptions for opioid analgesics (OA), benzodiazepines and benzodiazepine-related drugs, gabapentinoids, ADHD medication and antidepressants/antipsychotics were explored by k-means cluster analysis. Associations with drug-induced deaths were estimated by conditional logistic regression adjusted for sociodemographic characteristics. Overlap of filled OA prescriptions and OA as cause of death was estimated. RESULTS Five clusters were identified: 'few prescriptions', 'weak OA', 'ADHD medication', 'sedative/psychiatric morbidity' and 'strong OA'. The 'strong OA' cluster had higher socioeconomic status compared to the other groupings. The risk of drug-induced death was also highest in this cluster (OR = 35.5; CI 25.6-49.3) and, for 68% (CI 64-73) of cases, filled prescriptions for OA was indicated as the underlying cause of death. CONCLUSIONS The cluster analysis identified a subgroup with filled prescriptions of OA and other pharmaceuticals and a higher socioeconomic status than other subgroups. This subgroup had a high risk of drug-induced death that needs to be addressed.
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Affiliation(s)
- Ellen J Amundsen
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway
| | - Ingvild Odsbu
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
| | - Svetlana O Skurtveit
- Department of Chronic Diseases, Norwegian Institute of Public Health, Oslo, Norway
- Norwegian Centre for Addiction Research (SERAF), University of Oslo, Oslo, Norway
| | - Linn Gjersing
- Department of Alcohol, Tobacco and Drugs, Norwegian Institute of Public Health, Oslo, Norway
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Crush J, Levy N, Knaggs RD, Lobo DN. The pitfalls of labelling opioids as weak or strong. Response to Br J Anaesth 2022; 129:e150-e153. Br J Anaesth 2023; 130:e16-e17. [PMID: 36939496 DOI: 10.1016/j.bja.2022.09.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 09/23/2022] [Accepted: 09/26/2022] [Indexed: 11/15/2022] Open
Affiliation(s)
- Jos Crush
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St Edmunds, UK
| | - Roger D Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, University of Nottingham, Nottingham, UK; Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre and National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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Chen Z, Wang S, Meng Z, Ye Y, Shan G, Wang X, Zhao X, Jin Y. Tau protein plays a role in the mechanism of cognitive disorders induced by anesthetic drugs. Front Neurosci 2023; 17:1145318. [PMID: 36937655 PMCID: PMC10015606 DOI: 10.3389/fnins.2023.1145318] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 02/13/2023] [Indexed: 03/08/2023] Open
Abstract
Cognitive disorders are mental health disorders that can affect cognitive ability. Surgery and anesthesia have been proposed to increase the incidence of cognitive dysfunction, including declines in memory, learning, attention and executive function. Tau protein is a microtubule-associated protein located in the axons of neurons and is important for microtubule assembly and stability; its biological function is mainly regulated by phosphorylation. Phosphorylated tau protein has been associated with cognitive dysfunction mediated by disrupting the stability of the microtubule structure. There is an increasing consensus that anesthetic drugs can cause cognitive impairment. Herein, we reviewed the latest literature and compared the relationship between tau protein and cognitive impairment caused by different anesthetics. Our results substantiated that tau protein phosphorylation is essential in cognitive dysfunction caused by anesthetic drugs, and the possible mechanism can be summarized as "anesthetic drugs-kinase/phosphatase-p-Tau-cognitive impairment".
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Crush J, Levy N, Knaggs RD, Lobo DN. Misappropriation of the 1986 WHO analgesic ladder: the pitfalls of labelling opioids as weak or strong. Br J Anaesth 2022; 129:137-142. [PMID: 35397880 DOI: 10.1016/j.bja.2022.03.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 02/22/2022] [Accepted: 03/01/2022] [Indexed: 12/18/2022] Open
Abstract
Opioids have a vital role in alleviating pain from cancer and surgery. Despite good intentions, it is now recognised that the original WHO Cancer Pain Relief guidance from 1986, in which opioids were classified as either weak or strong, has been both inadvertently and purposefully misused, thereby contributing to harm from opioid use and misuse. However, the recommendation in the 2018 update of the WHO analgesic ladder that a combination of a high-potency opioid with simple analgesics is better than alternative analgesics for the maintenance of pain relief is also applicable to patients who require short-term opioids. Furthermore, because potential harm through opioid use and misuse is intrinsic to all opioids, whether weak or strong, we argue that the arbitrary classification of opioids either as weak or strong should be discontinued, as this description is not helpful to either prescribers or consumers.
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Affiliation(s)
- Jos Crush
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St. Edmunds, UK
| | - Nicholas Levy
- Department of Anaesthesia and Perioperative Medicine, West Suffolk Hospital NHS Foundation Trust, Bury St. Edmunds, UK
| | - Roger D Knaggs
- Division of Pharmacy Practice and Policy, School of Pharmacy, UK; Pain Centre Versus Arthritis, University of Nottingham, Nottingham, UK
| | - Dileep N Lobo
- Nottingham Digestive Diseases Centre, National Institute for Health Research Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and University of Nottingham, Queen's Medical Centre, Nottingham, UK; MRC Versus Arthritis Centre for Musculoskeletal Ageing Research, School of Life Sciences, University of Nottingham, Queen's Medical Centre, Nottingham, UK.
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Check DK, Avecilla RAV, Mills C, Dinan MA, Kamal AH, Murphy B, Rezk S, Winn A, Oeffinger KC. Opioid Prescribing and Use Among Cancer Survivors: A Mapping Review of Observational and Intervention Studies. J Pain Symptom Manage 2022; 63:e397-e417. [PMID: 34748896 DOI: 10.1016/j.jpainsymman.2021.10.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2021] [Revised: 10/22/2021] [Accepted: 10/23/2021] [Indexed: 12/12/2022]
Abstract
CONTEXT Recent years show a sharp increase in research on opioid use among cancer survivors, but evidence syntheses are lacking, leaving knowledge gaps. Corresponding research needs are unclear. OBJECTIVES To provide an evidence synthesis. METHODS We searched PubMed and Embase, identifying articles related to cancer, and opioid prescribing/use published through September 2020. We screened resulting titles/abstracts. Relevant studies underwent full-text review. Inclusion criteria were quantitative examination of and primary focus on opioid prescribing or use, and explicit inclusion of cancer survivors. Exclusion criteria included end-of-life opioid use and opioid use as a secondary or downstream outcome (for intervention studies). We extracted information on the opioid-related outcome(s) examined (including definitions and terminology used), study design, and methods. RESULTS Research returned 16,591 articles; 296 were included. Only 22 of 296 studies evaluated an intervention. There were 105 studies evaluating outcomes indicative of potentially high-risk, nonrecommended, or avoidable opioid use, e.g., continuous use-described as chronic use, prolonged use, and persistent use (n = 17); use after completion of curative-intent treatment-described as chronic opioid use, long-term opioid use, persistent opioid use, prolonged opioid use, continued opioid use, late opioid use, post-treatment opioid use (n = 27); use of opioids concurrent with other potentially high-risk medications (n = 13), and opioid misuse (n = 14). CONCLUSIONS We found lack of consistency in the measurement of and terms used to describe similar opioid use outcomes, and a lack of interventional research targeting well-documented patterns of potentially nonrecommended, potentially avoidable, or potentially high-risk opioid prescribing or use.
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Affiliation(s)
- Devon K Check
- Department of Population Health Sciences, Duke University School of Medicine (D.K.C.), Durham, North Carolina; Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina.
| | - Renee A V Avecilla
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Coleman Mills
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina
| | - Michaela A Dinan
- Department of Chronic Disease Epidemiology, Yale School of Public Health (M.A.D.), New Haven, Connecticut; Cancer Outcomes, Public Policy and Effectiveness Research (COPPER) Center, Yale Cancer Center (M.A.D.), New Haven, Connecticut
| | - Arif H Kamal
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University Medical Center (A.H.K.), Durham, North Carolina
| | - Beverly Murphy
- Duke University Medical Center Library & Archives, Duke University School of Medicine (B.M.), Durham, North Carolina
| | - Salma Rezk
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy (S.R.), Chapel Hill, North Carolina
| | - Aaron Winn
- School of Pharmacy, Medical College of Wisconsin (A.W.), Milwaukee, Wisconsin
| | - Kevin C Oeffinger
- Duke Cancer Institute, Duke University Medical Cente (D.K.C., R.A.A., C.M., A.H.K., K.C.O.), Durham, North Carolina; Department of Medicine, Duke University School of Medicine (K.C.O.), Durham, North Carolina
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Havens JR, Knudsen HK, Strickland JC, Young AM, Babalonis S, Lofwall MR, Walsh SL. Recent Increase in Methamphetamine Use in a Cohort of Rural People Who Use Drugs: Further Evidence for the Emergence of Twin Epidemics. Front Psychiatry 2021; 12:805002. [PMID: 35069295 PMCID: PMC8777215 DOI: 10.3389/fpsyt.2021.805002] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 12/16/2021] [Indexed: 01/14/2023] Open
Abstract
Appalachian Kentucky was at the epicenter of the prescription opioid epidemic in the early 2000's. As we enter the third decade of the epidemic, patterns have begun to emerge as people who use drugs (PWUD) transition from use of opioids to other drugs. The purpose of this analysis was to examine longitudinal changes in methamphetamine use in an ongoing cohort of rural people who use drugs (PWUD) in Appalachian Kentucky. All but five of the cohort participants (N = 503) reported nonmedical prescription opioid use (NMPOU) at baseline and those 498 are included in this longitudinal analysis encompassing eight waves of data (2008-2020). Past 6-month use of methamphetamine was the dependent variable. Given the correlated nature of the data, mixed effects logistic regression was utilized to examine changes in methamphetamine use over time. Significant increases in methamphetamine use were observed over the past decade in this cohort of PWUD, especially in recent years (2017-2020). Prevalence of recent use at baseline and each of the follow-up visits was as follows: 9.4, 5.6, 5.0, 5.4, 8.1, 6.8, 6.9, and 33.1%, respectively (p < 0.001). On the contrary, significant reductions in NMPO and heroin use were observed in the same time period. The odds of methamphetamine use at the most recent visit were 25.8 times greater than at baseline (95% CI: 14.9, 44.6) and 52.6% of those reporting methamphetamine use reported injecting the drug. These results provide further evidence of "twin epidemics" of methamphetamine use among NMPOU. While problematic on several fronts, of particular concern is the lack of effective treatment options for methamphetamine use disorder. As policies around the opioid epidemic continue to evolve, particular attention should be paid to the surge in stimulant use in opioid-endemic areas.
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Affiliation(s)
- Jennifer R Havens
- Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Hannah K Knudsen
- Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Justin C Strickland
- Department of Psychiatry and Behavioral Sciences, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - April M Young
- Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, United States.,Department of Epidemiology, University of Kentucky College of Public Health, Lexington, KY, United States
| | - Shanna Babalonis
- Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Michelle R Lofwall
- Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, United States
| | - Sharon L Walsh
- Department of Behavioral Science, Center on Drug and Alcohol Research, University of Kentucky College of Medicine, Lexington, KY, United States
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Richards GC, Mahtani KR, Muthee TB, DeVito NJ, Koshiaris C, Aronson JK, Goldacre B, Heneghan CJ. Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis. BMC Med 2020; 18:68. [PMID: 32223746 PMCID: PMC7104520 DOI: 10.1186/s12916-020-01528-7] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 02/12/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care. METHODS We conducted a systematic review of observational studies in high-income countries that used patient-level primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNTH) calculation on factors when applicable. RESULTS We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I2 = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I2 = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I2 = 0%, NNTH 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I2 = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I2 = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care. CONCLUSIONS High doses of opioids are associated with greater risks of harms. Associated factors such as the co-prescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed. STUDY REGISTRATION PROSPERO, CRD42018088057.
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Affiliation(s)
- Georgia C Richards
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK. .,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.
| | - Kamal R Mahtani
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Tonny B Muthee
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Nicholas J DeVito
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,EBMDatalab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Constantinos Koshiaris
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Ben Goldacre
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,EBMDatalab, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
| | - Carl J Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK.,Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG, UK
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