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Shepherd V, Wood F, Gillies K, O'Connell A, Martin A, Hood K. Recruitment interventions for trials involving adults lacking capacity to consent: methodological and ethical considerations for designing Studies Within a Trial (SWATs). Trials 2022; 23:756. [PMID: 36068637 PMCID: PMC9450319 DOI: 10.1186/s13063-022-06705-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 08/30/2022] [Indexed: 12/01/2022] Open
Abstract
BACKGROUND The number of interventions to improve recruitment and retention of participants in trials is rising, with a corresponding growth in randomised Studies Within Trials (SWATs) to evaluate their (cost-)effectiveness. Despite recognised challenges in conducting trials involving adults who lack capacity to consent, until now, no individual-level recruitment interventions have focused on this population. Following the development of a decision aid for family members making non-emergency trial participation decisions on behalf of people with impaired capacity, we have designed a SWAT to evaluate the decision aid in a number of host trials (CONSULT). Unlike in recruitment SWATs to date, the CONSULT intervention is aimed at a 'proxy' decision-maker (a family member) who is not a participant in the host trial and does not receive the trial intervention. This commentary explores the methodological and ethical considerations encountered when designing such SWATs, using the CONSULT SWAT as a case example. Potential solutions to address these issues are also presented. DISCUSSION We encountered practical issues around informed consent, data collection, and follow-up which involves linking the intervention receiver (the proxy) with recruitment and retention data from the host trial, as well as issues around randomisation level, resource use, and maintaining the integrity of the host trial. Unless addressed, methodological uncertainty about differential recruitment and heterogeneity between trial populations could potentially limit the scope for drawing robust inferences and harmonising data from different SWAT host trials. Proxy consent is itself ethically complex, and so when conducting a SWAT which aims to disrupt and enhance proxy consent decisions, there are additional ethical issues to be considered. CONCLUSIONS Designing a SWAT to evaluate a recruitment intervention for non-emergency trials with adults lacking capacity to consent has raised a number of methodological and ethical considerations. Explicating these challenges, and some potential ways to address them, creates a starting point for discussions about conducting these potentially more challenging SWATs. Increasing the evidence base for the conduct of trials involving adults lacking capacity to consent is intended to improve both the ability to conduct these trials and their quality, and so help build research capacity for this under-served population.
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Affiliation(s)
- Victoria Shepherd
- Centre for Trials Research, Cardiff University, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Fiona Wood
- Division of Population Medicine, School of Medicine, Cardiff University, 8th floor Neuadd Meirionnydd, Heath Park, Cardiff, UK
- PRIME Centre Wales, School of Medicine, Cardiff University, 8th floor Neuadd Meirionnydd, Heath Park, Cardiff, UK
| | - Katie Gillies
- Health Services Research Unit, University of Aberdeen, Health Sciences Building, Foresterhill, Aberdeen, UK
| | - Abby O'Connell
- Exeter Clinical Trials Unit, University of Exeter, Exeter, UK
| | - Adam Martin
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK
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Shepherd V, Islam I, Wood F, Williamson PR, Goodman C, Bath PM, Thompson C, Knapp M, Gordon AL, Hood K. Development of a core outcome set for the evaluation of interventions to prevent COVID-19 in care homes (COS-COVID-PCARE Study). BMC Geriatr 2022; 22:710. [PMID: 36028791 PMCID: PMC9417927 DOI: 10.1186/s12877-022-03395-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Accepted: 08/18/2022] [Indexed: 12/05/2022] Open
Abstract
Background People living in care homes have experienced devastating impact from COVID-19. As interventions to prevent the transmission of COVID-19 are developed and evaluated, there is an urgent need for researchers to agree on the outcomes used when evaluating their effectiveness. Having an agreed set of outcomes that are used in all relevant trials can ensure that study results can be compared. Objective The aim of the study was to develop a core outcome set (COS) for trials assessing the effectiveness of pharmacological and non-pharmacological interventions for preventing COVID-19 infection and transmission in care homes. Methods The study used established COS methodology. A list of candidate outcomes was identified by reviewing registered trials to evaluate interventions to prevent COVID-19 in care homes. Seventy key stakeholders participated in a Delphi survey, rating the candidate outcomes on a nine-point scale over two rounds, with the opportunity to propose additional outcomes. Stakeholders included care home representatives (n = 19), healthcare professionals (n = 20), people with personal experience of care homes (n = 7), researchers (n = 15) and others (n = 9). Outcomes were eligible for inclusion if they met an a priori threshold. A consensus meeting with stakeholders resulted in agreement of the final outcome set. Results Following the Delphi and consensus meeting, twenty-four outcomes were recommended for inclusion. These are grouped across four domains of infection, severity of illness, mortality, and ‘other’ (intervention specific or life impact). Due to the considerable heterogeneity between care homes, residents, and interventions, the relevance and importance of outcomes may differ between trial contexts. Intervention-specific outcomes would be included only where relevant to a given trial, thus reducing the measurement burden. Conclusion Using a rapid response approach, a COS for COVID-19 prevention interventions in care homes has been developed. Future work should focus on identifying instruments for measuring these outcomes, and the interpretation and application of the COS across different trial contexts. Beyond COVID-19, the outcomes identified in this COS may have relevance to other infectious diseases in care homes, and the rapid response approach may be useful as preparation for future pandemics. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03395-8.
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Affiliation(s)
- Victoria Shepherd
- Centre for Trials Research, Cardiff University, 4th floor Neuadd Meirionnydd, Heath Park, CF14 4YS, Cardiff, UK.
| | - Ishrat Islam
- PRIME Centre Wales, Wales, UK.,Division of Population Medicine, Cardiff University, Cardiff, Wales, UK
| | - Fiona Wood
- PRIME Centre Wales, Wales, UK.,Division of Population Medicine, Cardiff University, Cardiff, Wales, UK
| | | | - Claire Goodman
- Centre for Research in Public Health and Community Care (CRIPACC, University of Hertfordshire, Hatfield, UK.,NIHR Applied Research Collaboration (ARC) East of England Cambridge, Cambridge, UK
| | - Philip M Bath
- Stroke Trials Unit, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, UK
| | - Carl Thompson
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | - Martin Knapp
- Care Policy and Evaluation Centre, London School of Economics and Political Science, London, UK
| | - Adam L Gordon
- Unit of Inflammation, Injury and Recovery Sciences, School of Medicine, University of Nottingham, Nottingham, UK.,NIHR Applied Research Collaboration-East Midlands (ARC-EM), Nottingham, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, 4th floor Neuadd Meirionnydd, Heath Park, CF14 4YS, Cardiff, UK
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Zhang L, Zeng X, Guo D, Zou Y, Gan H, Huang X. Early use of probiotics might prevent antibiotic-associated diarrhea in elderly (>65 years): a systematic review and meta-analysis. BMC Geriatr 2022; 22:562. [PMID: 35794520 PMCID: PMC9260993 DOI: 10.1186/s12877-022-03257-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 06/29/2022] [Indexed: 02/08/2023] Open
Abstract
Background Antibiotic-associated diarrhea (AAD) is diarrhea associated with consuming antibiotics that cannot be explained by other causes. AAD prolongs admission time and increases mortality and financial costs. Elderly individuals are more prone to receive antibiotic treatment and develop AAD. The finding that living probiotic microorganisms decrease AAD incidence in adults (<65 years) has been clarified. However, it is controversial among elderly individuals. Methods We aimed to explore whether probiotics could prevent AAD in elderly individuals. We searched three electronic databases (PubMed, EMBASE, and The Cochrane Library), and two reviewers independently screened and assessed the studies. RevMan5.4 software was used to perform a meta-analysis according to the PRISMA guidelines. Results Eight RCTs of 4691 participants were included. We excluded two large studies because probiotics were used 48 hours after the first dose of antibiotics, and there was no effect. Subgroup analysis of 6 RCTs showed that probiotics given within two days of antibiotic treatment produced a lower AAD prevalence rate in elderly individuals. Conclusion We recommend that elderly individuals could be routinely distributed probiotics to prevent AAD development when receiving antibiotic treatment. Trial registration The review was not registered. Supplementary Information The online version contains supplementary material available at 10.1186/s12877-022-03257-3.
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Affiliation(s)
- Liying Zhang
- The Center of Gerontology and Geriatrics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaofeng Zeng
- The Center of Gerontology and Geriatrics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Daxin Guo
- The Center of Gerontology and Geriatrics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Yupei Zou
- The Center of Gerontology and Geriatrics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Huatian Gan
- The Center of Gerontology and Geriatrics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.,Laboratory of Inflammatory bowel disease, the Center for Inflammatory Bowel Disease, Clinical Institute of Inflammation and Immunology, Frontiers Science Center for Disease-related Molecular Network, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Xiaoli Huang
- The Center of Gerontology and Geriatrics, National Clinical Research Center for Geriatrics, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China.
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Shepherd V, Hood K, Wood F. Unpacking the 'black box of horrendousness': a qualitative exploration of the barriers and facilitators to conducting trials involving adults lacking capacity to consent. Trials 2022; 23:471. [PMID: 35668460 PMCID: PMC9167903 DOI: 10.1186/s13063-022-06422-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 05/24/2022] [Indexed: 11/10/2022] Open
Abstract
Background Trials involving adults who lack capacity to consent encounter a range of ethical and methodological challenges, resulting in these populations frequently being excluded from research. Currently, there is little evidence regarding the nature and extent of these challenges, nor strategies to improve the design and conduct of such trials. This qualitative study explored researchers’ and healthcare professionals’ experiences of the barriers and facilitators to conducting trials involving adults lacking capacity to consent. Methods Semi-structured interviews were conducted remotely with 26 researchers and healthcare professionals with experience in a range of roles, trial populations and settings across the UK. Data were analysed using thematic analysis. Results A number of inter-related barriers and facilitators were identified and mapped against key trial processes including during trial design decisions, navigating ethical approval, assessing capacity, identifying and involving alternative decision-makers and when revisiting consent. Three themes were identified: (1) the perceived and actual complexity of trials involving adults lacking capacity, (2) importance of having access to appropriate support and resources and (3) need for building greater knowledge and expertise to support future trials. Barriers to trials included the complexity of the legal frameworks, the role of gatekeepers, a lack of access to expertise and training, and the resource-intensive nature of these trials. The ability to conduct trials was facilitated by having prior experience with these populations, effective communication between research teams, public involvement contributions, and the availability of additional data to inform the trial. Participants also identified a range of context-specific recruitment issues and highlighted the importance of ‘designing in’ flexibility and the use of adaptive strategies which were especially important for trials during the COVID-19 pandemic. Participants identified a need for better training and support. Conclusions Researchers encountered a number of barriers, including both generic and context or population-specific challenges, which may be reinforced by wider factors such as resource limitations and knowledge deficits. Greater access to expertise and training, and the development of supportive interventions and tailored guidance, is urgently needed in order to build research capacity in this area and facilitate the successful delivery of trials involving this under-served population.
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Affiliation(s)
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Fiona Wood
- PRIME Centre Wales, Cardiff, UK.,Division of Population Medicine, Cardiff University, Cardiff, UK
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Sommermeyer H, Pituch HM, Wultanska D, Wojtyla-Buciora P, Piatek J, Bernatek M. Inhibition of Quinolone- and Multi-Drug-Resistant Clostridioides Difficile Strains by Multi Strain Synbiotics-An Option for Diarrhea Management in Nursing Facilities. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18115871. [PMID: 34070727 PMCID: PMC8198539 DOI: 10.3390/ijerph18115871] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/24/2021] [Revised: 05/18/2021] [Accepted: 05/28/2021] [Indexed: 12/17/2022]
Abstract
Diarrhea is a common problem in nursing homes. A survey among nursing facilities in Poland was used to characterize diarrhea outbreaks, the burden caused for residents and caregivers and the employed measures. Survey results confirmed that diarrhea is a common problem in nursing homes and in most cases affects groups of residents. The related burden is high or very high for 27% of residents and 40% of caregivers. In 80% of nursing facilities pro or synbiotics are part of the measures used to manage diarrhea. Administration of these kinds of products has been suggested for the management of diarrhea, especially in cases caused by Clostridioides (C.) difficile. C. difficile is one of many potential causes for diarrhea, but is of particular concern for nursing homes because it is responsible for a large proportion of diarrhea outbreaks and is often caused by multi-drug resistant strains. In vitro inhibition of a quinolone-resistant and a multi-drug resistant C. difficile strain was used to evaluate the growth inhibitory effects of commonly used products containing probiotic microorganisms. Growth of both strains was best inhibited by multi-strain synbiotic preparations. These findings suggest that multi-strain synbiotics can be considered as an interventional option for diarrhea caused by C. difficile.
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Affiliation(s)
- Henning Sommermeyer
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
| | - Hanna M. Pituch
- Department of Medical Microbiology, Medical University of Warsaw, ul. Żwirki i Wigury 61, 02-091 Warsaw, Poland; (H.M.P.); (D.W.)
| | - Dorota Wultanska
- Department of Medical Microbiology, Medical University of Warsaw, ul. Żwirki i Wigury 61, 02-091 Warsaw, Poland; (H.M.P.); (D.W.)
| | - Paulina Wojtyla-Buciora
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
| | - Jacek Piatek
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
- Correspondence: ; Tel.: +48-883389788
| | - Malgorzata Bernatek
- Department of Health Sciences, Calisia University-Kalisz, Nowy Swiat 4, 62-800 Kalisz, Poland; (H.S.); (P.W.-B.); (M.B.)
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Shepherd V. How nurses can support the inclusion in research of older people who lack capacity to consent. Nurs Older People 2021; 33:26-31. [PMID: 33084258 DOI: 10.7748/nop.2020.e1267] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/15/2020] [Indexed: 11/09/2022]
Abstract
Research is important because it underpins evidence-based care. However, people who lack capacity to consent are often excluded from research, due partly to ethical concerns and practical challenges, and partly to a lack of awareness among professionals of the legal framework that supports their inclusion. The COVID-19 pandemic, which has extensively affected care home residents, has reinforced the importance of including older people with cognitive impairment in research. Nurses who care for older people with impaired cognition have an important role in ensuring these people have the opportunity to contribute to and benefit from research. This article discusses some of the challenges associated with the inclusion in research of older people who lack capacity to consent, including the involvement of relatives and friends in decision-making. The article describes the findings of recent research and shares resources with the aim of supporting nurses to ensure that older people in their care who lack capacity can participate in research.
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Shepherd V. Advances and challenges in conducting ethical trials involving populations lacking capacity to consent: A decade in review. Contemp Clin Trials 2020; 95:106054. [PMID: 32526281 PMCID: PMC7832147 DOI: 10.1016/j.cct.2020.106054] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 05/21/2020] [Accepted: 06/03/2020] [Indexed: 01/28/2023]
Abstract
Informed consent is an essential requirement prior to clinical trial participation, however some 'vulnerable' groups, such as people with cognitive impairments and those in medical emergency situations, may lack decisional capacity to consent. This raises ethical and practical challenges when designing and conducting clinical trials involving these populations, who are frequently excluded as a result. Despite recent advances in improving informed consent processes, there has been far less attention paid to the enrolment of adults lacking capacity. Exclusion criteria are an important determinant of the external validity of clinical trial results. The exclusion of these populations, and consent-based recruitment biases which arise from the challenges of identifying and involving surrogate decision-makers, leads to trials which are not representative of the clinical population. This article discusses the involvement of adults who lack decisional capacity to consent in clinical trials and presents the advances over the previous decade and the remaining ethical challenges for the inclusion of this under-represented population in research.
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Affiliation(s)
- Victoria Shepherd
- Centre for Trials Research, 4th floor Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK.
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8
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Shepherd V. An under-represented and underserved population in trials: methodological, structural, and systemic barriers to the inclusion of adults lacking capacity to consent. Trials 2020; 21:445. [PMID: 32471488 PMCID: PMC7257506 DOI: 10.1186/s13063-020-04406-y] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/11/2020] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND There is increasing international recognition that populations included in trials should adequately represent the population treated in clinical practice; however, adults who lack the capacity to provide informed consent are frequently excluded from trials. Addressing the under-representation of groups such as those with impaired capacity to consent is essential to develop effective interventions and provide these groups with the opportunity to benefit from evidence-based care. While the spotlight has been on ensuring only appropriate and justifiable exclusion criteria are used in trials, barriers to the inclusion of adults lacking capacity are multifactorial and complex, and addressing their under-representation will require more than merely widening eligibility criteria. This commentary draws on the literature exploring the inclusion of adults lacking the capacity to consent in research and a number of recent studies to describe the methodological, structural, and systemic factors that have been identified. MAIN TEXT A number of potentially modifiable factors contributing to the under-representation of adults lacking the capacity to consent in trials have been identified. In addition to restrictive eligibility criteria, methodological issues include developing appropriate interventions and outcome measures for populations with impaired capacity. Structurally determined factors include the resource-intensive nature of these trials, the requirement for more appropriate research infrastructure, and a lack of interventions to inform and support proxy decision-makers. Systemic factors include the complexities of the legal frameworks, the challenges of ethical review processes, and paternalistic attitudes towards protecting adults with incapacity from the perceived harms of research. CONCLUSIONS Measures needed to address under-representation include greater scrutiny of exclusion criteria by those reviewing study proposals, providing education and training for personnel who design, conduct, and review research, ensuring greater consistency in the reviews undertaken by research ethics committees, and extending processes for advance planning to include prospectively appointing a proxy for research and documenting preferences about research participation. Negative societal and professional attitudes towards the inclusion of adults with impaired capacity in research should also be addressed, and the development of trials that are more person-centred should be encouraged. Further work to conceptualise under-representation in trials for such populations may also be helpful.
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van Wietmarschen HA, Busch M, van Oostveen A, Pot G, Jong MC. Probiotics use for antibiotic-associated diarrhea: a pragmatic participatory evaluation in nursing homes. BMC Gastroenterol 2020; 20:151. [PMID: 32404062 PMCID: PMC7222499 DOI: 10.1186/s12876-020-01297-w] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2019] [Accepted: 05/06/2020] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Antibiotic-associated diarrhea (AAD) occurs in 2-25% of nursing home residents, which may lead to dehydration, malnutrition, severe complications and hospitalizations. Research shows that probiotics can be effective and safe in reducing AAD. However, probiotics are not routinely used in Dutch nursing homes. The objectives of this evaluation were to develop a procedure for the implementation of probiotics to prevent AAD in nursing homes, to evaluate effects on AAD occurrence, and to evaluate the implementation process of probiotics in daily care. METHODS A pragmatic participatory evaluation (PPE) design was chosen, as it seemed a suitable approach for implementation of probiotics, as well as for evaluation of its effectiveness in daily nursing home practice. Probiotics administration was implemented in three nursing homes of the Rivas Zorggroep for residents with somatic and/or psychogeriatric conditions. Ninety-three residents provided data on 167 episodes of antibiotics use, of which 84 episodes that included supplementation with probiotics and 83 episodes with no probiotics supplementation. A multispecies probiotics was administered twice daily upon start of antibiotic treatment, up to 1 week after completing the antibiotics course. The occurrence of AAD was monitored and a process evaluation was conducted to assess facilitators and barriers of probiotics implementation. RESULTS The number of episodes with AAD when using probiotics was significantly lower than when no probiotics was used (20% vs 36%; p = 0,022, Chi-square). No significant differences in the occurrence of AAD were found between the residents taking amoxicillin/clavulanic acid or ciprofloxacin. Reported facilitators for implementation were perceived benefits of probiotics and prescription by medical staff. Reported challenges were probiotics intake by residents and individual decision-making as to which resident would benefit from it. CONCLUSION Successful implementation of probiotics demonstrated the prevention of AAD in nursing home residents. TRIAL REGISTRATION ISRCTN 94786163, retrospectively registered on 3 February 2020.
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Affiliation(s)
- Herman A van Wietmarschen
- Department Nutrition & Health, Louis Bolk Institute, Kosterijland 3-5, 3981, Bunnik, AJ, The Netherlands.
| | - Martine Busch
- Van Praag Institute, Springweg 7, 3511, Utrecht, VH, The Netherlands
| | | | - Gerda Pot
- Department Nutrition & Health, Louis Bolk Institute, Kosterijland 3-5, 3981, Bunnik, AJ, The Netherlands
| | - Miek C Jong
- Department of Health Sciences, Mid Sweden University, Holmgatan 10, 851 70, Sundsvall, Sweden
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Shepherd V, Wood F, Griffith R, Sheehan M, Hood K. Protection by exclusion? The (lack of) inclusion of adults who lack capacity to consent to research in clinical trials in the UK. Trials 2019; 20:474. [PMID: 31382999 PMCID: PMC6683336 DOI: 10.1186/s13063-019-3603-1] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 07/19/2019] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Around two million adults in the UK have significantly impaired decision-making capacity. However, there are concerns that this population is under-represented in research, due in part to the challenges around obtaining consent. Under-representation of populations denies those who would have wanted to participate the opportunity to make a contribution to society, but also fails to generate results that are applicable to them. Consequently, the evidence base for their care is poorer than for other populations. We recently published in this journal an analysis of Participant Information Sheets provided to consultees and legal representatives of adults who lack capacity and noted the small number of trials designed to include adults who lack capacity. In order to understand how many adults who lack capacity to consent are actually enrolled in clinical trials, we further explored how many of the participants lacked capacity, and who acted as a consultee or legal representative on their behalf. MAIN TEXT The ISRCTN registry was searched for UK clinical trials in conditions commonly associated with cognitive impairment that were designed to include (or not exclude) adults who lack capacity to consent. Details about participants and capacity status were obtained from published data or directly from the trial teams. Of the 80 retrieved clinical trials that had completed in the previous 3 years, we identified 15 which included adults who lack capacity to consent. Data regarding participants' capacity status were not available for five trials. Where capacity was reported, 5-100% participants lacked capacity to consent. Trials predominantly utilised personal consultees/legal representatives; however, 39% (634/1631) of participants required a professional to act as consultee/legal representative. CONCLUSIONS Only a small number of trials including adults who lacked capacity were identified. The majority of participants were represented by a personal consultee/legal representative; however, between 21 and 100% of participants across five trials required the involvement of a professional, suggesting it is not uncommon. Data relating to capacity status were rarely reported, potentially masking the under-representation of adults who lack capacity. The findings may help researchers and funders target resources towards studies involving under-represented populations to increase the much-needed evidence base for their care and treatment.
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Affiliation(s)
- Victoria Shepherd
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS UK
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
| | - Fiona Wood
- Division of Population Medicine, Cardiff University, Heath Park, Cardiff, CF14 4YS UK
| | - Richard Griffith
- College of Human and Health Studies, Swansea University, Singleton Park, Swansea, SA2 8PP UK
| | - Mark Sheehan
- Ethox Centre, University of Oxford, Big Data Institute, Old Road Campus, Oxford, OX3 7LF UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS UK
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Characterization of bacterial community changes and antibiotic resistance genes in lamb manure of different incidence. Sci Rep 2019; 9:10101. [PMID: 31300748 PMCID: PMC6625992 DOI: 10.1038/s41598-019-46604-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 07/02/2019] [Indexed: 01/08/2023] Open
Abstract
Bacterial enteritis is the most important disease in lamb for breeding greatly affects the growth of animals. Changes in the community of intestinal flora can cause the disorder of the colonic environment induced diarrhea. This study aimed to investigate the relationship between the incidence of bacterial enteritis and the number of intestinal microbiome, then the prevalence of drug-resistant genes was detected. Fecal samples were collected at five fattening sheep farms with different incidence of bacterial enteritis, pathogenic bacteria were isolated and identified, drug sensitivity tests were performed. Then, changes in number and structure of intestinal flora were compared by 16S rDNA V3-V4 region high-throughput sequencing, and the ARGs were detected using high-throughput real-time PCR. Our results revealed that the microbial communities were positively correlated with the incidence of bacterial enteritis in different farms. Bacterial communities were higher in YJ (with highest incidence of diarrhea) than any other farms. However, the ARGs seemed not to be more affected by the incidence of bacterial enteritis, but one of the significant findings to emerge from this study is that MCR-1 and NDM are detected in manure. This study has provided an insight of the changes occurring in intestinal flora and AGRs in fattening sheep farms with diverse incidence of bacterial enteritis.
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Owen-Jones E, Lowe R, Lown M, Gillespie D, Addison K, Bayer T, Calder PC, Davies J, Davoudianfar M, Downs J, Edwards A, Francis NA, Fuller R, Hobbs R, Hood K, Lau M, Little P, Moore M, Shepherd V, Stanton H, Toghill A, Wootton M, Butler CC. Protocol for a double-blind placebo-controlled trial to evaluate the efficacy of probiotics in reducing antibiotics for infection in care home residents: the Probiotics to Reduce Infections iN CarE home reSidentS (PRINCESS) trial. BMJ Open 2019; 9:e027513. [PMID: 31227535 PMCID: PMC6596947 DOI: 10.1136/bmjopen-2018-027513] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
INTRODUCTION Care home residents are at increased risk of infections and antibiotic prescription. Reduced antibiotic use from fewer infections would improve quality of life. The Probiotics to Reduce Infections iN CarE home reSidentS (PRINCESS) trial aims to determine the efficacy and investigate mechanisms of daily probiotics on antibiotic use and incidence of infections in care home residents. METHODS AND ANALYSIS PRINCESS is a double-blind, individually randomised, placebo-controlled trial that will assess the effect of a daily oral probiotic combination of Lactobacillus rhamnosus, GG (LGG) and Bifidobacterium animalis subsp. lactis, BB-12 (BB-12) on cumulative antibiotic administration days (CAADs) (primary outcome) for infection in up to 330 care home residents aged ≥65 years over up to 12 months. Secondary outcomes include: Infection: Total number of days of antibiotic administration for each infection type (respiratory tract infection, urinary tract infection, gastrointestinal infection, unexplained fever and other); number, site, duration of infection; estimation of incidence and duration of diarrhoea and antibiotic-associated diarrhoea; Stool microbiology: Clostridium difficile infection; Gram-negative Enterobacteriaceae and vancomycin-resistant enterococci; LGG and BB-12. Oral microbiology: Candida spp. Health and well-being: Self and/or proxy health-related quality of life EQ5D (5 L); self-and/or proxy-reported ICEpop CAPability measure for older people. Hospitalisations: number and duration of all-cause hospital stays. Mortality: deaths. Mechanistic immunology outcomes: influenza vaccine efficacy (haemagglutination inhibition assay and antibody titres); full blood count and immune cell phenotypes, plasma cytokines and chemokines; cytokine and chemokine response in whole blood stimulated ex vivo by toll-like receptor 2 and 4 agonists; monocyte and neutrophil phagocytosis of Escherichia coli; serum vitamin D. ETHICS AND DISSEMINATION Ethics approval is from the Wales Research Ethics Committee 3. Findings will be disseminated through peer-reviewed journals and conferences; results will be of interest to patient and policy stakeholders. TRIAL REGISTRATION NUMBER ISRCTN16392920; Pre-results.
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Affiliation(s)
| | - Rachel Lowe
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mark Lown
- Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | | | - Katy Addison
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Tony Bayer
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Cardiff University, Cardiff, UK
| | - Philip C Calder
- Human Development & Health, Faculty of Medicine, University of Southampton, Southampton, UK
- NIHR Southampton Biomedical Research Centre, University of Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Jane Davies
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mina Davoudianfar
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | | | - Alison Edwards
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Nick A Francis
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Cardiff University, Cardiff, UK
| | - Richard Fuller
- Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Richard Hobbs
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Mandy Lau
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Michael Moore
- Primary Care and Population Sciences, University of Southampton, Aldermoor Health Centre, Southampton, UK
| | - Victoria Shepherd
- Division of Population Medicine, School of Medicine, Neuadd Meirionnydd, Cardiff University, Cardiff, UK
| | - Helen Stanton
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | | | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales Microbiology Cardiff, University Hospital of Wales, Cardiff, UK
| | - Chris C Butler
- Clinical Trials Unit, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Research involving adults lacking capacity to consent: a content analysis of participant information sheets for consultees and legal representatives in England and Wales. Trials 2019; 20:233. [PMID: 31023383 PMCID: PMC6482489 DOI: 10.1186/s13063-019-3340-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Accepted: 04/02/2019] [Indexed: 11/10/2022] Open
Abstract
Background Research involving adults who lack the capacity to provide informed consent can be challenging. In England and Wales there are legal provisions for consulting with others who know the person with impaired capacity. The role of the ‘proxy’ (or ‘surrogate’) is to advise researchers about the person’s wishes and feelings or to provide consent on the person’s behalf for a clinical trial of a medicine. Information about the study is usually provided to the proxy; however, little information is available to proxies about their role, or the appropriate legal and ethical basis for their decision, to help inform their decision-making. The aim of this study was to analyse the written information that is provided to consultees and legal representatives. Methods Studies including adults lacking capacity to consent which utilised consultees or legal representatives were identified using the UK Clinical Trials Gateway database. A representative sample (n = 30) were randomly selected. Information sheets and other study documents provided to proxies were obtained, and relevant content was extracted. Content analysis was conducted through four stages: decontextualisation of the unit of analysis, recontextualisation, categorisation, and compilation. The data were summarised narratively according to each theme and category. Results Considerable variation was found in the written information sheets provided to proxies. Most directed proxies to consider the wishes and feelings of the person who lacked capacity and to consult with others during the decision-making process. However, a small number of studies extended the scope of the proxy’s role to consider the person’s suitability or eligibility for the study. Particular discrepancies were found in information provided to those acting as consultees or legal representatives in a professional, as opposed to a personal, capacity. Incorrect uses of terminology were frequently found, and a small number of studies inaccurately interpreted the law. Conclusions Despite undergoing ethical review, study documents lacked essential information, incorrectly used terminology, and conflated professionals’ clinical and representation roles. Future recommendations include ensuring proxies are provided with adequate and accurate information which complies with the legal frameworks. Further research is needed to explore the information and decision-making needs of those acting as consultees and legal representatives. Electronic supplementary material The online version of this article (10.1186/s13063-019-3340-5) contains supplementary material, which is available to authorized users.
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Ahmed H, Farewell D, Jones HM, Francis NA, Paranjothy S, Butler CC. Antibiotic prophylaxis and clinical outcomes among older adults with recurrent urinary tract infection: cohort study. Age Ageing 2019; 48:228-234. [PMID: 30165433 PMCID: PMC6424374 DOI: 10.1093/ageing/afy146] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 06/26/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND clinical guidelines recommend antibiotic prophylaxis for preventing recurrent urinary tract infections (UTIs), but there is little evidence for their effectiveness in older adults. METHODS this was a retrospective cohort study of health records from 19,696 adults aged ≥65 with recurrent UTIs. We used prescription records to ascertain ≥3 months' prophylaxis with trimethoprim, cefalexin or nitrofurantoin. We used random effects Cox recurrent event models to estimate hazard ratios (HR) and 95% confidence intervals (CI) for risks of clinical recurrence (primary outcome), acute antibiotic prescribing and hospitalisation. RESULTS of 4,043 men and 15,653 women aged ≥65 with recurrent UTIs, 508 men (12.6%) and 2,229 women (14.2%) were prescribed antibiotic prophylaxis. In men, prophylaxis was associated with a reduced risk of clinical recurrence (HR, 0.49; 95% CI, 0.45-0.54), acute antibiotic prescribing (HR, 0.54; 95% CI, 0.51-0.57) and UTI-related hospitalisation (HR, 0.78; 95% CI, 0.64-0.94). In women, prophylaxis was also associated with a reduced risk of clinical recurrence (HR, 0.57; 95% CI, 0.55-0.59) and acute antibiotic prescribing (HR, 0.61; 95% CI, 0.59-0.62), but estimates of the risk of UTI-related hospitalisation were inconsistent between our main analysis (HR, 1.16; 95% CI, 1.05-1.28) and sensitivity analysis (HR, 0.82; 95% CI, 0.72-0.94). CONCLUSIONS antibiotic prophylaxis was associated with lower rates of UTI recurrence and acute antibiotic prescribing in older adults. To fully understand the benefits and harms of prophylaxis, further research should determine the frequency of antibiotic-related adverse events and the impact on antimicrobial resistance and quality of life.
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Affiliation(s)
- Haroon Ahmed
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionydd, Heath Park, Cardiff, UK
| | - Daniel Farewell
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionydd, Heath Park, Cardiff, UK
| | - Hywel M Jones
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionydd, Heath Park, Cardiff, UK
| | - Nick A Francis
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionydd, Heath Park, Cardiff, UK
| | - Shantini Paranjothy
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionydd, Heath Park, Cardiff, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford, UK
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Ahmed H, Farewell D, Francis NA, Paranjothy S, Butler CC. Choice of Empirical Antibiotic Therapy and Adverse Outcomes in Older Adults With Suspected Urinary Tract Infection: Cohort Study. Open Forum Infect Dis 2019; 6:ofz039. [PMID: 30882011 PMCID: PMC6411277 DOI: 10.1093/ofid/ofz039] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/17/2019] [Indexed: 01/01/2023] Open
Abstract
Background Nitrofurantoin is widely recommended for empirical treatment of urinary tract infection (UTI), but primary care clinicians may prescribe alternative antibiotics to improve prognosis in older, sicker patients. We assessed whether prescribing alternative antibiotics was associated with reduced risk of adverse outcomes in older patients. Methods This retrospective cohort study included patients aged ≥65 years empirically treated for a UTI with nitrofurantoin, cefalexin, ciprofloxacin, or co-amoxiclav. We matched patients on their propensity to receive a nitrofurantoin prescription and used mixed-effects logistic regression to estimate odds ratios (ORs) and 95% confidence intervals (CIs) for reconsultation and represcription (proxy for treatment failure), hospitalization for UTI, sepsis, or acute kidney injury, and death. Results We identified 42 298 patients aged ≥65 years prescribed empirical nitrofurantoin, cefalexin, ciprofloxacin, or co-amoxiclav for a UTI. Compared with nitrofurantoin, patients prescribed cefalexin, ciprofloxacin, or co-amoxiclav had lower odds of reconsultation and represcription (OR for cefalexin = 0.85, 95% CI = 0.75–0.98; OR for ciprofloxacin = 0.48, 95% CI = 0.38–0.61, OR for co-amoxiclav = 0.77, 95% CI = 0.64–0.93). Patients prescribed cefalexin or ciprofloxacin had greater odds of hospitalization for sepsis (OR for cefalexin = 1.89, 95% CI = 1.03–3.47; OR for ciprofloxacin = 3.21, 95% CI = 1.59–6.50), and patients prescribed cefalexin had greater odds of death (OR = 1.44, 95% CI = 1.12–1.85). Conclusions Compared with nitrofurantoin, prescribing of alternative antibiotics for UTI in older people may be associated with lower rates of treatment failure but was not associated with reduced risk of UTI-related hospitalization or death.
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Affiliation(s)
- Haroon Ahmed
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, United Kingdom
| | - Daniel Farewell
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, United Kingdom
| | - Nick A Francis
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, United Kingdom
| | - Shantini Paranjothy
- Division of Population Medicine, Cardiff University School of Medicine, Neuadd Meirionnydd, Heath Park, United Kingdom
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, United Kingdom
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Shepherd V, Griffith R, Sheehan M, Wood F, Hood K. Healthcare professionals' understanding of the legislation governing research involving adults lacking mental capacity in England and Wales: a national survey. JOURNAL OF MEDICAL ETHICS 2018; 44:632-637. [PMID: 29695407 PMCID: PMC6119350 DOI: 10.1136/medethics-2017-104722] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2017] [Revised: 03/16/2018] [Accepted: 03/29/2018] [Indexed: 05/12/2023]
Abstract
OBJECTIVE To examine health and social care professionals' understanding of the legislation governing research involving adults lacking mental capacity in England and Wales. METHODS A cross-sectional online survey was conducted using a series of vignettes. Participants were asked to select the legally authorised decision-maker in each scenario and provide supporting reasons. Responses were compared with existing legal frameworks and analysed according to their level of concordance. RESULTS One hundred and twenty-seven professionals participated. Levels of discordance between responses and the legal frameworks were high across all five scenarios (76%-82%). Nearly half of the participants (46%) provided responses that were discordant in all scenarios. Only two participants (2%) provided concordant responses across all five scenarios. DISCUSSION Participants demonstrated a lack of knowledge about the legal frameworks, the locus of authority and the legal basis for decision-making. The findings raise concern about the accessibility of research for those who lack capacity, the ability to conduct research involving such groups and the impact on the evidence base for their care. CONCLUSION This is the first study to examine health and social care professionals' knowledge and understanding of the dual legal frameworks in the UK. Health and social care professionals' understanding and attitudes towards research involving adults with incapacity may warrant further in-depth exploration. The findings from this survey suggest that greater training and education is required.
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Affiliation(s)
- Victoria Shepherd
- Division of Population Medicine, Cardiff University, Cardiff, UK
- Centre for Trials Research, Cardiff University, Cardiff, UK
| | - Richard Griffith
- College of Human and Health Sciences, Swansea University, Swansea, UK
| | | | - Fiona Wood
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
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Ahmed H, Farewell D, Jones HM, Francis NA, Paranjothy S, Butler CC. Incidence and antibiotic prescribing for clinically diagnosed urinary tract infection in older adults in UK primary care, 2004-2014. PLoS One 2018; 13:e0190521. [PMID: 29304056 PMCID: PMC5755802 DOI: 10.1371/journal.pone.0190521] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Accepted: 12/15/2017] [Indexed: 11/18/2022] Open
Abstract
Urinary tract infections (UTI) are an important cause of morbidity and antibiotic use in older adults but there are little data describing disease burden in primary care. The aim of this study was to estimate the incidence of clinically diagnosed UTI and examine associated empirical antibiotic prescribing. We conducted a retrospective observational study using linked health records from almost one million patients aged ≥65 years old, registered with 393 primary care practices in England. We estimated incidence of clinically diagnosed UTI between March 2004 and April 2014, and used multilevel logistic regression to examine trends in empiric antibiotic prescribing. Of 931,945 older adults, 196,358 (21%) had at least one clinically diagnosed UTI over the study period. In men, the incidence of clinically diagnosed UTI per 100 person-years at risk increased from 2.81 to 3.05 in those aged 65–74, 5.90 to 6.13 in those aged 75–84, and 8.08 to 10.54 in those aged 85+. In women, incidence increased from 9.03 to 10.96 in those aged 65–74, 11.35 to 14.34 in those aged 75–84, and 14.65 to 19.80 in those aged 85+. Prescribing of broad-spectrum antibiotics decreased over the study period. There were increases in the proportion of older men (from 45% to 74%) and women (from 55% to 82%) with UTI, prescribed a UTI specific antibiotic. There were also increases in the proportion of older men (42% to 69%) and women (15% to 26%) prescribed antibiotics for durations recommended by clinical guidelines. This is the first population-based study describing the burden of UTI in UK primary care. Our findings suggest a need to better understand reasons for increasing rates of clinically diagnosed UTI and consider how best to address this important clinical problem.
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Affiliation(s)
- Haroon Ahmed
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
- * E-mail:
| | - Daniel Farewell
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Hywel M. Jones
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Nick A. Francis
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Shantini Paranjothy
- Division of Population Medicine, Cardiff University School of Medicine, Cardiff, United Kingdom
| | - Christopher C. Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom
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Shepherd V, Wood F, Hood K. Establishing a set of research priorities in care homes for older people in the UK: a modified Delphi consensus study with care home staff. Age Ageing 2017; 46:284-290. [PMID: 27852597 PMCID: PMC5386006 DOI: 10.1093/ageing/afw204] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2016] [Accepted: 09/30/2016] [Indexed: 12/21/2022] Open
Abstract
Background currently, there is little evidence base for much of the care provided for older people in care homes. Given the wide range of topics that require further investigation, and limited resources, one solution is to identify the priorities for future research. Methods a modified Delphi technique was used to identify research topics and develop consensus among care home staff participants. The survey was conducted across three rounds. Firstly to elicit topics that were considered by participants to require further research, secondly to prioritise the long list of research questions, followed by a third round to reach a consensus on the highest ranked 15 questions. Results eighty-three participants responded to the initial survey, providing 144 questions. Following analysis and review against existing evidence, 76 research questions remained. Of note, 40/83 participants responded to the interim prioritisation round and 43/83 participants responded to the final round, which ranked the top 15 research questions by importance. Two other groups of health and social care professionals also participated in the final ranking. The results from these groups had a similar ordering to those of the original cohort of participants. Conclusion this is the first study to establish a set of research priorities for older people in the UK care homes. It is hoped that sharing these results with clinicians, researchers and funding bodies will help to begin the process of ensuring that the future research agenda can be focused on the areas of greatest need. Further work to identify the priorities of other key stakeholders is required.
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Affiliation(s)
- Victoria Shepherd
- South East Wales Trials Unit, Centre for Trials Research, Cardiff University, Cardiff, UK
- Address correspondence to: Victoria Shepherd. Tel: (+44) (0)2920687641; Fax: (+44) (0)2920687611.
| | - Fiona Wood
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- Centre for Trials Research, Cardiff University, Cardiff, UK
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Shepherd V. Research involving adults lacking capacity to consent: the impact of research regulation on 'evidence biased' medicine. BMC Med Ethics 2016; 17:55. [PMID: 27609355 PMCID: PMC5016956 DOI: 10.1186/s12910-016-0138-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 06/17/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Society is failing in its moral obligation to improve the standard of healthcare provided to vulnerable populations, such as people who lack decision making capacity, by a misguided paternalism that seeks to protect them by excluding them from medical research. Uncertainties surround the basis on which decisions about research participation is made under dual regulatory regimes, which adds further complexity. Vulnerable individuals' exclusion from research as a result of such regulation risks condemning such populations to poor quality care as a result of 'evidence biased' medicine. MAIN TEXT This paper explores the research regulation provisions for proxy decision making for those unable to provide informed consent for themselves, and the subsequent legal and practical difficulties for decision-makers. There are two separate regulatory regimes governing research involving adults who lack capacity to consent in England and Wales. The Mental Capacity Act 2005 governs how incapacitated adults can be involved in research, however clinical trials of medicinal products are separately regulated by the Medicines for Human Use (Clinical Trials) Regulations 2004. There are significant differences under these dual regimes in the provisions for those lacking capacity to participate in medical research. The level of risk permitted differs, with a greater requirement for justification for participation in a clinical trial than other types of research. Who acts as proxy decision maker, how much information is provided to the person lacking capacity, and whether they retain the power of veto also significantly differs. CONCLUSION The development of two separate regulatory regimes has resulted in significant differences between the provisions for clinical trials and other forms of research, and from usual medical practice. The resulting uncertainty has reinforced the tendency of those approving and conducting research to exclude adults lacking capacity to avoid difficult decisions about seeking consent for their participation. Future developments, such as the incoming EU Regulations, may address some of these differences, however the justification and level of risk permitted requires review to ensure that requirements are appropriate and proportionate to the burdens and risks for the individual, and also to the benefits for the wider population represented.
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Affiliation(s)
- Victoria Shepherd
- South East Wales Trials Unit, Centre for Trials Research, College of Biomedical and Life Sciences, Cardiff University, Room 406, 4th Floor, Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
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Anstey S, Powell T, Coles B, Hale R, Gould D. Education and training to enhance end-of-life care for nursing home staff: a systematic literature review. BMJ Support Palliat Care 2016; 6:353-61. [PMID: 27329513 PMCID: PMC5013161 DOI: 10.1136/bmjspcare-2015-000956] [Citation(s) in RCA: 63] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2015] [Accepted: 05/05/2016] [Indexed: 11/09/2022]
Abstract
Background The delivery of end-of-life care in nursing homes is challenging. This situation is of concern as 20% of the population die in this setting. Commonly reported reasons include limited access to medical care, inadequate clinical leadership and poor communication between nursing home and medical staff. Education for nursing home staff is suggested as the most important way of overcoming these obstacles. Objectives To identify educational interventions to enhance end-of-life care for nursing home staff and to identify types of study designs and outcomes to indicate success and benchmark interventions against recent international guidelines for education for palliative and end-of-life care. Design Thirteen databases and reference lists of key journals were searched from the inception of each up to September 2014. Included studies were appraised for quality and data were synthesised thematically. Results Twenty-one studies were reviewed. Methodological quality was poor. Education was not of a standard that could be expected to alter clinical behaviour and was evaluated mainly from the perspectives of staff: self-reported increase in knowledge, skills and confidence delivering care rather than direct evidence of impact on clinical practice and patient outcomes. Follow-up was often short term, and despite sound economic arguments for delivering effective end-of-life care to reduce burden on the health service, no economic analyses were reported. Conclusions There is a clear and urgent need to design educational interventions that have the potential to improve end-of-life care in nursing homes. Robust evaluation of these interventions should include impact on residents, families and staff and include economic analysis.
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Affiliation(s)
- Sally Anstey
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Tom Powell
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Bernadette Coles
- Cancer Research Wales (CRW) Library, Velindre National Health Trust, Cardiff, UK
| | - Rachel Hale
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Dinah Gould
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
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Francis NA, Hood K, Lyons R, Butler CC. Understanding flucloxacillin prescribing trends and treatment non-response in UK primary care: a Clinical Practice Research Datalink (CPRD) study. J Antimicrob Chemother 2016; 71:2037-46. [PMID: 27090629 PMCID: PMC4896409 DOI: 10.1093/jac/dkw084] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2015] [Accepted: 02/23/2016] [Indexed: 12/27/2022] Open
Abstract
Objectives The volume of prescribed antibiotics is associated with antimicrobial resistance and, unlike most other antibiotic classes, flucloxacillin prescribing has increased. We aimed to describe UK primary care flucloxacillin prescribing and factors associated with subsequent antibiotic prescribing as a proxy for non-response. Patients and methods Clinical Practice Research Datalink patients with acute prescriptions for oral flucloxacillin between January 2004 and December 2013, prescription details, associated Read codes and patient demographics were identified. Monthly prescribing rates were plotted and logistic regression identified factors associated with having a subsequent antibiotic prescription within 28 days. Results 3 031 179 acute prescriptions for 1 667 431 patients were included. Average monthly prescription rates increased from 4.74 prescriptions per 1000 patient-months in 2004 to 5.74 (increase of 21.1%) in 2013. The highest prescribing rates and the largest increases in rates were seen in older adults (70+ years), but the overall increase in prescribing was not accounted for by an ageing population. Prescribing 500 mg tablets/capsules rather than 250 mg became more common. Children were frequently prescribed low doses and small volumes (5 day course) and prescribing declined for children, including for impetigo. Only 4.2% of new prescriptions involved co-prescription of another antibiotic. Age (<5 and ≥60 years), diagnosis of ‘cellulitis or abscess’ or no associated code, and 500 mg dose were associated with a subsequent antibiotic prescription, which occurred after 17.6% of first prescriptions. Conclusions There is a need to understand better the reasons for increased prescribing of flucloxacillin in primary care, optimal dosing (and the need to co-prescribe other antibiotics) and the reasons why one in five patients are prescribed a further antibiotic within 4 weeks.
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Affiliation(s)
- Nick A Francis
- Division of Population Medicine, School of Medicine, Cardiff University, 3rd Floor, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK
| | - Kerenza Hood
- Centre for Trials Research, College of Biomedical & Life Sciences, Cardiff University, 7th Floor, Neuadd Meirionnydd, Heath Park, Cardiff CF14 4YS, UK
| | - Ronan Lyons
- Farr Institute, Swansea University Medical School, Singleton Park SA2 8PP, UK
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6NW, UK
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Gillespie D, Hood K, Bayer A, Carter B, Duncan D, Espinasse A, Evans M, Nuttall J, Stanton H, Acharjya A, Allen S, Cohen D, Groves S, Francis N, Howe R, Johansen A, Mantzourani E, Thomas-Jones E, Toghill A, Wood F, Wigglesworth N, Wootton M, Butler CC. Antibiotic prescribing and associated diarrhoea: a prospective cohort study of care home residents. Age Ageing 2015; 44:853-60. [PMID: 26104506 DOI: 10.1093/ageing/afv072] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Accepted: 03/05/2015] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND the risk factors for and frequency of antibiotic prescription and antibiotic-associated diarrhoea (AAD) among care home residents are unknown. AIM to prospectively study frequency and risks for antibiotic prescribing and AAD for care home residents. DESIGN AND SETTING a 12-month prospective cohort study in care homes across South Wales. METHOD antibiotic prescriptions and the development of AAD were recorded on case report forms. We defined AAD as three or more loose stools in a 24-h period occurring within 8 weeks of exposure to an antibiotic. RESULTS we recruited 279 residents from 10 care homes. The incidence of antibiotic prescriptions was 2.16 prescriptions per resident year (95% CI: 1.90-2.46). Antibiotics were less likely to be prescribed to residents from dual-registered homes (OR compared with nursing homes: 0.38, 95% CI: 0.18-0.79). For those who were prescribed antibiotics, the incidence of AAD was 0.57 episodes per resident year (95% CI: 0.41-0.81 episodes). AAD was more likely in residents who were prescribed co-amoxiclav (hazards ratio, HR = 2.08, 95% confidence interval, CI: 1.18-3.66) or routinely used incontinence pads (HR = 2.54, 95% CI: 1.26-5.13) and less likely in residents from residential homes (HR compared with nursing homes: 0.14, 95% CI: 0.06-0.32). CONCLUSION residents of care homes, particularly of nursing homes, are frequently prescribed antibiotics and often experience diarrhoea following such prescriptions. Co-amoxiclav is associated with greater risk of AAD.
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Affiliation(s)
- David Gillespie
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Kerenza Hood
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Antony Bayer
- School of Medicine, Cardiff University, Cardiff, UK
| | - Ben Carter
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Donna Duncan
- Nutrition and Dietetics, Abertawe Bro Morgannwg Health Board, Port Talbot, UK
| | - Aude Espinasse
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Meirion Evans
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Jacqueline Nuttall
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | | | - Arun Acharjya
- Virus Reference Department, Public Health England, London, UK
| | - Stephen Allen
- College of Medicine, Swansea University, Swansea, UK
| | - David Cohen
- Health Economics and Policy Research Unit, University of South Wales, Pontypridd, UK
| | - Sam Groves
- Health Economics and Policy Research Unit, University of South Wales, Pontypridd, UK
| | - Nick Francis
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Robin Howe
- Microbiology Unit, Public Health Wales, Cardiff, UK
| | | | | | - Emma Thomas-Jones
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Alun Toghill
- South East Wales Trials Unit, School of Medicine, Cardiff University, Cardiff, UK
| | - Fiona Wood
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, Cardiff, UK
| | - Neil Wigglesworth
- Welsh Healthcare Associated Infection Programme, Public Health Wales, Cardiff, UK
| | - Mandy Wootton
- Specialist Antimicrobial Chemotherapy Unit, Public Health Wales, Cardiff, UK
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23
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Shepherd V, Nuttall J, Hood K, Butler CC. Setting up a clinical trial in care homes: challenges encountered and recommendations for future research practice. BMC Res Notes 2015; 8:306. [PMID: 26179284 PMCID: PMC4504165 DOI: 10.1186/s13104-015-1276-8] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 07/13/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Older adults in care homes have increasingly complex health care needs, and care provision should be evidence-based whenever possible. However, recruitment of frail, older people to research is a complex process and often results in care home residents being excluded from research participation. This paper draws on the experience of setting up a randomised controlled trial to determine the effectiveness of probiotics on antibiotic-associated diarrhoea in care home residents [Probiotics for Antibiotic Associated Diarrhoea in Care Homes (PAAD) Study] in Wales. FINDINGS Significant challenges were encountered setting up a clinical trial in care homes. There were a number of barriers and facilitative factors encountered that were unique to this research setting. The classification of the study intervention (a widely available food supplement with a low risk safety profile) as an investigational medicinal product, with the associated requirements including obtaining statutory approvals and research governance, had a major impact. CONCLUSION The process for setting up a clinical trial of an investigational medicinal product in care homes has been more complex and time consuming than the process for setting up an observational study in the same setting, and clinical trials in other health care settings. We recommend regulatory changes to ensure approvals processes are more proportionate to risk and context, to ensure that care home residents have the opportunity to participate in research and are able to help generate much needed evidence to underpin care. Recommendations made may inform future research practice. TRIAL REGISTRATION ISRCTN 25324586.
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Affiliation(s)
- Victoria Shepherd
- South East Wales Trials Unit, School of Medicine, Cardiff University, 7th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Jacqui Nuttall
- South East Wales Trials Unit, School of Medicine, Cardiff University, 7th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Kerenza Hood
- South East Wales Trials Unit, School of Medicine, Cardiff University, 7th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
| | - Christopher C Butler
- Nuffield Department of Primary Care Health Sciences, University of Oxford, New Radcliffe House, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6NW, UK.
- Cochrane Institute of Primary Care and Public Health, School of Medicine, Cardiff University, 5th Floor Neuadd Meirionnydd, Heath Park, Cardiff, CF14 4YS, UK.
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