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Mazuquin B, Moffatt M, Realpe A, Sherman R, Ireland K, Connan Z, Tildsley J, Manca A, Gc VS, Foster NE, Rees J, Drew S, Bateman M, Fakis A, Farnsworth M, Littlewood C. Clinical and cost-effectiveness of individualised (early) patient-directed rehabilitation versus standard rehabilitation after surgical repair of the rotator cuff of the shoulder: protocol for a multicentre, randomised controlled trial with integrated Quintet Recruitment Intervention (RaCeR 2). BMJ Open 2024; 14:e081284. [PMID: 38580365 PMCID: PMC11002397 DOI: 10.1136/bmjopen-2023-081284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 03/08/2024] [Indexed: 04/07/2024] Open
Abstract
INTRODUCTION Despite the high number of operations and surgical advancement, rehabilitation after rotator cuff repair has not progressed for over 20 years. The traditional cautious approach might be contributing to suboptimal outcomes. Our aim is to assess whether individualised (early) patient-directed rehabilitation results in less shoulder pain and disability at 12 weeks after surgical repair of full-thickness tears of the rotator cuff compared with current standard (delayed) rehabilitation. METHODS AND ANALYSIS The rehabilitation after rotator cuff repair (RaCeR 2) study is a pragmatic multicentre, open-label, randomised controlled trial with internal pilot phase. It has a parallel group design with 1:1 allocation ratio, full health economic evaluation and quintet recruitment intervention. Adults awaiting arthroscopic surgical repair of a full-thickness tear are eligible to participate. On completion of surgery, 638 participants will be randomised. The intervention (individualised early patient-directed rehabilitation) includes advice to the patient to remove their sling as soon as they feel able, gradually begin using their arm as they feel able and a specific exercise programme. Sling removal and movement is progressed by the patient over time according to agreed goals and within their own pain and tolerance. The comparator (standard rehabilitation) includes advice to the patient to wear the sling for at least 4 weeks and only to remove while eating, washing, dressing or performing specific exercises. Progression is according to specific timeframes rather than as the patient feels able. The primary outcome measure is the Shoulder Pain and Disability Index total score at 12-week postrandomisation. The trial timeline is 56 months in total, from September 2022. TRIAL REGISTRATION NUMBER ISRCTN11499185.
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Affiliation(s)
- Bruno Mazuquin
- Health Professions, Manchester Metropolitan University, Manchester, UK
| | - Maria Moffatt
- School of Allied Health Professios and Nursing, University of Liverpool, Liverpool, UK
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Rachelle Sherman
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | - Katie Ireland
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | - Zak Connan
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | - Jack Tildsley
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | - Andrea Manca
- Centre for Health Economics, York University, York, UK
| | - Vijay Singh Gc
- School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK
| | - Nadine E Foster
- STARS Education and Research Alliance, Surgical Treatment and Rehabilitation Service (STARS), The University of Queensland and Metro North Health, Saint Lucia, Queensland, Australia
| | - Jonathan Rees
- Nuffield Department of Orthopaedics Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Steven Drew
- University Hospitals Coventry & Warwickshire NHS Trust, Coventry, UK
| | - Marcus Bateman
- Derby Shoulder Unit, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
| | - Apostolos Fakis
- Derby Clinical Trials Support Unit, Royal Derby Hospital, Derby, UK
| | | | - Chris Littlewood
- Allied Health, Social Work & Wellbeing, Faculty of Health Social Care and Medicine, Edge Hill University, Ormskirk, UK
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Beasant L, Realpe A, Douglas S, Kenny L, Rai D, Mills N. Autistic adults' views on the design and processes within randomised controlled trials: The APRiCoT study. Autism 2023:13623613231202432. [PMID: 37882480 DOI: 10.1177/13623613231202432] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2023]
Abstract
LAY ABSTRACT Large randomised controlled trials are used to test healthcare treatments. Yet there are no large randomised controlled trials on effective treatments for common mental health issues affecting autistic adults. The purpose of this study was to learn what autistic adults think about randomised controlled trials in preparation for a randomised controlled trial testing a medication for anxiety. This means we wanted to know their opinions about the way randomised controlled trials are done, such as how people are chosen to be in the study and how the study is carried out. We did this by talking to 49 autistic adults individually and asking them questions. We found that most of the people we talked to were okay with the way randomised controlled trials are done. They thought it was fair and they liked that it was based on evidence. However, some autistic people might find it hard to take part in randomised controlled trials. Some people did not like the uncertainty of not knowing what treatment they would receive in a randomised controlled trial. Others felt too vulnerable and may have had bad experiences with healthcare in the past. We found that it is important to involve autistic people early on and at every stage when designing a clinical trial. Care about how clear and precise the study communication is will build trust and improve access to research. Our study indicates that it is possible to conduct large randomised controlled trials with and for autistic people. This can ultimately contribute to the improvement of healthcare outcomes for this population.
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Affiliation(s)
| | - Alba Realpe
- University of Bristol, UK
- Bristol NIHR Biomedical Research Centre, UK
| | | | | | - Dheeraj Rai
- University of Bristol, UK
- Bristol NIHR Biomedical Research Centre, UK
- Avon and Wiltshire Mental Health Partnership NHS Trust, UK
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Koutoukidis DA, Jebb SA, Foster C, Wheatstone P, Horne A, Hill TM, Taylor A, Realpe A, Achana F, Buczacki SJA. CARE: Protocol of a randomised trial evaluating the feasibility of preoperative intentional weight loss to support postoperative recovery in patients with excess weight and colorectal cancer. Colorectal Dis 2023; 25:1910-1920. [PMID: 37525408 DOI: 10.1111/codi.16687] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Revised: 06/12/2023] [Accepted: 06/19/2023] [Indexed: 08/02/2023]
Abstract
AIM Excess weight increases the risk of morbidity following colorectal cancer surgery. Weight loss may improve morbidity, but it is uncertain whether patients can follow an intensive weight loss intervention while waiting for surgery and there are concerns about muscle mass loss. The aim of this trial is to assess the feasibility of intentional weight loss in this setting and determine progression to a definitive trial. METHODS CARE is a prospectively registered, multicentre, feasibility, parallel, randomised controlled trial with embedded evaluation and optimisation of the recruitment process. Participants with excess weight awaiting curative colorectal resection for cancer are randomised 1:1 to care as usual or a low-energy nutritionally-replete total diet replacement programme with weekly remote behavioural support by a dietitian. Progression criteria will be based on the recruitment, engagement, adherence, and retention rates. Data will be collected on the 30-day postoperative morbidity, the typical primary outcome of prehabilitation trials. Secondary outcomes will include, among others, length of hospital stay, health-related quality of life, and body composition. Qualitative interviews will be used to understand patients' experiences of and attitudes towards trial participation and intervention engagement and adherence. CONCLUSION CARE will evaluate the feasibility of intensive intentional weight loss as prehabilitation before colorectal cancer surgery. The results will determine the planning of a definitive trial.
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Affiliation(s)
- Dimitrios A Koutoukidis
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Susan A Jebb
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
- NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Claire Foster
- Centre for Psychosocial Research in Cancer: CentRIC+ in Health Sciences, University of Southampton, Southampton, UK
| | | | - Alison Horne
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - T Martyn Hill
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Amy Taylor
- Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- NIHR Bristol Biomedical Research Centre, Bristol, UK
| | - Felix Achana
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Simon J A Buczacki
- NIHR Oxford Biomedical Research Centre, Oxford, UK
- Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
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Lorenc A, Rooshenas L, Conefrey C, Wade J, Farrar N, Mills N, Paramasivan S, Realpe A, Jepson M. Non-COVID-19 UK clinical trials and the COVID-19 pandemic: impact, challenges and possible solutions. Trials 2023; 24:424. [PMID: 37349850 PMCID: PMC10286467 DOI: 10.1186/s13063-023-07414-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Accepted: 05/25/2023] [Indexed: 06/24/2023] Open
Abstract
INTRODUCTION The COVID-19 pandemic impacted the operationalisation of non-COVID-19 clinical trials globally, particularly site and participant recruitment and trial success/stoppage. Trials which anticipate recruitment challenges may embed methods such as the QuinteT Recruitment Intervention (QRI) to help identify and understand the sources of challenges. Such interventions can help shed light on pandemic-related challenges. This paper reports our experience of the impact of the COVID-19 pandemic on conducting clinical trials with an embedded QRI, highlighting how the QRI aided in identifying challenges and potential solutions, particularly related to the site set-up and participant recruitment. MAIN BODY We report on 13 UK clinical trials which included a QRI. Information is from QRI data and researchers' experience and reflections. In most trials, recruitment was lower than even the lowest anticipated rates. The flexibility of the QRI facilitated rapid data collection to understand and document, and in some instances respond to, operational challenges. Challenges were mostly logistical, pandemic-related and beyond the control of the site or central trial teams. Specifically: disrupted and variable site opening timelines -often due to local research and development (R&D) delays- shortages of staff to recruit patients; fewer eligible patients or limited access to patients; and intervention-related factors. Almost all trials were affected by pandemic-related staffing issues including redeployment, prioritisation of COVID-19 care and research, and COVID-19-related staff illness and absence. Trials of elective procedures were particularly impacted by the pandemic, which caused changes to care/recruitment pathways, deprioritisation of services, reduced clinical and surgical capacity and longer waiting lists. Attempted solutions included extra engagement with staff and R&D departments, trial protocol changes (primarily moving online) and seeking additional resourcing. CONCLUSION We have highlighted wide-ranging, extensive and consistent pandemic-related challenges faced by UK clinical trials, which the QRI helped to identify and, in some cases, address. Many challenges were insurmountable at individual trials or trials unit level. This overview highlights the need to streamline trial regulatory processes, address staffing crises, improve recognition of NHS research staff and for clearer, more nuanced central guidance on the prioritisation of studies and how to deal with the backlog. Pre-emptively embedding qualitative work and stakeholder consultation into trials with anticipated difficulties, moving some processes online, and flexible trial protocols may improve the resilience of trials in the current challenging context.
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Affiliation(s)
- Ava Lorenc
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK.
| | - Leila Rooshenas
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Carmel Conefrey
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Julia Wade
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nicola Farrar
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Nicola Mills
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Sangeetha Paramasivan
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Alba Realpe
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
| | - Marcus Jepson
- QuinteT Group, Population Health Sciences, Bristol Medical School, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol, BS8 2PS, UK
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Lim E, Harris RA, McKeon HE, Batchelor TJ, Dunning J, Shackcloth M, Anikin V, Naidu B, Belcher E, Loubani M, Zamvar V, Dabner L, Brush T, Stokes EA, Wordsworth S, Paramasivan S, Realpe A, Elliott D, Blazeby J, Rogers CA. Impact of video-assisted thoracoscopic lobectomy versus open lobectomy for lung cancer on recovery assessed using self-reported physical function: VIOLET RCT. Health Technol Assess 2022; 26:1-162. [PMID: 36524582 PMCID: PMC9791462 DOI: 10.3310/thbq1793] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Lung cancer is the leading cause of cancer death. Surgery remains the main method of managing early-stage disease. Minimal-access video-assisted thoracoscopic surgery results in less tissue trauma than open surgery; however, it is not known if it improves patient outcomes. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of video-assisted thoracoscopic surgery lobectomy with open surgery for the treatment of lung cancer. DESIGN, SETTING AND PARTICIPANTS A multicentre, superiority, parallel-group, randomised controlled trial with blinding of participants (until hospital discharge) and outcome assessors conducted in nine NHS hospitals. Adults referred for lung resection for known or suspected lung cancer, with disease suitable for both surgeries, were eligible. Participants were followed up for 1 year. INTERVENTIONS Participants were randomised 1 : 1 to video-assisted thoracoscopic surgery lobectomy or open surgery. Video-assisted thoracoscopic surgery used one to four keyhole incisions without rib spreading. Open surgery used a single incision with rib spreading, with or without rib resection. MAIN OUTCOME MEASURES The primary outcome was self-reported physical function (using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30) at 5 weeks. Secondary outcomes included upstaging to pathologic node stage 2 disease, time from surgery to hospital discharge, pain in the first 2 days, prolonged pain requiring analgesia at > 5 weeks, adverse health events, uptake of adjuvant treatment, overall and disease-free survival, quality of life (Quality of Life Questionnaire Core 30, Quality of Life Questionnaire Lung Cancer 13 and EQ-5D) at 2 and 5 weeks and 3, 6 and 12 months, and cost-effectiveness. RESULTS A total of 503 patients were randomised between July 2015 and February 2019 (video-assisted thoracoscopic surgery, n = 247; open surgery, n = 256). One participant withdrew before surgery. The mean age of patients was 69 years; 249 (49.5%) patients were men and 242 (48.1%) did not have a confirmed diagnosis. Lobectomy was performed in 453 of 502 (90.2%) participants and complete resection was achieved in 429 of 439 (97.7%) participants. Quality of Life Questionnaire Core 30 physical function was better in the video-assisted thoracoscopic surgery group than in the open-surgery group at 5 weeks (video-assisted thoracoscopic surgery, n = 247; open surgery, n = 255; mean difference 4.65, 95% confidence interval 1.69 to 7.61; p = 0.0089). Upstaging from clinical node stage 0 to pathologic node stage 1 and from clinical node stage 0 or 1 to pathologic node stage 2 was similar (p ≥ 0.50). Pain scores were similar on day 1, but lower in the video-assisted thoracoscopic surgery group on day 2 (mean difference -0.54, 95% confidence interval -0.99 to -0.09; p = 0.018). Analgesic consumption was 10% lower (95% CI -20% to 1%) and the median hospital stay was less (4 vs. 5 days, hazard ratio 1.34, 95% confidence interval 1.09, 1.65; p = 0.006) in the video-assisted thoracoscopic surgery group than in the open-surgery group. Prolonged pain was also less (relative risk 0.82, 95% confidence interval 0.72 to 0.94; p = 0.003). Time to uptake of adjuvant treatment, overall survival and progression-free survival were similar (p ≥ 0.28). Fewer participants in the video-assisted thoracoscopic surgery group than in the open-surgery group experienced complications before and after discharge from hospital (relative risk 0.74, 95% confidence interval 0.66 to 0.84; p < 0.001 and relative risk 0.81, 95% confidence interval 0.66 to 1.00; p = 0.053, respectively). Quality of life to 1 year was better across several domains in the video-assisted thoracoscopic surgery group than in the open-surgery group. The probability that video-assisted thoracoscopic surgery is cost-effective at a willingness-to-pay threshold of £20,000 per quality-adjusted life-year is 1. LIMITATIONS Ethnic minorities were under-represented compared with the UK population (< 5%), but the cohort reflected the lung cancer population. CONCLUSIONS Video-assisted thoracoscopic surgery lobectomy was associated with less pain, fewer complications and better quality of life without any compromise to oncologic outcome. Use of video-assisted thoracoscopic surgery is highly likely to be cost-effective for the NHS. FUTURE WORK Evaluation of the efficacy of video-assisted thoracoscopic surgery with robotic assistance, which is being offered in many hospitals. TRIAL REGISTRATION This trial is registered as ISRCTN13472721. FUNDING This project was funded by the National Institute for Health and Care Research ( NIHR ) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 48. See the NIHR Journals Library website for further project information.
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Stokes EA, Harris RA, Dabner L, McKeon HE, Kaur S, Paramasivan S, Realpe A, Elliott D, Batchelor TJ, Dunning J, Shackcloth M, Anikin V, Naidu B, Belcher E, Loubani M, Zamvar V, De Sousa P, Blazeby JM, Rogers CA, Lim E, Wordsworth S. Cost-Effectiveness of Video-Assisted Thoracoscopic Surgery Compared to Open Lobectomy in Patients with Early-Stage Lung Cancer: Findings from the VIOLET Randomised Controlled Trial. Lung Cancer 2022. [DOI: 10.1016/j.lungcan.2022.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
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Mazuquin B, Bateman M, Realpe A, Drew S, Rees J, Littlewood C. Rehabilitation following rotator cuff repair: A survey exploring clinical equipoise among surgical members of the British Elbow and Shoulder Society. Shoulder Elbow 2022; 14:568-573. [PMID: 36199512 PMCID: PMC9527485 DOI: 10.1177/17585732211059804] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 10/26/2021] [Accepted: 10/26/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND We investigated clinical equipoise across surgical members of the British Elbow and Shoulder Society (BESS) in relation to rehabilitation following rotator cuff repair. METHOD An online survey explored clinical equipoise regarding early patient-directed versus standard rehabilitation after rotator cuff repair to inform the design of a national randomised controlled trial (RCT). It described different clinical scenarios relating to patient age, tear size, location and whether other patient-related and intra-operative factors would influence equipoise. RESULTS 76 surgeons completed the survey. 81% agreed/ strongly agreed that early mobilisation might benefit recovery; 57% were neutral/ disagreed that this approach risks re-tear. 87% agreed/ strongly agreed that there is clinical uncertainty about the effectiveness of different approaches to rehabilitation. As age of the patient and tear size increased, the proportion of respondents who would agree to recruit and accept the outcome of randomisation reduced, and this was compounded if subscapularis was torn. Other factors that influenced equipoise were diabetes and non-secure repair. CONCLUSION Surgical members of BESS recognise uncertainty about the effectiveness of different approaches to rehabilitation following rotator cuff repair. We identified a range of factors that influence clinical equipoise that will be considered in the design of a new RCT.
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Affiliation(s)
- Bruno Mazuquin
- Department of Health professions, Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK,Bruno Mazuquin, Faculty of Health and Education, Brooks Building, 53 Bonsall street, Manchester, M15 6GX, UK.
| | - Marcus Bateman
- Derby Shoulder Unit, University Hospitals Derby & Burton NHS Foundation Trust, Derby, UK
| | - Alba Realpe
- Population Health Sciences, University of Bristol, Bristol, UK
| | - Steve Drew
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Jonathan Rees
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Science, University of Oxford and NIHR Oxford Biomedical Research Centre, Oxford, UK
| | - Chris Littlewood
- Department of Health professions, Faculty of Health and Education, Manchester Metropolitan University, Manchester, UK
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Rooshenas L, Ijaz S, Richards A, Realpe A, Savovic J, Jones T, Hollingworth W, Donovan JL. Variations in policies for accessing elective musculoskeletal procedures in the English National Health Service: A documentary analysis. J Health Serv Res Policy 2022; 27:190-202. [PMID: 35574682 PMCID: PMC9277328 DOI: 10.1177/13558196221091518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE The overall aim of this study was to investigate how commissioning policies for accessing clinical procedures compare in the context of the English National Health Service. Our primary objective was to compare policy wording and categorise any variations identified. Our secondary objective was to explore how any points of variation relate to national guidance. METHODS This study entailed documentary analysis of commissioning policies that stipulated criteria for accessing eight elective musculoskeletal procedures. For each procedure, we retrieved policies held by regions with higher and lower rates of clinical activity relative to the national average. Policies were subjected to content and thematic analysis, using constant comparison techniques. Matrices and descriptive reports were used to compare themes across policies for each procedure and derive categories of variation that arose across two or more procedures. National guidance relating to each procedure were identified and scrutinised, to explore whether these provided context for explaining the policy variations. RESULTS Thirty-five policy documents held by 14 geographic regions were included in the analysis. Policies either focused on a single procedure/treatment or covered several procedures/treatments in an all-encompassing document. All policies stipulated criteria that needed to be fulfilled prior to accessing treatment, but there were inconsistences in the evidence cited. Policies varied in recurring ways, with respect to specification of non-surgical treatments and management, requirements around time spent using non-surgical approaches, diagnostic requirements, requirements around symptom severity and disease progression, and use of language, in the form of terms and phrases ('threshold modifiers') which could open up or restrict access to care. National guidance was identified for seven of the procedures, but this guidance did not specify criteria for accessing the procedures in question, making direct comparisons with regional policies difficult. CONCLUSIONS This, to our knowledge, is the first study to identify recurring ways in which policies for accessing treatment can vary within a single-payer system with universal coverage. The findings raise questions around whether formulation of commissioning policies should receive more central support to promote greater consistency - especially where evidence is uncertain, variable or lacking.
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Affiliation(s)
- Leila Rooshenas
- Population Health Sciences, Bristol Medical School, 1980University of Bristol, UK
| | - Sharea Ijaz
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), 1984University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - Alison Richards
- The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), 1984University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, 1980University of Bristol, UK
| | - Jelena Savovic
- Population Health Sciences, Bristol Medical School, 1980University of Bristol, UK.,The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), 1984University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - Tim Jones
- Population Health Sciences, Bristol Medical School, 1980University of Bristol, UK.,The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), 1984University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - William Hollingworth
- Population Health Sciences, Bristol Medical School, 1980University of Bristol, UK.,The National Institute for Health Research Applied Research Collaboration West (NIHR ARC West), 1984University Hospitals Bristol and Weston NHS Foundation Trust, UK
| | - Jenny L Donovan
- Population Health Sciences, Bristol Medical School, 1980University of Bristol, UK
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Lim E, Batchelor TJP, Dunning J, Shackcloth M, Anikin V, Naidu B, Belcher E, Loubani M, Zamvar V, Harris RA, Dabner L, McKeon HE, Paramasivan S, Realpe A, Elliott D, De Sousa P, Stokes EA, Wordsworth S, Blazeby JM, Rogers CA. Video-Assisted Thoracoscopic or Open Lobectomy in Early-Stage Lung Cancer. NEJM Evid 2022; 1:EVIDoa2100016. [PMID: 38319202 DOI: 10.1056/evidoa2100016] [Citation(s) in RCA: 55] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2024]
Abstract
Video-Assisted Thoracoscopic Surgery or Open Lobectomy in Early-Stage Lung CancerIn a patient with early-stage lung cancer, is resection by video-assisted thoracoscopic surgery (VATS) versus open resection superior with respect to the postoperative recovery? This question was addressed in a multicenter randomized trial in more than 500 patients. At 5 weeks after surgery, the physical function mean score was 73 in the VATS group and 67 in the open surgery group (function scores range from 0 to 100, with higher scores indicating better function). Of the participants allocated to VATS, 30.7% had serious adverse events after discharge compared with 37.8% of those allocated to open surgery. At 52 weeks, there were no differences in cancer progression-free survival.
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Affiliation(s)
- Eric Lim
- Academic Division of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London
- Imperial College London, London
| | - Tim J P Batchelor
- Thoracic Surgery, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Joel Dunning
- Department of Cardiothoracic Surgery, The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | - Michael Shackcloth
- Department of Thoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, United Kingdom
| | - Vladimir Anikin
- Academic Division of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London
- Department of Oncology and Reconstructive Surgery, I.M. Sechenov First Moscow State Medical University, Moscow
| | - Babu Naidu
- Department of Thoracic Surgery, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Elizabeth Belcher
- Cardiothoracic Surgery, John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Mahmoud Loubani
- Department of Cardiothoracic Surgery, Castle Hill Hospital, Hull University Teaching Hospitals, Cottingham, United Kingdom
| | - Vipin Zamvar
- Department of Cardiothoracic Surgery, Edinburgh Royal Infirmary, NHS Lothian, Edinburgh
| | - Rosie A Harris
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Lucy Dabner
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Holly E McKeon
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sangeetha Paramasivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Daisy Elliott
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, United Kingdom
| | - Paulo De Sousa
- Academic Division of Thoracic Surgery, Royal Brompton and Harefield Hospitals, London
| | - Elizabeth A Stokes
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Sarah Wordsworth
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, United Kingdom
- National Institute for Health Research Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Jane M Blazeby
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, United Kingdom
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Griffin DR, Dickenson EJ, Achana F, Griffin J, Smith J, Wall PD, Realpe A, Parsons N, Hobson R, Fry J, Jepson M, Petrou S, Hutchinson C, Foster N, Donovan J. Arthroscopic hip surgery compared with personalised hip therapy in people over 16 years old with femoroacetabular impingement syndrome: UK FASHIoN RCT. Health Technol Assess 2022; 26:1-236. [PMID: 35229713 PMCID: PMC8919110 DOI: 10.3310/fxii0508] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery or with physiotherapist-led conservative care. OBJECTIVE To compare the clinical effectiveness and cost-effectiveness of hip arthroscopy with best conservative care. DESIGN The UK FASHIoN (full trial of arthroscopic surgery for hip impingement compared with non-operative care) trial was a pragmatic, multicentre, randomised controlled trial that was carried out at 23 NHS hospitals. PARTICIPANTS Participants were included if they had femoroacetabular impingement, were aged ≥ 16 years old, had hip pain with radiographic features of cam or pincer morphology (but no osteoarthritis) and were believed to be likely to benefit from hip arthroscopy. INTERVENTION Participants were randomly allocated (1 : 1) to receive hip arthroscopy followed by postoperative physiotherapy, or personalised hip therapy (i.e. an individualised physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre using a central telephone randomisation service. Outcome assessment and analysis were masked. MAIN OUTCOME MEASURE The primary outcome was hip-related quality of life, measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed by intention to treat. RESULTS Between July 2012 and July 2016, 648 eligible patients were identified and 348 participants were recruited. In total, 171 participants were allocated to receive hip arthroscopy and 177 participants were allocated to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (N = 319; hip arthroscopy, n = 157; personalised hip therapy, n = 162). At 12 months, mean International Hip Outcome Tool (iHOT-33) score had improved from 39.2 (standard deviation 20.9) points to 58.8 (standard deviation 27.2) points for participants in the hip arthroscopy group, and from 35.6 (standard deviation 18.2) points to 49.7 (standard deviation 25.5) points for participants in personalised hip therapy group. In the primary analysis, the mean difference in International Hip Outcome Tool scores, adjusted for impingement type, sex, baseline International Hip Outcome Tool score and centre, was 6.8 (95% confidence interval 1.7 to 12.0) points in favour of hip arthroscopy (p = 0.0093). This estimate of treatment effect exceeded the minimum clinically important difference (6.1 points). Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment and one serious adverse event in the personalised hip therapy group was not. Thirty-eight (24%) personalised hip therapy patients chose to have hip arthroscopy between 1 and 3 years after randomisation. Nineteen (12%) hip arthroscopy patients had a revision arthroscopy. Eleven (7%) personalised hip therapy patients and three (2%) hip arthroscopy patients had a hip replacement within 3 years. LIMITATIONS Study participants and treating clinicians were not blinded to the intervention arm. Delays were encountered in participants accessing treatment, particularly surgery. Follow-up lasted for 3 years. CONCLUSION Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement in quality of life than personalised hip therapy, and this difference was clinically significant at 12 months. This study does not demonstrate cost-effectiveness of hip arthroscopy compared with personalised hip therapy within the first 12 months. Further follow-up will reveal whether or not the clinical benefits of hip arthroscopy are maintained and whether or not it is cost-effective in the long term. TRIAL REGISTRATION Current Controlled Trials ISRCTN64081839. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 26, No. 16. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Damian R Griffin
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Edward J Dickenson
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Felix Achana
- Warwick Medical School, University of Warwick, Coventry, UK
| | - James Griffin
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Joanna Smith
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Peter Dh Wall
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Alba Realpe
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nick Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Hobson
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - Marcus Jepson
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Stavros Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Charles Hutchinson
- Warwick Medical School, University of Warwick, Coventry, UK
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nadine Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences NIHR, Keele University, Keele, UK
| | - Jenny Donovan
- Bristol Medical School, University of Bristol, Bristol, UK
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Lim EKS, Batchelor TJ, Dunning J, Shackcloth M, Anikin V, Naidu B, Belcher E, Loubani M, Zamvar V, Harris RA, Dabner L, Mckeon HE, Paramasivan S, Realpe A, Elliot D, De Sousa P, Blazeby JM, Rogers CA. Video-assisted thoracoscopic versus open lobectomy in patients with early-stage lung cancer: One-year results from a randomized controlled trial (VIOLET). J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.8504] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
8504 Background: Video assisted thoracoscopic surgery (VATS) is a popular access for lung cancer resection. However, there is limited information from RCTs from in-hospital to one-year clinical efficacy, safety and oncologic outcomes of a minimal access approach. Methods: VIOLET is a parallel group multi-center RCT conducted in 9 centers in the United Kingdom that recruited participants with known or suspected (cT1-3, N0-1 and M0) lung cancer (ISRCTN13472721). Trial protocol: https://bmjopen.bmj.com/content/9/10/e029507.info. Results: From July 2015 to February 2019, 503 participants were randomized to VATS (n=247) or open (n=256) lobectomy. Patients allocated to VATS had less pain with a mean difference (MD) in visual analogue score of -0.54 (95%CI -0.99 to -0.10) despite less analgesic consumption (mean ratio 0.90, 95%CI 0.80 to 1.01). After discharge pain was consistent on multiple sub-scales including overall pain (MD -7.19, -10.59 to -3.80), chest pain (MD -4.66, -7.96 to -1.36) and an 18% relative risk (RR) reduction in incision pain (RR 0.82; 0.72 to 0.94) up to one-year. Better functional recovery continued in VATS arm after discharge with better physical function (primary outcome) with MD of 4.65 (1.69 to 7.61; P=0.002) at 5 weeks and overall improvement in global health status with a MD of 4.21 (1.62 to 6.79; P=0.001). In hospital, VATS arm had fewer complications (RR 0.74, 0.66 to 0.84; P<0.001) with no difference in serious adverse events (RR 0.98, 0.59 to 1.63; P=0.948). Median hospital stay was one day shorter in the VATS arm (4 vs 5 days) corresponding to hazard ratio (HR) for discharge of 1.34, 95%CI 1.09 to 1.65; P=0.006). After discharge VATS arm had 19% less serious adverse events (RR 0.81, 0.66 to 1.00; p=0.053) and lower readmission rates (29.0% vs. 35.9% respectively) to one-year. Of those with lymph node disease, 50.9% in the VATS and 45.9% in open arms received adjuvant treatment. There was no difference in the time to uptake of adjuvant chemotherapy (HR 1.12, 0.62 to 2.02; p=0.716). Recurrence with clinical follow up and CT at one-year was similar with 7.7% versus 8.1% in the VATS and open groups respectively. Progression-free survival (HR 0.74, 0.43 to 1.27; p=0.27) and overall survival HR 0.67, 0.32 to 1.40; p=0.282) was not significantly different. Conclusions: VATS lobectomy for lung cancer is associated with less pain, fewer in-hospital complications and shorter hospital stay, achieved without any compromise to early oncologic outcomes nor serious adverse events. Superior functional recovery continues in the post-operative period with improved physical function, lower re-admission rates and no difference in disease-free and overall survival up to one-year. Clinical trial information: ISRCTN13472721.
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Affiliation(s)
| | - Tim J.P. Batchelor
- Thoracic Surgery, Bristol Royal Infirmary, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, United Kingdom
| | - Joel Dunning
- The James Cook University Hospital, South Tees Hospitals NHS Foundation Trust, Middlesbrough, United Kingdom
| | - Michael Shackcloth
- Liverpool Heart and Chest Hospital NHS Foundation Trust, Liverpool, United Kingdom
| | - Vladimir Anikin
- Royal Brompton and Harefield Hospitals, London, United Kingdom
| | - Babu Naidu
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, United Kingdom
| | - Elizabeth Belcher
- John Radcliffe Hospital, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | | | - Vipin Zamvar
- Royal Infirmary of Edinburgh, NHS Lothian, Edinburgh, United Kingdom
| | - Rosie A. Harris
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Lucy Dabner
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Holly E. Mckeon
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Sangeetha Paramasivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Daisy Elliot
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, Bristol, United Kingdom
| | - Paulo De Sousa
- Royal Brompton and Harefield Hospitals, London, United Kingdom
| | - Jane M. Blazeby
- National Institute for Health Research Bristol Biomedical Research Centre, Surgical Innovation Theme, Centre for Surgical Research, University of Bristol, Bristol, United Kingdom
| | - Chris A. Rogers
- Bristol Trials Centre (CTEU), Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Paramasivan S, Davies P, Richards A, Wade J, Rooshenas L, Mills N, Realpe A, Raj JP, Subramani S, Ives J, Huxtable R, Blazeby JM, Donovan JL. What empirical research has been undertaken on the ethics of clinical research in India? A systematic scoping review and narrative synthesis. BMJ Glob Health 2021; 6:e004729. [PMID: 34006518 PMCID: PMC8137180 DOI: 10.1136/bmjgh-2020-004729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2020] [Revised: 02/13/2021] [Accepted: 02/24/2021] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION The post-2005 rise in clinical trials and clinical research conducted in India was accompanied by frequent reports of unethical practices, leading to a series of regulatory changes. We conducted a systematic scoping review to obtain an overview of empirical research pertaining to the ethics of clinical trials/research in India. METHODS Our search strategy combined terms related to ethics/bioethics, informed consent, clinical trials/research and India, across nine databases, up to November 2019. Peer-reviewed research exploring ethical aspects of clinical trials/research in India with any stakeholder groups was included. We developed an evidence map, undertook a narrative synthesis and identified research gaps. A consultation exercise with stakeholders in India helped contextualise the review and identify additional research priorities. RESULTS Titles/Abstracts of 9699 articles were screened, full text of 282 obtained and 80 were included. Research on the ethics of clinical trials/research covered a wide range of topics, often conducted with little to no funding. Studies predominantly examined what lay (patients/public) and professional participants (eg, healthcare staff/students/faculty) know about topics such as research ethics or understand from the information given to obtain their consent for research participation. Easily accessible groups, namely ethics committee members and healthcare students were frequently researched. Research gaps included developing a better understanding of the recruitment-informed consent process, including the doctor-patient interaction, in multiple contexts and exploring issues of equity and justice in clinical trials/research. CONCLUSION The review demonstrates that while a wide range of topics have been studied in India, the focus is largely on assessing knowledge levels across different population groups. This is a useful starting point, but fundamental questions remain unanswered about informed consent processes and broader issues of inequity that pervade the clinical trials/research landscape. A priority-setting exercise and appropriate funding mechanisms to support researchers in India would help improve the clinical trials/research ecosystem.
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Affiliation(s)
- Sangeetha Paramasivan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
| | - Philippa Davies
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Medical Research Council (MRC) ConDuCT-II Trials Methodology Hub, Bristol Medical School, University of Bristol, Bristol, UK
| | - Alison Richards
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Medical Research Council (MRC) ConDuCT-II Trials Methodology Hub, Bristol Medical School, University of Bristol, Bristol, UK
| | - Julia Wade
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Leila Rooshenas
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
| | - Nicola Mills
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
| | - Jeffrey Pradeep Raj
- Department of Clinical Pharmacology, Seth GS Medical College and KEM Hospital, Mumbai, Maharashtra, India
| | - Supriya Subramani
- Institute of Biomedical Ethics and History of Medicine, University of Zurich, Zurich, Switzerland
| | - Jonathan Ives
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Richard Huxtable
- Centre for Ethics in Medicine, University of Bristol, Bristol, UK
| | - Jane M Blazeby
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR Bristol Biomedical Research Centre, Bristol, UK
| | - Jenny L Donovan
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- University Hospitals Bristol NHS Foundation Trust, NIHR ARC West, Bristol, UK
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Realpe A, Elahi F, Bucci S, Birchwood M, Vlaev I, Taylor D, Thompson A. Co-designing a virtual world with young people to deliver social cognition therapy in early psychosis. Early Interv Psychiatry 2020; 14:37-43. [PMID: 30908854 DOI: 10.1111/eip.12804] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2018] [Revised: 01/25/2019] [Accepted: 02/17/2019] [Indexed: 12/14/2022]
Abstract
AIMS Co-design implies genuine partnership in the generation of knowledge between service users and researchers. Service user involvement in research has been encouraged in government policy, but it is rarely achieved, especially at trial initial stages. Co-designed with service users, we adapted existing manualised social cognition intervention for people with a first episode of psychosis to a virtual world environment. METHODS We invited a group of young people who have used mental health services to co-design a virtual environment to deliver an accessible social cognition intervention to a hard to engage service user group. We used an iterative process with young service users and the design team that included developing initial ideas, creating a prototype and testing the virtual world. RESULTS Twenty young service users of local mental healthcare services provided feedback on the design and delivery of the intervention. Reflecting the demographic of the sample, young people felt the virtual environment should be familiar, urban spaces, akin to therapy rooms or classrooms they have used in real-life situations rather than non-traditional therapy spaces that were initially proposed. CONCLUSION The co-design process led to the development of a specific design, approach and protocol to be tested in a proof-of-concept trial. Young service users were integral to an agile and iterative design. Technological innovations should be routinely co-designed and co-produced if they are to realise their potential to deliver acceptable and affordable mental health interventions.
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Affiliation(s)
- Alba Realpe
- Mental Health and Wellbeing Division, Warwick Medical School, University of Warwick, Coventry, UK
| | - Farah Elahi
- Mental Health and Wellbeing Division, Warwick Medical School, University of Warwick, Coventry, UK
| | - Sandra Bucci
- Division of Psychology and Mental Health, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Sciences, Manchester, UK.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
| | - Max Birchwood
- Mental Health and Wellbeing Division, Warwick Medical School, University of Warwick, Coventry, UK
| | - Ivo Vlaev
- Behavioural Science Group, Warwick Business School, University of Warwick, Coventry, UK
| | - David Taylor
- Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, London, UK
| | - Andrew Thompson
- Mental Health and Wellbeing Division, Warwick Medical School, University of Warwick, Coventry, UK
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Thompson A, Elahi F, Realpe A, Birchwood M, Taylor D, Vlaev I, Leahy F, Bucci S. A Feasibility and Acceptability Trial of Social Cognitive Therapy in Early Psychosis Delivered Through a Virtual World: The VEEP Study. Front Psychiatry 2020; 11:219. [PMID: 32269534 PMCID: PMC7109496 DOI: 10.3389/fpsyt.2020.00219] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2019] [Accepted: 03/05/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Addressing specific social cognitive difficulties is an important target in early psychosis and may help address poor functional outcomes. However, structured interventions using standard therapy settings including groups suffer from difficulties in recruitment and retention. AIMS To address these issues, we aimed to modify an existing group social cognitive intervention entitled 'Social Cognition and Interaction Training' (SCIT) to be delivered through a virtual world environment (Second Life ©). METHODS A single arm nonrandomized proof-of-concept trial of SCIT-VR was conducted. Five groups of three to five individuals per group were recruited over 6 months. Eight sessions of SCIT-VR therapy were delivered through the virtual world platform Second Life© over a 5-week intervention window. Feasibility was examined using recruitment rates and retention. Acceptability was examined using qualitative methods. Secondary outcomes including social cognitive indices, functioning, and anxiety were measured pre- and postintervention. RESULTS The SCIT-VR therapy delivered was feasible (36% consent rate and 73.3% intervention completion rate), acceptable (high overall postsession satisfaction scores) and safe (no serious adverse events), and had high levels of participant satisfaction. Users found the environment immersive. Prepost changes were found in emotion recognition scores and levels of anxiety. There were no signs of clinical deterioration on any of the secondary measures. CONCLUSION This proof-of-concept pilot trial suggested that delivering SCIT-VR through a virtual world is feasible and acceptable. There were some changes in prepost outcome measures that suggest the intervention has face validity. There is sufficient evidence to support a larger powered randomized controlled trial. CLINICAL TRIAL REGISTRATION ISRCTN, identifier 41443166.
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Affiliation(s)
- Andrew Thompson
- Orygen, the Centre for Excellence in Youth Mental Health, Melbourne, VIC, Australia.,Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Farah Elahi
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Alba Realpe
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - Max Birchwood
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - David Taylor
- Department of Surgery & Cancer, Faculty of Medicine, Imperial College London, University of London, London, United Kingdom
| | - Ivo Vlaev
- Behavioural Science Group, Warwick Business School, University of Warwick, Coventry, United Kingdom
| | - Fiona Leahy
- Warwick Medical School, University of Warwick, Coventry, United Kingdom
| | - Sandra Bucci
- Division of Psychology and Mental Health, Faculty of Biology, Medicine and Health, School of Health Sciences, Manchester Academic Health Sciences, Manchester, United Kingdom.,Greater Manchester Mental Health NHS Foundation Trust, Manchester, United Kingdom
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Thompson A, Winsper C, Marwaha S, Haynes J, Alvarez-Jimenez M, Hetrick S, Realpe A, Vail L, Dawson S, Sullivan SA. Maintenance antipsychotic treatment versus discontinuation strategies following remission from first episode psychosis: systematic review. BJPsych Open 2018; 4:215-225. [PMID: 29988997 PMCID: PMC6034451 DOI: 10.1192/bjo.2018.17] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 02/28/2018] [Accepted: 03/16/2018] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Understanding the relative risks of maintenance treatment versus discontinuation of antipsychotics following remission in first episode psychosis (FEP) is an important area of practice. METHOD A systematic review and meta-analysis. Prospective experimental studies including a parallel control group were identified to compare maintenance antipsychotic treatment with total discontinuation or medication discontinuation strategies following remission in FEP. RESULTS Seven studies were included. Relapse rates were higher in the discontinuation group (53%; 95% CIs: 39%, 68%; N = 290) compared with maintenance treatment group (19%; 95% CIs: 0.05%, 37%; N = 230). In subgroup analyses, risk difference of relapse was lower in studies with a longer follow-up period, a targeted discontinuation strategy, a higher relapse threshold, a larger sample size, and samples with patients excluded for drug or alcohol dependency. Insufficient studies included psychosocial functioning outcomes for a meta-analysis. CONCLUSIONS There is a higher risk of relapse for those who undergo total or targeted discontinuation strategies compared with maintenance antipsychotics in FEP samples. The effect size is moderate and the risk difference is lower in trials of targeted discontinuation strategies. DECLARATION OF INTEREST A.T. has received honoraria and support from Janssen-Cilag and Otsuka Pharmaceuticals for meetings and has been has been an investigator on unrestricted investigator-initiated trials funded by AstraZeneca and Janssen-Cilag. He has also previously held a Pfizer Neurosciences Research Grant. S.M. has received sponsorship from Otsuka and Lundbeck to attend an academic congress and owns shares in GlaxoSmithKline and AstraZeneca. J.H. has attended meetings supported by Sunovion Pharmaceuticals.
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Affiliation(s)
- Andrew Thompson
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick and North Warwickshire Early Intervention in Psychosis Service, Coventry and Warwickshire National Health Service Partnership Trust, UK
| | - Catherine Winsper
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, UK
| | - Steven Marwaha
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick and Affective Disorders Service, Coventry and Warwickshire National Health Service Partnership Trust, Tile Hill, UK
| | - Jon Haynes
- 2gether National Health Service Foundation Trust, Gloucester, UK
| | | | - Sarah Hetrick
- Orygen, The National Centre of Excellence in Youth Mental Health, Australia
| | - Alba Realpe
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, UK
| | - Laura Vail
- Division of Mental Health and Wellbeing, Warwick Medical School, University of Warwick, UK
| | - Sarah Dawson
- Centre for Academic Mental Health, University of Bristol, UK
| | - Sarah A Sullivan
- Centre for Academic Mental Health, University of Bristol and National Institute for Health Research Collaborations for Leadership in Applied Health Research and Care West, UK
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16
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Griffin DR, Dickenson EJ, Wall PDH, Achana F, Donovan JL, Griffin J, Hobson R, Hutchinson CE, Jepson M, Parsons NR, Petrou S, Realpe A, Smith J, Foster NE. Hip arthroscopy versus best conservative care for the treatment of femoroacetabular impingement syndrome (UK FASHIoN): a multicentre randomised controlled trial. Lancet 2018; 391:2225-2235. [PMID: 29893223 PMCID: PMC5988794 DOI: 10.1016/s0140-6736(18)31202-9] [Citation(s) in RCA: 346] [Impact Index Per Article: 57.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2018] [Revised: 04/19/2018] [Accepted: 04/24/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Femoroacetabular impingement syndrome is an important cause of hip pain in young adults. It can be treated by arthroscopic hip surgery, including reshaping the hip, or with physiotherapist-led conservative care. We aimed to compare the clinical effectiveness of hip arthroscopy with best conservative care. METHODS UK FASHIoN is a pragmatic, multicentre, assessor-blinded randomised controlled trial, done at 23 National Health Service hospitals in the UK. We enrolled patients with femoroacetabular impingement syndrome who presented at these hospitals. Eligible patients were at least 16 years old, had hip pain with radiographic features of cam or pincer morphology but no osteoarthritis, and were believed to be likely to benefit from hip arthroscopy. Patients with bilateral femoroacetabular impingement syndrome were eligible; only the most symptomatic hip was randomly assigned to treatment and followed-up. Participants were randomly allocated (1:1) to receive hip arthroscopy or personalised hip therapy (an individualised, supervised, and progressive physiotherapist-led programme of conservative care). Randomisation was stratified by impingement type and recruiting centre and was done by research staff at each hospital, using a central telephone randomisation service. Patients and treating clinicians were not masked to treatment allocation, but researchers who collected the outcome assessments and analysed the results were masked. The primary outcome was hip-related quality of life, as measured by the patient-reported International Hip Outcome Tool (iHOT-33) 12 months after randomisation, and analysed in all eligible participants who were allocated to treatment (the intention-to-treat population). This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN64081839, and is closed to recruitment. FINDINGS Between July 20, 2012, and July 15, 2016, we identified 648 eligible patients and recruited 348 participants: 171 participants were allocated to receive hip arthroscopy and 177 to receive personalised hip therapy. Three further patients were excluded from the trial after randomisation because they did not meet the eligibility criteria. Follow-up at the primary outcome assessment was 92% (319 of 348 participants). At 12 months after randomisation, mean iHOT-33 scores had improved from 39·2 (SD 20·9) to 58·8 (27·2) for participants in the hip arthroscopy group, and from 35·6 (18·2) to 49·7 (25·5) in the personalised hip therapy group. In the primary analysis, the mean difference in iHOT-33 scores, adjusted for impingement type, sex, baseline iHOT-33 score, and centre, was 6·8 (95% CI 1·7-12·0) in favour of hip arthroscopy (p=0·0093). This estimate of treatment effect exceeded the minimum clinically important difference (6·1 points). There were 147 patient-reported adverse events (in 100 [72%] of 138 patients) in the hip arthroscopy group) versus 102 events (in 88 [60%] of 146 patients) in the personalised hip therapy group, with muscle soreness being the most common of these (58 [42%] vs 69 [47%]). There were seven serious adverse events reported by participating hospitals. Five (83%) of six serious adverse events in the hip arthroscopy group were related to treatment, and the one in the personalised hip therapy group was not. There were no treatment-related deaths, but one patient in the hip arthroscopy group developed a hip joint infection after surgery. INTERPRETATION Hip arthroscopy and personalised hip therapy both improved hip-related quality of life for patients with femoroacetabular impingement syndrome. Hip arthroscopy led to a greater improvement than did personalised hip therapy, and this difference was clinically significant. Further follow-up will reveal whether the clinical benefits of hip arthroscopy are maintained and whether it is cost effective in the long term. FUNDING The Health Technology Assessment Programme of the National Institute of Health Research.
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Affiliation(s)
- Damian R Griffin
- University of Warwick, Coventry, UK; University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK.
| | - Edward J Dickenson
- University of Warwick, Coventry, UK; University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Peter D H Wall
- University of Warwick, Coventry, UK; University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | | | | | - Charles E Hutchinson
- University of Warwick, Coventry, UK; University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | | | | | - Alba Realpe
- University of Warwick, Coventry, UK; University of Bristol, Bristol, UK
| | - Joanna Smith
- University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute for Primary Care and Health Sciences, Keele University, Keele, UK
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Griffin D, Wall P, Realpe A, Adams A, Parsons N, Hobson R, Achten J, Fry J, Costa M, Petrou S, Foster N, Donovan J. UK FASHIoN: feasibility study of a randomised controlled trial of arthroscopic surgery for hip impingement compared with best conservative care. Health Technol Assess 2018; 20:1-172. [PMID: 27117505 DOI: 10.3310/hta20320] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Femoroacetabular impingement (FAI) is a syndrome of hip or groin pain associated with shape abnormalities of the hip joint. Treatments include arthroscopic surgery and conservative care. This study explored the feasibility of a randomised controlled trial to compare these treatments. OBJECTIVES The objectives of this study were to estimate the number of patients available for a full randomised controlled trial (RCT); to explore clinician and patient willingness to participate in such a RCT; to develop consensus on eligibility criteria, surgical and best conservative care protocols; to examine possible outcome measures and estimate the sample size for a full RCT; and to develop trial procedures and estimate recruitment and follow-up rates. METHODS Pre-pilot work: we surveyed all UK NHS hospital trusts (n = 197) to identify all FAI surgeons and to estimate how much arthroscopic FAI surgery they performed. We interviewed a purposive sample of 18 patients, 36 physiotherapists, 18 surgeons and two sports physicians to explore attitudes towards a RCT and used consensus-building methods among them to develop treatment protocols and patient information. Pilot RCT: we performed a pilot RCT in 10 hospital trusts. Patients were randomised to receive either hip arthroscopy or best conservative care and then followed up at 3, 6 and 12 months using patient-reported questionnaires for hip pain and function, activity level, quality of life, and a resource-use questionnaire. Qualitative recruitment intervention: we performed semistructured interviews with all researchers and clinicians involved in the pilot RCT in eight hospital trusts and recorded and analysed diagnostic and recruitment consultations with eligible patients. RESULTS We identified 120 surgeons who reported treating at least 1908 patients with FAI by hip arthroscopy in the NHS in the financial year 2011/12. There were 34 hospital trusts that performed ≥ 20 arthroscopic FAI operations in the year. We found that clinicians were positive about a RCT: only half reported equipoise, but most said that they would be prepared to randomise patients. Patients strongly supported a RCT, but expressed concerns about its design; these were used to develop patient information for the pilot RCT. We developed a surgical protocol and showed that this could be used in a RCT. We developed a physiotherapy-led exercise-based package of best conservative care called 'personalised hip therapy' and showed that this was practicable. In the pilot RCT, we recruited 42 out of 60 eligible patients (70%) across nine sites. The mean duration and recruitment rate across all sites were 4.5 months and one patient per site per month, respectively. The lead site recruited for the longest period (9.3 months) and accrued the largest number of patients (2.1 patients per month). We recorded and analysed 84 diagnostic and recruitment consultations in 60 patients and used these to develop a model for an optimal recruitment consultation. We identified the International Hip Outcome Tool at 12 months as an appropriate outcome measure and estimated the sample size for a full trial as 344 participants: a number that could be recruited in 25 centres over 18 months. CONCLUSION We have demonstrated that it is feasible to perform a RCT to establish the clinical effectiveness of hip arthroscopy compared with best conservative care for FAI. We have designed a full trial and developed and tested procedures for it, including an innovative approach to recruitment. We propose that a full trial be implemented. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Damian Griffin
- Division of Health Sciences, University of Warwick, Warwick, UK
| | - Peter Wall
- Division of Health Sciences, University of Warwick, Warwick, UK
| | - Alba Realpe
- Division of Mental Health and Wellbeing, University of Warwick, Warwick, UK
| | - Ann Adams
- Division of Mental Health and Wellbeing, University of Warwick, Warwick, UK
| | - Nick Parsons
- Department of Statistics and Epidemiology, University of Warwick, Warwick, UK
| | - Rachel Hobson
- Division of Health Sciences, University of Warwick, Warwick, UK
| | - Juul Achten
- Division of Health Sciences, University of Warwick, Warwick, UK
| | | | - Matthew Costa
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Stavros Petrou
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - Nadine Foster
- Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, UK
| | - Jenny Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Barlow T, Scott P, Thomson L, Griffin D, Realpe A. The decision-making threshold and the factors that affect it: A qualitative study of patients' decision-making in knee replacement surgery. Musculoskeletal Care 2017; 16:3-12. [PMID: 28471033 DOI: 10.1002/msc.1190] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Osteoarthritis is a significant cause of burden to the ageing population and knee replacement is a common operation for treatment of end-stage disease. We aimed to explore these factors to help understand patients' decision-making, which is critical in informing patient-centred care. These can be used to enhance decision-making and dialogue between clinicians and patients, allowing a more informed choice. METHODS The study consisted of two focus groups, in a patient cohort after total knee replacement followed by more in-depth interviews to further test and explore themes from the focus groups, in patients in either the deliberation stage or the decision-making stage. RESULTS Using qualitative research methods (iterative thematic analysis) reviewing decision-making and deliberation phases of making informed choices we found nine key themes that emerged from the study groups. CONCLUSIONS An awareness of the deliberation phase, the factors that influence it, the stress associated with it, preferred models of care, and the influence of the decision-making threshold will aid useful communication between doctors and patients.
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Affiliation(s)
| | - P Scott
- University of Warwickshire, UK
| | - L Thomson
- United Lincolnshire Hospitals Trust, UK
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Wall PD, Dickenson EJ, Robinson D, Hughes I, Realpe A, Hobson R, Griffin DR, Foster NE. Personalised Hip Therapy: development of a non-operative protocol to treat femoroacetabular impingement syndrome in the FASHIoN randomised controlled trial. Br J Sports Med 2017; 50:1217-23. [PMID: 27629405 PMCID: PMC5036255 DOI: 10.1136/bjsports-2016-096368] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/09/2016] [Indexed: 11/03/2022]
Abstract
INTRODUCTION Femoroacetabular impingement (FAI) syndrome is increasingly recognised as a cause of hip pain. As part of the design of a randomised controlled trial (RCT) of arthroscopic surgery for FAI syndrome, we developed a protocol for non-operative care and evaluated its feasibility. METHODS In phase one, we developed a protocol for non-operative care for FAI in the UK National Health Service (NHS), through a process of systematic review and consensus gathering. In phase two, the protocol was tested in an internal pilot RCT for protocol adherence and adverse events. RESULTS The final protocol, called Personalised Hip Therapy (PHT), consists of four core components led by physiotherapists: detailed patient assessment, education and advice, help with pain relief and an exercise-based programme that is individualised, supervised and progressed over time. PHT is delivered over 12-26 weeks in 6-10 physiotherapist-patient contacts, supplemented by a home exercise programme. In the pilot RCT, 42 patients were recruited and 21 randomised to PHT. Review of treatment case report forms, completed by physiotherapists, showed that 13 patients (62%) received treatment that had closely followed the PHT protocol. 13 patients reported some muscle soreness at 6 weeks, but there were no serious adverse events. CONCLUSION PHT provides a structure for the non-operative care of FAI and offers guidance to clinicians and researchers in an evolving area with limited evidence. PHT was deliverable within the National Health Service, is safe, and now forms the comparator to arthroscopic surgery in the UK FASHIoN trial (ISRCTN64081839). TRIAL REGISTRATION NUMBER ISRCTN 09754699.
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Affiliation(s)
- Peter Dh Wall
- Warwick Medical School, University of Warwick, Coventry, UK
| | | | - David Robinson
- Southbank Hospital Worcester, Spire Healthcare, Worcester, UK
| | - Ivor Hughes
- University Hospitals Coventry and Warwickshire, Coventry, UK
| | - Alba Realpe
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Rachel Hobson
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Damian R Griffin
- University Hospitals of Coventry and Warwickshire NHS Trust and Warwick Medical School, University of Warwick, Coventry, UK
| | - Nadine E Foster
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences NIHR Professor of Musculoskeletal Health in Primary Care, Keele University, Keele, UK
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Griffin D, Dickenson E, Wall P, Realpe A, Adams A, Parsons N, Hobson R, Achten J, Costa M, Foster N, Hutchinson C, Petrou S, Donovan J. The feasibility of conducting a randomised controlled trial comparing arthroscopic hip surgery to conservative care for patients with femoroacetabular impingement syndrome: the FASHIoN feasibility study. J Hip Preserv Surg 2016; 3:304-311. [PMID: 29632690 PMCID: PMC5883184 DOI: 10.1093/jhps/hnw026] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2016] [Accepted: 06/24/2016] [Indexed: 11/13/2022] Open
Abstract
To determine whether it was feasible to perform a randomized controlled trial (RCT) comparing arthroscopic hip surgery to conservative care in patients with femoroacetabular impingement (FAI). This study had two phases: a pre-pilot and pilot RCT. In the pre-pilot, we conducted interviews with clinicians who treated FAI and with FAI patients to determine their views about an RCT. We developed protocols for operative and conservative care. In the pilot RCT, we determined the rates of patient eligibility, recruitment and retention, to investigate the feasibility of the protocol and we established methods to assess treatment fidelity. In the pre-pilot phase, 32 clinicians were interviewed, of which 26 reported theoretical equipoise, but in example scenarios 7 failed to show clinical equipoise. Eighteen patients treated for FAI were also interviewed, the majority of whom felt that surgery and conservative care were acceptable treatments. Surgery was viewed by patients as a 'definitive solution'. Patients were motivated to participate in research but were uncomfortable about randomization. Randomization was more acceptable if the alternative was available at the end of the trial. In the pilot phase, 151 patients were assessed for eligibility. Sixty were eligible and invited to take part in the pilot RCT; 42 consented to randomization. Follow-up was 100% at 12 months. Assessments of treatment fidelity were satisfactory. An RCT to compare arthroscopic hip surgery with conservative care in patients with FAI is challenging but feasible. Recruitment has started for a full RCT.
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Affiliation(s)
- D.R. Griffin
- Warwick Medical School, University of Warwick, Warwick, UK
| | - E.J. Dickenson
- Warwick Medical School, University of Warwick, Warwick, UK
| | - P.D.H. Wall
- Warwick Medical School, University of Warwick, Warwick, UK
| | - A. Realpe
- Warwick Medical School, University of Warwick, Warwick, UK
| | - A. Adams
- Division of Mental Health and Wellbeing, University of Warwick, Warwick, UK
| | - N. Parsons
- Department of Statistics and Epidemiology, University of Warwick, Warwick, UK
| | - R. Hobson
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - J. Achten
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - M.L. Costa
- Warwick Clinical Trials Unit, University of Warwick, Warwick, UK
| | - N.E. Foster
- Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, UK
| | | | - S. Petrou
- Arthritis Research UK Primary Care Centre, Keele University, Staffordshire, UK
| | - J.L. Donovan
- School of Social and Community Medicine, University of Bristol, Bristol, UK
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Griffin DR, Dickenson EJ, Wall PDH, Donovan JL, Foster NE, Hutchinson CE, Parsons N, Petrou S, Realpe A, Achten J, Achana F, Adams A, Costa ML, Griffin J, Hobson R, Smith J. Protocol for a multicentre, parallel-arm, 12-month, randomised, controlled trial of arthroscopic surgery versus conservative care for femoroacetabular impingement syndrome (FASHIoN). BMJ Open 2016; 6:e012453. [PMID: 27580837 PMCID: PMC5013508 DOI: 10.1136/bmjopen-2016-012453] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Femoroacetabular impingement (FAI) syndrome is a recognised cause of young adult hip pain. There has been a large increase in the number of patients undergoing arthroscopic surgery for FAI; however, a recent Cochrane review highlighted that there are no randomised controlled trials (RCTs) evaluating treatment effectiveness. We aim to compare the clinical and cost-effectiveness of arthroscopic surgery versus best conservative care for patients with FAI syndrome. METHODS We will conduct a multicentre, pragmatic, assessor-blinded, two parallel arm, RCT comparing arthroscopic surgery to physiotherapy-led best conservative care. 24 hospitals treating NHS patients will recruit 344 patients over a 26-month recruitment period. Symptomatic adults with radiographic signs of FAI morphology who are considered suitable for arthroscopic surgery by their surgeon will be eligible. Patients will be excluded if they have radiographic evidence of osteoarthritis, previous significant hip pathology or previous shape changing surgery. Participants will be allocated in a ratio of 1:1 to receive arthroscopic surgery or conservative care. Recruitment will be monitored and supported by qualitative intervention to optimise informed consent and recruitment. The primary outcome will be pain and function assessed by the international hip outcome tool 33 (iHOT-33) measured 1-year following randomisation. Secondary outcomes include general health (short form 12), quality of life (EQ5D-5L) and patient satisfaction. The primary analysis will compare change in pain and function (iHOT-33) at 12 months between the treatment groups, on an intention-to-treat basis, presented as the mean difference between the trial groups with 95% CIs. The study is funded by the Health Technology Assessment Programme (13/103/02). ETHICS AND DISSEMINATION Ethical approval is granted by the Edgbaston Research Ethics committee (14/WM/0124). The results will be disseminated through open access peer-reviewed publications, including Health Technology Assessment, and presented at relevant conferences. TRIAL REGISTRATION NUMBER ISRCTN64081839; Pre-results.
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Affiliation(s)
- D R Griffin
- University of Warwick, University Hospitals of Coventry and Warwickshire NHS Trust, Coventry, UK
| | - E J Dickenson
- Warwick Medical School, University of Warwick, Coventry, UK
| | - P D H Wall
- Warwick Medical School, University of Warwick, Coventry, UK
| | - J L Donovan
- University of Bristol, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - N E Foster
- Arthritis Research UK Primary Care Centre, Research Institute of Primary Care and Health Sciences NIHR, Keele University, Keele, UK
| | - C E Hutchinson
- Warwick Medical School, University of Warwick, Coventry, UK
| | - N Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - S Petrou
- Warwick Medical School, University of Warwick, Coventry, UK
| | - A Realpe
- Warwick Medical School, University of Warwick, Coventry, UK
| | - J Achten
- Warwick Medical School, University of Warwick, Coventry, UK
| | - F Achana
- Warwick Medical School, University of Warwick, Coventry, UK
| | - A Adams
- Warwick Medical School, University of Warwick, Coventry, UK
| | - M L Costa
- Warwick Medical School, University of Warwick, Coventry, UK
| | - J Griffin
- Warwick Medical School, University of Warwick, Coventry, UK
| | - R Hobson
- Warwick Medical School, University of Warwick, Coventry, UK
| | - J Smith
- Warwick Medical School, University of Warwick, Coventry, UK
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Barlow T, Scott P, Griffin D, Realpe A. How outcome prediction could affect patient decision making in knee replacements: a qualitative study. BMC Musculoskelet Disord 2016; 17:304. [PMID: 27444429 PMCID: PMC4957427 DOI: 10.1186/s12891-016-1165-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2016] [Accepted: 07/12/2016] [Indexed: 12/16/2022] Open
Abstract
Background There is approximately a 17 % dissatisfaction rate with knee replacements. Calls for tools that can pre-operatively identify patients at risk of being dissatisfied have been widespread. However, it is not known how to present such information to patients, how it would affect their decision making process, and at what part of the pathway such a tool should be used. Methods Using focus groups involving 12 participants and in-depth interviews with 10 participants, we examined how individual predictions of outcome could affect patients’ decision making by providing fictitious predictions to patients at different stages of treatment. A thematic analysis was used to analyse the data. Results Our results demonstrate several interesting findings. Firstly, patients who have received information from friends and family are unwilling to adjust their expectation of outcome down (i.e. to a worse outcome), but highly willing to adjust it up (to a better outcome). This is an example of the optimism bias, and suggests that the effect on expectation of a poor outcome prediction would be blunted. Secondly, patients generally wanted a “bottom line” outcome, rather than lots of detail. Thirdly, patients who were earlier in their treatment for osteoarthritis were more likely to find the information useful, and it was more likely to affect their decision, than patients later in their treatment pathway. Conclusion This research suggest that an outcome prediction tool would have most effect targeted towards people at the start of their treatment pathway, with a “bottom line” prediction of outcome. However, any effect on expectation and decision making of a poor outcome prediction is likely to be blunted by the optimism bias. These findings merit replication in a larger sample size. Electronic supplementary material The online version of this article (doi:10.1186/s12891-016-1165-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Timothy Barlow
- CSB, University of Warwick, UHCW, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Patricia Scott
- CSB, University of Warwick, UHCW, Clifford Bridge Road, Coventry, CV2 2DX, UK
| | - Damian Griffin
- CSB, University of Warwick, UHCW, Clifford Bridge Road, Coventry, CV2 2DX, UK.
| | - Alba Realpe
- CSB, University of Warwick, UHCW, Clifford Bridge Road, Coventry, CV2 2DX, UK
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Realpe A, Adams A, Wall P, Griffin D, Donovan JL. A new simple six-step model to promote recruitment to RCTs was developed and successfully implemented. J Clin Epidemiol 2016; 76:166-74. [PMID: 26898705 PMCID: PMC5045272 DOI: 10.1016/j.jclinepi.2016.02.002] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 01/29/2016] [Accepted: 02/12/2016] [Indexed: 12/13/2022]
Abstract
OBJECTIVES How a randomized controlled trial (RCT) is explained to patients is a key determinant of recruitment to that trial. This study developed and implemented a simple six-step model to fully inform patients and to support them in deciding whether to take part or not. STUDY DESIGN AND SETTING Ninety-two consultations with 60 new patients were recorded and analyzed during a pilot RCT comparing surgical and nonsurgical interventions for hip impingement. Recordings were analyzed using techniques of thematic analysis and focused conversation analysis. RESULTS Early findings supported the development of a simple six-step model to provide a framework for good recruitment practice. Model steps are as follows: (1) explain the condition, (2) reassure patients about receiving treatment, (3) establish uncertainty, (4) explain the study purpose, (5) give a balanced view of treatments, and (6) Explain study procedures. There are also two elements throughout the consultation: (1) responding to patients' concerns and (2) showing confidence. The pilot study was successful, with 70% (n = 60) of patients approached across nine centers agreeing to take part in the RCT, so that the full-scale trial was funded. CONCLUSION The six-step model provides a promising framework for successful recruitment to RCTs. Further testing of the model is now required.
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Affiliation(s)
- Alba Realpe
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Ann Adams
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Peter Wall
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom
| | - Damian Griffin
- Warwick Medical School, University of Warwick, Coventry CV4 7AL, United Kingdom.
| | - Jenny L Donovan
- School of Social and Community Medicine, University of Bristol, Canynge Hall, 39 Whatley Road, Bristol BS8 2PS, Bristol, United Kingdom
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Realpe A, Adams A, Wall P, Griffin D, Donovan JL. What does a good RCT recruitment consultation look like? A new simple six-step model to promote information sharing and recruitment to RCTs. Trials 2015. [PMCID: PMC4658828 DOI: 10.1186/1745-6215-16-s2-o21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Dale J, Potter R, Owen K, Parsons N, Realpe A, Leach J. Retaining the general practitioner workforce in England: what matters to GPs? A cross-sectional study. BMC Fam Pract 2015; 16:140. [PMID: 26475707 PMCID: PMC4608111 DOI: 10.1186/s12875-015-0363-1] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/30/2015] [Accepted: 10/08/2015] [Indexed: 12/04/2022]
Abstract
Background The general practice (GP) workforce in England is in crisis, reflected in increasing rates of early retirement and intentions to reduce hours of working. This study aimed to investigate underlying factors and how these might be mitigated. Methods GPs in central England were invited to participate in an on-line survey exploring career plans and views and experiences of work-related pressures. Quantitative data were analysed using logistic regression analysis and principal components analysis. Qualitative data were analysed using a thematic framework approach. Results Of 1,192 GPs who participated, 978 (82.0 %) stated that they intend to leave general practice, take a career break and/or reduce clinical hours of work within the next five years. This included 488 (41.9 %) who intend to leave practice, and almost a quarter (279; 23.2 %) intending to take a career break. Only 67 (5.6 %) planned to increase their hours of clinical work. For participants planning to leave practice, the issues that most influenced intentions were volume and intensity of workload, time spent on “unimportant tasks”, introduction of seven-day working and lack of job satisfaction. Four hundred fifty five participants responded to open questions (39128 words in total). The main themes were the cumulative impact of work-related pressures, the changing and growing nature of the workload, and the consequent stress. Reducing workload intensity, workload volume, administrative activities, with increased time for patient care, no out-of-hour commitments, more flexible working conditions and greater clinical autonomy were identified as the most important requirements to address the workforce crisis. In addition, incentive payments, increased pay and protected time for education and training were also rated as important. Conclusions New models of professionalism and organisational arrangements may be needed to address the issues described here. Without urgent action, the GP workforce crisis in England seems set to worsen. Electronic supplementary material The online version of this article (doi:10.1186/s12875-015-0363-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jeremy Dale
- Warwick Medical School, Coventry, CV4 7AL, UK.
| | | | | | | | - Alba Realpe
- Warwick Medical School, Coventry, CV4 7AL, UK.
| | - Jonathan Leach
- Davenal House Surgery, Bromsgrove, Worcestershire, B61 0DD, UK.
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Abstract
Objectives A patient-centred approach, usually achieved through shared decision
making, has the potential to help improve decision making around
knee arthroplasty surgery. However, such an approach requires an
understanding of the factors involved in patient decision making.
This review’s objective is to systematically examine the qualitative literature
surrounding patients’ decision making in knee arthroplasty. Methods A systematic literature review using Medline and Embase was conducted
to identify qualitative studies that examined patients’ decision
making around knee arthroplasty. An aggregated account of what is
known about patients’ decision making in knee arthroplasties is
provided. Results Seven studies with 234 participants in interviews or focus groups
are included. Ten themes are replicated across studies, namely:
expectations of surgery; coping mechanisms; relationship with clinician;
fear; pain; function; psychological implications; social network;
previous experience of surgery; and conflict in opinions. Conclusions This review is helpful in not only directing future research
to areas that are not understood, or require confirmation, but also
in highlighting areas that future interventions could address. These
include those aimed at delivering information, which are likely
to affect the satisfaction rate, demand, and use of knee arthroplasties. Cite this article: Bone Joint Res 2015;4;163–169.
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Affiliation(s)
- T Barlow
- Warwick University, UHCW, Clifford Bridge Road, CV2 2DX, UK
| | | | - D Barlow
- Wrexham Maelor Hospital, Croesnewydd Road, Wrexham LL13 7TD, UK
| | - A Realpe
- Warwick University, UHCW, Clifford Bridge Road, CV2 2DX, UK
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Adams A, Realpe A, Vail L, Buckingham CD, Erby LH, Roter D. How doctors' communication style and race concordance influence African-Caribbean patients when disclosing depression. Patient Educ Couns 2015; 98:1266-73. [PMID: 26319363 DOI: 10.1016/j.pec.2015.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/26/2015] [Revised: 08/11/2015] [Accepted: 08/13/2015] [Indexed: 05/10/2023]
Abstract
OBJECTIVE To determine the impact of doctors' communication style and doctor-patient race concordance on UK African-Caribbeans' comfort in disclosing depression. METHODS 160 African-Caribbean and 160 white British subjects, stratified by gender and history of depression, participated in simulated depression consultations with video-recorded doctors. Doctors were stratified by black or white race, gender and a high (HPC) or low patient-centred (LPC) communication style, giving a full 2×2×2 factorial design. Afterwards, participants rated aspects of doctors' communication style, their comfort in disclosing depression and treatment preferences RESULTS Race concordance had no impact on African-Caribbeans' comfort in disclosing depression. However a HPC versus LPC communication style made them significantly more positive about their interactions with doctors (p=0.000), their overall comfort (p=0.003), their comfort in disclosing their emotional state (p=0.001), and about considering talking therapy (p=0.01); but less positive about considering antidepressant medication (p=0.01). CONCLUSION Doctors' communication style was shown to be more important than patient race or race concordance in influencing African Caribbeans' depression consultation experiences. Changing doctors' communication style may help reduce disparities in depression care. PRACTICE IMPLICATIONS Practitioners should cultivate a HPC style to make African-Caribbeans more comfortable when disclosing depression, so that it is less likely to be missed.
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Affiliation(s)
- A Adams
- Warwick Medical School, University of Warwick, Coventry, UK.
| | - A Realpe
- Warwick Medical School, University of Warwick, Coventry, UK.
| | - L Vail
- Warwick Medical School, University of Warwick, Coventry, UK.
| | | | - L H Erby
- School of Public Health, Johns Hopkins University, Baltimore, USA.
| | - D Roter
- School of Public Health, Johns Hopkins University, Baltimore, USA.
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Roter DL, Erby LH, Adams A, Buckingham CD, Vail L, Realpe A, Larson S, Hall JA. Talking about depression: an analogue study of physician gender and communication style on patient disclosures. Patient Educ Couns 2014; 96:339-45. [PMID: 24882087 PMCID: PMC4145035 DOI: 10.1016/j.pec.2014.05.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/11/2014] [Revised: 04/26/2014] [Accepted: 05/01/2014] [Indexed: 05/14/2023]
Abstract
OBJECTIVES To disentangle the effects of physician gender and patient-centered communication style on patients' oral engagement in depression care. METHODS Physician gender, physician race and communication style (high patient-centered (HPC) and low patient-centered (LPC)) were manipulated and presented as videotaped actors within a computer simulated medical visit to assess effects on analogue patient (AP) verbal responsiveness and care ratings. 307 APs (56% female; 70% African American) were randomly assigned to conditions and instructed to verbally respond to depression-related questions and indicate willingness to continue care. Disclosures were coded using Roter Interaction Analysis System (RIAS). RESULTS Both male and female APs talked more overall and conveyed more psychosocial and emotional talk to HPC gender discordant doctors (all p<.05). APs were more willing to continue treatment with gender-discordant HPC physicians (p<.05). No effects were evident in the LPC condition. CONCLUSIONS Findings highlight a role for physician gender when considering active patient engagement in patient-centered depression care. This pattern suggests that there may be largely under-appreciated and consequential effects associated with patient expectations in regard to physician gender that these differ by patient gender. PRACTICE IMPLICATIONS High patient-centeredness increases active patient engagement in depression care especially in gender discordant dyads.
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Affiliation(s)
- Debra L Roter
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA.
| | - Lori H Erby
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
| | | | | | | | | | - Susan Larson
- Department of Health, Behavior, and Society, Johns Hopkins Bloomberg School of Public Health, Baltimore, USA
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Wall P, Realpe A, Griffin D, Hobson R, Adams A. Treatment for femoroacetabular impingement: a qualitative method for exploring equipoise amongst hip arthroscopy surgeons. Trials 2013. [PMCID: PMC3981597 DOI: 10.1186/1745-6215-14-s1-p103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Realpe A, Wall P, Griffin D, Hobson R, Donovan J, Adams A. Involving patients in optimising RCT participant information sheets and exploring patient acceptability of clinical trials. Trials 2013. [PMCID: PMC3980244 DOI: 10.1186/1745-6215-14-s1-o71] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Sharma S, Wallace LM, Kosmala-Anderson J, Realpe A, Turner A. Perceptions and experiences of co-delivery model for self-management training for clinicians working with patients with long-term conditions at three healthcare economies in U.K. World Hosp Health Serv 2011; 47:22-24. [PMID: 22073878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
This paper presents a case study evaluation of self-management training courses for clinicians working with patients with COPD and Depression, at three NHS sites in United Kingdom. These courses were part of the Health Foundation's Co-Creating Health Initiative project and were co-delivered by a trained patient and clinician tutors. Interviews with 30 clinician attendees, four clinician tutors and two patient tutors suggested that the course content and delivery style were valued by everyone and clinicians reported a higher use of self-management skills following training. Analyses of the video-recorded consultation sessions of two trained clinicians showed limited use of co-production skills.
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