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Day J, Simmonds RL, Shaw L, Price CI, McClelland G, Ford GA, James M, White P, Stein K, Pope C. Healthcare professional views about a prehospital redirection pathway for stroke thrombectomy: a multiphase deductive qualitative study. Emerg Med J 2024:emermed-2023-213350. [PMID: 38729751 DOI: 10.1136/emermed-2023-213350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 04/10/2024] [Indexed: 05/12/2024]
Abstract
BACKGROUND Mechanical thrombectomy for stroke is highly effective but time-critical. Delays are common because many patients require transfer between local hospitals and regional centres. A two-stage prehospital redirection pathway consisting of a simple ambulance screen followed by regional centre assessment to select patients for direct admission could optimise access. However, implementation might be challenged by the limited number of thrombectomy providers, a lack of prehospital diagnostic tests for selecting patients and whether finite resources can accommodate longer ambulance journeys plus greater central admissions. We undertook a three-phase, multiregional, qualitative study to obtain health professional views on the acceptability and feasibility of a new pathway. METHODS Online focus groups/semistructured interviews were undertaken designed to capture important contextual influences. We purposively sampled NHS staff in four regions of England. Anonymised interview transcripts underwent deductive thematic analysis guided by the NASSS (Non-adoption, Abandonment and Challenges to Scale-up, Spread and Sustainability, Implementation) Implementation Science framework. RESULTS Twenty-eight staff participated in 4 focus groups, 2 group interviews and 18 individual interviews across 4 Ambulance Trusts, 5 Hospital Trusts and 3 Integrated Stroke Delivery Networks (ISDNs). Five deductive themes were identified: (1) (suspected) stroke as a condition, (2) the pathway change, (3) the value participants placed on the proposed pathway, (4) the possible impact on NHS organisations/adopter systems and (5) the wider healthcare context. Participants perceived suspected stroke as a complex scenario. Most viewed the proposed new thrombectomy pathway as beneficial but potentially challenging to implement. Organisational concerns included staff shortages, increased workflow and bed capacity. Participants also reported wider socioeconomic issues impacting on their services contributing to concerns around the future implementation. CONCLUSIONS Positive views from health professionals were expressed about the concept of a proposed pathway while raising key content and implementation challenges and useful 'real-world' issues for consideration.
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Affiliation(s)
- Jo Day
- NIHR Applied Research Collaboration South West Peninsula, Health and Community Sciences, University of Exeter, Exeter, Devon, UK
| | | | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Graham McClelland
- North East Ambulance Service NHS Foundation Trust, Newcastle Upon Tyne, UK
- Northumbria University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Foundation Trust and Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Martin James
- Royal Devon University Healthcare NHS Foundation Trust and University of Exeter, University of Exeter, Exeter, Devon, UK
| | - Phil White
- Stroke Research Group, Clinical and Translational Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Ken Stein
- NIHR Applied Research Collaboration South West Peninsula, University of Exeter, Exeter, Devon, UK
| | - Catherine Pope
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Warmoth K, Rees J, Day J, Cockcroft E, Aylward A, Pollock L, Coxon G, Craig T, Walton B, Stein K. Assessing deprescribing tools for implementation in care homes: A qualitative study of the views of care home staff. Res Social Adm Pharm 2024; 20:379-388. [PMID: 38245383 DOI: 10.1016/j.sapharm.2023.11.008] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2023] [Revised: 11/22/2023] [Accepted: 11/26/2023] [Indexed: 01/22/2024]
Abstract
BACKGROUND Care home residents often experience polypharmacy (defined as taking five or more regular medicines). Therefore, we need to ensure that residents only take the medications that are appropriate or provide value (also known as medicines optimisation). To achieve this, deprescribing, or the reduction or stopping of prescription medicines that may no longer be providing benefit, can help manage polypharmacy and improve outcomes. Various tools, guides, and approaches have been developed to help support health professionals to deprescribe in regular practice. Little evaluation of these tools has been conducted and no work has been done in the care home setting. OBJECTIVE This qualitative study aimed to assess distinct types of deprescribing tools for acceptability, feasibility, and suitability for the care home setting. METHODS Cognitive (think-aloud) interviews with care home staff in England were conducted (from December 2021 to June 2022) to assess five different deprescribing tools. The tools included a general deprescribing guidance, a generic (non-drug specific) deprescribing framework, a drug-specific deprescribing guideline/guide, a tool for identifying potentially inappropriate medications, and an electronic clinical decision support tool. Participants were recruited via their participation in another deprescribing study. The Consolidated Framework for Implementation Research informed the data collection and analysis. RESULTS Eight care home staff from 7 different care homes were interviewed. The five deprescribing tools were reviewed and assessed as not acceptable, feasible, or suitable for the care home setting. All would require significant modifications for use in the care home setting (e.g., language, design, and its function or use with different stakeholders). CONCLUSIONS As none of the tools were deemed acceptable, feasible, and suitable, future work is warranted to develop and tailor deprescribing tools for the care home setting, considering its specific context and users. Deprescribing implemented safely and successfully in care homes can benefit residents and the wider health economy.
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Affiliation(s)
- Krystal Warmoth
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK; National Institute for Health Research Applied Research Collaboration East of England, Cambridge, UK.
| | - Jessica Rees
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK; National Institute for Health Research Applied Research Collaboration East of England, Cambridge, UK
| | - Jo Day
- Health and Community Sciences, University of Exeter, Exeter, UK; National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Emma Cockcroft
- Health and Community Sciences, University of Exeter, Exeter, UK; National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Alex Aylward
- Peninsula Public Involvement Group, National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Lucy Pollock
- Musgrove Park Hospital, Somerset NHS Foundation Trust, Taunton, UK
| | | | | | - Bridget Walton
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Ken Stein
- Health and Community Sciences, University of Exeter, Exeter, UK; National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
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Hurst A, Shaw N, Carrieri D, Stein K, Wyatt K. Exploring the rise and diversity of health and societal issues that use a public health approach: A scoping review and narrative synthesis. PLOS Glob Public Health 2024; 4:e0002790. [PMID: 38198448 PMCID: PMC10781110 DOI: 10.1371/journal.pgph.0002790] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Accepted: 12/09/2023] [Indexed: 01/12/2024]
Abstract
There is an increase in calls across diverse issues for a "public health approach" however, it is not clear whether there is any shared understanding in approach in its conceptualisation or implementation. Our aims were to (1) identify and categorise the issues which discuss a public health approach within published literature since 2010, (2) chart the descriptions and applications of public health approaches across and within four purposively sampled categories of issues, and (3) capture any evaluations conducted. A scoping review of published literature was undertaken; Seven leading databases were searched: AMED, APA PsycInfo, ASSIA, CINAHL complete, Cochrane Library (Review), Embase, and MEDLINE for articles published between 2010 and 2022 which have applied, described or called for a "public health approach" to address any issue. 3,573 studies were identified through our initial searches, of these 1,635 articles were recognised for possible inclusion from analysis of titles and abstract. The final number of included studies was 1,314. We identified 28 categories, 26 of which were societal issues, where a public health approach is being advocated. We purposively selected four of these categories; adverse childhood experiences; end of life care; gambling addiction and violence reduction/ knife crime for further analysis of the approach including how it was conceptualised and operationalised; less than 13% of the studies described the implementation of a public health approach and there was considerable heterogeneity across and within categories as to how this was done. Since 2010 there have been increasing calls for a public health approach to be taken to address health and societal challenges. However, the operationalisation of a public health approach varied extensively and there were few evaluations of the approach. This has implications for policy makers and those involved in commissioning related approaches in the future as the evidence-base is limited.
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Affiliation(s)
- Alison Hurst
- Faculty of Health and Life Sciences, Department of Health and Community Sciences, Relational Health Group, University of Exeter Medical School, Exeter, United Kingdom
| | - Nick Shaw
- Gloucestershire Hospitals NHS Foundation Trust, Gloucester, United Kingdom
| | - Daniele Carrieri
- Faculty of Health and Life Sciences, Department of Health and Community Sciences, Relational Health Group, University of Exeter Medical School, Exeter, United Kingdom
| | - Ken Stein
- National Institute for Health Research Applied Research Collaboration South West Peninsula (PenARC), University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
| | - Katrina Wyatt
- Faculty of Health and Life Sciences, Department of Health and Community Sciences, Relational Health Group, University of Exeter Medical School, Exeter, United Kingdom
- National Institute for Health Research Applied Research Collaboration South West Peninsula (PenARC), University of Exeter Medical School, University of Exeter, Exeter, United Kingdom
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Warmoth K, Rees J, Day J, Cockcroft E, Aylward A, Pollock L, Coxon G, Craig T, Walton B, Stein K. Determinants of implementing deprescribing for older adults in English care homes: a qualitative interview study. BMJ Open 2023; 13:e081305. [PMID: 37996237 PMCID: PMC10668129 DOI: 10.1136/bmjopen-2023-081305] [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: 10/24/2023] [Accepted: 11/02/2023] [Indexed: 11/25/2023] Open
Abstract
OBJECTIVES To explore the factors that may help or hinder deprescribing practice for older people within care homes. DESIGN Qualitative semistructured interviews using framework analysis informed by the Consolidated Framework for Implementation Research (CFIR). SETTING Participants were recruited from two care home provider organisations (a smaller independently owned organisation and a large organisation) in England. PARTICIPANTS A sample of 23 care home staff, 8 residents, 4 family members and 1 general practitioner were associated with 15 care homes. RESULTS Participants discussed their experiences and perceptions of implementing deprescribing within care homes. Major themes of (1) deprescribing as a complex process and (2) internal and external contextual factors influencing deprescribing practice (such as beliefs, abilities and relationships) were interrelated and spanned several CFIR constructs and domains. The quality of local relationships with and support from healthcare professionals were considered more crucial factors than the type of care home management structure. CONCLUSIONS Several influencing social and contextual factors need to be considered for implementing deprescribing for older adults in care homes. Additional training, tools, support and opportunities need to be made available to care home staff, so they can feel confident and able to question or raise concerns about medicines with prescribers. Further work is warranted to design and adopt a deprescribing approach which addresses these determinants to ensure successful implementation.
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Affiliation(s)
- Krystal Warmoth
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
- National Institute for Health Research Applied Research Collaboration East of England, Cambridge, UK
| | - Jessica Rees
- Department of Global Health & Social Medicine, King's College London, London, UK
| | - Jo Day
- University of Exeter Medical School, University of Exeter, Exeter, UK
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Emma Cockcroft
- University of Exeter Medical School, University of Exeter, Exeter, UK
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Alex Aylward
- Patient and Public Involvement Group, National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | | | | | | | - Bridget Walton
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
| | - Ken Stein
- University of Exeter Medical School, University of Exeter, Exeter, UK
- National Institute for Health Research Applied Research Collaboration South West Peninsula, Exeter, UK
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Whear R, Bethel A, Abbott R, Rogers M, Orr N, Manzi S, Ukoumunne OC, Stein K, Coon JT. Systematic reviews of convalescent plasma in COVID-19 continue to be poorly conducted and reported: a systematic review. J Clin Epidemiol 2022; 151:53-64. [PMID: 35934268 PMCID: PMC9351208 DOI: 10.1016/j.jclinepi.2022.07.005] [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] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Revised: 05/18/2022] [Accepted: 07/07/2022] [Indexed: 12/25/2022]
Abstract
OBJECTIVES To suggest possible approaches to combatting the impact of the COVID-19 infodemic to prevent research waste in future health emergencies and in everyday research and practice. STUDY DESIGN AND SETTING Systematic review. The Epistemonikos database was searched in June 2021 for systematic reviews on the effectiveness of convalescent plasma for COVID-19. Two reviewers independently screened the retrieved references with disagreements resolved by discussion. Data extraction was completed by one reviewer with a proportion checked by a second. We used the Assessment of Multiple Systematic Reviews to assess the quality of conduct and reporting of included reviews. RESULTS Fifty one systematic reviews are included with 193 individual studies included within the systematic reviews. There was considerable duplication of effort; multiple reviews were conducted at the same time with inconsistencies in the evidence included. The reviews were of low methodological quality, poorly reported, and did not adhere to preferred reporting items for systematic reviews and meta-analysis guidance. CONCLUSION Researchers need to conduct, appraise, interpret, and disseminate systematic reviews better. All in the research community (researchers, peer-reviewers, journal editors, funders, decision makers, clinicians, journalists, and the public) need to work together to facilitate the conduct of robust systematic reviews that are published and communicated in a timely manner, reducing research duplication and waste, increasing transparency and accessibility of all systematic reviews.
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Affiliation(s)
- Rebecca Whear
- Evidence Synthesis Team, National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, Devon, UK,Corresponding author. St Lukes Campus, University of Exeter, 3.09 South Cloisters, Heavitree Road, Exeter EX1 2LU. Tel.: +1392 726064
| | - Alison Bethel
- Evidence Synthesis Team, National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Rebecca Abbott
- Evidence Synthesis Team, National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Morwenna Rogers
- Evidence Synthesis Team, National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Noreen Orr
- Evidence Synthesis Team, University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Sean Manzi
- National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Obioha C. Ukoumunne
- National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Ken Stein
- Evidence Synthesis Team, National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, Devon, UK
| | - Jo Thompson Coon
- Evidence Synthesis Team, National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) South West Peninsula (PenARC), University of Exeter Medical School, College of Medicine and Health, University of Exeter, Exeter, Devon, UK
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Allen M, James C, Frost J, Liabo K, Pearn K, Monks T, Everson R, Stein K, James M. Use of Clinical Pathway Simulation and Machine Learning to Identify Key Levers for Maximizing the Benefit of Intravenous Thrombolysis in Acute Stroke. Stroke 2022; 53:2758-2767. [PMID: 35862194 PMCID: PMC9389935 DOI: 10.1161/strokeaha.121.038454] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Expert opinion is that about 20% of emergency stroke patients should receive thrombolysis. Currently, 11% to 12% of patients in England and Wales receive thrombolysis, ranging from 2% to 24% between hospitals. The aim of this study was to assess how much variation is due to differences in local patient populations, and how much is due to differences in clinical decision-making and stroke pathway performance, while estimating a realistic target thrombolysis use.
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Affiliation(s)
- Michael Allen
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Charlotte James
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Julia Frost
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Kristin Liabo
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Kerry Pearn
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Thomas Monks
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Richard Everson
- Computer Science, University of Exeter, Streatham Campus, United Kingdom (R.E.)
| | - Ken Stein
- Medical School, University of Exeter, St Luke’s Campus, United Kingdom (M.A., C.J., J.F., K.L., K.P., T.M., K.S.)
| | - Martin James
- Royal Devon and Exeter Hospital, Royal Devon and Exeter NHS Foundation Trust, United Kingdom (M.J.)
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Abbott R, Bethel A, Rogers M, Whear R, Orr N, Shaw L, Stein K, Thompson Coon J. Characteristics, quality and volume of the first 5 months of the COVID-19 evidence synthesis infodemic: a meta-research study. BMJ Evid Based Med 2022; 27:169-177. [PMID: 34083212 PMCID: PMC9132873 DOI: 10.1136/bmjebm-2021-111710] [Citation(s) in RCA: 26] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/24/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVE The academic and scientific community has reacted at pace to gather evidence to help and inform about COVID-19. Concerns have been raised about the quality of this evidence. The aim of this review was to map the nature, scope and quality of evidence syntheses on COVID-19 and to explore the relationship between review quality and the extent of researcher, policy and media interest. DESIGN AND SETTING A meta-research: systematic review of reviews. INFORMATION SOURCES PubMed, Epistemonikos COVID-19 evidence, the Cochrane Library of Systematic Reviews, the Cochrane COVID-19 Study Register, EMBASE, CINAHL, Web of Science Core Collection and the WHO COVID-19 database, searched between 10 June 2020 and 15 June 2020. ELIGIBILITY CRITERIA Any peer-reviewed article reported as a systematic review, rapid review, overview, meta-analysis or qualitative evidence synthesis in the title or abstract addressing a research question relating to COVID-19. Articles described as meta-analyses but not undertaken as part of a systematic or rapid review were excluded. STUDY SELECTION AND DATA EXTRACTION Abstract and full text screening were undertaken by two independent reviewers. Descriptive information on review type, purpose, population, size, citation and attention metrics were extracted along with whether the review met the definition of a systematic review according to six key methodological criteria. For those meeting all criteria, additional data on methods and publication metrics were extracted. RISK OF BIAS For articles meeting all six criteria required to meet the definition of a systematic review, AMSTAR-2 ((A MeaSurement Tool to Assess systematic Reviews, version 2.0) was used to assess the quality of the reported methods. RESULTS 2334 articles were screened, resulting in 280 reviews being included: 232 systematic reviews, 46 rapid reviews and 2 overviews. Less than half reported undertaking critical appraisal and a third had no reproducible search strategy. There was considerable overlap in topics, with discordant findings. Eighty-eight of the 280 reviews met all six systematic review criteria. Of these, just 3 were rated as of moderate or high quality on AMSTAR-2, with the majority having critical flaws: only a third reported registering a protocol, and less than one in five searched named COVID-19 databases. Review conduct and publication were rapid, with 52 of the 88 systematic reviews reported as being conducted within 3 weeks, and a half published within 3 weeks of submission. Researcher and media interest, as measured by altmetrics and citations, was high, and was not correlated with quality. DISCUSSION This meta-research of early published COVID-19 evidence syntheses found low-quality reviews being published at pace, often with short publication turnarounds. Despite being of low quality and many lacking robust methods, the reviews received substantial attention across both academic and public platforms, and the attention was not related to the quality of review methods. INTERPRETATION Flaws in systematic review methods limit the validity of a review and the generalisability of its findings. Yet, by being reported as 'systematic reviews', many readers may well regard them as high-quality evidence, irrespective of the actual methods undertaken. The challenge especially in times such as this pandemic is to provide indications of trustworthiness in evidence that is available in 'real time'. PROSPERO REGISTRATION NUMBER CRD42020188822.
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Affiliation(s)
- Rebecca Abbott
- NIHR ARC South West Peninsula, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Alison Bethel
- NIHR ARC South West Peninsula, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Morwenna Rogers
- NIHR ARC South West Peninsula, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Rebecca Whear
- NIHR ARC South West Peninsula, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Noreen Orr
- NIHR ARC South West Peninsula, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Liz Shaw
- University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Ken Stein
- NIHR ARC South West Peninsula, University of Exeter Medical School, University of Exeter, Exeter, UK
| | - Jo Thompson Coon
- NIHR ARC South West Peninsula, University of Exeter Medical School, University of Exeter, Exeter, UK
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Saba S, Nair D, Ellis CR, Ciuffo A, Cox M, Gupta N, Sharma S, Jain S, Winner M, Mehta S, Simon T, Stein K, Ellenbogen KA. Usefulness of Multisite Ventricular Pacing in Nonresponders to Cardiac Resynchronization Therapy. Am J Cardiol 2022; 164:86-92. [PMID: 34815062 DOI: 10.1016/j.amjcard.2021.10.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Revised: 10/14/2021] [Accepted: 10/18/2021] [Indexed: 12/28/2022]
Abstract
Cardiac resynchronization therapy (CRT) is an established treatment for heart failure patients with myocardial dysfunction and delayed ventricular activation, but approximately 25% to 40% of patients do not respond to CRT. Left ventricular (LV) multisite pacing (MSP) has been proposed as a tool to improve CRT response. The goal of this study is to examine the safety and efficacy of LV MSP in CRT nonresponders. Between January 2018, and September 2019, the Strategic Management to Improve CRT Using Multi-Site Pacing trial prospectively enrolled 584 CRT-defibrillator recipients for established indications at 52 sites across the United States and evaluated their response at 6 months using the clinical composite score (CCS). Of the nonresponders, 102 patients had the LV MSP feature turned on and 78 patients completed the 12-month CCS evaluation. The LV MSP feature-related complication-free rate was 99.0% with a lower 95% confidence interval limit of 94.9%, which was higher than the performance goal of 90%. The proportion of nonresponders with an improved CCS from 6 to 12 months was 51.3% with a lower 95% confidence interval limit of 41.4%, which was higher than the performance goal of 5%. The estimated mean reduction in battery longevity with the LV MSP feature was about 3.6 months (estimated battery longevity of 8.87 ± 2.08 years at 6 months and 8.07 ± 2.23 years at 12 months). In conclusion, in CRT nonresponders, the use of the LV MSP feature is safe and associated with a ∼50% conversion rate with a small projected reduction in CRT-defibrillator battery longevity. LV MSP should be considered in the management of CRT nonresponders.
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Affiliation(s)
- Samir Saba
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania.
| | - Devi Nair
- Cardiology Associates of Northeast Arkansas, Jonesboro, Arkansas
| | | | | | - Marilyn Cox
- Tallahasse Memorial Hospital, Tallahassee, Florida
| | - Nigel Gupta
- Kaiser Permanente Los Angeles Medical Center, Los Angeles, California
| | - Saumya Sharma
- University of Texas Health Science Center, Houston, Texas
| | - Sandeep Jain
- Heart and Vascular Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
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Allen M, Pearn K, Ford GA, White P, Rudd AG, McMeekin P, Stein K, James M. National implementation of reperfusion for acute ischaemic stroke in England: How should services be configured? A modelling study. Eur Stroke J 2021; 7:28-40. [PMID: 35300255 PMCID: PMC8921787 DOI: 10.1177/23969873211063323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Revised: 10/25/2021] [Accepted: 10/29/2021] [Indexed: 11/21/2022] Open
Abstract
Objectives To guide policy when planning thrombolysis (IVT) and thrombectomy (MT) services for acute stroke in England, focussing on the choice between ‘mothership’ (direct conveyance to an MT centre) and ‘drip-and-ship’ (secondary transfer) provision and the impact of bypassing local acute stroke centres. Design Outcome-based modelling study. Setting 107 acute stroke centres in England, 24 of which provide IVT and MT (IVT/MT centres) and 83 provide only IVT (IVT-only units). Participants 242,874 emergency admissions with acute stroke over 3 years (2015–2017). Intervention Reperfusion delivered by drip-and-ship, mothership or ‘hybrid’ models; impact of additional travel time to directly access an IVT/MT centre by bypassing a more local IVT-only unit; effect of pre-hospital selection for large artery occlusion (LAO). Main outcome measures Population benefit from reperfusion, time to IVT and MT, admission numbers to IVT-only units and IVT/MT centres. Results Without pre-hospital selection for LAO, 94% of the population of England live in areas where the greatest clinical benefit, assuming unknown patient status, accrues from direct conveyance to an IVT/MT centre. However, this policy produces unsustainable admission numbers at these centres, with 78 out of 83 IVT-only units receiving fewer than 300 admissions per year (compared to 3 with drip-and-ship). Implementing a maximum permitted additional travel time to bypass an IVT-only unit, using a pre-hospital test for LAO, and selecting patients based on stroke onset time, all help to mitigate the destabilising effect but there is still some significant disruption to admission numbers, and improved selection of patients suitable for MT selectively reduces the number of patients who would receive IVT at IVT-only centres, challenging the sustainability of IVT expertise in IVT-only centres. Conclusions Implementation of reperfusion for acute stroke based solely on achieving the maximum population benefit potentially leads to destabilisation of the emergency stroke care system. Careful planning is required to create a sustainable system, and modelling may be used to help planners maximise benefit from reperfusion while creating a sustainable emergency stroke care system.
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Affiliation(s)
- Michael Allen
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Kerry Pearn
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University and Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil White
- Translational and Clinical Research Institute, Newcastle University and Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Anthony G Rudd
- Kings College London and Guy’s and St Thomas, NHS Foundation Trust, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle Upon Tyne, UK
| | - Ken Stein
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
| | - Martin James
- University of Exeter, Medical School and the National Institute for Health Research (NIHR) Applied Research Collaboration South West Peninsula (SWPenARC), Exeter, UK
- Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
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Weingaertner O, Beier L, Stein K. Different perspectives of patients and physicians on LDL-C target achievement in the treatment of hypercholesterolemia: results on secondary prevention from the German PROCYON survey. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2541] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Abstract
Background
Lowering low-density lipoprotein cholesterol (LDL-C) in hypercholesterolemia patients at very high cardiovascular (CV) risk is essential in preventing future CV events. However, LDL-C targets often remain unattained.
Purpose
The purpose of the present survey was to identify possible reasons for insufficient LDL-C target achievement despite the availability of efficacious lipid lowering drugs in the clinical setting of hypercholesterolemia management in secondary prevention patients in Germany.
Methods
PROCYON was an online survey with over 5,000 participants on disease perception, awareness, burden, and management of hypercholesterolemia consisting of a patient survey (PROCYON A) and a healthcare practitioner (HCP) survey (PROCYON B). To quantify patient self-activation, the PAM-13 Patient Activation Measure by Insignia Health was incorporated. Results on 1,696 patients in secondary prevention are presented.
Results
Most post-CV event patients do not achieve their LDL-C target. HCPs assume patients' poor adherence to medication and lifestyle adaptions to be the most important reason (Figure 1). However, this contradicts the patients' perception. Accordingly, 87% of the patients are on a lipid lowering therapy and 81% of them have stated to take their medication regularly. They rank their medication for LDL-C reduction as equally important as that for other diseases. In contrast, HCPs think that 46% of their patients do not take hypercholesterolemia seriously. However, HCPs also believe, that LDL target attainment is still “important” or “very important” to 81% of their patients. This is in line with the patients' perception: 84% of the patients consider reaching their target as “important” or “very important”. PAM-13 results underline these results: 60% of the patients are already activated and want to gain control over their disease (PAM-13 level 3 of 4) and 12% reach highest self-activation levels (level 4 of 4). The HCP remains the major source of information for 77% of the patients and only 42% reach out for online resources. The importance of educating patients on adherence is acknowledged by all HCPs. Therefore, 71% express their desire of educational material. With respect to LDL-C levels, 49% of the patients reported no improvement. Of the patients under treatment without LDL-C improvement, only 23% take more than one drug, and 47% reported a change of dose. Furthermore, collaboration between GPs and specialists (cardiologists, diabetologists, lipidologists) was not evident.
Conclusion
Although secondary prevention patients are motivated to pursue their LDL-C targets, HCPs consider patient adherence as major reason for failure. Instead, the survey indicated that therapeutic strategies are not fully exhausted and there is space for treatment improvement either by dose escalation or addition of further lipid lowering drugs. Furthermore, patient education and specialist collaboration could improve patient management.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Novartis Pharma GmbH Figure 1
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Affiliation(s)
- O Weingaertner
- University Hospital Jena, Klinik für Innere Medizin I, Jena, Germany
| | - L Beier
- Novartis Pharma GmbH, Nuremberg, Germany
| | - K Stein
- Novartis Pharma GmbH, Nuremberg, Germany
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Weingaertner O, Beier L, Stein K. Differences in hypercholesterolemia patient management in secondary and primary care: lessons learned from the German PROCYON survey. Eur Heart J 2021. [DOI: 10.1093/eurheartj/ehab724.2540] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
In Germany, cardiovascular (CV) disease was the leading cause of mortality (39% of all deaths), responsible for 340,000 deaths in 2014 (1). Considering its role as a major risk factor for CV disease, awareness for hypercholesterolemia in clinical practice seems insufficient.
Purpose
The purpose of the present survey was to identify patients' journey differences between primary and secondary prevention in patients with hypercholesterolemia.
Methods
PROCYON was a two-part online survey on disease perception, awareness, burden, and management of hypercholesterolemia consisting of a patient survey (PROCYON A) and a healthcare practitioner (HCP) survey (PROCYON B). The survey included over 5,000 patients with and without prior CV events as well as 109 HCPs (general practitioners, internists, cardiologists) involved in primary and secondary prevention.
Results
71% of the HCPs consider low-density lipoprotein cholesterol (LDL-C) as “very important” to assess a patients CV risk and 96% acknowledge a “causal relationship” between CV risk and LDL-C levels. Despite the theoretical awareness of LDL-C as a risk factor, 58% of the secondary prevention patients were initially diagnosed with hypercholesterolemia only while hospitalized due to a CV event, indicating insufficient translation of LDL-C awareness into clinical screening routine.
General practitioners (GP) and internists are the main point of contact for patients with hypercholesterolemia after the diagnosis. In primary and even in secondary prevention, cardiologists play a minor role in hypercholesterolemia patient care (cardiologist vs. GP/internist ratio 1:5), the majority of patients are managed by their general practitioners and internists and (cardiologist vs. GP/internist ratio 2:3) (Table 1). The frequency of LDL-C control assessments is lower in primary prevention patients compared to secondary prevention (Table 2). In primary prevention, only 43% of the patients are on a lipid lowering therapy compared to 87% in secondary prevention. From the point of diagnosis, LDL-C levels improved at least to some extent in only 30% of the primary prevention patients and 51% of the secondary prevention patients. Of the patients without LDL-C improvement who are on drug therapy, 53% (primary prevention) and 39% (the secondary prevention) are still on their initial treatment since diagnosis.
Conclusion(s)
Major differences in relation to assessment intervals, treatment initiation, and specialist care were identified between primary and secondary prevention populations, reflecting a major focus in secondary prevention with respect to primary prevention. The high percentage of patients on secondary prevention diagnosed after the first CV event reflects the need to improve preventive screening. It is essential to identify measures to increase LDL-C risk awareness, improve screening efforts and efficient LDL-C reduction in order to prevent future CV events in both populations.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Novartis Pharma GmbH
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Affiliation(s)
- O Weingaertner
- University Hospital Jena, Klinik für Innere Medizin I, Jena, Germany
| | - L Beier
- Novartis Pharma GmbH, Nuremberg, Germany
| | - K Stein
- Novartis Pharma GmbH, Nuremberg, Germany
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12
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Stein K, Warne N, Heron J, Zucker N, Bould H. Do children with recurrent abdominal pain grow up to become adolescents who control their weight by fasting? Results from a UK population-based cohort. Int J Eat Disord 2021; 54:915-924. [PMID: 33939186 PMCID: PMC8344098 DOI: 10.1002/eat.23513] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 12/27/2020] [Revised: 03/04/2021] [Accepted: 03/23/2021] [Indexed: 12/17/2022]
Abstract
OBJECTIVE Gastrointestinal (GI) problems are common in eating disorders, but it is unclear whether these problems predate the onset of disordered eating. Recurrent abdominal pain (RAP) is the most prevalent GI problem of childhood, and this study aimed to explore longitudinal associations between persistent RAP (at ages 7 and 9) and fasting for weight control at 16. METHOD The Avon Longitudinal Study of Parents and Children (ALSPAC) is a UK population cohort of children. Childhood RAP was reported by mothers and defined as RAP 5+ (5 pain episodes in the past year) in our primary analysis, and RAP 3+ (3 pain episodes) in our sensitivity analysis. Fasting for weight control was reported by adolescents at 16. We used logistic regression models to examine associations, with adjustments for potential confounders. RESULTS After adjustments, we found no association between childhood RAP 5+ and adolescent fasting for weight control at 16 (OR 1.30 (95% Confidence Intervals [CI] 0.87, 1.94) p = .197). However, we did find an association between RAP 3+ and later fasting, in the fully adjusted model (OR 1.50 [95% CI 1.16, 1.94] p = .002), and after excluding those with pre-existing anxiety (OR 1.52 [95% CI 1.17, 1.97] p = .002). DISCUSSION Our findings suggest a possible independent contribution of RAP to later risk of fasting for weight control, and RAP should be enquired about in the assessment of eating disorders. However, frequency of childhood abdominal pain (as captured by ALSPAC) may be less important to long-term outcomes than functional impairment.
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Affiliation(s)
- K. Stein
- Academic Clinical Fellow in Child and Adolescent Psychiatry, University of Oxford; Warneford Hospital, Oxford OX3 7JX
| | - N. Warne
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School, University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN
| | - J. Heron
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN
| | - N. Zucker
- Associate Professor of Clinical Psychology, Department of Psychology and Neuroscience, Duke University, Durham, North Carolina
| | - H. Bould
- Centre for Academic Mental Health, Population Health Sciences, Bristol Medical School University of Bristol, Oakfield House, Oakfield Grove, Bristol BS8 2BN & Gloucestershire Health and Care NHS Foundation Trust, Gloucester, UK
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Dietz J, Spengler U, Müllhaupt B, Schulze Zur Wiesch J, Piecha F, Mauss S, Seegers B, Hinrichsen H, Antoni C, Wietzke-Braun P, Peiffer KH, Berger A, Matschenz K, Buggisch P, Backhus J, Zizer E, Boettler T, Neumann-Haefelin C, Semela D, Stauber R, Berg T, Berg C, Zeuzem S, Vermehren J, Sarrazin C, Giostra E, Berning M, Hampe J, De Gottardi A, Rauch A, Semmo N, Discher T, Trauth J, Fischer J, Gress M, Günther R, Heinzow H, Schmidt J, Herrmann A, Stallmach A, Hilgard G, Deterding K, Lange C, Ciesek S, Wedemeyer H, Hoffmann D, Klinker H, Schulze P, Kocheise F, Müller-Schilling M, Kodal A, Kremer A, Ganslmayer M, Siebler J, Lammert F, Rissland J, Löbermann M, Götze T, Canbay A, Lohse A, von Felden J, Jordan S, Maieron A, Moradpour D, Chave JP, Moreno C, Müller T, Muche M, Epple HJ, Port K, von Hahn T, Cornberg M, Manns M, Reinhardt L, Ellenrieder V, Rockstroh J, Schattenberg J, Sprinzl M, Galle P, Roeb E, Steckstor M, Schmiegel W, Brockmeyer N, Seufferlein T, Stremmel W, Strey B, Thimme R, Teufel A, Vogelmann R, Ebert M, Tomasiewicz K, Trautwein C, Tacke F, Koenen T, Weber T, Zachoval R, Mayerle J, Raziorrouh B, Angeli W, Beckebaum S, Doberauer C, Durmashkina E, Hackelsberger A, Erhardt A, Garrido-Lüneburg A, Gattringer H, Genné D, Gschwantler M, Gundling F, Hametner S, Schöfl R, Hartmann C, Heyer T, Hirschi C, Jussios A, Kanzler S, Kordecki N, Kraus M, Kullig U, Wollschläger S, Magenta L, Beretta-Piccoli BT, Menges M, Mohr L, Muehlenberg K, Niederau C, Paulweber B, Petrides A, Pinkernell M, Piso R, Rambach W, Reiser M, Riecken B, Rieke A, Roth J, Schelling M, Schlee P, Schneider A, Scholz D, Schott E, Schuchmann M, Schulten-Baumer U, Seelhoff A, Stich A, Stickel F, Ungemach J, Walter E, Weber A, Winzer T, Abels W, Adler M, Audebert F, Baermann C, Bästlein E, Barth R, Barthel K, Becker W, Behrends J, Benninger J, Berger F, Berzow D, Beyer T, Bierbaum M, Blaukat O, Bodtländer A, Böhm G, Börner N, Bohr U, Bokemeyer B, Bruch H, Bucholz D, Burkhard O, Busch N, Chirca C, Delker R, Diedrich J, Frank M, Diehl M, Dienethal A, Dietel P, Dikopoulos N, Dreck M, Dreher F, Drude L, Ende K, Ehrle U, Baumgartl K, Emke F, Glosemeyer R, Felten G, Hüppe D, Fischer J, Fischer U, Frederking D, Frick B, Friese G, Gantke B, Geyer P, Schwind H, Glas M, Glaunsinger T, Goebel F, Göbel U, Görlitz B, Graf R, Gruber H, Härter G, Herder M, Heuchel T, Heuer S, Höffl KH, Hörster H, Sonne JU, Hofmann W, Holst F, Hunstiger M, Hurst A, Jägel-Guedes E, John C, Jung M, Kallinowski B, Kapzan B, Kerzel W, Khaykin P, Klarhof M, Klüppelberg U, Klugewitz K, Knapp B, Knevels U, Kochsiek T, Körfer A, Köster A, Kuhn M, Langekamp A, Künzig B, Link R, Littman M, Löhr H, Lutz T, Knecht G, Lutz U, Mainz D, Mahle I, Maurer P, Mayer C, Meister V, Möller H, Heyne R, Moritzen D, Mroß M, Mundlos M, Naumann U, Nehls O, Ningel K, Oelmann A, Olejnik H, Gadow K, Pascher E, Petersen J, Philipp A, Pichler M, Polzien F, Raddant R, Riedel M, Rietzler S, Rössle M, Rufle W, Rump A, Schewe C, Hoffmann C, Schleehauf D, Schmidt K, Schmidt W, Schmidt-Heinevetter G, Schmidtler-von Fabris J, Schnaitmann E, Schneider L, Schober A, Niehaus-Hahn S, Schwenzer J, Seidel T, Seitel G, Sick C, Simon K, Stähler D, Stenschke F, Steffens H, Stein K, Steinmüller M, Sternfeld T, Strey B, Svensson K, Tacke W, Teuber G, Teubner K, Thieringer J, Tomesch A, Trappe U, Ullrich J, Urban G, Usadel S, von Lucadou A, Weinberger F, Werheid-Dobers M, Werner P, Winter T, Zehnter E, Zipf A. Efficacy of Retreatment After Failed Direct-acting Antiviral Therapy in Patients With HCV Genotype 1-3 Infections. Clin Gastroenterol Hepatol 2021; 19:195-198.e2. [PMID: 31706062 DOI: 10.1016/j.cgh.2019.10.051] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2019] [Revised: 09/19/2019] [Accepted: 10/25/2019] [Indexed: 02/07/2023]
Abstract
Hepatitis C virus infection is causing chronic liver disease, cirrhosis, and hepatocellular carcinoma. By combining direct-acting antivirals (DAAs), high sustained virologic response rates (SVRs) can be achieved. Resistance-associated substitutions (RASs) are commonly observed after DAA failure, and especially nonstructural protein 5A (NS5A) RASs may impact retreatment options.1-3 Data on retreatment of DAA failure patients using first-generation DAAs are limited.4-7 Recently, a second-generation protease- and NS5A-inhibitor plus sofosbuvir (voxilaprevir/velpatasvir/sofosbuvir [VOX/VEL/SOF]) was approved for retreatment after DAA failure.8 However, this and other second-generation regimens are not available in many resource-limited countries or are not reimbursed by regular insurance, and recommendations regarding the selection of retreatment regimens using first-generation DAAs are very important. This study aimed to analyze patients who were re-treated with first-generation DAAs after failure of a DAA combination therapy.
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Affiliation(s)
- Julia Dietz
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt, and German Center for Infection Research (DZIF), External Partner Site, Frankfurt, Germany
| | - Ulrich Spengler
- Department of Internal Medicine I, University of Bonn, Bonn, and German Center for Infection Research (DZIF), Partner Site, Cologne-Bonn, Germany
| | - Beat Müllhaupt
- Swiss Hepato-Pancreato-Biliary Center and Department of Gastroenterology and Hepatology, University Hospital Zürich, Zürich, Switzerland
| | - Julian Schulze Zur Wiesch
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, and German Center for Infection Research (DZIF), Partner Site, Hamburg-Lübeck-Borstel-Riems, Germany
| | - Felix Piecha
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, and German Center for Infection Research (DZIF), Partner Site, Hamburg-Lübeck-Borstel-Riems, Germany
| | - Stefan Mauss
- Center for HIV and Hepatogastroenterology, Düsseldorf, Germany
| | - Barbara Seegers
- Gastroenterologisch-Hepatologisches Zentrum Kiel, Kiel, Germany
| | | | - Christoph Antoni
- Department of Internal Medicine II, University Hospital Mannheim, Mannheim, Germany
| | | | - Kai-Henrik Peiffer
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt, and German Center for Infection Research (DZIF), External Partner Site, Frankfurt, Germany
| | - Annemarie Berger
- Institute for Medical Virology, University Hospital Frankfurt, Frankfurt, Germany
| | | | - Peter Buggisch
- Institute for Interdisciplinary Medicine IFI, Hamburg, Germany
| | - Johanna Backhus
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - Eugen Zizer
- Department of Internal Medicine I, Ulm University, Ulm, Germany
| | - Tobias Boettler
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christoph Neumann-Haefelin
- Department of Medicine II, Medical Center, University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - David Semela
- Division of Gastroenterology and Hepatology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Rudolf Stauber
- Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Berg
- Department of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Christoph Berg
- Department of Internal Medicine I, University of Tübingen, Tübingen, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt, and German Center for Infection Research (DZIF), External Partner Site, Frankfurt, Germany
| | - Johannes Vermehren
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt, and German Center for Infection Research (DZIF), External Partner Site, Frankfurt, Germany
| | - Christoph Sarrazin
- Department of Internal Medicine 1, University Hospital Frankfurt, Goethe University, Frankfurt, and German Center for Infection Research (DZIF), External Partner Site, Frankfurt, Germany; Medizinische Klinik 2, St Josefs-Hospital, Wiesbaden, Germany.
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Warmoth K, Day J, Cockcroft E, Reed DN, Pollock L, Coxon G, Heneker J, Walton B, Stein K. Understanding stakeholders’ perspectives on implementing deprescribing for older people living in long-term residential care homes: the STOPPING study protocol. Implement Sci Commun 2020. [DOI: 10.1186/s43058-020-00067-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Older people with multimorbidity often experience polypharmacy. Taking multiple medicines can be beneficial; however, some older adults are prescribed multiple medicines when they are unlikely to improve clinical outcomes and may lead to harm. Deprescribing means reducing or stopping prescription medicines which may no longer be providing benefit. While appropriate deprescribing may usually be safely undertaken, there is a lack of guidance about how to implement it in practice settings such as care homes. Implementing deprescribing in care homes is often challenging, due to differing concerns of residents, staff, clinicians, friends/family members and carers along with differences in care home structures. The STOPPING study will support the development of better deprescribing practice in care homes, considering different views and environments. This paper aims to introduce the research protocol.
Methods
We will use qualitative approaches informed by the widely accepted Consolidated Framework for Implementation Research (CFIR) to aid analysis. To understand the barriers, facilitators, and contextual factors influencing deprescribing in care homes, we will employ individual interviews with care home residents and family members, focus groups with care home staff and healthcare professionals, and observations from care homes. Then, we will examine acceptability, feasibility, and suitability of existing deprescribing approaches using cognitive interviews with care home staff and healthcare professionals. Lastly, we will use narrative synthesis to integrate findings and develop guidance for implementing a deprescribing approach for care homes.
Discussion
This research will support the development of implementable approaches to deprescribing in care homes. The insights from this project will be shared with various stakeholders: care home residents, staff, pharmacists, general practitioners, nurses, and other health professionals, carers, researchers, and the public. This work will support deprescribing to be implemented effectively in care homes to benefit residents and the wider health economy.
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Ledermann J, Shapira-Frommer R, Santin A, Lisyanskaya A, Pignata S, Vergote I, Raspagliesi F, Sonke G, Birrer M, Provencher D, Sehouli J, Colombo N, González Martín A, Oaknin A, Saadatpour A, Kobie J, Jelinic P, Stein K, Matulonis U. 843P Association of gene expression signatures and TMB with response to pembrolizumab (pembro) in patients (pts) with recurrent ovarian cancer (ROC) enrolled in KEYNOTE-100. Ann Oncol 2020. [DOI: 10.1016/j.annonc.2020.08.982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022] Open
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Whear R, Thompson‐Coon J, Rogers M, Abbott RA, Anderson L, Ukoumunne O, Matthews J, Goodwin VA, Briscoe S, Perry M, Stein K. Patient-initiated appointment systems for adults with chronic conditions in secondary care. Cochrane Database Syst Rev 2020; 4:CD010763. [PMID: 32271946 PMCID: PMC7144896 DOI: 10.1002/14651858.cd010763.pub2] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Missed hospital outpatient appointments is a commonly reported problem in healthcare services around the world; for example, they cost the National Health Service (NHS) in the UK millions of pounds every year and can cause operation and scheduling difficulties worldwide. In 2002, the World Health Organization (WHO) published a report highlighting the need for a model of care that more readily meets the needs of people with chronic conditions. Patient-initiated appointment systems may be able to meet this need at the same time as improving the efficiency of hospital appointments. OBJECTIVES To assess the effects of patient-initiated appointment systems compared with consultant-led appointment systems for people with chronic or recurrent conditions managed in secondary care. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, and six other databases. We contacted authors of identified studies and conducted backwards and forwards citation searching. We searched for current/ongoing research in two trial registers. Searches were run on 13 March 2019. SELECTION CRITERIA We included randomised trials, published and unpublished in any language that compared the use of patient-initiated appointment systems to consultant-led appointment systems for adults with chronic or recurrent conditions managed in secondary care if they reported one or more of the following outcomes: physical measures of health status or disease activity (including harms), quality of life, service utilisation or cost, adverse effects, patient or clinician satisfaction, or failures of the 'system'. DATA COLLECTION AND ANALYSIS Two review authors independently screened all references at title/abstract stage and full-text stage using prespecified inclusion criteria. We resolved disagreements though discussion. Two review authors independently completed data extraction for all included studies. We discussed and resolved discrepancies with a third review author. Where needed, we contacted authors of included papers to provide more information. Two review authors independently assessed the risk of bias using the Cochrane Effective Practice and Organisation of Care 'Risk of bias' tool, resolving any discrepancies with a third review author. Two review authors independently assessed the certainty of the evidence using GRADE. MAIN RESULTS The 17 included randomised trials (3854 participants; mean age 41 to 76 years; follow-up 12 to 72 months) covered six broad health conditions: cancer, rheumatoid arthritis, asthma, chronic obstructive pulmonary disease, psoriasis and inflammatory bowel disease. The certainty of the evidence using GRADE ratings was mainly low to very low. The results suggest that patient-initiated clinics may make little or no difference to anxiety (odds ratio (OR) 0.87, 95% confidence interval (CI) 0.68 to 1.12; 5 studies, 1019 participants; low-certainty evidence) or depression (OR 0.79 95% CI 0.51 to 1.23; 6 studies, 1835 participants; low-certainty evidence) compared to the consultant-led appointment system. The results also suggest that patient-initiated clinics may make little or no difference to quality of life (standardised mean difference (SMD) 0.12, 95% CI 0.00 to 0.25; 7 studies, 1486 participants; low-certainty evidence) compared to the consultant-led appointment system. Results for service utilisation (contacts) suggest there may be little or no difference in service utilisation in terms of contacts between the patient-initiated and consultant-led appointment groups; however, the effect is not certain as the rate ratio ranged from 0.68 to 3.83 across the studies (median rate ratio 1.11, interquartile (IQR) 0.93 to 1.37; 15 studies, 3348 participants; low-certainty evidence). It is uncertain if service utilisation (costs) are reduced in the patient-initiated compared to the consultant-led appointment groups (8 studies, 2235 participants; very low-certainty evidence). The results suggest that adverse events such as relapses in some conditions (inflammatory bowel disease and cancer) may have little or no reduction in the patient-initiated appointment group in comparison with the consultant-led appointment group (MD -0.20, 95% CI -0.54 to 0.14; 3 studies, 888 participants; low-certainty evidence). The results are unclear about any differences the intervention may make to patient satisfaction (SMD 0.05, 95% CI -0.41 to 0.52; 2 studies, 375 participants) because the certainty of the evidence is low, as each study used different questions to collect their data at different time points and across different health conditions. Some areas of risk of bias across all the included studies was consistently high (i.e. for blinding of participants and personnel and blinding of outcome assessment, other areas were largely of low risk of bias or were affected by poor reporting making the assessment unclear). AUTHORS' CONCLUSIONS Patient-initiated appointment systems may have little or no effect on patient anxiety, depression and quality of life compared to consultant-led appointment systems. Other aspects of disease status and experience also appear to show little or no difference between patient-initiated and consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on service utilisation in terms of service contact and there is uncertainty about costs compared to consultant-led appointment systems. Patient-initiated appointment systems may have little or no effect on adverse events such as relapse or patient satisfaction compared to consultant-led appointment systems.
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Affiliation(s)
- Rebecca Whear
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusUniversity of ExeterExeterDevonUKEX1 2LU
| | - Joanna Thompson‐Coon
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusUniversity of ExeterExeterDevonUKEX1 2LU
| | - Morwenna Rogers
- University of Exeter Medical SchoolNIHR PenCLAHRC, Institute of Health ResearchExeterDevonUKEX1 2LU
| | - Rebecca A Abbott
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusUniversity of ExeterExeterDevonUKEX1 2LU
| | - Lindsey Anderson
- University of Exeter Medical SchoolInstitute of Health ResearchVeysey Building, Salmon Pool LaneExeterUKEX2 4SG
| | - Obioha Ukoumunne
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusUniversity of ExeterExeterDevonUKEX1 2LU
| | - Justin Matthews
- University of Exeter Medical SchoolNIHR PenCLAHRC, Institute of Health ResearchExeterDevonUKEX1 2LU
| | - Victoria A Goodwin
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusUniversity of ExeterExeterDevonUKEX1 2LU
| | - Simon Briscoe
- University of Exeter Medical SchoolNIHR CLAHRC South West Peninsula (PenCLAHRC)St Luke's CampusUniversity of ExeterExeterDevonUKEX1 2LU
| | - Mark Perry
- Derriford HospitalRheumatologyPlymouthDevonUKPL6 8DH
| | - Ken Stein
- University of Exeter Medical School, University of ExeterPeninsula Technology Assessment Group (PenTAG)Salmon Pool LaneExeterUKEX2 4SG
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Abbott RA, Moore DA, Rogers M, Bethel A, Stein K, Coon JT. Effectiveness of pharmacist home visits for individuals at risk of medication-related problems: a systematic review and meta-analysis of randomised controlled trials. BMC Health Serv Res 2020; 20:39. [PMID: 31941489 PMCID: PMC6961241 DOI: 10.1186/s12913-019-4728-3] [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] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 11/07/2019] [Indexed: 11/10/2022] Open
Abstract
Background Medication mismanagement is a major cause of both hospital admission and nursing home placement of frail older adults. Medication reviews by community pharmacists aim to maximise therapeutic benefit but also minimise harm. Pharmacist-led medication reviews have been the focus of several systematic reviews, but none have focussed on the home setting. Review methods To determine the effectiveness of pharmacist home visits for individuals at risk of medication-related problems we undertook a systematic review and meta-analysis of randomised controlled trials (RCTs). Thirteen databases were searched from inception to December 2018. Forward and backward citation of included studies was also performed. Articles were screened for inclusion independently by two reviewers. Randomised controlled studies of home visits by pharmacists for individuals at risk of medication-related problems were eligible for inclusion. Data extraction and quality appraisal were performed by one reviewer and checked by a second. Random-effects meta-analyses were performed where sufficient data allowed and narrative synthesis summarised all remaining data. Results Twelve RCTs (reported in 15 articles), involving 3410 participants, were included in the review. The frequency, content and purpose of the home visit varied considerably. The data from eight trials were suitable for meta-analysis of the effects on hospital admissions and mortality, and from three trials for the effects on quality of life. Overall there was no evidence of reduction in hospital admissions (risk ratio (RR) of 1.01 (95%CI 0.86 to 1.20, I2 = 69.0%, p = 0.89; 8 studies, 2314 participants)), or mortality (RR of 1.01 (95%CI 0.81 to 1.26, I2 = 0%, p = 0.94; 8 studies, 2314 participants)). There was no consistent evidence of an effect on quality of life, medication adherence or knowledge. Conclusion A systematic review of twelve RCTs assessing the impact of pharmacist home visits for individuals at risk of medication related problems found no evidence of effect on hospital admission or mortality rates, and limited evidence of effect on quality of life. Future studies should focus on using more robust methods to assess relevant outcomes.
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Affiliation(s)
- Rebecca A Abbott
- Evidence Synthesis Team, PenCLAHRC University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Darren A Moore
- Graduate School of Education, St Luke's Campus, Exeter, EX1 2LU, UK
| | - Morwenna Rogers
- Evidence Synthesis Team, PenCLAHRC University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK
| | - Alison Bethel
- Evidence Synthesis Team, PenCLAHRC University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK
| | - Ken Stein
- Evidence Synthesis Team, PenCLAHRC University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK
| | - Jo Thompson Coon
- Evidence Synthesis Team, PenCLAHRC University of Exeter Medical School, St Luke's Campus, Exeter, EX1 2LU, UK
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Raftery J, Williams HC, Clarke A, Thornton J, Norrie J, Snooks H, Stein K. 'Not clinically effective but cost-effective' - paradoxical conclusions in randomised controlled trials with 'doubly null' results: a cross-sectional study. BMJ Open 2020; 10:e029596. [PMID: 31924631 PMCID: PMC6955496 DOI: 10.1136/bmjopen-2019-029596] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES Randomised controlled trials in healthcare increasingly include economic evaluations. Some show small differences which are not statistically significant. Yet these sometimes come to paradoxical conclusions such as: 'the intervention is not clinically effective' but 'is probably cost-effective'. This study aims to quantify the extent of non-significant results and the types of conclusions drawn from them. DESIGN Cross-sectional retrospective analysis of randomised trials published by the UK's National Institute for Health Research (NIHR) Health Technology Assessment programme. We defined as 'doubly null' those trials that found non-statistically significant differences in both primary outcome and cost per patient. Paradoxical was defined as concluding in favour of an intervention, usually compared with placebo or usual care. No human participants were involved. Our sample was 226 randomised trial projects published by the Health Technology Assessment programme 2004 to 2017. All are available free online. RESULTS The 226 projects contained 193 trials with a full economic evaluation. Of these 76 (39%) had at least one 'doubly null' comparison. These 76 trials contained 94 comparisons. In these 30 (32%) drew economic conclusions in favour of an intervention. Overall report conclusions split roughly equally between those favouring the intervention (14), and those favouring either the control (7) or uncertainty (9). DISCUSSION Trials with 'doubly null' results and paradoxical conclusions are not uncommon. The differences observed in cost and quality-adjustedlife year were small and non-statistically significant. Almost all these trials were also published in leading peer-reviewed journals. Although some guidelines for reporting economic results require cost-effectiveness estimates regardless of statistical significance, the interpretability of paradoxical results has nowhere been addressed. CONCLUSIONS Reconsideration is required of the interpretation of cost-effectiveness analyses in randomised controlled trials with 'doubly null' results, particularly when economics favours a novel intervention.
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Affiliation(s)
- James Raftery
- Faculty of Medicine, Southampton University, Southampton, UK
| | | | - Aileen Clarke
- Division of Health Sciences, University of Warwick, Coventry, UK
| | | | - John Norrie
- Edinburgh Clinical Trials Unit, University of Edinburgh No. 9, Bioquarter, Edinburgh, UK
| | | | - Ken Stein
- PenTAG, University of Exeter Medical School, Exeter, UK
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19
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Newlove-Delgado T, Ford TJ, Hamilton W, Janssens A, Stein K, Ukoumunne OC. Resumption of attention-deficit hyperactivity disorder medication in early adulthood: findings from a UK primary care prescribing study. Eur Child Adolesc Psychiatry 2019; 28:1589-1596. [PMID: 30949828 PMCID: PMC6861538 DOI: 10.1007/s00787-019-01325-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 03/26/2019] [Indexed: 11/30/2022]
Abstract
This study aimed to examine the resumption of attention-deficit hyperactivity disorder (ADHD) prescriptions in early adulthood in young people whose ADHD prescriptions stopped in adolescence. Whilst prescribing studies indicate that the proportion of those with ADHD stopping treatment in late adolescence remains in excess of the proportion expected to be symptom free, very few studies have examined patterns of resumption amongst young adults previously prescribed medication. Primary care records from the UK Clinical Practice Research Datalink from 2008 to 2013 were used to examine the outcome of resumption of ADHD prescriptions from age 20 years in a sample of cases with ADHD whose prescriptions stopped aged 14-18 years. A Cox regression model was fitted to explore variables that could theoretically be associated with resumption of prescriptions. Of 1440 cases, 109 (7.6%) had their ADHD prescriptions resumed. Characteristics associated with an increased probability of resumption included female gender, learning disability, referral to adult mental health services, and prescription of antipsychotic medication. In this study, only a small proportion of adolescents who stopped ADHD medication subsequently resumed their prescriptions in primary care. Those that did resume were a more complex group. As many vulnerable individuals with ongoing ADHD symptoms may not have the resources required to surmount the barriers to re-enter services, the implication is that not all those who could benefit from resuming medication are able to do so. The findings raise questions around whether current care models are flexible enough and whether primary care services are adequately supported in managing this group.
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Affiliation(s)
- Tamsin Newlove-Delgado
- University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Tamsin J Ford
- Child and Adolescent Psychiatry, University of Exeter Medical School, Exeter, UK
| | - Willie Hamilton
- Primary Care Diagnostics, University of Exeter Medical School, Exeter, UK
| | - Astrid Janssens
- Department of Public Health, University of Southern Denmark, Odense, Denmark
| | - Ken Stein
- Public Health, NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Obioha C Ukoumunne
- Medical Statistics, NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
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20
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McMeekin P, Flynn D, Allen M, Coughlan D, Ford GA, Lumley H, Balami JS, James MA, Stein K, Burgess D, White P. Estimating the effectiveness and cost-effectiveness of establishing additional endovascular Thrombectomy stroke Centres in England: a discrete event simulation. BMC Health Serv Res 2019; 19:821. [PMID: 31703684 PMCID: PMC6842187 DOI: 10.1186/s12913-019-4678-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 10/25/2019] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND We have previously modelled that the optimal number of comprehensive stroke centres (CSC) providing endovascular thrombectomy (EVT) in England would be 30 (net 6 new centres). We now estimate the relative effectiveness and cost-effectiveness of increasing the number of centres from 24 to 30. METHODS We constructed a discrete event simulation (DES) to estimate the effectiveness and lifetime cost-effectiveness (from a payer perspective) using 1 year's incidence of stroke in England. 2000 iterations of the simulation were performed comparing baseline 24 centres to 30. RESULTS Of 80,800 patients admitted to hospital with acute stroke/year, 21,740 would be affected by the service reconfiguration. The median time to treatment for eligible early presenters (< 270 min since onset) would reduce from 195 (IQR 155-249) to 165 (IQR 105-224) minutes. Our model predicts reconfiguration would mean an additional 33 independent patients (modified Rankin scale [mRS] 0-1) and 30 fewer dependent/dead patients (mRS 3-6) per year. The net addition of 6 centres generates 190 QALYs (95%CI - 6 to 399) and results in net savings to the healthcare system of £1,864,000/year (95% CI -1,204,000 to £5,017,000). The estimated budget impact was a saving of £980,000 in year 1 and £7.07 million in years 2 to 5. CONCLUSION Changes in acute stroke service configuration will produce clinical and cost benefits when the time taken for patients to receive treatment is reduced. Benefits are highly likely to be cost saving over 5 years before any capital investment above £8 million is required.
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Affiliation(s)
- Peter McMeekin
- School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health and Social Care, Teesside University, Tees Valley, UK
| | - Mike Allen
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, Bristol, UK
| | - Diarmuid Coughlan
- Institute of Health and Society, Newcastle University, Newcastle Upon Tyne, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Trust, Oxford, UK.,Oxford University, Oxford, UK.,Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK
| | - Hannah Lumley
- Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK
| | | | - Martin A James
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, Bristol, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Ken Stein
- National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, Bristol, UK
| | - David Burgess
- Clinical Research Network North East and North Cumbria, North East and North Cumbria Stroke Patient & Carer Panel, Newcastle upon Tyne, UK.,North East and North Cumbria Stroke Patient & Carer Panel, Newcastle upon Tyne, UK
| | - Phil White
- Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, UK.
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Fujiwara K, Shapira-Frommer R, Alexandre J, Monk B, Fehm T, Colombo N, Caceres M, Hasegawa K, Dubot C, Li J, Stein K, Keefe S, Tewari K. KEYNOTE-826: A phase III randomized study of chemotherapy with or without pembrolizumab for first-line treatment of persistent, recurrent, or metastatic cervical cancer. Ann Oncol 2019. [DOI: 10.1093/annonc/mdz426.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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22
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Rigney M, Stein K. P1.07-01 Lung Cancer Support Groups: Still Relevant in a Digital World? J Thorac Oncol 2019. [DOI: 10.1016/j.jtho.2019.08.1010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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23
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Rosero S, Jones P, Goldenberg I, Zareba W, Stein K, McNitt S, Brown M, Polonsky B, Kutyifa V. P2277Utility of cardiovascular implantable electronic device (CIED)-derived patient activity, a novel digital biomarker, to predict inappropriate therapy. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0754] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The role of cardiovascular implantable electronic device (CIED)-derived activity to predict inappropriate implantable cardioverter-defibrillator (ICD) therapy is not known. The Multicenter Automatic Defibrillator Implantation Trial – Reduce Inappropriate Therapy (MADIT-RIT) enrolled 1500 patients with contemporary indication for an ICD or a CRT-D. We aimed to identify whether activity, as a digital biomarker, predicted inappropriate therapy.
Methods
In 1500 patients enrolled in MADIT-RIT, CIED-derived patient activity was acquired daily. CIED-derived activity was averaged for the first 30 days following randomization and utilized in this study to predict inappropriate therapy post- 30-day. Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression models were used to evaluate first inappropriate therapy by 30-day CIED-derived patient activity quintiles, and by 30-day device derived patient activity as a continuous measurement.
Results
There were a total of 1463 patients with activity data available (90%), 135 patients received at least one inappropriate therapy during the post-30 day follow-up period. Patients in the highest quintile (Q5) of CIED-derived activity (more active) were younger, more often males and more likely to have had a prior ablation of an atrial arrhythmia. Patients in the highest quintile of 30-day CIED-derived median activity had the highest risk of receiving inappropriate therapy, 21% at 2 years as compared 7–11% in the other four quintiles (Figure, p<0.001 for the overall duration). Patients with the highest level of 30-day median patient activity (Q5) had 1.75 times higher risk of any inappropriate therapy as compared with lower levels of activity, Q1-Q4 (HR=1.75, 95% CI: 1.23–2.50, p<0.002). Each 10% increase in CIED-derived 30-day median patient activity was associated with a significant, 73% increase in risk of receiving inappropriate therapy (HR=1.73, 95% CI: 1.17–2.54, p=0.005). Patients in the highest quintile for activity had a 68% increase in the risk of SVT excluding atrial fibrillation, atrial flutter or atrial tachycardia (HR=1.69, 95% CI: 1.26–2.25, p=0.004), despite 96% receiving beta-blocker medications.
Inappropriate ICD Therapies by Activity
Conclusions
CIED-derived 30-day median patient activity predicted subsequent inappropriate therapy in ICD and CRT-D patients enrolled in MADIT-RIT. Patients with high levels of 30-day CIED-derived median patient activity were at a significantly higher risk of receiving inappropriate therapy. Activity, as a digital biomarker, may have utility in predicting and managing the risk of inappropriate therapy in this population.
Acknowledgement/Funding
Boston Scientific
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Affiliation(s)
- S Rosero
- University of Rochester, Clinical Cardiovascular Research Center, Rochester, United States of America
| | - P Jones
- Boston Scientific, Minneapolis, United States of America
| | - I Goldenberg
- University of Rochester, Clinical Cardiovascular Research Center, Rochester, United States of America
| | - W Zareba
- University of Rochester, Clinical Cardiovascular Research Center, Rochester, United States of America
| | - K Stein
- Boston Scientific, Minneapolis, United States of America
| | - S McNitt
- University of Rochester, Clinical Cardiovascular Research Center, Rochester, United States of America
| | - M Brown
- University of Rochester, Clinical Cardiovascular Research Center, Rochester, United States of America
| | - B Polonsky
- University of Rochester, Clinical Cardiovascular Research Center, Rochester, United States of America
| | - V Kutyifa
- University of Rochester, Clinical Cardiovascular Research Center, Rochester, United States of America
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24
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Kutyifa V, Jones P, Goldenberg I, Brown M, Zareba W, Stein K, McNitt S, Polonsky S, Rosero S. 2179Clinical significance of device-derived activity in ICD and CRT-D patients - Data from MADIT-RIT. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
The Multicenter Automatic Defibrillator Implantation Trial – Reduce Inappropriate Therapy (MADIT-RIT) enrolled 1500 patients and showed that novel ICD programming reduced inappropriate therapy and improved survival. However, the role of device-derived patient activity to predict mortality is not known.
Methods
In 1500 patients enrolled in MADIT-RIT, device-derived patient activity was captured daily. Device-derived activity was averaged for the first 30 days following randomization, and utilized in this study to predict mortality post-30 days. Kaplan-Meier survival analysis and multivariate Cox proportional hazards regression models were used to evaluate all-cause mortality by 30-day device derived patient activity quintiles, and as a 3-level function of 30-day device derived patient activity (Q1, Q2–3, Q4–5).
Results
There were a total of 1463 patients with data available (98%), 66 of them died during the follow-up post-30 days. Patients in the lowest quintile (Q1: 4%∼1 hour daily activity) of device-derived activity were older, they were more often female, and they more often had diabetes and NYHA class III HF symptoms. Patients in the lowest quintile of 30-day device derived median activity (1 hour daily activity) had the highest risk of mortality, 15% in 2 years as compared to Q2–3 (1–2 hours daily activity, 8–7% 2-year mortality), and Q4–5 (>2 hours daily activity, 2–3% 2-year mortality) (Figure, p<0.001 for the overall duration). Each quintile decrease in device-derived 30-day median patient activity was associated with a significant, 41% increase in mortality (HR=1.41, 95% CI: 1.15–1.71, p=0.001). Patients with the lowest level of 30-day median patient activity (Q1) had 4.13-times higher risk of mortality as compared to the highest level of activity patients, Q4–5 (HR=4.13, 95% CI: 1.89–9.03, p<0.001). Patients with intermediate levels of activity (Q2–3) still had a 2.8-fold increase in death as compared to the highest activity level cohort of patients (HR=2.79, 95% CI: 1.31–5.91, p=0.008).
Figure 1
Conclusions
Device-derived 30-day median patient activity predicted subsequent all-cause mortality in ICD and CRT-D patients enrolled in MADIT-RIT. Patients with low and moderate levels of 30-day device-derived median patient activity (less than 2 hours daily activity) were at a significantly higher risk of death, and these cohorts warrant further investigation and management to improve outcomes.
Acknowledgement/Funding
MADIT-RIT was funded by an unrestricted research grant from Boston Scientific to the University of Rochester.
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Affiliation(s)
- V Kutyifa
- University of Rochester Medical Center, Cardiology Division, Rochester, United States of America
| | - P Jones
- University of Rochester Medical Center, Cardiology Division, Rochester, United States of America
| | - I Goldenberg
- University of Rochester Medical Center, Cardiology Division, Rochester, United States of America
| | - M Brown
- University of Rochester Medical Center, Cardiology Division, Rochester, United States of America
| | - W Zareba
- University of Rochester Medical Center, Cardiology Division, Rochester, United States of America
| | - K Stein
- University of Rochester Medical Center, Cardiology Division, Rochester, United States of America
| | - S McNitt
- University of Rochester Medical Center, Cardiology Division, Rochester, United States of America
| | - S Polonsky
- University of Rochester Medical Center, Cardiology Division, Rochester, United States of America
| | - S Rosero
- University of Rochester Medical Center, Cardiology Division, Rochester, United States of America
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25
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Allen M, Pearn K, Monks T, Bray BD, Everson R, Salmon A, James M, Stein K. Can clinical audits be enhanced by pathway simulation and machine learning? An example from the acute stroke pathway. BMJ Open 2019; 9:e028296. [PMID: 31530590 PMCID: PMC6756466 DOI: 10.1136/bmjopen-2018-028296] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 08/05/2019] [Accepted: 08/21/2019] [Indexed: 01/02/2023] Open
Abstract
OBJECTIVE To evaluate the application of clinical pathway simulation in machine learning, using clinical audit data, in order to identify key drivers for improving use and speed of thrombolysis at individual hospitals. DESIGN Computer simulation modelling and machine learning. SETTING Seven acute stroke units. PARTICIPANTS Anonymised clinical audit data for 7864 patients. RESULTS Three factors were pivotal in governing thrombolysis use: (1) the proportion of patients with a known stroke onset time (range 44%-73%), (2) pathway speed (for patients arriving within 4 hours of onset: per-hospital median arrival-to-scan ranged from 11 to 56 min; median scan-to-thrombolysis ranged from 21 to 44 min) and (3) predisposition to use thrombolysis (thrombolysis use ranged from 31% to 52% for patients with stroke scanned with 30 min left to administer thrombolysis). A pathway simulation model could predict the potential benefit of improving individual stages of the clinical pathway speed, whereas a machine learning model could predict the benefit of 'exporting' clinical decision making from one hospital to another, while allowing for differences in patient population between hospitals. By applying pathway simulation and machine learning together, we found a realistic ceiling of 15%-25% use of thrombolysis across different hospitals and, in the seven hospitals studied, a realistic opportunity to double the number of patients with no significant disability that may be attributed to thrombolysis. CONCLUSIONS National clinical audit may be enhanced by a combination of pathway simulation and machine learning, which best allows for an understanding of key levers for improvement in hyperacute stroke pathways, allowing for differences between local patient populations. These models, based on standard clinical audit data, may be applied at scale while providing results at individual hospital level. The models facilitate understanding of variation and levers for improvement in stroke pathways, and help set realistic targets tailored to local populations.
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Affiliation(s)
| | - Kerry Pearn
- Medical School, University of Exeter, Exeter, UK
| | | | | | | | | | - Martin James
- Stroke Consultant, Royal Devon & Exeter NHS Trust, Exeter, UK
| | - Ken Stein
- Medical School, University of Exeter, Exeter, UK
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Abbott R, Orr N, McGill P, Whear R, Bethel A, Garside R, Stein K, Thompson‐Coon J. How do "robopets" impact the health and well-being of residents in care homes? A systematic review of qualitative and quantitative evidence. Int J Older People Nurs 2019; 14:e12239. [PMID: 31070870 PMCID: PMC6766882 DOI: 10.1111/opn.12239] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [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: 02/18/2019] [Accepted: 04/05/2019] [Indexed: 12/21/2022]
Abstract
BACKGROUND Robopets are small animal-like robots which have the appearance and behavioural characteristics of pets. OBJECTIVE To bring together the evidence of the experiences of staff, residents and family members of interacting with robopets and the effects of robopets on the health and well-being of older people living in care homes. DESIGN Systematic review of qualitative and quantitative research. DATA SOURCES We searched 13 electronic databases from inception to July 2018 and undertook forward and backward citation chasing. METHODS Eligible studies reported the views and experiences of robopets from residents, family members and staff (qualitative studies using recognised methods of qualitative data collection and analysis) and the effects of robopets on the health and well-being of care home residents (randomised controlled trials, randomised crossover trials and cluster randomised trials). Study selection was undertaken independently by two reviewers. We used the Wallace criteria and the Cochrane Risk of Bias tool to assess the quality of the evidence. We developed a logic model with stakeholders and used this as a framework to guide data extraction and synthesis. Where appropriate, we used meta-analysis to combine effect estimates from quantitative studies. RESULTS Nineteen studies (10 qualitative, 2 mixed methods and 7 randomised trials) met the inclusion criteria. Interactions with robopets were described as having a positive impact on aspects of well-being including loneliness, depression and quality of life by residents and staff, although there was no corresponding statistically significant evidence from meta-analysis for these outcomes. Meta-analysis showed evidence of a reduction in agitation with the robopet "Paro" compared to control (-0.32 [95% CI -0.61 to -0.04, p = 0.03]). Not everyone had a positive experience of robopets. CONCLUSIONS Engagement with robopets appears to have beneficial effects on the health and well-being of older adults living in care homes, but not all chose to engage. Whether the benefits can be sustained are yet to be investigated. IMPLICATIONS FOR PRACTICE Robopets have the potential to benefit people living in care homes, through increasing engagement and interaction. With the robopet acting as a catalyst, this engagement and interaction may afford comfort and help reduce agitation and loneliness.
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Affiliation(s)
- Rebecca Abbott
- Evidence Synthesis Team, NIHR CLAHRC South West Peninsula (PenCLAHRC), College of Medicine and HealthUniversity of ExeterExeterUK
| | - Noreen Orr
- Evidence Synthesis Team, NIHR CLAHRC South West Peninsula (PenCLAHRC), College of Medicine and HealthUniversity of ExeterExeterUK
| | - Paige McGill
- College of Medicine and HealthUniversity of ExeterExeterUK
| | - Rebecca Whear
- Evidence Synthesis Team, NIHR CLAHRC South West Peninsula (PenCLAHRC), College of Medicine and HealthUniversity of ExeterExeterUK
| | - Alison Bethel
- Evidence Synthesis Team, NIHR CLAHRC South West Peninsula (PenCLAHRC), College of Medicine and HealthUniversity of ExeterExeterUK
| | - Ruth Garside
- European Centre for Environment and Human HealthUniversity of Exeter Medical School, University of ExeterExeterUK
| | - Ken Stein
- Evidence Synthesis Team, NIHR CLAHRC South West Peninsula (PenCLAHRC), College of Medicine and HealthUniversity of ExeterExeterUK
| | - Jo Thompson‐Coon
- Evidence Synthesis Team, NIHR CLAHRC South West Peninsula (PenCLAHRC), College of Medicine and HealthUniversity of ExeterExeterUK
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Thompson-Coon J, Abbott R, Orr N, McGill P, Whear R, Bethel A, Garside R, Stein K. 45HOW DO ‘ROBOPETS’ IMPACT THE HEALTH AND WELLBEING OF RESIDENTS IN CARE HOMES? A SYSTEMATIC REVIEW OF QUALITATIVE AND QUANTITATIVE EVIDENCE. Age Ageing 2019. [DOI: 10.1093/ageing/afz075.05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- J Thompson-Coon
- NIHR Collaboration for Applied Health Research and Care (South West Peninsula)
| | - R Abbott
- NIHR Collaboration for Applied Health Research and Care (South West Peninsula)
| | - N Orr
- NIHR Collaboration for Applied Health Research and Care (South West Peninsula)
| | - P McGill
- University of Exeter, College of Medicine and Health
| | - R Whear
- NIHR Collaboration for Applied Health Research and Care (South West Peninsula)
| | - A Bethel
- NIHR Collaboration for Applied Health Research and Care (South West Peninsula)
| | - R Garside
- European Centre for Environment and Human Health, University of Exeter
| | - K Stein
- NIHR Collaboration for Applied Health Research and Care (South West Peninsula)
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Donziger M, Zaleta A, McManus S, Olson J, Salani R, Lee N, Santiago K, La Cava S, Smith M, DeFeo S, Stein K. Risk for anxiety and depression among individuals with ovarian cancer: The interplay between age and distress. Gynecol Oncol 2019. [DOI: 10.1016/j.ygyno.2019.04.397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Allen M, Pearn K, Villeneuve E, James M, Stein K. Planning and Providing Acute Stroke Care in England: The Effect of Planning Footprint Size. Front Neurol 2019; 10:150. [PMID: 30873107 PMCID: PMC6400850 DOI: 10.3389/fneur.2019.00150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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] [Received: 11/26/2018] [Accepted: 02/05/2019] [Indexed: 11/15/2022] Open
Abstract
Background: Guidelines in England recommend that hyperacute stroke units (HASUs) should have a minimum of 600 confirmed stroke admissions per year in order to sustain expert consultant-led services, and that travel time for patients should ideally be 30 min or less. Currently, 61% of stroke patients attend a unit with at least 600 admissions per year and 56% attend such a unit and have a travel time of no more than 30 min. Objective: We have sought to understand how varying the planning and provision footprint in England affects access to care whilst achieving the recommended admission numbers for hyper-acute stroke care. We have compared two different planning footprints to national-level planning: planning using five NHS Regions in England, and planning using 44 Sustainability and Transformation Partnerships (STPs) in England. Methods: Computer modeling and optimization using a multi-objective genetic algorithm. Results: The number of stroke admissions between STPs varies by seven-fold, while the number of stroke admissions between NHS Regions varies by 2.5-fold. In order to meet stroke admission guidelines (600/year) for all units the maximum possible proportion of patients within 30 min would be 82, 78, and 72% with no boundaries to planning/provision, NHS Region boundaries, and STP boundaries (in these scenarios patients cannot move outside of their own STP or NHS Region). If STP or NHS Region boundaries are removed for provision of service (after planning is performed at these local levels), travel time is improved, but number of admissions to individual hospitals become significantly changed, especially at STP planning level where admission numbers per unit changed by an average of 204 (19%), and not all units maintained 600 admissions after removal of boundaries. Conclusion: Planning and providing services at STP level could lead to sub-optimal service provision compared with using larger and more consistently populated planning areas.
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Affiliation(s)
- Michael Allen
- NIHR CLAHRC South West Peninsula, University of Exeter College Of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Kerry Pearn
- NIHR CLAHRC South West Peninsula, University of Exeter College Of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Emma Villeneuve
- NIHR CLAHRC South West Peninsula, University of Exeter College Of Medicine and Health, University of Exeter, Exeter, United Kingdom
| | - Martin James
- Royal Devon and Exeter NHS Foundation Trust and the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, Exeter, United Kingdom
| | - Ken Stein
- NIHR CLAHRC South West Peninsula, University of Exeter College Of Medicine and Health, University of Exeter, Exeter, United Kingdom
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McManus S, Zaleta AK, Miller MF, Olson J, Saxton MC, Stein K. Abstract P1-11-09: Sleep disturbance and quality of life among breast cancer survivors. Cancer Res 2019. [DOI: 10.1158/1538-7445.sabcs18-p1-11-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Introduction: Breast cancer survivors are at risk for substantial sleep disturbance, which can negatively affect quality of life. Sleep disturbance can be exacerbated by co-occurring emotional concerns such as depressive symptoms and anxiety. Prior research has largely focused on linkages between sleep disturbance and emotional concerns among individuals with early stage disease. To dive deeper, we examined sleep disturbance and its correlates among breast cancer survivors with and without metastatic disease.
Methods: 631 female breast cancer survivors (168 ever experiencing metastatic disease [MBC]; 463 never metastatic [BC]) enrolled in the Cancer Support Community's online Cancer Experience Registry, provided socio-demographic information, and reported cancer-related distress (CancerSupportSource®, a 25-item measure with depression and anxiety risk screening subscales) and levels of pain interference (PI) and sleep disturbance (PROMIS-29 subscales). We examined associations between risk for depression/anxiety, PI, and worse sleep disturbance with multivariate regression, adjusting for metastatic disease, treatment history, and number of comorbidities.
Results: Participants were 84% non-Hispanic White; mean age=54.8 years, SD=12.2; mean time since diagnosis=4.4 years, SD=5.5. 72% ever received chemotherapy; 60% radiation therapy; 56% hormone therapy; 91% had surgery for their cancer. 47% reported moderate to very serious concern about sleep problems; concern about sleep did not differ by metastatic history. 20% of participants reported a level of sleep disturbance that was significantly worse (>1SD) than the U.S. population average and 18% reported PI that was significantly worse (>1SD) than the U.S. population average; these did not differ by metastatic history. Using CancerSupportSource anxiety and depression risk screening subscales, 47% of participants were identified as at risk for clinically significant levels of anxiety, and 35% at risk for clinically significant levels of depression. Participants with MBC were more likely to be at risk for clinically significant levels of anxiety (χ2=.7.98, p<.01). Depression risk did not differ between MBC and BC survivors. Greater sleep disturbance was associated with having ever received radiation therapy (r=.11, p<.01), number of reported comorbidities (r=.37, p<.001), greater PI (r=.46, p<.001), and greater risk for clinically significant depression (r=.38, p<.001) and anxiety (r=.35, p<.001). In multivariate analysis, risk for clinically significant levels of depression (semipartial r=.12, p< .005), anxiety (semipartial r=.05, p< .05), and greater PI (semipartial r=.24, p< .001) remained associated with greater sleep disturbance after controlling for treatment history, metastatic status, and number of comorbidities, (R2=.28, F(4,588)=56.26, p<.001).
Conclusion: Being at risk for clinically significant levels of depression and anxiety and experiencing greater pain interference are associated with worse sleep disturbance among breast cancer survivors across the illness trajectory. Health care providers are encouraged to discuss with patients how they can address sleep disturbance concerns, including referrals to integrative therapies that address the constellation of affective, pain, and sleep symptoms.
Citation Format: McManus S, Zaleta AK, Miller MF, Olson J, Saxton MC, Stein K. Sleep disturbance and quality of life among breast cancer survivors [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-11-09.
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Affiliation(s)
- S McManus
- Cancer Support Community, Research and Training Institute, Philadelphia, PA; Cancer Support Community, Washington, DC
| | - AK Zaleta
- Cancer Support Community, Research and Training Institute, Philadelphia, PA; Cancer Support Community, Washington, DC
| | - MF Miller
- Cancer Support Community, Research and Training Institute, Philadelphia, PA; Cancer Support Community, Washington, DC
| | - J Olson
- Cancer Support Community, Research and Training Institute, Philadelphia, PA; Cancer Support Community, Washington, DC
| | - MC Saxton
- Cancer Support Community, Research and Training Institute, Philadelphia, PA; Cancer Support Community, Washington, DC
| | - K Stein
- Cancer Support Community, Research and Training Institute, Philadelphia, PA; Cancer Support Community, Washington, DC
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Newlove-Delgado T, Hamilton W, Ford TJ, Stein K, Ukoumunne OC. Prescribing for young people with attention deficit hyperactivity disorder in UK primary care: analysis of data from the Clinical Practice Research Datalink. ACTA ACUST UNITED AC 2019; 11:255-262. [PMID: 30730035 DOI: 10.1007/s12402-019-00288-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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: 02/22/2018] [Accepted: 01/28/2019] [Indexed: 11/25/2022]
Abstract
Guidance on management of attention deficit hyperactivity disorder (ADHD) in the UK was issued by the National Institute for Clinical Excellence in 2008. No UK study has examined all psychotropic prescribing in young people with ADHD since the introduction of the guidance; this is especially relevant due to the high prevalence of psychiatric comorbidity in this population. The aim of this study was to describe primary care prescribing of ADHD and other psychotropic medications for young people with ADHD. The analysis of records of patients with an ADHD diagnosis in the UK Clinical Practice Research Datalink from 2005 to 2013 was performed. Estimation of the prevalence of prescribing of ADHD and other psychotropic medications over 8-year follow-up for cases aged 10-20 years in 2005 was carried out. Of 9390 ADHD cases, 61.6% [95% confidence interval (CI) 60.6-62.5%] had a prescription at some point for ADHD medication. Prescribing of other psychotropic medications was higher in girls than in boys (36.4% vs. 22.7%; p < 0.001). ADHD prescribing prevalence declined steeply between the ages of 16 and 18 from 37.8% (95% CI 36.6-38.9) to 23.7% (95% CI 22.7-24.6%). There was a parallel increase in prescribing of other psychotropics from 3.8% (95% CI 3.4-4.3%) to 6.6% (95% CI 6.0-7.3%). There is scope to optimise the management of ADHD and psychiatric comorbidities in young people, and there is a need for sustainable models of ADHD care for young adults, supported by appropriate training and specialist services.
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Affiliation(s)
- Tamsin Newlove-Delgado
- University of Exeter Medical School, St. Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - William Hamilton
- University of Exeter Medical School, St. Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Tamsin J Ford
- University of Exeter Medical School, St. Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Ken Stein
- NIHR CLAHRC South West Peninsula [PenCLAHRC], University of Exeter Medical School, Exeter, UK
| | - Obioha C Ukoumunne
- NIHR CLAHRC South West Peninsula [PenCLAHRC], University of Exeter Medical School, Exeter, UK
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Moore DA, Richardson M, Gwernan-Jones R, Thompson-Coon J, Stein K, Rogers M, Garside R, Logan S, Ford TJ. Non-Pharmacological Interventions for ADHD in School Settings: An Overarching Synthesis of Systematic Reviews. J Atten Disord 2019; 23:220-233. [PMID: 25755258 DOI: 10.1177/1087054715573994] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [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] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This overarching synthesis brings together the findings of four systematic reviews including 138 studies focused on non-pharmacological interventions for ADHD used in school settings. These reviews considered the effectiveness of school-based interventions for ADHD, attitudes toward and experience of school-based interventions for ADHD, and the experience of ADHD in school settings. METHOD We developed novel methods to compare the findings across these reviews inductively and deductively. RESULTS Key contextual issues that may influence the effectiveness and implementation of interventions include the relationships that pupils with ADHD have with their teachers and peers, the attributions individuals make about the etiology of ADHD, and stigma related to ADHD or intervention attendance. CONCLUSION Although we found some positive effects for some outcomes and intervention categories, heterogeneity in effect size estimates and research evidence suggests a range of diverse contextual factors potentially moderate the implementation and effectiveness of school-based interventions for ADHD.
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Wright D, Williams E, Bryce C, le May A, Stein K, Milne R, Walley T. A novel approach to sharing all available information from funded health research: the NIHR Journals Library. Health Res Policy Syst 2018; 16:70. [PMID: 30064444 PMCID: PMC6069813 DOI: 10.1186/s12961-018-0339-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Accepted: 06/12/2018] [Indexed: 01/15/2023] Open
Abstract
Background Relevant information on health research must be made publicly available in an accurate, timely and accessible manner if evidence is to inform practice and benefit patient care. Failure to publish research information represents a significant waste of research funds. However, recent studies have demonstrated that non-publication and selective or biased reporting remains a significant problem. The role of online publications in rectifying these issues by providing open access to study information is increasingly recognised. Objective This paper details a novel approach to publishing research information developed by the National Institute for Health Research (NIHR), a major funder of health research in the United Kingdom. The NIHR has enhanced its Journals Library (www.journalslibrary.nihr.ac.uk), providing an online repository of information from research funded through five programmes. We describe how the NIHR Journals Library provides a ‘thread’ of relevant information for each study, including protocols, participant information sheets, data linkages, final reports, publications and diverse knowledge products. We also discuss the Library as a ‘living’ resource, one that is updated as each study progresses from inception to completion. Finally, we consider the implications of the Library for the NIHR, other journals and research teams submitting information. Conclusion Openly publishing information from funded research in the NIHR Journals Library serves as a model of knowledge sharing, maximising return on investment and enhancing the usability and replicability of research findings for different evidence-user communities. The Library also supports wider ‘research on research’ ambitions, enabling users to interrogate the repository of NIHR-funded studies, enhancing the understanding of research commissioning, design, dissemination and impact. Video abstract: www.youtube.com/watch?v=8H03uxN_iTE. Electronic supplementary material The online version of this article (10.1186/s12961-018-0339-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- David Wright
- National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Alpha House, Enterprise Road, Southampton, SO16 7NS, United Kingdom.
| | - Elaine Williams
- National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Alpha House, Enterprise Road, Southampton, SO16 7NS, United Kingdom
| | - Colin Bryce
- National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Alpha House, Enterprise Road, Southampton, SO16 7NS, United Kingdom
| | - Andrée le May
- Health Sciences, University of Southampton, University Road, Southampton, SO17 1BJ, United Kingdom
| | - Ken Stein
- University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, United Kingdom
| | - Ruairidh Milne
- National Institute for Health Research Evaluation, Trials and Studies Coordinating Centre, University of Southampton, Alpha House, Enterprise Road, Southampton, SO16 7NS, United Kingdom
| | - Tom Walley
- Institute of Psychology, Health and Society, University of Liverpool, Liverpool, L69 3BX, United Kingdom
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Allen M, Pearn K, James M, Ford GA, White P, Rudd AG, McMeekin P, Stein K. Maximising access to thrombectomy services for stroke in England: A modelling study. Eur Stroke J 2018; 4:39-49. [PMID: 31165093 DOI: 10.1177/2396987318785421] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2018] [Accepted: 05/24/2018] [Indexed: 12/11/2022] Open
Abstract
Purpose Both intravenous thrombolysis (IVT) and intra-arterial endovascular thrombectomy (ET) improve the outcome of patients with acute ischaemic stroke, with endovascular thrombectomy being an option for those patients with large vessel occlusions. We sought to understand how organisation of services affects time to treatment for both intravenous thrombolysis and endovascular thrombectomy. Method A multi-objective optimisation approach was used to explore the relationship between the number of intravenous thrombolysis and endovascular thrombectomy centres and times to treatment. The analysis is based on 238,887 emergency stroke admissions in England over 3 years (2013-2015). Results Providing hyper-acute care only in comprehensive stroke centres (CSC, providing both intravenous thrombolysis and endovascular thrombectomy, and performing >150 endovascular thrombectomy per year, maximum 40 centres) in England would lead to 15% of patients being more than 45 min away from care, and would create centres with up to 4300 stroke admissions/year. Mixing hyper-acute stroke units (providing intravenous thrombolysis only) with comprehensive stroke centres speeds time to intravenous thrombolysis and mitigates admission numbers to comprehensive stroke centres, but at the expense of increasing time to endovascular thrombectomy. With 24 comprehensive stroke centres and all remaining current acute stroke units as hyper-acute stroke units, redirecting patients directly to attend a comprehensive stroke centre by accepting a small delay (15-min maximum) in intravenous thrombolysis reduces time to endovascular thrombectomy: 25% of all patients would be redirected from hyper-acute stroke units to a comprehensive stroke centre, with an average delay in intravenous thrombolysis of 8 min, and an average improvement in time to endovascular thrombectomy of 80 min. The balance of comprehensive stroke centre:hyper-acute stroke unit admissions would change from 24:76 to 49:51. Conclusion Planning of hyper-acute stroke services is best achieved when considering all forms of acute care and ambulance protocol together. Times to treatment need to be considered alongside manageable and sustainable admission numbers.
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Affiliation(s)
- Michael Allen
- University of Exeter Medical School, Exeter, UK.,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, UK
| | - Kerry Pearn
- University of Exeter Medical School, Exeter, UK.,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, UK
| | - Martin James
- University of Exeter Medical School, Exeter, UK.,Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Gary A Ford
- Radcliffe Department of Medicine, Oxford University, Oxford, UK.,Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle-upon-Tyne, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle-upon-Tyne, UK
| | - Anthony G Rudd
- Kings College London, London, UK.,Guy's and St Thomas NHS Foundation Trust, London, UK
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle-upon-Tyne, UK
| | - Ken Stein
- University of Exeter Medical School, Exeter, UK.,National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) South West Peninsula, UK
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Newlove-Delgado T, Ford TJ, Stein K, Garside R. ‘You’re 18 now, goodbye’: the experiences of young people with attention deficit hyperactivity disorder of the transition from child to adult services. Emotional and Behavioural Difficulties 2018. [DOI: 10.1080/13632752.2018.1461476] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
| | - Tamsin J. Ford
- Child and Adolescent Psychiatry, University of Exeter Medical School, Exeter, UK
| | - Ken Stein
- Public Health, NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, Exeter, UK
| | - Ruth Garside
- Evidence Synthesis, European Centre for Environment & Human Health, University of Exeter Medical School, Knowledge Spa, Royal Cornwall Hospital, Truro, Cornwall, UK
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DeMello MM, Pinto BM, Mitchell S, Dunsiger SI, Stein K. Peer support for physical activity adoption among breast cancer survivors: Do the helped resemble the helpers? Eur J Cancer Care (Engl) 2018; 27:e12849. [PMID: 29637645 DOI: 10.1111/ecc.12849] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/06/2018] [Indexed: 11/29/2022]
Abstract
Interventions offering peer mentoring programmes promoting moderate-to-vigorous physical activity (MVPA) have shown improvements in MVPA and well-being from baseline; however, research is limited. The purpose of this study was to compare the physical activity (PA) levels and psychosocial well-being of coaches and participants at baseline and following a 12-week intervention. Breast cancer survivors (<5 years) were recruited and randomised into either exercise (Reach-to-Recovery (RTR) + PA) or control (RTR Control). Participants in both groups were individually assigned one of the 18 available coaches who delivered either the MVPA intervention or the control condition via telephone. PA (7-Day PA Recall), psychosocial well-being, fatigue and mood were assessed at baseline and intervention completion. Seventy-six breast cancer survivors (average age = 55.62 (±9.55)) were randomised. At baseline, all participants showed significantly lower MVPA (p = .001) and well-being (p < .05) as compared to coaches. However, post-intervention showed significant improvement in PA and well-being in RTR + PA, so that they were no longer significantly different from the coaches. Post-intervention, MVPA (p < .01), quality of life (p < .05) and fatigue (p < .05) remained significantly lower in RTR Controls compared to coaches. Future interventions should consider the behavioural patterns not only of the participants, but also of those who deliver the interventions.
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Affiliation(s)
- M M DeMello
- College of Nursing, University of South Carolina, Columbia, SC, USA
| | - B M Pinto
- College of Nursing, University of South Carolina, Columbia, SC, USA
| | - S Mitchell
- College of Nursing, University of South Carolina, Columbia, SC, USA
| | - S I Dunsiger
- Centers for Behavioral and Preventive Medicine, Miriam Hospital and W. Alpert Medical School of Brown University, Providence, RI, USA
| | - K Stein
- Department of Behavioral Sciences and Health Education, Emory University, Atlanta, GA, USA
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Newlove-Delgado T, Ford TJ, Hamilton W, Stein K, Ukoumunne OC. Prescribing of medication for attention deficit hyperactivity disorder among young people in the Clinical Practice Research Datalink 2005-2013: analysis of time to cessation. Eur Child Adolesc Psychiatry 2018; 27:29-35. [PMID: 28589222 PMCID: PMC5799339 DOI: 10.1007/s00787-017-1011-1] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2017] [Accepted: 05/26/2017] [Indexed: 11/26/2022]
Abstract
The aim of this study was to examine the time to cessation of ADHD medication amongst young people with ADHD aged 16 in the period 2005-2013. Previous studies of prescribing in primary care reported high rates of medication cessation amongst 16 and 17 year olds with ADHD. The examination of trends since the introduction of new NICE guidance in 2008 will support service planning and improvement of outcomes over the vulnerable transition period from child to adult services. We used primary care records from the Clinical Practice Research Datalink and identified cases prescribed ADHD medication at the time of their 16th birthday during the study period. The outcome was time to medication cessation from the age of 16. Cessation of medication was defined as occurring at the beginning of a gap of over 6 months in prescriptions. 1620 cases were included. The median time to cessation was 1.51 years (95% CI 1.42-1.67).The estimated probability of remaining on medication was 0.63 (95% CI 0.61-0.65) at age 17 (i.e., at 1 year) and 0.41 (95% CI 0.39-0.43) at age 18. Young people with ADHD remain at high risk of cessation of medication during the transition from child to adult services. Despite the restriction that only primary care prescribing data were available, the results suggest continuing disparity between expected levels of symptom persistence and continuation of medication.
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Affiliation(s)
- Tamsin Newlove-Delgado
- University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK.
| | - Tamsin J Ford
- University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - William Hamilton
- University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Ken Stein
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
| | - Obioha C Ukoumunne
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU, UK
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Abstract
OBJECTIVES The policy of centralising hyperacute stroke units (HASUs) in England aims to provide stroke care in units that are both large enough to sustain expertise (>600 admissions/year) and dispersed enough to rapidly deliver time-critical treatments (<30 min maximum travel time). Currently, just over half (56%) of patients with stroke access care in such a unit. We sought to model national configurations of HASUs that would optimise both institutional size and geographical access to stroke care, to maximise the population benefit from the centralisation of stroke care. DESIGN Modelling of the effect of the national reconfiguration of stroke services. Optimal solutions were identified using a heuristic genetic algorithm. SETTING 127 acute stroke services in England, serving a population of 54 million people. PARTICIPANTS 238 887 emergency admissions with acute stroke over a 3-year period (2013-2015). INTERVENTION Modelled reconfigurations of HASUs optimised for institutional size and geographical access. MAIN OUTCOME MEASURE Travel distances and times to HASUs, proportion of patients attending a HASU with at least 600 admissions per year, and minimum and maximum HASU admissions. RESULTS Solutions were identified with 75-85 HASUs with annual stroke admissions in the range of 600-2000, which achieve up to 82% of patients attending a stroke unit within 30 min estimated travel time (with at least 95% and 98% of the patients being within 45 and 60 min travel time, respectively). CONCLUSIONS The reconfiguration of hyperacute stroke services in England could lead to all patients being treated in a HASU with between 600 and 2000 admissions per year. However, the proportion of patients within 30 min of a HASU would fall from over 90% to 80%-82%.
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Affiliation(s)
- Michael Allen
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Kerry Pearn
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Emma Villeneuve
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Thomas Monks
- NIHR CLAHRC Wessex Data Science Hub, Southampton General Hospital, Southampton, UK
| | - Ken Stein
- Institute of Health Research, University of Exeter Medical School, St Luke’s Campus, Exeter, UK
| | - Martin James
- Stroke Services, Royal Devon & Exeter NHS trust, Exeter, UK
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Welzel TM, Hinrichsen H, Sarrazin C, Buggisch P, Baumgarten A, Christensen S, Berg T, Mauss S, Teuber G, Stein K, Deterding K, van Bömmel F, Heyne R, John C, Zimmermann T, Lutz T, Schott E, Hettinger J, Kleine H, König B, Hüppe D, Wedemeyer H. Real-world experience with the all-oral, interferon-free regimen of ombitasvir/paritaprevir/ritonavir and dasabuvir for the treatment of chronic hepatitis C virus infection in the German Hepatitis C Registry. J Viral Hepat 2017; 24:840-849. [PMID: 28342229 DOI: 10.1111/jvh.12708] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Accepted: 02/16/2017] [Indexed: 12/13/2022]
Abstract
Real-world studies are relevant to complement clinical trials on novel antiviral therapies against chronic hepatitis C; however, clinical practice data are currently limited. This study investigated effectiveness and safety of ombitasvir/paritaprevir/ritonavir (OBV/PTV/r)±dasabuvir (DSV)±ribavirin (RBV) for treatment of HCV genotype (GT) 1 and GT4 infection in a large real-world cohort. The German Hepatitis C Registry is an observational cohort study prospectively collecting clinical practice data on direct-acting antiviral therapies. Patients with GT1/4 infection treated with OBV/PTV/r±DSV±RBV were analysed. Effectiveness was assessed by sustained virologic response in 558 patients who reached post-treatment week 12 (SVR12). Safety is reported in 1017 patients who initiated treatment. Of the patients, 892 (88%) had GT1 and 125 (12%) had GT4 infection. Prior treatment experience and cirrhosis were reported in 598 (59%) and 228 (22%) patients, respectively. Overall, SVR12 (mITT) was 96% (486/505) in GT1- and 100% (53/53) in GT4 patients. SVR12 rates were high across subgroups including patients with cirrhosis (95%, 123/129), patients with moderate to severe renal impairment (100%, 34/34), and subgroups excluded from registrational trials like patients ≥70 years (96%, 64/67) and failures to prior protease inhibitor treatment (96%, 46/48). Adverse events (AEs) and serious AEs were reported in 52% (525/1017) and 2% (21/1017) of patients, respectively, and led to treatment discontinuation in 1.5% (15/1017) of patients. OBV/PTV/r±DSV±RBV was effective and generally well tolerated for treatment of HCV infection in clinical practice.
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Affiliation(s)
- T M Welzel
- Department of Medicine 1, University Hospital, J.W. Goethe University, Frankfurt am Main, Germany
| | - H Hinrichsen
- Gastroenterology-Hepatology Center Kiel, Kiel, Germany
| | - C Sarrazin
- Department of Medicine 1, University Hospital, J.W. Goethe University, Frankfurt am Main, Germany.,Medical Department II, Gastroenterology, Hepatology, Infectiology, St. Josefs-Hospital, Wiesbaden, Germany
| | - P Buggisch
- Liver Unit, Asklepios Clinic St. Georg, IFI-Institute, Hamburg, Germany
| | | | - S Christensen
- Center for Interdisciplinary Medicine (CIM), Münster, Germany
| | - T Berg
- Section of Hepatology, Clinic for Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - S Mauss
- Center for HIV and Hepatogastroenterology, Düsseldorf, Germany
| | - G Teuber
- Private Practice, Frankfurt am Main, Germany
| | - K Stein
- Hepatologie - Magdeburg, Magdeburg, Germany
| | - K Deterding
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - F van Bömmel
- Section of Hepatology, Clinic for Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - R Heyne
- Leberzentrum am Checkpoint Berlin, Berlin, Germany
| | - C John
- Private Practice for Internal Medicine, Berlin, Germany
| | - T Zimmermann
- Department of Medicine I, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - T Lutz
- Infektiologikum, Frankfurt am Main, Germany
| | - E Schott
- Department of Hepatology and Gastroenterology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - J Hettinger
- AbbVie Deutschland GmbH & Co KG, Wiesbaden, Germany
| | - H Kleine
- AbbVie Deutschland GmbH & Co KG, Wiesbaden, Germany
| | - B König
- AbbVie Deutschland GmbH & Co KG, Wiesbaden, Germany
| | - D Hüppe
- Center for Gastroenterology and Hepatology, Herne
| | - H Wedemeyer
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
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Grigore B, Peters J, Hyde C, Stein K. EXPLICIT: a feasibility study of remote expert elicitation in health technology assessment. BMC Med Inform Decis Mak 2017; 17:131. [PMID: 28870196 PMCID: PMC5584524 DOI: 10.1186/s12911-017-0527-0] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 08/18/2017] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Expert opinion is often sought to complement available information needed to inform model-based economic evaluations in health technology assessments. In this context, we define expert elicitation as the process of encoding expert opinion on a quantity of interest, together with associated uncertainty, as a probability distribution. When availability for face-to-face expert elicitation with a facilitator is limited, elicitation can be conducted remotely, overcoming challenges of finding an appropriate time to meet the expert and allowing access to experts situated too far away for practical face-to-face sessions. However, distance elicitation is associated with reduced response rates and limited assistance for the expert during the elicitation session. The aim of this study was to inform the development of a remote elicitation tool by exploring the influence of mode of elicitation on elicited beliefs. METHODS An Excel-based tool (EXPLICIT) was developed to assist the elicitation session, including the preparation of the expert and recording of their responses. General practitioners (GPs) were invited to provide expert opinion about population alcohol consumption behaviours. They were randomised to complete the elicitation by either a face-to-face meeting or email. EXPLICIT was used in the elicitation sessions for both arms. RESULTS Fifteen GPs completed the elicitation session. Those conducted by email were longer than the face-to-face sessions (13 min 30 s vs 10 min 26 s, p = 0.1) and the email-elicited estimates contained less uncertainty. However, the resulting aggregated distributions were comparable. CONCLUSIONS EXPLICIT was useful in both facilitating the elicitation task and in obtaining expert opinion from experts via email. The findings support the opinion that remote, self-administered elicitation is a viable approach within the constraints of HTA to inform policy making, although poor response rates may be observed and additional time for individual sessions may be required.
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Affiliation(s)
- Bogdan Grigore
- Evidence Synthesis & Modelling for Health Improvement (ESMI), Institute for Health Research, University of Exeter Medical School, University of Exeter, Room 3.09.3, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Jaime Peters
- Evidence Synthesis & Modelling for Health Improvement (ESMI), Institute for Health Research, University of Exeter Medical School, University of Exeter, Room 3.09.3, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Christopher Hyde
- Evidence Synthesis & Modelling for Health Improvement (ESMI), Institute for Health Research, University of Exeter Medical School, University of Exeter, Room 3.09.3, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Ken Stein
- Evidence Synthesis & Modelling for Health Improvement (ESMI), Institute for Health Research, University of Exeter Medical School, University of Exeter, Room 3.09.3, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
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Mehnert J, Rugo H, O'Neil B, Santoro A, Schellens J, Cohen R, Doi T, Ott P, Pishvaian M, Puzanov I, Aung K, Hsu C, Le Tourneau C, Soria JC, Elez E, Tamura K, Gould M, Zhao G, Stein K, Piha-Paul S. Pembrolizumab for patients with PD-L1–positive advanced carcinoid or pancreatic neuroendocrine tumors: Results from the KEYNOTE-028 study. Ann Oncol 2017. [DOI: 10.1093/annonc/mdx368] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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42
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Bojke L, Grigore B, Jankovic D, Peters J, Soares M, Stein K. Informing Reimbursement Decisions Using Cost-Effectiveness Modelling: A Guide to the Process of Generating Elicited Priors to Capture Model Uncertainties. Pharmacoeconomics 2017; 35:867-877. [PMID: 28616775 DOI: 10.1007/s40273-017-0525-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/22/2023]
Abstract
In informing decisions, utilising health technology assessment (HTA), expert elicitation can provide valuable information, particularly where there is a less-developed evidence-base at the point of market access. In these circumstances, formal methods to elicit expert judgements are preferred to improve the accountability and transparency of the decision-making process, help reduce bias and the use of heuristics, and also provide a structure that allows uncertainty to be expressed. Expert elicitation is the process of transforming the subjective and implicit knowledge of experts into their quantifiable expressions. The use of expert elicitation in HTA is gaining momentum, and there is particular interest in its application to diagnostics, medical devices and complex interventions such as in public health or social care. Compared with the gathering of experimental evidence, elicitation constitutes a reasonably low-cost source of evidence. Given its inherent subject nature, the potential biases in elicited evidence cannot be ignored and, due to its infancy in HTA, there is little guidance to the analyst wishing to conduct a formal elicitation exercise. This article attempts to summarise the stages of designing and conducting an expert elicitation, drawing on key literature and examples, most of which are not in HTA. In addition, we critique their applicability to HTA, given its distinguishing features. There are a number of issues that the analyst should be mindful of, in particular the need to appropriately characterise the uncertainty associated with model inputs and the fact that there are often numerous parameters required, not all of which can be defined using the same quantities. This increases the need for the elicitation task to be as straightforward as possible for the expert to complete.
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Affiliation(s)
- Laura Bojke
- Centre for Health Economics, University of York, York, UK.
| | - Bogdan Grigore
- Peninsula Technology Assessment Group, University of Exeter, Exeter, UK
| | - Dina Jankovic
- Centre for Health Economics, University of York, York, UK
| | - Jaime Peters
- Peninsula Technology Assessment Group, University of Exeter, Exeter, UK
| | - Marta Soares
- Centre for Health Economics, University of York, York, UK
| | - Ken Stein
- Peninsula Technology Assessment Group, University of Exeter, Exeter, UK
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Ott P, Bang YJ, Razak A, Bennouna J, Soria JC, Rugo H, Cohen R, O'Neil B, Mehnert J, Lopez J, Doi T, van Brummelen E, Levitan D, Zhao G, Emancipator K, Stein K, Joe A, Ayers M, Lunceford J, Piha-Paul S. Relationship of PD-L1 and a T-cell inflamed gene expression profile (GEP) to clinical response in a multicohort trial of solid tumors (KEYNOTE [KN]028). Ann Oncol 2017. [DOI: 10.1093/annonc/mdx363] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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44
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Cikes M, Sanchez Martinez S, Biering Sorensen T, Pouleur A, Knappe D, Kutyifa V, Moss A, Stein K, Bijnens B, Solomon S. 5118Machine-learning characterization of myocardial deformation patterns to identify responders to resynchronization therapy. Eur Heart J 2017. [DOI: 10.1093/eurheartj/ehx493.5118] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hoffmann TC, Oxman AD, Ioannidis JP, Moher D, Lasserson TJ, Tovey DI, Stein K, Sutcliffe K, Ravaud P, Altman DG, Perera R, Glasziou P. Enhancing the usability of systematic reviews by improving the consideration and description of interventions. BMJ 2017; 358:j2998. [PMID: 28729459 DOI: 10.1136/bmj.j2998] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Tammy C Hoffmann
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
| | - Andrew D Oxman
- Centre for Informed Health Choice, Norwegian Institute of Public Health, Oslo, Norway
| | - John Pa Ioannidis
- Departments of Medicine, of Health Research and Policy, and of Statistics, and Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA
| | - David Moher
- Ottawa Hospital Research Institute, Ottawa, Canada
| | | | - David I Tovey
- Cochrane Editorial Unit, Cochrane Central Executive, London, UK
| | - Ken Stein
- Institute for Health Research, University of Exeter Medical School, Exeter, Devon, UK
| | - Katy Sutcliffe
- EPPI-Centre (Evidence for Policy and Practice Information and Co-ordinating Centre), Institute of Education, University College London
| | - Philippe Ravaud
- Centre de Recherche Epidémiologie et Statistique, INSERM U1153, Paris, France; and Faculté de Médecine, Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Paul Glasziou
- Centre for Research in Evidence-Based Practice, Faculty of Health Sciences and Medicine, Bond University, Queensland, Australia
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Lourida I, Abbott RA, Rogers M, Lang IA, Stein K, Kent B, Thompson Coon J. Dissemination and implementation research in dementia care: a systematic scoping review and evidence map. BMC Geriatr 2017; 17:147. [PMID: 28709402 PMCID: PMC5513053 DOI: 10.1186/s12877-017-0528-y] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [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] [Received: 11/09/2016] [Accepted: 06/30/2017] [Indexed: 11/22/2022] Open
Abstract
Background The need to better understand implementing evidence-informed dementia care has been recognised in multiple priority-setting partnerships. The aim of this scoping review was to give an overview of the state of the evidence on implementation and dissemination of dementia care, and create a systematic evidence map. Methods We sought studies that addressed dissemination and implementation strategies or described barriers and facilitators to implementation across dementia stages and care settings. Twelve databases were searched from inception to October 2015 followed by forward citation and grey literature searches. Quantitative studies with a comparative research design and qualitative studies with recognised methods of data collection were included. Titles, abstracts and full texts were screened independently by two reviewers with discrepancies resolved by a third where necessary. Data extraction was performed by one reviewer and checked by a second. Strategies were mapped according to the ERIC compilation. Results Eighty-eight studies were included (30 quantitative, 34 qualitative and 24 mixed-methods studies). Approximately 60% of studies reported implementation strategies to improve practice: training and education of professionals (94%), promotion of stakeholder interrelationships (69%) and evaluative strategies (46%) were common; financial strategies were rare (15%). Nearly 70% of studies reported barriers or facilitators of care practices primarily within residential care settings. Organisational factors, including time constraints and increased workload, were recurrent barriers, whereas leadership and managerial support were often reported to promote implementation. Less is known about implementation activities in primary care and hospital settings, or the views and experiences of people with dementia and their family caregivers. Conclusion This scoping review and mapping of the evidence reveals a paucity of robust evidence to inform the successful dissemination and implementation of evidence-based dementia care. Further exploration of the most appropriate methods to evaluate and report initiatives to bring about change and of the effectiveness of implementation strategies is necessary if we are to make changes in practice that improve dementia care. Electronic supplementary material The online version of this article (doi:10.1186/s12877-017-0528-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ilianna Lourida
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, University of Exeter, South Cloisters, St Luke's Campus, Exeter, EX1 2LU, UK.
| | - Rebecca A Abbott
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, University of Exeter, South Cloisters, St Luke's Campus, Exeter, EX1 2LU, UK
| | - Morwenna Rogers
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, University of Exeter, South Cloisters, St Luke's Campus, Exeter, EX1 2LU, UK
| | - Iain A Lang
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, University of Exeter, South Cloisters, St Luke's Campus, Exeter, EX1 2LU, UK
| | - Ken Stein
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, University of Exeter, South Cloisters, St Luke's Campus, Exeter, EX1 2LU, UK
| | - Bridie Kent
- School of Nursing and Midwifery, Plymouth University, Plymouth, UK
| | - Jo Thompson Coon
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter Medical School, University of Exeter, South Cloisters, St Luke's Campus, Exeter, EX1 2LU, UK
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Manzi S, Chalk D, Day J, Pearson M, Lang I, Stein K, Pitt M. A novel modelling and simulation capacity development initiative for the National Health Service. BMJ STEL 2017; 4:97-98. [DOI: 10.1136/bmjstel-2017-000205] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 03/20/2017] [Indexed: 11/04/2022]
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Phillips K, Santoso T, Sanders P, Alison J, Chan JLK, Pak H, Chandavimol M, Ghamdi MAL, Stein K, Shanker A, Omar R. Percutaneous Left Atrial Appendage Closure with the WATCHMAN Device: 12 Month Outcomes from the WASP Asia-Pacific Registry. Heart Lung Circ 2017. [DOI: 10.1016/j.hlc.2017.06.330] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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49
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Janssen M, Putz J, Giessing M, Fornara P, Friedersdorff F, Dreikorn K, Heynemann H, Stein K, Wunderlich H, Stöckle M. [Report of the 23rd annual meeting of the Working Group Kidney Transplantation of the German Society of Urology in Homburg (Saar)]. Urologe A 2016; 56:69-71. [PMID: 27966097 DOI: 10.1007/s00120-016-0295-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Affiliation(s)
- M Janssen
- Klinik für Urologie und Kinderurologie, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrbergerstr., 66424, Homburg/Saar, Deutschland.
| | - J Putz
- Klinik und Poliklinik für Urologie, Universitätsklinikum Carl Gustav Carus der Technischen Universität Dresden, Dresden, Deutschland
| | - M Giessing
- Urologische Klinik, Heinrich Heine-Universitätsklinikum Düsseldorf, Düsseldorf, Deutschland
| | - P Fornara
- Universitätsklinik und Poliklinik für Urologie, Universitätsklinikum Halle (Saale), Halle/Saale, Deutschland
| | - F Friedersdorff
- Klinik für Urologie - Campus Mitte, Charité Universitätsmedizin Berlin, Berlin, Deutschland
| | - K Dreikorn
- AK Nierentransplantation, Ärztezentrum Horn, Bremen, Bremen, Deutschland
| | - H Heynemann
- AK Nierentransplantation, Halle, Deutschland
| | - K Stein
- Urologische Praxis Große Wasserstraße, Rostock, Deutschland
| | - H Wunderlich
- Klinik für Urologie und Kinderurologie, St. Georg-Klinikum Eisenach, Eisenach, Deutschland
| | - M Stöckle
- Klinik für Urologie und Kinderurologie, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Kirrbergerstr., 66424, Homburg/Saar, Deutschland
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Coon JT, Gwernan-Jones R, Moore D, Richardson M, Shotton C, Pritchard W, Morris C, Stein K, Ford T. End-user involvement in a systematic review of quantitative and qualitative research of non-pharmacological interventions for attention deficit hyperactivity disorder delivered in school settings: reflections on the impacts and challenges. Health Expect 2016; 19:1084-97. [PMID: 26389784 PMCID: PMC5053289 DOI: 10.1111/hex.12400] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/29/2015] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND The benefits of end-user involvement in health-care research are widely recognized by research agencies. There are few published evaluations of end-user involvement in systematic reviews. OBJECTIVES (i) Describe end-user involvement in a complex mixed-methods systematic review of ADHD in schools, (ii) reflect on the impact of end-user involvement, (iii) highlight challenges and benefits experienced and (iv) provide suggestions to inform future involvement. METHODS End-users were involved in all stages of the project, both as authors and as members of an advisory group. In addition, several events were held with groups of relevant end-users during the project. RESULTS End-user input (i) guided the direction of the research, (ii) contributed to a typology of interventions and outcomes, (iii) contributed to the direction of data analysis and (iv) contributed to the robustness of the syntheses by demonstrating the alignment of interim findings with lived experiences. Challenges included (i) managing expectations, (ii) managing the intensity of emotion, (iii) ensuring that involvement was fruitful for all not just the researcher, (iv) our capacity to communicate and manage the process and (v) engendering a sense of involvement amongst end-users. CONCLUSIONS End-user involvement was an important aspect of this project. To minimize challenges in future projects, a recognition by the project management team and the funding provider that end-user involvement even in evidence synthesis projects is resource intensive is essential to allow appropriate allocation of time and resources for meaningful engagement.
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Affiliation(s)
- Jo Thompson Coon
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter, Exeter, UK.
| | | | - Darren Moore
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter, Exeter, UK
| | - Michelle Richardson
- Health Service and Population Research Department, Kings College London, London, UK
| | - Catherine Shotton
- Child Health Group, University of Exeter Medical School, University of Exeter, Exeter, UK
| | | | | | - Ken Stein
- NIHR CLAHRC South West Peninsula (PenCLAHRC), University of Exeter, Exeter, UK
| | - Tamsin Ford
- Child Health Group, University of Exeter Medical School, University of Exeter, Exeter, UK
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