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Effects of empagliflozin on progression of chronic kidney disease: a prespecified secondary analysis from the empa-kidney trial. Lancet Diabetes Endocrinol 2024; 12:39-50. [PMID: 38061371 PMCID: PMC7615591 DOI: 10.1016/s2213-8587(23)00321-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Sodium-glucose co-transporter-2 (SGLT2) inhibitors reduce progression of chronic kidney disease and the risk of cardiovascular morbidity and mortality in a wide range of patients. However, their effects on kidney disease progression in some patients with chronic kidney disease are unclear because few clinical kidney outcomes occurred among such patients in the completed trials. In particular, some guidelines stratify their level of recommendation about who should be treated with SGLT2 inhibitors based on diabetes status and albuminuria. We aimed to assess the effects of empagliflozin on progression of chronic kidney disease both overall and among specific types of participants in the EMPA-KIDNEY trial. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA), and included individuals aged 18 years or older with an estimated glomerular filtration rate (eGFR) of 20 to less than 45 mL/min per 1·73 m2, or with an eGFR of 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher. We explored the effects of 10 mg oral empagliflozin once daily versus placebo on the annualised rate of change in estimated glomerular filtration rate (eGFR slope), a tertiary outcome. We studied the acute slope (from randomisation to 2 months) and chronic slope (from 2 months onwards) separately, using shared parameter models to estimate the latter. Analyses were done in all randomly assigned participants by intention to treat. EMPA-KIDNEY is registered at ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and then followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroups of eGFR included 2282 (34·5%) participants with an eGFR of less than 30 mL/min per 1·73 m2, 2928 (44·3%) with an eGFR of 30 to less than 45 mL/min per 1·73 m2, and 1399 (21·2%) with an eGFR 45 mL/min per 1·73 m2 or higher. Prespecified subgroups of uACR included 1328 (20·1%) with a uACR of less than 30 mg/g, 1864 (28·2%) with a uACR of 30 to 300 mg/g, and 3417 (51·7%) with a uACR of more than 300 mg/g. Overall, allocation to empagliflozin caused an acute 2·12 mL/min per 1·73 m2 (95% CI 1·83-2·41) reduction in eGFR, equivalent to a 6% (5-6) dip in the first 2 months. After this, it halved the chronic slope from -2·75 to -1·37 mL/min per 1·73 m2 per year (relative difference 50%, 95% CI 42-58). The absolute and relative benefits of empagliflozin on the magnitude of the chronic slope varied significantly depending on diabetes status and baseline levels of eGFR and uACR. In particular, the absolute difference in chronic slopes was lower in patients with lower baseline uACR, but because this group progressed more slowly than those with higher uACR, this translated to a larger relative difference in chronic slopes in this group (86% [36-136] reduction in the chronic slope among those with baseline uACR <30 mg/g compared with a 29% [19-38] reduction for those with baseline uACR ≥2000 mg/g; ptrend<0·0001). INTERPRETATION Empagliflozin slowed the rate of progression of chronic kidney disease among all types of participant in the EMPA-KIDNEY trial, including those with little albuminuria. Albuminuria alone should not be used to determine whether to treat with an SGLT2 inhibitor. FUNDING Boehringer Ingelheim and Eli Lilly.
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T, Tamori Y, Tamura R, Tamura Y, Tan CHH, Tan EZZ, Tanabe A, Tanabe K, Tanaka A, Tanaka A, Tanaka N, Tang S, Tang Z, Tanigaki K, Tarlac M, Tatsuzawa A, Tay JF, Tay LL, Taylor J, Taylor K, Taylor K, Te A, Tenbusch L, Teng KS, Terakawa A, Terry J, Tham ZD, Tholl S, Thomas G, Thong KM, Tietjen D, Timadjer A, Tindall H, Tipper S, Tobin K, Toda N, Tokuyama A, Tolibas M, Tomita A, Tomita T, Tomlinson J, Tonks L, Topf J, Topping S, Torp A, Torres A, Totaro F, Toth P, Toyonaga Y, Tripodi F, Trivedi K, Tropman E, Tschope D, Tse J, Tsuji K, Tsunekawa S, Tsunoda R, Tucky B, Tufail S, Tuffaha A, Turan E, Turner H, Turner J, Turner M, Tuttle KR, Tye YL, Tyler A, Tyler J, Uchi H, Uchida H, Uchida T, Uchida T, Udagawa T, Ueda S, Ueda Y, Ueki K, Ugni S, Ugwu E, Umeno R, Unekawa C, Uozumi K, Urquia K, Valleteau A, Valletta C, van Erp R, Vanhoy C, Varad V, Varma R, Varughese A, Vasquez P, Vasseur A, Veelken R, Velagapudi C, Verdel K, Vettoretti S, Vezzoli G, Vielhauer V, Viera R, Vilar E, Villaruel S, Vinall L, Vinathan J, Visnjic M, Voigt E, von-Eynatten M, Vourvou M, Wada J, Wada J, Wada T, Wada Y, Wakayama K, Wakita Y, Wallendszus K, Walters T, Wan Mohamad WH, Wang L, Wang W, Wang X, Wang X, Wang Y, Wanner C, Wanninayake S, Watada H, Watanabe K, Watanabe K, Watanabe M, Waterfall H, Watkins D, Watson S, Weaving L, Weber B, Webley Y, Webster A, Webster M, Weetman M, Wei W, Weihprecht H, Weiland L, Weinmann-Menke J, Weinreich T, Wendt R, Weng Y, Whalen M, Whalley G, Wheatley R, Wheeler A, Wheeler J, Whelton P, White K, Whitmore B, Whittaker S, Wiebel J, Wiley J, Wilkinson L, Willett M, Williams A, Williams E, Williams K, Williams T, Wilson A, Wilson P, Wincott L, Wines E, Winkelmann B, Winkler M, Winter-Goodwin B, Witczak J, Wittes J, Wittmann M, Wolf G, Wolf L, Wolfling R, Wong C, Wong E, Wong HS, Wong LW, Wong YH, Wonnacott A, Wood A, Wood L, Woodhouse H, Wooding N, Woodman A, Wren K, Wu J, Wu P, Xia S, Xiao H, Xiao X, Xie Y, Xu C, Xu Y, Xue H, Yahaya H, Yalamanchili H, Yamada A, Yamada N, Yamagata K, Yamaguchi M, Yamaji Y, Yamamoto A, Yamamoto S, Yamamoto S, Yamamoto T, Yamanaka A, Yamano T, Yamanouchi Y, Yamasaki N, Yamasaki Y, Yamasaki Y, Yamashita C, Yamauchi T, Yan Q, Yanagisawa E, Yang F, Yang L, Yano S, Yao S, Yao Y, Yarlagadda S, Yasuda Y, Yiu V, Yokoyama T, Yoshida S, Yoshidome E, Yoshikawa H, Young A, Young T, Yousif V, Yu H, Yu Y, Yuasa K, Yusof N, Zalunardo N, Zander B, Zani R, Zappulo F, Zayed M, Zemann B, Zettergren P, Zhang H, Zhang L, Zhang L, Zhang N, Zhang X, Zhao J, Zhao L, Zhao S, Zhao Z, Zhong H, Zhou N, Zhou S, Zhu D, Zhu L, Zhu S, Zietz M, Zippo M, Zirino F, Zulkipli FH. Impact of primary kidney disease on the effects of empagliflozin in patients with chronic kidney disease: secondary analyses of the EMPA-KIDNEY trial. Lancet Diabetes Endocrinol 2024; 12:51-60. [PMID: 38061372 DOI: 10.1016/s2213-8587(23)00322-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/24/2023] [Accepted: 10/25/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND The EMPA-KIDNEY trial showed that empagliflozin reduced the risk of the primary composite outcome of kidney disease progression or cardiovascular death in patients with chronic kidney disease mainly through slowing progression. We aimed to assess how effects of empagliflozin might differ by primary kidney disease across its broad population. METHODS EMPA-KIDNEY, a randomised, controlled, phase 3 trial, was conducted at 241 centres in eight countries (Canada, China, Germany, Italy, Japan, Malaysia, the UK, and the USA). Patients were eligible if their estimated glomerular filtration rate (eGFR) was 20 to less than 45 mL/min per 1·73 m2, or 45 to less than 90 mL/min per 1·73 m2 with a urinary albumin-to-creatinine ratio (uACR) of 200 mg/g or higher at screening. They were randomly assigned (1:1) to 10 mg oral empagliflozin once daily or matching placebo. Effects on kidney disease progression (defined as a sustained ≥40% eGFR decline from randomisation, end-stage kidney disease, a sustained eGFR below 10 mL/min per 1·73 m2, or death from kidney failure) were assessed using prespecified Cox models, and eGFR slope analyses used shared parameter models. Subgroup comparisons were performed by including relevant interaction terms in models. EMPA-KIDNEY is registered with ClinicalTrials.gov, NCT03594110. FINDINGS Between May 15, 2019, and April 16, 2021, 6609 participants were randomly assigned and followed up for a median of 2·0 years (IQR 1·5-2·4). Prespecified subgroupings by primary kidney disease included 2057 (31·1%) participants with diabetic kidney disease, 1669 (25·3%) with glomerular disease, 1445 (21·9%) with hypertensive or renovascular disease, and 1438 (21·8%) with other or unknown causes. Kidney disease progression occurred in 384 (11·6%) of 3304 patients in the empagliflozin group and 504 (15·2%) of 3305 patients in the placebo group (hazard ratio 0·71 [95% CI 0·62-0·81]), with no evidence that the relative effect size varied significantly by primary kidney disease (pheterogeneity=0·62). The between-group difference in chronic eGFR slopes (ie, from 2 months to final follow-up) was 1·37 mL/min per 1·73 m2 per year (95% CI 1·16-1·59), representing a 50% (42-58) reduction in the rate of chronic eGFR decline. This relative effect of empagliflozin on chronic eGFR slope was similar in analyses by different primary kidney diseases, including in explorations by type of glomerular disease and diabetes (p values for heterogeneity all >0·1). INTERPRETATION In a broad range of patients with chronic kidney disease at risk of progression, including a wide range of non-diabetic causes of chronic kidney disease, empagliflozin reduced risk of kidney disease progression. Relative effect sizes were broadly similar irrespective of the cause of primary kidney disease, suggesting that SGLT2 inhibitors should be part of a standard of care to minimise risk of kidney failure in chronic kidney disease. FUNDING Boehringer Ingelheim, Eli Lilly, and UK Medical Research Council.
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Lim WS, Avery A, Kon OM, Dedicoat M. Anti-tuberculosis drug-induced liver injury. BMJ 2023; 383:e074866. [PMID: 37890885 DOI: 10.1136/bmj-2023-074866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/29/2023]
Affiliation(s)
- Wei Shen Lim
- Respiratory Medicine, Nottingham University Hospitals NHS Trust, NG5 1PB, England UK
| | - Anthony Avery
- Faculty of Medicine & Health Sciences, University of Nottingham, NG7 2RD, England UK
| | - Onn Min Kon
- Chest & Allergy clinic, Imperial College Healthcare NHS Trust, St Mary's Hospital, London W2 1NY, England UK
| | - Martin Dedicoat
- Department of Infection, University Hospitals Birmingham, Birmingham. B9 5SS, England, UK
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Joseph R, Knaggs R, Coupland C, Taylor A, Vinogradova Y, Butler D, Waldram D, Iyen B, Akyea R, Ashcroft D, Avery A, Jack R. Observational study assessing the frequency and impact of medication reviews in UK primary care for people aged ≥65 years. Br J Gen Pract 2023; 73:bjgp23X733545. [PMID: 37479307 DOI: 10.3399/bjgp23x733545] [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: 07/23/2023] Open
Abstract
BACKGROUND Medication reviews are considered an opportunity for reducing polypharmacy. However, there is little evidence about their impact in a real-world setting. AIM To quantify numbers of older adults having a medication review in 2019, identify systematic differences in access to medication reviews, and assess the impact of medication reviews on the numbers of medicines prescribed. METHOD We defined a population of people aged ≥65 years with at least one active prescription on 01/01/2019 using anonymised electronic health records from the Clinical Practice Research Datalink. We used Cox regression to compare characteristics of people who did and did not have a medication review recorded in their health records in 2019. We compared the maximum number of concurrent prescriptions ('polypharmacy count') in the 3 months before and after a recorded medication review. RESULTS Of 591 552 people (median age = 74 years, 54.5% female), 305 503 (51.6%) had a medication review in 2019. Living in a care home (hazard ratio [HR] 1.51, 95% confidence interval [CI] =1.40 to 1.62), a prior medication review in 2018 (HR 1.83, 95% CI = 1.69 to 1.98), and increasing baseline polypharmacy count (5-9 medicines versus 1 medicine HR 1.41, 95% CI = 1.37 to 1.46) were most strongly associated with having a review. Overall, there was a small mean increase in polypharmacy count after a review (+0.13 medicines, 0.12-0.14). For people prescribed ≥10 medicines before the review, polypharmacy count decreased on average (mean -0.14 medicines, -0.15 to -0.12). CONCLUSION Although a majority (>50%) of people had a recorded medication review in 2019, these reviews had a small overall impact on polypharmacy in this study population.
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Cattell M, Hyde K, Bell B, Dawson T, Hills T, Iyen B, Khimji A, Avery A. Retrospective review of medication-related incidents at a major teaching hospital and the potential mitigation of these incidents with electronic prescribing and medicines administration. Eur J Hosp Pharm 2023:ejhpharm-2022-003515. [PMID: 36868849 DOI: 10.1136/ejhpharm-2022-003515] [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: 08/17/2022] [Accepted: 02/06/2023] [Indexed: 03/05/2023] Open
Abstract
OBJECTIVES To describe the frequency of the different types of medication-related incidents that caused patient harm, or adverse consequences, in a major teaching hospital and investigate whether the likelihood of these incidents occurring would have been reduced by electronic prescribing and medicines administration (EPMA). METHODS A retrospective review of harmful incidents (n=387) was completed for medication-related reports at the hospital between 1 September 2020 and 31 August 2021. Frequencies of different types of incidents were collated. The potential for EPMA to have prevented these incidents was assessed by reviewing DATIX reports and additional information, including results of any investigations. RESULTS The largest proportion of harmful medication incidents were administration related (n=215, 55.6%), followed by incidents classified as 'other' and 'prescribing'. Most incidents were classified as low harm (n=321, 83.0%). EPMA could have reduced the likelihood of all incidents which caused harm by 18.6% (n=72) without configuration, and a further 7.5% (n=29) with configuration where configuration refers to adapting the software's functionality without supplier input or development. For 18.4% of the low-harm incidents (n=59) and 20.3% (n=13) of the moderate-harm incidents, EPMA could reduce the likelihood of the incident occurring without configuration. Medication errors most likely to be reduced by EPMA were due to illegibility, multiple drug charts or missing drug charts. CONCLUSION This study found that administration incidents were the most common type of medication-related incidents. Most of the incidents (n=243, 62.8%) could not be mitigated by EPMA in any circumstance, even with connectivity between technologies. EPMA has the potential to prevent certain types of harmful medication-related incidents, and further improvements could be achieved with configuration and development.
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Affiliation(s)
| | - Kira Hyde
- University of Nottingham, Nottingham, UK
| | - Brian Bell
- University of Nottingham, Nottingham, UK
| | - Thomas Dawson
- Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Tim Hills
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Marsh K, Avery A, Sahota O. 1179 4.5 TONNES OF FOOD WASTED ACROSS A HOSPITAL WARD: A SERVICE EVALUATION OF DIETARY INTAKE AND FOOD WASTE. Age Ageing 2023. [DOI: 10.1093/ageing/afac322.024] [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: 01/19/2023] Open
Abstract
Abstract
Introduction
Malnutrition is a debilitating condition in hospitalised older people. There has been limited studies exploring dietary intake and oral nutritional supplement (ONS) compliance in these people. The purpose of this service evaluation was to observe daily energy and protein intake, plate waste and ONS compliance and to report food waste at ward level.
Methods
Three-day dietary (food-only) intake and plate waste of 19 older (≥ 65 years) people on a hospital trauma and orthopaedic (T&O) ward were assessed. Patients were categorised as ‘nutritionally well’ or ‘nutritionally vulnerable’ as per British Dietetics Association’s (BDA) Nutrition and Hydration Digest criteria. Dietary intake was calculated by a Dietitian and compared with adjusted BDA standards to exclude energy and protein from drinks. Ward plate and food trolley waste were weighed after lunch and supper for five days. Thirty-three ONS from 11 patients were collected before disposal and weighed.
Results
Mean age of the patients were 84 ± 9 years (9 female, and 10 male) with the most common injury hip fracture (68.4%). Mean (standard deviation, SD) intake for ‘nutritionally well’ was 1592 (257) kcal/day and 65.7(8.5) g/day protein and ‘nutritionally vulnerable’ (n= 15) 643 (354) kcal/day and 24.8 (14.0) g/day protein. Plate waste for ‘nutritionally well’ was 4.1 (5.8)% at main meals and 1.7 (3.4)% at pudding and for ‘nutritionally vulnerable’ 53.1 (26.6)% at main meals and 38.6 (32.2)% at pudding. Compliance to ONS was 28.3 (38.8)%. The combined mealtime plate waste weighed 6.2 (1.2) kg/day and food-trolley waste 6.2 (0.9) kg/day. This equates to approximately 4526kg/year (4.5T).
Conclusions
Energy and protein intake and compliance to ONS in older T&O patients is sub-optimal. Food waste is high and urgently needs addressing. Further, interventions are warranted to improve dietary intake in hospital and to explore the acceptability of alternative ONS food/drink styles.
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Affiliation(s)
- K Marsh
- Nottingham University School of Biosciences,
- Nottingham University Hospitals NHS Trust Department of Health Care of Older People,
| | - A Avery
- Nottingham University School of Biosciences,
| | - O Sahota
- Nottingham University Hospitals NHS Trust Department of Health Care of Older People,
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Affiliation(s)
- Sam Patel
- NHS Education for Scotland, Glasgow G3 8BW, UK
| | - Ann Slee
- Usher Institute, University of Edinburgh, Edinburgh EH16 4UX, UK
| | - Anthony Avery
- Centre for Academic Primary Care, School of Medicine University of Nottingham, Nottingham NG7 2RD, UK
| | - Aziz Sheikh
- Usher Institute, University of Edinburgh, Edinburgh EH16 4UX, UK
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Hawkey C, Avery A, Coupland CAC, Crooks C, Dumbleton J, Hobbs FDR, Kendrick D, Moore M, Morris C, Rubin G, Smith M, Stevenson D. Helicobacter pylori eradication for primary prevention of peptic ulcer bleeding in older patients prescribed aspirin in primary care (HEAT): a randomised, double-blind, placebo-controlled trial. Lancet 2022; 400:1597-1606. [PMID: 36335970 DOI: 10.1016/s0140-6736(22)01843-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 08/20/2022] [Revised: 09/13/2022] [Accepted: 09/20/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Peptic ulcers in patients receiving aspirin are associated with Helicobacter pylori infection. We aimed to investigate whether H pylori eradication would protect against aspirin-associated ulcer bleeding. METHODS We conducted a randomised, double-blind, placebo-controlled trial (Helicobacter Eradication Aspirin Trial [HEAT]) at 1208 primary care centres in the UK, using routinely collected clinical data. Eligible patients were aged 60 years or older who were receiving aspirin at a daily dose of 325 mg or less (with four or more 28-day prescriptions in the past year) and had a positive C13 urea breath test for H pylori at screening. Patients receiving ulcerogenic or gastroprotective medication were excluded. Participants were randomly assigned (1:1) to receive either a combination of oral clarithromycin 500 mg, metronidazole 400 mg, and lansoprazole 30 mg (active eradication), or oral placebo (control), twice daily for 1 week. Participants, their general practitioners and health-care providers, and the research nurses, trial team, adjudication committee, and analysis team were all masked to group allocation throughout the trial. Follow-up was by scrutiny of electronic data in primary and secondary care. The primary outcome was time to hospitalisation or death due to definite or probable peptic ulcer bleeding, and was analysed by Cox proportional hazards methods in the intention-to-treat population. This trial is registered with EudraCT, 2011-003425-96. FINDINGS Between Sept 14, 2012, and Nov 22, 2017, 30 166 patients had breath testing for H pylori, 5367 had a positive result, and 5352 were randomly assigned to receive active eradication (n=2677) or placebo (n=2675) and were followed up for a median of 5·0 years (IQR 3·9-6·4). Analysis of the primary outcome showed a significant departure from proportional hazards assumptions (p=0·0068), requiring analysis over separate time periods. There was a significant reduction in incidence of the primary outcome in the active eradication group in the first 2·5 years of follow-up compared with the control group (six episodes adjudicated as definite or probable peptic ulcer bleeds, rate 0·92 [95% CI 0·41-2·04] per 1000 person-years vs 17 episodes, rate 2·61 [1·62-4·19] per 1000 person-years; hazard ratio [HR] 0·35 [95% CI 0·14-0·89]; p=0·028). This advantage remained significant after adjusting for the competing risk of death (p=0·028) but was lost with longer follow-up (HR 1·31 [95% CI 0·55-3·11] in the period after the first 2·5 years; p=0·54). Reports of adverse events were actively solicited; taste disturbance was the most common event (787 patients). INTERPRETATION H pylori eradication protects against aspirin-associated peptic ulcer bleeding, but this might not be sustained in the long term. FUNDING National Institute for Health and Care Research Health Technology Assessment.
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Affiliation(s)
- Chris Hawkey
- STAR (Simple Trials for Academic Research) Unit, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Anthony Avery
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Carol A C Coupland
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Colin Crooks
- STAR (Simple Trials for Academic Research) Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - Jennifer Dumbleton
- STAR (Simple Trials for Academic Research) Unit, School of Medicine, University of Nottingham, Nottingham, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Denise Kendrick
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Michael Moore
- Primary Care Research Centre, University of Southampton, Southampton, UK
| | | | - Gregory Rubin
- Population Health Sciences Institute, Newcastle University, Newcastle, UK
| | - Murray Smith
- Community and Health Research Unit, University of Lincoln, Lincoln, UK
| | - Diane Stevenson
- STAR (Simple Trials for Academic Research) Unit, School of Medicine, University of Nottingham, Nottingham, UK
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Laing L, Salema NE, Jeffries M, Shamsuddin A, Sheikh A, Chuter A, Waring J, Avery A, Keers RN. Understanding factors that could influence patient acceptability of the use of the PINCER intervention in primary care: A qualitative exploration using the Theoretical Framework of Acceptability. PLoS One 2022; 17:e0275633. [PMID: 36240174 PMCID: PMC9565699 DOI: 10.1371/journal.pone.0275633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/20/2022] [Indexed: 11/05/2022] Open
Abstract
Introduction Medication errors are an important cause of morbidity and mortality. The pharmacist-led IT-based intervention to reduce clinically important medication errors (PINCER) intervention was shown to reduce medication errors when tested in a cluster randomised controlled trial and when implemented across one region of England. Now that it has been rolled out nationally, and to enhance findings from evaluations with staff and stakeholders, this paper is the first to report patients’ perceived acceptability on the use of PINCER in primary care and proposes suggestions on how delivery of PINCER related care could be delivered in a way that is acceptable and not unnecessarily burdensome. Methods A total of 46 participants living with long-term health conditions who had experience of medication reviews and/or monitoring were recruited through patient participant groups and social media. Semi-structured, qualitative interviews and focus groups were conducted face-to-face or via telephone. A thematic analysis was conducted and findings mapped to the constructs of the Theoretical Framework of Acceptability (TFA). Results Two themes were identified and interpreted within the most relevant TFA construct: Perceptions on the purpose and components of PINCER (Affective Attitude and Intervention Coherence) and Perceived patient implications (Burden and Self-efficacy). Overall perceptions on PINCER were positive with participants showing good understanding of the components. Access to medication reviews, which PINCER related care can involve, was reported to be limited and a lack of consistency in practitioners delivering reviews was considered challenging, as was lack of communication between primary care and other health-care providers. Patients thought it would be helpful if medication reviews and prescription renewal times were synchronised. Remote medication review consultations were more convenient for some but viewed as a barrier to communication by others. It was acknowledged that some patients may be more resistant to change and more willing to accept changes initiated by general practitioners. Conclusions Participants found the concept of PINCER acceptable; however, acceptability could be improved if awareness on the role of primary care pharmacists is raised and patient-pharmacist relationships enhanced. Being transparent with communication and delivering streamlined and consistent but flexible PINCER related care is recommended.
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Affiliation(s)
- Libby Laing
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
- * E-mail:
| | - Nde-eshimuni Salema
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Mark Jeffries
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, United Kingdom
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, Manchester Academic Health Sciences Centre (MAHSC), University of Manchester, Manchester, United Kingdom
| | - Azwa Shamsuddin
- Faculty of Health Sciences, University of Hull, Hull, United Kingdom
| | - Aziz Sheikh
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, United Kingdom
| | | | - Justin Waring
- School of Social Policy, Health Services Management Centre, University of Birmingham, Birmingham, United Kingdom
| | - Anthony Avery
- Lifespan and Population Health, School of Medicine, University of Nottingham, Nottingham, United Kingdom
| | - Richard N. Keers
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, United Kingdom
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Savic L, Ardern-Jones M, Avery A, Cook T, Denman S, Farooque S, Garcez T, Gold R, Jay N, Krishna MT, Leech S, McKibben S, Nasser S, Premchand N, Sandoe J, Sneddon J, Warner A. BSACI guideline for the set-up of penicillin allergy de-labelling services by non-allergists working in a hospital setting. Clin Exp Allergy 2022; 52:1135-1141. [PMID: 36128691 DOI: 10.1111/cea.14217] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [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: 05/04/2022] [Revised: 06/13/2022] [Accepted: 06/30/2022] [Indexed: 01/26/2023]
Abstract
The Standards of Care Committee of the British Society for Allergy and Clinical Immunology (BSACI) and a committee of experts and key stakeholders have developed this guideline for the evaluation and testing of patients with an unsubstantiated label of penicillin allergy. The guideline is intended for UK clinicians who are not trained in allergy or immunology, but who wish to develop a penicillin allergy de-labelling service for their patients. It is intended to supplement the BSACI 2015 guideline "Management of allergy to penicillin and other beta-lactams" and therefore does not detail the epidemiology or aetiology of penicillin allergy, as this is covered extensively in the 2015 guideline (1). The guideline is intended for use only in patients with a label of penicillin allergy and does not apply to other beta-lactam allergies. The recommendations include a checklist to identify patients at low risk of allergy and a framework for the conduct of drug provocation testing by non-allergists. There are separate sections for adults and paediatrics within the guideline, in recognition of the common differences in reported allergy history and likelihood of true allergy.
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Affiliation(s)
- Louise Savic
- Department of Anaesthesia, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Michael Ardern-Jones
- Faculty of Medicine, University of Southampton, Southamptom, UK.,Department of Dermatology, University Hospitals Southampton NHS Foundation Trust, Southamptom, UK
| | - Anthony Avery
- Centre for Academic Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Tim Cook
- Department of Anaesthesia and Intensive Care, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Sarah Denman
- Medicines Management and Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Sophie Farooque
- Department of Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Tomaz Garcez
- Dept of Immunology, Manchester University NHS Foundation Trust, Manchester, UK
| | | | - Nicola Jay
- Department of Paediatric Allergy, Sheffield Childrens NHS Foundation Trust, Sheffield, UK
| | - Mamidipudi Thirumala Krishna
- Department of Allergy and Immunology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK.,Institute of Immunology and Immunotherapy, University of Birmingham, Birmingham, UK
| | - Sue Leech
- Department of Paedaitric Allergy, Kings College Hospital NHS Foundation Trust, London, UK
| | - Shauna McKibben
- Department of Asthma and Allergy, Imperial College Healthcare NHS Trust, London, UK
| | - Shuaib Nasser
- Department of Allergy, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Nikhil Premchand
- Department of Clinical Infection, Northumbria Healthcare NHS Foundation Trust, Newcastle, UK
| | - Jonathan Sandoe
- Leeds Institute of Medical Research, University of Leeds, Leeds, UK.,Department of Microbiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jacqueline Sneddon
- British Society for Antimicrobial Chemotherapy, Birmingham, UK.,Health Improvement Scotland, Glasgow, UK
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Rej A, Avery A, Aziz I, Black CJ, Bowyer RK, Buckle RL, Seamark L, Shaw CC, Thompson J, Trott N, Williams M, Sanders DS. Diet and irritable bowel syndrome: an update from a UK consensus meeting. BMC Med 2022; 20:287. [PMID: 36096789 PMCID: PMC9469508 DOI: 10.1186/s12916-022-02496-w] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 07/25/2022] [Indexed: 11/17/2022] Open
Abstract
There has been a renewed interest in the role of dietary therapies to manage irritable bowel syndrome (IBS), with diet high on the agenda for patients. Currently, interest has focussed on the use of traditional dietary advice (TDA), a gluten-free diet (GFD) and the low FODMAP diet (LFD). A consensus meeting was held to assess the role of these dietary therapies in IBS, in Sheffield, United Kingdom.Evidence for TDA is from case control studies and clinical experience. Randomised controlled trials (RCT) have demonstrated the benefit of soluble fibre in IBS. No studies have assessed TDA in comparison to a habitual or sham diet. There have been a number of RCTs demonstrating the efficacy of a GFD at short-term follow-up, with a lack of long-term outcomes. Whilst gluten may lead to symptom generation in IBS, other components of wheat may also play an important role, with recent interest in the role of fructans, wheat germ agglutinins, as well as alpha amylase trypsin inhibitors. There is good evidence for the use of a LFD at short-term follow-up, with emerging evidence demonstrating its efficacy at long-term follow-up. There is overlap between the LFD and GFD with IBS patients self-initiating gluten or wheat reduction as part of their LFD. Currently, there is a lack of evidence to suggest superiority of one diet over another, although TDA is more acceptable to patients.In view of this evidence, our consensus group recommends that dietary therapies for IBS should be offered by dietitians who first assess dietary triggers and then tailor the intervention according to patient choice. Given the lack of dietetic services, novel approaches such as employing group clinics and online webinars may maximise capacity and accessibility for patients. Further research is also required to assess the comparative efficacy of dietary therapies to other management strategies available to manage IBS.
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Affiliation(s)
- A Rej
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK.
| | - A Avery
- Division of Nutritional Sciences, School of Biosciences, University of Nottingham, Nottingham, UK
| | - I Aziz
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - C J Black
- Leeds Gastroenterology Institute, St James's University Hospital, Leeds, UK; Leeds Institute of Medical Research at St James's, University of Leeds, Leeds, UK
| | - R K Bowyer
- Department of Nutrition and Dietetics, Royal United Hospitals NHS Foundation Trust, Bath, UK
| | - R L Buckle
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - L Seamark
- Specialist Gastroenterology Community Dietetic Service, Somerset Partnership NHS Foundation Trust, Bridgwater, UK
| | - C C Shaw
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - J Thompson
- Information Manager/Specialist Gastroenterology Dietitian, Guts UK Charity, 3 St Andrews Place, London, NW1 4LB, UK
| | - N Trott
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
| | - M Williams
- Specialist Gastroenterology Community Dietetic Service, Somerset Partnership NHS Foundation Trust, Bridgwater, UK
| | - D S Sanders
- Academic Unit of Gastroenterology, Royal Hallamshire Hospital, Sheffield Teaching Hospital NHS Foundation Trust, Sheffield, UK
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Uflacker A, Keefe N, Bruner E, Avery A, Salzar R, Henderson K, Spratley M, Nacey N, Miller W, Chahin J, Grewal S, Safavian D, Haskal Z. Abstract No. 348 ▪ FEATURED ABSTRACT Assessing effects of geniculate artery embolization in a non-surgical animal model of osteoarthritis. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
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Cipolletta E, Nakafero G, Mamas M, Avery A, Tata L, Abhishek A. POS1172 RISK OF VENOUS THROMBOEMBOLISM AFTER GOUT FLARES. Ann Rheum Dis 2022. [DOI: 10.1136/annrheumdis-2022-eular.4633] [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: 11/03/2022]
Abstract
BackgroundSeveral population-based cohort studies have reported an increased risk of venous thromboembolism (VTE) in gout patients. However, none of these studies has investigated the temporal relationship between gout flares and VTE.ObjectivesTo explore whether gout flares increase the risk of VTE in the short-term using the self-controlled case series (SCCS) method.MethodsWe identified participants with incident gout from the Clinical Practice Research Datalink (CPRD). Participants having less than one year of registration in CPRD and patients with a history of VTE or anticoagulant prescription more than one year before the first gout consultation were excluded.Participants with at least one gout flare and a diagnosis of VTE were selected. VTEs and gout flares were ascertained using primary care data, hospitalisation and mortality records, using previously validated algorithms (positive predictive value of 94% for VTE [1] and 68-95% for gout flares [2,3]).SCCS method involves fitting a Poisson model conditioned on the number of VTEs, and it calculates the adjusted incidence risk ratio (aIRR) and its 95% confidence interval (95%CI) for each stratum of the “at-risk” period as compared with the “baseline” period (Figure 1). The analysis was adjusted for age and calendar season.Figure 1.Schematic description of the observation period (“at-risk” and baseline periods).The “at-risk” period (in red) was defined as the period following the exposure (the gout flare), and it was subdivided as follows: days 0-30, 31-60 and 61-120 after each gout flare. The baseline period (in green) consisted of a pre-exposure and a post-exposure period of 365 days each.The length of each period varied according to the occurrence of the next flare and its timing. Panel A and panel B provide a schematic representation of patients with a single observation period and with multiple “non-overlapping” observation periods, respectively. In such cases, the length of the “at risk” period was 120 days, while the length of the pre-exposure and post-exposure period was 365 days each.ResultsAmong the 104,962 patients with an incident diagnosis of gout in CPRD between 1997 and 2020, we identified 2,678 VTE (4.0 events/1,000 person-years).There were 53 VTE (13.3 events/month) during the “at-risk” period and 143 (6.0 events/month) during the “baseline” period (crude incidence rate ratio, 1.75; 95%CI: 1.27-2.42). The rates were highest in the first month after gout flares and then fell progressively (Table 1). Sensitivity analyses were consistent with the main analysis (Table 1).Table 1.Gout flareNumber of events per monthaIRR (95%CI)ptrendMain analysis0-30 days17.02.11 (1.27-3.50)0.0131-60 days14.01.86 (1.07-3.24)61-90 days11.01.50 (0.95-2.37)Baseline period6.0ReferenceSensitivity analysis (excluding participants with risk factors for VTE) [4]0-30 days14.03.13 (1.77-5.53)0.0131-60 days7.01.66 (0.76-3.61)61-90 days8.01.75 (0.94-3.37)Baseline period3.4ReferenceConclusionA transitory increase in the risk of VTE was observed after gout flares.References[1]Huerta C, et al. Risk factors and short-term mortality of venous thromboembolism diagnosed in the primary care setting in the United Kingdom. Arch Intern Med. 2007;167:935-43.[2]Zheng C, et al. Using natural language processing and machine learning to identify gout flares from electronic clinical notes. Arthritis Care Res (Hoboken). 2014;66:1740-8.[3]MacFarlane LA, Liu et al. Validation of claims-based algorithms for gout flares. Pharmacoepidemiol Drug Saf. 2016;25:820-6.[4]Konstantinides SV, et al. 2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS). Eur Heart J. 2020;41:543-603.Disclosure of InterestsNone declared
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Latif A, Faull C, Waring J, Wilson E, Anderson C, Avery A, Pollock K. Managing medicines at the end of life: a position paper for health policy and practice. J Health Organ Manag 2021; 35:368-377. [PMID: 34841822 PMCID: PMC9136861 DOI: 10.1108/jhom-11-2020-0440] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Purpose The impact of population ageing is significant, multifaceted and characterised by frailty and multi-morbidity. The COVID-19 pandemic has accelerated care pathways and policies promoting self-management and home-based care. One under-researched area is how patients and family caregivers manage the complexity of end-of-life therapeutic medicine regimens. In this position paper the authors bring attention to the significant strain that patients and family caregivers experience when navigating and negotiating this aspect of palliative and end-of-life care. Design/methodology/approach Focussing on self-care and organisation of medicines in the United Kingdom (UK) context, the paper examines, builds on and extends the debate by considering the underlying policy assumptions and unintended consequences for individual patients and family care givers as they assume greater palliative and end-of-life roles and responsibilities. Findings Policy makers and healthcare professionals often lack awareness of the significant burden and emotional work associated with managing and administering often potent high-risk medicines (i.e. opioids) in the domiciliary setting. The recent “revolution” in professional roles associated with the COVID-19 pandemic, including remote consultations and expanding community-based care, means there are opportunities for commissioners to consider offering greater support. The prospect of enhancing the community pharmacist's medicine optimisation role to further support the wider multi-disciplinary team is considered. Originality/value The paper takes a person-focused perspective and adopts a holistic view of medicine management. The authors argue for urgent review, reform and investment to enable and support terminally ill patients and family caregivers to more effectively manage medicines in the domiciliary setting. There are clear implications for pharmacists and these are discussed in the context of public awareness, inter-professional collaboration, organisational drivers, funding and regulation and remote care delivery.
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Affiliation(s)
- Asam Latif
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | | | - Justin Waring
- Health Services Management Centre, University of Birmingham, Birmingham, UK
| | - Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Claire Anderson
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Anthony Avery
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
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Khawagi WY, Steinke D, Carr MJ, Wright AK, Ashcroft DM, Avery A, Keers RN. Evaluating the safety of mental health-related prescribing in UK primary care: a cross-sectional study using the Clinical Practice Research Datalink (CPRD). BMJ Qual Saf 2021; 31:364-378. [PMID: 34433681 PMCID: PMC9046740 DOI: 10.1136/bmjqs-2021-013427] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Accepted: 08/07/2021] [Indexed: 01/28/2023]
Abstract
Background Most patients with mental illness are managed in primary care, yet there is a lack of data exploring potential prescribing safety issues in this setting for this population. Objectives Examine the prevalence of, between-practice variation in, and patient and practice-level risk factors for, 18 mental health-related potentially hazardous prescribing indicators and four inadequate medication monitoring indicators in UK primary care. Method Cross-sectional analyses of routinely collected electronic health records from 361 practices contributing to Clinical Practice Research Datalink GOLD database. The proportion of patients ‘at risk’ (based on an existing diagnosis, medication, age and/or sex) triggering each indicator and composite indicator was calculated. To examine between-practice variation, intraclass correlation coefficient (ICC) and median OR (MOR) were estimated using two-level logistic regression models. The relationship between patient and practice characteristics and risk of triggering composites including 16 of the 18 prescribing indicators and four monitoring indicators were assessed using multilevel logistic regression. Results 9.4% of patients ‘at risk’ (151 469 of 1 611 129) triggered at least one potentially hazardous prescribing indicator; between practices this ranged from 3.2% to 24.1% (ICC 0.03, MOR 1.22). For inadequate monitoring, 90.2% of patients ‘at risk’ (38 671 of 42 879) triggered at least one indicator; between practices this ranged from 33.3% to 100% (ICC 0.26, MOR 2.86). Patients aged 35–44, females and those receiving more than 10 repeat prescriptions were at greatest risk of triggering a prescribing indicator. Patients aged less than 25, females and those with one or no repeat prescription were at greatest risk of triggering a monitoring indicator. Conclusion Potentially hazardous prescribing and inadequate medication monitoring commonly affect patients with mental illness in primary care, with marked between-practice variation for some indicators. These findings support health providers to identify improvement targets and inform development of improvement efforts to reduce medication-related harm.
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Affiliation(s)
- Wael Y Khawagi
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Department of Clinical Pharmacy, College of Pharmacy, Taif University, Taif, Saudi Arabia
| | - Douglas Steinke
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Matthew J Carr
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Alison K Wright
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Manchester Academic Health Science Centre, Manchester, UK
| | - Darren M Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Anthony Avery
- NIHR Greater Manchester Patient Safety Translational Research Centre, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Division of Primary Care, School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Richard Neil Keers
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
- Pharmacy Department, Greater Manchester Mental Health NHS Foundation Trust, Manchester, UK
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Pollock K, Wilson E, Caswell G, Latif A, Caswell A, Avery A, Anderson C, Crosby V, Faull C. Family and health-care professionals managing medicines for patients with serious and terminal illness at home: a qualitative study. Health Serv Deliv Res 2021. [DOI: 10.3310/hsdr09140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Background
More effective ways of managing symptoms of chronic and terminal illness enable patients to be cared for, and to die, at home. This requires patients and family caregivers to manage complex medicines regimens, including powerful painkillers that can have serious side effects. Little is known about how patients and family caregivers manage the physical and emotional work of managing medicines in the home or the support that they receive from health-care professionals and services.
Objective
To investigate how patients with serious and terminal illness, their family caregivers and the health-care professionals manage complex medication regimens and routines of care in the domestic setting.
Design
A qualitative study involving (1) semistructured interviews and group discussions with 40 health-care professionals and 21 bereaved family caregivers, (2) 20 patient case studies with up to 4 months’ follow-up and (3) two end-of-project stakeholder workshops.
Setting
This took place in Nottinghamshire and Leicestershire, UK.
Results
As patients’ health deteriorated, family caregivers assumed the role of a care co-ordinator, undertaking the everyday work of organising and collecting prescriptions and storing and administering medicines around other care tasks and daily routines. Participants described the difficulties of navigating a complex and fragmented system and the need to remain vigilant about medicines prescribed, especially when changes were made by different professionals. Access to support, resilience and coping capacity are mediated through the resources available to patients, through the relationships that they have with people in their personal and professional networks, and, beyond that, through the wider connections – or disconnections – that these links have with others. Health-care professionals often lacked understanding of the practical and emotional challenges involved. All participants experienced difficulties in communication and organisation within a health-care system that they felt was complicated and poorly co-ordinated. Having a key health professional to support and guide patients and family caregivers through the system was important to a good experience of care.
Limitations
The study achieved diversity in the recruitment of patients, with different characteristics relating to the type of illness and socioeconomic circumstances. However, recruitment of participants from ethnically diverse and disadvantaged or hard-to-reach populations was particularly challenging, and we were unable to include as many participants from these groups as had been originally planned.
Conclusions
The study identified two key and inter-related areas in which patient and family caregiver experience of managing medicines at home in end-of-life care could be improved: (1) reducing work and responsibility for medicines management and (2) improving co-ordination and communication in health care. It is important to be mindful of the need for transparency and open discussion about the extent to which patients and family caregivers can and should be co-opted as proto-professionals in the technically and emotionally demanding tasks of managing medicines at the end of life.
Future work
Priorities for future research include investigating how allocated key professionals could integrate and co-ordinate care and optimise medicines management; the role of domiciliary home care workers in supporting medicines management in end-of-life care; patient and family perspectives and understanding of anticipatory prescribing and their preferences for involvement in decision-making; the experience of medicines management in terminal illness among minority, disadvantaged and hard-to-reach patient groups; and barriers to and facilitators of increased involvement of community pharmacists in palliative and end-of-life care.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 14. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Kristian Pollock
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Eleanor Wilson
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Glenys Caswell
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Asam Latif
- School of Health Sciences, University of Nottingham, Nottingham, UK
| | - Alan Caswell
- Patient and Public Involvement Representative, Dementia, Frail Older and Palliative Care Patient and Public Involvement Advisory Group, University of Nottingham, Nottingham, UK
| | - Anthony Avery
- School of Medicine, Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Claire Anderson
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Vincent Crosby
- Nottingham University Hospitals NHS Trust, Nottingham, UK
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Litchfield I, Marsden K, Doos L, Perryman K, Avery A, Greenfield S. A comparative assessment of two tools designed to support patient safety culture in UK general practice. BMC Fam Pract 2021; 22:98. [PMID: 34020597 PMCID: PMC8138091 DOI: 10.1186/s12875-021-01438-4] [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] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/23/2020] [Accepted: 04/08/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND The NHS has recognised the importance of a high quality patient safety culture in the delivery of primary health care in the rapidly evolving environment of general practice. Two tools, PC-SafeQuest and MapSaf, were developed with the intention of assessing and improving patient safety culture in this setting. Both have been made widely available through their inclusion in the Royal College of General Practitioners' Patient Safety Toolkit and our work offerss a timely exploration of the tools to inform practice staff as to how each might be usefully applied and in which circumstances. Here we present a comparative analysis of their content, and describe the perspectives of staff on their design, outputs and the feasibility of their sustained use. METHODS We have used a content analysis to provide the context for the qualitative study of staff experiences of using the tools at a representative range of practices recruited from across the Midlands (UK). Data was collected through moderated focus groups using an identical topic guide. RESULTS A total of nine practices used the PC-SafeQuest tool and four the MapSaf tool. A total of 159 staff completed the PC-SafeQuest tool 52 of whom took part in the subsequent focus group discussions, and 25 staff completed the MapSaf tool all of whom contributed to the focus group discussions. PC-SafeQuest was perceived as quick and easy to use with direct questions pertinent to the work of GP practices providing useful quantitative insight into important areas of safety culture. Though MaPSaF was more logistically challenging, it created a forum for synchronous cross- practice discussions raising awareness of perceptions of safety culture across the practice team. CONCLUSIONS Both tools were able to promote reflective and reflexive practice either in individual staff members or across the broader practice team and the oversight they granted provided useful direction for senior staff looking to improve patient safety. Because PC SafeQuest can be easily disseminated and independently completed it is logistically suited to larger practice organisations, whereas the MapSaf tool lends itself to smaller practices where assembling staff in a single workshop is more readily achieved.
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Affiliation(s)
- Ian Litchfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
| | - Kate Marsden
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Lucy Doos
- Institute of Cancer and Genomic Sciences, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Katherine Perryman
- Alliance Manchester Business School, University of Manchester, Manchester, UK
| | - Anthony Avery
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sheila Greenfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Bell B, Avery A, Bishara D, Coupland C, Ashcroft D, Orrell M. Anticholinergic drugs and risk of dementia: Time for action? Pharmacol Res Perspect 2021; 9:e00793. [PMID: 34087056 PMCID: PMC8177062 DOI: 10.1002/prp2.793] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 04/21/2021] [Indexed: 11/06/2022] Open
Abstract
Evidence suggests that the prescription of bladder anticholinergics is increasing. Recent studies have accentuated concerns about whether certain prescribed medications could increase risk of dementia, including anticholinergic drugs, and specifically anticholinergics used for bladder symptoms. Nevertheless, it can be difficult to draw together the evidence to review the case for possible causation. Recognising this issue in 1965, Bradford-Hill set out nine criteria to help assess whether evidence of a causal relationship could be inferred between a presumed cause and an observed effect. In this commentary, we explore the extent to which associations between anticholinergics and dementia satisfy the Bradford-Hill criteria and examine the potential implications. First, we look at studies that have examined the relationship between anticholinergic drugs with urological properties (bladder drugs) and the onset of dementia, and then present those studies which specifically focus on the cognitive effects of bladder drugs that affect muscarinic receptors in the brain versus the bladder on older people along with suggestions for future research. We also discuss the risks and benefits of these drugs for treating overactive bladder. If it can be shown that certain medications carry a specific risk of dementia, it is possible that initiatives to change prescribing could become a key tool in reducing the risk of dementia and may be easier to implement than some lifestyle changes.
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Affiliation(s)
- Brian Bell
- Department of Primary CareUniversity of NottinghamNottinghamUK
| | - Anthony Avery
- Department of Primary CareUniversity of NottinghamNottinghamUK
| | - Delia Bishara
- NIHR Maudsley Biomedical Research CentreSouth London and Maudsley NHS TrustLondonUK
| | - Carol Coupland
- Department of Primary CareUniversity of NottinghamNottinghamUK
| | - Darren Ashcroft
- School of Pharmacy and Pharmaceutical SciencesUniversity of ManchesterManchesterUK
| | - Martin Orrell
- Institute of Mental HealthUniversity of NottinghamNottinghamUK
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Litchfield I, Perryman K, Avery A, Campbell S, Gill P, Greenfield S. From policy to patient: Using a socio-ecological framework to explore the factors influencing safe practice in UK primary care. Soc Sci Med 2021; 277:113906. [PMID: 33878667 DOI: 10.1016/j.socscimed.2021.113906] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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] [Revised: 12/18/2020] [Accepted: 04/01/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND The recent and rapid changes in the model of primary care delivery have led to an increased focus on patient safety in what is one of the most diverse and complex healthcare settings. However, previous initiatives have failed to deliver the expected improvements, leading to calls for a better understanding of how a range of personal and contextual factors influence the decisions and behaviours of individual care providers. METHODS The socio-ecological framework, successfully used in public health settings to interpret the complex influences on individual behaviours, enabled a post-hoc deductive analysis of a series of semi-structured interviews conducted with clinical staff and senior managers at a range of practices across five geographically diverse regions in England to explore their perspectives on the factors that influence safe practice. RESULTS The five levels of the socio-ecological framework successfully helped unpick the myriad influences on safe primary care practice, including, at the Individual level, assumptions of responsibility and previous experience; at the Interpersonal, equitable communication in support of a team ethos; at the Organisational, the physical infrastructure, size and complexity of the practice; at the Community, the health profile and literacy of patients; and at the Policy, meeting the demands of competing local and national governing bodies. CONCLUSIONS Coherent, realistic and achievable goals are needed for improving patient safety in primary care addressing personal, organisational and environmental factors. Such goals and the tools and interventions designed to meet them must therefore be sympathetic to the demands on resources and the characteristics of patients, staff, and their organisations. Using the framework to interpret our findings provided much needed insight into the impact of these varying influences, and highlights the importance of recognising and communicating the relationship between specific contextual factors and the ability of individual providers to provide safe primary care.
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Affiliation(s)
- Ian Litchfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
| | | | - Anthony Avery
- School of Medicine, Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Stephen Campbell
- Institute of Population Health - Centre for Primary Care, University of Manchester, Manchester, UK; Centre for Research and Action in Public Health (CeRAPH), Building 22, Floor B, University of Canberra, University Drive, Bruce, ACT, 2617, Australia
| | - Paramjit Gill
- Division of Health Sciences, Warwick Medical School, University of Warwick, UK
| | - Sheila Greenfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
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Salema NE, Clement N, Hysenagolli R, Hibberd R, Bell BG, Gookey G, Avery A, Knox R. The evaluation of an e-learning prescribing course for general practice. Educ Prim Care 2021; 32:219-225. [PMID: 33794750 DOI: 10.1080/14739879.2021.1874250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Prescribed medication may lead to significant morbidity or mortality as a result of these medications causing adverse events, or because of a prescribing error. E-learning is a common tool used in supporting training in prescribing. This paper describes the development of an e-learning course and the subsequent evaluation undertaken by the users with the aim of obtaining an effective e-learning course for prescribing. The e-learning course was developed by general practitioners and pharmacists and focussed on the principles of good prescribing, examined the common reasons for prescribing errors, and was evaluated using self-reported quantitative and qualitative measures. Scores significantly increased on an assessment given before and after the course. The majority of respondents reported that the e-learning course had a positive impact on prescribing knowledge, skills and attitudes, with medication reviews the top area where a change in prescribing practice was reported. Over 90% of the respondents agreed that the e-learning course was easy to use and a useful part of their continuing professional education. This study shows that clinicians recognise the on-going need for training in prescribing, but the lack of training is one of the factors contributing to errors, which suggests that more education is needed, not just for GPs in training, but for qualified GPs as well.
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Affiliation(s)
- Nde-Eshimuni Salema
- School of Medicine, Division of Primary Care, University Of Nottingham, Nottingham, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Naomi Clement
- School of Medicine, Division of Primary Care, University Of Nottingham, Nottingham, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Rexhep Hysenagolli
- School of Medicine, Division of Primary Care, University Of Nottingham, Nottingham, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Rachel Hibberd
- School of Medicine, Division of Primary Care, University Of Nottingham, Nottingham, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Brian G Bell
- School of Medicine, Division of Primary Care, University Of Nottingham, Nottingham, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Gill Gookey
- NHS Rushcliffe CCG, Nottingham, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Anthony Avery
- School of Medicine, Division of Primary Care, University Of Nottingham, Nottingham, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
| | - Richard Knox
- School of Medicine, Division of Primary Care, University Of Nottingham, Nottingham, UK.,NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester Academic Health Science Centre, Manchester, UK
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21
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Vedhara K, Royal S, Sunger K, Caldwell DM, Halliday V, Taylor CM, Fairclough L, Avery A, Welton NJ. Effects of non-pharmacological interventions as vaccine adjuvants in humans: a systematic review and network meta-analysis. Health Psychol Rev 2020; 15:245-271. [PMID: 33222621 DOI: 10.1080/17437199.2020.1854050] [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] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
INTRODUCTION Psychological and behavioural may enhance vaccine effectiveness. We conducted a systematic review and network meta-analysis (NMA) to examine the effects of non-pharmacological adjuvants on vaccine effectiveness, as measured by antibody responses to vaccination. AREAS COVERED Electronic databases (EMBASE, Medline, PsychINFO, CINAHL) were searched from inception to 6th February 2018. This yielded 100 eligible papers, reporting 106 trials: 79 interventions associated with diet and/or nutrition; 12 physical activity interventions and 9 psychological interventions.Over half (58/106) of trials reported evidence of an enhanced antibody response to vaccination across one or more outcomes. The NMA considered the comparative effects between all intervention types, control and placebo for antibody titres (48 studies), seroconversion (25 studies) and seroprotection (23 studies) separately. The NMA provided weak evidence in support of nutritional formulae and probiotics in increasing antibody titres. EXPERT OPINION This review offers a comprehensive summary of the literature on non-pharmacological interventions as vaccine adjuvants. The evidence is characterised by considerable heterogeneity but provides early evidence in support of nutritional formulae and probiotic interventions. Psychological and exercise-based interventions were characterised by limited and unreliable evidence. Large, well-designed studies including consistent core outcomes and measures of intervention adherence and fidelity are required.
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Affiliation(s)
- Kavita Vedhara
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Simon Royal
- University of Nottingham Health Service, Cripps Health Centre, Nottingham, UK
| | - Kanchan Sunger
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Deborah M Caldwell
- School of Social & Community Medicine, University of Bristol, Bristol, UK.,NIHR Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
| | - Vanessa Halliday
- School of Health & Related Research, University of Sheffield, Sheffield, UK
| | - Caroline M Taylor
- Centre for Academic Child Health, Bristol Medical School, University of Bristol, Bristol, UK
| | - Lucy Fairclough
- School of Life Sciences, University of Nottingham, Nottingham, UK
| | - Anthony Avery
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Nicky J Welton
- School of Social & Community Medicine, University of Bristol, Bristol, UK.,NIHR Health Protection Research Unit in Behavioural Science and Evaluation, University of Bristol, Bristol, UK
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22
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Hodkinson A, Tyler N, Ashcroft DM, Keers RN, Khan K, Phipps D, Abuzour A, Bower P, Avery A, Campbell S, Panagioti M. Preventable medication harm across health care settings: a systematic review and meta-analysis. BMC Med 2020; 18:313. [PMID: 33153451 PMCID: PMC7646069 DOI: 10.1186/s12916-020-01774-9] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 09/01/2020] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Mitigating or reducing the risk of medication harm is a global policy priority. But evidence reflecting preventable medication harm in medical care and the factors that derive this harm remain unknown. Therefore, we aimed to quantify the prevalence, severity and type of preventable medication harm across medical care settings. METHODS We performed a systematic review and meta-analysis of observational studies to compare the prevalence of preventable medication harm. Searches were carried out in Medline, Cochrane library, CINAHL, Embase and PsycINFO from 2000 to 27 January 2020. Data extraction and critical appraisal was undertaken by two independent reviewers. Random-effects meta-analysis was employed followed by univariable and multivariable meta-regression. Heterogeneity was quantified using the I2 statistic, and publication bias was evaluated. PROSPERO CRD42020164156. RESULTS Of the 7780 articles, 81 studies involving 285,687 patients were included. The pooled prevalence for preventable medication harm was 3% (95% confidence interval (CI) 2 to 4%, I2 = 99%) and for overall medication harm was 9% (95% CI 7 to 11%, I2 = 99.5%) of all patient incidence records. The highest rates of preventable medication harm were seen in elderly patient care settings (11%, 95% 7 to 15%, n = 7), intensive care (7%, 4 to 12%, n = 6), highly specialised or surgical care (6%, 3 to 11%, n = 13) and emergency medicine (5%, 2 to 12%, n = 12). The proportion of mild preventable medication harm was 39% (28 to 51%, n = 20, I2 = 96.4%), moderate preventable harm 40% (31 to 49%, n = 22, I2 = 93.6%) and clinically severe or life-threatening preventable harm 26% (15 to 37%, n = 28, I2 = 97%). The source of the highest prevalence rates of preventable harm were at the prescribing (58%, 42 to 73%, n = 9, I2 = 94%) and monitoring (47%, 21 to 73%, n = 8, I2 = 99%) stages of medication use. Preventable harm was greatest in medicines affecting the 'central nervous system' and 'cardiovascular system'. CONCLUSIONS This is the largest meta-analysis to assess preventable medication harm. We conclude that around one in 30 patients are exposed to preventable medication harm in medical care, and more than a quarter of this harm is considered severe or life-threatening. Our results support the World Health Organisation's push for the detection and mitigation of medication-related harm as being a top priority, whilst highlighting other key potential targets for remedial intervention that should be a priority focus for future research.
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Affiliation(s)
- Alexander Hodkinson
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Williamson Building, Oxford Road, Manchester, M13 9PL, UK.
| | - Natasha Tyler
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Williamson Building, Oxford Road, Manchester, M13 9PL, UK.,National Institute for HealthResearch Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Darren M Ashcroft
- National Institute for HealthResearch Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK.,Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
| | - Richard N Keers
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK.,Pharmacy Department, Greater Manchester Mental Health NHS Foundation Trust, University of Manchester, Manchester, M25 3BL, UK
| | - Kanza Khan
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Williamson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Denham Phipps
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
| | - Aseel Abuzour
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, University of Manchester, Manchester, UK
| | - Peter Bower
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Williamson Building, Oxford Road, Manchester, M13 9PL, UK
| | - Anthony Avery
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, NG7 2RD, UK
| | - Stephen Campbell
- National Institute for HealthResearch Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
| | - Maria Panagioti
- National Institute for Health Research School for Primary Care Research, Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Williamson Building, Oxford Road, Manchester, M13 9PL, UK.,National Institute for HealthResearch Greater Manchester Patient Safety Translational Research Centre, School of Health Sciences, University of Manchester, Manchester, M13 9PL, UK
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23
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Litchfield I, Spencer R, Bell BG, Avery A, Perryman K, Marsden K, Greenfield S, Campbell S. Development of the prototype concise safe systems checklist tool for general practice. BMC Health Serv Res 2020; 20:544. [PMID: 32546167 PMCID: PMC7296969 DOI: 10.1186/s12913-020-05396-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 06/03/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND In the course of producing a patient safety toolkit for primary care, we identified the need for a concise safe-systems checklist designed to address areas of patient safety which are under-represented in mandatory requirements and existing tools. This paper describes the development of a prototype checklist designed to be used in busy general practice environments to provide an overview of key patient safety related processes and prompt practice wide-discussion. METHODS An extensive narrative review and a survey of world-wide general practice organisations were used to identify existing primary care patient safety issues and tools. A RAND panel of international experts rated the results, summarising the findings for importance and relevance. The checklist was created to include areas that are not part of established patient safety tools or mandatory and legal requirements. Four main themes were identified: information flow, practice safety information, prescribing, and use of IT systems from which a 13 item checklist was trialled in 16 practices resulting in a nine item prototype checklist, which was tested in eight practices. Qualitative data on the utility and usability of the prototype was collected through a series of semi-structured interviews. RESULTS In testing the prototype four of nine items on the checklist were achieved by all eight practices. Three items were achieved by seven of eight practices and two items by six of eight practices. Participants welcomed the brevity and ease of use of the prototype, that it might be used within time scales at their discretion and its ability to engage a range of practice staff in relevant discussions on the safety of existing processes. The items relating to prescribing safety were considered particularly useful. CONCLUSIONS As a result of this work the concise patient safety checklist tool, specifically designed for general practice, has now been made available as part of an online Patient Safety Toolkit hosted by the Royal College of General Practitioners. Senior practice staff such as practice managers and GP partners should find it a useful tool to understand the safety of less explored yet important safety processes within the practice.
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Affiliation(s)
- Ian Litchfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK.
| | - Rachel Spencer
- Unit of academic primary care, Warwick Medical School, University of Warwick, Coventry, UK
| | - Brian G Bell
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Anthony Avery
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Katherine Perryman
- Division of Population Health, Health Services Research and Primary Care, hester Patient Safety Translational Research Centre, School for Health Sciences, University of Manchester, Manchester, UK
| | - Kate Marsden
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Sheila Greenfield
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Stephen Campbell
- Division of Population Health, Health Services Research and Primary Care, hester Patient Safety Translational Research Centre, School for Health Sciences, University of Manchester, Manchester, UK
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24
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Bick D, Taylor C, Bhavnani V, Healey A, Seed P, Roberts S, Zasada M, Avery A, Craig V, Khazaezadah N, McMullen S, O'Connor S, Oki B, Ntim EO, Poston L, Ussher M. Lifestyle information and commercial weight management groups to support maternal postnatal weight management and positive lifestyle behaviour: the SWAN feasibility randomised controlled trial. BJOG 2019; 127:636-645. [DOI: 10.1111/1471-0528.16043] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/25/2019] [Indexed: 11/29/2022]
Affiliation(s)
- D Bick
- Warwick Clinical Trials Unit Warwick Medical School University of Warwick Coventry UK
| | - C Taylor
- School of Health Sciences University of Surrey Guildford UK
| | | | - A Healey
- Kings Health Economics, Health Services and Population Research Department Institute of Psychiatry, Psychology and Neuroscience King's College London London UK
| | - P Seed
- Department of Women and Children's Health King's College London London UK
| | - S Roberts
- Kings Health Economics, Health Services and Population Research Department Institute of Psychiatry, Psychology and Neuroscience King's College London London UK
| | - M Zasada
- School of Health Sciences University of Surrey Guildford UK
| | - A Avery
- Faculty of Science University of Nottingham Nottingham UK
| | - V Craig
- Guy's and St Thomas' NHS Foundation Trust London UK
| | - N Khazaezadah
- Public Health London Borough of Lambeth Lambeth London UK
| | | | - S O'Connor
- Guy's and St Thomas' NHS Foundation Trust London UK
| | - B Oki
- Public Health London Borough of Lambeth Lambeth London UK
| | - EO Ntim
- Guy's and St Thomas' NHS Foundation Trust London UK
| | - L Poston
- Department of Women and Children's Health King's College London London UK
| | - M Ussher
- Population Health Research Institute St George's University of London London UK
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25
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Roddy E, Clarkson K, Blagojevic-Bucknall M, Mehta R, Oppong R, Avery A, Hay EM, Heneghan C, Hartshorne L, Hooper J, Hughes G, Jowett S, Lewis M, Little P, McCartney K, Mahtani KR, Nunan D, Santer M, Williams S, Mallen CD. Open-label randomised pragmatic trial (CONTACT) comparing naproxen and low-dose colchicine for the treatment of gout flares in primary care. Ann Rheum Dis 2019; 79:276-284. [PMID: 31666237 PMCID: PMC7025732 DOI: 10.1136/annrheumdis-2019-216154] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [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: 08/09/2019] [Revised: 10/11/2019] [Accepted: 10/16/2019] [Indexed: 12/02/2022]
Abstract
Objectives To compare the effectiveness and safety of naproxen and low-dose colchicine for treating gout flares in primary care. Methods This was a multicentre open-label randomised trial. Adults with a gout flare recruited from 100 general practices were randomised equally to naproxen 750 mg immediately then 250 mg every 8 hours for 7 days or low-dose colchicine 500 mcg three times per day for 4 days. The primary outcome was change in worst pain intensity in the last 24 hours (0–10 Numeric Rating Scale) from baseline measured daily over the first 7 days: mean change from baseline was compared between groups over days 1–7 by intention to treat. Results Between 29 January 2014 and 31 December 2015, we recruited 399 participants (naproxen n=200, colchicine n=199), of whom 349 (87.5%) completed primary outcome data at day 7. There was no significant between-group difference in average pain-change scores over days 1–7 (colchicine vs naproxen: mean difference −0.18; 95% CI −0.53 to 0.17; p=0.32). During days 1–7, diarrhoea (45.9% vs 20.0%; OR 3.31; 2.01 to 5.44) and headache (20.5% vs 10.7%; 1.92; 1.03 to 3.55) were more common in the colchicine group than the naproxen group but constipation was less common (4.8% vs 19.3%; 0.24; 0.11 to 0.54). Conclusion We found no difference in pain intensity over 7 days between people with a gout flare randomised to either naproxen or low-dose colchicine. Naproxen caused fewer side effects supporting naproxen as first-line treatment for gout flares in primary care in the absence of contraindications. Trial registration number ISRCTN (69836939), clinicaltrials.gov (NCT01994226), EudraCT (2013-001354-95).
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Affiliation(s)
- Edward Roddy
- Primary Care Centre Versus Arthritis; School of Primary, Community and Social Care, Keele University, Keele, UK .,Haywood Academic Rheumatology Centre, Midland Partnership NHS Foundation Trust, Stoke-on-Trent, UK
| | - Kris Clarkson
- Primary Care Centre Versus Arthritis; School of Primary, Community and Social Care, Keele University, Keele, UK.,Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Milica Blagojevic-Bucknall
- Primary Care Centre Versus Arthritis; School of Primary, Community and Social Care, Keele University, Keele, UK.,Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Rajnikant Mehta
- Birmingham Acute Care Research/Heart of England NHS Foundation Trust/Institute of Applied Health Research (BCTU), University of Birmingham, Birmingham, UK
| | - Raymond Oppong
- Health Economics, University of Birmingham, Birmingham, UK
| | - Anthony Avery
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Elaine M Hay
- Primary Care Centre Versus Arthritis; School of Primary, Community and Social Care, Keele University, Keele, UK
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Liz Hartshorne
- Primary Care Centre Versus Arthritis; School of Primary, Community and Social Care, Keele University, Keele, UK.,Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Julie Hooper
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Gemma Hughes
- Primary Care Centre Versus Arthritis; School of Primary, Community and Social Care, Keele University, Keele, UK.,Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Sue Jowett
- Primary Care Centre Versus Arthritis; School of Primary, Community and Social Care, Keele University, Keele, UK.,Health Economics, University of Birmingham, Birmingham, UK
| | - Martyn Lewis
- Primary Care Centre Versus Arthritis; School of Primary, Community and Social Care, Keele University, Keele, UK.,Keele Clinical Trials Unit, Keele University, Keele, UK
| | - Paul Little
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Karen McCartney
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Kamal R Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - David Nunan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Miriam Santer
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Sam Williams
- Primary Care and Population Sciences, University of Southampton, Southampton, UK
| | - Christian D Mallen
- Primary Care Centre Versus Arthritis; School of Primary, Community and Social Care, Keele University, Keele, UK
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26
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Nayak S, Avery A, Griffiss JM, Charles C, Culwell K. A randomized placebo-controlled pilot study of the effect and duration of Amphora, a multipurpose vaginal pH regulator, on vaginal pH. CLIN EXP OBSTET GYN 2019. [DOI: 10.12891/ceog5058.2019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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27
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Carson-Stevens A, Campbell S, Bell BG, Cooper A, Armstrong S, Ashcroft D, Boyd M, Prosser Evans H, Mehta R, Sheehan C, Sheikh A, Avery A. Identifying 'avoidable harm' in family practice: a RAND/UCLA Appropriateness Method consensus study. BMC Fam Pract 2019; 20:134. [PMID: 31585529 PMCID: PMC6777037 DOI: 10.1186/s12875-019-0990-z] [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] [Subscribe] [Scholar Register] [Received: 06/08/2018] [Accepted: 07/08/2019] [Indexed: 11/17/2022]
Abstract
Background Health care-related harm is an internationally recognized threat to public health. The United Kingdom’s national health services demonstrate that upwards of 90% of health care encounters can be delivered in ambulatory settings. Other countries are transitioning to more family practice-based health care systems, and efforts to understand avoidable harm in these settings is needed. Methods We developed 100 scenarios reflecting a range of diseases and informed by the World Health Organization definition of ‘significant harm’. Scenarios included different types of patient safety incidents occurring by commission and omission, demonstrated variation in timeliness of intervention, and conditions where evidence-based guidelines are available or absent. We conducted a two-round RAND / UCLA Appropriateness Method consensus study with a panel of family practitioners in England to define “avoidable harm” within family practice. Panelists rated their perceptions of avoidability for each scenario. We ran a k-means cluster analysis of avoidability ratings. Results Panelists reached consensus for 95 out of 100 scenarios. The panel agreed avoidable harm occurs when a patient safety incident could have been probably, or totally, avoided by the timely intervention of a health care professional in family practice (e.g. investigations, treatment) and / or an administrative process (e.g. referrals, alerts in electronic health records, procedures for following up results) in accordance with accepted evidence-based practice and clinical governance. Fifty-four scenarios were deemed avoidable, whilst 31 scenarios were rated unavoidable and reflected outcomes deemed inevitable regardless of family practice intervention. Scenarios with low avoidability ratings (1 s or 2 s) were not represented by the categories that were used to generate scenarios, whereas scenarios with high avoidability ratings (7 s 8 s or 9 s) were represented by these a priori categories. Discussion The findings from this RAND/UCLA Appropriateness Method study define the characteristics and conditions that can be used to standardize measurement of outcomes for primary care patient safety. Conclusion We have developed a definition of avoidable harm that has potential for researchers and practitioners to apply across primary care settings, and bolster international efforts to design interventions to target avoidable patient safety incidents that cause the most significant harm to patients. Electronic supplementary material The online version of this article (10.1186/s12875-019-0990-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, 8th Floor Neuadd Meirionnydd, Cardiff, UK. .,Australian Institute of Health Innovation, Macquarie University, Sydney, Australia.
| | - Stephen Campbell
- Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, UK
| | - Brian G Bell
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Alison Cooper
- Division of Population Medicine, School of Medicine, Cardiff University, 8th Floor Neuadd Meirionnydd, Cardiff, UK
| | - Sarah Armstrong
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Darren Ashcroft
- Drug Usage and Pharmacy Practice Group, University of Manchester, Manchester, UK
| | - Matthew Boyd
- School of Pharmacy, University of Nottingham, Nottingham, UK
| | - Huw Prosser Evans
- Division of Population Medicine, School of Medicine, Cardiff University, 8th Floor Neuadd Meirionnydd, Cardiff, UK
| | - Rajnikant Mehta
- School of Medicine, University of Nottingham, Nottingham, UK
| | | | - Aziz Sheikh
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, UK.,Harvard Medical School, Harvard University, Boston, USA
| | - Anthony Avery
- School of Medicine, University of Nottingham, Nottingham, UK
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28
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Chambers L, Avery A, Dalrymple J, Farrell L, Gibson G, Harrington J, Rijkers G, Rowland I, Spiro A, Varela‐Moreiras G, Vokes L, Younge L, Whelan K, Stanner S. Translating probiotic science into practice. NUTR BULL 2019. [DOI: 10.1111/nbu.12385] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
| | - A. Avery
- University of Nottingham Nottingham UK
| | - J. Dalrymple
- Primary Care Society for Gastroenterology London UK
| | | | | | | | - G. Rijkers
- University College Roosevelt Middelburg The Netherlands
| | | | - A. Spiro
- British Nutrition Foundation London UK
| | | | - L. Vokes
- British Dietetic Association Birmingham UK
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29
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Vedhara K, Ayling K, Sunger K, Caldwell DM, Halliday V, Fairclough L, Avery A, Robles L, Garibaldi J, Welton NJ, Royal S. Psychological interventions as vaccine adjuvants: A systematic review. Vaccine 2019; 37:3255-3266. [DOI: 10.1016/j.vaccine.2019.04.091] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 04/25/2019] [Accepted: 04/26/2019] [Indexed: 12/20/2022]
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30
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Niforatos J, Yax J, Avery A. 181 Clinical Knowledge of Human Immunodeficiency Virus Among Emergency Providers at Two Level 1 Trauma Centers in Cleveland, Ohio. Ann Emerg Med 2018. [DOI: 10.1016/j.annemergmed.2018.08.186] [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: 10/28/2022]
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31
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Griffiss J, Avery A, Nayak S, Friend D, Culwell K. Post hoc analysis of a randomized placebo-controlled pilot study on the effect of Amphora®, an acid-buffering vaginal gel, on vaginal pH by baseline vaginal pH level. Fertil Steril 2018. [DOI: 10.1016/j.fertnstert.2018.07.147] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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32
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McCall CA, Turkheimer E, Tsang S, Avery A, Duncan GE, Watson NF. 0177 Sleep and Resilient Coping: A Twin Study. Sleep 2018. [DOI: 10.1093/sleep/zsy061.176] [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: 11/12/2022] Open
Affiliation(s)
- C A McCall
- University of Washington Medicine Sleep Disorders Center, Seattle, WA
| | - E Turkheimer
- University of Virginia, Department of Psychology, Charlottesville, VA
| | - S Tsang
- Columbia University, MSPH, Department of Epidemiology, New York, NY
| | - A Avery
- Washington State University, Spokane, WA
| | - G E Duncan
- Washington State University, Department of Nutrition and Exercise Physiology, Spokane, WA
| | - N F Watson
- University of Washington Medicine Sleep Disorders Center and University of Washington, Department of Neurology, Seattle, WA
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Miani C, Martin A, Exley J, Doble B, Wilson E, Payne R, Avery A, Meads C, Kirtley A, Jones MM, King S. Clinical effectiveness and cost-effectiveness of issuing longer versus shorter duration (3-month vs. 28-day) prescriptions in patients with chronic conditions: systematic review and economic modelling. Health Technol Assess 2017; 21:1-128. [PMID: 29268843 PMCID: PMC5757186 DOI: 10.3310/hta21780] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND To reduce expenditure on, and wastage of, drugs, some commissioners have encouraged general practitioners to issue shorter prescriptions, typically 28 days in length; however, the evidence base for this recommendation is uncertain. OBJECTIVE To evaluate the evidence of the clinical effectiveness and cost-effectiveness of shorter versus longer prescriptions for people with stable chronic conditions treated in primary care. DESIGN/DATA SOURCES The design of the study comprised three elements. First, a systematic review comparing 28-day prescriptions with longer prescriptions in patients with chronic conditions treated in primary care, evaluating any relevant clinical outcomes, adherence to treatment, costs and cost-effectiveness. Databases searched included MEDLINE (PubMed), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane Central Register of Controlled Trials. Searches were from database inception to October 2015 (updated search to June 2016 in PubMed). Second, a cost analysis of medication wastage associated with < 60-day and ≥ 60-day prescriptions for five patient cohorts over an 11-year period from the Clinical Practice Research Datalink. Third, a decision model adapting three existing models to predict costs and effects of differing adherence levels associated with 28-day versus 3-month prescriptions in three clinical scenarios. REVIEW METHODS In the systematic review, from 15,257 unique citations, 54 full-text papers were reviewed and 16 studies were included, five of which were abstracts and one of which was an extended conference abstract. None was a randomised controlled trial: 11 were retrospective cohort studies, three were cross-sectional surveys and two were cost studies. No information on health outcomes was available. RESULTS An exploratory meta-analysis based on six retrospective cohort studies suggested that lower adherence was associated with 28-day prescriptions (standardised mean difference -0.45, 95% confidence interval -0.65 to -0.26). The cost analysis showed that a statistically significant increase in medication waste was associated with longer prescription lengths. However, when accounting for dispensing fees and prescriber time, longer prescriptions were found to be cost saving compared with shorter prescriptions. Prescriber time was the largest component of the calculated cost savings to the NHS. The decision modelling suggested that, in all three clinical scenarios, longer prescription lengths were associated with lower costs and higher quality-adjusted life-years. LIMITATIONS The available evidence was found to be at a moderate to serious risk of bias. All of the studies were conducted in the USA, which was a cause for concern in terms of generalisability to the UK. No evidence of the direct impact of prescription length on health outcomes was found. The cost study could investigate prescriptions issued only; it could not assess patient adherence to those prescriptions. Additionally, the cost study was based on products issued only and did not account for underlying patient diagnoses. A lack of good-quality evidence affected our decision modelling strategy. CONCLUSIONS Although the quality of the evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28-day prescriptions in patients with chronic conditions being treated in primary care. FUTURE WORK There is a need to more reliably evaluate the impact of differing prescription lengths on adherence, on patient health outcomes and on total costs to the NHS. The priority should be to identify patients with particular conditions or characteristics who should receive shorter or longer prescriptions. To determine the need for any further research, an expected value of perfect information analysis should be performed. STUDY REGISTRATION This study is registered as PROSPERO CRD42015027042. FUNDING The National Institute for Health Research Health Technology Assessment programme.
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Affiliation(s)
- Céline Miani
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | - Adam Martin
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
- Academic Unit of Health Economics, Leeds Institute of Health Sciences, University of Leeds, Leeds, UK
| | - Josephine Exley
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | - Brett Doble
- Cambridge Centre for Health Services Research, Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
- Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
| | - Ed Wilson
- Cambridge Centre for Health Services Research, Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Rupert Payne
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, Bristol, UK
| | - Anthony Avery
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Catherine Meads
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
- School of Nursing and Midwifery, Faculty of Health, Social Care and Education, Anglia Ruskin University, Cambridge, UK
| | - Anne Kirtley
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
- Strategy Division, Wellcome Trust, London, UK
| | - Molly Morgan Jones
- Cambridge Centre for Health Services Research, RAND Europe, Cambridge, UK
| | - Sarah King
- Cambridge Institute of Public Health, School of Clinical Medicine, University of Cambridge, Cambridge, UK
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Culwell K, Griffiss M, Nayak S, Avery A, Friend D. A randomized, placebo-controlled pilot study to determine the effect and duration of acidform gel (AMPHORA) on vaginal pH. Fertil Steril 2017. [DOI: 10.1016/j.fertnstert.2017.07.161] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Cooper A, Edwards A, Williams H, Evans HP, Avery A, Hibbert P, Makeham M, Sheikh A, J. Donaldson L, Carson-Stevens A. Sources of unsafe primary care for older adults: a mixed-methods analysis of patient safety incident reports. Age Ageing 2017; 46:833-839. [PMID: 28520904 PMCID: PMC5860504 DOI: 10.1093/ageing/afx044] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [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: 09/06/2016] [Revised: 02/08/2017] [Indexed: 11/14/2022] Open
Abstract
Background older adults are frequent users of primary healthcare services, but are at increased risk of healthcare-related harm in this setting. Objectives to describe the factors associated with actual or potential harm to patients aged 65 years and older, treated in primary care, to identify action to produce safer care. Design and Setting a cross-sectional mixed-methods analysis of a national (England and Wales) database of patient safety incident reports from 2005 to 2013. Subjects 1,591 primary care patient safety incident reports regarding patients aged 65 years and older. Methods we developed a classification system for the analysis of patient safety incident reports to describe: the incident and preceding chain of incidents; other contributory factors; and patient harm outcome. We combined findings from exploratory descriptive and thematic analyses to identify key sources of unsafe care. Results the main sources of unsafe care in our weighted sample were due to: medication-related incidents e.g. prescribing, dispensing and administering (n = 486, 31%; 15% serious patient harm); communication-related incidents e.g. incomplete or non-transfer of information across care boundaries (n = 390, 25%; 12% serious patient harm); and clinical decision-making incidents which led to the most serious patient harm outcomes (n = 203, 13%; 41% serious patient harm). Conclusion priority areas for further research to determine the burden and preventability of unsafe primary care for older adults, include: the timely electronic tools for prescribing, dispensing and administering medication in the community; electronic transfer of information between healthcare settings; and, better clinical decision-making support and guidance.
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Affiliation(s)
- Alison Cooper
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - Adrian Edwards
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - Huw Williams
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - Huw P. Evans
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, UK
| | - Anthony Avery
- School of Medicine, University of Nottingham, Nottingham,UK
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney NSW, Australia
| | - Meredith Makeham
- Australian Institute of Health Innovation, Macquarie University, Sydney NSW, Australia
| | - Aziz Sheikh
- Centre of Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, UK
- Harvard Medical School, Boston, MA, USA
| | | | - Andrew Carson-Stevens
- Division of Population Medicine, School of Medicine, Cardiff University, Cardiff, Wales, UK
- Australian Institute of Health Innovation, Macquarie University, Sydney NSW, Australia
- University of British Columbia, Vancouver, British Columbia, Canada
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Jeffries M, Phipps D, Howard RL, Avery A, Rodgers S, Ashcroft D. Understanding the implementation and adoption of an information technology intervention to support medicine optimisation in primary care: qualitative study using strong structuration theory. BMJ Open 2017; 7:e014810. [PMID: 28495815 PMCID: PMC5736096 DOI: 10.1136/bmjopen-2016-014810] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/07/2022] Open
Abstract
OBJECTIVES Using strong structuration theory, we aimed to understand the adoption and implementation of an electronic clinical audit and feedback tool to support medicine optimisation for patients in primary care. DESIGN This is a qualitative study informed by strong structuration theory. The analysis was thematic, using a template approach. An a priori set of thematic codes, based on strong structuration theory, was developed from the literature and applied to the transcripts. The coding template was then modified through successive readings of the data. SETTING Clinical commissioning group in the south of England. PARTICIPANTS Four focus groups and five semi-structured interviews were conducted with 18 participants purposively sampled from a range of stakeholder groups (general practitioners, pharmacists, patients and commissioners). RESULTS Using the system could lead to improved medication safety, but use was determined by broad institutional contexts; by the perceptions, dispositions and skills of users; and by the structures embedded within the technology. These included perceptions of the system as new and requiring technical competence and skill; the adoption of the system for information gathering; and interactions and relationships that involved individual, shared or collective use. The dynamics between these external, internal and technological structures affected the adoption and implementation of the system. CONCLUSIONS Successful implementation of information technology interventions for medicine optimisation will depend on a combination of the infrastructure within primary care, social structures embedded in the technology and the conventions, norms and dispositions of those utilising it. Future interventions, using electronic audit and feedback tools to improve medication safety, should consider the complexity of the social and organisational contexts and how internal and external structures can affect the use of the technology in order to support effective implementation.
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Affiliation(s)
- Mark Jeffries
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Denham Phipps
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | | | - Anthony Avery
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Sarah Rodgers
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Darren Ashcroft
- Centre for Pharmacoepidemiology and Drug Safety, School of Health Sciences, University of Manchester, Manchester, UK
- NIHR Greater Manchester Primary Care Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
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Rees P, Edwards A, Powell C, Hibbert P, Williams H, Makeham M, Carter B, Luff D, Parry G, Avery A, Sheikh A, Donaldson L, Carson-Stevens A. Patient Safety Incidents Involving Sick Children in Primary Care in England and Wales: A Mixed Methods Analysis. PLoS Med 2017; 14:e1002217. [PMID: 28095408 PMCID: PMC5240916 DOI: 10.1371/journal.pmed.1002217] [Citation(s) in RCA: 44] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Accepted: 12/08/2016] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND The UK performs poorly relative to other economically developed countries on numerous indicators of care quality for children. The contribution of iatrogenic harm to these outcomes is unclear. As primary care is the first point of healthcare contact for most children, we sought to investigate the safety of care provided to children in this setting. METHODS AND FINDINGS We undertook a mixed methods investigation of reports of primary care patient safety incidents involving sick children from England and Wales' National Reporting and Learning System between 1 January 2005 and 1 December 2013. Two reviewers independently selected relevant incident reports meeting prespecified criteria, and then descriptively analyzed these reports to identify the most frequent and harmful incident types. This was followed by an in-depth thematic analysis of a purposive sample of reports to understand the reasons underpinning incidents. Key candidate areas for strengthening primary care provision and reducing the risks of systems failures were then identified through multidisciplinary discussions. Of 2,191 safety incidents identified from 2,178 reports, 30% (n = 658) were harmful, including 12 deaths and 41 cases of severe harm. The children involved in these incidents had respiratory conditions (n = 387; 18%), injuries (n = 289; 13%), nonspecific signs and symptoms, e.g., fever (n = 281; 13%), and gastrointestinal or genitourinary conditions (n = 268; 12%), among others. Priority areas for improvement included safer systems for medication provision in community pharmacies; triage processes to enable effective and timely assessment, diagnosis, and referral of acutely sick children attending out-of-hours services; and enhanced communication for robust safety netting between professionals and parents. The main limitations of this study result from underreporting of safety incidents and variable data quality. Our findings therefore require further exploration in longitudinal studies utilizing case review methods. CONCLUSIONS This study highlights opportunities to reduce iatrogenic harm and avoidable child deaths. Globally, healthcare systems with primary-care-led models of delivery must now examine their existing practices to determine the prevalence and burden of these priority safety issues, and utilize improvement methods to achieve sustainable improvements in care quality.
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Affiliation(s)
- Philippa Rees
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Institute of Child Health, University College London, London, United Kingdom
| | - Adrian Edwards
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Colin Powell
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Peter Hibbert
- Australian Institute for Healthcare Innovation, Macquarie University, Macquarie, Australia
| | - Huw Williams
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
| | - Meredith Makeham
- Australian Institute for Healthcare Innovation, Macquarie University, Macquarie, Australia
| | - Ben Carter
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Department of Biostatistics and Health Informatics, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, United Kingdom
| | - Donna Luff
- Institute for Professionalism and Ethical Practice, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Department of Anesthesia, Boston Children’s Hospital, Boston, Massachusetts, United States of America
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
| | - Gareth Parry
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
- Institute for Healthcare Improvement, Cambridge, Massachusetts, United States of America
| | - Anthony Avery
- Division of General Practice, University of Nottingham, Nottingham, United Kingdom
| | - Aziz Sheikh
- Harvard Medical School, Harvard University, Boston, Massachusetts, United States of America
- Usher Institute of Population Health Sciences and Informatics, University of Edinburgh, Edinburgh, United Kingdom
| | - Liam Donaldson
- Department of Non-communicable Disease Epidemiology, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Andrew Carson-Stevens
- Division of Population Medicine, Cardiff University, Cardiff, United Kingdom
- Australian Institute for Healthcare Innovation, Macquarie University, Macquarie, Australia
- Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
- * E-mail:
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McArdle PD, Greenfield SM, Avery A, Adams GG, Gill PS. Dietitians' practice in giving carbohydrate advice in the management of type 2 diabetes: a mixed methods study. J Hum Nutr Diet 2016; 30:385-393. [DOI: 10.1111/jhn.12436] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- P. D. McArdle
- Birmingham Community Healthcare NHS Foundation Trust (BCHC); Birmingham UK
| | - S. M. Greenfield
- Primary Care Clinical Sciences; College of Medical & Dental Sciences; University of Birmingham; Birmingham UK
| | - A. Avery
- Faculty of Science; The University of Nottingham; Sutton Bonington UK
| | - G. G. Adams
- Faculty of Science; The University of Nottingham; Sutton Bonington UK
| | - P. S. Gill
- Primary Care Clinical Sciences; College of Medical & Dental Sciences; University of Birmingham; Birmingham UK
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Mackenzie IS, Ford I, Walker A, Hawkey C, Begg A, Avery A, Taggar J, Wei L, Struthers AD, MacDonald TM. Multicentre, prospective, randomised, open-label, blinded end point trial of the efficacy of allopurinol therapy in improving cardiovascular outcomes in patients with ischaemic heart disease: protocol of the ALL-HEART study. BMJ Open 2016; 6:e013774. [PMID: 27609859 PMCID: PMC5020706 DOI: 10.1136/bmjopen-2016-013774] [Citation(s) in RCA: 54] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Ischaemic heart disease (IHD) is one of the most common causes of death in the UK and treatment of patients with IHD costs the National Health System (NHS) billions of pounds each year. Allopurinol is a xanthine oxidase inhibitor used to prevent gout that also has several positive effects on the cardiovascular system. The ALL-HEART study aims to determine whether allopurinol improves cardiovascular outcomes in patients with IHD. METHODS AND ANALYSIS The ALL-HEART study is a multicentre, controlled, prospective, randomised, open-label blinded end point (PROBE) trial of allopurinol (up to 600 mg daily) versus no treatment in a 1:1 ratio, added to usual care, in 5215 patients aged 60 years and over with IHD. Patients are followed up by electronic record linkage and annual questionnaires for an average of 4 years. The primary outcome is the composite of non-fatal myocardial infarction, non-fatal stroke or cardiovascular death. Secondary outcomes include all-cause mortality, quality of life and cost-effectiveness of allopurinol. The study will end when 631 adjudicated primary outcomes have occurred. The study is powered at 80% to detect a 20% reduction in the primary end point for the intervention. Patient recruitment to the ALL-HEART study started in February 2014. ETHICS AND DISSEMINATION The study received ethical approval from the East of Scotland Research Ethics Service (EoSRES) REC 2 (13/ES/0104). The study is event-driven and results are expected after 2019. Results will be reported in peer-reviewed journals and at scientific meetings. Results will also be disseminated to guideline committees, NHS organisations and patient groups. TRIAL REGISTRATION NUMBER 32017426, pre-results.
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Affiliation(s)
- Isla S Mackenzie
- Medicines Monitoring Unit (MEMO) and Hypertension Research Centre, Division of Molecular and Clinical Medicine, University of Dundee and Ninewells Hospital, Dundee, UK
| | - Ian Ford
- Glasgow Clinical Trials Unit, Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Andrew Walker
- Glasgow Clinical Trials Unit, Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Chris Hawkey
- Nottingham Centre for Digestive Disorders, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Alan Begg
- Townhead Medical Practice, Montrose, UK
| | - Anthony Avery
- School of Medicine, University of Nottingham, Nottingham, UK
| | - Jaspal Taggar
- Division of Primary Care, School of Medicine, University of Nottingham, Nottingham, UK
| | - Li Wei
- Robertson Centre for Biostatistics, Glasgow Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Allan D Struthers
- Division of Molecular and Clinical Medicine, University of Dundee and Ninewells Hospital, Dundee, UK
| | - Thomas M MacDonald
- Medicines Monitoring Unit (MEMO) and Hypertension Research Centre, Division of Molecular and Clinical Medicine, University of Dundee and Ninewells Hospital, Dundee, UK
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Carson-Stevens A, Hibbert P, Williams H, Evans HP, Cooper A, Rees P, Deakin A, Shiels E, Gibson R, Butlin A, Carter B, Luff D, Parry G, Makeham M, McEnhill P, Ward HO, Samuriwo R, Avery A, Chuter A, Donaldson L, Mayor S, Panesar S, Sheikh A, Wood F, Edwards A. Characterising the nature of primary care patient safety incident reports in the England and Wales National Reporting and Learning System: a mixed-methods agenda-setting study for general practice. Health Serv Deliv Res 2016. [DOI: 10.3310/hsdr04270] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundThere is an emerging interest in the inadvertent harm caused to patients by the provision of primary health-care services. To date (up to 2015), there has been limited research interest and few policy directives focused on patient safety in primary care. In 2003, a major investment was made in the National Reporting and Learning System to better understand patient safety incidents occurring in England and Wales. This is now the largest repository of patient safety incidents in the world. Over 40,000 safety incident reports have arisen from general practice. These have never been systematically analysed, and a key challenge to exploiting these data has been the largely unstructured, free-text data.AimsTo characterise the nature and range of incidents reported from general practice in England and Wales (2005–13) in order to identify the most frequent and most harmful patient safety incidents, and relevant contributory issues, to inform recommendations for improving the safety of primary care provision in key strategic areas.MethodsWe undertook a cross-sectional mixed-methods evaluation of general practice patient safety incident reports. We developed our own classification (coding) system using an iterative approach to describe the incident, contributory factors and incident outcomes. Exploratory data analysis methods with subsequent thematic analysis was undertaken to identify the most harmful and most frequent incident types, and the underlying contributory themes. The study team discussed quantitative and qualitative analyses, and vignette examples, to propose recommendations for practice.Main findingsWe have identified considerable variation in reporting culture across England and Wales between organisations. Two-thirds of all reports did not describe explicit reasons about why an incident occurred. Diagnosis- and assessment-related incidents described the highest proportion of harm to patients; over three-quarters of these reports (79%) described a harmful outcome, and half of the total reports described serious harm or death (n = 366, 50%). Nine hundred and ninety-six reports described serious harm or death of a patient. Four main contributory themes underpinned serious harm- and death-related incidents: (1) communication errors in the referral and discharge of patients; (2) physician decision-making; (3) unfamiliar symptom presentation and inadequate administration delaying cancer diagnoses; and (4) delayed management or mismanagement following failures to recognise signs of clinical (medical, surgical and mental health) deterioration.ConclusionsAlthough there are recognised limitations of safety-reporting system data, this study has generated hypotheses, through an inductive process, that now require development and testing through future research and improvement efforts in clinical practice. Cross-cutting priority recommendations include maximising opportunities to learn from patient safety incidents; building information technology infrastructure to enable details of all health-care encounters to be recorded in one system; developing and testing methods to identify and manage vulnerable patients at risk of deterioration, unscheduled hospital admission or readmission following discharge from hospital; and identifying ways patients, parents and carers can help prevent safety incidents. Further work must now involve a wider characterisation of reports contributed by the rest of the primary care disciplines (pharmacy, midwifery, health visiting, nursing and dentistry), include scoping reviews to identify interventions and improvement initiatives that address priority recommendations, and continue to advance the methods used to generate learning from safety reports.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Andrew Carson-Stevens
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
- Wales Primary and Emergency Care (PRIME) Research Centre, Cardiff University, Cardiff, UK
- Department of Family Practice, University of British Columbia, Vancouver, BC, Canada
| | - Peter Hibbert
- Australian Institute for Health Innovation (AIHI), Macquarie University, Sydney, NSW, Australia
| | - Huw Williams
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Huw Prosser Evans
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Alison Cooper
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Philippa Rees
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Anita Deakin
- Australian Patient Safety Foundation, University of South Australia, Adelaide, SA, Australia
| | - Emma Shiels
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Russell Gibson
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Amy Butlin
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Ben Carter
- Centre for Medical Education, Cardiff University, Cardiff, UK
| | - Donna Luff
- Harvard Medical School, Harvard University, Boston, MA, USA
| | - Gareth Parry
- Harvard Medical School, Harvard University, Boston, MA, USA
- Institute for Healthcare Improvement (IHI), Cambridge, MA, USA
| | - Meredith Makeham
- Australian Institute for Health Innovation (AIHI), Macquarie University, Sydney, NSW, Australia
| | - Paul McEnhill
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Hope Olivia Ward
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Raymond Samuriwo
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
- School of Healthcare Sciences, Cardiff University, Cardiff, UK
| | - Anthony Avery
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | | | - Liam Donaldson
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Sharon Mayor
- Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Sukhmeet Panesar
- Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aziz Sheikh
- Harvard Medical School, Harvard University, Boston, MA, USA
- Centre for Medical Informatics, University of Edinburgh, Edinburgh, UK
| | - Fiona Wood
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
| | - Adrian Edwards
- Primary Care Patient Safety (PISA) Research Group, Division of Population Medicine, Cardiff University, Cardiff, UK
- Wales Primary and Emergency Care (PRIME) Research Centre, Cardiff University, Cardiff, UK
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Avery A, Langley-Evans SC, Harrington M, Swift JA. Setting targets leads to greater long-term weight losses and 'unrealistic' targets increase the effect in a large community-based commercial weight management group. J Hum Nutr Diet 2016; 29:687-696. [PMID: 27302147 PMCID: PMC5111772 DOI: 10.1111/jhn.12390] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [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] [Indexed: 12/22/2022]
Abstract
Background Setting personal targets is an important behavioural component in weight management programmes. Normal practice is to encourage ‘realistic’ weight loss, although the underlying evidence base for this is limited and controversial. The present study investigates the effect of number and size of weight‐loss targets on long‐term weight loss in a large community sample of adults. Methods Weight change, attendance and target weight data for all new UK members, joining from January to March 2012, were extracted from a commercial slimming organisation's electronic database. Results Of the 35 380 members who had weight data available at 12 months after joining, 69.1% (n = 24 447) had a starting body mass index (BMI) ≥30 kg m–2. Their mean (SD) weight loss was 12.9% (7.8%) and, for both sexes, weight loss at 12 months was greater for those who set targets (P < 0.001). Those that set ≥4 targets achieved the greatest loss (P < 0.001). The odds ratio for weight loss ≥10% at 12 months was 10.3 (95% confidence interval = 9.7–11.1, P < 0.001) where targets had been set compared to none. At the highest quintile of target size, the size of the first target explained 47.2% (P < 0.001) of the variance in weight loss achieved at 12 months. The mean (SD) BMI reduction in those with a target >25% was 7.6 (4.0) kg m–2. A higher percentage of obese members did not set targets (P < 0.001) compared to those with a BMI <30 kg m–2. Conclusions Much of the variance in weight loss achieved in this population was explained by the number of targets set and the size of the first target. Although obese people were less likely to set targets, doing so increased the likelihood of achieving clinically significant weight loss and, for some ‘unrealistic’ targets, improved the results.
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Affiliation(s)
- A Avery
- School of Biosciences, University of Nottingham, Nottingham, UK.,Slimming World, Derbys, UK
| | | | - M Harrington
- School of Biosciences, University of Nottingham, Nottingham, UK
| | - J A Swift
- School of Biosciences, University of Nottingham, Nottingham, UK
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Akbarov A, Kontopantelis E, Sperrin M, Stocks SJ, Williams R, Rodgers S, Avery A, Buchan I, Ashcroft DM. Primary Care Medication Safety Surveillance with Integrated Primary and Secondary Care Electronic Health Records: A Cross-Sectional Study. Drug Saf 2016; 38:671-82. [PMID: 26100143 PMCID: PMC4486763 DOI: 10.1007/s40264-015-0304-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [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: 11/29/2022]
Abstract
Introduction The extent of preventable medication-related hospital admissions and medication-related issues in primary care is significant enough to justify developing decision support systems for medication safety surveillance. The prerequisite for such systems is defining a relevant set of medication safety-related indicators and understanding the influence of both patient and general practice characteristics on medication prescribing and monitoring. Objective The aim of the study was to investigate the feasibility of linked primary and secondary care electronic health record data for surveillance of medication safety, examining not only prescribing but also monitoring, and associations with patient- and general practice-level characteristics. Methods A cross-sectional study was conducted using linked records of patients served by one hospital and over 50 general practices in Salford, UK. Statistical analysis consisted of mixed-effects logistic models, relating prescribing safety indicators to potential determinants. Results The overall prevalence (proportion of patients with at least one medication safety hazard) was 5.45 % for prescribing indicators and 7.65 % for monitoring indicators. Older patients and those on multiple medications were at higher risk of prescribing hazards, but at lower risk of missed monitoring. The odds of missed monitoring among all patients were 25 % less for males, 50 % less for patients in practices that provide general practitioner training, and threefold higher in practices serving the most deprived compared with the least deprived areas. Practices with more prescribing hazards did not tend to show more monitoring issues. Conclusions Systematic collection, collation, and analysis of linked primary and secondary care records produce plausible and useful information about medication safety for a health system. Medication safety surveillance systems should pay close attention to patient age and polypharmacy with respect to both prescribing and monitoring failures; treat prescribing and monitoring as different statistical processes, rather than a combined measure of prescribing safety; and audit the socio-economic equity of missed monitoring. Electronic supplementary material The online version of this article (doi:10.1007/s40264-015-0304-x) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Artur Akbarov
- Centre for Health Informatics, Institute of Population Health, University of Manchester, Vaughan House, Portsmouth St, Manchester, M13 9GB, UK,
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Abstract
OBJECTIVES Although most health care interactions in the developed world occur in general practice, most of the literature on patient safety has focused on secondary care services. To address this issue, we have constructed a patient safety toolkit for English general practices. We report how practice and respondent characteristics affect scores on our safety climate measure, the PC-Safequest, and address recent concerns with high levels of workload in English general practices. METHODS We administered the PC-Safequest, a 30-item tool that was designed to measure safety climate in primary care practices, to 335 primary care staff members in 31 practices in England. Practice characteristics, such as list size and deprivation in the area the practice served, and respondent characteristics, such as whether the respondent was a manager, were also collected and used in a multilevel analysis to predict PC-Safequest scores. RESULTS Managers gave their practices significantly higher safety climate scores than did non-managers. Respondents with more years of experience had a more negative perception of the level of workload in their practice. Practices with more registered patients and in areas of higher deprivation provided lower safety climate scores. CONCLUSIONS Managers rated their practices more positively on our safety climate measure, so the differences between the perceptions of managers and other staff may need to be reduced in order to build a strong safety culture. Excessive workload for more experienced staff and lower safety climate scores for larger practices may reflect 'burnout'. Concerns that pressures in primary care could affect patient safety are discussed.
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Affiliation(s)
- Brian G Bell
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - David Reeves
- Centre for Primary Care, University of Manchester, Manchester, UK
| | - Kate Marsden
- Division of Primary Care, University of Nottingham, Nottingham, UK
| | - Anthony Avery
- Division of Primary Care, University of Nottingham, Nottingham, UK
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Carson-Stevens A, Hibbert P, Avery A, Butlin A, Carter B, Cooper A, Evans HP, Gibson R, Luff D, Makeham M, McEnhill P, Panesar SS, Parry G, Rees P, Shiels E, Sheikh A, Ward HO, Williams H, Wood F, Donaldson L, Edwards A. A cross-sectional mixed methods study protocol to generate learning from patient safety incidents reported from general practice. BMJ Open 2015; 5:e009079. [PMID: 26628526 PMCID: PMC4680001 DOI: 10.1136/bmjopen-2015-009079] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Incident reports contain descriptions of errors and harms that occurred during clinical care delivery. Few observational studies have characterised incidents from general practice, and none of these have been from the England and Wales National Reporting and Learning System. This study aims to describe incidents reported from a general practice care setting. METHODS AND ANALYSIS A general practice patient safety incident classification will be developed to characterise patient safety incidents. A weighted-random sample of 12,500 incidents describing no harm, low harm and moderate harm of patients, and all incidents describing severe harm and death of patients will be classified. Insights from exploratory descriptive statistics and thematic analysis will be combined to identify priority areas for future interventions. ETHICS AND DISSEMINATION The need for ethical approval was waivered by the Aneurin Bevan University Health Board research risk review committee given the anonymised nature of data (ABHB R&D Ref number: SA/410/13). The authors will submit the results of the study to relevant journals and undertake national and international oral presentations to researchers, clinicians and policymakers.
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Affiliation(s)
- Andrew Carson-Stevens
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
- Department of Family Practice, Faculty of Medicine, University of British Columbia, Vancouver, Canada
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Scotland, UK
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
- Australian Patient Safety Foundation, Adelaide, Australia
| | - Anthony Avery
- Division of General Practice, College of Community Health Sciences, University of Nottingham, Nottingham, UK
| | - Amy Butlin
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Ben Carter
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Alison Cooper
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Huw Prosser Evans
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Russell Gibson
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Donna Luff
- Department of Anesthesia, Boston Children's Hospital, Boston, Massachusetts, USA
- Harvard Medical School, Boston, Massachusetts, USA
| | - Meredith Makeham
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Paul McEnhill
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Sukhmeet S Panesar
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Scotland, UK
| | - Gareth Parry
- Harvard Medical School, Boston, Massachusetts, USA
- Institute for Healthcare Improvement, Cambridge, Massachusetts, USA
| | - Philippa Rees
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Emma Shiels
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Aziz Sheikh
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Scotland, UK
- Harvard Medical School, Boston, Massachusetts, USA
- Division of General Internal Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Hope Olivia Ward
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Huw Williams
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Fiona Wood
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
| | - Liam Donaldson
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Adrian Edwards
- Primary Care Patient Safety (PISA) Research Group, Primary and Emergency Care Research (PRIME) Centre Wales, School of Medicine, Cardiff University, Wales, UK
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Patel S, Kai J, Atha C, Avery A, Guo B, James M, Malins S, Sampson C, Stubley M, Morriss R. Clinical characteristics of persistent frequent attenders in primary care: case-control study. Fam Pract 2015; 32:624-30. [PMID: 26450918 PMCID: PMC5926457 DOI: 10.1093/fampra/cmv076] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Most frequent attendance in primary care is temporary, but persistent frequent attendance is expensive and may be suitable for psychological intervention. To plan appropriate intervention and service delivery, there is a need for research involving standardized psychiatric interviews with assessment of physical health and health status. OBJECTIVE To compare the mental and physical health characteristics and health status of persistent frequent attenders (FAs) in primary care, currently and over the preceding 2 years, with normal attenders (NAs) matched by age, gender and general practice. METHODS Case-control study of 71 FAs (30 or more GP or practice nurse consultations in 2 years) and 71 NAs, drawn from five primary care practices, employing standardized psychiatric interview, quality of life, health anxiety and primary care electronic record review over the preceding 2 years. RESULTS Compared to NAs, FAs were more likely to report a lower quality of life (P < 0.001), be unmarried (P = 0.03) and have no educational qualifications (P = 0.009) but did not differ in employment status. FAs experienced greater health anxiety (P < 0.001), morbid obesity (P = 0.02), pain (P < 0.001) and long-term pathological and ill-defined physical conditions (P < 0.001). FAs had more depression including dysthymia, anxiety and somatoform disorders (all P < 0.001). CONCLUSIONS Persistent frequent attendance in primary care was associated with poor quality of life and high clinical complexity characterized by diverse and often persistent physical and mental multimorbidity. A brokerage model with GPs working in close liaison with skilled psychological therapists is required to manage such persistent complexity.
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Affiliation(s)
- Shireen Patel
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Joe Kai
- Division of Primary Care and
| | - Christopher Atha
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | | | - Boliang Guo
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Marilyn James
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Samuel Malins
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Christopher Sampson
- Health Economics, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Michelle Stubley
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands
| | - Richard Morriss
- Division of Psychiatry and Applied Psychology and CLAHRC East Midlands,
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Rees P, Edwards A, Panesar S, Powell C, Carter B, Williams H, Hibbert P, Luff D, Parry G, Mayor S, Avery A, Sheikh A, Donaldson SL, Carson-Stevens A. Safety incidents in the primary care office setting. Pediatrics 2015; 135:1027-35. [PMID: 25941305 DOI: 10.1542/peds.2014-3259] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [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] [Accepted: 03/19/2015] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND In the United Kingdom, 26% of child deaths have identifiable failures in care. Although children account for 40% of family physicians' workload, little is known about the safety of care in the community setting. Using data from a national patient safety incident reporting system, this study aimed to characterize the pediatric safety incidents occurring in family practice. METHODS We undertook a retrospective, cross-sectional, mixed methods study of pediatric reports submitted to the UK National Reporting and Learning System from family practice. Analysis involved detailed data coding using multiaxial frameworks, descriptive statistical analysis, and thematic analysis of a special-case sample of reports. Using frequency distributions and cross-tabulations, the relationships between incident types and contributory factors were explored. RESULTS Of 1788 reports identified, 763 (42.7%) described harm to children. Three crosscutting priority areas were identified: medication management, assessment and referral, and treatment. The 4 incident types associated with the most harmful outcomes are errors associated with diagnosis and assessment, delivery of treatment and procedures, referrals, and medication provision. Poor referral and treatment decisions in severely unwell or vulnerable children, along with delayed diagnosis and insufficient assessment of such children, featured prominently in incidents resulting in severe harm or death. CONCLUSION This is the first analysis of nationally collected, family practice-related pediatric safety incident reports. Recommendations to mitigate harm in these priority areas include mandatory pediatric training for all family physicians; use of electronic tools to support diagnosis, management, and referral decision-making; and use of technological adjuncts such as barcode scanning to reduce medication errors.
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Affiliation(s)
- Philippa Rees
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, Wales
| | - Adrian Edwards
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, Wales
| | - Sukhmeet Panesar
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, Scotland
| | - Colin Powell
- Institute of Molecular and Experimental Medicine, School of Medicine, Cardiff University, Cardiff, Wales
| | - Ben Carter
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, Wales
| | - Huw Williams
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, Wales
| | - Peter Hibbert
- Australian Institute of Health Innovation, Macquarie University, Sydney, New South Wales, Australia
| | - Donna Luff
- Department of Anaesthesia, Institute for Professionalism and Ethical Practice and Department of Anesthesia, Boston Children's Hospital, Boston, Massachusetts
| | - Gareth Parry
- Department of Pediatrics, and Institute for Healthcare Improvement, Cambridge, Massachusetts
| | - Sharon Mayor
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, Wales
| | - Anthony Avery
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Aziz Sheikh
- Centre for Medical Informatics, Usher Institute of Population Health Sciences and Informatics, The University of Edinburgh, Edinburgh, Scotland; Department of Medicine, Harvard Medical School, Boston, Massachusetts; Division of General Internal Medicine and Primary Care, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sir Liam Donaldson
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom; and
| | - Andrew Carson-Stevens
- Cochrane Institute of Primary Care and Public Health, Cardiff University, Cardiff, Wales; Department of Family Practice, University of British Columbia, Vancouver, British Columbia, Canada
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Barber J, Pallister C, Avery A, Lavin J. Investigating motivations for weight loss and benefits of attending a commercial weight management organisation post-natally. Appetite 2015. [DOI: 10.1016/j.appet.2014.12.141] [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: 11/30/2022]
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Avery A, Bostock L, McCullough F. A systematic review investigating interventions that can help reduce consumption of sugar-sweetened beverages in children leading to changes in body fatness. J Hum Nutr Diet 2014; 28 Suppl 1:52-64. [PMID: 25233843 PMCID: PMC4309175 DOI: 10.1111/jhn.12267] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [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] [Indexed: 11/26/2022]
Abstract
BACKGROUND Both the prevalence of childhood obesity and the consumption of sugar-sweetened beverages (SSBs) have increased globally. The present review describes interventions that reduce the consumption of SSBs in children and determines whether this leads to subsequent changes in body fatness. METHODS Three databases were searched from 2000 to August 2013. Only intervention control trials, ≥6 months in duration, which aimed to reduce the consumption of SSBs in >100 children aged 2-18 years, and reporting changes in body fatness, were included. The quality of selected papers was assessed. RESULTS Eight studies met inclusion criteria. Six interventions achieved significant (P < 0.05) reductions in SSB intake, although this was not always sustained. In the two interventions providing replacement drinks, significant differences in body mass index (12- or 18-month follow-up) were reported (P = 0.001 and 0.045). The risk of being overweight/obesity was reduced (P < 0.05) in three of the five education programmes but in one programme only for girls who were overweight at baseline and in one programme only for pupils perceived to be at greater risk at baseline. In the one study that included both provision of water and education, the risk of being overweight was reduced by 31% (P = 0.04) in the intervention group. CONCLUSIONS The evidence suggests that school-based education programmes focusing on reducing SSB consumption, but including follow-up modules, offer opportunities for implementing effective, sustainable interventions. Peer support and changing the school environment (e.g. providing water or replacement drinks) to support educational programmes could improve their effectiveness. Home delivery of more suitable drinks has a big impact on reducing SSB consumption, with associated reductions in body weight.
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Affiliation(s)
- A Avery
- Division of Nutritional Sciences, University of Nottingham, Leics, UK
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Anderson C, Kirkpatrick S, Avery A, Ziebland S. ‘I Can Be The Me I Want To Be By Taking an Antidepressant Regularly’: People’s Feelings About Taking Antidepressants. Res Social Adm Pharm 2014. [DOI: 10.1016/j.sapharm.2014.07.010] [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: 11/16/2022]
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Vopat B, Paller D, Machan JT, Avery A, Kane P, Christino M, Fadale P. Effectiveness of low-profile supplemental fixation in anterior cruciate ligament reconstructions with decreased bone mineral density. Arthroscopy 2013; 29:1540-5. [PMID: 23871386 DOI: 10.1016/j.arthro.2013.05.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [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: 10/22/2012] [Revised: 04/29/2013] [Accepted: 05/10/2013] [Indexed: 02/02/2023]
Abstract
PURPOSE The purpose of this study was to compare anterior cruciate ligament (ACL) fixation using a bioabsorbable interference screw (BIS) and a supplemental low-profile suture anchor (PushLock 4.5-mm polyetheretherketone anchor; Arthrex, Naples, FL) with a standard BIS fixation to determine if fixation methods were dependent on tibial bone mineral density (BMD). METHODS Ten matched pairs of fresh-frozen human female knee specimens (20 total) were harvested with specimen ages ranging from 40 to 65 years. The BMD for each specimen was determined with a dual-energy x-ray absorptiometry scanner. The specimens were divided into 2 groups, 1 with a BIS and the other with a BIS plus a PushLock. Tibial-sided ACL fixation with hamstring tendon grafts was performed on all the specimens. Then, load to failure and stiffness were biomechanically tested. RESULTS The BIS-plus-PushLock specimens had a significantly higher mean yield load compared with specimens with the BIS alone (702 N v 517 N, P = .047). However, in samples with lower bone density, there was no statistically significant difference in failure loads between fixation techniques (P = .8566 at BMD of 0.5 g/cm(2)). As the bone density of the samples increased, the failure loads increased for both techniques (P < .0001 for PushLock and P = .0057 for BIS). This BMD-associated increase was greater for the PushLock (P = .0148), resulting in a statistically significant difference in failure load at the upper range tested (P = .0293 at BMD of 0.9 g/cm(2)). CONCLUSIONS Supplemental fixation of ACL reconstructions with a PushLock is beneficial in persons with a normal BMD of the proximal tibia, but at a lower BMD, there was no difference in our study. CLINICAL RELEVANCE Individuals with normal BMDs may benefit from this supplemental fixation. However, caution should be used in postmenopausal women or individuals with chronic ACL injuries when using this fixation strategy.
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Affiliation(s)
- Bryan Vopat
- Warren Alpert Medical School at Brown University/Rhode Island Hospital, Providence, Rhode Island, USA.
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