Are children living with obesity more likely to experience musculoskeletal symptoms during childhood? A linked longitudinal cohort study using primary care records

OBJECTIVE

To assess whether there is a higher incidence of musculoskeletal consultations in general practice among children with obesity.

DESIGN

Longitudinal SETTING: 285 north-east London general practitioners (GPs).

PARTICIPANTS

63 418 (50.9% boys) Reception and 55 364 (50.8% boys) Year 6 National Child Measurement Programme (NCMP) participants, linked to GP electronic health records (EHRs).

MAIN OUTCOME MEASURE

A GP consultation with a recorded musculoskeletal symptom or diagnosis.

METHODS

We calculated proportions with a musculoskeletal consultation by ethnic-adjusted weight status (underweight <2nd; overweight ≥91st; obese ≥98th centile), sex, ethnicity, and area-level deprivation. We estimated mutually-adjusted hazard ratios (HR) and 95% confidence intervals (95% CI) using Cox's proportional regression models stratified by school year and sex.

RESULTS

We identified 1868 (3.0%) Reception and 4477 (8.1%) Year 6 NCMP participants with at least one musculoskeletal consultation. In adjusted analyses, Reception year girls with a body mass index (BMI) classified as overweight (HR 1.24, 95% CI 1.02 to 1.52) or obese (HR 1.67, 95% CI 1.35 to 2.06) were more likely to have at least one musculoskeletal consultation. Year 6 girls with obesity were more likely (HR 1.20, 95% CI 1.07 to 1.35), and boys with a BMI in the underweight range were less likely (HR 0.39, 95% CI 0.21 to 0.73), to have a musculoskeletal consultation.

CONCLUSIONS

Girls living with obesity at the start or end of primary school are more likely to attend their GP for a musculoskeletal consultation. Routine linkage of NCMP data to EHRs provides useful insights into childhood health conditions related to excess weight in early childhood. Recognition of obesity as a contributing factor for musculoskeletal symptoms may inform clinical management, particularly in girls.

Making ends meet - relating a self-reported indicator of financial hardship to health status

BACKGROUND

Area-based index of multiple deprivation (IMD) indicators of financial hardship lack individual specificity and sensitivity. This study compared self-reports of hardship with area measures in relation to health status.

METHODS

Interviews in one London Borough, reported financial hardship and health status. Associations of health status with most and least deprived quintiles of the IMD 2015 were compared with self-reported hardship; always or sometimes 'having difficulty making ends meet at the end of the month' in relation to never.

RESULTS

1024 interviews reported hardship status in 1001 (98%). 392 people (39%) reported they 'always' or 'sometimes' had hardship. In multivariate analysis, self-reported hardship was more strongly associated with smoking; odds ratio = 5.4 (95% CI: 2.8-10.4) compared with IMD, odds ratio = 1.9 (95% CI: 1.2-3.2). Health impairment was also more likely with self-reported hardship, odds ratio = 11.1 (95% CI: 4.9-25.4) compared with IMD; odds ratio = 2.7 (95% CI: 1.4-5.3). Depression was similarly related; odds ratio = 2.4 (95% CI: 1.0-5.6) and 2.7 (95% CI: 1.2-6.6), respectively.

CONCLUSIONS

Self-reported hardship was more strongly related to health status than area-based indicators. Validity and implementation in routine health care settings remains to be established.

Impact of the COVID-19 pandemic on timeliness and equity of measles, mumps and rubella vaccinations in North East London: a longitudinal study using electronic health records

OBJECTIVES

To quantify the effect of the COVID-19 pandemic on the timeliness of, and geographical and sociodemographic inequalities in, receipt of first measles, mumps and rubella (MMR) vaccination.

DESIGN

Longitudinal study using primary care electronic health records.

SETTING

285 general practices in North East London.

PARTICIPANTS

Children born between 23 August 2017 and 22 September 2018 (pre-pandemic cohort) or between 23 March 2019 and 1 May 2020 (pandemic cohort).

MAIN OUTCOME MEASURE

Receipt of timely MMR vaccination between 12 and 18 months of age.

METHODS

We used logistic regression to estimate the ORs (95% CIs) of receipt of a timely vaccination adjusting for sex, deprivation, ethnic background and Clinical Commissioning Group. We plotted choropleth maps of the proportion receiving timely vaccinations.

RESULTS

Timely MMR receipt fell by 4.0% (95% CI: 3.4% to 4.6%) from 79.2% (78.8% to 79.6%) to 75.2% (74.7% to 75.7%) in the pre-pandemic (n=33 226; 51.3% boys) and pandemic (n=32 446; 51.4%) cohorts, respectively. After adjustment, timely vaccination was less likely in the pandemic cohort (0.79; 0.76 to 0.82), children from black (0.70; 0.65 to 0.76), mixed/other (0.77; 0.72 to 0.82) or with missing (0.77; 0.74 to 0.81) ethnic background, and more likely in girls (1.07; 1.03 to 1.11) and those from South Asian backgrounds (1.39; 1.30 to 1.48). Children living in the least deprived areas were more likely to receive a timely MMR (2.09; 1.78 to 2.46) but there was no interaction between cohorts and deprivation (Wald statistic: 3.44; p=0.49). The proportion of neighbourhoods where less than 60% of children received timely vaccination increased from 7.5% to 12.7% during the pandemic.

CONCLUSIONS

The COVID-19 pandemic was associated with a significant fall in timely MMR receipt and increased geographical clustering of measles susceptibility in an area of historically low and inequitable MMR coverage. Immediate action is needed to avert measles outbreaks and support primary care to deliver timely and equitable vaccinations.

Are children living with obesity more likely to consult their general practitioner for knee pain? Longitudinal analysis of linked primary care and National Child Measurement Programme (NCMP) records

ObjectivesMore than one in four 11-year-old children in England are living with obesity. The implications for future musculoskeletal health remain unclear. We assessed whether general practitioner consultations for knee pain were more likely among children with obesity, and how this varied by sex, ethnic background, and area-level deprivation. ApproachOf 61,478 11-year-old NCMP participants (2013-19), we linked 60,723 (98.8%) to their primary care records. 58,761 children (50.9% male) had no recorded knee pain consultation (including arthralgia and Osgood-Schlatter’s disease) prior to the NCMP measurement date. We calculated the proportion with a consultation for knee pain by ethnic-adjusted weight status (underweight<2nd; overweight≥91st; obese≥98th centile), sex, ethnic background and Index of Multiple Deprivation quintile. We studied time to first general practitioner consultation for knee pain after the NCMP date by fitting Cox proportional hazards models, estimating mutually-adjusted hazard ratios (aHRs) and 95% confidence intervals (CI) for boys and girls separately. ResultsWe identified 2503 (4.3%) children with at least one consultation for knee pain after the NCMP date. Boys were more likely to consult than girls (mean difference 1.5%; 95% CI: 1.2,1.9). Median time to first knee pain consultation was 1.88 years (IQR: 0.94,2.93). In adjusted analyses, boys with underweight (aHR 0.16; 95% CI: 0.05,0.51), from South Asian ethnic backgrounds (0.80; 0.69,0.92) and living in less deprived areas (Wald test statistic: 11.41; p-value=0.0223) were less likely, and those from Black ethnic backgrounds (1.31; 1.13,1.51) more likely, to consult with knee pain. Girls from South Asian ethnic backgrounds (0.70; 0.59,0.84) and those living in less deprived areas (15.44; p-value=0.0039) were less likely, and those with a BMI considered obese (1.30; 1.10,1.54) more likely to do so. ConclusionAdolescent girls, but not boys, living with obesity are more likely to consult their general practitioner with knee pain. Ethnic differences in knee pain consultations merit further study. Linkage of primary care and NCMP records enables greater understanding of health service utilisation by children by weight status and demographic characteristics.

Obesity Predicts Liver Function Testing and Abnormal Liver Results

OBJECTIVE

Abnormal liver function tests in children and young people (CYP) predict a greater burden of liver disease in adulthood, especially in the context of obesity. This study aimed to determine whether obesity and metabolic risk factors predict liver function testing and abnormal liver test results in CYP.

METHODS

This was a retrospective cross-sectional population study using electronic health care records from 257,746 CYP aged 10 to 25 years who were registered with 170 contiguous general practices in London, UK. Demographic and clinical data were extracted, including serum alanine aminotransferase (ALT) tests between 2015 and 2017. BMI category thresholds were adjusted according to age group and ethnicity.

RESULTS

Fourteen percent of CYP had ALT measured, of whom 5.4% had abnormal results; 36.3% had BMI indicating overweight or obesity. Nonalcoholic fatty liver disease was the most common liver diagnosis. Multivariate analyses demonstrated that overweight or obesity was an independent predictor of ALT testing in young people (ages 18-25) but not in children (ages 10-17) and of abnormal test results in all CYP, irrespective of ALT threshold.

CONCLUSIONS

Overweight and obesity are predictors of liver testing (not in children) and abnormal test results, irrespective of ALT threshold. Given the rising prevalence of metabolic dysfunction, a coordinated strategy is needed for liver testing and interpreting results in this young population.

Occupational Therapy Treatment to Improve Upper Extremity Function in Individuals with Early Systemic Sclerosis: A Pilot Study

OBJECTIVE

To determine the feasibility and preliminary effects of occupational therapy to improve upper extremity function in patients with early systemic sclerosis (SSc; scleroderma) who have upper extremity contractures.

METHODS

A single-group pilot clinical rehabilitation trial was conducted at the University of Michigan Scleroderma Center. Patients with SSc and ≥1 upper extremity contracture (n = 21) participated in a total of 8 weekly in-person occupational therapy sessions. The therapy consisted of thermal modalities, tissue mobilization, and upper extremity mobility exercises. The participants were instructed to perform upper extremity exercises at home between sessions. Feasibility was measured by the percent enrollment as well as session attendance and session duration. The primary outcome measure was the Shortened Disabilities of the Arm, Shoulder and Hand measure (QuickDASH); secondary and exploratory outcomes included the Patient-Reported Outcomes Measurement Information System (PROMIS) physical function measures; objective measures of upper extremity mobility, strength, and coordination; and skin thickening. Linear mixed models were used to determine the effects of treatment on the primary and secondary outcomes.

RESULTS

Fifty percent of potentially eligible subjects (24 of 48) were interested in participating. Twenty-one (88%) of the 24 subjects were enrolled, and 19 (91%) of these 21 subjects completed all sessions. The mean ± SD age of the participants was 47.9 ± 16.1 years; 100% had diffuse SSc, and the mean disease duration was 3.1 years. At 8 weeks, participants had statistically significant improvement in the QuickDASH and PROMIS physical function measure (P = 0.0012 and P = 0.004, respectively). Approximately one-half of participants in the sample achieved improvement in the QuickDASH and PROMIS measure that exceeded minimally important differences.

CONCLUSION

In-person treatment sessions were feasible in the patients with SSc and resulted in statistically significant and clinically meaningful improvements in upper extremity and physical function. In future studies, the effects of SSc should be compared with those in a control condition, and the durability of treatment effects should be examined.

Reliability, construct validity and responsiveness to change of the PROMIS-29 in systemic sclerosis-associated interstitial lung disease

OBJECTIVES

PROMIS-29 is a generic health-related quality of life instrument. Our objective was to assess the reliability, construct validity, and responsiveness to change of PROMIS-29 in systemic sclerosis-associated interstitial lung disease (SSc-ILD).

METHODS

Seventy-three participants with SSc-ILD were administered patient reported outcomes (PROs) at baseline and follow-up visits which included PROMIS-29 and other measures of generic health, dyspnea, and cough instruments. We assessed internal consistency reliability using Cronbach's α, an alpha of ≥ 0.70 was considered satisfactory. We assessed the responsiveness to change using linear regression models.

RESULTS

Mean age of the participants was 51.9 years and the mean disease duration was 7.9 years after first non-Raynaud's symptom. Of the 73 participants, 56.2% were classified as diffuse SSc and 26% limited SSc. The baseline (mean ± SD) FVC % predicted was 73.9±15.5 with a DLCO % predicted of 57.7±21.1; 95.9% had fibrotic NSIP pattern on HRCT. PROMIS-29 scores were 0.2 to 0.9 SD below the US population. Cronbach's α reliability was acceptable for all domains (ranged from 0.77 to 0.98). All scales showed statistically significant correlations with hypothesised PROMIS-29 domains (p≤0.05 for all comparisons). PROMIS-29 showed none-to-small discriminatory ability in comparison with physiologic measures (FVC and DLCO). There was no significant relationship between the change in FVC versus the change in PROMIS-29 measures over time.

CONCLUSIONS

PROMIS-29 has adequate reliability and construct validity for evaluation in SSc-ILD. It has moderate-to-large correlations with other PROs. The PROMIS-29 domains were not found to change over time in this cohort, likely due to stable nature of the observational cohort.

Predictors of late presentation to renal dialysis: a cohort study of linked primary and secondary care records in East London

OBJECTIVES

The outcomes and experience of care for patients who start renal replacement therapy (RRT) in an unplanned manner are worse than for those who have planned care. The objective of this study was to examine the primary care predictors of unplanned starts to RRT.

DESIGN

Retrospective cohort study with linked primary care and hospital data.

SETTING

128 general practices in East London with a combined population of 1 043 346 people.

PARTICIPANTS

999 consecutive patients starting dialysis at Barts Health National Health Service Trust between September 2014 and August 2017.

PRIMARY OUTCOME MEASURES

Unplanned versus a planned start to dialysis among the cohort of 389 patients with a linked primary care record. An unplanned start to dialysis is defined as receiving nephrology care in the low clearance clinic (or equivalent) for less than 90 days. A planned start is defined as access to pre-dialysis counselling and care for at least 90 days prior to commencing dialysis.

RESULTS

The adjusted logistic regression analysis showed that the most important modifiable risk factors for unplanned dialysis were the absence of a chronic kidney disease (CKD) code in the general practice (GP) record (OR 8.02, 95% CI 3.65 to 17.63) and the absence of prescribed lipid lowering medication (OR 2.37, 95% CI 1.05 to 5.34). Other contributing factors included male gender and a greater number of long-term conditions.

CONCLUSIONS

Improving CKD coding in primary care and the additional review and clinical scrutiny associated with this may contribute to a further reduction in unplanned RRT rates.

Prevalence, Treatment, and Outcomes of Coexistent Pulmonary Hypertension and Interstitial Lung Disease in Systemic Sclerosis

OBJECTIVE

Systemic sclerosis (SSc) is associated with interstitial lung disease (ILD) and pulmonary hypertension (PH). This study was undertaken to determine the prevalence, characteristics, treatment, and outcomes of PH in a cohort of patients with SSc-associated ILD.

METHODS

Patients with SSc-associated ILD on high-resolution computed tomography (HRCT) were included in a prospective observational cohort. Patients were screened for PH based on a standardized screening algorithm and underwent right-sided heart catheterization (RHC) if indicated. PH classification was based on hemodynamic findings and the extent of ILD on HRCT. Summary statistics and survival using the Kaplan-Meier method were calculated.

RESULTS

Of the 93 patients with SSc-associated ILD included in the study, 76% were women and 65.6% had diffuse cutaneous SSc. The mean age was 54.9 years, and the mean SSc disease duration was 8 years. Twenty-nine patients (31.2%) had RHC-proven PH; of those 29 patients, 24.1% had PAH, 55.2% had World Health Organization (WHO) Group III PH, 34.5% had WHO Group III PH with pulmonary vascular resistance >3.0 Wood units, 48.3% had a PH diagnosis within 7 years of SSc onset, 82.8% received therapy for ILD, and 82.8% received therapy for PAH. The survival rate 3 years after SSc-associated ILD diagnosis for all patients was 97%. The survival rate 3 years after PH diagnosis for those with SSc-associated ILD and PH was 91%.

CONCLUSION

In a large cohort of patients with SSc-associated ILD, a significant proportion of patients had coexisting PH, which often occurs early after SSc diagnosis. Most patients were treated with ILD and PAH therapies, and survival was good. Patients with SSc-associated ILD should be evaluated for coexisting PH.

Opioid prescribing for chronic musculoskeletal pain in UK primary care: results from a cohort analysis of the COPERS trial

OBJECTIVE

To establish the level of opioid prescribing for patients with chronic musculoskeletal pain in a sample of patients from primary care and to estimate prescription costs.

DESIGN

Secondary data analyses from a two-arm pragmatic randomised controlled trial (COPERS) testing the effectiveness of group self-management course and usual care against relaxation and usual care for patients with chronic musculoskeletal pain (ISRCTN 24426731).

SETTING

25 general practices and two community musculoskeletal services in the UK (London and Midlands).

PARTICIPANTS

703 chronic pain participants; 81% white, 67% female, enrolled in the COPERS trial.

MAIN OUTCOME MEASURES

Anonymised prescribing data over 12 months extracted from GP electronic records.

RESULTS

Of the 703 trial participants with chronic musculoskeletal pain, 413 (59%) patients were prescribed opioids. Among those prescribed an opioid, the number of opioid prescriptions varied from 1 to 52 per year. A total of 3319 opioid prescriptions were issued over the study period, of which 53% (1768/3319) were for strong opioids (tramadol, buprenorphine, morphine, oxycodone, fentanyl and tapentadol). The mean number of opioid prescriptions per patient prescribed any opioid was 8.0 (SD=7.9). A third of patients on opioids were prescribed more than one type of opioid; the most frequent combinations were: codeine plus tramadol and codeine plus morphine. The cost of opioid prescriptions per patient per year varied from £3 to £4844. The average annual prescription cost was £24 (SD=29) for patients prescribed weak opioids and £174 (SD=421) for patients prescribed strong opioids. Approximately 40% of patients received >3 prescriptions of strong opioids per year, with an annual cost of £236 per person.

CONCLUSIONS

Long-term prescribing of opioids for chronic musculoskeletal pain is common in primary care. For over a quarter of patients receiving strong opioids, these drugs may have been overprescribed according to national guidelines.

TRIAL REGISTRATION NUMBER

ISRCTN24426731; Post-results.

Improving the self-management of chronic pain: COping with persistent Pain, Effectiveness Research in Self-management (COPERS)

Background

Chronic musculoskeletal pain is a common problem that is difficult to treat. Self-management support interventions may help people to manage this condition better; however, there is limited evidence showing that they improve clinical outcomes. Our overarching research question was ‘Does a self-management support programme improve outcomes for people living with chronic musculoskeletal pain?’.

Aim

To develop, evaluate and test the clinical effectiveness and cost-effectiveness of a theoretically grounded self-management support intervention for people living with chronic musculoskeletal pain.

Methods

In phase 1 we carried out two systematic reviews to synthesise the evidence base for self-management course content and delivery styles likely to help those with chronic pain. We also considered the psychological theories that might underpin behaviour change and pain management principles. Informed by these data we developed the Coping with persistent Pain, Evaluation Research in Self-management (COPERS) intervention, a group intervention delivered over 3 days with a top-up session after 2 weeks. It was led by two trained facilitators: a health-care professional and a layperson with experience of chronic pain. To ensure that we measured the most appropriate outcomes we reviewed the literature on potential outcome domains and measures and consulted widely with patients, tutors and experts. In a feasibility study we demonstrated that we could deliver the COPERS intervention in English and, to increase the generalisability of our findings, also in Sylheti for the Bangladeshi community. In phase 2 we ran a randomised controlled trial to test the clinical effectiveness and cost-effectiveness of adding the COPERS intervention to a best usual care package (usual care plus a relaxation CD and a pain toolkit leaflet). We recruited adults with chronic musculoskeletal pain largely from primary care and musculoskeletal physiotherapy services in two localities: east London and Coventry/Warwickshire. We collected follow-up data at 12 weeks (self-efficacy only) and 6 and 12 months. Our primary outcome was pain-related disability (Chronic Pain Grade disability subscale) at 12 months. We also measured costs, health utility (European Quality of Life-5 Dimensions), anxiety, depression [Hospital Anxiety and Depression Scale (HADS)], coping, pain acceptance and social integration. Data on the use of NHS services by participants were extracted from NHS electronic records.

Results

We recruited 703 participants with a mean age of 60 years (range 19–94 years); 81% were white and 67% were female. Depression and anxiety symptoms were common, with mean HADS depression and anxiety scores of 7.4 [standard deviation (SD) 4.1] and 9.2 (SD 4.6), respectively. Intervention participants received 85% of the course content. At 12 months there was no difference between treatment groups in our primary outcome of pain-related disability [difference –1.0 intervention vs. control, 95% confidence interval (CI) –4.9 to 3.0]. However, self-efficacy, anxiety, depression, pain acceptance and social integration all improved more in the intervention group at 6 months. At 1 year these differences remained for depression (–0.7, 95% CI –1.2 to –0.2) and social integration (0.8, 95% CI, 0.4 to 1.2). The COPERS intervention had a high probability (87%) of being cost-effective compared with usual care at a threshold of £30,000 per quality-adjusted life-year.

Conclusions

Although the COPERS intervention did not affect our primary outcome of pain-related disability, it improved psychological well-being and is likely to be cost-effective according to current National Institute for Health and Care Excellence criteria. The COPERS intervention could be used as a substitute for less well-evidenced (and more expensive) pain self-management programmes. Effective interventions to improve hard outcomes in chronic pain patients, such as disability, are still needed.

Trial registration

Current Controlled Trials ISRCTN22714229.

Funding

The project was funded by the National Institute for Health Research Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 4, No. 14. See the NIHR Journals Library website for further project information.

Novel Three-Day, Community-Based, Nonpharmacological Group Intervention for Chronic Musculoskeletal Pain (COPERS): A Randomised Clinical Trial

BACKGROUND

Chronic musculoskeletal pain is the leading cause of disability worldwide. The effectiveness of pharmacological treatments for chronic pain is often limited, and there is growing concern about the adverse effects of these treatments, including opioid dependence. Nonpharmacological approaches to chronic pain may be an attractive alternative or adjunctive treatment. We describe the effectiveness of a novel, theoretically based group pain management support intervention for chronic musculoskeletal pain.

METHODS AND FINDINGS

We conducted a multi-centre, pragmatic, randomised, controlled effectiveness and cost-effectiveness (cost-utility) trial across 27 general practices and community musculoskeletal services in the UK. We recruited 703 adults with musculoskeletal pain of at least 3 mo duration between August 1, 2011, and July 31, 2012, and randomised participants 1.33:1 to intervention (403) or control (300). Intervention participants were offered a participative group intervention (COPERS) delivered over three alternate days with a follow-up session at 2 wk. The intervention introduced cognitive behavioural approaches and was designed to promote self-efficacy to manage chronic pain. Controls received usual care and a relaxation CD. The primary outcome was pain-related disability at 12 mo (Chronic Pain Grade [CPG] disability subscale); secondary outcomes included the CPG disability subscale at 6 mo and the following measured at 6 and 12 mo: anxiety and depression (Hospital Anxiety and Depression Scale [HADS]), pain acceptance (Chronic Pain Acceptance Questionnaire), social integration (Health Education Impact Questionnaire social integration and support subscale), pain-related self-efficacy (Pain Self-Efficacy Questionnaire), pain intensity (CPG pain intensity subscale), the census global health question (2011 census for England and Wales), health utility (EQ-5D-3L), and health care resource use. Analyses followed the intention-to-treat principle, accounted for clustering by course in the intervention arm, and used multiple imputation for missing or incomplete primary outcome data. The mean age of participants was 59.9 y, with 81% white, 67% female, 23% employed, 85% with pain for at least 3 y, and 23% on strong opioids. Symptoms of depression and anxiety were common (baseline mean HADS scores 7.4 [standard deviation 4.1] and 9.2 [4.6], respectively). Overall, 282 (70%) intervention participants met the predefined intervention adherence criterion. Primary outcome data were obtained from 88% of participants. There was no significant difference between groups in pain-related disability at 6 or 12 mo (12 mo: difference -1.0, intervention versus control, 95% CI -4.9 to 3.0), pain intensity, or the census global health question. Anxiety, depression, pain-related self-efficacy, pain acceptance, and social integration were better in the intervention group at 6 mo; at 12 mo, these differences remained statistically significant only for depression (-0.7, 95% CI -1.2 to -0.2) and social integration (0.8, 95% CI 0.4 to 1.2). Intervention participants received more analgesics than the controls across the 12 mo. The total cost of the course per person was £145 (US$214). The cost-utility analysis showed there to be a small benefit in terms of quality-adjusted life years (QALYs) (0.0325, 95% CI -0.0074 to 0.0724), and on the cost side the intervention was a little more expensive than usual care (i.e., £188 [US$277], 95% CI -£125 [-US$184] to £501 [US$738]), resulting in an incremental cost-effectiveness ratio of £5,786 (US$8,521) per QALY. Limitations include the fact that the intervention was relatively brief and did not include any physical activity components.

CONCLUSIONS

While the COPERS intervention was brief, safe, and inexpensive, with a low attrition rate, it was not effective for reducing pain-related disability over 12 mo (primary outcome). For secondary outcomes, we found sustained benefits on depression and social integration at 6 and 12 mo, but there was no effect on anxiety, pain-related self-efficacy, pain acceptance, pain intensity, or the census global health question at 12 mo. There was some evidence that the intervention may be cost-effective based on a modest difference in QALYs between groups.

TRIAL REGISTRATION

ISRCTN Registry 24426731.

Evaluating a DVD promoting breast cancer awareness among black women aged 25-50 years in East London

BACKGROUND

The mean age of presentation for breast cancer among black women is substantially earlier than their white counterparts. Black women also present with adverse prognostic factors that have major clinical implications, including lower survival. To pilot the use of a 6 min DVD on breast cancer in young (under 50 years) black women, to raise awareness and examine the impact of the DVD on increased consultation and referral rates among these women.

METHODS

Two general practices (intervention practices) in the Hackney area were randomised to have the DVD mailed to all black women aged 25-50 years registered with the practices, and two practices to no intervention (control practices). EMIS data was used to compare consultation rates preintervention and postintervention, in the intervention as well as control practices. Interviews with practice staff and focus groups with patients in participating practices provided qualitative data on the study context and DVD effectiveness.

RESULTS

A trend of declining consultations for breast symptoms was observed (-22% and -31% among non-black women in the control and intervention practices, and -23% among black women in the control practice) except among the target population of black women aged 25-50 years for the DVD in the intervention practices, which saw an increase of 28% in consultations. The qualitative data indicated that the DVD was well received in the target population, and suggested further ways of disseminating awareness messages and overcoming barriers to help-seeking.

CONCLUSIONS

Pilot results suggest that the strategy of distributing the DVD may increase consultations for breast problems.

Statin prescribing for primary prevention of cardiovascular disease: a cross-sectional, observational study

BACKGROUND

The updated (2014) National Institute for Health and Care Excellence (NICE) guideline lowered the recommended threshold for statin prescription from 20% to 10% 10-year cardiovascular disease (CVD) risk.

AIM

To determine the characteristics of patients prescribed statins for primary prevention according to their CVD risk.

DESIGN AND SETTING

Cross-sectional study in primary care settings in the three east London CCGs (Newham, City and Hackney, and Tower Hamlets).

METHOD

Data were extracted from electronic health records of 930 000 patients registered with 137 of 141 general practices for a year ending 1 April 2014.

RESULTS

Of 341 099 patients aged 30-74 years, excluding those with CVD or diabetes, 22 393 were prescribed statins and had a 10-year CVD risk recorded. Of these, 9828 (43.9%) had a CVD risk ≥20%, 7121 (31.8%) had a CVD risk of 10-19%, and 5444 (24.3%) had a CVD risk <10%. Statins were prescribed to 9828/19 755 (49.7%) of those at ≥20% CVD risk, to 7121/37 111 (19.2%) of those with CVD risk 10-19%, and to 5444/146 676 (3.7%) of those with CVD risk <10%. Statin prescription below the 20% CVD risk threshold targeted individuals in the 10-19% risk band in association with hypertension, high serum cholesterol, positive family history, older age, and south Asian ethnicity.

CONCLUSION

This study confirms continuing undertreatment of patients at highest CVD risk (≥20%). GPs prescribed statins to only one-fifth of those in the 10-19% risk band usually in association with known major risk factors. Only 3.7% of individuals below 10% were prescribed statins.

Coping with persistent pain, effectiveness research into self-management (COPERS): statistical analysis plan for a randomised controlled trial

BACKGROUND

The Coping with Persistent Pain, Effectiveness Research into Self-management (COPERS) trial assessed whether a group-based self-management course is effective in reducing pain-related disability in participants with chronic musculoskeletal pain. This article describes the statistical analysis plan for the COPERS trial.

METHODS AND DESIGN

COPERS was a pragmatic, multicentre, unmasked, parallel group, randomised controlled trial. This article describes (a) the overall analysis principles (including which participants will be included in each analysis, how results will be presented, which covariates will be adjusted for, and how we will account for clustering in the intervention group); (b) the primary and secondary outcomes, and how each outcome will be analysed; (c) sensitivity analyses; (d) subgroup analyses; and (e) adherence-adjusted analyses.

TRIAL REGISTRATION

ISRCTN24426731.

Fidelity in complex behaviour change interventions: a standardised approach to evaluate intervention integrity

OBJECTIVES

The aim of this study was to (1) demonstrate the development and testing of tools and procedures designed to monitor and assess the integrity of a complex intervention for chronic pain (COping with persistent Pain, Effectiveness Research into Self-management (COPERS) course); and (2) make recommendations based on our experiences.

DESIGN

Fidelity assessment of a two-arm randomised controlled trial intervention, assessing the adherence and competence of the facilitators delivering the intervention.

SETTING

The intervention was delivered in the community in two centres in the UK: one inner city and one a mix of rural and urban locations.

PARTICIPANTS

403 people with chronic musculoskeletal pain were enrolled in the intervention arm and 300 attended the self-management course. Thirty lay and healthcare professionals were trained and 24 delivered the courses (2 per course). We ran 31 courses for up to 16 people per course and all were audio recorded.

INTERVENTIONS

The course was run over three and a half days; facilitators delivered a semistructured manualised course.

OUTCOMES

We designed three measures to evaluate fidelity assessing adherence to the manual, competence and overall impression.

RESULTS

We evaluated a random sample of four components from each course (n=122). The evaluation forms were reliable and had good face validity. There were high levels of adherence in the delivery: overall adherence was two (maximum 2, IQR 1.67-2.00), facilitator competence exhibited more variability, and overall competence was 1.5 (maximum 2, IQR 1.25-2.00). Overall impression was three (maximum 4, IQR 2.00-3.00).

CONCLUSIONS

Monitoring and assessing adherence and competence at the point of intervention delivery can be realised most efficiently by embedding the principles of fidelity measurement within the design stage of complex interventions and the training and assessment of those delivering the intervention. More work is necessary to ensure that more robust systems of fidelity evaluation accompany the growth of complex interventions.

TRIAL REGISTRATION ISRCTN NO

ISRCTN24426731.

Pain management for chronic musculoskeletal conditions: the development of an evidence-based and theory-informed pain self-management course

OBJECTIVE

To devise and test a self-management course for chronic pain patients based on evidence and underpinned by theory using the Medical Research Council (MRC) framework for developing complex interventions.

DESIGN

We used a mixed method approach. We conducted a systematic review of the effectiveness of components and characteristics of pain management courses. We then interviewed chronic pain patients who had attended pain and self-management courses. Behavioural change theories were mapped onto our findings and used to design the intervention. We then conducted a feasibility study to test the intervention.

SETTING

Primary care in the inner city of London, UK.

PARTICIPANTS

Adults (18 years or older) with chronic musculoskeletal pain.

OUTCOMES

Related disability, quality of life, coping, depression, anxiety, social integration and healthcare resource use.

RESULTS

The systematic reviews indicated that group-based courses with joint lay and healthcare professional leadership and that included a psychological component of short duration (<8 weeks) showed considerable promise. The qualitative research indicated that participants liked relaxation, valued social interaction and course location, and that timing and good tutoring were important determinants of attendance. We used behavioural change theories (social learning theory and cognitive behaviour approaches (CBA)) to inform course content. The course addressed: understanding and accepting pain, mood and pain, unhelpful thoughts and behaviour, problem solving, goal setting, action planning, movement, relaxation and social integration/reactivation. Attendance was 85%; we modified the recruitment of patients, the course and the training of facilitators as a result of testing.

CONCLUSIONS

The MRC guidelines were helpful in developing this intervention. It was possible to train both lay and non-psychologists to facilitate the courses and deliver CBA. The course was feasible and well received.

Effectiveness and cost-effectiveness of a novel, group self-management course for adults with chronic musculoskeletal pain: study protocol for a multicentre, randomised controlled trial (COPERS)

INTRODUCTION

Chronic musculoskeletal pain is a common condition that often responds poorly to treatment. Self-management courses have been advocated as a non-drug pain management technique, although evidence for their effectiveness is equivocal. We designed and piloted a self-management course based on evidence for effectiveness for specific course components and characteristics.

METHODS/ANALYSIS

COPERS (coping with persistent pain, effectiveness research into self-management) is a pragmatic randomised controlled trial testing the effectiveness and cost-effectiveness of an intensive, group, cognitive behavioural-based, theoretically informed and manualised self-management course for chronic pain patients against a control of best usual care: a pain education booklet and a relaxation CD. The course lasts for 15 h, spread over 3 days, with a -2 h follow-up session 2 weeks later. We aim to recruit 685 participants with chronic musculoskeletal pain from primary, intermediate and secondary care services in two UK regions. The study is powered to show a standardised mean difference of 0.3 in the primary outcome, pain-related disability. Secondary outcomes include generic health-related quality of life, healthcare utilisation, pain self-efficacy, coping, depression, anxiety and social engagement. Outcomes are measured at 6 and 12 months postrandomisation. Pain self-efficacy is measured at 3 months to assess whether change mediates clinical effect.

ETHICS/DISSEMINATION

Ethics approval was given by Cambridgeshire Ethics 11/EE/046. This trial will provide robust data on the effectiveness and cost-effectiveness of an evidence-based, group self-management programme for chronic musculoskeletal pain. The published outcomes will help to inform future policy and practice around such self-management courses, both nationally and internationally.

TRIAL REGISTRATION

ISRCTN24426731.

Evidence for non-communicable diseases: analysis of Cochrane reviews and randomised trials by World Bank classification

INTRODUCTION

Prevalence of non-communicable diseases (NCDs) is increasing globally, with the greatest projected increases in low-income and middle-income countries. We sought to quantify the proportion of Cochrane evidence relating to NCDs derived from such countries.

METHODS

We searched the Cochrane database of systematic reviews for reviews relating to NCDs highlighted in the WHO NCD action plan (cardiovascular, cancers, diabetes and chronic respiratory diseases). We excluded reviews at the protocol stage and those that were repeated or had been withdrawn. For each review, two independent researchers extracted data relating to the country of the corresponding author and the number of trials and participants from countries, using the World Bank classification of gross national income per capita.

RESULTS

797 reviews were analysed, with a reported total number of 12 340 trials and 10 937 306 participants. Of the corresponding authors 90% were from high-income countries (41% from the UK). Of the 746 reviews in which at least one trial had met the inclusion criteria, only 55% provided a summary of the country of included trials. Analysis of the 633 reviews in which country of trials could be established revealed that almost 90% of trials and over 80% of participants were from high-income countries. 438 (5%) trials including 1 145 013 (11.7%) participants were undertaken in low-middle income countries. We found that only 13 (0.15%) trials with 982 (0.01%) participants were undertaken in low-income countries. Other than the five Cochrane NCD corresponding authors from South Africa, only one other corresponding author was from Africa (Gambia).

DISCUSSION

The overwhelming body of evidence for NCDs pertains to high-income countries, with only a small number of review authors based in low-income settings. As a consequence, there is an urgent need for research infrastructure and funding for the undertaking of high-quality trials in this area.

In vitro comparison of two NONOates (novel nitric oxide donors) on rat pulmonary arteries

The pulmonary vasorelaxant properties of two NONOates (diazeniumdiolates) were examined because this novel group of nitric oxide (NO) donors may be useful in pulmonary hypertension. MAHMA NONOate ((Z)-1-¿N-Methyl-N-[6-(N-methylammoniohexyl)amino]¿ diazen-1-ium-1,2-diolate) and spermine NONOate ((Z)- 1-¿N-[3-aminopropyl]-N-[4-(3-aminopropylammonio)butyl]-amino¿di azen-1-ium-1,2-diolate) decomposed at different rates (half-lives 1.3 min and 73 min, respectively; 37 degrees C, pH 7.3) but generated the same total amount of NO. They fully relaxed submaximally contracted ring preparations of main and intralobar pulmonary arteries from rats. Responses were inhibited by the guanylate cyclase inhibitor, ODQ (1H-[1,2,4]Oxadiazolo[4,3-a]quinoxalin-1-one). Potency was not affected by choice of contractile spasmogen (phenylephrine, endothelin-1, thromboxane-mimetic) or endothelium removal, and tolerance did not develop; thus the drugs had properties important for use in pulmonary hypertension. MAHMA NONOate was 10-40-fold more potent than spermine NONOate but responses to spermine NONOate were more sustained (spermine NONOate > 60 min; MAHMA NONOate < 7 min). It is concluded that the differences in potency and time-course reflect the different rates of NO generation by these NONOates.