Scholarly Works - Public Health and Primary Care - Primary Care Unit

The Primary Care Unit is based within the Department of Public Health and Primary Care which is one of Europe’s premier university departments of population health sciences. Staff from the unit make a major contribution to clinical teaching within the Cambridge Clinical School, to postgraduate education by supporting Masters and PhD students and Academic Clinical Fellows, and to research. Research hosted within the unit includes the Diabetes & Cardiovascular Disease Group, the Behavioural Science Group, a Department of Health Policy Research Unit on Behaviour and Health, the Cancer, Genetics and Palliative Care Group, and the Cambridge Centre for Health Services Research.

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  • ItemPublished versionOpen Access
    Perceptions of self-rated health among stroke survivors: a qualitative study in the United Kingdom.
    (Springer Science and Business Media LLC, 2018-04-02) Mavaddat, N; Sadler, E; Lim, L; Williams, K; Warburton, E; Kinmonth, AL; Mant, J; Burt, J; McKevitt, C; Lim, Lisa [0000-0002-3779-6095]; Williams, Kate [0000-0002-6188-9363]; Mant, Jonathan [0000-0002-9531-0268]; Burt, Jenni [0000-0002-0037-274X]
    BACKGROUND: Self-rated health predicts health outcomes independently of levels of disability or mood. Little is known about what influences the subjective health experience of stroke survivors. Our aim was to investigate stroke survivors' perceptions of self-rated health, with the intention of informing the design of interventions that may improve their subjective health experience. METHODS: We conducted semi-structured interviews with a purposive sample of 28 stroke survivors recruited from a stroke unit and follow-up outpatient clinic, 4-6 months after stroke, to explore what factors are perceived to be part of self-rated health in the early stages of recovery. Qualitative data were analysed using a thematic analysis approach to identify underlying themes. RESULTS: Participants' accounts show that stroke survivors' perceptions of self-rated health are multifactorial, comprising physical, psychological and social components. Views on future recovery after stroke play a role in present health experience and are shaped by psychosocial resources that are influenced by past experiences of ill-health, dispositional outlook such as degree of optimism, a sense of control and views on ageing. CONCLUSIONS: Severity of physical limitations alone does not influence perceptions of self-rated health among stroke survivors. Self-rated health in stroke survivors is a multidimensional construct shaped by changes in health status occurring after the stroke, individual characteristics and social context. Understanding the factors stroke survivors themselves associate with better health will inform the development of effective approaches to improve rehabilitation and recovery after stroke.
  • ItemAccepted versionOpen Access
    Long-Term Costs and Health Consequences of Issuing Shorter Duration Prescriptions for Patients with Chronic Health Conditions in the English NHS.
    (Springer Science and Business Media LLC, 2018-06) Martin, Adam; Payne, Rupert; Wilson, Edward Cf; Martin, Adam [0000-0002-2559-6483]
    BACKGROUND: The National Health Service (NHS) in England spends over £9 billion on prescription medicines dispensed in primary care, of which over two-thirds is accounted for by repeat prescriptions. Recently, GPs in England have been urged to limit the duration of repeat prescriptions, where clinically appropriate, to 28 days to reduce wastage and hence contain costs. However, shorter prescriptions will increase transaction costs and thus may not be cost saving. Furthermore, there is evidence to suggest that shorter prescriptions are associated with lower adherence, which would be expected to lead to lower clinical benefit. The objective of this study is to estimate the cost-effectiveness of 3-month versus 28-day repeat prescriptions from the perspective of the NHS. METHODS: We adapted three previously developed UK policy-relevant models, incorporating transaction (dispensing fees, prescriber time) and drug wastage costs associated with 3-month and 28-day prescriptions in three case studies: antihypertensive medications for prevention of cardiovascular events; drugs to improve glycaemic control in patients with type 2 diabetes; and treatments for depression. RESULTS: In all cases, 3-month prescriptions were associated with lower costs and higher QALYs than 28-day prescriptions. This is driven by assumptions that higher adherence leads to improved disease control, lower costs and improved QALYs. CONCLUSION: Longer repeat prescriptions may be cost-effective compared with shorter ones. However, the quality of the evidence base on which this modelling is based is poor. Any policy rollout should be within the context of a trial such as a stepped-wedge cluster design.
  • ItemAccepted versionOpen Access
    OPtimising Treatment for MIld Systolic hypertension in the Elderly (OPTiMISE): A protocol for a randomised controlled trial
    (Wiley-Blackwell, 2017) Burt, J; Sheppard, J; Lown, M; Mant, J; Little, P; McManus, RJ; Burt, Jenni [0000-0002-0037-274X]; Mant, Jonathan [0000-0002-9531-0268]
    Hypertension is the number one co-morbid condition in older people with multiple chronic conditions, and over half of those aged >80 years are prescribed two or more antihypertensive medications (equivalent to approximately 1.25 million people in the UK). Blood pressure lowering has been shown to be effective at preventing stroke and cardiovascular disease in healthy individuals aged >80 years with systolic blood pressure of >160mmHg. However, more recent evidence suggests that larger blood pressure reductions and multiple antihypertensive prescriptions may be harmful in older people. Whilst reducing the number of antihypertensive drugs prescribed to certain older patients may be beneficial, the lack of evidence to support such an approach limits the practice in routine clinical care.
  • ItemPublished versionOpen Access
    The Improving Rural Cancer Outcomes Trial: a cluster-randomised controlled trial of a complex intervention to reduce time to diagnosis in rural cancer patients in Western Australia.
    (Springer Science and Business Media LLC, 2017-11-07) Emery, Jon D; Gray, Victoria; Walter, Fiona M; Cheetham, Shelley; Croager, Emma J; Slevin, Terry; Saunders, Christobel; Threlfall, Timothy; Auret, Kirsten; Nowak, Anna K; Geelhoed, Elizabeth; Bulsara, Max; Holman, C D'Arcy J; Walter, Fiona [0000-0002-7191-6476]
    BACKGROUND: Rural Australians have poorer survival for most common cancers, due partially to later diagnosis. Internationally, several initiatives to improve cancer outcomes have focused on earlier presentation to healthcare and timely diagnosis. We aimed to measure the effect of community-based symptom awareness and general practice-based educational interventions on the time to diagnosis in rural patients presenting with breast, prostate, colorectal or lung cancer in Western Australia. METHODS: 2 × 2 factorial cluster randomised controlled trial. Community Intervention: cancer symptom awareness campaign tailored for rural Australians. GP intervention: resource card with symptom risk assessment charts and local cancer referral pathways implemented through multiple academic detailing visits. Trial Area A received the community symptom awareness and Trial Area B acted as the community campaign control region. Within both Trial Areas general practices were randomised to the GP intervention or control. PRIMARY OUTCOME: total diagnostic interval (TDI). RESULTS: 1358 people with incident breast, prostate, colorectal or lung cancer were recruited. There were no significant differences in the median or ln mean TDI at either intervention level (community intervention vs control: median TDI 107.5 vs 92 days; ln mean difference 0.08 95% CI -0.06-0.23 P=0.27; GP intervention vs control: median TDI 97 vs 96.5 days; ln mean difference 0.004 95% CI -0.18-0.19 P=0.99). There were no significant differences in the TDI when analysed by factorial design, tumour group or sub-intervals of the TDI. CONCLUSIONS: This is the largest trial to test the effect of community campaign or GP interventions on timeliness of cancer diagnosis. We found no effect of either intervention. This may reflect limited dose of the interventions, or the limited duration of follow-up. Alternatively, these interventions do not have a measurable effect on time to cancer diagnosis.
  • ItemPublished versionOpen Access
    Randomised trial of coconut oil, olive oil or butter on blood lipids and other cardiovascular risk factors in healthy men and women.
    (BMJ, 2018-03-06) Khaw, Kay-Tee; Sharp, Stephen J; Finikarides, Leila; Afzal, Islam; Lentjes, Marleen; Luben, Robert; Forouhi, Nita G; Lentjes, Marleen [0000-0003-4713-907X]; Luben, Robert [0000-0002-5088-6343]
    INTRODUCTION: High dietary saturated fat intake is associated with higher blood concentrations of low-density lipoprotein cholesterol (LDL-C), an established risk factor for coronary heart disease. However, there is increasing interest in whether various dietary oils or fats with different fatty acid profiles such as extra virgin coconut oil may have different metabolic effects but trials have reported inconsistent results. We aimed to compare changes in blood lipid profile, weight, fat distribution and metabolic markers after four weeks consumption of 50 g daily of one of three different dietary fats, extra virgin coconut oil, butter or extra virgin olive oil, in healthy men and women in the general population. DESIGN: Randomised clinical trial conducted over June and July 2017. SETTING: General community in Cambridgeshire, UK. PARTICIPANTS: Volunteer adults were recruited by the British Broadcasting Corporation through their websites. Eligibility criteria were men and women aged 50-75 years, with no known history of cancer, cardiovascular disease or diabetes, not on lipid lowering medication, no contraindications to a high-fat diet and willingness to be randomised to consume one of the three dietary fats for 4 weeks. Of 160 individuals initially expressing an interest and assessed for eligibility, 96 were randomised to one of three interventions; 2 individuals subsequently withdrew and 94 men and women attended a baseline assessment. Their mean age was 60 years, 67% were women and 98% were European Caucasian. Of these, 91 men and women attended a follow-up assessment 4 weeks later. INTERVENTION: Participants were randomised to extra virgin coconut oil, extra virgin olive oil or unsalted butter and asked to consume 50 g daily of one of these fats for 4 weeks, which they could incorporate into their usual diet or consume as a supplement. MAIN OUTCOMES AND MEASURES: The primary outcome was change in serum LDL-C; secondary outcomes were change in total and high-density lipoprotein cholesterol (TC and HDL-C), TC/HDL-C ratio and non-HDL-C; change in weight, body mass index (BMI), waist circumference, per cent body fat, systolic and diastolic blood pressure, fasting plasma glucose and C reactive protein. RESULTS: LDL-C concentrations were significantly increased on butter compared with coconut oil (+0.42, 95% CI 0.19 to 0.65 mmol/L, P<0.0001) and with olive oil (+0.38, 95% CI 0.16 to 0.60 mmol/L, P<0.0001), with no differences in change of LDL-C in coconut oil compared with olive oil (-0.04, 95% CI -0.27 to 0.19 mmol/L, P=0.74). Coconut oil significantly increased HDL-C compared with butter (+0.18, 95% CI 0.06 to 0.30 mmol/L) or olive oil (+0.16, 95% CI 0.03 to 0.28 mmol/L). Butter significantly increased TC/HDL-C ratio and non-HDL-C compared with coconut oil but coconut oil did not significantly differ from olive oil for TC/HDL-C and non-HDL-C. There were no significant differences in changes in weight, BMI, central adiposity, fasting blood glucose, systolic or diastolic blood pressure among any of the three intervention groups. CONCLUSIONS AND RELEVANCE: Two different dietary fats (butter and coconut oil) which are predominantly saturated fats, appear to have different effects on blood lipids compared with olive oil, a predominantly monounsaturated fat with coconut oil more comparable to olive oil with respect to LDL-C. The effects of different dietary fats on lipid profiles, metabolic markers and health outcomes may vary not just according to the general classification of their main component fatty acids as saturated or unsaturated but possibly according to different profiles in individual fatty acids, processing methods as well as the foods in which they are consumed or dietary patterns. These findings do not alter current dietary recommendations to reduce saturated fat intake in general but highlight the need for further elucidation of the more nuanced relationships between different dietary fats and health. TRIAL REGISTRATION NUMBER: NCT03105947; Results.
  • ItemAccepted versionOpen Access
    Possible missed opportunities for diagnosing colorectal cancer in Dutch primary care: a multimethods approach.
    (Royal College of General Practitioners, 2018-01) Brandenbarg, Daan; Groenhof, Feikje; Siewers, Ilse M; van der Voort, Anna; Walter, Fiona M; Berendsen, Annette J; Walter, Fiona [0000-0002-7191-6476]
    BACKGROUND: Early detection of colorectal cancer (CRC) is important to achieve better survival. Discriminating symptoms suggestive of CRC from benign conditions is a challenge for GPs because most known 'alarm symptoms' have low predictive values. AIM: To further understand the diagnostic process of CRC in general practice in terms of healthcare use and by analysing factors related to diagnostic intervals. DESIGN AND SETTING: A multimethod approach comprising a historical, prospective registry study and qualitative content analysis. METHOD: Healthcare use in the year before referral for colonoscopy was compared between patients diagnosed with CRC and an age-, sex,- and GP-matched control population. Qualitative content analysis was performed on free texts in electronic patient records from a purposive sample of patients with CRC. RESULTS: Patients with CRC (n = 287) had 41% (25-59%) more face-to-face contacts and 21% (7-37%) more medication prescriptions than controls (n = 828). Forty-six per cent of patients with CRC had two or more contacts for digestive reasons, compared with 12.2% of controls, more often for symptoms than diagnoses. From qualitative analysis two themes emerged: 'possible missed diagnostic opportunities' and 'improvements in diagnostic process unlikely'. Possible missed diagnostic opportunities were related to patients waiting before presenting symptoms, doctors attributing symptoms to comorbid conditions or medication use, or doctors sticking to an initial diagnosis. CONCLUSION: Fewer missed diagnostic opportunities might occur if GPs are aware of pitfalls in diagnosing CRC: the assumption that symptoms are caused by comorbid conditions or medication, or relating complaints to pre-existing medical conditions. GPs also need to be aware that repeated digestive complaints warrant rethinking an earlier diagnosis.
  • ItemAccepted versionOpen Access
    Maximising the Potential of Longitudinal Cohorts for Research in Neurodegenerative Diseases: A Community Perspective
    (Frontiers, 2017-08-29) Brayne, CEG; Moody, CJ; Mitchell, D; Kiser, G; Aarsland, D; Berg, D; Brayne, C; Costa, A; Ikram, MA; Mountain, G; Rohrer, JD; Teunissen, CE; van den Berg, LH; Wardlaw, JM; Brayne, Carol [0000-0001-5307-663X]
    Despite a wealth of activity across the globe in the area of longitudinal population cohorts, surprisingly little information is available on the natural biomedical history of a number of age-related neurodegenerative diseases (ND), and the scope for intervention studies based on these cohorts is only just beginning to be explored. The Joint Programming Initiative on Neurodegenerative Disease Research (JPND) recently developed a novel funding mechanism to rapidly mobilise scientists to address these issues from a broad, international community perspective. Ten expert Working Groups, bringing together a diverse range of community members and covering a wide ND landscape (Alzheimer’s, Parkinson’s, frontotemporal degeneration, amyotrophic lateral sclerosis, Lewy-body and vascular dementia) were formed to discuss and propose potential approaches to better exploiting and coordinating cohort studies. The purpose of this work is to highlight the novel funding process along with a broad overview of the guidelines and recommendations generated by the ten groups, which include investigations into multiple methodologies such as cognition/functional assessment, biomarkers and biobanking, imaging, health and social outcomes, and pre-symptomatic ND. All of these were published in reports that are now publicly available online.
  • ItemPublished versionOpen Access
    Understanding symptom appraisal and help-seeking in people with symptoms suggestive of pancreatic cancer: a qualitative study
    (BMJ Publishing Group, 2017-09-01) Walter, FM; Mills, K; Birt, L; Walter, Fiona [0000-0002-7191-6476]; Mills, Katie [0000-0002-6563-2944]
    Objective Pancreatic cancer has poor survival rates due to non-specific symptoms leading to later diagnosis. Understanding how patients interpret their symptoms could inform approaches to earlier diagnosis. This study sought to explore symptom appraisal and help-seeking among patients referred to secondary care for symptoms suggestive of pancreatic cancer. Design Qualitative analysis of semi-structured in-depth interviews. Data were analysed iteratively and thematically, informed by the Model of Pathways to Treatment. Participants and setting Pancreatic cancer occurs rarely in younger adults, therefore patients aged ≥ 40 years were recruited from nine hospitals after being referred to hospital with symptoms suggestive of pancreatic cancer; all were participants in a cohort study. Interviews were conducted soon after referral, and where possible, before diagnosis. Results Twenty-six interviews were conducted (cancer n=13 (pancreas n=9, other intra-abdominal n=4), non-cancer conditions n=13; age range 48-84 years; 14 women). Time from first symptoms to first presentation to healthcare ranged from 1 to 270 days, median 21 days. We identified three main themes. Initial symptom appraisal usually began with intermittent, non-specific symptoms such as tiredness or appetite changes, attributed to diet and lifestyle, existing gastrointestinal conditions or side-effects of medication. Responses to initial symptom appraisal included changes in meal type or frequency, or self-medication. Symptom changes such as alterations in appetite and enjoyment of food or weight loss usually prompted further appraisal. Triggers to seek help included a change or worsening of symptoms, particularly pain, which was often a ‘tipping point’. Help-seeking was often encouraged by others. We found no differences in symptom appraisal and help seeking between people diagnosed with cancer and those with other conditions. Conclusions Greater public and healthcare professional awareness of the combinations of subtle and intermittent symptoms, and their evolving nature, is needed to prompt timelier help-seeking and investigation among people with symptoms of pancreatic cancer.
  • ItemAccepted versionOpen Access
    The Descriptive Epidemiology of the Diurnal Profile of Bouts and Breaks in Sedentary Time in English Older Adults
    (OUP, 2017-08-08) Yerrakalva, D; Cooper, AJ; Westgate, K; Khaw, KT; Wareham, NJ; Brage, S; Griffin, SJ; Wijndaele, KL; Westgate, Kate [0000-0002-0283-3562]; Khaw, Kay-Tee [0000-0002-8802-2903]; Wareham, Nicholas [0000-0003-1422-2993]; Brage, Soren [0000-0002-1265-7355]; Griffin, Simon [0000-0002-2157-4797]; Wijndaele, Katrien [0000-0003-2199-7981]
    Background: High sedentary time is associated with adverse metabolic health outcomes and mortality in older adults. It has been suggested that breaking up sedentary time may be beneficial for metabolic health; however, population prevalence data are lacking on the patterns of sedentary behaviour which would identify opportunities for intervention. Methods: We used data of adults aged ≥ 60 years (n = 3705) from the population-based EPIC-Norfolk cohort, to characterize the patterns of total sedentary time, breaks in sedentary time and sedentary bouts across the day and assess their associations with participant characteristics, using multi-level regression. Sedentary time was measured objectively by a hip-mounted accelerometer (Actigraph™ GT1M) worn for 7 days during waking time. Results: More than 50% of every waking hour was spent sedentary, increasing to a peak of 83% in the evening. On average fewer breaks were accrued in the evenings compared with earlier in the day. Marginally more sedentary time was accrued on weekend days compared with weekdays (difference 7.4 min, 95% confidence interval 5.0–9.7). Large proportions of this sedentary time appear to be accrued in short bouts (bouts of < 10 min for 32% of the time). Older age, being male, being retired, not being in paid employment and having a higher body mass index were associated with greater sedentary time and fewer breaks. Conclusion: Sedentary time is common throughout the day but peaks in the evenings with fewer breaks and longer bouts. We identified a number of characteristics associated with sedentary time and additionally inversely associated with sedentary breaks, which should inform the development and targeting of strategies to reduce sedentary time among older adults.
  • ItemPublished versionOpen Access
    AHRQ series on complex intervention systematic reviews – paper 2: defining complexity, formulating scope, and questions
    (Elsevier, 2017-10) Kelly, M; Noyes, J; Kane, RL; Chang, C; Uhl, S; Robinson, KA; Springs, S; Butler, ME; Guise, J-M; Kelly, Mike [0000-0002-2029-5841]
    $\textbf{Background:}$ The early stages of a systematic review set the scope and expectations. This can be particularly challenging for complex interventions given their multidimensional and dynamic nature. $\textbf{Rationale:}$ This paper builds on concepts introduced in paper 1 of this series. It describes the methodological, practical, and philosophical challenges and potential approaches for formulating the questions and scope of systematic reviews of complex interventions. Furthermore, it discusses the use of theory to help organize reviews of complex interventions. $\textbf{Discussion:}$ Many interventions in medicine, public health, education, social services, behavioral health, and community programs are complex, and they may not fit neatly within the established paradigm for reviews of straightforward interventions. This paper provides conceptual and operational guidance for these early stages of scope formulation to assist authors of systematic reviews of complex interventions.
  • ItemAccepted versionOpen Access
    Cost-Effectiveness Analysis of Natriuretic Peptide Testing and Specialist Management in Patients with Suspected Acute Heart Failure
    (Elsevier, 2017-07-11) Griffin, EA; Wonderling, D; Ludman, AJ; Al-Mohammad, A; Cowie, MR; Hardman, SMC; McMurray, JJV; Kendall, J; Mitchell, P; Shote, A; Dworzynski, K; Mant, J; Mant, Jonathan [0000-0002-9531-0268]
    Objectives: To determine the cost-effectiveness of natriuretic peptide (NP) testing and specialist outreach in patients with acute heart failure (AHF) residing off the cardiology ward. Methods: We used a Markov model to estimate costs and quality-adjusted life-years (QALYs) for patients presenting to hospital with suspected AHF. We examined diagnostic workup with and without the NP test in suspected new cases, and we examined the impact of specialist heart failure outreach in all suspected cases. Inputs for the model were derived from systematic reviews, the UK national heart failure audit, randomized controlled trials, expert consensus from a National Institute for Health and Care Excellence guideline development group, and a national online survey. The main benefit from specialist care (cardiology ward and specialist outreach) was the increased likelihood of discharge on disease-modifying drugs for people with left ventricular systolic dysfunction, which improve mortality and reduce re-admissions due to worsened heart failure (associated with lower utility). Costs included diagnostic investigations, admissions, pharmacological therapy, and follow-up heart failure care. Results: NP testing and specialist outreach are both higher cost, higher QALY, cost-effective strategies (incremental cost-effectiveness ratios of £11,656 and £2,883 per QALY gained, respectively). Combining NP and specialist outreach is the most cost-effective strategy. This result was robust to both univariate deterministic and probabilistic sensitivity analyses. Conclusions: NP testing for the diagnostic workup of new suspected AHF is cost-effective. The use of specialist heart failure outreach for inpatients with AHF residing off the cardiology ward is cost-effective. Both interventions will help improve outcomes for this high-risk group.
  • ItemPublished versionOpen Access
    Controlling hypertension immediately post stroke: a cost utility analysis of a pilot randomised controlled trial.
    (Springer Science and Business Media LLC, 2010-03-23) Wilson, Edward Cf; Ford, Gary A; Robinson, Tom; Mistri, Amit; Jagger, Carol; Potter, John F; Wilson, Ed [0000-0002-8369-1577]
    BACKGROUND: Elevated blood pressure (BP) levels are common following acute stroke. However, there is considerable uncertainty if and when antihypertensive therapy should be initiated. METHOD: Economic evaluation alongside a double-blind randomised placebo-controlled trial (National Research Register Trial Number N0484128008) of 112 hypertensive patients receiving an antihypertensive regimen (labetalol or lisinopril) within 36 hours post stroke versus 59 receiving placebo. Outcomes were incremental cost per incremental: QALY, survivor, and patient free from death or severe disability (modified Rankin scale score < 4) at three months and 14 days post stroke. RESULTS: Actively treated patients on average had superior outcomes and lower costs than controls at three months. From the perspective of the acute hospital setting, there was a 96.5% probability that the incremental cost per QALY gained at three months is below pound30,000, although the probability may be overstated due to data limitations. CONCLUSION: Antihypertensive therapy when indicated immediately post stroke may be cost-effective compared with placebo from the acute hospital perspective. Further research is required to confirm both efficacy and cost-effectiveness and establish whether benefits are maintained over a longer time horizon.
  • ItemPublished versionOpen Access
    Developing a prioritisation framework in an English Primary Care Trust.
    (Springer Science and Business Media LLC, 2006-02-17) Wilson, Edward CF; Rees, John; Fordham, Richard J; Wilson, Ed [0000-0002-8369-1577]
    BACKGROUND: In the English NHS, Primary Care Trusts (PCTs) are required to commission health services, to maximise the well-being of the population, subject to the available budget. There are numerous techniques employed to make decisions, some more rational and transparent than others. A weighted benefit score can be used to rank options but this does not take into account value for money from investments. METHODS: We developed a weighted benefit score framework for use in an English PCT which ranked options in order of 'cost-value' or 'cost per point of benefit'. Our method differs from existing techniques by explicitly combining cost and a composite weighted benefit score into the cost-value ratio. RESULTS: The technique proved readily workable, and was able to accommodate a wide variety of data and competing criteria. Participants felt able to assign scores to proposed services, and generate a ranked list, which provides a solid starting point for the PCT Board to discuss and make funding decisions. Limitations included potential for criteria to be neither exhaustive nor mutually exclusive and the lack of an interval property in the benefit score limiting the usefulness of a cost-value ratio. CONCLUSION: A technical approach to decision making is insufficient for making prioritisation decisions, however our technique provides a very valuable, structured and informed starting point for PCT decision making.
  • ItemPublished versionOpen Access
    How do stroke survivors and their carers use practitioners' advice on secondary prevention medications? Qualitative study of an online forum
    (Oxford University Press, 2017-09-01) Izuka, NJ; Alexander, MAW; Balasooriya-Smeekens, C; Mant, J; Simoni, AD; Mant, Jonathan [0000-0002-9531-0268]
    $\textbf{Background}$: Secondary prevention medications reduce risk of stroke recurrence, yet many people do not receive recommended treatment, nor take medications optimally. $\textbf{Objective}$: Exploring how patients report making use of practitioners' advice on secondary prevention medicines on an online forum and what feedback was received from other participants. $\textbf{Methods}$: Thematic analysis of the archive of Talkstroke (2004-2011), UK. Posts including any secondary prevention medication terms, General Practitioner (GP) and their replies were identified. $\textbf{Results}$: Fifity participants talked about practitioners' advice on secondary prevention medications in 43 discussion threads. Patients consulted practitioners for reassurance and dealing with side effects. Practitioners' advice varied from altering to maintaining current treatment. Three main themes emerged from the use of practitioners' advice: patients following advice (reassured, happy when side effects made tolerable, or still retaining anxiety about treatment); patients not following advice (admitting adherence on-off or stopping medications as side effects still not tolerable); asking other participants for feedback on advice received. Practitioners' advice was disregarded mainly when related to dealing with statin side effects, after one or two consultations. Themes for feedback involved sharing experience, directing back to practitioners, or to external evidence. $\textbf{Conclusions}$: Side effects of secondary prevention medications and statins in particular, cause anxiety and resentment in some patients, and their concerns are not always addressed by practitioners. Practitioners could consider more proactive strategies to manage such side effects. Forum feedback was appropriate and supportive of the practitioners' advice received. Our findings from peer-to-peer online conversations confirm and widen previous research.
  • ItemAccepted versionOpen Access
    Education and Successful Aging Trajectories: A Longitudinal Population-Based Latent Variable Modelling Analysis
    (Cambridge University Press, 2017-12) Costco, T; Stephan, B; Brayne, C; Muniz, G; Brayne, Carol [0000-0001-5307-663X]
    As the population ages, interest is increasing in studying aging well. However, more refined means of examining predictors of biopsychosocial conceptualizations of successful aging (SA) are required. Existing evidence of the relationship between early-life education and later-life SA is unclear. The Successful Aging Index (SAI) was mapped onto the Cognitive Function and Aging Study (CFAS), a longitudinal population-based cohort (n = 1,141). SAI scores were examined using growth mixture modelling (GMM) to identify SA trajectories. Unadjusted and adjusted (age, sex, occupational status) ordinal logistic regressions were conducted to examine the association between trajectory membership and education level. GMM identified a three-class model, capturing high, moderate, and low functioning trajectories. Adjusted ordinal logistic regression models indicated that individuals in higher SAI classes were significantly more likely to have higher educational attainment than individuals in the lower SAI classes. These results provide evidence of a life course link between education and SA.
  • ItemAccepted versionOpen Access
    The association between clinical frailty and walking speed in older hospitalized medical patients: A retrospective observational study
    (Elsevier BV, 2017) Hartley, P; Keevil, VL; Romero-Ortuno, R; Hartley, Peter [0000-0002-1033-5897]; Keevil, Victoria [0000-0001-6148-0640]; Romero-Ortuno, Roman [0000-0002-3882-7447]
    $\textbf{Introduction}$ This study aims to further evaluate the use of the clinical frailty scale (CFS) by assessing its correlation with usual walking speed (UWS) in older medical inpatients. $\textbf{Methods}$ Retrospective observational study in an English tertiary university hospital. We analysed all admission episodes of people admitted to the Department of Medicine for the Elderly wards during a 3-month period. We excluded those who died or had a CFS score of 9, indicating terminal illness. The CFS was recorded on admission and 6 meter UWS was measured on the day of hospital discharge. Other variables collected were: age, sex, the four-item version of the Abbreviated Metal Test (AMT4), and the Emergency Department Modified Early Warning Score. $\textbf{Results}$ There were 1022 patients admitted over the study period, of which 741 met inclusion criteria and had both CFS and walking speed data available. Five hundred and seventy were able to mobilise at least 6 m. The median UWS was 0.33 (0.21–0.50) m/s. Logistic ordinal regression showed that lower CFS, being male and higher score in the AMT4 were associated with higher odds of being in a higher walking speed category (odds ratio for CFS after covariable adjustment: 0.57 [95% CI, 0.50 to 0.65]). $\textbf{Conclusions}$ We observed a strong association between higher admission CFS and lower discharge UWS. This association was not explained by variation in age, sex, presence of cognitive impairment or illness acuity and provides further evidence that the CFS maybe a valid measure of frailty in acute clinical settings.
  • ItemPublished versionOpen Access
    Association of comorbidity and health service usage among patients with dementia in the UK: a population-based study
    (BMJ Publishing Group, 2017-03-01) Browne, J; Edwards, DA; Rhodes, KM; Brimicombe, DJ; Payne, RA; Edwards, Duncan [0000-0003-1500-2108]; Rhodes, Kirsty [0000-0002-8568-4979]; Brimicombe, James [0000-0002-3443-3256]
    $\textbf{BACKGROUND}$: The majority of people with dementia have other long-term diseases, the presence of which may affect the progression and management of dementia. This study aimed to identify subgroups with higher healthcare needs, by analysing how primary care consultations, number of prescriptions and hospital admissions by people with dementia varies with having additional long-term diseases (comorbidity). $\textbf{METHODS}$: A retrospective cohort study based on health data from the Clinical Practice Research Datalink (CPRD) was conducted. Incident cases of dementia diagnosed in the year starting 1/3/2008 were selected and followed for up to 5 years. The number of comorbidities was obtained from a set of 34 chronic health conditions. Service usage (primary care consultations, hospitalisations and prescriptions) and time-to-death were determined during follow-up. Multilevel negative binomial regression and Cox regression, adjusted for age and gender, were used to model differences in service usage and death between differing numbers of comorbidities. $\textbf{RESULTS}$: Data from 4999 people (14 866 person-years of follow-up) were analysed. Overall, 91.7% of people had 1 or more additional comorbidities. Compared with those with 2 or 3 comorbidities, people with ≥6 comorbidities had higher rates of primary care consultations (rate ratio (RR) 1.31, 95% CI 1.25 to 1.36), prescriptions (RR 1.68, 95% CI 1.57 to 1.81), and hospitalisation (RR 1.62, 95% CI 1.44 to 1.83), and higher risk of death (HR 1.56, 95% CI 1.37 to 1.78). $\textbf{DISCUSSION}$: In the UK, people with dementia with higher numbers of comorbidities die earlier and have considerably higher health service usage in terms of primary care consultations, hospital admissions and prescribing. This study provides strong evidence that comorbidity is a key factor that should be considered when allocating resources and planning care for people with dementia.
  • ItemAccepted versionOpen Access
    Diagnosing adult primary brain tumours: can we do better?
    (Royal College of General Practitioners, 2017-06) Penford, C; Joannides, A; Bell, J; Walter, FM; Joannides, Alexis [0000-0002-6618-256X]; Walter, Fiona [0000-0002-7191-6476]
  • ItemPublished versionOpen Access
    Intensive versus Guideline Blood Pressure and Lipid Lowering in Patients with Previous Stroke: Main Results from the Pilot 'Prevention of Decline in Cognition after Stroke Trial' (PODCAST) Randomised Controlled Trial.
    (Public Library of Science (PLoS), 2017) Bath, Philip M; Scutt, Polly; Blackburn, Daniel J; Ankolekar, Sandeep; Krishnan, Kailash; Ballard, Clive; Burns, Alistair; Mant, Jonathan; Passmore, Peter; Pocock, Stuart; Reckless, John; Sprigg, Nikola; Stewart, Rob; Wardlaw, Joanna M; Ford, Gary A; PODCAST Trial Investigators; Bath, Philip M [0000-0003-2734-5132]
    BACKGROUND: Stroke is associated with the development of cognitive impairment and dementia. We assessed the effect of intensive blood pressure (BP) and/or lipid lowering on cognitive outcomes in patients with recent stroke in a pilot trial. METHODS: In a multicentre, partial-factorial trial, patients with recent stroke, absence of dementia, and systolic BP (SBP) 125-170 mmHg were assigned randomly to at least 6 months of intensive (target SBP <125 mmHg) or guideline (target SBP <140 mmHg) BP lowering. The subset of patients with ischaemic stroke and total cholesterol 3.0-8.0 mmol/l were also assigned randomly to intensive (target LDL-cholesterol <1.3 mmol/l) or guideline (target LDL-c <3.0 mmol/l) lipid lowering. The primary outcome was the Addenbrooke's Cognitive Examination-Revised (ACE-R). RESULTS: We enrolled 83 patients, mean age 74.0 (6.8) years, and median 4.5 months after stroke. The median follow-up was 24 months (range 1-48). Mean BP was significantly reduced with intensive compared to guideline treatment (difference -10·6/-5·5 mmHg; p<0·01), as was total/LDL-cholesterol with intensive lipid lowering compared to guideline (difference -0·54/-0·44 mmol/l; p<0·01). The ACE-R score during treatment did not differ for either treatment comparison; mean difference for BP lowering -3.6 (95% CI -9.7 to 2.4), and lipid lowering 4.4 (95% CI -2.1 to 10.9). However, intensive lipid lowering therapy was significantly associated with improved scores for ACE-R at 6 months, trail making A, modified Rankin Scale and Euro-Qol Visual Analogue Scale. There was no difference in rates of dementia or serious adverse events for either comparison. CONCLUSION: In patients with recent stroke and normal cognition, intensive BP and lipid lowering were feasible and safe, but did not alter cognition over two years. The association between intensive lipid lowering and improved scores for some secondary outcomes suggests further trials are warranted. TRIAL REGISTRATION: ISRCTN ISRCTN85562386.
  • ItemPublished versionOpen Access
    Investigating the relationship between consultation length and patient experience: a cross-sectional study in primary care.
    (Royal College of General Practitioners, 2016-12) Elmore, Natasha; Burt, Jenni; Abel, Gary; Maratos, Frances A; Montague, Jane; Campbell, John; Roland, Martin; Burt, Jenni [0000-0002-0037-274X]; Roland, Martin [0000-0002-8533-3060]
    BACKGROUND: Longer consultations in primary care have been linked with better quality of care and improved health-related outcomes. However, there is little evidence of any potential association between consultation length and patient experience. AIM: To examine the relationship between consultation length and patient-reported communication, trust and confidence in the doctor, and overall satisfaction. DESIGN AND SETTING: Analysis of 440 videorecorded consultations and associated patient experience questionnaires from 13 primary care practices in England. METHOD: Patients attending a face-to-face consultation with participating GPs consented to having their consultations videoed and completed a questionnaire. Consultation length was calculated from the videorecording. Linear regression (adjusting for patient and doctor demographics) was used to investigate associations between patient experience (overall communication, trust and confidence, and overall satisfaction) and consultation length. RESULTS: There was no evidence that consultation length was associated with any of the three measures of patient experience (P >0.3 for all). Adjusted changes on a 0-100 scale per additional minute of consultation were: communication score 0.02 (95% confidence interval [CI] = -0.20 to 0.25), trust and confidence in the doctor 0.07 (95% CI = -0.27 to 0.41), and satisfaction -0.14 (95% CI = -0.46 to 0.18). CONCLUSION: The authors found no association between patient experience measures of communication and consultation length, and patients may sometimes report good experiences from very short consultations. However, longer consultations may be required to achieve clinical effectiveness and patient safety: aspects also important for achieving high quality of care. Future research should continue to study the benefits of longer consultations, particularly for patients with complex multiple conditions.