Search results
Found 19914 matches for
©
Shutterstock
Clinical and cost-effectiveness of a personalised guided consultation versus usual physiotherapy care in people presenting with shoulder pain: a protocol for the PANDA-S cluster randomised controlled trial and process evaluation.
INTRODUCTION: Musculoskeletal shoulder pain is a common reason for people to be treated in physiotherapy services, but diagnosis can be difficult and often does not guide treatment or predict outcome. People with shoulder pain cite a need for clear information, and timely, tailored consultations for their pain. This trial will evaluate the introduction of a personalised guided consultation to help physiotherapists manage care for individuals with shoulder pain. METHODS AND ANALYSIS: This is a cluster randomised controlled trial to evaluate the clinical and cost-effectiveness of introducing a personalised guided consultation compared with usual UK NHS physiotherapy care. Physiotherapy services (n=16) will be randomised in a 1:1 ratio to either intervention (physiotherapy training package and personalised guided consultation incorporating a new prognostic tool) or control (usual care); 832 participants (416 in each arm) identified from participating physiotherapy service waiting lists aged 18 years or over with shoulder pain will be enrolled. Follow-up will occur at 3 time points: 6 weeks, 6 months and 12 months. The primary outcome will be the Shoulder Pain and Disability Index (SPADI) score over 12 months. Secondary outcomes include global perceived change of the shoulder condition, sleep, work absence and the impact of shoulder pain on work performance, healthcare utilisation and health-related quality of life (using EuroQol 5 Dimension 5 Level (EQ-5D-5L)). A multimethod process evaluation will investigate views and experiences of participants and physiotherapists, assess uptake, facilitators and barriers to delivery, and changes in factors assumed to explain intervention outcomes. Primary analysis of effectiveness will be by intention-to-treat, and a health economic evaluation will assess cost-utility of introducing the personalised consultation. ETHICS AND DISSEMINATION: The trial received ethics approval from the Yorkshire & The Humber (South Yorkshire) Research Ethics Committee (REC reference: 23/YH/0070). Findings will be shared through journal publications, media outlets and conference presentations. Supported by patient contributors and clinical advisors, we will communicate findings through a designated website, networks, newsletters, leaflets and in the participating physiotherapy services. TRIAL REGISTRATION NUMBER: ISRCTN45377604.
Improving the understanding of cancer and cancer care by applying data science and machine learning methods to electronic patient records
Electronic health records (EHR) hold great potential for improving the understanding of cancer care by containing high-resolution real-world data for large numbers of patients. This dissertation explores the application of data science and machine learning (ML) methods to EHRs for the purposes of translational colorectal cancer (CRC) research. I first explore the challenges in using EHRs throughout the data life cycle. I present a lightweight information extraction pipeline that retrieves TNM staging scores---common descriptors of cancer severity---from free text clinical reports with high sensitivity and precision, and also retrieves information about the presence and recurrence of CRC. These data items are essential to CRC research, for identifying cases, studying treatment variation, and comparing treatment outcomes. The pipeline was developed using data from Oxford University Hospitals (OUH) and Royal Marsden (RMH) NHS Foundation Trusts (FT), and supported the establishment of the National Institute for Health Research (NIHR) Health Informatics Collaborative (HIC) CRC database. I then focus on a specific application: combining the faecal immunochemical test (FIT) results with routinely collected data to predict CRC in symptomatic patients. The current practice is to refer patients with FIT above 10 μg/g for invasive endoscopic investigations, but only one in six investigated have CRC, motivating prediction model development. I demonstrate that an externally-derived model does not outperform FIT in the Oxford University Hospitals FIT dataset (OUH-FIT), and highlight the importance of clinically-relevant performance measures. I then show that employing more predictors, a spectrum of ML models, and novel training methods, was not sufficient to outperform FIT on OUH-FIT data. Finally, I build on and incorporate an existing sequence analysis method into an interactive app that allows to explore and cluster thousands of medical event sequences, such as visualising treatment patterns of CRC patients. The principal contributions are: a holistic discussion of EHR data quality; a staging extraction algorithm that facilitates further research/audits; a comprehensive pipeline for developing/evaluating FIT-based CRC prediction models; and a fast medical sequence exploration app that can help check data quality and identify treatment variations. There is considerable potential to use these tools on larger datasets to understand if FIT-based models are bound to fail (or if they may work on subgroups with more severe disease); and to contrast different treatment patterns employed for subgroups of CRC patients with complex disease, such as those with liver metastases.
Navigating change and crisis: an ethnographic case study of the digitalisation of general practice work between 2020-2024
Since 2020, changes in the organisation and delivery of UK general practice have been extensive and far-reaching. The widespread scale-up of remote and digital forms of working in UK general practice during the COVID-19 pandemic has driven the development of new routines and working styles, affecting how work is done, and the conditions in which it is completed, with repercussions for the wellbeing of the workforce. In the work reported here, I aim to build a more nuanced understanding of the impact of digitalisation on the kinds of work performed by patients and staff in UK GP practices, the impact thereof on staff wellbeing, and ascertain what further learning could be gleaned about how change and crisis are navigated in practice teams. I conducted a narrative literature synthesis and a multi-sited ethnographic case study of UK GP practice, informed by the Eisenhardt method. To do so, I employed multiple qualitative methods to collect data from two in-depth ethnographic case study sites. I also collected and reanalysed previously collected qualitative data from eight comparative case study sites. I analysed these data at three sequential levels: inductively, thematically, and abductively, to build and extend theory in conversation with my data. In this thesis, I make several novel contributions to empirical, methodological, and theoretical literature. I split my results on the impact of digitalisation during 2020-24 across four chapters. The first outlines the work that patients must now perform to achieve digital candidacy and craft a digital facsimile to access their GP practice successfully. The second looks at the impact on the work and wellbeing of support staff, highlighting the unique translational work they perform. The third describes the impacts on the whole practice team, and identifies new risks to their wellbeing: technostress, technosuffering, and relational strain. Finally, the fourth results chapter illustrates the organisational conditions that are most protective of staff wellbeing when navigating these kinds of change and crisis events and suggests a model for how these conditions can be constructed, maintained, or slip away. I have disseminated these findings to academic, public, policy, and practice audiences.
Intensive blood-glucose control with sulphonylureas or insulin compared with conventional treatment and risk of complications in patients with type 2 diabetes (UKPDS 33)
Background: Improved blood-glucose control decreases the progression of diabetic microvascular disease, but the effect on macrovascular complications is unknown. There is concern that sulphonylureas may increase cardiovascular mortality in patients with type 2 diabetes and that high insulin concentrations may enhance atheroma formation. We compared the effects of intensive blood-glucose control with either sulphonylurea or insulin and conventional treatment on the risk of microvascular and macrovascular complications in patients with type 2 diabetes in a randomised controlled trial. Methods: 3867 newly diagnosed patients with type 2 diabetes, median age 54 years (IQR 48-60 years), who after 3 months' diet treatment had a mean of two fasting plasma glucose (FPG) concentrations of 6.1-15.0 mmol/L were randomly assigned intensive policy with a sulphonylurea (chlorpropamide, glibenclamide, or glipizide) or with insulin, or conventional policy with diet. The aim in the intensive group was FPG less than 6 mmol/L. In the conventional group, the aim was the best achievable FPG with diet alone; drugs were added only if there were hyperglycaemic symptoms or FPG greater than 15 mmol/L. Three aggregate endpoints were used to assess differences between conventional and intensive treatment: any diabetes-related endpoint (sudden death, death from hyperglycaemia or hypoglycaemia, fatal or non-fatal myocardial infarction, angina, heart failure, stroke, renal failure, amputation [of at least one digit], vitreous haemorrhage, retinopathy requiring photocoagulation, blindness in one eye, or cataract extraction); diabetes-related death (death from myocardial infarction, stroke, peripheral vascular disease, renal disease, hyperglycaemia or hypoglycaemia, and sudden death); all-cause mortality. Single clinical endpoints and surrogate subclinical endpoints were also assessed. All analyses were by intention to treat and frequency of hypoglycaemia was also analysed by actual therapy. Findings: Over 10 years, haemoglobin A(1c) (HbA(1c)) was 7.0% (6.2-8.2) in the intensive group compared with 7.9% (6.9-8.8) in the conventional group - an 11% reduction. There was no difference in HbA(1c) among agents in the intensive group. Compared with the conventional group, the risk in the intensive group was 12% lower (95% CI 1-21, p = 0.029) for any diabetes-related endpoint; 10% lower (-11 to 27, p = 0.34) for any diabetes-related death; and 6% lower (-10 to 20, p = 0.44) for all-cause mortality. Most of the risk reduction in the any diabetes-related aggregate endpoint was due to a 25% risk reduction (7-40, p = 0.0099) in microvascular endpoints, including the need for retinal photocoagulation. There was no difference for any of the three aggregate endpoints between the three intensive agents (chlorpropamide, glibenclamide, or insulin). Patients in the intensive group had more hypoglycaemic episodes than those in the conventional group on both types of analysis (both p < 0.0001). The rates of major hypoglycaemic episodes per year were 0.7% with conventional treatment, 1.0% with chlorpropamide, 1.4% with glibenclamide, and 1.8% with insulin. Weight gain was significantly higher in the intensive group (mean 2.9 kg) than in the conventional group (p < 0.001), and patients assigned insulin had a greater gain in weight (4.0 kg) than those assigned chlorpropamide (2.6 kg) or glibenclamide (1.7 kg). Interpretation: Intensive blood-glucose control by either sulphonylureas or insulin substantially decreases the risk of microvascular complications, but not macrovascular disease, in patients with type 2 diabetes. None of the individual drugs had an adverse effect on cardiovascular outcomes. All intensive treatment increased the risk of hypoglycaemia.
Remote consulting
Remote care is a feature of contemporary general practice but brings additional challenges for GP registrars. Communication and rapport are more challenging in telephone calls. They can be enhanced through strategies such as the use of open questions, active listening, summarising and clarifying next steps. Remote clinical assessment can be complemented by using video, texted photos or home instruments such as thermometers, blood pressure machines and pulse oximeters. Decision making can be affected causing over or under investigation, referral or prescribing. If a condition is failing to resolve or to progress as expected following an initial remote consultation, subsequent encounters should be in person. Effective remote consulting needs to be supported by adequate infrastructure and practice processes. Solutions are required for patients whose needs mean that remote consulting is less appropriate. Quality of care may be compromised, particularly in long-term conditions.
Valve thrombosis and antithrombotic therapy after bioprosthetic mitral valve replacement: a systematic review and meta-analysis
Aims: Transcatheter mitral valve replacement (TMVR) has become a feasible alternative to surgical mitral valve replacement (SMVR) in selected patients at high surgical risk. The risk of valve thrombosis following SMVR and TMVR, and the optimal antithrombotic therapy following these procedures, remains uncertain. We aimed to compare the incidence of bioprosthetic mitral valve thrombosis (bMVT) after SMVR and TMVR, and the incidence of bMVT between patients on different antithrombotic regimens. Methods and results: A literature search of Medline, Embase, and Cochrane Library was performed between January 2000 and August 2024. Random-effects models were used to derive pooled estimates of the incidence of bMVT in the absence of prior or active endocarditis and valve thrombosis. A total of 47 studies (6170 patients, total follow-up 9541.8 patient-years) were eligible for inclusion. The overall incidence of bMVT was 5.05 [95% confidence interval (CI) 3.18-8.01, I2 = 82%] per 100-patient-years. Subclinical bMVT was more common than clinically significant bMVT: incidence 19.11 vs. 7.91 per 100-patient-years, adjusted incidence rate ratio (aIRR) 4.62 (95% CI 1.39-15.36), P = 0.012. bMVT was numerically more common after TMVR than SMVR, but the comparison was not statistically significant: incidence 7.03 vs. 0.58 per 100-patient-years, aIRR 2.19 (95% CI 0.72-6.72), P = 0.170. Patients on vitamin-K antagonists (VKA) had a lower incidence of bMVT than patients on direct oral anticoagulants (DOAC; incidence 5.72 vs. 17.08, aIRR 0.31, 95% CI 0.13-0.73, P = 0.007). Conclusions: bMVT is not uncommon, with numerically higher incidence in transcatheter compared to surgical valves, but the comparison was not statistically significant. VKAs are associated with a lower incidence of bMVT compared to DOACs.
Identification of undetected SARS-CoV-2 infections by clustering of Nucleocapsid antibody trajectories.
During the COVID-19 pandemic, numerous SARS-CoV-2 infections remained undetected. We combined results from routine monthly nose and throat swabs, and self-reported positive swab tests, from a UK household survey, linked to national swab testing programme data from England and Wales, together with Nucleocapsid (N-)antibody trajectories clustered using a longitudinal variation of K-means (N = 185,646) to estimate the number of infections undetected by either approach. Using N-antibody (hypothetical) infections and swab-positivity, we estimated that 7.4% (95%CI: 7.0-7.8%) of all true infections (detected and undetected) were undetected by both approaches, 25.8% (25.5-26.1%) by swab-positivity-only and 28.6% (28.4-28.9%) by trajectory-based N-antibody-classifications-only. Congruence with swab-positivity was respectively much poorer and slightly better with N-antibody classifications based on fixed thresholds or fourfold increases. Using multivariable logistic regression N-antibody seroconversion was more likely as age increased between 30-60 years, in non-white participants, those less (recently/frequently) vaccinated, for lower cycle threshold values in the range above 30, and in symptomatic and Delta (vs. BA.1) infections. Comparing swab-positivity data sources showed that routine monthly swabs were insufficient to detect infections and incorporating national testing programme/self-reported data substantially increased detection. Overall, whilst N-antibody serosurveillance can identify infections undetected by swab-positivity, optimal use requires fourfold-increase-based or trajectory-based analysis.
From ‘A Rapid and Necessary Revolution’ to ‘Telemedicine Killed the PE Teacher’: Changing Representations of Remote GP Consultations in UK Media During the COVID-19 Pandemic
The abrupt shift from face-to-face general practitioner (GP) consultations to remote ones was one of the most radical changes to the UK National Health Service (NHS) since it was set up in 1948. Overnight, people were blocked from turning up at their GP’s surgery and instead offered telephone, video or email contacts. This chapter considers how the lay press interpreted and conveyed this shift. We systematically collected UK newspaper stories about remote general practice from early 2020, mid 2020 and late 2021, and analysed these for their narrative content and form. The three time periods represented three distinct ‘eras’. Early in the pandemic, newspapers depicted remote consultations positively as an essential component of the country’s war against the virus (‘technology as superhero’). By summer 2020, the incidence of COVID-19 had fallen to a low level, lockdown had ended and many aspects of life were returning to normal. But the Secretary of State for Health (a technology enthusiast) had declared that virtual consultations should continue in order to make the NHS more efficient and modern. The mainstream media made much of this misalignment through funny and tragic stories of remote consultations which were clearly inappropriate or unsafe (‘technology as farce’). In 2021, the pandemic grumbled on and a backlog of unmet needs began to surface. The NHS was busier than ever; staff were exhausted; secondary care sought to redistribute work to primary care; and many key posts were unfilled because of early retirement, long-term staff illness and Brexit. In this context—a system under extreme stress—GPs used remote triage as a tool to control their workload. The media responded aggressively, running front-page campaigns to demand a better service from ‘lazy’ GPs who were depicted as being on the golf course while making occasional calls to sick patients on their smartphones. In this period, the focus of media stories was on the perceived lack of traditional face-to-face appointments and patients who had been ‘fobbed off’ with telephone calls (‘technology as cop-out’). Over the course of 2 years, media narratives on technology-mediated consultations thus shifted from hopeful (reproducing a discourse of modernity and efficiency) to nostalgic (demanding a return to a golden era when patients could be seen ‘properly’). We discuss the implications of these depictions for the future of remote (and face-to-face) consultations.
Statin safety in prevention of cardiovascular diseases: causal inference and risk prediction
Background: The widespread concerns about statin safety have resulted in low uptake of and poor adherence to statin treatment for prevention of cardiovascular diseases. The use of statins for primary prevention has been particularly challenging due to the controversy about the balance between benefits and harms of treatment. Personalised clinical decision-making and stratified treatment strategies that take into account the risk of adverse events are potential approaches towards better use of statins. Methods: A systematic review of randomised controlled trials was conducted, with pair-wise, network, and dose-response meta-analyses, to assess the associations between statins and common adverse events and explore the variations by drug type and dose in primary prevention patients. A prognostic model (StatinMD) was derived and externally validated to predict the personalised risk of serious muscle disorders in individuals eligible for statin treatment, using a competing risk model with data from electronic healthcare records. Results: Statins were associated with a small increase in the risk of muscle symptoms, liver dysfunction, renal insufficiency, and eye conditions, but not with muscle disorders or diabetes. There was little evidence of the difference between statin drugs or the dose-response relationships of their adverse effects. The StatinMD model included 22 predictors to predict the risk of serious muscle disorders in 1, 5, and 10 years. The model showed overall good discrimination and calibration in the majority of the population. Conclusions: The overall balance between benefits and harms of statins supports their use for primary prevention of cardiovascular diseases. The StatinMD model provides a reliable predicted risk of serious muscle disorders for most individuals to assist clinical decision-making on statin treatment.