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A pragmatic effectiveness-implementation study comparing trial evidence with routinely collected outcome data for patients receiving the REACH-HF home-based cardiac rehabilitation programme
Background Cardiac rehabilitation for heart failure continues to be greatly underused worldwide despite being a Class I recommendation in international clinical guidelines and uptake is low in women and patients with mental health comorbidities. Methods Rehabilitation EnAblement in CHronic Heart Failure (REACH-HF) programme was implemented in four UK National Health Service early adopter sites (‘Beacon Sites’) between June 2019 and June 2020. Implementation and patient-reported outcome data were collected across sites as part of the National Audit of Cardiac Rehabilitation. The change in key outcomes before and after the supervised period of REACH-HF intervention across the Beacon Sites was assessed and compared to those of the intervention arm of the REACH-HF multicentre trial. Results Compared to the REACH-HF multicentre trial, patients treated at the Beacon Site were more likely to be female (33.8% vs 22.9%), older (75.6 vs 70.1), had a more severe classification of heart failure (26.5% vs 17.7%), had poorer baseline health-related quality of life (MLHFQ score 36.1 vs 31.4), were more depressed (HADS score 6.4 vs 4.1) and anxious (HADS score 7.2 vs 4.7), and had lower exercise capacity (ISWT distance 190 m vs 274.7 m). There appeared to be a substantial heterogeneity in the implementation process across the four Beacon Sites as evidenced by the variation in levels of patient recruitment, operationalisation of the REACH-HF intervention and patient outcomes. Overall lower improvements in patient-reported outcomes at the Beacon Sites compared to the trial may reflect differences in the population studied (having higher morbidity at baseline) as well as the marked challenges in intervention delivery during the COVID-19 pandemic. Conclusion The results of this study illustrate the challenges in consistently implementing an intervention (shown to be clinically effective and cost-effective in a multicentre trial) into real-world practice, especially in the midst of a global pandemic. Further research is needed to establish the real-world effectiveness of the REACH-HF intervention in different populations.
Incidence of postural hypotension recorded in UK general practice: an electronic health records study
Background Postural hypotension is a common condition associated with adverse outcomes in older adults. General practice plays an important role in identification of the condition. Aim To examine the incidence of postural hypotension between 2008 and 2018 in general practice and how trends vary by age, sex, year, and social deprivation. Design and setting Retrospective cohort study using electronic health records from the IQVIA Medical Research Data (IMRD) between 2008 and 2018. Method Patients were included if they were aged ≥50 years. Incident postural hypotension was identified as a new (first) recording of a postural hypotension code. Recording of incident postural hypotension was estimated per 10 000 person–years at risk (PYAR) according to age, sex, year, and social deprivation. Incident rate ratios were estimated by multivariable Poisson regression. Results Of 2 911 260 patients, 24 973 had an electronic record indicating a new diagnosis of postural hypotension between 2008 and 2018. This was equivalent to 17.9 cases per 10 000 PYAR in males (95% confidence interval [CI] = 17.6 to 18.2) and 16.2 cases per 10 000 PYAR in females (95% CI = 15.9 to 16.5). A significant age–sex interaction was identified. Recorded postural hypotension rate increased with age and social deprivation, and reduced between 2008 and 2018. The rate was higher in males compared with females, particularly in older age groups (>80 years). Conclusion To the authors’ knowledge, this is the first study to quantify incident recorded postural hypotension in general practice. The rate is lower than expected compared with studies in screened older populations. Potential barriers to identification include underreporting, underdetection owing to lack of time and/or poorly standardised methods of measurement, and poor coding. Future research should investigate current practice and approaches for increased detection such as education, practical methods of screening, and standardised measurement of postural blood pressure.
Managing medication at the end of life: supporting family carers
Effective medicines management is key in enabling timely end-of-life symptom control in the community (Payne et al, 2015; Latif et al, 2021). Managing medications in home is a complex, multi-faceted activity, one that is intertwined with the practical and emotional stresses experienced by patients and their families. Family (and friend) carers usually shoulder these responsibilities as patients become increasingly ill and dependent on their support. They typically oversee and manage the patient’s end-of-life medications and are also expected to undertake complex care and technical medication tasks with little or no training (Oliver et al, 2013; Wilson et al, 2018; Bowers et al, 2022). Community nurses can act as a ‘linchpin’ in supporting families with medication management at the end of life, informing, supporting and advocating on the family’s behalf (Huisman et al, 2020). However, persistently over-stretched resources mean that community nursing input for supporting medication management is often restricted to functional and reactive interventions (Bowers, 2021; Pollock et al, 2021). In the context of constrained health and social care support, community nurses need to consider how personalised, timely professional advice and support with medication management can be best achieved.
Community pharmacy and general practice collaborative and integrated working: a realist review protocol
Abstract Introduction Increasing collaborative and integrated working between General practice (GP) and Community pharmacy (CP) is a key priority of the UK National Health Service and has been proposed as a solution to reducing health system fragmentation, improving synergies and coordination of care. However, there is limited understanding regarding how and under which circumstances collaborative and integrated working between GP and CP can be achieved in practice and how regulatory, organisational and systemic barriers can be overcome. Methods and analysis The aim of our review is to understand how, when and why working arrangements between GP and CP can provide the conditions necessary for optimal communication, decision-making, and collaborative and integrated working. A realist review approach will be used to synthesise the evidence to make sense of the complexities inherent in the working relationships between GP and CP. Our review will follow Pawson’s five iterative stages: (1) finding existing theories; (2) searching for evidence (our main searches were conducted in April 2022); (3) article selection; (4) data extraction and (5) synthesising evidence and drawing conclusions. We will synthesise evidence from grey literature, qualitative, quantitative and mixed-methods research. The research team will work closely with key stakeholders and include patient and public involvement and engagement throughout the review process to refine the focus of the review and the programme theory. Collectively, our refined programme theory will explain how collaborative and integrated working between GP and CP works (or not), for whom, how and under which circumstances. Ethics and dissemination Formal ethical approval is not required for this review as it draws on secondary data from published articles and grey literature. Findings will be widely disseminated through: publication in peer-reviewed journals, seminars, international conference presentations, patients’ association channels, social media, symposia and user-friendly summaries.
Self-management strategies in people with heart failure-related fatigue: a systematic review [version 1; peer review: awaiting peer review]
Abstract Introduction: Fatigue is a common symptom of heart failure which can be distressing for patients and negatively impact both their quality of life and prognosis. We report the efficacy of self-management strategies for people with heart failure-related fatigue. Methods and results: We searched the MEDLINE, Psychinfo, Emcare and Cochrane Central Register of Controlled Trials (CENTRAL) databases from inception to August 2021 for relevant trials. Twenty-two papers were included describing 21 trials (15 RCTs), comprising 515 participants. Definitions of interventions are given and were grouped as either supported self-management or self-management interventions. Supported self-management included education and person-centred care interventions (n=5). Self-management interventions included mind-body therapies (10), and diet and supplements (6). The Cochrane risk of bias did not show significant high risk across the domains, however the number of participants recruited was small. There was heterogeneity in intervention type, delivery and outcome measures preventing meta-analysis. Evidence for supported self-management interventions involving education and a person-centred approach, and self-management interventions such as CBT, mindfulness, and some supplements for heart failure-related fatigue is positive, but is limited to individual, small trials. Only eight trials provided a definition of fatigue, and 11 types of fatigue outcome measures were used. Conclusion: The evidence base for the efficacy of supported self-management and self-management interventions for alleviating heart failure-related fatigue is modest in both study number, size, and quality. Further well-designed trials are needed, along with consensus work on fatigue definitions and reporting.
Diagnostic delay in axial spondyloarthritis: a systematic review
Identification of axial spondyloarthritis (axSpA) remains challenging, frequently resulting in a diagnostic delay for patients. Current benchmarks of delay are usually reported as mean data, which are typically skewed and therefore may be overestimating delay. Our aim was to determine the extent of median delay patients’ experience in receiving a diagnosis of axSpA and examine whether specific factors are associated with the presence of such delay. We conducted a systematic review across five literature databases (from inception to November 2021), with studies reporting the average time period of diagnostic delay in patients with axSpA being included. Any additional information examining associations between specific factors and delay were also extracted. A narrative synthesis was used to report the median range of diagnostic delay experienced by patients with axSpA and summarise which factors have a role in the delay. From an initial 11,995 articles, 69 reported an average time period of diagnostic delay, with 25 of these providing a median delay from symptom onset to diagnosis. Across these studies, delay ranged from 0.67 to 8 years, with over three-quarters reporting a median of between 2 years and 6 years. A third of all studies reported median delay data ranging from just 2 to 2.3 years. Of seven variables reported with sufficient frequency to evaluate, only ‘gender’ and ‘family history of axSpA’ had sufficient concordant data to draw any conclusion on their role, neither influenced the extent of the delay. Despite improvements in recent decades, patients with axSpA frequently experience years of diagnostic delay and this remains an extensive worldwide problem. This is further compounded by a mixed picture of the disease, patient and healthcare-related factors influencing delay.
Interventions to identify and manage depression delivered by ‘nontraditional’ providers to community‐dwelling older adults: A realist review
Abstract Background: Mental health problems experienced by older adults (60+ years of age)may remain hidden due to individual and system‐level barriers. Opportunities to support early identification and management are therefore crucial. The National Health Service recommends wider public services that are embedded within local communities, but are not traditionally part of the healthcare landscape (i.e.,‘nontraditional’), could facilitate engagement with healthcare by members of the public. Evidence for interventions involving Fire and Rescue, Police, Library services and postal workers, as nontraditional providers of mental health services, has not been synthesized previously. This review aims to understand how, why and in what contexts mental health interventions delivered by these nontraditional providers, to older adults, work. Methods: A realist review of interventions to identify and/or manage mental health problems (depression with or without anxiety) experienced by older adults. Systematic, cluster and iterative literature searches were conducted. Intervention evidence was appraised for rigour and explanatory relevance and then coded to inform context‐mechanism‐outcome configurations (CMOCs). A public advisory group supported our initial evidence search strategy and definition of key terms. This review is registered with PROSPERO (CRD42020212498).Results: Systematic searches revealed a dearth of evidence reporting mental health interventions delivered by nontraditional providers. Our scope was adjusted to consider interventions delivered by Fire and Police services only and for wider health and wellbeing concerns (e.g., dementia, falls prevention, mental health crises). Forty‐three pieces of evidence were synthesized. Key themes included: legitimizing expanded roles, focusing on risk, intervention flexibility and organization integration; further subthemes are described. Themes map onto CMOCs and inform a preliminary programme theory. Findings were transposed to mental health contexts. Conclusions: Findings highlight challenges and opportunities for Fire and Police services, as nontraditional providers, to deliver interventions that identify and/or manage mental health problems among older adults. Our programme theory explains what could work, how, for whom and also by whom (i.e., which public services).Further empirical evidence is needed to test interventions, understand acceptability and inform implementation. Patient or Public Contribution: A public advisory group comprising older adults with lived experience of mental health problems and informal caregivers contributed to the original application, reviewed the scope and informed the approach to dissemination.
Simultaneously reassuring and unsettling: a longitudinal qualitative study of community anticipatory medication prescribing for older patients
Background The prescription of injectable anticipatory medications is widely accepted by clinicians to be key in facilitating effective last-days-of-life symptom control. Community end-of-life care and admission avoidance is particularly strongly advocated for older patients. However, patient and informal caregiver views and experiences of anticipatory medication have been little studied to date. Objective To understand older patients’, informal caregivers’ and clinicians’ views and experiences of the prescribing and use of anticipatory medications. Design Qualitative study. Setting Patients’ homes and residential care homes. Participants Purposive sample of six older patients, nine informal caregivers and six clinicians. Methods Multi-perspective, longitudinal interview study based on 11 patient cases. Semi-structured interviews (n = 28) were analysed thematically. Results Three themes were identified: (i) living in the present whilst making plans: anticipatory medications were used by clinicians as a practical tool in planning for uncertainty, while patients and informal caregivers tried to concentrate on living in the present; (ii) anticipation of dying: it was rare for patients and informal caregivers to discuss explicitly the process and experience of dying with clinicians; and (iii) accessing timely care: the use of anticipatory medications generally helped symptom control. However, informal caregivers reported difficulties in persuading nurses to administer them to patients. Conclusions Anticipatory medications are simultaneously reassuring and a source of unease to older patients and their informal caregivers. Prescriptions need careful discussion and tailoring to their preferences and experience. Nurses’ decisions to administer medication should consider informal caregivers’ insights into patient distress, especially when patients can no longer communicate their needs.
Trends and variation in antidepressant prescribing in English primary care: a retrospective longitudinal study
Background: Antidepressants are commonly prescribed. There are clear national guidelines in relation to treatment sequencing. This study examines trends and variation in antidepressant prescribing across English primary care. Aim: To examine trends and variation in antidepressant prescribing in England, with a focus on: monoamine oxidase inhibitors (MAOIs); paroxetine; and dosulepin and trimipramine. DESIGN & SETTIN: gRetrospective longitudinal study using national and practice-level data on antidepressant items prescribed per year (1998-2018) and per month (2010-2019). Method: Class- and drug-specific proportions were calculated at national and practice levels. Descriptive statistics were generated, percentile charts and maps were plotted, and logistic regression analysis was conducted. Results: Antidepressant prescriptions more than tripled between 1998 and 2018, from 377 items per 1000 population to 1266 per 1000. MAOI prescribing fell substantially, from 0.7% of all antidepressant items in 1998 to 0.1% in 2018. There was marked variation between practices in past year prescribing of paroxetine (median practice proportion [MPP] = 1.7%, interdecile range [IDR] = 2.6%) and dosulepin (MPP = 0.7%, IDR = 1.8%), but less for trimipramine (MPP = 0%, IDR = 0.2%). Conclusion: Rapid growth and substantial variation in antidepressant prescribing behaviour was found between practices. The causes could be explored using mixed-methods research. Interventions to reduce prescribing of specific antidepressants, such as dosulepin, could include review prompts, alerts at the time of prescribing, and clinician feedback through tools like OpenPrescribing.net.
Maintaining face-to-face contact during the COVID-19 pandemic: a longitudinal qualitative investigation in UK primary care
Background In March 2020, the COVID-19 pandemic required a rapid reconfiguration of UK general practice to minimise face-to-face contact with patients to reduce infection risk. However, some face-to-face contact remained necessary and practices needed to ensure such contact could continue safely. Aim To examine how practices determined when face-to-face contact was necessary and how face-to-face consultations were reconfigured to reduce COVID-19 infection risk. Design & setting Qualitative interview study in general practices in Bristol, North Somerset, and South Gloucestershire. Method Longitudinal semi-structured interviews with clinical and managerial practice staff were undertaken at four timepoints between May and July 2020. Results Practices worked flexibly within general national guidance to determine when face-to-face contact with patients was necessary, influenced by knowledge of the patient, experience, and practice resilience. For example, practices prioritised patients according to clinical need using face-to-face contact to resolve clinician uncertainty or provide adequate reassurance to patients. To make face-to-face contact as safe as possible and keep patients separated, practices introduced a heterogeneous range of measures that exploited features of their indoor and outdoor spaces, and altered their appointment processes. As national restrictions eased in June and July, the number and proportion of patients seen face to face generally increased. However, the reconfiguration of buildings and processes reduced the available capacity and put increased pressure on practices. Conclusion Practices responded rapidly and creatively to the initial lockdown restrictions. The variety of ways practices organised face-to-face contact to minimise infection highlights the need for flexibility in guidance.
Combining timelining and storyboarding to create a novel method for INtervention DesIGn with stakehOlders: INDIGO
Design is a key part of the healthcare intervention development process, yet it is often viewed as unclear, unstructured, and challenging. INDIGO (“INtervention DesIGn with stakehOlders”) is a new mixed method that brings structure and creativity to the healthcare intervention design process and facilitates a holistic perspective of complex interventions. INDIGO combines and adapts timelining and storyboarding and enables users to create a visual representation of a complex intervention. It comprises card storyboard tokens representing intervention elements that can be moved around on a timeline chart. We discuss the background and development of INDIGO, including existing mixed methods approaches to intervention design. We then provide examples of the use of INDIGO in two empirical studies that informed the development of a brief mindfulness-based intervention, illustrating how INDIGO supported the generation of new insights. We go on to discuss the practicalities, benefits and challenges of INDIGO, including feedback from study participants. This article contributes to the field of mixed methods research by extending the scope and utility of timelining and storyboarding, and by clearly describing INDIGO so the method can be used by other researchers or intervention developers.
Development and external validation of a risk prediction model for falls in patients with an indication for antihypertensive treatment: retrospective cohort study
Objective To develop and externally validate the STRAtifying Treatments In the multi-morbid Frail elderlY (STRATIFY)-Falls clinical prediction model to identify the risk of hospital admission or death from a fall in patients with an indication for antihypertensive treatment. Design Retrospective cohort study. Setting Primary care data from electronic health records contained within the UK Clinical Practice Research Datalink (CPRD). Participants Patients aged 40 years or older with at least one blood pressure measurement between 130 mm Hg and 179 mm Hg. Main outcome measure First serious fall, defined as hospital admission or death with a primary diagnosis of a fall within 10 years of the index date (12 months after cohort entry). Model development was conducted using a Fine-Gray approach in data from CPRD GOLD, accounting for the competing risk of death from other causes, with subsequent recalibration at one, five, and 10 years using pseudo values. External validation was conducted using data from CPRD Aurum, with performance assessed through calibration curves and the observed to expected ratio, C statistic, and D statistic, pooled across general practices, and clinical utility using decision curve analysis at thresholds around 10%. Results Analysis included 1 772 600 patients (experiencing 62 691 serious falls) from CPRD GOLD used in model development, and 3 805 366 (experiencing 206 956 serious falls) from CPRD Aurum in the external validation. The final model consisted of 24 predictors, including age, sex, ethnicity, alcohol consumption, living in an area of high social deprivation, a history of falls, multiple sclerosis, and prescriptions of antihypertensives, antidepressants, hypnotics, and anxiolytics. Upon external validation, the recalibrated model showed good discrimination, with pooled C statistics of 0.833 (95% confidence interval 0.831 to 0.835) and 0.843 (0.841 to 0.844) at five and 10 years, respectively. Original model calibration was poor on visual inspection and although this was improved with recalibration, under-prediction of risk remained (observed to expected ratio at 10 years 1.839, 95% confidence interval 1.811 to 1.865). Nevertheless, decision curve analysis suggests potential clinical utility, with net benefit larger than other strategies. Conclusions This prediction model uses commonly recorded clinical characteristics and distinguishes well between patients at high and low risk of falls in the next 1-10 years. Although miscalibration was evident on external validation, the model still had potential clinical utility around risk thresholds of 10% and so could be useful in routine clinical practice to help identify those at high risk of falls who might benefit from closer monitoring or early intervention to prevent future falls. Further studies are needed to explore the appropriate thresholds that maximise the model’s clinical utility and cost effectiveness.
Derivation and External Validation of a Clinical Model to Predict Heart Failure Onset in Patients With Incident Diabetes
OBJECTIVE Heart failure (HF) often develops in patients with diabetes and is recognized for its role in increased cardiovascular morbidity and mortality in this population. Most existing models predict risk in patients with prevalent rather than incident diabetes and fail to account for sex differences in HF risk factors. We derived sex-specific models in Ontario, Canada to predict HF at diabetes onset and externally validated these models in the U.K. RESEARCH DESIGN AND METHODS Retrospective cohort study using international population-based data. Our derivation cohort comprised all Ontario residents aged ≥18 years who were diagnosed with diabetes between 2009 and 2018. Our validation cohort comprised U.K. patients aged ≥35 years who were diagnosed with diabetes between 2007 and 2017. Primary outcome was incident HF. Sex-stratified multivariable Fine and Gray subdistribution hazard models were constructed, with death as a competing event. RESULTS A total of 348,027 Ontarians (45% women) and 54,483 U.K. residents (45% women) were included. At 1, 5, and 9 years, respectively, in the external validation cohort, the C-statistics were 0.81 (95% CI 0.79–0.84), 0.79 (0.77–0.80), and 0.78 (0.76–0.79) for the female-specific model; and 0.78 (0.75–0.80), 0.77 (0.76–0.79), and 0.77 (0.75–0.79) for the male-specific model. The models were well-calibrated. Age, rurality, hypertension duration, hemoglobin, HbA1c, and cardiovascular diseases were common predictors in both sexes. Additionally, mood disorder and alcoholism (heavy drinker) were female-specific predictors, while income and liver disease were male-specific predictors. CONCLUSIONS Our findings highlight the importance of developing sex-specific models and represent an important step toward personalized lifestyle and pharmacologic prevention of future HF development.
Unintended consequences of patient online access to health records: a qualitative study in UK primary care
Background Health systems are seeking to harness digital tools to promote patient autonomy and increase the efficiency of care worldwide. The NHS Long Term Plan created the right for patients to access ‘digital first’ primary care by 2023–2024, including online patient access to full medical records. Aim To identify and understand the unintended consequences of online patient access to medical records. Design and setting Qualitative interview study in 10 general practices in South West and North West England. Method Semi-structured individual interviews with 13 patients and 16 general practice staff with experience of patient online access to health records. Results Online access generated unintended consequences that negatively impacted patients’ understanding of their health care, with patients finding surprising or difficult to interpret information. Online access impacted GPs’ documentation practices, such as when GPs pre-emptively attempted to minimise potential misunderstandings to aid patient understanding of their health care. In other cases, this negatively impacted the quality of the records and patient safety when GPs avoided documenting speculations or concerns. Contrary to assumptions that workload would be reduced, online access introduced extra work, such as managing and monitoring access, and taking measures to prevent possible harm to patients. Conclusion The unintended consequences described by both staff and patients show that, to achieve the intended consequences set out in NHS policy, additional work is necessary to prepare records for sharing and to prepare patients about what to expect. It is crucial that practices are adequately supported and resourced to manage the unintended consequences of online access, now that it is the default position. A table of potential unintended consequences and mitigation measures is provided to aid practice managers and clinicians implementing online access.
Associations of physician burnout with career engagement and quality of patient care: systematic review and meta-analysis
Objective To examine the association of physician burnout with the career engagement and the quality of patient care globally. Design Systematic review and meta-analysis. Data sources Medline, PsycINFO, Embase, and CINAHL were searched from database inception until May 2021. Eligibility criteria for selecting studies Observational studies assessing the association of physician burnout (including a feeling of overwhelming emotional exhaustion, feelings of cynicism and detachment from job defined as depersonalisation, and a sense of ineffectiveness and little personal accomplishment) with career engagement (job satisfaction, career choice regret, turnover intention, career development, and productivity loss) and the quality of patient care (patient safety incidents, low professionalism, and patient satisfaction). Data were double extracted by independent reviewers and checked through contacting all authors, 84 (49%) of 170 of whom confirmed their data. Random-effect models were used to calculate the pooled odds ratio, prediction intervals expressed the amount of heterogeneity, and meta-regressions assessed for potential moderators with significance set using a conservative level of P<0.10. Results 4732 articles were identified, of which 170 observational studies of 239 246 physicians were included in the meta-analysis. Overall burnout in physicians was associated with an almost four times decrease in job satisfaction compared with increased job satisfaction (odds ratio 3.79, 95% confidence interval 3.24 to 4.43, I2=97%, k=73 studies, n=146 980 physicians). Career choice regret increased by more than threefold compared with being satisfied with their career choice (3.49, 2.43 to 5.00, I2=97%, k=16, n=33 871). Turnover intention also increased by more than threefold compared with retention (3.10, 2.30 to 4.17, I2=97%, k=25, n=32 271). Productivity had a small but significant effect (1.82, 1.08 to 3.07, I2=83%, k=7, n=9581) and burnout also affected career development from a pooled association of two studies (3.77, 2.77 to 5.14, I2=0%, n=3411). Overall physician burnout doubled patient safety incidents compared with no patient safety incidents (2.04, 1.69 to 2.45, I2=87%, k=35, n=41 059). Low professionalism was twice as likely compared with maintained professionalism (2.33, 1.96 to 2.70, I2=96%, k=40, n=32 321), as was patient dissatisfaction compared with patient satisfaction (2.22, 1.38 to 3.57, I2=75%, k=8, n=1002). Burnout and poorer job satisfaction was greatest in hospital settings (1.88, 0.91 to 3.86, P=0.09), physicians aged 31-50 years (2.41, 1.02 to 5.64, P=0.04), and working in emergency medicine and intensive care (2.16, 0.98 to 4.76, P=0.06); burnout was lowest in general practitioners (0.16, 0.03 to 0.88, P=0.04). However, these associations did not remain significant in the multivariable regressions. Burnout and patient safety incidents were greatest in physicians aged 20-30 years (1.88, 1.07 to 3.29, P=0.03), and people working in emergency medicine (2.10, 1.09 to 3.56, P=0.02). The association of burnout with low professionalism was smallest in physicians older than 50 years (0.36, 0.19 to 0.69, P=0.003) and greatest in physicians still in training or residency (2.27, 1.45 to 3.60, P=0.001), in those who worked in a hospital (2.16, 1.46 to 3.19, P<0.001), specifically in emergency medicine specialty (1.48, 1.01 to 2.34, P=0.042), or situated in a low to middle income country (1.68, 0.94 to 2.97, P=0.08). Conclusions This meta-analysis provides compelling evidence that physician burnout is associated with poor function and sustainability of healthcare organisations primarily by contributing to the career disengagement and turnover of physicians and secondarily by reducing the quality of patient care. Healthcare organisations should invest more time and effort in implementing evidence-based strategies to mitigate physician burnout across specialties, and particularly in emergency medicine and for physicians in training or residency. Systematic review registration PROSPERO number CRD42021249492.
Improving a trial participant information sheet through user testing in British South Asian women
[version 1; peer review: awaiting peer review] Background: People from ethnic minorities in the UK have higher rates of mental health problems and are less likely to take part in mental health research. Previous research indicates that participant information sheets (PIS) are complex, and this complexity may impair comprehension more significantly for ethnic minority participants. Improving the readability of patient information can be achieved through user testing. We aimed to improve the readability of a PIS through user testing in an ethnic minority group in an ongoing trial (ROSHNI-2). Methods: An independent groups design was used to test the readability of the ROSHNI-2 PIS among South Asian women. There were two rounds of testing (n=31 women in total). South Asian women were asked to read the original PIS, then find and demonstrate an understanding of 19 key aspects of the trial. Based on the findings from the first round, the PIS was rewritten, redesigned, and retested. Results: Using the original PIS, only 2 of the 19 (11%) questions were found and understood by at least 80% of participants. In the revised PIS, 6 of the 19 (32%) questions were found and understood by at least 80% of participants. Conclusions: User testing and re-writing of a PIS resulted in a higher proportion of participants comprehending important information about a trial. This approach could improve participation in trials among ethnic minority communities.
Cumulative complexity: a qualitative analysis of patients’ experiences of living with heart failure with preserved ejection fraction
Aims To investigate how heart failure with preserved ejection fraction (HFpEF), within the context of limited clinical services, impacts patients’ lives. Methods and results Secondary thematic analysis informed by the cumulative complexity model (CCM), of interview transcripts from 77 people diagnosed with HFpEF and their carers. Four themes corresponding to the core concepts of workload, capacity, access, and outcome described in the CCM were generated. Theme 1: Shouldering a heavy workload described the many tasks expected of people living with HFpEF. Theme 2: The multiple threats to capacity described how patients and carers strived to engage with this work, but were often faced with multiple threats such as symptoms and mobility limitations. Deficient illness identity (Theme 3) reflects how HFpEF either was not recognized or was perceived as a more benign form of HF and therefore afforded less importance or priority. These themes contributed to a range of negative physical, social, and psychological outcomes and the perception of loss of control described in Theme 4: Spiraling complexity. Conclusions The constellation of HFpEF, multi-morbidity, and ageing creates many demands that people with HFpEF are expected to manage. Concurrently, the same syndromes threaten their ability to physically enact this work. Patients’ recollections of their interactions with health professionals suggest that there is a widespread misunderstanding of HFpEF, which can prohibit access to care that could potentially reduce or prevent deterioration.
Association between continuity of primary care and both prescribing and adherence of common cardiovascular medications: a cohort study among patients in England
Abstract Objectives To investigate whether better continuity of care is associated with increased prescribing of clinically relevant medication and improved medication adherence. Setting Random sample of 300 000 patients aged 30+ in 2017 within 83 English general practitioner (GP) practices from the Clinical Practice Research Datalink. Design Patients were assigned to a randomly selected index date in 2017 on which medication use and continuity of care were determined. Adjusted associations between continuity of care and the prescribing and adherence of five cardiovascular medication groups were examined using logistic regression. Participants Continuity of Care Index was calculated for 173 993 patients with 4+ GP consultations 2 years prior to their index date and divided into five categories: absence of continuity, below-average continuity, average, above-average continuity and perfect continuity. Main outcome measures (A) Prescription for statins (primary or secondary prevention separately), anticoagulants, antiplatelet agents and antihypertensives covering the patient’s index date. (B) Adherence (>80%) estimated using medication possession ratio. Results There was strong evidence (p<0.01) that prescription of all five cardiovascular medication groups increased with greater continuity of care. Patients with absence of continuity were less likely to be prescribed cardiovascular medications than patients with above-average continuity (statins primary prevention OR 0.73, 95% CI 0.59 to 0.85; statins secondary prevention 0.77, 95% CI 0.57 to 1.03; antiplatelets 0.55, 95% CI 0.33 to 0.92; antihypertensives 0.51, 95% CI 0.39 to 0.65). Furthermore, patients with perfect continuity were more likely to be prescribed cardiovascular medications than those with above-average continuity (statins primary prevention OR 1.23, 95% CI 1.01 to 1.49; statins secondary prevention 1.37, 95% CI 1.10 to 1.71; antiplatelets 1.37, 95% CI 1.08 to 1.74; antihypertensives 1.10, 95% CI 0.99 to 1.23). Continuity was generally not associated with medication adherence, except for adherence to statins for secondary prevention (OR 0.75, 95% CI 0.60 to 0.94 for average compared with above-average continuity). Conclusion Better continuity of care is associated with improved prescribing of medication to patients at higher risk of cardiovascular disease but does not appear to be related to patient’s medication adherence.
Antidepressant use and risk of adverse outcomes: population-based cohort study
Abstract Background Antidepressants are one of the most widely prescribed drugs in the global north. However, little is known about the health consequences of long-term treatment. Aims This study aimed to investigate the association between antidepressant use and adverse events. Method The study cohort consisted of UK Biobank participants whose data was linked to primary care records (N = 222 121). We assessed the association between antidepressant use by drug class (selective serotonin reuptake inhibitors (SSRIs) and ‘other’) and four morbidity (diabetes, hypertension, coronary heart disease (CHD), cerebrovascular disease (CV)) and two mortality (cardiovascular disease (CVD) and all-cause) outcomes, using Cox's proportional hazards model at 5- and 10-year follow-up. Results SSRI treatment was associated with decreased risk of diabetes at 5 years (hazard ratio 0.64, 95% CI 0.49–0.83) and 10 years (hazard ratio 0.68, 95% CI 0.53–0.87), and hypertension at 10 years (hazard ratio 0.77, 95% CI 0.66–0.89). At 10-year follow-up, SSRI treatment was associated with increased risks of CV (hazard ratio 1.34, 95% CI 1.02–1.77), CVD mortality (hazard ratio 1.87, 95% CI 1.38–2.53) and all-cause mortality (hazard ratio 1.73, 95% CI 1.48–2.03), and ‘other’ class treatment was associated with increased risk of CHD (hazard ratio 1.99, 95% CI 1.31–3.01), CVD (hazard ratio 1.86, 95% CI 1.10–3.15) and all-cause mortality (hazard ratio 2.20, 95% CI 1.71–2.84). Conclusions Our findings indicate an association between long-term antidepressant usage and elevated risks of CHD, CVD mortality and all-cause mortality. Further research is needed to assess whether the observed associations are causal, and elucidate the underlying mechanisms.
Mortality from angiotensin-converting enzyme-inhibitors and angiotensin receptor blockers in people infected with COVID-19: a cohort study of 3.7 million people
Background Concerns have been raised that angiotensin-converting enzyme-inhibitors (ACE-I) and angiotensin receptor blockers (ARBs) might facilitate transmission of severe acute respiratory syndrome coronavirus 2 leading to more severe coronavirus disease (COVID-19) disease and an increased risk of mortality. We aimed to investigate the association between ACE-I/ARB treatment and risk of death amongst people with COVID-19 in the first 6 months of the pandemic. Methods We identified a cohort of adults diagnosed with either confirmed or probable COVID-19 (from 1 January to 21 June 2020) using computerized medical records from the Oxford-Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care database. This comprised 465 general practices in England, United Kingdom with a nationally representative population of 3.7 million people. We constructed mixed-effects logistic regression models to quantify the association between ACE-I/ARBs and all-cause mortality among people with COVID-19, adjusted for sociodemographic factors, comorbidities, concurrent medication, smoking status, practice clustering, and household number. Results There were 9,586 COVID-19 cases in the sample and 1,463 (15.3%) died during the study period between 1 January 2020 and 21 June 2020. In adjusted analysis ACE-I and ARBs were not associated with all-cause mortality (adjusted odds ratio [OR] 1.02, 95% confidence interval [CI] 0.85–1.21 and OR 0.84, 95% CI 0.67–1.07, respectively). Conclusion Use of ACE-I/ARB, which are commonly used drugs, did not alter the odds of all-cause mortality amongst people diagnosed with COVID-19. Our findings should inform patient and prescriber decisions concerning continued use of these medications during the pandemic.
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