Strengthening the body of research: SPCR Showcase 2019
Tuesday, 26 November 2019
Royal College of Physicians, London
This year we celebrate our tenth cohort of trainees at the Royal College of Physicians on 26 November. We will highlight innovation and collaboration in primary care research from our capacity and development trainees and alumni with a very exciting programme of talks and poster presentations.
Strengthening the body of research: SPCR showcase 2019
| 9.30 - 10.15 | Registration, refreshments and poster hanging | Registration desk, Osler and Long Rooms to hang posters |
| 10.15 - 10.30 |
Welcome: Professor Richard Hobbs Prizes presented for 'Exceptional Contribution to Patient and Public Involvement' and 'Impactful Contribution in Patient and Public Involvement and Engagement' competitions |
Wolfson Auditorium |
| 10.30 - 11.30 |
Plenary session 1 |
Wolfson Auditorium |
| 11.30 - 12.30 |
Parallel session 1 |
Wolfson Auditorium |
| 12.30 - 13.45 |
Lunch and poster viewing (poster presenters to please stand next to your posters from 13.30 - 13.45) |
Osler and Long Rooms |
| 13.45 - 14.45 |
Parallel session 2 |
Wolfson Auditorium Sloane Room, Linacre Room and Council Chamber |
| 14.45 - 15.15 | Refreshments | Osler and Long Rooms |
| 15.15 - 16.15 |
Plenary session 2 |
Wolfson Auditorium |
| 16.15 | Close (Please be considerate of our plenary speakers when booking your transport) | Wolfson Auditorium |
career progression journeys by past trainees
| SESSION 1 |  |
All in Wolfson Auditorium |
| 10.30 - 10.45 | Amanda Lewis, Trial Manager, University of Bristol | |
| 10.45 - 11.00 | Amy O'Donnell, Faculty Fellow, Newcastle University | |
| 11.00 - 11.15 | Evan Kontopantelis, Professor of Data Science & Health Services Research, University of Manchester | |
| 11.15 - 11.30 | Jane Vennik, Research Fellow, University of Southampton | |
| SESSION 2 |  |
|
| 15.15 - 15.30 | Helen Atherton, Associate Professor, Unit of Academic Primary Care, University of Warwick | |
| 15.30 - 15.45 | Rachel Johnson, NIHR Clinical Lecturer in Primary Health Care, University of Bristol | |
| 15.45 - 16.00 | Nathan Davies, Senior Research Fellow, UCL | |
| 16.00 - 16.15 | Jenny Lund, Wellcome Trust Clinical Fellow, University of Cambridge |
A Realist Review of Delegated Home Visits in General Practice: Task Shifting, Sharing, Mixing and Delegating
Ruth Abrams1, Geoff Wong2, Nia Roberts3, Kamal Mahtani2, Stephanie Tierney2, Anne-Marie Boylan2, Sophie Park1
1Department of Primary Care and Population Health, University College London, United Kingdom. 2Nuffield Department of Primary Care Health Sciences, University of Oxford, United Kingdom. 3Bodleian Health Care Libraries, University of Oxford
Abstract
Introduction:
UK General Practice is being shaped by new ways of working with the release of both the NHS long-term plan and GP contract (BMA, 2019; NHS, 2019). Traditional GP tasks are being delegated to other staff with the intention of reducing GP workload, hospital admissions and improving patient access to care. One such task is patient generated home visits. Yet the mechanisms of delegation remain opaque and are likely to be dependent on a range of contexts. Our evidence synthesis explores how the process of delegating home visits work, for whom and in what contexts.
Methods:
We have synthesised relevant data including qualitative, quantitative, mixed-methods research and grey literature, following the systematic realist review stages advocated by Pawson et al (2005).
Results:
A total of 70 studies relating to primary care, with similar healthcare systems to the UK and discussing delegation are included. Three overarching themes have been constructed, comprising of a series of context-mechanism-outcome configurations.
Discussion:
The nature of employment, patient conditions and GP perspectives form complex contexts for work delegation to occur in. Whilst outcomes such as patient satisfaction appear to be high, the ability of delegation to reduce clinical workload is unclear. Mechanisms such as risk tolerance and trust among multidisciplinary teams are likely to affect delegation processes and tensions exist between the sustainability of this intervention. Our review findings may help with the future implementation of delegated home visits and provide guidance to support GP decision-making about how and when to delegate patient home visits.
Patient and Public Involvement (PPI)
Stakeholders such as Clinical commissioners, CCG members, GPs and paramedics were consulted during the early stage of this review to help the research team understand the ways in which home visit delegation is conceptualised and operationalised in practice. The research team are currently seeking funding for PPE in order to translate review findings from an academic to a general public setting with the support of patients.
Patient awareness and use of online services in general practice: the Digital Access Now Survey
Carol Bryce1, Matthew O'Connell2, Jeremy Dale1, Martin Underwood1, Helen Atherton1
1University of Warwick, United Kingdom. 2King's College London, United Kingdom
Abstract
Introduction
There is international interest in the potential role of digital and communications technology to improve access to healthcare. Digital routes of access to both book, and have, a face to face consultation are increasingly encouraged as a route to help manage demand. Without understanding whether patients are aware of, or interacting with, the full range of online services, it is not possible to shape services to suit patients and their needs.
Methods
Using a cross sectional survey design we have recruited over 40 general practices across the West Midlands covering a range of practice characteristics. A randomly sampled 5% of patients aged 18+ from each practice list is sent the survey which can be completed in paper form or online. A total of 15,000 surveys will be sent out between February and June. The survey collects data on awareness and use of digital general practice access, internet use, health status and demographics. Using multivariable statistical analyses we will identify the key predictors of online use and awareness and whether differences across population subgroups are explained by other characteristics.
Results
The survey is still being administered with early indications showing a response rate of 15%. Full findings will be presented at the conference.
Discussion
Understanding awareness and use of digital services has the potential to influence the design and commissioning of services in general practice and will help healthcare commissioners to shape services. The findings will provide the first data on how patients are using private online general practice services.
Patient and Public Involvement (PPI)
In August 2018 we hosted a workshop to garner broad public views on the importance (or not) of online and digital methods to access and delivery of GP appointments. During the workshop 7 participants read through a draft version of the survey and gave specific feedback on its content and value. A survey was considered valuable. Following revision of the survey a further 5 members of the public completed the questionnaire during a cognitive interview. This method enabled us to ascertain whether the questionnaire was clear and the questions were understood in the intended way before final revisions were made.
Development of a patient-reported outcome measure for polymyalgia rheumatica
Helen Twohig1, Sara Muller1, Caroline Mitchell2, Georgina Jones3, Christian Mallen1
1Keele University, United Kingdom. 2University of Sheffield, United Kingdom. 3Leeds Beckett University, United Kingdom
Abstract
Background
Polymyalgia rheumatica (PMR) causes pain, stiffness and disability in older adults. It usually has a sub-acute onset and responds rapidly to treatment with steroid medication, although the initial large improvement in health is typically followed by longer periods of lower level symptoms and episodes of relapse. Steroids themselves cause significant morbidity and adverse effects have to be balanced against PMR symptoms. Therefore, measuring the impact of PMR and its associated treatments from the patient’s perspective is of high importance. We have developed a patient-reported outcome measure (PROM) to assess PMR-related quality of life and present an overview of this process.
Methods
Scoping the problem: systematic review of outcome measures used in studies of PMR
Defining the construct: qualitative study exploring 22 patient experiences of PMR
Item development: formation of items based on the interview data, validation with participants.
Pilot testing: postal survey with 28 patients with PMR using the QQ-10 questionnaire to assess face validity, utility and feasibility.
Item reduction and formation of dimension structure: postal survey to gather responses from 256 people with PMR. Classical and modern test theory methods used to refine the PROM and determine scoring.
Results
We have developed the first PROM evaluating PMR-related quality of life. It comprises a 9-item functional scale and a 4-item psychological well-being scale as well as key symptoms and medication side effects.
Next steps
Evaluation of the PROM’s validity, responsiveness and reliability to establish it as a tool fit for use in research and clinical practice.
Patient and Public Involvement (PPI)
We have worked with the National charity for PMR, PMRGCAuk at all stages of the PROM development process, including in the establishment of the need for such a tool. I met with members of the North East Support Group for the charity on several occasions and have fed back the results of each stage of the process. Trustees of the charity have reviewed funding proposals, study materials and helped with plans for recruitment for each of the studies.
The incidence of diabetes after gestational diabetes: A systematic review and meta-analysis of over 100 studies
Rebecca Dennison, Eileen Chen, Madeline Green, Chloe Legard, Rebecca Ward, Juliet Usher-Smith, Simon Griffin
University of Cambridge, United Kingdom
Abstract
Introduction
Women affected by gestational diabetes (GDM) are 8-times more likely to go on to develop diabetes than unaffected women. However, absolute risk of diabetes was last assessed systematically in 2002, with incidence of diabetes between 2.6% and 70% reported in studies with follow-up from 6 weeks to 28 years postpartum. We aim to revise this estimate in light of more recent data and changing diagnostic criteria.
Methods
We searched 5 electronic databases in September 2017. Unlike previous reviews, we included any study design that reported incidence of diabetes after GDM. Following independent assessment against inclusion criteria, data extraction and quality assessment, we are conducting a random-effects meta-analysis and meta-regression of diabetes incidence after GDM (subgroups include geographical region, follow-up duration and GDM/diabetes diagnostic sensitivity), and calculating the relative risk of diabetes in women with and without GDM in studies with a comparator population.
Results
After screening 23,160 citations and 405 full texts, we included 110 studies. This provides data on 280,000 women with GDM between 1971 and 2015 in 35 countries. 58% studies had a follow-up of ≥5 years. 90% studies were medium or high quality. 21% women (19 to 23%, n=110) developed diabetes after GDM, with highest estimates in studies from Central and South America and with ≥10 years follow-up.
Discussion
These updated data on the frequency and timing of diabetes after GDM, plus greater understanding of factors associated with incidence, will inform screening strategies and approaches to reduce risk of diabetes in this population.
Patient and Public Involvement (PPI)
None
Associations between GP-delivered behavioral change techniques and patient weight loss in the BWeL trial
Eleanor Ayre, Joseph Lee, Kerstin Frie, Paul Aveyard, Charlotte Albury
University of Oxford, United Kingdom
Abstract
Introduction
GP-delivered brief weight loss advice leads to population-level weight loss, and can reduce the prevalence of obesity and associated diseases. However, despite guidelines encouraging intervention, GPs rarely discuss weight with patients with obesity. GPs report needing more knowledge to discuss weight loss in a helpful and motivational way. Using anonymised audio-recorded data from the brief Interventions for Weight Loss (BWeL) trial, where GPs delivered brief weight loss advice to unselected patients with a BMI>30, we aim to identify the behavioural change techniques (BCTs) used by GPs that are associated with patient weight loss.
Methods
We plan to use the Behaviour change techniques (BCT) taxonomy to code up to 200 recordings of primary care consultations where weight loss advice is given, to identify what BCTs GPs use to give advice. We will then use logistic regression analyses to identify specific techniques used by GPs which are associated with patient action on their weight in the short and long-term.
Results
Data are collected and available. We anticipate results of the coding and analysis by September 2019. These will show (1) whether using specific BCTs in brief weight management interventions is associated with patient weight loss, and (2) if there is an association between weight loss and the number of BCTs incorporated into an intervention.
Conclusion
We will conclude whether particular GP-delivered brief advice that incorporates particular BCTs seems to influence patients’ likelihood of weight loss.This work will help GPs tailor their approach by using BCTs associated with weight loss.
Patient and Public Involvement (PPI)
People with obesity were part of the steering committee for the BWeL trial. We plan to invite people with obesity to comment on the BCTs which we identify, and to work with this group to develop a dissemination strategy when this work is complete.
How common is antidepressant use in people with type 2 diabetes and who is more at risk?
Kingshuk Pal, Manuj Sharma, Naaheed Mukadam, Irene Petersen
UCL, United Kingdom
Abstract
Introduction
Diabetes is the third most common long-term condition in England after hypertension and depression. People with type 2 diabetes appear to be more at risk of developing depression and have poorer outcomes if they are depressed. This study will describe quantity the use of antidepressant use in people with type 2 diabetes and identify those most at risk.
Methods
This was a retrospective cohort study using data from The Health Improvement Network (THIN) primary care database.
Results
This abstract contains results from the initial analysis. The hazard ratio for starting on antidepressant medication was 1.18 (95% CI 1.17 to 1.20) in people with type 2 diabetes compared to the comparison cohort. The risk in woman was 1.53 times that of men (95% CI 1.17 to 1.20). Risks increased with social deprivation and rates of anti-depressant prescribing were 62% higher in the most deprived quintile (95% CI 1.59 to 1.65). People using insulin were 1.5 times more likely to be on an antidepressant than people not treated with insulin (95% CI 1.46 to 1.57). The risk of being prescribed an anti-depressant medication appeared to have a U-shaped distribution with the highest risks at the extremes of age and the lowest risk in the 7th decade.
Discussion
People with type 2 diabetes were 20% more likely to be started on antidepressant medication than people without type 2 diabetes. Women were 50% more likely to prescribed antidepressants and the risks increased with deprivation, extremes of age and if people were on insulin.
Patient and Public Involvement (PPI)
We currently do not have any funding for PPI involvement, but we will be applying for grants and if we can get funding, we will have PPI input into both the final paper and the lay summary.
Exploring Online Resources for Childhood Eczema: A Survey of Parents’ Online Resource Use
Bethan Treadgold1, Ingrid Muller1, Emma Teasdale1, Neil Coulson2, Miriam Santer1
1University of Southampton, United Kingdom. 2University of Nottingham, United Kingdom
Abstract
Introduction: Parents and carers of children with eczema often turn to online resources for their information and peer-support needs. Little is known about which online resources families use, for what type of advice, and how parents’ online experiences may influence their management of their children’s eczema.
Methods: We carried out an online survey study, which was developed in collaboration with PPI partners. Participants were recruited through Twitter, Facebook, online parenting forums, skin charities, and community advertising from August to December 2018. Data were analysed with descriptive statistics, and a content analysis performed on free-text data.
Findings: 133 parents completed the survey. Health information websites (e.g. NHS Choices) were reported as most popular to use in the early eczema stages (47%), with subsequent use transitioning to social media sites (e.g. Facebook) (43%). Facebook support groups were reported as the most commonly used online platform (61%), followed by a range of online discussion forums. Advice regarding eczema treatments was most searched for (35%). Parents more often reported that they had acted upon information they had read on social media sites and discussion forums (e.g. Mumsnet) (90%) than on health information websites (85%).
Discussion: This study provides academics and clinicians in primary care with a greater insight into parents’ perspectives of using online resources for advice about eczema treatments. This study has also identified three popular social media sites and online discussion forums used by parents, which will be further explored in a subsequent study of parents’ exchanges online about eczema treatments.
Patient and Public Involvement (PPI)
We involved PPI in many aspects of this study, including feedback on our study protocol, survey draft, ethics form and participant information sheet before applying for ethics. They helped us to design the survey to ensure relevance to the population, guided us on where and how to advertise the survey online, and recommended participatory incentives.
Clinical perspectives on the assessment and diagnosis of developmental conditions in children.
Barry Coughlan1, Dr Robbie Duschinsky1, Matt Woolgar 2, Marinus van IJzendoorn1
1University of Cambridge, United Kingdom. 2Kings College London, United Kingdom
Abstract
Context: The assessment and conceptualisation of autism spectrum conditions (hereafter autism) can present challenges for both primary and secondary care professionals. In the absence of established biomedical markers, clinical judgment is often an important factor in referral and diagnosis. While diagnosis typically takes place in specialists services, it is often General Practitioners (hereafter GPs) who are tasked with making the initial referral (Crane et al., 2016). However, there is little research on how GPs make these decisions (Unigwe et al., 2016). This is also within a context where symptoms cut-across conditions. For instance, autism shares a symptomatic overlap with traditionally distinct conceptualisations, such as ADHD and attachment-related conditions. Yet the process of differential conceptualisation is not well understood.
Aim: To understand how health care professionals make decisions about referral and conceptualisation of these conditions in practice.
Methods: Semi-structured interviews were conducted with professionals (i.e. GPs, psychologists, psychiatrists, and allied health professionals) from across the assessment pathway. We interviewed 8 GPs and 16 professionals from various CAMHs and specialist assessment services. Interviews topics include case conceptualisation and referral pathways. Interviews were recorded, and data were analysed thematically.
Results: Analysis is currently on-going.
Implications: The data gleaned from this analysis will a) identify the pertinent features to be collected at a primary care level to assist with subsequent formal assessment b) capture the symptoms which clinicians consider differential in each case c) inform best practice guidelines.
Patient and Public Involvement (PPI)
PPI panel at Addenbrooke's Hospital were consulted with regarding research materials (i.e. information sheet, consent forms) and assisted with the development of the interview schedule.
Primary Care Practitioners’ experiences and views of communication and communication-related training within osteoarthritis consultations: Qualitative Interview study
Stephanie Hughes1, Jane Vennik1, Kirsten Smith1, Hajira Dambha-Miller2, Leanne Morrison1, Jeremy Howick3, Mohana Ratnapalan1, Emily Lyness1, Felicity Bishop1, Hazel Everitt1
1University of Southampton, United Kingdom. 2University of Southampton. 3University of Oxford, United Kingdom
Abstract
Background: Positive healthcare interactions can significantly improve health outcomes, quality of life and patient satisfaction with care. This qualitative interview study is a part of the larger NIHR SPCR Empathica “Expectation Management for Patients with Osteoarthritis (OA)” study, which aims to develop a brief digital training intervention for primary care professionals to enhance empathic communication and expectation management in OA consultations.
Aim: The aim was to identify key barriers and facilitators of empathic communication within primary care OA consultations and of engagement with a digital training intervention.
Methods:
Design
Qualitative interview study.
Participants and Recruitment
A purposively-varied sample of 20 PCPs (sampled to provide variety on : GP/physiotherapist/nurse, large/small practices, partner/salaried/sessional, time since qualification, ethnicity, age) were interviewed using a semi-structured interview guide. Participants were recruited until data saturation was achieved.
Data Analysis
Interview transcripts were transcribed verbatim and analysed using inductive thematic analysis to develop themes explicating participants’ preferences and perceived needs for a digital training intervention to enhance communication. Techniques from grounded theory (open-coding, constant comparison, deviant case analysis) were employed, to facilitate coding and the identification of themes that capture important patterns in the data.
Results: Rich data is emerging with a wide variety of views on factors influencing empathic communication and engagement with digital training. We will report final results.
Conclusion: Findings from this study will be used to inform the development of a brief digital intervention to support communication in primary care osteoarthritis consultations.
Patient and Public Involvement (PPI)
Our PPI representatives have had input throughout the design and development of this work. They have provided valuable feedback with regards to our interview schedule.
Towards an understanding of GPs’ viewpoints on diagnosing postnatal depression in primary care: a realist evaluation
Ashvanthi Sriranjan, Sophie Park, Ruth Abrams
UCL Research Department of Primary Care and Population Health, United Kingdom
Abstract
Introduction
Less than half of postnatal depression cases are identified in routine clinical assessment. Guidelines and current literature suggest that GPs may have an opportunistic role in detecting postnatal depression due to their early contact and existing rapport with many new mothers. There is limited research on the diagnostic approaches chosen by GPs in different GP-patient contexts. Our study intends to evaluate the thought-processes GPs take when forming a clinical diagnosis of postnatal depression in different contexts.
Method
Seven GP participants were interviewed for this study using an adapted version of Johari’s window framework. A realist approach to analysis was undertaken with the intention of understanding GPs’ responses to different situations. Context-mechanism-outcome configurations were constructed and a programme theory was formed to consolidate the findings.
Results
Findings suggest that diagnoses may be a clinician-led or collaborative process between GP and patient. In collaborative contexts, stigmatising views were addressed by GPs, time for self-reflection was encouraged, and mothers’ views were accounted for. Clinician-led diagnoses often occurred in contexts where safety was a concern. The personal and clinical experience of GPs themselves, as well as effective communication channels with other primary care professionals were significant mechanisms.
Discussion
GPs use a variety of strategies to support patient disclosure and acceptance of their condition. The complexity of GP-patient contexts may influence the clinical thought-process. We address the absence of literature by exploring postnatal depression diagnosis in primary care and provide tentative configurations to suggest what works, for whom and in what contexts.
Patient and Public Involvement (PPI)
Not applicable to this study
Including people with experience of dementia in a conversation analysis of out-of-hours primary care.
Jemima Dooley
Centre for Academic Primary Care, University of Bristol, United Kingdom
Abstract
Introduction: People with dementia are a vulnerable patient group due to their age, multimorbidities and cognitive frailty (Tonelli et al, 2017). Evidence shows that important decisions such as introducing social care support, institutionalisation, prescribing or de-prescribing, and hospital admission are often made when urgent care is required (Dening et al, 2011). However, ‘diagnostic overshadowing’ can occur, where people may be receiving substandard care because dementia takes precedent above other conditions (Voss et al, 2017). The impact of dementia on communication can also impair appropriate decision making. As an added complexity, it is family or professional carers who often make contact with services (Livingston et al, 2010).
This launching fellowship is an exploratory project exploring decision making when people with dementia require urgent primary care.
Methods: We are collecting audio and video recordings of telephone and face-to-face consultations in out-of-hours primary care. Conversation analysis will identify interactional challenges involved in the clinician-carer-person with dementia triad. A group of people living with dementia and those with experience caring for people with dementia will be analysing the recordings.
Emerging findings: The people with lived experience of dementia will identify aspects of the communication evident in the recordings that are most salient to them. This conference paper will detail how people with experience of dementia were involved in the conversation analysis of the data, how the results differed from a conventional analytic approach, what the challenges were and what this added to the research project.
Patient and Public Involvement (PPI)
This launching fellowship project has had people with experience of dementia feed into the project design, protocol development, ethics application, and literature review. This steering group will also contribute to the analysis of the audio and video recordings I have been collecting from GP out-of-hours services. This will be the topic of my paper for the SPCR showcase.
What weight loss is offered in routine practice?
Heather Tong , Elizabeth Morris, Susan Jebb, Dimitrios Koutoukidis
University of Oxford, United Kingdom
Abstract
Introduction
NICE recommends that health practitioners advise their patients with obesity to lose weight. However, the advice being delivered in routine practice produces only small effects in terms of weight loss. One reason for this might be that the health care practitioners do not have standardised protocols for weight loss advice. This lack of a protocolised intervention may lead to variable delivery and, subsequently, to a variable degree of weight loss.
Aims
The aim of the project is to characterise the currently provided advice in routine care.
Methods
A trained researcher will listen to the audio-recorded weight loss consultations provided as part of usual care in a previous randomised controlled clinical trial. They will code the advice given in two ways: Firstly, they will code it against an existing framework of behaviour change techniques (BCT Taxonomy v1). Secondly, they will also code the advice in terms of the diet intake and physical activity guidance provided and adapt an existing framework for the advice provided. A second coder will code a proportion of the consultation and the degree of agreement between the two will be calculated. A third coder will assist in resolving discrepancies.
Discussion
This project will provide a descriptive analysis of the current BCTs nurses use and the advice they provide on diet and physical activity. It will facilitate further understanding on the content and consistency of the advice provided, and whether specific techniques or advice are associated with greater weight loss.
Patient and Public Involvement (PPI)
We will communicate the results of the study through our existing panel of people with overweight and obesity. We will seek their opinion on developing a standardising intervention with the potential effective weight loss components that could be tested as the new standard of care.
Exploring patient and practitioner perspectives of healthcare interactions for osteoarthritis: a meta-ethnographic approach
Jane Vennik1, Felicity Bishop2, Steph Hughes1, Kirsten Smith1, Jeremy Howick3, Leanne Morrison2, Lucy Yardley4, Paul Little1, Christian Mallen5, Hajira Dambha-Miller1, Emily Lyness1, Mohana Ratnapalan1, Hazel Everitt1
1University of Southampton, United Kingdom. 2University of Southampton, USA. 3University of Oxford, United Kingdom. 4University of Bristol, United Kingdom. 5University of Keele, United Kingdom
Background
Positive healthcare interactions can significantly improve patient health outcomes and quality of life. This study aims to explore patients and primary care practitioners (PCP) concerns, priorities and expectations of interactions for osteoarthritis (OA) pain in primary care. This study forms part of a larger study (Empathica) which aims to develop a brief training intervention to enhance empathic communication and expectation management in OA consultations.
Aim
The aim is to identify patients’ and PCPs’ perceptions of healthcare interactions for OA.
Methods
Relevant studies were identified through a systematic search of electronic databases (1990-present; Embase, CINAHL, Medline, PsychInfo). Titles were screened by multiple researchers. Full papers were appraised using the CASP tool and relevant data extracted. A meta-ethnographic approach was used to synthesize and interpret the findings.
Results
Patient and PCP perceptions were explored in separate analyses. Findings were triangulated to identify common themes and divergent views. Preliminary analysis found that PCPs can normalise OA as ‘simply part of getting older’, and make assumptions about patient priorities. However, patients don’t always articulate their concerns or be explicit about their needs. Listening to the patient story, exploring priorities, and taking an individualised approach to management, may enhance primary care interactions for OA. Final results will be presented.
Conclusions
Outcomes of the work will inform the development of a digital training intervention to support communication for OA in primary care. Ultimately, enhancing empathic communication may improve the long-term effectiveness of treatments for OA pain, and improve patient quality of life.
Patient and Public Involvement (PPI)
PPI representatives were involved in the design and application process for the Empathica project, of which this study forms a part. A patient contributor from the Empathica research management team will review the outcomes of this study from a patient perspective and is writing a lay summary to help with dissemination.
Gender and socioeconomic differences in medication use: findings from the Newcastle 85+ Study
Laurie Davies, Andrew Kingston, Adam Todd, Rachel Duncan, Barbara Hanratty
Newcastle University, United Kingdom
Abstract
Introduction
Previous research has described prescribing amongst the very old (85+ years) over time. However, little is known about gender and socioeconomic differences in medication use in this population. This study aims to characterise gender and socioeconomic inequalities in later-life prescribing, using data from the Newcastle 85+ Study.
Methods
The Newcastle 85+ Study is a prospective cohort of people from North-East England, born in 1921. Prescribed medications were analysed by gender and socioeconomic status for survivors (n=343) at three intervals (age 85.5, 88.5 and 90.5). Socioeconomic status was measured via the Index of Multiple Deprivation (IMD) categorised as <10th, 10-90th and >90th centiles, to examine differences in medication use and account for the diminished social gradient in later life. Analyses were undertaken in R-3.5.0 and presented through bar graphs.
Results
Medication prescription varied by gender. Cardiovascular, gout and genitourinary medications were more frequently prescribed for men, whereas osteoporosis medications, analgesics and antidepressants were more common amongst women. Prescribing also differed by socioeconomic status. Symptomatic medications, including non-steroidal anti-inflammatory drugs and bulk-forming laxatives, were more frequently prescribed for socioeconomically disadvantaged people (<10th centile IMD). Conversely, preventive medications including aspirin, statins and vitamin D with calcium, were more common amongst the most affluent (>90th centile IMD).
Discussion
Understanding and addressing clinically significant gender and socioeconomic differences in medication use amongst the very old may help to reduce health inequalities in later life. Further work is needed to identify the reasons underlying lower levels of preventive medications for the most disadvantaged older people.
Patient and Public Involvement (PPI)
The implications of this work will be discussed with the Newcastle University/INVOLVE supported patient engagement organisation, VOICE.
Effectiveness of practice based pharmacist interventions - systematic review
Ben Fletcher
University of Oxford, United Kingdom
Abstract
In a report published in 2016 by the Kings Fund, UK general practice was described as being “in crisis”, with increased workloads not matched by growth in funding or in workforce. The same report encouraged, as an immediate priority, the further development of the primary care workforce through the use of nurses, pharmacists and physician associates. In the current policy environment, NHS England is putting significant funding into the introduction of general practice-based pharmacists (GPBPs). Pharmacists have worked in general practices for a number of years, but never in a widespread and coordinated way.
Since July 2015 NHS England have run a pilot where 490 clinical pharmacists have been placed in 650 general practices at a cost of £31 million. It was hoped that having GPBPs would allow GPs to “focus their skills where they are most needed, for example treating patients with complex conditions”. The General Practice Forward View committed to a further £112 million investment, with the aim of placing a further 1,500 pharmacists in general practices by 2020. The new GP contract in 2019 includes funding for one whole-time equivalent GPBP in each primary care network.
Given the current focus on GPBP in England it is timely to appraise the available evidence.
We will present a review of interventions delivered by GPBPs, with the aim of providing areas where there is currently high quality evidence for GPBPs, and areas for future research/audit.
Patient and Public Involvement (PPI)
NA
Association of blood lipids, atherosclerosis and statin use with dementia and cognitive impairment after stroke: a systematic review and meta-analysis
Zhirong Yang1, Hanyuying Wang2, Duncan Edwards1, Chengyi Ding3, Li Yan4, Carol Brayne2, Jonathan Mant1
1Primary Care Unit, University of Cambridge, United Kingdom. 2Institute of Public Health, University of Cambridge, United Kingdom. 3Research Department of Epidemiology and Public Health, University College London, United Kingdom. 4MRC-PHE Centre for Environment and Health, King's College London, United Kingdom
Abstract
Introduction: The association of blood lipids, atherosclerosis and statin use with dementia and cognitive impairment (CI) is uncertain in stroke patients, who are at higher risk of cognitive decline.
Methods: MEDLINE, EMBASE, the Cochrane Library and trial registries were searched. We included randomised controlled trials or observational cohort studies conducted among patients with stroke and reported on the association of blood lipids, atherosclerosis or statin use with dementia or CI. Meta-analysis of was conducted separately for crude and maximally adjusted odds ratios(OR) and hazard ratios(HR).
Results: 56 studies (one RCT and 55 cohort studies, with 38,423 patients). For coronary heart disease, the pooled OR of dementia and CI was 1.32 (1.10-1.58) and 1.23 (0.99-1.54), respectively. For peripheral artery disease, the pooled OR of dementia and CI was 3.59 (1.47-8.76) and 2.70 (1.09-6.69), respectively. For post-stroke statin use, the pooled OR of dementia and CI was 0.89 ( 0.65-1.21) and 0.56 (0.46-0.69) respectively. No association was found for hypercholesterolemia. These results were mostly consistent with pooled adjusted ORs or HRs, which were reported from limited evidence.
Discussion: Atherosclerosis may be associated with an increased risk of post-stroke dementia. Post-stroke statin use was associated with decreased risk of CI. To confirm whether statins confer advantages in the post-stroke population in terms of preventing cognitive decline over and above their known effectiveness in reducing risk of further vascular events, further stroke trials including cognitive assessment and observational analyses adjusted for key confounders, focusing on key subgroups or statin use patterns are required.
GP and parent views of allergy testing in children with eczema: qualitative study within the Trial of Eczema allergy Screening Tests (TEST) feasibility study
Matthew Ridd1, Clare Clement1, Alison Shaw1, Doug Webb1, Kirsty Roberts1, Miriam Santer2, Joanne Chalmers3, Deborah Marriage4, Lisa Waddell3, Kirsty Garfield1, Joanna Coast1, Ingrid Muller2, Elizabeth Angier2, Nicholas Turner1, Peter Blair1, Jodi Taylor1, Robert Boyle5, Lucy Selman1
1University of Bristol, United Kingdom. 2University of Southampton, United Kingdom. 3University of Nottingham, United Kingdom. 4Bristol Royal Children's Hospital, United Kingdom. 5Imperial College London, United Kingdom
Abstract
Introduction: Little is known about parents’ and GPs’ understanding and experience of food allergy testing for children with eczema. A better understanding will help interpret and explain the findings of the Trial of Eczema allergy Screening Tests (TEST) feasibility trial.
Method: GPs and parents of children participating in the TEST are purposively sampled to take part in an interview, ensuring diversity in relevant characteristics. Families who decline to participate or withdraw during TEST are also being sampled. Semi-structured interviews are audio-recorded and transcribed verbatim. Data are being analysed thematically.
Results: The TEST study is ongoing, with 11 GP and 13 parent interviews conducted to date. Emergent findings indicate that GPs believe food allergy testing to be acceptable in children with eczema. However, they only consider food allergy in complex cases. GPs want more information to guide decision making and to advise parents. While parents are unsure of the role of food allergy in eczema, they are motivated to try anything which might help. Parent’s complex beliefs regarding allergy and intolerance may conflict with test results. Participating GPs and parents believe that a definitive trial of test-guided dietary management for managing eczema in children is needed. Reasons for parents not taking part include not wanting their child to have an invasive test and believing their child’s eczema to be too mild.
Discussion: The shared uncertainty regarding the role of food allergy and eczema, and the acceptability of food allergy tests, supports the feasibility of a definitive trial.
Patient and Public Involvement (PPI)
We have consulted a PPI advisory group and PPI members of the TMG. Feedback from both have been used to refine the study information leaflet and parent interview topic guides; and raised awareness of flexibility when booking interviews with parents. We have also consulted with them to sense check preliminary qualitative findings.
Helping parents of children with respiratory tract infections decide when to consult primary care: a UCLA/RAND appropriateness study
Louise Newbould1, George Edwards2, Alastair Hay3, Gail Hayward2, Rebecca Morris1, Stephen Campbell1
1The University of Manchester, United Kingdom. 2University of Oxford, United Kingdom. 3University of Bristol, United Kingdom
Abstract
Introduction
English primary care is struggling to cope with demand for care. Respiratory tract infections (RTIs) in children are the most common reason for primary care consultations. There is considerable parental uncertainty regarding if and when to consult when children fall ill with RTIs. This project aims to develop a guide for parents on when to consult their GP if their child has an RTI.
Methods
A three-stage RAND/UCLA Appropriateness Method will be employed to reach consensus across relevant professions on average child (symptoms) characteristics of RTI that can guide parents to seeking medical advice from primary care, emergency services or self-care. These are:
- A systematic review, to identify symptoms/clinical markers that may lead to poor prognosis in children with RTI symptoms.
- A RAND/UCLA expert panel to rate the appropriateness scenarios developed
- Co-design event (healthcare professionals and parents) to design the parent guide.
Results
Six symptoms were identified for inclusion. We found no compelling evidence that these six symptoms could be used by clinicians to predict poor prognosis and therefore which children need to be seen. This was due to heterogeneity within the study population (ages, conditions, setting), outcomes, in the definition of symptoms (esp. fever), and/or in analysis techniques, and conflicting results.
Discussion
This suggests that further research is needed, and supports the RAND-UCLA approach being used in this study. This will be followed by a co-design with health care professionals and parents to design the parent guide.
Patient and Public Involvement (PPI)
With our PPI group we will run a co-design event (with parents, GPs and pharmacists) where we will develop a short guide/card. The event will consist of firstly brainstorm ideas about what working criteria parents currently use to make decisions in everyday settings when they are deciding whether (and when) to consult when their child has a RTI. Secondly, we will discuss the RTI guide outline and key components for a preliminary website. This will include how the guide can be implemented in practice and will inform the guide refinement. We aim to have 20-30 people attend the event.
The Evidence for Primary Care- Which Mixed Method Research Synthesis Methodologies are Best Suited for Use in Primary Care?
Ananya Namdeo, Dawn Craig
Newcastle University , United Kingdom
Abstract
GP’s routinely rely on evidence sources such as guidelines and systematic reviews to inform their decision-making and guide the treatment plans of patients in order to provide timely, evidence based care. In some clinical areas however, guidelines from influential sources such as NICE may unavailable or insufficient, leaving clinicians to decide the relevance and quality of many different competing types of evidence that may be available to them. This is especially true of mixed method reviews which have only recently become popularised.
Currently there are a number of methods to underpin mixed methods reviews, with some uncertainty as to which are most appropriate or robust. Guidelines and systematic reviews often utilise a range of methods although some may be constrained by stringent frameworks dictated by their respective commissioning bodies. In order to fill this knowledge gap, a series of reviews will be undertaken. The first will explore how, and under which circumstances, mixed method synthesis methodologies are used in Primary Care systematic review literature, as compared to the wider healthcare review literature. Further to this we will explore their use in primary care guidelines as compared other areas of healthcare.
Finally any differences between the methodologies used in reviews as opposed to guidelines will be analysed. Based on this work two case studies will be identified and used to explore and identify an optimal synthesis method that will be specific and tailored for use in primary care, enabling clinicians to make fully informed decisions even in areas of complexity.
Patient and Public Involvement (PPI)
None currently.
Establishing research priorities to improve the management of patients with advanced heart failure using the James Lind Alliance method.
Rachel Johnson1, Alyson Huntley1, Amy Gadoud2, Richard Lehman3, Nicholas Jones4, Jonathan Mant5, Richard Hobbs4, Gene Feder1, Clare Taylor4
1University of Bristol, United Kingdom. 2Lancaster University, United Kingdom. 3University of Birmingham, United Kingdom. 4University of Oxford, United Kingdom. 5University of Cambridge, United Kingdom
Abstract
Introduction
Advanced heart failure (AHF) is life-limiting, burdensome condition affecting mostly elderly people. The James Lind Alliance has developed methods for identifying and prioritising research ideas proposed by people living with a health condition, their carers and healthcare professionals (stakeholders). We set up a priority setting partnership for AHF. http://www.jla.nihr.ac.uk/priority-setting-partnerships/advanced-heart-failure/
Methods
A survey gathered research questions from key stakeholders. The results were collated and categorised by the steering group, generating summary questions. A second survey was used to prioritise the summary questions. At a workshop in February 2019, these questions were further prioritised using a nominal group technique to develop a top 10 list of research questions for which there is no or limited evidence.
Results
191 participants (74 patients [ 49% ≥60 years, 7% ≥80 years], 17 carers, 91 health professionals and 17 ‘other’) responded to the initial survey generating 476 research uncertainties. After removing out of scope questions, and rationalising duplicate and overlapping questions, 65 summary questions remained, reflecting a wide range of issues fatigue that are rarely the focus of guidelines e.g. including understanding AHF, emotional/psychological needs, and management of symptoms. The summary questions were prioritised in a second stakeholder survey (122 respondents) before the final workshop. The top ten will be presented at the SPCR showcase.
Discussion
The JLA process has allowed us to foreground the concerns of patients and their carers, to highlight the need for research in previously neglected areas, and established research priorities for AHF which will be disseminated widely.
Patient and Public Involvement (PPI)
A steering group including patients and carers alongside clinicians and representatives of charities oversaw the project and contributed to design of the surveys, promotion of surveys to a wide group of stakeholders, analysis of the survey data, and dissemination of findings. Patients and carers were well represented in the final workshop at which the top 10 priorities were determined. In addition, a separate PPI group of patients and carers contributed throughout the project, including to development and piloting of the survey materials.
Simulation-based sample size calculations for studies externally validating a prediction model
Kym Snell1, Lucinda Archer1, Joie Ensor1, Laura Bonnett2, Bob Phillips3, Gary Collins4, Richard Riley1
1Keele University, United Kingdom. 2University of Liverpool, United Kingdom. 3University of York. 4University of Oxford, United Kingdom
Abstract
Background: Prediction models require external validation before being implemented in clinical practice. It is important to ensure that validation studies are large enough to accurately and precisely estimate the model’s predictive performance, however current sample size guidance simply suggests having at least 100 (or even 200) events and non-events in the validation study. Although often overlooked, it is not only the point estimates of performance measures that are of interest but also the precision in these estimates. Researchers should therefore ensure that validation studies are large enough to estimate performance measures (such as calibration and discrimination) with reasonable precision.
Methods: We propose a simulation-based approach to determine a sample size that ensures precise estimates of a model’s predictive performance. This can be applied by specifying the desired precision in predictive performance measures and using the reported distribution of the linear predictor (risk score) from the development cohort. Datasets of increasing size are then generated until the desired precision is achieved.
Results: We will demonstrate the approach for a variety of validation settings including those with varying degrees of mis-calibration, mimicking a population with a different prevalence level for example. The approach will be illustrated for a diagnostic prediction model for deep vein thrombosis using published data from the model development.
Discussion: Current sample size guidance is too simplistic and does not work well in individual settings. Where the distribution of the linear predictor can be ascertained, our simulation-based approach allows tailored sample size calculations for external validation studies.
Patient and Public Involvement (PPI)
Work presented is based on statistical methodology research, which is challenging for PPI, however patients and the public are and will be involved in other aspects of my Fellowship research.
Trial of Eczema allergy Screening Tests (TEST) feasibility study
Matthew Ridd1, Doug Webb1, Kirsty Roberts1, Nicholas Turner1, Miriam Santer2, Joanna Chalmers3, Deborah Marriage4, Lisa Waddell3, Kirsty Garfield1, Joanna Coast1, Lucy Selman1, Clare Clement1, Alison Shaw1, Ingrid Muller1, Elizabeth Angier2, Peter Blair1, Jodi Taylor1, Joe Kai3, Robert Boyle5
1University of Bristol, United Kingdom. 2University of Southampton, United Kingdom. 3University of Nottingham, United Kingdom. 4Bristol Royal Children's Hosital, United Kingdom. 5Imperial College London, United Kingdom
Abstract
Introduction: Parents of children with eczema often pursue dietary restrictions as a way of managing eczema and seek allergy testing to guide dietary management. There is a lack of evidence to support this approach and uncertainties about the design and viability of a clinical trial. TEST aims to determine the feasibility of an RCT comparing food allergy testing and advice versus usual care, for the management of eczema in children.
Method: Children 3 months-5 years with eczema were recruited via GP surgeries and randomised to intervention or usual care. Intervention participants underwent structured allergy history and skin prick tests (SPT) for cow’s milk, hen’s egg, wheat, peanut, cashew and codfish; and based on the findings, advised to include or exclude one or more foods from their diet. All participants are followed-up for 24-weeks with four weekly questionnaires and an end-of-study skin assessment.
Results: 17/47 GP surgeries who expressed an interest sent 1053 invitation letters. 141/206 replies were potentially eligible, with 84 children randomised (mean age 33 months, range 8 to 58). 16/42 intervention participants had no parent-reported symptoms of food allergy and normal SPTs; and 26/42 had “positive” tests to one or more foods (9 with equivocal or positive SPTs: 4 egg, 3 peanut, 1 milk, 1 cashew). 6 participants were advised 8 home dietary trials of inclusion/exclusion and 1 underwent oral food challenge.
Discussion: Follow-up will finish in August 2019 and information on participant retention, adherence, data completeness and feasibility of follow-on trial will be presented.
Patient and Public Involvement (PPI)
“What role might food allergy tests play in treating eczema?” and “What is the role of (exclusion) diets in treating eczema?” were research questions identified in the James Lind Alliance eczema research priority setting partnership (2013). Two mothers of children with eczema regularly attend TMG meetings and a lay member also sits on TS/DM-C. We have a wider PPI advisory group with whom we meet regularly. PPI has informed trial design (putative primary outcome, type of allergy test, duration of follow-up) and conduct (content and layout of information leaflets and questionnaires).
Influence of the human microbiome in community-acquired respiratory tract infections: a systematic review
Ashley Hammond, Tanzeela Khalid, Alastair Hay
University of Bristol, United Kingdom
Abstract
Introduction
The human microbiome describes the ecological community of commensal, symbiotic and pathogenic microorganisms which share our body space. It encompasses the collective genomes of all the microorganisms or microbiota that reside within a particular environment, including in humans the respiratory and gastrointestinal tract. As we continue to learn more about these microbes, it has become increasingly clear that subtle changes within microbial populations can also affect human health. Changes in composition of microorganism communities within certain human environments has been associated with hospital-acquired infections, but less is known about its role in community-acquired infections. This review will examine the current evidence of the role the human microbiota plays in community-acquired RTI acquisition.
Methods
We systematically searched for studies published between 1946 and 2019 investigating the role of the microbiome in community-acquired RTIs. Studies which investigated community-acquired RTI microbiome in hospitalised patients were eligible, hospital-acquired respiratory infections were excluded. Two reviewers screened titles and abstracts. Full text papers for eligible studies were obtained and data extracted independently by two reviewers.
Results
Analysis is currently ongoing, results will be presented in full at conference.
Discussion
Our continued understanding of the role resident microbes play in influencing infection may lead to more focused and appropriate treatments in the future. This could also contribute to reducing the demand on NHS primary health care services and reduce the number of patients receiving a potentially inappropriate antibiotic treatment for self-limiting infections.
Patient and Public Involvement (PPI)
No PPI was conducted specifically for this review.
Joint modelling of multiple primary outcomes in randomised controlled trials.
Multiple primary outcomes may be specified in randomised controlled trials when a single outcome is not sufficient on its own to capture the range of clinically relevant intervention benefits for a particular health condition. The outcomes may be of different types, say a mixture of survival and continuous outcomes. For example, in a trial evaluating the effectiveness of long-term treatment for depression, the primary outcomes may be the time to relapse and number of depression symptoms. Joint models can be used to link survival outcomes with continuous outcomes. These models could provide better estimates of the intervention effect compared to analysing the outcomes independently. Survival and continuous outcomes may be analysed using a survival model and a longitudinal model, respectively and the models may be linked by sharing parameters or by using joint random effects.
Methods
This simulation study evaluates the performance of joint models in terms of bias and efficiency of the estimated treatment effects. The results are compared to the estimates obtained when analysing the outcomes separately. Several simulation scenarios were investigated by varying the strength of the association between the outcomes and the level of missing data.
Results
The results show that when the outcomes are analysed separately, parameter estimation for the survival outcome is typically biased. The bias is reduced when using the joint models. When there is strong association between the outcomes, the joint models performed best in terms of the mean square error of the estimated intervention effect on the survival outcome.
The special 10th anniversary showcase will take place at the Royal College of Physicians this year.
Welcome, plenaries, one parallel session, closing comments
Wolfson Theatre
Poster boards, refreshments and buffet lunch
Osler Long Room
Parallel Orals
Wolfson, Council Chamber, Sloane, Linacre