Glen Swanwick

Multicentre cluster randomised trial comparing a community group exercise programme and home-based exercise with usual care for people aged 65 years and over in primary care

BACKGROUND Regular physical activity (PA) reduces the risk of falls and hip fractures, and mortality from all causes. However, PA levels are low in the older population and previous intervention studies have demonstrated only modest, short-term improvements. OBJECTIVE To evaluate the impact of two exercise promotion programmes on PA in people aged ≥ 65 years. DESIGN The ProAct65+ study was a pragmatic, three-arm parallel design, cluster randomised controlled trial of class-based exercise [Falls Management Exercise (FaME) programme], home-based exercise [Otago Exercise Programme (OEP)] and usual care among older people (aged ≥ 65 years) in primary care. SETTING Forty-three UK-based general practices in London and Nottingham/Derby. PARTICIPANTS A total of 1256 people ≥ 65 years were recruited through their general practices to take part in the trial. INTERVENTIONS The FaME programme and OEP. FaME included weekly classes plus home exercises for 24 weeks and encouraged walking. OEP included home exercises supported by peer mentors (PMs) for 24 weeks, and encouraged walking. MAIN OUTCOME MEASURES The primary outcome was the proportion that reported reaching the recommended PA target of 150 minutes of moderate to vigorous physical activity (MVPA) per week, 12 months after cessation of the intervention. Secondary outcomes included functional assessments of balance and falls risk, the incidence of falls, fear of falling, quality of life, social networks and self-efficacy. An economic evaluation including participant and NHS costs was embedded in the clinical trial. RESULTS In total, 20,507 patients from 43 general practices were invited to participate. Expressions of interest were received from 2752 (13%) and 1256 (6%) consented to join the trial; 387 were allocated to the FaME arm, 411 to the OEP arm and 458 to usual care. Primary outcome data were available at 12 months after the end of the intervention period for 830 (66%) of the study participants. The proportions reporting at least 150 minutes of MVPA per week rose between baseline and 12 months after the intervention from 40% to 49% in the FaME arm, from 41% to 43% in the OEP arm and from 37.5% to 38.0% in the usual-care arm. A significantly higher proportion in the FaME arm than in the usual-care arm reported at least 150 minutes of MVPA per week at 12 months after the intervention [adjusted odds ratio (AOR) 1.78, 95% confidence interval (CI) 1.11 to 2.87; p = 0.02]. There was no significant difference in MVPA between OEP and usual care (AOR 1.17, 95% CI 0.72 to 1.92; p = 0.52). Participants in the FaME arm added around 15 minutes of MVPA per day to their baseline physical activity level. In the 12 months after the close of the intervention phase, there was a statistically significant reduction in falls rate in the FaME arm compared with the usual-care arm (incidence rate ratio 0.74, 95% CI 0.55 to 0.99; p = 0.042). Scores on the Physical Activity Scale for the Elderly showed a small but statistically significant benefit for FaME compared with usual care, as did perceptions of benefits from exercise. Balance confidence was significantly improved at 12 months post intervention in both arms compared with the usual-care arm. There were no statistically significant differences between intervention arms and the usual-care arm in other secondary outcomes, including quality-adjusted life-years. FaME is more expensive than OEP delivered with PMs (£269 vs. £88 per participant in London; £218 vs. £117 in Nottingham). The cost per extra person exercising at, or above, target was £1919.64 in London and £1560.21 in Nottingham (mean £1739.93). CONCLUSION The FaME intervention increased self-reported PA levels among community-dwelling older adults 12 months after the intervention, and significantly reduced falls. Both the FaME and OEP interventions appeared to be safe, with no significant differences in adverse reactions between study arms. TRIAL REGISTRATION This trial is registered as ISRCTN43453770. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 18, No. 49. See the NIHR Journals Library website for further project information.

Research into practice: safe prescribing

Over the past 10 years our team has been involved in a wide range of studies of prescribing in general practice, but one we feel that has really made a difference is the PRACtICe study, which was funded by the General Medical Council.1,2 In this study we took a sample of 15 general practices across England and did a retrospective review of the clinical records of a random sample of over 1700 patients, and over 6000 prescription items. Using a definition of error that focused on clinically important problems,1 we found that one in 20 (5%) prescription items was associated with one or more prescribing or monitoring errors, and that one in 550 prescription items contained what we regarded as a severe error1 (with seriously inadequate monitoring of patients taking warfarin the biggest culprit). We found that per prescription item, errors were more common in children and older people, and that nearly half of patients receiving >10 items over the course of a year were the recipients of an error. The commonest types of error related to incomplete information on the prescription, dose-strength errors, and timing-frequency errors. Using interviews, root cause analyses and focus groups, we explored the underlying causes of the errors and, not surprisingly, found them to be multifactorial.2 Of the various underlying causes, we felt that several were amenable to intervention, including improving safety systems in general practices; making best use of our electronic prescribing systems, including computerised clinical decision support; improving prescribing and monitoring at the interface between primary and secondary care, and better training for GPs in therapeutics and safe prescribing (accepting that most GPs already have good therapeutic knowledge and are highly committed to patient safety). We made a number of recommendations from our research and have taken …

Essential prescribing tips for GP Associates-in-Training

Prescribing is an essential role in general practice but it is also, at times, a high risk activity. GP Associates-in-Training (GP AiTs) have been highlighted as needing further support to reduce the risk of prescribing errors. This article highlights some common prescribing errors to help GP AiTs to review their prescribing and develop prescribing habits to avoid errors. The general practice workforce is changing and there are more pharmacists working in general practice. This article describes the role of clinical pharmacists in prescribing safety and in supporting GP AiTs.