Ricky Mullis

A primary care back pain screening tool: identifying patient subgroups for initial treatment.

OBJECTIVE To develop and validate a tool that screens for back pain prognostic indicators relevant to initial decision making in primary care. METHODS The setting was UK primary care adults with nonspecific back pain. Constructs that were independent prognostic indicators for persistence were identified from secondary analysis of 2 existing cohorts and published literature. Receiver operating characteristic curve analysis identified single screening questions for relevant constructs. Psychometric properties of the tool, including concurrent and discriminant validity, internal consistency, and repeatability, were assessed within a new development sample (n = 131) and tool score cutoffs were established to enable allocation to 3 subgroups (low, medium, and high risk). Predictive and external validity were evaluated within an independent external sample (n = 500). RESULTS The tool included 9 items: referred leg pain, comorbid pain, disability (2 items), bothersomeness, catastrophizing, fear, anxiety, and depression. The latter 5 items were identified as a psychosocial subscale. The tool demonstrated good reliability and validity and was acceptable to patients and clinicians. Patients scoring 0-3 were classified as low risk, and those scoring 4 or 5 on a psychosocial subscale were classified as high risk. The remainder were classified as medium risk. CONCLUSION We validated a brief screening tool, which is a promising instrument for identifying subgroups of patients to guide the provision of early secondary prevention in primary care. Further work will establish whether allocation to treatment subgroups using the tool, linked with targeting treatment appropriately, improves patient outcomes.

Effect of stratified care for low back pain in family practice (IMPaCT Back): a prospective population-based sequential comparison.

PURPOSE We aimed to determine the effects of implementing risk-stratified care for low back pain in family practice on physician’s clinical behavior, patient outcomes, and costs. METHODS The IMPaCT Back Study (IMplementation to improve Patient Care through Targeted treatment) prospectively compared separate patient cohorts in a preintervention phase (6 months of usual care) and a postintervention phase (12 months of stratified care) in family practice, involving 64 family physicians and linked physical therapy services. A total of 1,647 adults with low back pain were invited to participate. Stratified care entailed use of a risk stratification tool to classify patients into groups at low, medium, or high risk for persistent disability and provision of risk-matched treatment. The primary outcome was 6-month change in disability as assessed with the Roland-Morris Disability Questionnaire. Process outcomes captured physician behavior change in risk-appropriate referral to physical therapy, diagnostic tests, medication prescriptions, and sickness certifications. A cost-utility analysis estimated incremental quality-adjusted life-years and back-related health care costs. Analysis was by intention to treat. RESULTS The 922 patients studied (368 in the preintervention phase and 554 in the postintervention phase) had comparable baseline characteristics. At 6 months follow-up, stratified care had a small but significant benefit relative to usual care as seen from a mean difference in Roland-Morris Disability Questionnaire scores of 0.7 (95% CI, 0.1–1.4), with a large, clinically important difference in the high risk group of 2.3 (95% CI, 0.8–3.9). Mean time off work was 50% shorter (4 vs 8 days, P = .03) and the proportion of patients given sickness certifications was 30% lower (9% vs 15%, P = .03) in the postintervention cohort. Health care cost savings were also observed. CONCLUSIONS Stratified care for back pain implemented in family practice leads to significant improvements in patient disability outcomes and a halving in time off work, without increasing health care costs. Wider implementation is recommended.

ICF CORE SETS FOR LOW BACK PAIN: DO THEY INCLUDE WHAT MATTERS TO PATIENTS?

OBJECTIVE To investigate whether the International Classification of Functioning Disability and Health (ICF) Core Sets for low back pain encompass the key functional problems of patients. DESIGN Cross-sectional evaluation of patient-centred problems with low back pain. SUBJECTS A total of 402 patients living in the UK recruited into a randomized clinical trial. METHODS Patients with acute or subacute low back pain were asked to identify: (i) the one thing they find most difficult to do, and (ii) something they usually enjoyed but were unable to do because of their back pain. Two raters classified responses according to the ICF. Inter-rater agreement was measured using the kappa statistic. The response categories were examined for inclusion within the Core Sets. RESULTS For question (i) above, agreement between raters was 323/397 (81%), kappa (95% confidence interval (95% CI)) = 0.78 (0.73-0.82). A total of 329 (83%) fell within the ICF Brief Core Set; all except 3 were contained within the Comprehensive Core Set. For question (ii) agreement was 290/312 (93%), kappa (95% CI) = 0.91 (0.87-0.95). Only 54 (17%) of these fell within the Brief Core Set; the 2 most chosen categories (recreation and leisure: d920; caring for household objects: d650) accounted for 70% of responses, and were not included. All except 2 responses were encompassed by the Comprehensive Core Set. CONCLUSION Addition of codes d920 and d650 to the low back pain Brief Core Set would significantly increase the inclusion rate in this cohort.

Crutch length: Effect on energy cost and activity intensity in non–weight-bearing ambulation

OBJECTIVE To investigate the effect of forearm crutch length on energy cost in three-point, non-weight-bearing (NWB) ambulation. DESIGN Double-blind repeated measures design using crutch length as the independent variable. SETTING Overland walking circuit at a university campus. PARTICIPANTS Volunteer, convenience sample of 20 subjects consisting of university students and staff without cardiovascular, respiratory, or orthopedic conditions. INTERVENTION Subjects used a three-point, NWB gait with forearm crutches set to length using conventional guidelines, and at 2.5 cm above and below this value. MAIN OUTCOME MEASURES Oxygen consumption, carbon dioxide production, heart rate, speed of ambulation, and perceived exertion under steady-state conditions. RESULTS In terms of oxygen cost, ambulation with crutches set to the length recommended in conventional guidelines was not significantly more energy efficient than ambulation with either the longer or shorter crutches. Using crutches set 2.5 cm longer than conventional guidelines produced the lowest respiratory exchange ratio (Vco2/Vo2) and the lowest ratings of perceived exertion. However, none of these differences reached statistical significance. CONCLUSION Since exact crutch length was not critical in terms of oxygen cost, walking speed, or perceived exertion during NWB ambulation, the importance of rigidly adhering to specific guidelines for setting crutch length was not substantiated in this study. Clinically, consideration of patient preference regarding crutch length (within 2.5 cm) can be advocated.

The associations of “fatness,” “fitness,” and physical activity with all-cause mortality in older adults: A systematic review

This review explored whether cardiorespiratory fitness or physical activity act as either confounders or effect modifiers of the relationship between adiposity markers and all‐cause mortality in older adults.

Barriers to medication adherence for the secondary prevention of stroke: a qualitative interview study in primary care

Background Medications are highly effective at reducing risk of recurrent stroke, but success is influenced by adherence to treatment. Among survivors of stroke and transient ischaemic attack (TIA), adherence to medication is known to be suboptimal. Aim To identify and report barriers to medication adherence for the secondary prevention of stroke/TIA. Design and setting A qualitative interview study was conducted within general practice surgeries in the East of England, UK. Method Patients were approached by letter and invited to take part in a qualitative research study. Semi-structured interviews were undertaken with survivors of stroke, caregivers, and GPs to explore their perspectives and views around secondary prevention and perceived barriers to medication adherence. Key themes were identified using a grounded theory approach. Verbatim quotes describing the themes are presented here. Results In total, 28 survivors of stroke, including 14 accompanying caregivers and five GPs, were interviewed. Two key themes were identified. Patient level barriers included ability to self-care, the importance people attach to a stroke event, and knowledge of stroke and medication. Medication level barriers included beliefs about medication and beliefs about how pills work, medication routines, changing medications, and regimen complexity and burden of treatment. Conclusion Patients who have had a stroke are faced with multiple barriers to taking secondary prevention medications in UK general practice. This research suggests that a collaborative approach between caregivers, survivors, and healthcare professionals is needed to address these barriers and facilitate medication-taking behaviour.

Medicines optimisation in primary care: can community pharmacies deliver?

One pound in every eight of NHS spending is on medicines, yet it is generally agreed that up to half of all the medicines prescribed are not used as the prescriber intended.1 The problem of sub-optimal use of medicines in chronic diseases has been recognised for many years, but only recently has ‘medicines optimisation’ been on the agenda of policy makers. Medicines optimisation refers to the process of making the use of medication by patients as safe, effective, and efficient as possible. A key part of the government’s strategy towards achieving this has been to extend the role of community pharmacies, and to make better use of pharmacists’ specific medicines-related skills and knowledge. This strategy for medicines optimisation began with the 2005 Medicines Use Review (MUR) service, and received another fillip in October last year with the launch of the New Medicines Service (NMS) in England.2 Whereas the focus of the MUR was on improving medicines use by patients already taking multiple medicines for a period of time, the NMS aims to provide early support to patients who are newly prescribed a medicine for a long-term condition. Similar services have been introduced in Scotland and Wales. Given the investment of scarce NHS resources (up to £55 million pounds per annum until 2013 in England for the NMS) what are the chances of success? Here we explore the potential, the evidence, and the challenges of the NMS service. The NMS seeks to improve medicines use in people with long-term conditions who are newly prescribed …

Stroke survivors', caregivers' and GPs' attitudes towards a polypill for the secondary prevention of stroke: a qualitative interview study

Objectives To understand the perspectives of stroke survivors, caregivers and general practitioners (GPs) on a polypill approach, consisting of blood pressure and cholesterol-lowering therapies, with or without aspirin, for the secondary prevention of stroke. Methods A qualitative interview study was undertaken in 5 GP surgeries in the East of England. 28 survivors of stroke/transient ischaemic attack (TIA) were interviewed, 14 of them with a caregiver present, along with a convenience sample of 5 GPs, to assess attitudes towards a polypill and future use. Topic guides explored participants attitudes, potential uptake and long-term use, management of polypill medication and factors influencing the decision to prescribe. Data were analysed using a grounded theory approach. Key themes are presented and illustrated with verbatim quotes. Results The analysis identified 3 key themes: polypill benefits, polypill concerns and polypill lessons for implementation. Stroke/TIA survivors were positive about the polypill concept and considered it acceptable in the secondary prevention of stroke. Perceived benefits of a polypill included convenience resulting in improved adherence and reduced burden of treatment. Caregivers felt that a polypill would improve medication-taking practices, and GPs were open to prescribing it to those at increased cardiovascular risk. However, concerns raised included whether a polypill provided equivalent therapeutic benefit, side effects through combining medications, consequences of non-adherence, lack of flexibility in regulating dosage, disruption to current treatment and suitability to the wider stroke population. Conclusions Participants acknowledged potential advantages in a polypill approach for secondary prevention of stroke; however, significant concerns remain. Further research on the efficacy of a polypill is needed to reassure practitioners whose concerns around inflexibility and treatment suitability are likely to influence the decision to prescribe a polypill for secondary prevention of stroke. Acceptability among survivors, caregivers and GPs is likely to determine the uptake and subsequent use of a polypill in the future.

Understanding stroke survivors’ and informal carers’ experiences of and need for primary care and community health services—a systematic review of the qualitative literature: protocol

Introduction Despite the rising prevalence of stroke, no comprehensive model of postacute stroke care exists. Research on stroke has focused on acute care and early supported discharge, with less attention dedicated to longer term support in the community. Likewise, relatively little research has focused on long-term support for informal carers. This review aims to synthesise and appraise extant qualitative evidence on: (1) long-term healthcare needs of stroke survivors and informal carers, and (2) their experiences of primary care and community health services. The review will inform the development of a primary care model for stroke survivors and informal carers. Methods and analysis We will systematically search 4 databases: MEDLINE, EMBASE, PsycINFO and CINAHL for published qualitative evidence on the needs and experiences of stroke survivors and informal carers of postacute care delivered by primary care and community health services. Additional searches of reference lists and citation indices will be conducted. The quality of articles will be assessed by 2 independent reviewers using a Critical Appraisal Skills Programme (CASP) checklist. Disagreements will be resolved through discussion or third party adjudication. Meta-ethnography will be used to synthesise the literature based on first-order, second-order and third-order constructs. We will construct a theoretical model of stroke survivors’ and informal carers’ experiences of primary care and community health services. Ethics and dissemination The results of the systematic review will be disseminated via publication in a peer-reviewed journal and presented at a relevant conference. The study does not require ethical approval as no patient identifiable data will be used.

Stroke survivors' and informal caregivers' experiences of primary care and community healthcare services - A systematic review and meta-ethnography.

Objective To describe and explain stroke survivors and informal caregivers’ experiences of primary care and community healthcare services. To offer potential solutions for how negative experiences could be addressed by healthcare services. Design Systematic review and meta-ethnography. Data sources Medline, CINAHL, Embase and PsycINFO databases (literature searched until May 2015, published studies ranged from 1996 to 2015). Eligibility criteria Primary qualitative studies focused on adult community-dwelling stroke survivors’ and/or informal caregivers’ experiences of primary care and/or community healthcare services. Data synthesis A set of common second order constructs (original authors’ interpretations of participants’ experiences) were identified across the studies and used to develop a novel integrative account of the data (third order constructs). Study quality was assessed using the Critical Appraisal Skills Programme checklist. Relevance was assessed using Dixon-Woods’ criteria. Results 51 studies (including 168 stroke survivors and 328 caregivers) were synthesised. We developed three inter-dependent third order constructs: (1) marginalisation of stroke survivors and caregivers by healthcare services, (2) passivity versus proactivity in the relationship between health services and the patient/caregiver dyad, and (3) fluidity of stroke related needs for both patient and caregiver. Issues of continuity of care, limitations in access to services and inadequate information provision drove perceptions of marginalisation and passivity of services for both patients and caregivers. Fluidity was apparent through changing information needs and psychological adaptation to living with long-term consequences of stroke. Limitations Potential limitations of qualitative research such as limited generalisability and inability to provide firm answers are offset by the consistency of the findings across a range of countries and healthcare systems. Conclusions Stroke survivors and caregivers feel abandoned because they have become marginalised by services and they do not have the knowledge or skills to re-engage. This can be addressed by: (1) increasing stroke specific health literacy by targeted and timely information provision, and (2) improving continuity of care between specialist and generalist services. Systematic review registration number PROSPERO 2015:CRD42015026602