Shakir Hussain

Self management of oral anticoagulation: randomised trial

Abstract Objective To determine the clinical effectiveness of self management compared with routine care in patients on long term oral anticoagulants. Design Multicentre open randomised controlled trial. Setting Midlands region of the UK. Participants 617 patients aged over 18 and receiving warfarin randomised to intervention (n = 337) and routine care (n = from 2470 invited; 193/337 (57%) completed the 12 month intervention. Intervention Intervention patients used a point of care device to measure international normalised ratio twice a week and a simple dosing chart to interpret their dose of warfarin. Main outcome measure Percentage of time spent within the therapeutic range of international normalised ratio. Results No significant differences were found in percentage of time in the therapeutic range between self managment and routine care (70% v 68%). Self managed patients with poor control before the study showed an improvement in control that was not seen in the routine care group. Nine patients (2.8/100 patient years) had serious adverse events in the self managed group, compared with seven (2.7/100 patient years) in the routine care arm (χ2(df = 1) = 0.02, P = 0.89). Conclusion With appropriate training, self management is safe and reliable for a sizeable proportion of patients receiving oral anticoagulation treatment. It may improve the time spent the therapeutic range for patients with initially poor control. Trial registration ISRCTN 19313375.

Comparison of the role of self-efficacy and illness representations in relation to dietary self-care and diabetes distress in adolescents with type 1 diabetes

This cross-sectional study examined the joint effects of self-efficacy and illness representations on dietary self-care and diabetes distress in adolescents with type 1 diabetes by comparing two theoretical models: the Self-regulation Model (Leventhal, H., Meyer, D., & Nerenz, D. (1980). The common-sense representations of illness danger. In S. Rachman (Ed.), Medical Psychology (Vol. 2, pp. 7–30). New York: Pergamon.) and Social Cognitive Theory (Bandura, A. (1997). Self efficacy: The exercise of control. New York: W.H. Freeman.). One hundred and fifty-one adolescents with type 1 diabetes completed self-report measures of dietary self-efficacy, illness representations, dietary self-care and diabetes distress. Data were analysed using structural equation modelling. The model best supported by the data (Leventhals Self-regulation Model) showed that dietary self-efficacy, perceived consequences and treatment effectiveness had direct and independent effects on both dietary self-care and diabetes distress. Together with dietary self-efficacy, perceived short-term treatment effectiveness was a significant predictor of dietary self-care. Age was found to be a negative predictor of short-term treatment effectiveness beliefs. Diabetes distress was best predicted by self-efficacy and perceived consequences. It can be concluded that to target effectively dietary self-care and distress, clinicians should focus on key illness representation variables (perceived short-term treatment effectiveness and perceived consequences) in conjunction with self-efficacy.

Patient self management of oral anticoagulation in routine care in the UK

Background: Self management of anticoagulation: a randomised trial (SMART) was the first large scale UK trial to assess clinical and cost effectiveness of patient self management (PSM) of oral anticoagulation therapy compared to routine care. SMART showed that while PSM was as clinically effective as routine care, it was not as cost effective. SMART adds to the growing body of trial data to support PSM; however there are no data on clinical effectiveness and cost of PSM in routine care. Aim: To evaluate clinical effectiveness of PSM compared to routine care outside trial conditions. Methods: A retrospective multicentre matched control study. 63 PSM patients from primary care in the West Midlands were matched by age and international normalised ratio (INR) target with controls. INR results were collected for the period 1 July 2003–30 June 2004. The primary outcome measure was INR control. Results: 38 PSM and 40 control patients were recruited. INR percentage time in range was 70% PSM vs 64% controls. 60% PSM were having a regular clinical review, 45% were performing an internal quality control (IQC) test and 82% were performing external quality assurance (EQA) on a regular basis. Conclusion: PSM outside trial conditions is as clinically effective as routine UK care.

Estimation and forecasting hospital admissions due to Influenza: Planning for winter pressure. The case of the West Midlands, UK

Abstract Winters are a difficult period for the National Health Service (NHS) in the United Kingdom (UK), due to the combination of cold weather and the increased likelihood of respiratory infections, especially influenza. In this article we present a proper statistical time series approach for modelling and analysing weekly hospital admissions in the West Midlands in the UK during the period week 15/1990 to week 14/1999. We consider three variables, namely, hospital admissions, general practitioner consultants, and minimum temperature. The autocorrelations of each series are shown to decay hyperbolically. The correlations of hospital admission and the lag of other series also decay hyperbolically but with different speed and directions. One of the main objectives of this paper is to show that each of the three series can be represented by a Fractional Differenced Autoregressive integrated moving average model, (FDA). Further, the hospital admission winter and summer residuals shows significant interdependency, which may be interpreted as hidden periodicities within the last 10-years time interval. The short-range (8 weeks) forecasting of hospital admission of the FDA model and a fourth-order AutoRegressive AR(4) model are quite similar. However, our results reveal that the long-range forecasting of FDA is more realistic. This implies that, using the FDA approach, the respective authority can plan for winter pressure properly.

The demand of part-time in European companies: a multilevel modelling approach

Part-time work is one of the most well-known ‘atypical’ working time arrangements. In contrast to previous studies focusing on the supply side, the originality of our research is to investigate the demand-side of part-time work and to examine how and why companies use part-time work. Based on a large and unique sample of European firms operating in 21 member states, we use a multilevel multinomial modelling in a Bayesian environment. Our results suggest that the variations in the extent of part-time workers at the establishment level is determined more by country-specific features than by industry-specific factors.

The impact of a diabetes local enhanced service on quality outcome framework diabetes outcomes.

Background The rising challenge of diabetes requires novel service delivery approaches. In the UK, Local Enhanced Services (LES) have been commissioned for diabetes. Health professionals from general practices (GPs) who signed up to LES were given additional training (and a monetary incentive) to improve management of patients with diabetes. All practices in the PCT were invited to the LES initiative, which ensured avoiding selection bias. The aim of the study was to examine the impact of LES in terms of diabetes Quality Outcome Framework (QOF) indicators: DM23(glycaemia), DM17(lipid) and DM12(blood pressure; BP). Methods QOF diabetes indicators were examined using data from 76 general practices for 2009–2010 in a large primary care trust area in Birmingham, UK. Data were extracted from Quality Management Analysis System. The primary outcome was a difference in achievement of QOF indicators between LES and NLES practices. A secondary outcome was the difference between LES and non-LES practices for hospital first and follow-up appointments. Results We did not find any difference for DM12(BP) and DM17(lipid) outcomes between LES and NLES practices. However, LES practices were more likely to achieve the DM23(glycaemia) outcome (estimated odds 1.459;95% CI:1.378-1.544; P=0.0001). The probability of achieving satisfactory level of DM23(glycaemia) increased by almost 10% when GPs belonged to LES groups compared with GPs in NLES group. LES practices were less likely to refer patients to secondary care. Conclusion Overall, LES practices performed better in the achievement of DM23(glycaemia) and also referred fewer patients to hospital, thereby meeting their objectives. This suggests that the LES approach is beneficial and needs to be further explored in order to ascertain whether the impact exerted was due to LES.

Effects of Nutritional Supplementation during Pregnancy on Early Adult Disease Risk: Follow Up of Offspring of Participants in a Randomised Controlled Trial Investigating Effects of Supplementation on Infant Birth Weight

Background Observational evidence suggests that improving fetal growth may improve adult health. Experimental evidence from nutritional supplementation trials undertaken amongst pregnant women in the less developed world does not show strong or consistent effects on adult disease risk and no trials from the more developed world have previously been reported. Objective To test the hypothesis that nutritional supplementation during pregnancy influences offspring disease risk in adulthood Design Clinical assessment of a range of established diseases risk markers in young adult offspring of 283 South Asian mothers who participated in two trials of nutritional supplementation during pregnancy (protein/energy/vitamins; energy/vitamins or vitamins only) at Sorrento Maternity Hospital in Birmingham UK either unselected or selected on the basis of nutritional status. Results 236 (83%) offspring were traced and 118 (50%) of these were assessed in clinic. Protein/energy/vitamins supplementation amongst undernourished mothers was associated with increased infant birthweight. Nutritional supplementation showed no strong association with any one of a comprehensive range of markers of adult disease risk and no consistent pattern of association with risk across markers in offspring of either unselected or undernourished mothers. Conclusions We found no evidence that nutritional supplements given to pregnant women are an important influence on adult disease risk however our study lacked power to estimate small effects. Our findings do not provide support for a policy of nutritional supplementation for pregnant women as an effective means to improve adult health in more developed societies.

A Simple Method to Ensure Plausible Multiple Imputation for Continuous Multivariate Data

Multiple Imputation (MI) is an established approach for handling missing values. We show that MI for continuous data under the multivariate normal assumption is susceptible to generating implausible values. Our proposed remedy, is to: (1) transform the observed data into quantiles of the standard normal distribution; (2) obtain a functional relationship between the observed data and its corresponding standard normal quantiles; (3) undertake MI using the quantiles produced in step 1; and finally, (4) use the functional relationship to transform the imputations into their original domain. In conclusion, our approach safeguards MI from imputing implausible values.

Performance Evaluation Based on the Robust Mahalanobis Distance and Multilevel Modeling Using Two New Strategies

In this article, we propose a general framework for performance evaluation of organizations and individuals over time using routinely collected performance variables or indicators. Such variables or indicators are often correlated over time, with missing observations, and often come from heavy-tailed distributions shaped by outliers. Two new double robust and model-free strategies are used for evaluation (ranking) of sampling units. Strategy 1 can handle missing data using residual maximum likelihood (RML) at stage two, while strategy two handles missing data at stage one. Strategy 2 has the advantage that overcomes the problem of multicollinearity. Strategy one requires independent indicators for the construction of the distances, where strategy two does not. Two different domain examples are used to illustrate the application of the two strategies. Example one considers performance monitoring of gynecologists and example two considers the performance of industrial firms.

A simple method for detecting fractional cointegration relation : An Application to Finnish Data

The cointegration technique, based originally on nonstationary component, reduced ‘Dimension Reduction’ to some linear combination that is stationary. The obtained dimension has unit minimum and s - 1 maximum linear combination setting, where s stands for number of components in the system. In this paper a new reduction concept is provided that explains fractional cointegrated system. This reduction is located on specific angle and defined as the cointegration direction. The reduction ‘Level Reduction’ exists with smaller level of fractional orders, i.e. when -0.5 < dz < 0.5, where dz represent the fractional differences of the linear combination series, while the original series orders are in ⩾ 0.5 level and the system is fractionally cointegrated. This, of course, can be considered as a new way to detect fractional cointegration relation among variables of the same order of differencing in the frequency domain. A concept Periodogram Roughness (PR) is used to estimate and test the cointegration direction. The description of the direction property will be presented. A test statistic is presented that is based on the difference between the maximum and minimum of the PR. Using Monte Carlo simulations, it is found that the properties of the test perform satisfactorily regarding both size and power. Fractional differencing of linear combination series is estimated using Periodogram Roughness. This approach is illustrated using quarterly data on the government spending and revenue in Finland during the period of 1960 to 1997.