Author Archives: Niroshan Siriwardena

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Making an impact: what’s new in prehospital emergency care research

Members of the Community and Health Research Unit (CaHRU) recently attended a one-day prehospital emergency care conference in999EMS Cardiff on 27 February 2013 to present studies on behalf of the study teams and being undertaken as part of the Prehospital Emergency Quality and Outcomes (PEQO) programme of research at CaHRU. The conference was sponsored by the Thematic Research Network for Unscheduled and Trauma care (TRUST), Welsh Ambulance Service Trust and the 999 EMS Research Forum.

Viet-Hai Phung presented posters on  “Leadership, innovation and engagement in quality improvement in the Ambulance Services Cardiovascular Quality Initiative: cross sectional study” and “Prehospital outcomes for ambulance service care: systematic review”. Fiona Togher and Viet-Hai Phung presented a poster on “What do users value about the emergency ambulance service?“.

cardiffProfessor Niro Siriwardena presented one of the four oral presentations selected at the conference on the resuslts from the Ambulance Services Cardiovascular Quality Initiative (ASCQI), “The effect of a national ambulance Quality Improvement Collaborative on performance in care bundles for acute myocardial infarction and stroke”. In the afternoon he also conducted a workshop with Dr Steven Macey on “How to include anonymised routine data in emergency care research”.

The conference was a real success and an important opportunity for team members to meet with other leading prehospital researchers in the United Kingdom.

 

 

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Trent Regional Society for Academic Primary Care conference

A team from the Community and Health Research Unit recently delivered four oral presentations at the Trent Regional Society for Academic Primary Care conference in Sheffield on 5 March 2013.

Dr Zahid Asghar presented research from the IPVASTIA study funded by the National Institute for Health Research (NIHR) Research for Patient benefit programme on “Influenza vaccination and risk of stroke: self-controlled case-series study” which showed a significant reduction in stroke risk associated with influenza vaccination.

Coral Sirdifield presented an international study involving the University of Lincoln and University of Ghent, Belgium on “General practitioners prescribing of benzodiazepines in Western Primary Care: metasynthesis of qualitative studies”. Jo Middlemass presented work from a recently completed study, Exploring social Networks to Augment Cognitive behavioural Therapy (ENACT) funded by the EPSRC, Patients’ and clinicians’ experiences and perceptions of the primary care management of insomnia: qualitative study.

Finally, Fiona Togher presented preliminary findings from a study, “What do users value about the emergency ambulance service?” sphyg1funded by an NIHR Programme Grant for Applied Health Research, Prehospital Outcomes for Evidence Based Evaluation (PhOEBE).

All four members of the team gave excellent presentations and ably responded to questions. The studies involve a range of programmes of work, including studies on the link between influenza and vascular disease, primary care management of insomnia and prehospital outcome measures, led by Professor Niroshan Siriwardena. The next 2014 Trent Regional Society for Academic Primary Care conference will be held in Lincoln, the first time the University of Lincoln will be hosting the event.

 

 

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New study shows that one third of patients with diabetes attended by an ambulance for severe hypoglycaemia transported to hospital

EMAS - A&E 5A new study has been published in Primary Care Diabetes on ‘Severe hypoglycaemia requiring emergency medical assistance by ambulance services in the East Midlands: a retrospective study’. Hypoglycaemia or low blood sugar is important because this may be linked to greater risk of death.

The study involved a new collaboration between the University of Leicester Cardiovascular and Diabetes group (Professors Kamlesh Khunti and Melanie Davies), University of Bristol (Harriet Fisher),  University of Queensland, Australia (Sanjoy Paul),University of Lincoln and East Midlands Ambulance Service NHS Trust (Mohammad Iqbal, Professor Niro Siriwardena).

The study aimed to report the characteristics, treatment and provider costs for people with diabetes requiring an emergency ambulance for severe hypoglycaemia and involved an analysis of routinely collected data on 90,435 emergency calls collected over four months by the East Midlands Ambulance Trust, UK.

There were 523 (0.6%) ambulance attendances for severe hypoglycaemia, with an incidence of 2.76 per 100 patient years: 28% of events occurred at night and 32% of those attended were transported to hospital. Those patients with a higher respiratory rate, indicating difficulty breathing, were more likely to be transported to hospital, whereas patients on treatment with insulin and those with higher blood glucose after treatment of hypoglycaemia were less likely to be transported to hospital.

Median ambulance costs were higher at £176 for individuals not transported to hospital whereas those transported cost £92 reflecting the greater time ambulance staff spent with patients who were enabled to remain at home.

The research team are planning further studies investigating longer term outcomes of prehospital care for hypoglycaemia as part of CaHRU’s Prehospital and Emergency Quality and Outcomes (PEQO) programme.

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How well do newer Z drug sleeping tablets work?

A new study from the CaHRU was published online this December 2012. The full paper is available from the link below:

Huedo-Medina T, Kirsch I, Middlemass J, Klonizakis M, Siriwardena AN.  Effectiveness of non-benzodiazepine hypnotics in treatment of adult insomnia: meta-analysis of data submitted to the Food and Drug Administration. British Medical Journal 2012; 345: e8343 doi: 10.1136/bmj.e8343.

BMJ paper

Newer (Z drug or non-benzodiazepine) sleeping tablets are known to have short term benefits for treatment of insomnia but their effectiveness has been questioned because of publication and reporting bias reported in previous meta-analyses. Publication bias is due to positive trials being more likely to be published and reporting bias is where positive results are more likely to be published in papers. The placebo response contributes a large part of the effect of drugs like antidepressants but we know little about the extent of the placebo response to hypnotics.

This review of data submitted to the FDA showed that Z drugs decreased the time to fall asleep both subjectively and measured in a sleep lab. There was little demonstrable effect on other outcomes, partly because most studies tended not to measure these outcomes such as sleep quality, sleep efficiency, waking during the night after going to sleep, although these outcomes are often more important to patients than time to fall asleep.

There is a lot of debate currently about the lack of data from pharmaceutical industry (‘pharma’) trials to undertake independent analyses. The FDA data provide all pharma data prior to drug approval and are a helpful way of independently evaluating drug effects and side effects. Pharma trials tend to be more positive than non-pharma trials so the effects of studies submitted tend to be an overestimate of the effects of the drugs. Most of the pharma trials included in this meta-analysis were of short duration (up to 30 days) and in people with primary insomnia, not linked to depression or pain.

The drugs had more effect with larger doses, which is not surprising, but also had more effect in younger or female patients and regardless of type of drug, which is more surprising.  The drug effect and the placebo response were small and, but the two together produced to a reasonably large response. Around half the effect of the drug was a placebo response, which means the placebo response is important in this type of treatment.

Psychological treatments for insomnia work as well as sleeping tablets in the short term and better in the longer term so focusing on increasing access to these treatments, for example through Resources for Effective Sleep Treatment, would benefit people with sleep problems.

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SAFER 2 (Support and Assessment for Fall Emergency Referrals) trial protocol published

The SAFER 2 study is a randomised controlled trial of the clinical and cost effectiveness of new protocols for emergency ambulance personnel to assess and refer older people who fall to appropriate community based care.  The protocol for the study, led by Prof Helen Snooks at Swansea University and including Prof. Niro Siriwardena of the CaHRU and East Midlands Ambulance Service NHS Trust as a collaborator, has recently been published in BMJ Open:

Snooks H, Anthony R, Chatters R, Cheung WY, Dale J, Donohoe R, Gaze S, Halter M, Koniotou M, Logan L, Lyons R, Mason S,  Nicholl J, Phillips C, Phillips J, Russell I, Siriwardena AN, Wani M, Watkins A, Whitfield R, Wilson L. Support and assessment for fall emergency referrals (SAFER 2) research protocol: cluster randomised trial of the clinical and cost effectiveness of new protocols for emergency ambulance paramedics to assess and refer to appropriate community-based care. BMJ Open 2012;2: e002169. doi:10.1136/bmjopen-2012-002169

The study measured the costs and benefits of a novel protocol implemented by emergency ambulance paramedics caring for older people who had fallen, allowing the paramedic to assess and refer appropriate patients to a community based falls service. The study involved ambulance services in London,Wales,East Midlands. Stations were randomly allocated to implement the new protocol (intervention) or continue to provide care according to their standard practice (control).

Paramedics based at the stations selected for the intervention group received additional training, protocols and clinical support to enable them to assess older people and decide whether they need to be taken to the Emergency Department (ED) immediately, or whether they could benefit from being left at home, with a referral to a community falls service. The study compared costs, processes and outcomes of care (particularly subsequent 999 calls and ED attendances for falls) at 1 and 6 months for patients aged 65 or over who had fallen together with other quantitative and qualitative data.

The study was recently been completed and, currently in the final data collection phase, is due to be published next year.