Researchers from CaHRU attended the national Society for Academic Primary Care (SAPC) Annual Scientific Meeting at the University of Nottingham from Wednesday 3rd – Friday 5th July 2013. The 42nd Conference of the SAPC was jointly organised by the Universities of Nottingham and Leicester, with the over-arching aim of ‘Making a Difference’. There was also an element of poignancy about the conference, dedicated as it was to the memory of Professor Helen Lester, who was hugely influential in the development of the SAPC into the thriving organisation it is today.
On the opening afternoon’s poster session, there was a lot of interest in Jo Middlemass’ work on her qualitative study of Patients’ and Clinicians’ Experiences and Perceptions of the Primary Care Management of Insomnia. The first full day opened with a keynote speech by former Health Secretary, Stephen Dorrell on the meaning of Primary Care. This was then followed by a lively session where four presenters proposed some ‘dangerous ideas’, which the audience were invited to vote on.
In the following Thursday afternoon session, there were two presentations from members of the CaHRU team. First, Coral Sirdifield presented a systematic review and meta-synthesis on ‘Clinicians’ Experiences and Perceptions of Benzodiazepine Prescribing in Western Primary Care Settings’. Later in the session, Fiona Togher presented her research on ‘What Service Users Value in their Experience of Emergency Ambulance Use’. On the final morning session of the conference, Zahid Asghar presented a ‘Self-Controlled Study on Influenza Vaccination and the Risk of Stroke’. The presentations and posters were well-received and all provoked informative discussions.
The Conference wasn’t all about work, work, work; there was also time to relax. Thursday night’s Bollywood-themed conference dinner was excellent. Delegates were provided with a rapid lesson on Indian dancing techniques such as ‘changing a light bulb’ and ‘stroking a Labrador’. The Bollywood dancers were very impressive in their hand-eye co-ordination; some of the delegates less so!
Co-Chair, Professor Kamlesh Khunti, from the University of Leicester presided over the closing session, in which a number of prizes were awarded for outstanding presentations. There was also a taster of what to expect from next year’s Conference in Edinburgh, where CaHRU will once again have a strong presence!
Fiona Togher, Viet-Hai Phung and Professor Niroshan Siriwardena from CaHRU recently attended the World Congress on Disaster and Emergency Medicine which took place in Manchester on 28th to 31st May 2013. Together with Janette Turner from the University of Sheffield, the group gave three oral presentions on studies from Pre-hospital Outcomes for Evidence Based Evaluation (PhOEBE), a 5-year programme of work funded by the National Institute for Health Research Programme Grants for Applied Research.
Fiona Togher presented a qualitative study, ‘What do service users value about the emergency ambulance service?‘. Viet-Hai Phung presented a ‘Systematic review of pre-hospital outcomes for evidence-based evaluation of ambulance service care’. Finally Janette Turner presented, ‘What outcome measures should be developed for pre-hospital care? Results of a consensus event.’ All three studies sought to identify existing and new outcome (together with process and structural) measures for ambulance services. The presentations were well delivered and received and there were a number of constructive questions and comments from an international audience.
The day began with a keynote lecture entitled ‘A Brief History of Resuscitation’. from Professor Douglas Chamberlain, preeminent in and one of the founders of resuscitation medicine in the UK. Professor Chamberlain received the Peter Safar award for his international work in resuscitation. He was also one of the leaders in development of the paramedic role.
A 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.
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.
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.
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.