Potential impact on prevalence of obesity in the UK of a 20% price increase in high sugar snacks: modelling study.
OBJECTIVE: To estimate the potential impact on body mass index (BMI) and prevalence of obesity of a 20% price increase in high sugar snacks. DESIGN: Modelling study. SETTING: General adult population of the United Kingdom. PARTICIPANTS: 36 324 households with data on product level household expenditure from UK Kantar FMCG (fast moving consumer goods) panel for January 2012 to December 2013. Data were used to estimate changes in energy (kcal, 1 kcal=4.18 kJ=0.00418 MJ) purchase associated with a 20% price increase in high sugar snacks. Data for 2544 adults from waves 5 to 8 of the National Diet and Nutrition Survey (2012-16) were used to estimate resulting changes in BMI and prevalence of obesity. MAIN OUTCOME MEASURES: The effect on per person take home energy purchases of a 20% price increase for three categories of high sugar snacks: confectionery (including chocolate), biscuits, and cakes. Health outcomes resulting from the price increase were measured as changes in weight, BMI (not overweight (BMI <25), overweight (BMI ≥25 and <30), and obese (BMI ≥30)), and prevalence of obesity. Results were stratified by household income and BMI. RESULTS: For income groups combined, the average reduction in energy consumption for a 20% price increase in high sugar snacks was estimated to be 8.9×103 kcal (95% confidence interval -13.1×103 to -4.2×103 kcal). Using a static weight loss model, BMI was estimated to decrease by 0.53 (95% confidence interval -1.01 to -0.06) on average across all categories and income groups. This change could reduce the UK prevalence of obesity by 2.7 percentage points (95% confidence interval -3.7 to -1.7 percentage points) after one year. The impact of a 20% price increase in high sugar snacks on energy purchase was largest in low income households classified as obese and smallest in high income households classified as not overweight. CONCLUSIONS: Increasing the price of high sugar snacks by 20% could reduce energy intake, BMI, and prevalence of obesity. This finding was in a UK context and was double that modelled for a similar price increase in sugar sweetened beverages.
Automated virtual reality (VR) cognitive therapy for patients with psychosis: study protocol for a single-blind parallel group randomised controlled trial (gameChange).
INTRODUCTION: Many patients with psychosis experience everyday social situations as anxiety-provoking. The fears can arise, for example, from paranoia, hallucinations, social anxiety or negative-self beliefs. The fears lead patients to withdraw from activities, and this isolation leads to a cycle of worsening physical and mental health. Breaking this cycle requires highly active treatment directly in the troubling situations so that patients learn that they can safely and confidently enter them. However patients with psychosis seldom receive such life-changing interventions. To solve this problem we have developed an automated psychological treatment delivered in virtual reality (VR). It allows patients to experience computer simulations of the situations that they find anxiety-provoking. A virtual coach guides patients, using cognitive techniques, in how to overcome their fears. Patients are willing to enter VR simulations of anxiety-provoking situations because they know the simulations are not real, but the learning made transfers to the real world. METHODS AND ANALYSIS: 432 patients with psychosis and anxious avoidance of social situations will be recruited from National Health Service (NHS) secondary care services. In the gameChange trial, they will be randomised (1:1) to the six-session VR cognitive treatment added to treatment as usual or treatment as usual alone. Assessments will be conducted at 0, 6 (post-treatment) and 26 weeks by a researcher blind to allocation. The primary outcome is avoidance and distress in real-life situations, using a behavioural assessment task, at 6 weeks. The secondary outcomes are psychiatric symptoms, activity levels and quality of life. All main analyses will be intention-to-treat. Moderation and mediation will be tested. An economic evaluation will be conducted. ETHICS AND DISSEMINATION: The trial has received ethical approval from the NHS South Central - Oxford B Research Ethics Committee (19/SC/0075). A key output will be a high-quality automated VR treatment for patients to overcome anxious avoidance of social situations. TRIAL REGISTRATION NUMBER: ISRCTN17308399.
Importance: Little is known about variation in outcomes of surgery, nor about factors that can explain why such variation exists. Objectives: To describe variation in patient outcomes and costs for primary hip and knee replacement across health areas and to identify whether patient, surgical and hospital factors can explain such variation. Design: Retrospective observational cohort study Setting: National Joint Registry, linked to English Hospital Episode Statistics and Patient Reported Outcome Measures datasets Participants: Patients undergoing primary total hip/knee replacement aged ≥18 from 2014 to 2016 Exposures: Patient (age, gender, body mass index, deprivation); surgical (surgeon volume, surgeon grade); hospital organisation (operating theatres, specialist consultants, hospital volume) Main outcome measures: Multilevel regression models were generated for the outcomes: length of stay, bed-day costs, change in Oxford hip/knee scores 6-months after surgery, complications by 6 months. Geographical Information Systems were used to display maps describing adjusted estimates of variation in outcomes across health areas. Results: 173,107 primary total hip replacements and 210,275 total knee replacements were available, nested in 207 health areas. We identified a number of factors that predicted poorer outcomes of surgery: Public hospitals, low volume of surgeries per surgeon and hospital and workforce with a high number of less experienced doctors were associated with poorer outcomes of surgery. Although these factors did not attenuate the magnitude of variation across health areas, they had ecological correlations with the observed geographical variations in outcomes of surgery by health area. Across health areas, predicted mean length of stay ranged from 3 to 7 days and associated bed-day costs from £4727 to £8800, for both total hip and knee replacement. The absolute predicted mean change in Oxford hip score varied from 18.7 to 24.6 points (13.1 to 18.8 for Oxford knee score). Predicted 6-month complications ranged from 3% to 6%, for both total hip and knee replacement. Conclusions and Relevance: Our models indicate that a minimum surgical volume by surgeon and by hospital; and private hospitals are associated with better outcomes of surgery, while a higher proportion of less experienced doctors by hospital might compromise achieving those outcomes. This variation is observed geographically.
Implementation of secondary fracture prevention services after hip fracture: a qualitative study using extended Normalization Process Theory.
BACKGROUND: National and international guidance emphasizes the need for hospitals to have effective secondary fracture prevention services, to reduce the risk of future fractures in hip fracture patients. Variation exists in how hospitals organize these services, and there remain significant gaps in care. No research has systematically explored reasons for this to understand how to successfully implement these services. The objective of this study was to use extended Normalization Process Theory to understand how secondary fracture prevention services can be successfully implemented. METHODS: Forty-three semi-structured interviews were conducted with healthcare professionals involved in delivering secondary fracture prevention within 11 hospitals that receive patients with acute hip fracture in one region in England. These included orthogeriatricians, fracture prevention nurses and service managers. Extended Normalization Process Theory was used to inform study design and analysis. RESULTS: Extended Normalization Process Theory specifies four constructs relating to collective action in service implementation: capacity, potential, capability and contribution. The capacity of healthcare professionals to co-operate and co-ordinate their actions was achieved using dedicated fracture prevention co-ordinators to organize important processes of care. However, participants described effective communication with GPs as challenging. Individual potential and commitment to operationalize services was generally high. Shared commitments were promoted through multi-disciplinary team working, facilitated by fracture prevention co-ordinators. Healthcare professionals had capacity to deliver multiple components of services when co-ordinators 'freed up' time. As key agents in its intervention, fracture prevention coordinators were therefore indispensable to effective implementation. Aside from difficulty of co-ordination with primary care, the intervention was highly workable and easily integrated into practice. Nevertheless, implementation was threatened by under-staffed and under-resourced services, lack of capacity to administer scans and poor patient access. To ensure ongoing service delivery, the contributions of healthcare professionals were shaped by planning, in multi-disciplinary team meetings, the use of clinical databases to identify patients and define the composition of clinical work and monitoring to improve clinical practice. CONCLUSIONS: Findings identify and describe elements needed to implement secondary fracture prevention services successfully. The study highlights the value of Normalization Process Theory to achieve comprehensive understanding of healthcare professionals' experiences in enacting a complex intervention.
Exercise or manual physiotherapy compared with a single session of physiotherapy for osteoporotic vertebral fracture: three-arm PROVE RCT.
BACKGROUND: A total of 25,000 people in the UK have osteoporotic vertebral fracture (OVF). Evidence suggests that physiotherapy may have an important treatment role. OBJECTIVE: The objective was to investigate the clinical effectiveness and cost-effectiveness of two different physiotherapy programmes for people with OVF compared with a single physiotherapy session. DESIGN: This was a prospective, adaptive, multicentre, assessor-blinded randomised controlled trial (RCT) with nested qualitative and health economic studies. SETTING: This trial was based in 21 NHS physiotherapy departments. PARTICIPANTS: The participants were people with symptomatic OVF. INTERVENTIONS: Seven sessions of either manual outpatient physiotherapy or exercise outpatient physiotherapy compared with the best practice of a 1-hour single session of physiotherapy (SSPT). MAIN OUTCOME MEASURES: Outcomes were measured at 4 and 12 months. The primary outcomes were quality of life and muscle endurance, which were measured by the disease-specific QUALEFFO-41 (Quality of Life Questionnaire of the European Foundation for Osteoporosis - 41 items) and timed loaded standing (TLS) test, respectively. Secondary outcomes were (1) thoracic kyphosis angle, (2) balance, evaluated via the functional reach test (FRT), and (3) physical function, assessed via the Short Physical Performance Battery (SPPB), 6-minute walk test (6MWT), Physical Activity Scale for the Elderly, a health resource use and falls diary, and the EuroQol-5 Dimensions, five-level version. RESULTS: A total of 615 participants were enrolled, with 216, 203 and 196 randomised by a computer-generated program to exercise therapy, manual therapy and a SSPT, respectively. Baseline data were available for 613 participants, 531 (86.6%) of whom were women; the mean age of these participants was 72.14 years (standard deviation 9.09 years). Primary outcome data were obtained for 69% of participants (429/615) at 12 months: 175 in the exercise therapy arm, 181 in the manual therapy arm and 173 in the SSPT arm. Interim analysis met the criteria for all arms to remain in the study. For the primary outcomes at 12 months, there were no significant benefits over SSPT of exercise [QUALEFFO-41, difference -0.23 points, 95% confidence interval (CI) -3.20 to 1.59 points; p = 1.000; and TLS test, difference 5.77 seconds, 95% CI -4.85 to 20.46 seconds; p = 0.437] or of manual therapy (QUALEFFO-41, difference 1.35 points, 95% CI -1.76 to 2.93 points; p = 0.744; TLS test, difference 9.69 seconds (95% CI 0.09 to 24.86 seconds; p = 0.335). At 4 months, there were significant gains for both manual therapy and exercise therapy over SSPT in the TLS test in participants aged < 70 years. Exercise therapy was superior to a SSPT at 4 months in the SPPB, FRT and 6MWT and manual therapy was superior to a SSPT at 4 months in the TLS test and FRT. Neither manual therapy nor exercise therapy was cost-effective relative to a SSPT using the threshold of £20,000 per quality-adjusted life-year. There were no treatment-related serious adverse events. CONCLUSIONS: This is the largest RCT to date assessing physiotherapy in participants with OVFs. At 1 year, neither treatment intervention conferred more benefit than a single 1-hour physiotherapy advice session. The focus of future work should be on the intensity and duration of interventions to determine if changes to these would demonstrate more sustained effects. TRIAL REGISTRATION: Current Controlled Trials ISRCTN49117867. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 44. See the NIHR Journals Library website for further project information.
Statistical models for the deterioration of kidney function in a primary care population: A retrospective database analysis
Background: Evidence for kidney function monitoring intervals in primary care is weak, and based mainly on expert opinion. In the absence of trials of monitoring strategies, an approach combining a model for the natural history of kidney function over time combined with a cost-effectiveness analysis offers the most feasible approach for comparing the effects of monitoring under a variety of policies. This study aimed to create a model for kidney disease progression using routinely collected measures of kidney function. Methods: This is an open cohort study of patients aged ≥18 years, registered at 643 UK general practices contributing to the Clinical Practice Research Datalink between 1 April 2005 and 31 March 2014. At study entry, no patients were kidney transplant donors or recipients, pregnant or on dialysis. Hidden Markov models for estimated glomerular filtration rate (eGFR) stage progression were fitted to four patient cohorts defined by baseline albuminuria stage; adjusted for sex, history of heart failure, cancer, hypertension and diabetes, annually updated for age. Results: Of 1,973,068 patients, 1,921,949 had no recorded urine albumin at baseline, 37,947 had normoalbuminuria (<3mg/mmol), 10,248 had microalbuminuria (3–30mg/mmol), and 2,924 had macroalbuminuria (>30mg/mmol). Estimated annual transition probabilities were 0.75–1.3%, 1.5–2.5%, 3.4–5.4% and 3.1–11.9% for each cohort, respectively. Misclassification of eGFR stage was estimated to occur in 12.1% (95%CI: 11.9–12.2%) to 14.7% (95%CI: 14.1–15.3%) of tests. Male gender, cancer, heart failure and age were independently associated with declining renal function, whereas the impact of raised blood pressure and glucose on renal function was entirely predicted by albuminuria. Conclusions: True kidney function deteriorates slowly over time, declining more sharply with elevated urine albumin, increasing age, heart failure, cancer and male gender. Consecutive eGFR measurements should be interpreted with caution as observed improvement or deterioration may be due to misclassification.
Use of illicit substances and violent behaviour in psychotic disorders: two nationwide case-control studies and meta-analyses.
BACKGROUND: Substance use disorder explains much of the excess risk of violent behaviour in psychotic disorders. However, it is unclear to what extent the pharmacological properties and subthreshold use of illicit substances are associated with violence. METHODS: Individuals with psychotic disorders were recruited for two nationwide projects: GROUP (N = 871) in the Netherlands and NEDEN (N = 921) in the United Kingdom. Substance use and violent behaviour were assessed with standardized instruments and multiple sources of information. First, we used logistic regression models to estimate the associations of daily and nondaily use with violence for cannabis, stimulants, depressants and hallucinogens in the GROUP and NEDEN samples separately. Adjustments were made for age, sex and educational level. We then combined the results in random-effects meta-analyses. RESULTS: Daily use, compared with nondaily or no use, and nondaily use, compared with no use, increased the pooled odds of violence in people with psychotic disorders for all substance categories. The increases were significant for daily use of cannabis [pooled odds ratio (pOR) 1.6, 95% confidence interval (CI) 1.2-2.0), stimulants (pOR 2.8, 95% CI 1.7-4.5) and depressants (pOR 2.2, 95% CI 1.1-4.5), and nondaily use of stimulants (pOR 1.6, 95% CI 1.2-2.0) and hallucinogens (pOR 1.5, 95% CI 1.1-2.1). Daily use of hallucinogens, which could only be analysed in the NEDEN sample, significantly increased the risk of violence (adjusted odds ratio 3.3, 95% CI 1.2-9.3). CONCLUSIONS: Strategies to prevent violent behaviour in psychotic disorders should target any substance use.
Identifying routine clinical predictors of non-adherence to second line therapies in Type 2 diabetes: a retrospective cohort analysis in a large primary care database.
AIMS: Non-adherence to medication is a major problem for patients with diabetes leading to poor response to therapy. Many factors associated with poor adherence have been identified, but their combined predictive ability has not been assessed. We investigated whether combinations of routinely available clinical features can predict which patients are likely to be non-adherent. MATERIALS AND METHODS: 67882 patients with prescription records for their first and second oral glucose lowering therapies were identified from electronic healthcare records (Clinical Practice Research Datalink (CPRD)). Non-adherence was defined as a medical possession ratio (MPR) ≤80%. Potential predictors were examined including age at diagnosis, sex, BMI, duration of diabetes, HbA1c, Charlson Index and other recent prescriptions. RESULTS: Routine clinical features were poor at predicting non-adherence to the first diabetes therapy (c-statistic=0.601 for all in combined model). Non-adherence to the second drug was better predicted for all combined factors (c=0.715) but this improvement was predominantly a result of including adherence to the first drug (c=0.695 for this alone). Patients with MPR≤80% on their first drug were 3.6 (95% CI 3.3,3.8) times more likely to be non-adherent on their second drug (32% v 9%). CONCLUSIONS: Although certain clinical features are associated with poor adherence, their performance for predicting who is likely to be non-adherent, even when combined, is weak. The strongest predictor of adherence to second-line therapy is adherence to the first therapy. Examining previous prescription records could offer a practical way for clinicians to identify potentially non-adherent patients and is an area warranting further research. This article is protected by copyright. All rights reserved.
© 2019, Nature. Teach people to think critically about claims and comparisons — they will make better decisions. [Figure not available: see fulltext.].
Publisher Correction: The metabolite BH4 controls T cell proliferation in autoimmunity and cancer (Nature, (2018), 563, 7732, (564-568), 10.1038/s41586-018-0701-2)
© 2019, The Author(s), under exclusive licence to Springer Nature Limited. In this Letter, owing to an error in the production process, author Martin Aichinger was inadvertently associated with affiliation 14 (Karolinska Institute, Department of Medicine Solna, Center for Molecular Medicine, Karolinska University Hospital Solna, Stockholm, Sweden) instead of affiliation 13 (Research Institute of Molecular Pathology, Vienna Biocenter, Campus-Vienna-Biocenter 1, Vienna, Austria). In addition, the chemical structure of QM385 in Fig. 3a was incorrect. Figure 1 of this Amendment shows the incorrect and corrected structures, for transparency. These errors have been corrected online.