Showing papers by "Rod S Taylor published in 2010"

Home based versus centre based cardiac rehabilitation: Cochrane systematic review and meta-analysis

Abstract: Objective To compare the effect of home based and supervised centre based cardiac rehabilitation on mortality and morbidity, health related quality of life, and modifiable cardiac risk factors in patients with coronary heart disease. Design Systematic review. Data sources Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library, Medline, Embase, CINAHL, and PsycINFO, without language restriction, searched from 2001 to January 2008. Review methods Reference lists checked and advice sought from authors. Included randomised controlled trials that compared centre based cardiac rehabilitation with home based programmes in adults with acute myocardial infarction, angina, or heart failure or who had undergone coronary revascularisation. Two reviewers independently assessed the eligibility of the identified trials and extracted data independently. Authors were contacted when possible to obtain missing information. Results 12 studies (1938 participants) were included. Most studies recruited patients with a low risk of further events after myocardial infarction or revascularisation. No difference was seen between home based and centre based cardiac rehabilitation in terms of mortality (relative risk 1.31, 95% confidence interval 0.65 to 2.66), cardiac events, exercise capacity (standardised mean difference −0.11, −0.35 to 0.13), modifiable risk factors (weighted mean difference systolic blood pressure (0.58 mm Hg, −3.29 mm Hg to 4.44 mm Hg), total cholesterol (−0.13 mmol/l, −0.31 mmol/l to 0.05 mmol/l), low density lipoprotein cholesterol (−0.15 mmol/l, −0.31 mmol/l to 0.01 mmol/l), or relative risk for proportion of smokers at follow-up (0.98, 0.73 to 1.31)), or health related quality of life, with the exception of high density lipoprotein cholesterol (−0.06, −0.11 to −0.02) mmol/l). In the home based participants, there was evidence of superior adherence. No consistent difference was seen in the healthcare costs of the two forms of cardiac rehabilitation. Conclusions Home and centre based forms of cardiac rehabilitation seem to be equally effective in improving clinical and health related quality of life outcomes in patients with a low risk of further events after myocardial infarction or revascularisation. This finding, together with the absence of evidence of differences in patients’ adherence and healthcare costs between the two approaches, supports the further provision of evidence based, home based cardiac rehabilitation programmes such as the “Heart Manual.” The choice of participating in a more traditional supervised centre based or evidence based home based programme should reflect the preference of the individual patient.

Exercise Training for Systolic Heart Failure: Cochrane Systematic Review and Meta-Analysis

Abstract: Aims To determine the effect of exercise training on clinical events and health-related quality of life (HRQoL) of patients with systolic heart failure. Methods and results We searched electronic databases including Medline, EMBASE, and Cochrane Library up to January 2008 to identify randomized controlled trials (RCTs) comparing exercise training and usual care with a minimum follow-up of 6 months. Nineteen RCTs were included with a total of 3647 patients, the majority of whom were male, low-to-medium risk, and New York Heart Association class II–III with a left ventricular ejection fraction of <40%. There was no significant difference between exercise and control in short-term (≤12 months) or longer-term all-cause mortality or overall hospital admissions. Heart failure-related hospitalizations were lower [relative risk: 0.72, 95% confidence interval (CI): 0.52–0.99] and HRQoL improved (standardized mean difference: −0.63, 95% CI: −0.80 to −0.37) with exercise therapy. Any effect of cardiac exercise training on total mortality and HRQoL was independent of degree of left ventricular dysfunction, type of cardiac rehabilitation, dose of exercise intervention, length of follow-up, trial quality, and trial publication date. Conclusion Compared with usual care, in selected heart failure patients, exercise training reduces heart failure-related hospitalizations and results in clinically important improvements in HRQoL. High-quality RCT and cost-effectiveness evidence is needed for the effect of exercise training in community-based settings and in more severe heart failure patients, elderly people, and women.

The burden of neuropathic pain: a systematic review and meta-analysis of health utilities.

Abstract: Patients with neuropathic pain (NeuP) experience substantially lower health-related quality of life (HRQoL) than the general population. The aim of this systematic review and meta-analysis is to test the hypothesis that NeuP is associated with low levels of health utility. A structured search of electronic databases (MEDLINE, EMBASE, Cochrane Library and CINAHL) was undertaken. Reference lists of retrieved reports were also reviewed. Studies reporting utility single-index measures (preference based) in NeuP were included. Random effects meta-analysis was used to pool EQ-5D index utility estimates across NeuP conditions. The association of utilities and pre-defined factors (NeuP condition, patient age, sex, duration and severity of pain and method of utility scoring) was examined using meta-regression. Twenty-four studies reporting health utility values in patients with NeuP were included in the review. Weighted pooled utility score across the studies varied from a mean of 0.15 for failed back surgery syndrome to 0.61 for post-herpetic neuralgia and diabetic neuropathy. Although there was substantial heterogeneity (P < 0.0001) across studies, we found little variation in utility as a function of patient and study characteristics. The single exception was a significant relationship (P < 0.0001) between increasing neuropathic pain severity and a reduction in utility. This study confirms the hypothesis that patients with NeuP experience low utilities and therefore low HRQoL. However, the contribution of non-NeuP co-morbidity remains unclear. Neuropathic pain severity emerged as a primary predictor of the negative health impact of NeuP.

Nurse led interventions to improve control of blood pressure in people with hypertension: systematic review and meta-analysis

Abstract: Objective To review trials of nurse led interventions for hypertension in primary care to clarify the evidence base, establish whether nurse prescribing is an important intervention, and identify areas requiring further study. Design Systematic review and meta-analysis. Data sources Ovid Medline, Cochrane Central Register of Controlled Trials, British Nursing Index, Cinahl, Embase, Database of Abstracts of Reviews of Effects, and the NHS Economic Evaluation Database. Study selection Randomised controlled trials of nursing interventions for hypertension compared with usual care in adults. Data extraction Systolic and diastolic blood pressure, percentages reaching target blood pressure, and percentages taking antihypertensive drugs. Intervention effects were calculated as relative risks or weighted mean differences, as appropriate, and sensitivity analysis by study quality was undertaken. Data synthesis Compared with usual care, interventions that included a stepped treatment algorithm showed greater reductions in systolic blood pressure (weighted mean difference −8.2 mm Hg, 95% confidence interval −11.5 to −4.9), nurse prescribing showed greater reductions in blood pressure (systolic −8.9 mm Hg, −12.5 to −5.3 and diastolic −4.0 mm Hg, −5.3 to −2.7), telephone monitoring showed higher achievement of blood pressure targets (relative risk 1.24, 95% confidence interval 1.08 to 1.43), and community monitoring showed greater reductions in blood pressure (weighted mean difference, systolic −4.8 mm Hg, 95% confidence interval −7.0 to −2.7 and diastolic −3.5 mm Hg, −4.5 to −2.5). Conclusions Nurse led interventions for hypertension require an algorithm to structure care. Evidence was found of improved outcomes with nurse prescribers from non-UK healthcare settings. Good quality evidence from UK primary health care is insufficient to support widespread employment of nurses in the management of hypertension within such healthcare systems.

The cost-effectiveness of spinal cord stimulation in the treatment of failed back surgery syndrome.

Abstract: OBJECTIVES Healthcare policy makers and payers require cost-effectiveness evidence to inform their treatment funding decisions. Thus, in 2008, the United Kingdom's National Institute of Health and Clinical Excellence analyzed the cost effectiveness of spinal cord stimulation (SCS) compared with conventional medical management (CMM) and with reoperation and recommended approval of SCS in selected patients with failed back surgery syndrome (FBSS). We present previously unavailable details of the National Institute of Health and Clinical Excellence analysis and an analysis of the impact on SCS cost effectiveness of rechargeable implanted pulse generators (IPGs). METHODS We used a decision analytic model to examine the cost effectiveness of SCS versus CMM and versus reoperation in patients with FBSS. We also modeled the impact of nonrechargeable versus rechargeable IPGs. RESULTS The incremental cost-effectiveness of SCS compared with CMM was pound5624 per quality-adjusted life year, with 89% probability that SCS is cost effective at a willingness to pay threshold of pound20,000. Compared with reoperation, the incremental cost-effectiveness of SCS was pound6392 per quality-adjusted life year, with 82% probability of cost-effectiveness at the pound20,000 threshold. When the longevity of an IPG is 4 years or less, a rechargeable (and initially more expensive) IPG is more cost-effective than a nonrechargeable IPG. DISCUSSION In selected patients with FBSS, SCS is cost effective both as an adjunct to CMM and as an alternative to reoperation. Despite their initial increased expense, rechargeable IPGs should be considered when IPG longevity is likely to be short.

Exercise based rehabilitation for heart failure (Review)

Abstract: Background: From previous systematic reviews and meta-analyses there is consensus about the positive effect of exercise training on exercise capacity; however, the effects on health-related quality of life, mortality and hospital admissions in heart failure remain uncertain Objectives: To update the previous systematic review which determined the effectiveness of exercise-based interventions on the mortality, hospitalisation admissions, morbidity and health-related quality of life for patients with systolic heart failure Search strategy: We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2007, Issue 4) To update searches from the previous review, MEDLINE, EMBASE, CINAHL, and PsycINFO were searched (2001 to January 2008) ISI Proceedings and bibliographies of identified reviews were checked Selection criteria: Randomised controlled trials of exercise-based interventions with six months follow up or longer compared to usual medical care or placebo The study population comprised adults of all ages (> 18 years) with evidence of chronic systolic heart failure Data collection and analysis: All identified references were independently screened by two review authors and those that were clearly ineligible were rejected Full papers of potentially relevant trials were obtained Data were independantly extracted from the included trials and their risk of bias assessed by a single review author and checked by a second Main results: Nineteen trials (3647 participants) met the inclusion criteria One large trial recuited 2331 of the participants There was no significant difference in pooled mortality between groups in the 13 trials with 1 year follow up A reduction in the hospitalisation rate was demonstrated with exercise training programmes Hospitalisations due to systolic heart failure were reduced with exercise and there was a significant improvement in health-related quality of life (HRQoL) The effect of cardiac exercise training on total mortality and HRQoL were independent of the degree of left ventricular dysfunction, type of cardiac rehabilitation, dose of exercise intervention, length of follow up, trial quality, and trial publication date Authors' conclusions: The previous version of this review showed that exercise training improved exercise capacity in the short term in patients with mild to moderate heart failure when compared to usual care This updated review provides evidence that in a similar population of patients, exercise does not increase the risk of all-cause mortality and may reduce heart failure-related hospital admissions Exercise training may offer important improvements in patients' health-related quality of life

An analysis of the components of pain, function, and health-related quality of life in patients with failed back surgery syndrome treated with spinal cord stimulation or conventional medical management.

Abstract: Objectives: Failed back surgery syndrome (FBSS) patients experience pain, functional disability, and reduced health-related quality of life (HRQoL) despite anatomically successful surgery Examining sub-dimensions of health outcomes measures provides insight into patient well-being Materials and Methods: The international multicenter PROCESS trial collected detailed HRQoL (EuroQol-5D; Short-Form 36) and function (Oswestry Disability Index) information on 100 FBSS patients Results: At baseline, patients reported moderate-to-severe leg and back pain adversely affecting all dimensions of function and HRQoL Compared with conventional medical management alone, patients also receiving spinal cord stimulation (SCS) reported superior pain relief, function, and HRQoL at six months on overall and most sub-component scores The majority of these improvements with SCS were sustained at 24 months Nonetheless, 36–40% of patients experienced ongoing marked disability (standing, lifting) and HRQoL problems (pain/discomfort) Conclusions: Longer-term patient management and research must focus on these refractory FBSS patients with persisting poor function and HRQoL outcomes

Nurse-led interventions used to improve control of high blood pressure in people with diabetes: a systematic review and meta-analysis.

Abstract: Diabet. Med. 28, 250–261 (2011) Abstract Background Previous reviews demonstrate uncertainty about the effectiveness of nurse-led interventions in the management of hypertension. No specific reviews in diabetes have been identified. We have systematically reviewed the evidence for effectiveness of nurse-led interventions for people with diabetes mellitus. Methods In this systematic review and meta-analysis, searches of Medline, Embase, CINAHL and the Cochrane Central Trials register were undertaken to identify studies comparing any intervention conducted by nurses in managing hypertension in diabetes with usual doctor-led care. Additional citations were identified from papers retrieved and correspondence with authors. Outcome measures were absolute systolic and diastolic blood pressure, change in blood pressure, proportions achieving study target blood pressure and proportions prescribed anti-hypertensive medication. Results Eleven studies were identified. Interventions included adoption of treatment algorithms, nurse-led clinics and nurse prescribing. Meta-analysis showed greater reductions in blood pressure in favour of any nurse-led interventions (systolic weighted mean difference −5.8 mmHg, 95% CI −9.6 to −2.0; diastolic weighted mean difference −4.2 mmHg, 95% CI −7.6 to −0.7) compared with usual doctor-led care. No overall superiority in achievement of study targets or in the use of medication was evident for any nurse-based interventions over doctor-led care. Conclusions There is some evidence for improved blood pressure outcomes with nurse-led interventions for hypertension in people with diabetes compared with doctor-led care. Nurse-based interventions require an algorithm to structure care and there is some preliminary evidence for better outcomes with nurse prescribing. Further work is needed to elucidate which nurse-led interventions are most effective.

Study protocol for a randomized controlled trial comparing mindfulness-based cognitive therapy with maintenance anti-depressant treatment in the prevention of depressive relapse/recurrence: the PREVENT trial

Abstract: Background: Depression is a common and distressing mental health problem that is responsible for significant individual disability and cost to society. Medication and psychological therapies are effective for treating depression and maintenance anti-depressants (m-ADM) can prevent relapse. However, individuals with depression often express a wish for psychological help that can help them recover from depression in the long-term. We need to develop psychological therapies that prevent depressive relapse/recurrence. A recently developed treatment, Mindfulness-based Cognitive Therapy (MBCT, see http://www.mbct.co.uk) shows potential as a brief group programme for people with recurring depression. In two studies it has been shown to halve the rates of depression recurring compared to usual care. This trial asks the policy research question, is MBCT superior to m-ADM in terms of: a primary outcome of preventing depressive relapse/recurrence over 24 months; and, secondary outcomes of (a) depression free days, (b) residual depressive symptoms, (c) antidepressant (ADM) usage, (d) psychiatric and medical co-morbidity, (e) quality of life, and (f) cost effectiveness? An explanatory research question asks is an increase in mindfulness skills the key mechanism of change? Methods/Design: The design is a single blind, parallel RCT examining MBCT vs. m-ADM with an embedded process study. To answer the main policy research question the proposed trial compares MBCT plus ADM-tapering with m-ADM for patients with recurrent depression. Four hundred and twenty patients with recurrent major depressive disorder in full or partial remission will be recruited through primary care. Depressive relapse/recurrence over two years is the primary outcome variable. The explanatory question will be addressed in two mutually informative ways: quantitative measurement of potential mediating variables pre/post-treatment and a qualitative study of service users’ views and experiences. Discussion: If the results of our exploratory trial are extended to this definitive trial, MBCT will be established as an alternative approach to maintenance anti-depressants for people with a history of recurrent depression. The process studies will provide evidence about the effective components which can be used to improve MBCT and inform theory as well as other therapeutic approaches. Trial registration number: ISRCTN26666654

Systematic reviews of the effectiveness and cost‐effectiveness of multi‐channel unilateral cochlear implants for adults

Abstract: Clin. Otolaryngol. 2010, 35, 87–96 Objective: In the UK approximately 3% of over 50 years olds and 8% of over 70 year olds have severe (794–94 dBHL) to deafness. As deafness increased, hearing aids become increasingly ineffective. Cochelear implants can provide an alternative treatment. Objective of review: To bring together the research evidence through the robustness of a systematic review of the effectiveness of unilateral cochlear implants for adults. We also sought to systematically review the published literature on cost-effectiveness. Types of review: Systematic review. Search strategy: This examined 16 electronic databases, plus bibliographies and references for published and unpublished studies from inception to june 2009. Evaluation method: Abstracts were independently assessed against inclusion criteria by two researchers were compared and disagreements resolved. Included papers were then retrieved and further independently assessed in a similar way. Remaining studies had their data independently extracted by one of five reviewers and checked by another reviewer. Results: From 1,580 titles and abstracts nine studies were included. These were of variable quality; some study's results should be viewed with caution. The studies were too hetrogeneous to pool the data. However, overall the results firmly supported the use of unilateral cochler implants for severe to profoundly deaf adults. Additionally, four UK based economic evaluations found unilateral cochlear implants to be cost-effectivene in adults at UK implants centres. Conclusion: The methodologically weak but universally positive body of effectiveness evidence supports the use of unilateral cochlear implants in adults. Previous economic evaluations indicate that such implants are likely to be cost-effective.

Patient education in the contemporary management of coronary heart disease

Abstract: This is the protocol for a review and there is no abstract. The objectives are as follows: To assess the effects of patient education compared with usual care on mortality and morbidity in patients with CHD.To explore the potential study level predictors of the effects of patient education in patients with CHD.

Questions about Turner et al. Spinal cord stimulation for failed back surgery syndrome: outcomes in a worker's compensation setting.

Abstract: We question the design and implementation of this prospective study of spinal cord stimulation (SCS), pain clinic (PC) treatment, and usual care (UC) in Washington State Department of Labor and Industry (DLI) worker’s compensation (WC) claimants with failed back surgery syndrome. We also question the way results were analyzed and reported. For a similar effort and cost, this study could have been a well-designed randomized controlled trial (RCT). This would have answered the lead author’s previous call for RCTs involving SCS [10]. The fact that the DLI covered SCS only for study participants would have facilitated recruitment, and an RCT would have improved the equity of access to SCS among subjects. The authors’ assertion that RCTs are not always generalizable to specific populations is a compelling reason for conducting an RCT in this WC population. The choice of study design requires explanation. The three non-randomized comparison groups were sourced and filtered differently, which introduced selection bias. The study sponsors approved SCS for only 61 (54%) of the 112 physiciannominated patients, whereas potential PC and UC subjects were ‘‘identified from administrative data.” Percentages deemed ineligible were notably imbalanced (48% SCS, 28% PC, and 23% UC). Furthermore, the presence of a chronic co-morbid pain condition that could confound pain relief results was not a criterion for exclusion. The impact of these subject selection decisions, especially the rationale for allowing the study sponsor to handpick the SCS group, requires consideration. The composite primary outcome measure (at least 50% leg pain relief, less than daily opioid use, and improvement in function) is unreferenced and, to our knowledge, unprecedented. Elements of the measure might cancel each other out, for example, increased function might increase pain, and the benefit of opioids for neuropathic pain is controversial. This outcome measure requires justification. Follow-up was linked to the time of study entry (or SCS referral for ‘‘crossovers”) not to treatment start dates; thus, some SCS outcomes were assessed before SCS was administered (e.g., three patients had no screening trial at 6 months). These data require adjustment. The authors obscure their unacknowledged presentation of worst-case scenario data in Table 2 by reporting percentages without raw numbers. Figure 1 does not agree with numbers at 24 months in Table 4 or with numbers at 6 months in Table 6. An interim report of this study, issued on 4/30/07 [4], notes that 31 PC patients visited the pain clinic more than several times per week. This is 9 (17.6%) more than the 22 reported in Pain. Logically, any change in the number treated between the time of an interim report and a final publication should be an increase, not a decrease. These reporting discrepancies require correction. The investigators apparently did not require the clinicians to follow the accepted SCS screening and treatment protocols [8] that help identify potential SCS patients and protect patient safety. This lack might have contributed to the unusually low SCS trial success rate, especially in a WC population [6], the unusually high SCS complication rate [3], and the occurrence of a rare life-threatening complication in this small sample. The authors’ claim that they evaluated SCS ‘‘in actual practice” rings hollow in the absence of prior ‘‘actual practice” in DLI claimants. The level of experience of the unidentified implanting physicians [1,7] and how they were chosen require description. The authors write that ‘‘industry-sponsored studies” introduce sponsorship bias that ‘‘yield[s] more favorable results.” Sponsorship bias, however, can also produce unfavorable results when a payer/sponsor does not want to cover a therapy. Such ‘‘policybased evidence making” [2,5], is contrary to the premise behind a recent editorial in Pain advocating publication of ‘‘negative” trials [9]. Any steps the authors might have taken to counteract the bias of conducting a study for a payer that has consistently refused to cover SCS in actual practice require discussion. We would be the first to agree with the authors’ observation: ‘‘SCS outcomes may vary according to patient selection criteria, physician technical expertise, and SCS implant techniques and hardware.” This report, however, details only one of these variables – SCS patient selection criteria, which we believe were insufficient. Without information on additional, crucial variables of SCS treatment, how can policy makers judge the merits of the reported results and how can researchers test the validity of these results through study replication?

Nurse-led management of hypertension

Abstract: We read the paper of Voogdt-Pruis et al 1 with interest, since we have recently reviewed the literature for nurse interventions in primary care management of hypertension. We would like to offer the following observations: Firstly, although no previous study …