The effects of implementing a point-of-care electronic template to prompt routine anxiety and depression screening in patients consulting for osteoarthritis (the Primary Care Osteoarthritis Trial): A cluster randomised trial in primary care

Background This study aimed to evaluate whether prompting general practitioners (GPs) to routinely assess and manage anxiety and depression in patients consulting with osteoarthritis (OA) improves pain outcomes. Methods and findings We conducted a cluster randomised controlled trial involving 45 English general practices. In intervention practices, patients aged ≥45 y consulting with OA received point-of-care anxiety and depression screening by the GP, prompted by an automated electronic template comprising five questions (a two-item Patient Health Questionnaire–2 for depression, a two-item Generalized Anxiety Disorder–2 questionnaire for anxiety, and a question about current pain intensity [0–10 numerical rating scale]). The template signposted GPs to follow National Institute for Health and Care Excellence clinical guidelines for anxiety, depression, and OA and was supported by a brief training package. The template in control practices prompted GPs to ask the pain intensity question only. The primary outcome was patient-reported current pain intensity post-consultation and at 3-, 6-, and 12-mo follow-up. Secondary outcomes included pain-related disability, anxiety, depression, and general health. During the trial period, 7,279 patients aged ≥45 y consulted with a relevant OA-related code, and 4,240 patients were deemed potentially eligible by participating GPs. Templates were completed for 2,042 patients (1,339 [31.6%] in the control arm and 703 [23.1%] in the intervention arm). Of these 2,042 patients, 1,412 returned questionnaires (501 [71.3%] from 20 intervention practices, 911 [68.0%] from 24 control practices). Follow-up rates were similar in both arms, totalling 1,093 (77.4%) at 3 mo, 1,064 (75.4%) at 6 mo, and 1,017 (72.0%) at 12 mo. For the primary endpoint, multilevel modelling yielded significantly higher average pain intensity across follow-up to 12 mo in the intervention group than the control group (adjusted mean difference 0.31; 95% CI 0.04, 0.59). Secondary outcomes were consistent with the primary outcome measure in reflecting better outcomes as a whole for the control group than the intervention group. Anxiety and depression scores did not reduce following the intervention. The main limitations of this study are two potential sources of bias: an imbalance in cluster size (mean practice size 7,397 [intervention] versus 5,850 [control]) and a difference in the proportion of patients for whom the GP deactivated the template (33.6% [intervention] versus 27.8% [control]). Conclusions In this study, we observed no beneficial effect on pain outcomes of prompting GPs to routinely screen for and manage comorbid anxiety and depression in patients presenting with symptoms due to OA, with those in the intervention group reporting statistically significantly higher average pain scores over the four follow-up time points than those in the control group. Trial registration ISRCTN registry ISRCTN4072198

Cost‐utility analysis of routine anxiety and depression screening in patients consulting for osteoarthritis: results from a clinical, randomized controlled trial

Objective: To investigate the cost‐effectiveness (cost‐utility) of introducing general practitioner screening for anxiety and depression in patients consulting with osteoarthritis (OA). Methods: A cluster‐randomised trial‐based economic evaluation to assess general practitioners screening for anxiety and depression symptoms in patients consulting with OA compared to usual care (screening for pain intensity) was undertaken over a 12‐month period from a UK National Health Service and Societal perspective. Patient‐level mean costs and mean quality‐adjusted life years (QALYs) were estimated and cost‐effectiveness acceptability curves controlling for cluster‐level data were constructed. The base‐case analysis used the net‐benefit regressions approach. The two‐stage non‐parametric sampling technique was explored in a sensitivity analysis. Results: The base‐case analysis demonstrated that the intervention was as costly as, and less effective than, the control (QALY diff, 95% CI: ‐ 0.029 (95% CI ‐0.062 to 0.003)). In the base‐case analyses, GP screening for anxiety and depression was unlikely to be a cost‐effective option (probability < 5% at £20,000/QALY). Similar results were observed in all sensitivity analyses. Conclusions: Prompting GP's to routinely screen and manage comorbid anxiety and depression in patients presenting with OA is unlikely to be cost‐effective. Further research is needed to explore clinically‐effective and cost‐effective models of managing anxiety and depression in patients presenting with clinical OA

Improving patient safety for older people in acute admissions: implementation of the Frailsafe checklist in 12 hospitals across the UK.

Background checklists are increasingly proposed as a means to enhance safety and quality of care. However, their use has been met with variable levels of success. The Frailsafe project focused on introducing a checklist with the aim to increase completion of key clinical assessments and to facilitate communication for the care of older patients in acute admissions. Objectives to examine the use of the Frailsafe checklist, including potential to contribute to improved safety, quality and reliability of care. Methods 110 qualitative interviews and group discussions with healthcare professionals and other specialties, 172 h of ethnographic observation in 12 UK hospitals and reporting of high-level process data (completion of checklist and relevant frailty assessments). Qualitative analysis followed a thematic and theory-driven approach. Results through use of the checklist, hospital teams identified limitations in their existing assessments (e.g. absence of delirium protocols) and practices (e.g. unnecessary catheter use). This contributed to hospitals reporting just 24.0% of sampled patients as having received all clinical assessments across key domains for this population for the duration of the project (1,687/7,021 checklists as fully completed). Staff perceptions and experiences of using the checklist varied significantly, primarily driven by the extent to which the aims of this quality improvement project aligned with local service priorities and pre-existing team communications styles. Conclusions the Frailsafe checklist highlighted limitations with frailty assessment in acute care and motivated teams to review routine practices. Further work is needed to understand whether and how checklists can be embedded in complex, multidisciplinary care

Contouring variation affects estimates of normal tissue complication probability for breast fibrosis after radiotherapy

Background: Normal tissue complication probability (NTCP) models can be useful to estimate the risk of fibrosis after breast-conserving surgery (BCS) and radiotherapy (RT) to the breast. However, they are subject to uncertainties. We present the impact of contouring variation on the prediction of fibrosis. Materials and methods: 280 breast cancer patients treated BCS-RT were included. Nine Clinical Target Volume (CTV) contours were created for each patient: i) CTV_crop (reference), cropped 5 mm from the skin and ii) CTV_skin, uncropped and including the skin, iii) segmenting the 95% isodose (Iso95%) and iv) 3 different auto-contouring atlases generating uncropped and cropped contours (Atlas_skin/Atlas_crop). To illustrate the impact of contour variation on NTCP estimates, we applied two equations predicting fibrosis grade ≥ 2 at 5 years, based on Lyman-Kutcher-Burman (LKB) and Relative Seriality (RS) models, respectively, to each contour. Differences were evaluated using repeated-measures ANOVA. For completeness, the association between observed fibrosis events and NTCP estimates was also evaluated using logistic regression. Results: There were minimal differences between contours when the same contouring approach was followed (cropped and uncropped). CTV_skin and Atlas_skin contours had lower NTCP estimates (−3.92%, IQR 4.00, p < 0.05) compared to CTV_crop. No significant difference was observed for Atlas_crop and Iso95% contours compared to CTV_crop. For the whole cohort, NTCP estimates varied between 5.3% and 49.5% (LKB) or 2.2% and 49.6% (RS) depending on the choice of contours. NTCP estimates for individual patients varied by up to a factor of 4. Estimates from “skin” contours showed higher agreement with observed events. Conclusion: Contour variations can lead to significantly different NTCP estimates for breast fibrosis, highlighting the importance of standardising breast contours before developing and/or applying NTCP models