Paul Roderick

University of Southampton, Southampton, England, United Kingdom

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Publications (172)895.84 Total impact

  • The Lancet 11/2015; 386:S63. DOI:10.1016/S0140-6736(15)00901-0 · 45.22 Impact Factor
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  • Graham Moon · Grant Aitken · Paul Roderick · Simon Fraser · Gill Rowlands ·
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    ABSTRACT: The relative contributions of functional literacy and functional numeracy to health disparities remain poorly understood in developed world contexts. We seek to unpack their distinctive contributions and to examine how these contributions are framed by place-based deprivation and rurality. We present a multilevel logistic analysis of the 2011 Skills for Life Survey (SfLS), a representative governmental survey of adults aged 16-65 in England. Outcome measures were self-assessed health status and the presence of self-reported long-term health conditions. Exposure variables were functional literacy (FL) and functional numeracy (FN). Age, sex, individual socio-economic status, ethnicity, whether English was a first language, non-UK birthplaces, housing tenure and geography were included as potential confounders and mediators. Geography was measured as area-based deprivation and urban/rural status. FL and FN were both independently associated with self-assessed health status, though the association attenuated after taking account of confounders and mediators. For long-term conditions, the association with FN remained significant following inclusion of confounders and mediators whilst FL attenuated to non-significance. Rurality did not influence these associations. Area deprivation was a significant factor in attenuating the association between FL and self-assessed health status. Policy makers and health professionals will need to be aware of the distinctive impact of FN as well as FL when combating health inequalities, promoting health and managing long-term conditions.
    Social Science [?] Medicine 09/2015; 143:185-193. DOI:10.1016/j.socscimed.2015.08.045 · 2.89 Impact Factor
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    ABSTRACT: To assess the feasibility and acceptability of screening attendees at a sexual health clinic (SHC) for alcohol misuse, and delivering a brief intervention (BI). To explore the effect of this BI on drinking and sexual behaviour. A consecutive sample of consenting SHC attendees aged ≥16 years were screened using Alcohol Use Disorders Identification Test Consumption (AUDIT-C). Men scoring ≥5 and women scoring ≥4 were invited to complete the full AUDIT, alcohol diary and baseline questionnaire. Participants were randomised to receive BI by a trained sexual health professional or a standard alcohol leaflet (usual care, UC). All were followed up for changes in alcohol and sexual behaviour at 6 weeks and 6 months. A fidelity check and staff focus group were undertaken. Of 664 participants screened, 215 (32%) were eligible for randomisation and 207 were included in the final analysis: 103 (BI) and 104 (UC). Follow-up rates were 54% and 47% at 6 weeks and 6 months, respectively. Both groups reduced alcohol consumption though the degree of change did not differ between them. There was some evidence of positive changes in sexual health risk in both groups. BI was delivered as intended, adding 5 minutes to the consultation, and staff feedback was positive. Alcohol misuse was common in SHC attendees. Systematic assessment and BI for alcohol misuse was feasible and acceptable to staff and patients. Identification and provision of standard information alone appeared to influence drinking and sexual behaviour. ISRCTN19452424. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to
    08/2015; DOI:10.1136/jfprhc-2014-100912
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    ABSTRACT: The number of patients with advanced chronic kidney disease opting for conservative management rather than dialysis is unknown but likely to be growing as increasingly frail patients with advanced renal disease present to renal services. Conservative kidney management includes ongoing medical input and support from a multidisciplinary team. There is limited evidence concerning patient and carer experience of this choice. This study will explore quality of life, symptoms, cognition, frailty, performance decision making, costs and impact on carers in people with advanced chronic kidney disease managed without dialysis and is funded by the National Institute of Health Research in the UK. In this prospective, multicentre, longitudinal study, patients will be recruited in the UK, by renal research nurses, once they have made the decision not to embark on dialysis. Carers will be asked to 'opt-in' with consent from patients. The approach includes longitudinal quantitative surveys of quality of life, symptoms, decision making and costs for patients and quality of life and costs for carers, with questionnaires administered quarterly over 12 months. Additionally, the decision making process will be explored via qualitative interviews with renal physicians/clinical nurse specialists. The study is designed to capture patient and carer profiles when conservative kidney management is implemented, and understand trajectories of care-receiving and care-giving with the aim of optimising palliative care for this population. It will explore the interactions that lead to clinical care decisions and the impact of these decisions on informal carers with the intention of improving clinical outcomes for patients and the experiences of care givers.
    BMC Nephrology 07/2015; 16(1):104. DOI:10.1186/s12882-015-0084-7 · 1.69 Impact Factor
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    ABSTRACT: Background Chronic kidney disease (CKD) has become a significant part of the GP’s workload since the introduction of the National Institute for Health and Care Excellence guidelines in 2008. Patients with advanced CKD (stages G4 and G5) often have comorbidities, varied disease progression, and are likely to be older. GPs may experience difficulties with management decisions for patients with advanced CKD, including when to refer to nephrology. Aim To explore GPs’ views of managing patients with advanced CKD and referral to secondary care. Design and setting Qualitative study with GPs in four areas of England: London, Bristol, Birmingham, and Stevenage. Method Semi-structured interviews with 19 GPs. Transcribed interviews were thematically analysed. Results GPs had little experience of managing patients with advanced CKD, including those on dialysis or having conservative care (treatment without dialysis or a transplant), and welcomed guidance. Some GPs referred patients based on renal function alone and some used wider criteria including age and multimorbidity. GPs reported a tension between national guidance and local advice, and some had learnt from experience that patients were discharged back to primary care. GPs with more experience of managing CKD referred patients later, or sometimes not at all, if there were no additional problems and if dialysis was seen as not in the patient’s interests. Conclusion GPs want guidance on managing older patients with advanced CKD and comorbidities, which better incorporates agreement between local and national recommendations to clarify referral criteria. GPs are not generally aware of conservative care programmes provided by renal units, however, they appear happy to contribute to such care or alternatively, lead conservative management with input from renal teams.
    British Journal of General Practice 07/2015; 65(636). DOI:10.3399/bjgp15X685693 · 2.29 Impact Factor
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    ABSTRACT: Point prevalence studies in care homes show a high use of antibiotics, especially to treat urinary tract infections (UTI). There is a lack of large studies presenting annual antibiotic prescription data in care homes compared to those not in care homes. This study aimed to describe the pattern of antibiotic prescribing in those 75 years and over, with a focus on UTI. In this retrospective longitudinal cohort study we used the Hampshire Health Record (HHR) containing routine data from general practices in Hampshire area, UK covering 1.24 million residents. Data were extracted throughout 2011 from the Hampshire Health Record on age, gender, care home status, antibiotic prescriptions, urinary catheters and comorbidity. Prescription pattern expressed as rate per 100 people. Nursing home residence defined by postcode. Logistic regression was used to assess independent risk of one or more antibiotic prescriptions in care home residents adjusting for age, sex and comorbidity, separately by catheter use. 102,020 of 1,244,313 residents in the Hampshire Health Record (8.2 %) were aged ≥75 years of whom 7481 (7.3 %) were resident in care home settings. The annual antibiotic prescriptions increased from 53/100 inhabitants among those <75 years, to 142/100 among those ≥75 years not in a care home and to 199/100 among those ≥75 years in a care home. Care home residents with urinary catheters (4.4 %) had even higher use at 440/100 versus 188/100 if no catheter. UTI antibiotics showed a similar but more rapidly increasing pattern. For those in care homes without a urinary catheter, the odds ratio was 2.2 (2.1-2.3) higher for prescriptions of UTI antibiotics compared to those not in care homes after adjusting for age, gender and comorbidity. For those with a urinary catheter the odds ratio was 1.4 (1.1-1.8) for UTI antibiotics compared to those not in care homes. For all antibiotics the odds ratio was 1.2 (1.2-1.3). Residence in a care home setting is associated with high antibiotic consumption; this is especially evident for UTI antibiotics where the odds of prescription is doubled.
    BMC Geriatrics 06/2015; 15(1):71. DOI:10.1186/s12877-015-0073-5 · 1.68 Impact Factor
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    ABSTRACT: In a number of countries, reimbursement to hospitals providing renal dialysis services is set according to a fixed tariff. While the cost of maintenance dialysis and transplant surgery are amenable to a system of fixed tariffs, patients with established renal failure commonly present with comorbid conditions that can lead to variations in the need for hospitalization beyond the provision of renal replacement therapy. Patient-level cost data for incident renal replacement therapy patients in England were obtained as a result of linkage of the Hospital Episodes Statistics dataset to UK Renal Registry data. Regression models were developed to explore variations in hospital costs in relation to treatment modality, number of years on treatment and factors such as age and comorbidities. The final models were then used to predict annual costs for patients with different sets of characteristics. Excluding the cost of renal replacement therapy itself, inpatient costs generally decreased with number of years on treatment for haemodialysis and transplant patients, whereas costs for patients receiving peritoneal dialysis remained constant. Diabetes was associated with higher mean annual costs for all patients irrespective of treatment modality and hospital setting. Age did not have a consistent effect on costs. Combining predicted hospital costs with the fixed costs of renal replacement therapy showed that the total cost differential for a patient continuing on dialysis rather than receiving a transplant is considerable following the first year of renal replacement therapy, thus reinforcing the longer-term economic advantage of transplantation over dialysis for the health service. © The Author 2015. Published by Oxford University Press on behalf of ERA-EDTA. All rights reserved.
    Nephrology Dialysis Transplantation 06/2015; 30(10). DOI:10.1093/ndt/gfv224 · 3.58 Impact Factor
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    ABSTRACT: The usefulness of estimated glomerular filtration rate (eGFR) and albuminuria for prediction of cardiovascular outcomes is controversial. We aimed to assess the addition of creatinine-based eGFR and albuminuria to traditional risk factors for prediction of cardiovascular risk with a meta-analytic approach. We meta-analysed individual-level data for 637 315 individuals without a history of cardiovascular disease from 24 cohorts (median follow-up 4·2-19·0 years) included in the Chronic Kidney Disease Prognosis Consortium. We assessed C statistic difference and reclassification improvement for cardiovascular mortality and fatal and non-fatal cases of coronary heart disease, stroke, and heart failure in a 5 year timeframe, contrasting prediction models for traditional risk factors with and without creatinine-based eGFR, albuminuria (either albumin-to-creatinine ratio [ACR] or semi-quantitative dipstick proteinuria), or both. The addition of eGFR and ACR significantly improved the discrimination of cardiovascular outcomes beyond traditional risk factors in general populations, but the improvement was greater with ACR than with eGFR, and more evident for cardiovascular mortality (C statistic difference 0·0139 [95% CI 0·0105-0·0174] for ACR and 0·0065 [0·0042-0·0088] for eGFR) and heart failure (0·0196 [0·0108-0·0284] and 0·0109 [0·0059-0·0159]) than for coronary disease (0·0048 [0·0029-0·0067] and 0·0036 [0·0019-0·0054]) and stroke (0·0105 [0·0058-0·0151] and 0·0036 [0·0004-0·0069]). Dipstick proteinuria showed smaller improvement than ACR. The discrimination improvement with eGFR or ACR was especially evident in individuals with diabetes or hypertension, but remained significant with ACR for cardiovascular mortality and heart failure in those without either of these disorders. In individuals with chronic kidney disease, the combination of eGFR and ACR for risk discrimination outperformed most single traditional predictors; the C statistic for cardiovascular mortality fell by 0·0227 (0·0158-0·0296) after omission of eGFR and ACR compared with less than 0·007 for any single modifiable traditional predictor. Creatinine-based eGFR and albuminuria should be taken into account for cardiovascular prediction, especially when these measures are already assessed for clinical purpose or if cardiovascular mortality and heart failure are outcomes of interest. ACR could have particularly broad implications for cardiovascular prediction. In populations with chronic kidney disease, the simultaneous assessment of eGFR and ACR could facilitate improved classification of cardiovascular risk, supporting current guidelines for chronic kidney disease. Our results lend some support to also incorporating eGFR and ACR into assessments of cardiovascular risk in the general population. US National Kidney Foundation, National Institute of Diabetes and Digestive and Kidney Diseases. Copyright © 2015 Elsevier Ltd. All rights reserved.
    05/2015; 3(7). DOI:10.1016/S2213-8587(15)00040-6
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    ABSTRACT: This paper presents findings from a survey of pre-service teacher training institutions in England with regard to the provision of health and well-being education. It examines factors affecting the inclusion of health and well-being, and explores educational implications in light of the changing landscape of pre-service teacher education in England. Provision of health and well-being education is noticeably variable across institutions, and many course leaders are unclear about the coverage in their partner schools. Course leaders regard health and well-being as an important part of the curriculum, but the focus is usually on generic health-related themes such as child protection and behaviour management, which address Government priorities, rather than on specific topics such as education about diet, drugs, alcohol, smoking, sex and relationships and physical activity. The paper argues that these aspects should be addressed for pre-service teachers to have an increased sense of self-efficacy and become capable health promoters.
    European Journal of Teacher Education 05/2015; 38(2). DOI:10.1080/02619768.2015.1030069 · 0.57 Impact Factor
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    ABSTRACT: Alcoholic hepatitis is a clinical syndrome characterized by jaundice and liver impairment that occurs in patients with a history of heavy and prolonged alcohol use. The short-term mortality among patients with severe disease exceeds 30%. Prednisolone and pentoxifylline are both recommended for the treatment of severe alcoholic hepatitis, but uncertainty about their benefit persists. We conducted a multicenter, double-blind, randomized trial with a 2-by-2 factorial design to evaluate the effect of treatment with prednisolone or pentoxifylline. The primary end point was mortality at 28 days. Secondary end points included death or liver transplantation at 90 days and at 1 year. Patients with a clinical diagnosis of alcoholic hepatitis and severe disease were randomly assigned to one of four groups: a group that received a pentoxifylline-matched placebo and a prednisolone-matched placebo, a group that received prednisolone and a pentoxifylline-matched placebo, a group that received pentoxifylline and a prednisolone-matched placebo, or a group that received both prednisolone and pentoxifylline. A total of 1103 patients underwent randomization, and data from 1053 were available for the primary end-point analysis. Mortality at 28 days was 17% (45 of 269 patients) in the placebo-placebo group, 14% (38 of 266 patients) in the prednisolone-placebo group, 19% (50 of 258 patients) in the pentoxifylline-placebo group, and 13% (35 of 260 patients) in the prednisolone-pentoxifylline group. The odds ratio for 28-day mortality with pentoxifylline was 1.07 (95% confidence interval [CI], 0.77 to 1.49; P=0.69), and that with prednisolone was 0.72 (95% CI, 0.52 to 1.01; P=0.06). At 90 days and at 1 year, there were no significant between-group differences. Serious infections occurred in 13% of the patients treated with prednisolone versus 7% of those who did not receive prednisolone (P=0.002). Pentoxifylline did not improve survival in patients with alcoholic hepatitis. Prednisolone was associated with a reduction in 28-day mortality that did not reach significance and with no improvement in outcomes at 90 days or 1 year. (Funded by the National Institute for Health Research Health Technology Assessment program; STOPAH EudraCT number, 2009-013897-42 , and Current Controlled Trials number, ISRCTN88782125 ).
    New England Journal of Medicine 04/2015; 372(17):1619-28. DOI:10.1056/NEJMoa1412278 · 55.87 Impact Factor
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    ABSTRACT: Increasing numbers of the population are living with long-term life-limiting conditions with a significant proportion characterised by multimorbidity. Patients with these conditions often experience high volumes of clinical interaction involving them, their caregivers and healthcare providers in complex patterns of organising, coordinating, negotiating and managing care. A better understanding of the sources of experienced complexity and multimorbidity, from the patient perspective is paramount to improve capacity and manage workload to promote improved experience of illness, more effective healthcare utilisation and improved healthcare outcomes. To better understand the sources of complexity we will undertake an evidence synthesis of qualitative studies of patient and informal carer experiences of three common long-term life-limiting conditions. We will investigate what is known about these diseases at different stages in disease progression, treatment regimens and places of care. We will include qualitative studies of patients' and carers' (aged >18) accounts of their experiences of healthcare provision in a range of settings and healthcare systems. We will conduct an extensive electronic database search of publications in English between 2000 and 2014. Results and discussions sections of the papers will be regarded as formal data using the constant comparison method of qualitative analysis. From the meta-synthesis results, we will build a conceptual model of mechanisms and processes that shape patients' journeys towards end of life to suggest where in the patient journey new interventions to improve patient and carer experience can be developed and delivered. The study is being conducted between 1 December 2014 and 31 December 2015. No human subjects or personal data are involved and no ethical issues are anticipated. An important element of dissemination is informing user communities about the practical implications of the work through workshops, meetings and social media. Scientific results will be published in peer reviewed journals and disseminated through conferences. PROSPERO CRD42014014547. Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to
    BMJ Open 04/2015; 5(4):e007372. DOI:10.1136/bmjopen-2014-007372 · 2.27 Impact Factor
  • Retha Steenkamp · Anirudh Rao · Paul Roderick ·
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    ABSTRACT: Introduction: The analyses presented in this chapter examine (a) survival from the start of RRT of adult RRT patients; (b) projected life years remaining for adult patients starting RRT; (c) survival amongst prevalent adult dialysis patients alive on 31st December 2012; (d) the death rate in the UK compared to the general population; (e) cause of death for incident and prevalent adult RRT patients. Methods: Survival of incident patients was calculated both from the start of RRT and from 90 days after start. One year survival for prevalent dialysis patients were calculated by following patients up for one year in 2013. The relative risk of death was compared with the general UK population. Results: The age adjusted one year after 90 day survival for patients starting RRT in 2012 was 91.0% (90.9% in 2011). Age adjusted one year survival for prevalent dialysis patients remained relatively unchanged at 89.3% from the previous year. The age-standardised mortality ratio for prevalent RRT patients compared with the general population was 16.2 for age group 35-39 and 2.6 at age 85+ years. In the prevalent RRT dialysis population, cardiovascular disease accounted for 27% of deaths, infection and other causes for 21% each and treatment withdrawal for 16% of deaths. The median life years remaining for a 25-29 year old starting RRT was 18.5 years and approximately 2.4 years for a 75+ year old. Conclusions: Survival of patients starting RRT has improved substantially in last decade, overall, by age and for diabetic patients.
    02/2015; 129 Suppl 1(s1):99-129. DOI:10.1159/000370275
  • R. Pruthi · E. Curnow · P. Roderick · R. Ravanan ·
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    ABSTRACT: Background: Renal transplantation is recognised as being the optimal treatment modality for many patients with established renal failure. This analysis aimed to explore inter-centre variation in access to renal transplantation in the UK. Methods: Transplant activity and waiting list data were obtained from NHS Blood and Transplant, demographic and laboratory data were obtained from the UK Renal Registry. All incident RRT patients starting treatment between 1st January 2008 and 31st December 2010 from 71 renal centres were considered for inclusion. The cohort was followed until 31st December 2012 (or until transplantation or death, whichever was earliest). Results: Age, ethnicity and primary renal diagnosis were associated with both accessing the kidney transplant waiting list and receiving a kidney transplant. A patient starting dialysis in a non-transplanting renal centre was less likely to be registered for transplantation (OR 0.74, 95% CI 0.68-0.81) or receive a transplant from a donor after cardiac death or a living kidney donor (OR 0.75, 95% CI 0.67-0.84) compared with patients cared for in transplanting renal centres. Once registered for kidney transplantation, patients in both transplanting and non-transplanting renal centres had an equal chance of receiving a transplant from a donor after brainstem death (OR 0.93, 95% CI 0.78 to 1.10). Conclusion: There was wide variation in access to kidney transplantation between UK renal centres which cannot be explained by differences in case mix.
    Nephron 01/2015; 129:247-256. DOI:10.1159/000370281 · 13.26 Impact Factor
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    ABSTRACT: Background: Conservative kidney management (CKM) is recognised as an alternative to dialysis for a significant number of older adults with multi-morbid chronic kidney disease stage 5 (CKD5). However, little is known about the way CKM is delivered or how it is perceived. Aim: To determine the practice patterns for CKM of older patients with CKD5, to inform service development and future research. Objectives: i) To describe the differences between renal units in the extent and nature of CKM. ii) To explore how decisions are made about treatment options for older patients with CKD5. iii) To explore clinicians willingness to randomise patients with CKD5 to CKM versus dialysis. iv) To describe the interface between renal units and primary care in managing CKD5. v) To identify the resources involved and potential costs of CKM. Methods: Mixed methods study. Interviews with 42 patients aged >75 with CKD5 and 60 renal unit staff in a purposive sample of nine UK renal units. Interviews informed the design of a survey to assess CKM practice, sent to all 71 UK units. Nineteen general practitioners were interviewed concerning referral of CKD patients to secondary care. We sought laboratory data on new CKD5 patients aged >75 years to link with the nine renal units’ records to assess referral patterns. Results: 67/71 renal units completed the survey. Although terminology varied, there was general acceptance of the role of CKM. Only 52% of units were able to quantify the number of CKM patients. A wide range reflected varied interpretation of the designation ‘CKM’ by both staff and patients. It is used to characterise a future treatment option as well non dialysis care for end-stage kidney failure (ESKF, i.e. a disease state equivalent to being on dialysis), the number of patients in the latter group on CKM were relatively small (median 8 IQR 4.5-22). Patients’ expectations of CKM and dialysis were strongly influenced by renal staff. In a minority of units, CKM was not discussed. When discussed, often only limited information about illness progression was provided. Staff wanted more research into the relative benefits of CKM versus dialysis. There was almost universal support for an observational methodology and a quarter would definitely be willing to participate in a randomised clinical trial, indicating that clinicians placed value on high-quality evidence to inform decision making. Linked data indicated that most CKD5 patients were known to renal units. GPs expressed a need for guidance on when to refer older, multi-morbid patients with CKD5 to nephrology care. There was large variation in the scale and model of CKM delivery. In most, the CKM service was integrated within the service for all non-renal replacement therapy (RRT) CKD5 patients. A few units provided dedicated CKM clinics and some had dedicated modest funding for CKM. Conclusions: CKM is accepted across UK renal units but there is much variation in the way it is described and delivered. For best practice in CKM to be developed and systematised across all renal units in the UK, we recommend: a) a standard definition and terminology for CKM; b) research to measure the relative benefits of CKM and dialysis; and c) development of evidence-based staff training and patient education interventions.
    12/2014; 3(12). DOI:10.3310/hsdr03120
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    ABSTRACT: Purpose Evidence from high-quality randomised controlled trials (RCTs) is needed to establish the long-term benefit of bariatric surgery in people with type 2 diabetes mellitus (T2DM) and body mass index (BMI) 30–39.9 kg/m2. However, willingness amongst this group to be randomised and undergo surgery is uncertain. This study assessed UK patients’ perceptions of their weight and diabetes, and associations with willingness to participate in RCTs involving bariatric surgery, amongst this population. Materials and Methods Postal survey of 1820 patients from four regions in England. Eligible patients were as follows: BMI 30–39.9 kg/m2, 18–74 years, diagnosis of T2DM ≥2 years. A reminder survey was sent after 4 weeks. Independent predictors influencing patients’ willingness to consider RCT participation were identified using multiple logistic regression analysis. Results Thirty-four per cent (614/1820) of patients responded. Weight was considered to be harder to control than diabetes [468/584 (80 %) vs. 107/600 (17 %)]. More people reported a negative impact on life for weight rather than diabetes [379/579 (63 %) vs. 180/574 (31 %)]. Feeling unsatisfied/very unsatisfied with weight loss ability was common 261/578 (45 %). Sixty-four per cent (379/594, CI = 60–68) were willing to consider participating in an RCT. In multivariate analysis, negative impact of weight on life (OR = 2.55, 95 % CI = 1.68–3.89, P < 0.001) and feeling unsatisfied with weight loss ability (OR = 2.47, 95 % CI = 1.55–3.95, P < 0.001) positively influenced patients’ willingness to participate in an RCT. Conclusion Strong patient interest supports the feasibility of such trials for this group. Perceptions of obesity negatively impacting on life and difficulties in achieving weight loss were common and influenced attitudes to potential participation in bariatric surgery RCTs.
    Obesity Surgery 11/2014; 25(6). DOI:10.1007/s11695-014-1479-4 · 3.75 Impact Factor
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    ABSTRACT: Background and objectives: Conservative kidney management (CKM) has been developed in the United Kingdom (UK) as an alternative to dialysis for older patients with stage 5 CKD (CKD5) and multiple comorbidities. This national survey sought to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development. Design, setting, participants, & measurements: A survey on practice patterns of CKM for patients age 75 and older with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013. Results: Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although "conservative management" was the most frequently used term (46%). Lack of an agreed-upon definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. Fifty-two percent provided the number of CKM patients age ≥ 75 years in 2012; the median was 45 per unit (interquartile range [IQR], 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was eight (IQR, 4.5-22). CKM practice patterns varied: 35% had a written guideline, 23% had dedicated CKM clinics, 45% had dedicated staff, and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. Eighty percent identified a need for better evidence comparing outcomes on CKM versus dialysis, and 65% considered it appropriate to enter patients into a randomized trial. Conclusions: CKM is provided in almost all UK renal units, but scale and organization vary widely. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support for further research comparing outcomes with conservative care versus dialysis.
    Clinical Journal of the American Society of Nephrology 11/2014; 10(1). DOI:10.2215/CJN.05000514 · 4.61 Impact Factor
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    ABSTRACT: Background: Older adults with chronic kidney disease stage 5 may be offered a choice between dialysis and conservative management. Few studies have explored patients' reasons for choosing conservative management and none have compared the views of those who have chosen different treatments across renal units. Study Design: Qualitative study with semi-structured interviews. Settings & Participants: Patients 75 years or older recruited from 9 renal units. Units were chosen to reflect variation in the scale of delivery of conservative management. Methodology: Semi-structured interviews audio recorded and transcribed verbatim. Analytical Approach: Data were analyzed using thematic analysis. Results: 42 interviews were completed, 4 to 6 per renal unit. Patients were sampled from those receiving dialysis, those preparing for dialysis, and those choosing conservative management. 14 patients in each group were interviewed. Patients who had chosen different treatments held varying beliefs about what dialysis could offer. The information that patients reported receiving from clinical staff differed between units. Patients from units with a more established conservative management pathway were more aware of conservative management, less often believed that dialysis would guarantee longevity, and more often had discussed the future with staff. Some patients receiving conservative management reported that they would have dialysis if they became unwell in the future, indicating the conditional nature of their decision. Limitations: Recruitment of older adults with frailty and comorbid conditions was difficult and therefore transferability of findings to this population is limited. Conclusions: Older adults with chronic kidney disease stage 5 who have chosen different treatment options have contrasting beliefs about the likely outcomes of dialysis for those who are influenced by information provided by renal units. Supporting renal staff in discussing conservative management as a valid alternative to dialysis for a subset of patients will aid informed decision making. There is a need for better evidence about conservative management to support shared decision making for older people with chronic kidney failure.
    American Journal of Kidney Diseases 10/2014; 65(3). DOI:10.1053/j.ajkd.2014.08.011 · 5.90 Impact Factor
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    ABSTRACT: Background and objectives: Conservative Kidney Management (CKM) has developed in the UK as an alternative to dialysis for older patients with stage 5 chronic kidney disease (CKD5) and multiple comorbidities. We report on a national survey which aims to describe the current scale and pattern of delivery of conservative care in UK renal units and identify their priorities for its future development. Design, setting, participants, and measurements: A survey on practice patterns of CKM for patients aged over 75 years with CKD5 was sent to clinical directors of all 71 adult renal units in the UK in March 2013. Results: Sixty-seven units (94%) responded. All but one unit reported providing CKM for some patients. Terminology varied, although ‘conservative management’ was the most frequently used term (46%). Lack of an agreed definition of when a patient is receiving CKM made it difficult to obtain meaningful data on the numbers of such patients. 52% provided the number of CKM patients aged ≥75 in 2012; the median was 45 per unit (IQR: 20-83). The median number of symptomatic CKM patients who would otherwise have started dialysis was 8 (IQR: 4.5-22). CKM practice patterns varied: 35% had a written guideline; 23% dedicated CKM clinics; 45% dedicated staff; and 50% provided staff training on CKM. Most units (88%) provided primary care clinicians with information/advice regarding CKM. 80% identified a need for better evidence comparing outcomes on CKM versus dialysis and 65% considered it appropriate to enter patients into a randomized trial. Conclusions: CKM is provided in almost all UK renal units but with wide variation in scale and organization. Lack of common terminology and definitions hinders the development and assessment of CKM. Many survey respondents expressed support There is a need for clinical trials further research comparing outcomes with conservative care versus dialysis.
    Clinical Journal of the American Society of Nephrology 10/2014; · 4.61 Impact Factor
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    ABSTRACT: Aims: We wish to assess the clinical and cost-effectiveness of remote monitoring of heart failure patients with cardiac implanted electronic devices. Methods: REM-HF is a multicentre, randomized, non-blinded, parallel trial designed to compare weekly remote monitoring-driven management with usual care for patients with cardiac implanted electronic devices (ICD, CRT-D, or CRT-P). The trial is event driven, and the final analysis will be performed when 546 events have been observed or the study is terminated at the interim analysis. We have randomized 1650 patients to be followed up for a minimum of 2 years. Patients will remain in the trial up to study termination. The first patient was randomized in September 2011 and the study is expected to complete in early 2016. The primary combined endpoint is time to first event of all-cause death or unplanned hospitalization for cardiovascular reasons. An economic evaluation will be performed, estimating the cost per quality-adjusted life year, with direct costs estimated from the National Health Service perspective and quality of life assessed by the EQ-5D, Short-Form 12, and Kansas City Cardiomyopathy Questionnaires. The study design has been informed by a feasibility study. Conclusion: REM-HF is a multicentre randomized study that will provide important data on the effect of remote monitoring-driven management of implanted cardiac devices on morbidity and mortality, as well as the cost-effectiveness of this approach.
    European Journal of Heart Failure 09/2014; 16(9). DOI:10.1002/ejhf.149 · 6.53 Impact Factor

Publication Stats

6k Citations
895.84 Total Impact Points


  • 1999-2015
    • University of Southampton
      • • Faculty of Medicine
      • • Southampton Health Technology Assessments Centre
      Southampton, England, United Kingdom
    • Food Safety Authority Of Ireland
      Dublin, Leinster, Ireland
  • 2009
    • University of Portsmouth
      Portsmouth, England, United Kingdom
  • 1999-2001
    • London School of Hygiene and Tropical Medicine
      • Department of Infectious Disease Epidemiology
      Londinium, England, United Kingdom
  • 1995
    • Institut for Sygdomsforebyggelse
      København, Capital Region, Denmark