Rationale for sub-theme and summary of activity
Custom made solutions to specific medical problems/questions are required to avoid research wastage while producing best evidence that will impact on patient care. The Novel analyses and linkages sub-theme in the Multi-Morbidity and Long-Term Conditions Theme of the Oxford BRC initiated in 2012 and has spent the last four years developing custom made solutions.
The sub-theme benefits from the collaboration between three world-leading institutions at the University of Oxford, the Nuffield Department of Primary Care Health Sciences (NDPCHS), The Health Economics Research Centre (HERC) and the Centre for Statistics in Medicine (CSM). This has allowed the sub-theme to carry on work in three focus areas:
a) Statistical methods used in monitoring/diagnosis/prognosis,
b) Epidemiological methods for big data and
c) Health economics with a focus in Primary Care.
Focus area a) statistical methods in monitoring / prognosis / diagnosis
Personalised reference ranges: Current uses of reference ranges are based around the idea of an average ‘normal’ population. This prevents their direct use in individuals with even a single condition. As the population ages, this tends to exclude the majority of the population. This project aims to investigate the impact/potential of including an unhealthy population on the reference range estimations including these conditions as ‘reference range’ modifiers.
Impact of measurement error in prognostic models: Prognostic models are used to enhance/support clinical decision-making. Nevertheless these models do not take into consideration the impact of measurement error (e.g. inaccuracies in the reading of Systolic Blood Pressure) on the model. We have carried out some preliminary evaluations of this impact and as part of the next stage we plan two potential extensions: a) evaluating the interaction of the different types of missing data and the amount of measurement error in the performance of prognostic models; and b) considering measurement error (independent and correlated, systematic and random, for instance) at the development and validation stages.
Focus area b) epidemiological methods for big data
There are two large projects that are currently under way in this focus area both based on analysis of the Clinical Practice Research Datalink (CPRD): a) GP workload over time and b) the relationship between body mass index (BMI) and End Stage Kidney Disease (ESKD). It is expected that some aspects of these will be carried out through the BRC from 2017 to 2022.
GP workload over time: This is based on analysis of CPRD and includes three broad themes, the first of which focuses on the volume of workload in primary care, based on all GP practices within the CPRD with approval for linkages to other datasets. This aspect has been funded by the NIHR Policy Research Programme and is expected to finish towards the end of 2017. In the second phase (projected to start early 2018) will explore relationships between GP workload (consultation rates, no. of consultations per FTE member of clinical staff) and outcomes (e.g. mortality rates, patient satisfaction scores; QoF performance) in a random sample of the CPRD dataset used in the first theme.
Relationship between BMI and ESKD: The initial analysis will be carried out in 2017. The second phase (mid 2018) will analyse how, if at all, BMI interacts with the relationships between estimated glomerular filtration rate (eGFR) which measures kidney function or ACR and end-stage kidney disease (ESKD), cardiovascular disease (CVD and its major components) and mortality. The final phase will investigate how, if at all, BMI affect the relationships between estimated change in glomerular filtration rate (eGFR) and end-stage kidney disease (ESKD), CVD (and its major components) and mortality.
Focus area c) health economics with a focus in Primary Care
Application of economic evaluation techniques to provide evidence for aiding adaptation or implementation decision making of new health techniques or interventions at national and local level of NHS
Application of early economic decision analytical modelling technique to identify care pathways, treatment decision making and synthesise existing evidences to quantify the possible effects of new technology and associated uncertainties, and inform future prospective study design to collect evidence and price setting for the new technology.
Application of economic evaluation techniques to identify budget plan for local NHS authorities as to where the future costs and savings of new technologies would happen.
Use routinely collected clinical data linkage (CPRD, HES, PROMs, QOF, GP survey, Household panel survey data) and econometric methods to assess impact of health policy on NICE guidance, or assess quality or health expenditure of health care system.
Use behaviour economic theory or decision making techniques to support design of public health interventions at primary care.
Current Links within the NDPCHS
Statistics Group, Infectious Diseases group Oxford Diagnostic Evidence Cooperative, Monitoring of Renal Specific Endpoints Programme (MORSE), Oxford NIHR Collaboration for Leadership in Applied Research and Care (CLAHRC)
Current Links within the University of Oxford (focus on BRC members)
Oxford CSM, Department of Psychiatry, the Oxford Renal cross-sectional study of chronic kidney disease (OxRen), the Valvular Heart Disease Population Cohort Study (OxVALVE), Oxford HERC.
Current National and International links
National School of Primary Care Research, Clinical Practice Research Datalink (CPRD), EuroQol group, UK Health Economists’ study group, European Commission Joint Research Office, Echocardiographic Normal Ranges Meta-analysis of the Left Heart (EchoNormal) Collaboration (New Zealand), University Hospital (CHUV) Lausanne (Switzerland).
Professor Rafael Perera, Dr Clare Bankhead, Professor Richard Hobbs
Contact: Rafael Perera, Nuffield Department of Primary Care Health Sciences, Radcliffe Primary Care Building, Radcliffe Observatory Quarter, Woodstock Road, Oxford OX2 6JJ
Sub-Theme 2 Grants funded (to January 2016)
- COPD Exacerbation Alert for patient stratification. Small Business Research Initiative (SBRI) Stratified Medicine. £150,000, co-applicant. 2015
- The effectiveness and acceptability of urine collection devices to reduce contaminated urine samples in women presenting with symptoms of urinary tract infection: a three arm trial in UK primary care. NIHR research for Patient Benefit programme. £385,569. Co-applicant. 2015.
- Implementation of National Institute for Health and Care Excellence (NICE) and BTS/SIGN guidelines in primary care to address under-diagnosis, misdiagnosis and under-assessment of children with asthma. Health Education England and Aerocrine. Co-applicant. £234,000.
- Evaluating the cost and cost-effectiveness of replacing urine protein electrophoresis (UPE) with serum free light chain (sFLC) test for early diagnosis of multiple myeloma. National Institute for Health Research (NIHR) Research Capacity Funding. £47,776, Principle Investigator. 2015.
- Effectiveness and cost-effectiveness of a fully self-guided internet-based intervention for social anxiety symptoms: pragmatic, population-based randomised controlled trial. MQ (Mental Health Charity). £180,000, Co-applicant. 2015.
- Validating patient-reported outcome measures (PROMSs) in chronic kidney disease (CKD) patients at primary care setting. School for Primary Care Research, National Institute for Health Research (NIHR). （BZRWUV00）£39, 592. Principle Investigator. 2013.
- NSPCR FR8 – Improving Outcomes for Stroke Survivors in the community and in Care Homes: Adherence to guidance in primary care, co-applicant. 2014.
- Evaluation of a smoking cessation intervention. National Institute for Health Research (NIHR) Research Capacity Funding. £45,000. Co-principle Investigator. 2014.
- Assessing performance of Chinese public hospital and reform: a novel perspective from patients. Chinese National Science Funding. £60,000. Co-Principle Investigator, 2014.