Faculty Bibliography

BACKGROUND: Acquired adult-onset hearing loss is a common long-term condition for which the most common intervention is hearing aid fitting. However, up to 40% of people fitted with a hearing aid either fail to use it or may not gain optimal benefit from it. OBJECTIVES: To assess the long-term effectiveness of interventions to promote the use of hearing aids in adults with acquired hearing loss fitted with at least one hearing aid. SEARCH METHODS: We searched the Cochrane ENT Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 6 November 2013. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of interventions designed to improve or promote hearing aid use in adults with acquired hearing loss compared with usual care or another intervention. We excluded interventions that compared hearing aid technology. We classified interventions according to the 'chronic care model' (CCM). The primary outcomes were hearing aid use (measured as adherence or daily hours of use) and adverse effects (inappropriate advice or clinical practice, or patient complaints). Secondary patient-reported outcomes included quality of life, hearing handicap, hearing aid benefit and communication. Outcomes were measured over the short ( 12 to < 52 weeks) and long term (one year plus). DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We included 32 studies involving a total of 2072 participants. The risk of bias across the included studies was variable. We judged the GRADE quality of evidence to be very low or low for the primary outcomes where data were available.The majority of participants were over 65 years of age with mild to moderate adult-onset hearing loss. There was a mix of new and experienced hearing aid users. Six of the studies (1018 participants) were conducted in a military veteran population. Six of the studies (287 participants) assessed long-term outcomes.All 32 studies tested interventions that could be classified as self management support (ways to help someone to manage their hearing loss and hearing aid(s) better by giving information, practice and experience at listening/communicating or by asking people to practise tasks at home) and/or delivery system design interventions (just changing how the service was delivered) according to the CCM. Self management support interventions We found no studies that investigated the effect of these interventions on adherence, adverse effects or hearing aid benefit. Two studies reported daily hours of hearing aid use but we were unable to combine these in a meta-analysis. There was no evidence of a statistically significant effect on quality of life over the medium term. Self management support reduced short- to medium-term hearing handicap (two studies, 87 participants; mean difference (MD) -12.80, 95% confidence interval (CI) -23.11 to -2.48 (0 to 100 scale)) and increased the use of verbal communication strategies in the short to medium term (one study, 52 participants; MD 0.72, 95% CI 0.21 to 1.23 (0 to 5 scale)). The clinical significance of these statistical findings is uncertain but it is likely that the outcomes were clinically significant for some, but not all, participants. Our confidence in the quality of this evidence was very low. No self management support studies reported long-term outcomes. Delivery system design interventions These interventions did not significantly affect adherence or daily hours of hearing aid use in the short to medium term, or adverse effects in the long term. We found no studies that investigated the effect of these interventions on quality of life. There was no evidence of a statistically or clinically significant effect on hearing handicap, hearing aid benefit or the use of verbal communication strategies in the short to medium term. Our confidence in the quality of this evidence was low or very low. Long-term outcome measurement was rare. Combined self management support/delivery system design interventions We found no studies that investigated the effect of complex interventions combining components of self management support and delivery system design on adherence or adverse effects. There was no evidence of a statistically or clinically significant effect on daily hours of hearing aid use over the long term, or the short to medium term. Similarly, there was no evidence of an effect on quality of life over the long term, or short to medium term. These combined interventions reduced hearing handicap in the short to medium term (13 studies, 485 participants, standardised mean difference (SMD) -0.27, 95% CI -0.49 to -0.06). This represents a small-moderate effect size but there is no evidence of a statistically significant effect over the long term. There was evidence of a statistically, but not clinically, significant effect on long-term hearing aid benefit (two studies, 69 participants, MD 0.30, 95% CI 0.02 to 0.58 (1 to 5 scale)), but no evidence of effect over the short to medium term. There was evidence of a statistically, but not clinically, significant effect on the use of verbal communication strategies in the short term (four studies, 223 participants, MD 0.45, 95% CI 0.15 to 0.74 (0 to 5 scale)), but not the long term. Our confidence in the quality of this evidence was low or very low.We found no studies that assessed the effect of other CCM interventions (decision support, the clinical information system, community resources or health system changes). AUTHORS' CONCLUSIONS: There is some low to very low quality evidence to support the use of self management support and complex interventions combining self management support and delivery system design in adult auditory rehabilitation. However, effect sizes are small and the range of interventions that have been tested is relatively limited. Priorities for future research should be assessment of long-term outcome a year or more after the intervention, development of a core outcome set for adult auditory rehabilitation and development of study designs and outcome measures that are powered to detect incremental effects of rehabilitative healthcare system changes over and above the provision of a hearing aid.

BACKGROUND: Increased prescribing of inhaled long-acting anti-muscarinic (LAMA) and combined inhaled long-acting beta2-agonist and corticosteroid (LABA+ICS) drugs for the treatment of chronic obstructive pulmonary disease (COPD) has led to hopes of reduced hospital admissions from this disease. AIMS: To investigate the impact of rising primary care prescribing of LAMA and LABA+ICS drugs on COPD admissions. METHODS: This retrospective cohort study of general practice COPD admission and prescribing data between 2007 and 2010 comprised a representative group of 806 English general practices (population 5,264,506). Outcome measures were practice rates of COPD patient admissions and prescription costs of LAMA and LABA+ICS. General practice characteristics were based on the UK quality and outcomes framework. RESULTS: Rates of COPD admissions remained stable from 2001 to 2010. Practice-prescribing volumes of LAMA per practice patient and LABA+ICS per practice patient increased by 61 and 26%, respectively, between 2007 and 2010. Correlation between costs of LAMA and those of LABA+ICS increased year on year, and was the highest in 2010 (Pearson's r=0.68; 95% confidence interval (CI) 0.64 to 0.72). Practice COPD admission rates were positively predicted by practice-prescribing volumes of LAMA (2010: B=1.23, 95% CI 0.61 to 1.85) and of LABA+ICS (2010: B=0.32, 95% CI 0.12 to 0.52) when controlling for practice list size, COPD prevalence and deprivation. CONCLUSION: The increase in the prescribing of LAMA and LABA+ICS inhalers was not associated with the predicted fall in hospital admission rates for COPD patients. The positive correlation between high practice COPD prescribing and high practice COPD admissions was not explained.

In breast cancer patients undergoing sentinel lymph node biopsy (SLNB) analysis using one-step nucleic acid amplification (OSNA), clarity is required as to the determinants of further metastasis risk upon completion axillary lymph node dissection (ALND). This study aims to identify whether the proportion of sentinel nodes containing metastases predicts risk of further axillary disease.

Sheng-Chia Chung and colleagues report in The Lancet (23 January 2014) an international comparison of cardiovascular patient mortality between the UK and Sweden. They suggest that "more than 10000 deaths at 30 days would have been prevented or delayed had UK patients experienced the care of their Swedish counterparts." Further, they estimate that 1741 deaths would have been prevented in the UK had the Swedish pattern of primary percutaneous coronary intervention (PCI) and beta-blocker use been replicated in the NHS from 2004 to 2010. However, their study does not provide convincing evidence that faster uptake of primary PCI or beta-blockers on discharge would have had an effect on cardiovascular patient mortality in the UK.

BACKGROUND: The National Institute for Health and Care Excellence (NICE) recommends postpartum and annual monitoring for diabetes for females who have had a diagnosis of gestational diabetes mellitus (GDM). AIM: To describe the current state of follow-up after GDM in primary care, in England. DESIGN AND SETTING: A retrospective cohort study in 127 primary care practices. The total population analysed comprised 473 772 females, of whom 2016 had a diagnosis of GDM. METHOD: Two subgroups of females were analysed using electronic general practice records. In the first group of females (n = 788) the quality of postpartum follow-up was assessed during a 6-month period. The quality of long-term annual follow-up was assessed in a second group of females (n = 718), over a 5-year period. The two outcome measures were blood glucose testing performed within 6 months postpartum (first group) and blood glucose testing performed annually (second group). RESULTS: Postpartum follow-up was performed in 146 (18.5%) females within 6 months of delivery. Annual rates of long-term follow-up stayed consistently around 20% a year. Publication of the Diabetes in Pregnancy NICE guidelines, in 2008, had no effect on long-term screening rates. Substantial regional differences were identified among rates of follow-up. CONCLUSION: Monitoring of females after GDM is markedly suboptimal despite current recommendations.

OBJECTIVE: There is no standard method of publishing the code ranges in research using routine data. We report how code selection affects the reported prevalence and precision of results. DESIGN: We compared code ranges used to report the impact of pay-for-performance (P4P), with those specified in the P4P scheme, and those used by our informatics team to identify cases. We estimated the positive predictive values (PPV) of people with chronic conditions who were included in the study population, and compared the prevalence and blood pressure (BP) of people with hypertension (HT). SETTING: Routinely collected primary care data from the quality improvement in chronic kidney disease (QICKD-ISRCTN56023731) trial. MAIN OUTCOME MEASURES: The case study population represented roughly 85% of those in the HT P4P group (PPV = 0.842; 95%CI = 0.840-0.844; p < 0.001). We also found differences in the prevalence of stroke (PPV = 0.694; 95%CI = 0.687- 0.700) and coronary heart disease (PPV = 0.166; 95%CI = 0.162-0.170), where the paper restricted itself to myocardial infarction codes. RESULTS: We found that the long-term cardiovascular conditions and codes selected for these conditions were inconsistent with those in P4P or the QICKD trial. The prevalence of HT based on the case study codes was 10.3%, compared with 11.8% using the P4P codes; the mean BP was 138.3 mmHg (standard deviation (SD) 15.84 mmHg)/79.4 mmHg (SD 10.3 mmHg) and 137.3 mmHg (SD 15.31)/79.1 mmHg (SD 9.93 mmHg) for the case study and P4P populations, respectively (p < 0.001). CONCLUSION: The case study lacked precision, and excluded cases had a lower BP. Publishing code ranges made this comparison possible and should be mandated for publications based on routine data.