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NIHR Workshop on Research into Primary Care Interventions

NIHR Workshop on Research into Primary Care Interventions. 12 February 2013. Session Two: Developing Primary Care Research Projects. 12 February 2013. How to get a Fellowship in Primary Care Research. Professor Richard McManus University of Oxford. Overview.

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NIHR Workshop on Research into Primary Care Interventions

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  1. NIHR Workshop on Research into Primary Care Interventions 12 February 2013

  2. Session Two: Developing Primary Care Research Projects 12 February 2013

  3. How to get a Fellowship in Primary Care Research Professor Richard McManus University of Oxford

  4. Overview • Introduction – a bit about me • Getting started • Consolidation (What to do when it goes pear shaped) • Underpinning Success • Conclusions

  5. Background • Trained at St Mary’s 1985-1991 • House jobs / medical rotation / VTS • Started in Birmingham in 1997 immediately following qualification as a GP • Prior to that had done intercalated BSc, audit and some data collection for studies but had not been able to take projects to the next level • Started with clinical research fellow job (no academic trainee posts available apart from London) • Did MSc in Primary Care

  6. Getting started • 1999: failed to get fellowship (heart failure) • 2000: new project (self monitoring in hypertension) – successful application for Doctoral Fellowship (RDA) • 2001-4: PhD based on a RCT • Trial funding from the fellowship with backfill for a part time research assistant and service support costs for the practices

  7. Targets and self monitoring in the control of hypertension (TASMINH) • First UK RCT of self monitoring in hypertension • 441 people from 8 practices randomised to self monitoring vs usual care • Participants monitored BP in GP waiting rooms and attended GP if consistently above target • Follow up at 6 and 12 months • Primary Outcome change in SBP over time

  8. Self monitoring cost effective

  9. Clinical Bottom Line • Self monitoring alone leads to small reductions in blood pressure at 6 months that are not sustained at 12 months • Possible mechanism of action via non pharmacological changes (weight loss) • Self monitoring reduces consultation rate hence cost effective

  10. Doctoral fellowship lessons learnt • Pick something you are interested in! • Look for a gap in the evidence that’s relevant • You can never have too many patients/practices • Its hard to do a big study on your own • Think about what next even at the beginning • Side projects keep output up in lean years(routine data, systematic reviews…)

  11. Post Doctoral Work • TASMINH evolved into Telemonitoring and self management in the control of hypertension (TASMINH2) • New intervention developed comprising self monitoring with self titration • Patient and practice training packages • Post Doc Award 2005-7 • Back fill supported full time research fellow

  12. Post Doc Award • Co-Funding from Policy Research Programme (£330k) but long delay between recommendation for funding and funding • Expanded team • Qualitative arm • Increased health economics • External collaborators • Paul Little and Bryan Williams • Did systematic review in parallel

  13. McManus et al Lancet 2010

  14. TASMINH2 Research Questions Does self management with telemonitoring and titration of antihypertensive medication by people with poorly controlled treated hypertension result in: • Better control of blood pressure? • Changes in reported adverse events or health behaviours or costs? • Is it achievable in routine practice and is it acceptable to patients?

  15. The Trial • Eligibility • Age 35-85 • Treated hypertension (no more than 2 BP meds) • Baseline BP >140/90 mmHg • Willing to self monitor and self titrate medication • Patients individually randomised to self-management vs usual care stratified by practice and minimised on sex, baseline SBP, DM status • Practice GPs determine management

  16. Intervention • Self Monitoring – 1st week of every month

  17. Intervention • Blood Pressure Targets: • NICE (140/90 or 140/80 mmHg) • minus 10/5 mmHg i.e. 130/85 mmHg or 130/75 mmHg • Patients agreed titration schedule with their GP after randomisation • Traffic Light system to adjust medication

  18. Outcomes • Follow up at 6 & 12 months • Main outcome Systolic Blood Pressure • Secondary outcomes: Diastolic BP / costs / anxiety / health behaviours/ patient preferences / systems impact • Recruitment target 480 patients (240 x 2) • Sufficient to detect 5mmHg difference between groups

  19. Invited (n = 7637) Declined Invitation (n = 5987) Assessed for eligibility (n = 1650) Excluded(n = 1123) Not Eligible (n = 1044) Declined to participate (n=79) Randomised (n = 527) Control (n = 264)Received usual care (n = 264) Intervention (n = 263)Received intervention training (n = 241) Did not attend follow up (n=14)* Discontinued usual care (n = 0) Did not attend follow up (n=26)# Discontinued intervention (n = 53) Analysed (n = 246) Incomplete cases excluded (n = 18) Analysed (n = 234) Incomplete cases excluded (n = 29) Results 110% recruitment 80% completed intervention 91% follow up

  20. Baseline Results

  21. Results - primary outcome SBP

  22. Post Doc lessons learnt • Recruitment is getting harder • Everything takes longer than you think • Surround yourself with experts and take their advice • Get a good trial manager and research secretary • Continue with the side projects • 2007 – failed Career Scientist Application “…too early”

  23. Career Development Fellowship • Improving the management and understanding of hypertension in primary care (2009-12) • Programme had three parts • TASMINH3 – extension of self management work into stroke and TIA • Blood pressure measurement in different ethnic groups • Cardiovascular and renal prognosis in chronic kidney disease • 75% FTE over 4 years (rest HEFCE and service funded)

  24. Linked projects • NIHR Monitoring programme with Oxford • Systematic review of different methods of diagnosing hypertension • Economic analysis->NICE guideline / Lancet • ESRC/MRC Studentship • Sabrina Baral: Self-monitoring of blood pressure in patients with hypertension and diabetes: • UK Self Monitoring Collaboration • HTA funded national conference • Subsequent BMJ publication

  25. NIHR Professorship 4 Strands • Self Monitoring in Hypertension • Self Monitoring BP in Pregnancy • Self Monitoring Collaborations • Supporting Others Starts 1/3/2013…

  26. Underpinning success • Getting a mentor • Becoming a mentor • Synergistic funding • Building collaborations • Training • Outcomes on different levels

  27. Getting a mentor • Having a good mentor formalised through my fellowships has made a big difference to my progression • This started off as a supervisor / student relationship and has matured into a colleague / colleague collaboration • Since we started we have achieved an MD, PhD, several £ms income, 32 joint publications and counting, both now chairs • Hardest thing is probably finding the right person but once you have a mentor hang onto them… mine moved to Cambridge!

  28. Becoming a mentor • More senior fellowships give opportunity to develop mentor roles for others • Currently mentor for x4 • Current supervision • 3 PhD students • 1 MSc students • 1 Academic Clinical fellow • 2 medical students (electives) • Vital role in growing the discipline and providing a pipeline for new talent

  29. Synergistic funding • Co-funding of fellowship projects • Research funding • Service support / Treatment cost funding • Linked studentships • Bridging the gaps between fellowships • Linked projects make up career narrative • Institutional support (backfill)

  30. Building collaborations • Multidisciplinary working • Social scientists • Health economics • Academic and service clinicians • Specialists and generalists • Within institutions • Between institutions • National and International

  31. Training • Improve basic skills • Epidemiology (LSHTM) • Statistics (Oxford MSc) • Expand horizons • Qualitative (NatCen) • Health Economics (HEF) • Leadership • RCGP leadership programme • Brisbane Initiative

  32. Outcomes on different levels • Funding • Publications • Markers of esteem (funding committees, editorial boards, guideline development groups, guest lectures, ACCEA) • Training • Developing others • Career progression Don’t forget a broad range of success drives progression

  33. To sum up… All right... all right... but apart from seventeen out of eighteen years (2001-18) and paying for my education and funding most of my research and paying my team... what has the NIHR done for me? … …maybe they can do the same for you?

  34. Thank you

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