Welcome to the Research Institute for Primary Care & Health Sciences Blog

This blog was created to keep healthcare professionals, researchers, methodologists, and patients up to date with the latest primary care research. For more information about the Research Institute, visit our website; keele.ac.uk/pchs

Wednesday, 28 March 2018

SAPC Early Career Academic Networking Event - 30/01/2018

Written by Dr James Prior (Keele University) and Dr Rebecca Morris (University of Manchester)

This January saw the Society for Academic Primary Care (SAPC) hold their second early career academic networking event, hosted by the Institute of Population Health, University of Cambridge. 

The aim of this event is to bring together researchers from different academic primary care departments, both clinical and primary healthcare scientists (PHoCuS), and in the early stages of their career. This provides a platform for activities focused on how to progress an early career in academic primary care and also network with peers from other academic departments. Through sessions lead by senior academics, the aim is for those with successful careers to pass on useful information to the leading academics of tomorrow.

The event started with a Q&A session with Jonathan Mant, Professor of Primary Care Research and Head of the Primary Care Unit at the University of Cambridge. The title of this session was “Identifying opportunities and overcoming challenges as an early career academic” and was an extremely useful, frank and open discussion with the attendees. Prof Mant chatted about the path his career had taken in its earlier stage, the decisions he had made (based both on career and personal choices) and some of the reason he thought his career had taken the direction it did. A key message we took away was that there’s no typical academic careers so it’s important to do what you’re passionate about, finding a balance, and having an ongoing discussion with a mentor about career development. This sparked many questions from the attendees relating to topics such as pursuing promotions and managing expectations and people.

This discussion about an individual career and the choices which influenced it was followed by Bob McKinley, Professor of Education in General Practice at Keele University who presented on “Career pathways in education and research”. Taking a wider, more general view of career progression, Prof McKinley presented the formal academic career routes which lay open to clinical and PHoCuS researchers and educationalists, and what these different options entail and can mean for career direction. It was very useful to think about the range of career options open to us and the importance of making your CV stand out from everyone else’s.

One of the career paths that Prof McKinley discussed was that of the medical educationalist. However, teaching responsibilities in the wider researching community are becoming more and more common and a requirement of job roles. To this end, Dr Sophie Park from University College London was invited to talk to the attendees on the topic of “Engaging in teaching for researchers”. Dr Park addressed some of the key aspects of teaching, identifying that many of the same skills apply to both researching and teaching. The value of bringing research and education together was a key message as there’s a lot we can learn from each other.

Finally, Suzanne Richards, Professor of Primary Care Research ended the day with a practical and extremely useful session on “How to present your CV for maximum impact”. As someone who has sat on many interview panels and reviewed countless application forms and CVs, Prof Richards was able to provide the attendees with some extremely useful hints and tips to improve the chances of their CV catching the eye of a potential employer and increasing the chances of progressing their career. Top tip, good formatting is more important than you might think!!!

This event tied together many of the different aspects of being an early career academic and provided the attendees with much new information and many skills to take forward on their path towards a successful career in academic primary care. If you’d be interested in taking part in next year’s event then keep an eye on the SAPC website for further information.

Wednesday, 20 December 2017

Multi-state modelling: a brief introduction

Written by Chris Morton | PhD Student | www.keele.ac.uk/pchs | @PCSciences

Multi-state modelling, a flexible framework which describes complex clinical processes over time, is often overlooked by the more favourable survival and longitudinal models. In this blog, I hope to provide an accessible introduction to multi-state modelling, drawing on my recent dissertation for my MSc at Lancaster, whilst also introducing my current research. 

What is a multi-state model? 

The concepts of multi-state models may be more familiar to researchers than they realise. 

In a multi-state model, an individual/patient falls under one of several 'states', and may transition between those states over the course of their lifetime. 

So in a 3-state illness-death model, a healthy patient is in state 1, they transition to stage 2 if they become diseased and stage 3 reflects death. Traditional survival analysis can be considered a 2-state (alive or deceased) model. 

Health researchers are often interested though, in the effect of covariates (e.g. treatment regime) on the risk of an event at each instant of time. For a general multi-site model, the event is the transition from one state to another, and it is possible for separate baseline risk and covariate effects to be associated with each transition. 

Why use multi-site models in primary care? 

Multi-state models are commonly applied to clinical conditions where there is an increasing state of disease severity which precedes eventual death. Only using this approach though, it unnecessarily limiting - there are a wide range of potential applications of multi-site models in a primary care setting (e.g. mental health conditions and patient habits such as smoking and alcohol consumption). 

The biggest advantage of using a multi-site approach is the insight you can gain about every aspect of a process. For example, we can separately measure the factors affecting a smoker's decision to quit and those affecting a relapse into smoking. 

For my dissertation, the illness-death model is used to describe the progress of intact dental veneers (state 1), which may at first become discoloured (state 2) before eventually fracturing (state 3). My methodology focuses on the methodology rather than this particular application, but the example illustrates the diversity of potential uses for a multi-state approach. 

What are the key steps in model building? 

1) Representing clinical processes

The first step for a researcher is deciding how to represent a clinical process in terms of a discrete state and the permitted transitions between them - which isn't always straightforward. 

For example, when following the habits of a smoker, do two states ('current smoker' and 'current abstinence') adequately capture their behaviour? Or, do we want at least three - 'habitual smoker', 'withdrawal phase' and 'long-term abstinence' (see paper). 

2)  Matching covariates with state transitions

Consider which covariates act on each state transition and whether their effect should be constrained to be equal amongst transitions (due to a biological rationale, or to simplify model calculation). 

3) Model Fitting  

A natural starting point for model fitting is using freely available packages in R software: 'mstate' and 'msm'. Mstate' can be used if state transitions are observed at an exact date, such as when a patient dies. 'Msm' can handle panel data, such as when a patient is known only to have changed state at a time since their previous clinical observation. 

Beyond the functionality of the above packages, lies potential complications which were the focus of my dissertation. I analysed panel data with a clear dependence structure (multiple veneers in the same patient) and showing evidence of time-inhomogeneity (the instantaneous risk of a state transition changes over time). 

Unfortunately though, some of these more complicated models remain inaccessible to many researchers, largely due to a lack of software availability. 

What next? 

Fresh from a MSc in Statistics at Lancaster University, I now face the trials and tribulations of a PhD at the Research Institute for Primary Care and Health Sciences at Keele. My research investigates the treatment and symptom patterns of patients with polymyalgia rheumatica (PMR) and what factors predict these. 

Patients go from being treated with steroids to a state of remission, which may be followed by future relapses, again bringing to mind a multi-state framework. It is still too early to say whether such methods will provide me with an informative perspective, and research trajectories don't always run so smoothly. 

Regardless, multi-state modelling, together with longitudinal methods learned at Lancaster will always be a welcome tool to have in my future career as a primary care researcher, and I hope this blog has you already considering further applications for this interesting and useful area of methodology. 

About the author: 
Chris has recently started his SPCR funded PhD at Keele University, entitled 'early symptoms and treatment duration in polymyalgia rheumatica: a joint modelling approach'. In the previous academic year, Chris completed an MSc in Statistics at Lancaster University, for which he won two departmental prizes: the Tessella Industry Prize for 'Best Computational MSc Statistics Dissertation' and also a Postgraduate Statistics Centre Prize for 'Learning Excellence.'

Pain on a platform: STarT Back in Seattle

Written by Nicola Evans | Implementation Manager | www.keele.ac.uk/pchs | @PCSciences

Anyone familiar with the Research Institute will almost certainly have heard of the 'STarT Back' tool mentioned on more than one occassion. But for those unlucky few, the tool was established back in 2008 with the overarching aim to improve the care that patients suffering with back pain receive. Using a stratified (systematic) approach, the tool allows healthcare providers to suitably match the right treatment to patients according to their risk of experiencing persistent disabling low back pain. 

The STarT Back tool has certainly begun to put back pain on the healthcare agenda, and the tool is being implemented more and more by clinicians, commissioners and researchers all over the world. There is still a long way to go though, and through building collaborations we're able to address the currently challenges surrounding back pain. 

Myself and senior Knowledge Mobilisation Fellow, Kay Stevenson, recently spent two day ins Seattle to discuss the implementation of STarT Back with key collaborators, Kaiser Permanente. 

Although there is a longstanding history of collaboration between the Research institute and Kaiser Permanente (previously known as ‘Group Health’), most recently our focus has shifted to the world of implementation. Recent discussions shed light on a mutual concern with lack of materials available to explain chronic pain for patients, and a lack of training for primary care practitioners to give or support these explanations. 

The team at the Research Institute have tried to tackle this through the development of the STarT Back website, as well delivering training. Our collaboration with the Kaiser Permanente has led to a considerable impact of the STarT Back tool within the US and other countries, and recent discussions evolved into the development of a web-based ‘Pain Platform’ which will have a much wider reach and spread the word about the tool far and wide. 

The two-day visit enabled both teams to gain a better understanding of the relative perspectives and systems within chronic pain, and explore ways in which the ‘pain platform’ project will be taken forward.  

It was two wonderful days of sharing and learning, with both teams presenting their current implementation work and models for best practice in the area of chronic pain. Day two’s focus was future collaboration projects to strengthen implementation work that’s already been delivered. Our very own Professor Peter Croft introduced a seminar delivered by myself and Kay which highlighted the research-into-practice story - using STarT Back as an example of highlighting work within the NHS, finishing with a clear and strong story of the Impact Accelerator Unit and patient engagement. 

The visit was a clear success, enjoyed by both teams who built key strengths to help identify a plan to move forward. Clear opportunity for long-term collaboration on educational and training initiatives for clinicians involved in consultations and implementation research were also identified.

About the author: 
Nicki's role within the Impact Accelerator Unit is to support the operational delivery of key innovation projects on behalf of the Research Institute for Primary Care and Health Sciences (iPCHS). She takes the lead for the project management in the Unit, working closely with clinicians in the team as well as key groups within the NHS to ensure effective adoption and spread of our work. 

She graduated from University of Liverpool in 2001 with a degree in Nutrition and has worked in the NHS for over 10 years in the public health arena prior to joining the Impact Accelerator Unit in September 2015.