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NDORMS DPhil & MSc by Research

Research Project Outline

Background

The research has precedent due to the consultation conducted by NHS England with regards to evidence-based intervention commissioning, which has been revised in response to consultation feedback by the BSSH and the RCS.

Dupuytren’s disease is a common condition in which scar-like tissue forms under the skin of the palm.  This forms cords of new tissue that pull the fingers into the palm and limits function.  It is multifactorial, with a genetic component, and so tends to recur even after successful treatment. There are a variety of treatments available, which broadly fit into two groups.  The first group involves splitting the cords and leaving them in place. By doing so, the fingers can be straightened.  The second approach involves removing the diseased tissue, rather than dividing it.

Within each of the two subgroups, there are also different treatment options.

  1. Disease can be divided:

By agitating a hypodermic needle through the cord until it snaps (needle aponeurotomy, aka needle fasciotomy)

Or by injecting collagenase enzyme to chemically digest and break it (collagenase injection). 

  1. Disease can be excised:

And the existing skin stitched back (fasciectomy)

Or the skin and disease can be removed, and the area resurfaced with a skin graft from elsewhere on the body (dermofasciectomy).

Typically, treatments in the first group are viewed as “less invasive”, do not require general anaesthetic, and have comparatively shorter recovery times, and lower complication rates. However, people who undergo these treatments tend to experience recurrence more quickly.  Treatment can often be repeated in this instance, without difficulty.

Treatments in the second group involve more ‘significant’ surgery, under general or regional anaesthetic or with a block to numb the entire arm.  Recovery is slower (4-6 weeks versus a number of days), and the risk of complications, like altered feeling in the hand, is much greater is higher.  Some complications can be permanent.  However, the risk of recurrence and the need for further treatment is much lower.

Thus, the broad choice is between quick-fix minimally invasive procedures with higher recurrence rates, or procedures with longer recovery that are more likely to reduce the risk of recurrence.

Within each of the two subgroups, there are also different treatment options.  For example, disease can be divided by agitating a hypodermic needle through the cord until it snaps (needle aponeurotomy, aka needle fasciotomy), or by injecting collagenase enzyme to chemically digest and break it (collagenase injection).  In the excisional group, disease can be cut out and the existing skin stitched back (fasciectomy), or the skin and disease can be removed, and the area resurfaced with a skin graft from elsewhere on the body (dermofasciectomy).

Different treatments have different success rates, costs and risks. – even within treatment families.  Thus, it is important to compare them.  However, as recurrence may lead to a person having several treatments in a given period, simply comparing the efficacy of one-off treatments may be misleading about informing real-world effectiveness, the patient journey, and the value to the system.

Decision models can allow us to estimate the costs and effectiveness of each intervention through synthesising information from multiple sources.  They can account for the need for further treatments, and so may provide a more realistic, quantifiable way to understand the differences between treatments.

Such understanding would support informed shared decision making about treatment in clinical practice and could allow targeting and prioritisation of effective treatments.

Aims and Hypotheses

This project aims to understand the relative value of different treatments for Dupuytren’s disease. 

The objectives are:

  1. To establish the metrics for effectiveness of treatment
  2. To establish the costs of treatment and numbers of people who transition from one treatment to another
  3. To identify and extract appropriate data to model the journey for a patient with Dupuytren’s disease
  4. To build health economic models that most appropriately fit the data.

Materials and Methods 

Data Sources

Data to complete these objectives will be sourced from:

  1. A systematic literature review (effectiveness metrics)
  2. HRG groupers (costs)
  3. Hospital Episode Statistics (HES) data (numbers of patients transitioning from one treatment to another over time)
  4. UK Hand Registry (EQ5D-based health-related quality of life data to derive utilities for different health states)

Of this, HES and UKHR data have already been sourced by the research team and prepared for analysis in general.  The systematic review will be based on the Cochrane Review performed in 2015 by the supervisor.  HRG codes can be obtained reliably.

The systematic review will be designed and conducted in concordance with contemporary standards, such as those specified in the Cochrane Handbook, the PRISMA statement and the AMSTAR-2 criteria for systematic review quality.

Model construction 

Initially, a decision tree model will be constructed and populated using data from the systematic review and HES.  Time-allowing, cost and utility data from the HRG groupers and UKHR will be added to this, as part of this one-year project, or in further project work conducted by the group. 

Potential Outcomes:

No-one knows which interventions are best for restoring and maintaining hand function throughout the rest of the patient’s life, and which are the cheapest and most cost-effective in the long term. This research can complement and feed into ongoing and planned National Institute for Health Research studies aim to answer these concerns.

Details on specific training opportunities relevant to the project

The Botnar Research Centre plays host to the University of Oxford's Institute of Musculoskeletal Sciences, which enables and encourages research and education into the causes of musculoskeletal disease and their treatment. A core curriculum of lectures will be taken in the first term to provide a solid foundation in a broad range of subjects including musculoskeletal biology, inflammation, epigenetics, translational immunology, data analysis and the microbiome. All students are required to attend a 2 - day Statistical and Experimental Design course at NDORMS. The student will attend regular seminars within the department and those relevant in the wider University. 

Additional on the job training opportunities will arise, and the supervisors will encourage the student to pursue such opportunities. Attendance at formal training courses will be encouraged. In addition, courses from the Oxford Learning Institute and the Oxford University Computer Sciences on generic skills for scientific research will be available and encouraged. Students will be expected to present data regularly in the departmental PGR seminars, Furniss group meetings, and to attend external conferences to present their research globally. 

Contact details of potential supervisors

Dominic Furniss: dominic.furniss@ndorms.ox.ac.uk

Jeremy Rodrigues: Jeremy.rodrigues@ndorms.ox.ac.uk

How to Apply

The department accepts applications throughout the year but it is recommended that, in the first instance, you contact the relevant supervisors or the Graduate Studies Officer, Sam Burnell (Samuel.burnell@ndorms.ox.ac.uk), who will be able to advise you of the essential requirements.

Interested applicants should have or expect to obtain a first or upper second-class BSc degree or equivalent, and will also need to provide evidence of English language competence. The application guide and form are found online, and the MSc by research will commence in October 2019.

For further information, please visit http://www.ox.ac.uk/admissions/graduate/applying-to-oxford

 

 

Project reference number #NDORMS-2019/14

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