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Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time–series analysis
Aim: To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care. Design: Interrupted time–series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006–31 March 2008); (2) during the implementation of financial incentives (1 April 2008–31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015–31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points. Setting: England. Participants: Newly registered patients (16+) in 500 primary care practices for 2006–16 (n = 4 278 723). Measurements: The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher‐risk drinking; and (3) were reported as having received brief advice on alcohol consumption. Findings: There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21–3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87–14.23) per 1000 patients screening positive for higher‐risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen‐positive rates of 29.96 (95% CI = 19.56–40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51–2.77) per 1000. Screen‐positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30–28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26–0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97–24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28–1.12) per 1000 per month. Conclusions: Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme.
Reorganisation of general practice: be careful what you wish for
With the recent publication of the NHS Long Term Plan1 and the renewal of the GP Contract,2 it is timely to consider what we value within general practice. In this article we consider normative ways of thinking about general practice and the implications for primary healthcare organisation and funding. We examine some of the opportunities and challenges that current ‘common sense’ thinking produces, shaping ways in which particular ‘problems’ and ‘solutions’ are constructed and accepted.3 We discuss potential ‘gaps’ or ‘alternative’ ways of thinking and their potential contribution to future policy and practice.
Current understanding and implementation of ‘care navigation’ across England: a cross-sectional study of NHS clinical commissioning groups
Background: Care navigation is an avenue to link patients to activities or organisations that can help address non-medical needs affecting health and wellbeing. An understanding of how care navigation is being implemented across primary care is lacking. Aim: To determine how ‘care navigation’ is interpreted and currently implemented by clinical commissioning groups (CCGs). Design and setting: A cross-sectional study involving CCGs in England. Method: A questionnaire was sent to all CCGs inviting them to comment on who provided care navigation, the type of patients for whom care navigation was provided, how individuals were referred, and whether services were being evaluated. Responses were summarised using descriptive statistics. Results: The authors received usable responses from 83% of CCGs (n = 162), and of these >90% (n = 147) had some form of care navigation running in their area. A total of 75 different titles were used to describe the role. Most services were open to all adult patients, though particular groups may have been targeted; for example, people who are older and those with long-term conditions. Referrals tended to be made by a professional, or people were identified by a receptionist when they presented to a surgery. Evaluation of care navigation services was limited. Conclusion: There is a policy steer to engaging patients in social prescribing, using some form of care navigator to help with this. Results from this study highlight that, although this type of role is being provided, its implementation is heterogeneous. This could make comparison and the pooling of data on care navigation difficult. It may also leave patients unsure about what care navigation is about and how it could help them.
Is primary care research important and relevant to GPs?
INTRODUCTION Insufficient investment in primary care services, even in high-income countries, is challenging health systems, for example, through pressures on the primary care workforce from rising workloads, ageing practitioner profiles, and declining interest in primary care careers from young practitioners. Failure to invest in research to guide better practice, raising quality and reducing variations in care, may be a further risk. But is primary care research really that important? IMPORTANCE AND DOMINANCE OF BASIC SCIENCE MEDICAL RESEARCH Most biomedical research has historically been centred on basic science and the pursuit of discovery, for example, on the mechanisms of disease and their amelioration. Until latterly, the application of this science was seen merely as a professional responsibility — why don’t practitioners just get on and apply the important findings? But such implementation delays may be more to do with incomplete evidence than clinical inertia, hence one argument for more applied research evidence to inform discovery science. A century of serial multi-billion-dollar investments in basic and discovery science generated the interventions we use today. But this investment is being challenged by the dawning recognition by health systems that they need a better evidence base to inform the structure and provision of care, and how to apply the findings of much of this extraordinary biomedical science. Despite basic research consuming most of the global health research investment, much of health care remains empirical and non-evidence based. And, even when evidence gives a clear directive on what to do, slow translation into clinical practice may be as often due to uncertainties as to how to apply the data than on professional inertia. Belated recognition of such barriers to implementation has led to the introduction of a more applied clinical research focus in many countries with developed healthcare systems, such as the NHS, that complements basic science and discovery research. First came the science around evidence-based medicine (EBM), for 20 years developing and employing better methods of synthesising and presenting the totality of quality evidence and thereby reducing uncertainty. Latterly an investment in applied health research, and the capacity to better deliver this, has gathered impetus internationally, for example, via the main driver for such applied research in the UK, the National Institute for Health Research (NIHR). Primary care and primary care academics have steadily contributed to many aspects of health research, but it has been particularly important in applied research at the structural and inspirational levels.
HATRIC: a study of Pelargonium sidoides root extract EPs®7630 (Kaloba®) for the treatment of acute cough due to lower respiratory tract infection in adults—study protocol for a double blind, placebo-controlled randomised feasibility trial
Background: Acute lower respiratory tract infection is a common acute infection managed in primary care. The current dominant management strategy in the UK is antibiotics, despite widespread publicity regarding antimicrobial resistance and evidence that the small benefits of antibiotics do not outweigh the harms. There is a need to address the rising problem of antibiotic resistance by providing credible alternative strategies, which reduce symptom burden. There is sufficient evidence to recommend the use of Pelargonium sidoides root extract in order to warrant undertaking an independent clinical trial. We propose a feasibility study to demonstrate our ability to recruit and retain patients and conduct a placebo-controlled trial of Pelargonium sidoides extract EPs®7630 in lower respiratory tract infection where pneumonia is not suspected. Both the tablet and liquid formulations will be included. Methods: The HATRIC trial is a double-blind randomised placebo-controlled feasibility study aiming to determine the potential to conduct a fully powered trial of Pelargonium sidoides root extract as an alternative to the inappropriate use of antibiotics for acute bronchitis in UK primary care. Primary care sites will be equally randomised to one of two formulation groups (tablet or liquid preparation). Additionally, within each site, patients will be evenly randomised to active or placebo treatment. Antibiotic consumption will be monitored during the trial, but the use of a delayed prescription strategy is encouraged. The target sample size for this study is 160 patients overall or 40 per arm, recruited from approximately 20 primary care sites. The analysis will be descriptive focusing on estimation with no formal comparison of groups taking place. Discussion: If this trial demonstrates the feasibility of recruitment and delivery, we will seek funding for a fully powered placebo-controlled trial of Pelargonium sidoides root extract for the treatment of lower respiratory tract infections in primary care.
Biomarkers for diagnosing serious bacterial infections in older outpatients: a systematic review
Background: The value of biomarkers for diagnosing bacterial infections in older outpatients is uncertain and limited official guidance exists for clinicians in this area. The aim of this review is to critically appraise and evaluate biomarkers for diagnosing bacterial infections in older adults (aged 65 years and above). Methods: We searched Medline, Embase, Web of Science and the Cochrane Library, from inception to January 2018. We included studies assessing the diagnostic accuracy of blood, urinary, and salivary biomarkers in diagnosing bacterial infections in older adults. The QUADAS-2 tool was used to assess study quality. Results: We identified 11 eligible studies of moderate quality (11,034 participants) including 51 biomarkers at varying thresholds for diagnosing bacterial infections. An elevated Procalcitonin (≥ 0.2 ng/mL) may help diagnose bacteraemia in older adults [+ve LR range 1.50 to 2.60]. A CRP ≥ 50 mg/L only raises the probability of bacteraemia by 5%. A positive urine dipstick aids diagnosis of UTI (+ve LR range 1.23 to 54.90), and absence helps rule out UTI (−ve LR range 0.06 to 0.46). An elevated white blood cell count is unhelpful in diagnosing intra-abdominal infections (+ve LR range 0.75 to 2.62), but may aid differentiation of bacterial infection from other acute illness (+ve LR range 2.14 to 7.12). Conclusions: The limited available evidence suggests that many diagnostic tests useful in younger patients, do not help to diagnose bacterial infections in older adults. Further evidence from high quality studies is urgently needed to guide clinical practice. Until then, symptoms and signs remain the mainstay of diagnosis in community based populations.
Characteristics of patients with giant cell arteritis who experience visual symptoms
Permanent vision loss is one of the most serious complications of giant cell arteritis (GCA) and therefore prompt diagnosis is paramount. However, diagnosis of GCA remains challenging due to its frequently non-specific presentation. Our aim was to identify differences in the characteristics of GCA patients with, and without, current visual symptoms. A cross-sectional survey was mailed to patients with a GCA Read code entered in their GP electronic medical record. Responders were categorised as those currently reporting a visual symptom or not. We compared general and GCA-specific characteristics in these two groups. The association of diagnostic delay with subsequent experience of visual symptoms was examined using unadjusted and adjusted linear regression analysis. 318 GCA patients responded to the survey (59.6%). Responders were predominantly female (69.8%), with a mean age of 73.7 years (SD 8.2). 28% reported current visual symptoms. There was no statistically significant difference in the general characteristics between those with and without visual symptoms. Of GCA-specific characteristics, pre-GCA diagnosis of diplopia (p = 0.018), temporary (p ≤ 0.001) or permanent visual problems (p = 0.001) and hoarseness (p = 0.004) were more common among those reporting current visual symptoms. There was no association between the extent of diagnostic delay and reporting of current visual symptoms. Though we found few characteristics to distinguish between GCA patients with or without current visual symptoms, diagnostic delay was not associated with current visual symptoms. Our findings highlighted the continued difficulty for clinicians to identify GCA patients at the highest risk of visual complications.
Treating postoperative pain? Avoid tramadol, long-acting opioid analgesics and long-term use
A recent cohort study investigated ‘the risk of transitioning from acute to prolonged use’ of opioid analgesics in patients undergoing elective surgery. Patients given tramadol or long-acting opioids after discharge were at greater risk of prolonged opioid use than those who were given other short-acting opioids. EBM Verdict on: Chronic use of tramadol after acute pain episode: cohort study. BMJ 2019 May 14. doi: 10.1136/bmj.l1849. Long-acting opioids and tramadol should be avoided when discharging patients from hospital after elective surgery. Alternative short-acting opioids at low doses and for short durations are preferable. Strong pain-relieving medicines called opioids are commonly prescribed when patients are discharged from hospitals. However, pain after elective surgery is usually short-lived. This cohort study1 addresses an important question regarding the prolonged use of opioid analgesics after elective surgery in light of the opioid crisis in the USA and Canada and increased prescribing of opioids in high-income countries.2 Tramadol is both a weak mu-opioid receptor agonist and a serotonin and norepinephrine reuptake inhibitor. Its active metabolite, O-desmethyltramadol, is longer acting than tramadol itself and is a more potent mu-opioid receptor agonist. Responses to tramadol, therefore, vary according to the genotype of the main metabolising enzyme, CYP2D6.3 Tramadol has been available for over 30 years in the UK and for 24 years in the USA (see box 1). It is considered by many to be safer than other opioids. However, deaths from tramadol are increasing.4 Evidence is also emerging that tramadol’s adverse effects are similar to stronger opioids such as fentanyl, which receive stricter regulations by scheduling authorities than tramadol.
Designing and developing a co-produced theoretical and evidence-based online support for family caregivers of people with dementia at the end of life
Background: Caring for someone with dementia can be physically and emotionally difficult. Acting as a caregiver can make it difficult to access sources of support, particularly in the later stages of dementia. This paper reports the development and presents the targets (subject areas) and components of a prototype website to support family caregivers of a person with dementia towards the end of life. Methods: Adopting an iterative approach and co-production methods the development process consisted of four stages: Stage1-Synthesis of data: three sources of data (interviews, systematic review and theory) were synthesised using tabulation, to identify the targets of the prototype; Stage2-Identifying intervention targets and components: a research development group (health practitioners, a family caregiver and academic experts) met to discuss the development, using a modified nominal group process, refining the synthesis from stage 1; Stage3-Developing the intervention prototype: an outline of the prototype was developed based on stage 1 and 2; and Stage4–User testing: interviews with caregivers testing the prototype website. Results: Qualitative interviews with caregivers identified four targets for the intervention: 1) feeling prepared and equipped; 2) feeling connected and supported; 3) valuing themselves as a caregiver and as an individual; 4) maintaining control of the caring situation and being the coordinator of care. The systematic review provided evidence on how and what components could address these targets, including providing information, peer support, contact with professionals, and psychological support. Theory helped to narrow the focus within each of these targets. Active discussion with the research development group and end users provided an outline of the prototype website. The prototype website presented addresses these targets with written information, videos from other caregivers, and peer and professional support sections. The subject areas covered included expectations at the end of life, support with day-to-day caring, care planning, and communication. Conclusions: This paper provides a detailed account of the development process of a prototype website for caregiver support. The transparent methodology and key lessons learnt from developing the prototype should help those who are developing similar interventions, across complex, progressive conditions and not just limited to dementia.
Patient preferences for management of high blood pressure in the UK: a discrete choice experiment
Background With a variety of potentially effective hypertension management options, it is important to determine how patients value different models of care, and the relative importance of factors in their decision-making process. Aim To explore patient preferences for the management of hypertension in the UK. Design and setting: Online survey of patients who have hypertension in the UK including an unlabelled discrete choice experiment (DCE). Method: A DCE was developed to assess patient preferences for the management of hypertension based on four attributes: model of care, frequency of blood pressure (BP) measurement, reduction in 5-year cardiovascular risk, and costs to the NHS. A mixed logit model was used to estimate preferences, willingness-to-pay was modelled, and a scenario analysis was conducted to evaluate the impact of changes in attribute levels on the uptake of different models of care. Results: One hundred and sixty-seven participants completed the DCE (aged 61.4 years, 45.0% female, 82.0% >5 years since diagnosis). All four attributes were significant in choice (P<0.05). Reduction in 5-year cardiovascular risk was the main driver of patient preference as evidenced in the scenario and willingness-to-pay analyses. GP management was significantly preferred over self-management. Patients preferred scenarios with more frequent BP measurement, and lower costs to the NHS. Conclusion: Participants had similar preferences for GP management, pharmacist management, and telehealth, but a negative preference for self-management. When introducing new models of care for hypertension to patients, discussion of the potential benefits in terms of risk reduction should be prioritised to maximise uptake.
Hope, Agency, and the Lived Experience of Violence: A Qualitative Systematic Review of Children’s Perspectives on Domestic Violence and Abuse
There is a large body of research on the impact of domestic violence and abuse (DVA) on children, mostly reporting survey data and focusing largely on psychological outcomes. Qualitative research on the views of children has the potential to enable a child-centered understanding of their experience of DVA, so their needs can be better met by professionals. This systematic review reports general findings from the ViOlence: Impact on Children Evidence Synthesis (VOICES) project that synthesized published qualitative research on the experiences of DVA from the perspective of children and young people. A thematic synthesis of 33 reports identified six themes: lived experience of DVA, children’s agency and coping, turning points and transitions, managing relationships postseparation, impact of DVA on children, and children’s expressions of hope for the future. We conclude that professionals working with children affected by DVA should be mindful of the diversity in children’s experiences and listen carefully to children’s own accounts.
The comorbidity burden of type 2 diabetes mellitus: patterns, clusters and predictions from a large English primary care cohort
Background: The presence of additional chronic conditions has a significant impact on the treatment and management of type 2 diabetes (T2DM). Little is known about the patterns of comorbidities in this population. The aims of this study are to quantify comorbidity patterns in people with T2DM, to estimate the prevalence of six chronic conditions in 2027 and to identify clusters of similar conditions. Methods: We used the Clinical Practice Research Datalink (CPRD) linked with the Index of Multiple Deprivation (IMD) data to identify patients diagnosed with T2DM between 2007 and 2017. 102,394 people met the study inclusion criteria. We calculated the crude and age-standardised prevalence of 18 chronic conditions present at and after the T2DM diagnosis. We analysed longitudinally the 6 most common conditions and forecasted their prevalence in 2027 using linear regression. We used agglomerative hierarchical clustering to identify comorbidity clusters. These analyses were repeated on subgroups stratified by gender and deprivation. Results: More people living in the most deprived areas had ≥ 1 comorbidities present at the time of diagnosis (72% of females; 64% of males) compared to the most affluent areas (67% of females; 59% of males). Depression prevalence increased in all strata and was more common in the most deprived areas. Depression was predicted to affect 33% of females and 15% of males diagnosed with T2DM in 2027. Moderate clustering tendencies were observed, with concordant conditions grouped together and some variations between groups of different demographics. Conclusions: Comorbidities are common in this population, and high between-patient variability in comorbidity patterns emphasises the need for patient-centred healthcare. Mental health is a growing concern, and there is a need for interventions that target both physical and mental health in this population.
Behavioural analysis of postnatal physical activity in the UK according to the COM-B model: a multi-methods study
Objective Develop a behavioural analysis of factors influencing postnatal physical activity (PA) according to the ‘capability, opportunity, motivation and behaviour’ (COM-B) model of behaviour to inform intervention development using the Behaviour Change Wheel (BCW). Design Cross-sectional, multi-method study using semi-structured interviews and a quantitative questionnaire. Setting Children’s centres and mother and baby groups in Hertfordshire and Cambridgeshire, UK. Participants Convenience samples of postnatal women were interviewed (n=16) and completed the questionnaire (n=158). Methods Semi-structured interviews followed a preprepared topic guide exploring the COM-B model components and analysed using framework analysis. The questionnaire, based on the self-evaluation of behaviour questionnaire, was adapted using patient and public involvement and findings from the interviews. Questionnaire participants rated their agreement with 22 predefined statements related to COM-B model components. Mean, SD and 95% CI were calculated and each item categorised according to importance. Demographic data were collected. Results The questionnaire identified that new mothers would be more active if they had more time, felt less tired, had accessible childcare, were part of a group, advised by a healthcare professional, able to develop a habit and had more motivation. Additional themes emerging from qualitative data were engaging in PA groups with other new mothers, limited physical stamina following complicated births, social interaction, enjoyment and parental beliefs as motivation, provision of child-friendly PA facilities and environments and babies’ unpredictable routines. Conclusion The behavioural analysis presented in this paper identifies and adds detail on the range of factors influencing the target behaviour. Some are unique to the target population, requiring targeted interventions for postnatal women, whereas some are individualised, suggesting the need for individually tailored interventions. We will use the behavioural analysis presented to design an intervention using the subsequent steps in the BCW.
Communication practices for delivering health behaviour change conversations in primary care: a systematic review and thematic synthesis
Background Clinical guidelines exhort clinicians to encourage patients to improve their health behaviours. However, most offer little support on how to have these conversations in practice. Clinicians fear that health behaviour change talk will create interactional difficulties and discomfort for both clinician and patient. This review aims to identify how healthcare professionals can best communicate with patients about health behaviour change (HBC). Methods We included studies which used conversation analysis or discourse analysis to study recorded interactions between healthcare professionals and patients. We followed an aggregative thematic synthesis approach. This involved line-by-line coding of the results and discussion sections of included studies, and the inductive development and hierarchical grouping of descriptive themes. Top-level themes were organised to reflect their conversational positioning. Results Of the 17,562 studies identified through systematic searching, ten papers were included. Analysis resulted in 10 top-level descriptive themes grouped into three domains: initiating; carrying out; and closing health behaviour change talk. Of three methods of initiation, two facilitated further discussion, and one was associated with outright resistance. Of two methods of conducting behaviour change talk, one was associated with only minimal patient responses. One way of closing was identified, and patients did not seem to respond to this positively. Results demonstrated a series of specific conversational practices which clinicians use when talking about HBC, and how patients respond to these. Our results largely complemented clinical guidelines, providing further detail on how they can best be delivered in practice. However, one recommended practice - linking a patient’s health concerns and their health behaviours - was shown to receive variable responses and to often generate resistance displays. Conclusions Health behaviour change talk is smoothly initiated, conducted, and terminated by clinicians and this rarely causes interactional difficulty. However, initiating conversations by linking a person’s current health concern with their health behaviour can lead to resistance to advice, while other strategies such as capitalising on patient initiated discussions, or collaborating through question-answer sequences, may be well received.
The influence of training experiences on career intentions of the future GP workforce: a qualitative study of new GPs in England
Background The capacity of the UK GP workforce has not kept pace with increasing primary care workloads. Although many doctors successfully complete GP specialty training programmes, some do not progress to work in NHS general practice. Aim This article explores the training experiences and perceptions of newly qualified GPs to understand how their education, training, and early experiences of work influence their career plans. Design and setting A qualitative study of doctors in their final year of GP training (ST3) and within 5 years of completion of GP training (F5). Method Participants across England were recruited through training programmes, First5 groups, and publicity using social media and networks. Open narrative interviews were conducted with individuals and focus groups. Audiorecorded interviews were transcribed, and a thematic analysis was supported by NVivo and situational analysis mapping techniques. Results Fifteen participants engaged in individual interviews and 10 focus groups were carried out with a total of 63 participants. Most doctors reported that training programmes had prepared them to deal confidently with most aspects of routine clinical GP work. However, they felt underprepared for the additional roles of running a practice and in their understanding of wider NHS organisational structures. Doctors wished to avoid unacceptably heavy workloads and voiced concerns about the longer-term sustainability of general practice. Conclusion Strategies to attract and retain enough GPs to support delivery of comprehensive primary care should consider how doctors’ early career experiences influence their career intentions. A coherent plan is needed to improve their preparation and increase confidence that they can achieve a professionally satisfying, effective, and sustainable career in NHS general practice.
Polypharmacy patterns in the last year of life in patients with dementia
Purpose To describe prescribing of medicines in primary care in the last year of life in patients with dementia. Method A retrospective cohort analysis in UK primary care using routinely collected data from the Clinical Practice Research Datalink. Number of medications and potentially inappropriate medication prescribed one year prior to, and including death, was ascertained. Results Dementia patients (n = 6923) aged 86.6 ± 7.3 years (mean ± SD) were prescribed 4.8 ± 4.0 drugs 1 year prior to death, increasing to 5.6 ± 4.0 2 months prior, before falling to 4.9 ± 4.1 at death. One year prior to death, 50% of patients were prescribed a potentially inappropriate medication, falling to 41% at death. Cardiovascular medications were the most common, with decreases in drug count only occurring in the last month prior to death. Prescriptions for gastrointestinal and central nervous system medication increased throughout the year, particularly laxatives/analgaesics, antidepressants and hypnotic/antipsychotics. Women (vs. men) and patients with Alzheimer’s (vs. vascular dementia) were prescribed 4.7% (95% CI 2.3%–7%) and 14.6% (11.7–17.3%) fewer medications, respectively. Prescribing decreased with age and increased with additional comorbidities. Conclusions Dementia patients are prescribed high levels of medication, many potentially inappropriate, during their last year of life, with reductions occurring relatively late. Improvements to medication optimisation guidelines are needed to inform decision-making around deprescribing of long-term medications in patients with limited life-expectancy.
TEST (Trial of Eczema allergy Screening Tests): protocol for feasibility randomised controlled trial of allergy tests in children with eczema, including economic scoping and nested qualitative study
Background Early onset eczema is associated with food allergy, and allergic reactions to foods can cause acute exacerbations of eczema. Parents often pursue dietary restrictions as a way of managing eczema and seek allergy testing for their children to guide dietary management. However, it is unclear whether test-guided dietary management improves eczema symptoms, and whether the practice causes harm through reduced use of conventional eczema treatment or unnecessary dietary restrictions. The aim of the Trial of Eczema allergy Screening Tests Study is to determine the feasibility of conducting a trial comparing food allergy testing and dietary advice versus usual care, for the management of eczema in children. Methods and analysis Design: A single centre, two-group, individually randomised, feasibility randomised controlled trial (RCT) with economic scoping and a nested qualitative study. Setting: General Practioner (GP) surgeries in the west of England. Participants: children aged over 3 months and less than 5 years with mild to severe eczema. Interventions: allergy testing (structured allergy history and skin prick tests) or usual care. Sample size and outcome measures: we aim to recruit 80 participants and follow them up using 4-weekly questionnaires for 24 weeks. Nested qualitative study: We will conduct ~20 interviews with parents of participating children, 5–8 interviews with parents who decline or withdraw from the trial and ~10 interviews with participating GPs. Economic scoping: We will gather data on key costs and outcomes to assess the feasibility of carrying out a cost-effectiveness analysis in a future definitive trial.
The key aspects of online support that older family carers of people with dementia want at the end of life: A qualitative study
Objectives: Family carers towards the end of life face a range of difficult challenges and have high levels of support needs. The aim of this study was to explore the challenges carers of people with dementia face towards the end of life and the support needs which could be addressed by online support. Methods: Qualitative study using semi-structured interviews with 23 current and former family carers of people with dementia in England in 2016–2017. Interviews were analysed using thematic analysis methods. Results: Most carers interviewed had positive views of receiving support online via a website. Participants described a series of challenges they felt online support could address and help support them with when caring for someone with dementia towards the end of life: 1) feeling prepared and equipped; 2) feeling connected and supported; 3) balancing their own needs with those of the individual; and 4) maintaining control and being the co-ordinator of care. However many valued a mix of technology and human interaction in receiving support. Conclusions: This study has identified the key challenges for carers at the end of life that could be met by online support. Online support offers a source of support to supplement face-to-face contact, as many carers still wish to talk to someone in person. This could help alleviate pressures which health and social care systems currently face.
Understanding the influence of parent clinician communication on antibiotic prescribing for children with respiratory tract infections in primary care: a qualitative observational study using a conversation analysis approach
Background: Acute respiratory tract infections (RTI) in children are a common reason for antibiotic prescribing. Clinicians’ prescribing decisions are influenced by perceived parental expectations for antibiotics, however there is evidence that parents actually prefer to avoid antibiotics. This study aimed to investigate the influence of parent clinician communication on antibiotic prescribing for RTI in children in England. Methods: A mixed methods analysis of videoed primary care consultations for children (under 12 years) with acute cough and RTI. Consultations were video-recorded in six general practices in southern England, selected for socioeconomic diversity. 56 recordings were transcribed in detail and a subset of recordings and transcripts used to develop a comprehensive interaction-based coding scheme. The scheme was used to examine communication practices between parents and clinicians and how these related to antibiotic or non-antibiotic treatment strategies. Results: Parents’ communication rarely implied an expectation for antibiotics, some explicitly offering a possible viral diagnosis. Clinicians mostly gave, or implied, a viral diagnosis and mainly recommended non-antibiotic treatment strategies. In the minority of cases where parents’ communication behaviours implied they may be seeking antibiotic treatment, antibiotics were not usually prescribed. Where clinicians did prescribe antibiotics, they voiced concern about symptoms or signs, including chest pain, discoloured phlegm, prolonged fever, abnormal chest sounds, or pink /bulging ear drums. Conclusions: We found little evidence of a relationship between parents’ communication behaviours and antibiotic prescribing. Rather, where antibiotics were prescribed, this was associated with clinicians’ expressed concerns regarding symptoms and signs.
Women's views on screening for Type 2 diabetes after gestational diabetes: a systematic review, qualitative synthesis and recommendations for increasing uptake
Aim: Many women do not attend recommended glucose testing following a pregnancy affected by gestational diabetes (GDM). We aimed to synthesize the literature regarding the views and experiences of women with a history of GDM on postpartum glucose testing, focusing on barriers and facilitators to attendance. Methods: We systematically identified qualitative studies that examine women's experiences following GDM relating to glucose testing (diabetes screening) or experience of interventions to promote uptake of testing. We conducted a thematic synthesis to develop descriptive and then analytical themes, then developed recommendations to increase uptake based on the findings. We evaluated the quality of each study and the confidence that we had in the recommendations using published checklists. Results: We included 16 articles after screening 23 160 citations and 129 full texts. We identified four themes of influences relating to the healthcare system and personal factors that affected both ability and motivation to attend: relationship with health care, logistics of appointments and tests, family‐related practicalities and concern about diabetes. We developed 10 recommendations addressing diabetes risk information and education, and changes to healthcare systems to promote increased attendance at screening in this population, most with high or moderate confidence. Conclusions: We have identified a need to improve women's understanding about Type 2 diabetes and GDM, and to adjust healthcare provision during and after pregnancy to decrease barriers and increase motivation for testing. Encouraging higher uptake by incorporating these recommendations into practice will enable earlier management of diabetes and improve long‐term outcomes.