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Identifying and managing care for children with autism spectrum disorders in general practice: A systematic review and narrative synthesis
Many healthcare systems are organised such that General Practitioners (GPs) often have a key role in identifying autism spectrum disorders (hereafter collectively referred to as autism) in children. In this review, we explored what GPs know about autism and the factors that influence their ability to identify and manage care for their patients with autism in practice. We conducted a systematic narrative review using eight electronic databases. These included Embase and MEDLINE via Ovid, Web of Knowledge, PsycINFO via Ebscohost, PubMed, Scopus, ProQuest Dissertations and Thesis, and Applied Social Sciences Index and Abstracts (ASSIA) via ProQuest. Our search yielded 2,743 citations. Primary research studies were included, and we did not impose any geographical, language or date restrictions. We identified 17 studies that met our inclusion criteria. Studies included in the review were conducted between 2003 and 2019. We thematically synthesised the material and identified the following themes: the prototypical image of a child with autism; experience, sources of information, and managing care; barriers to identification; strategies to aid in identification; and characteristics that facilitate expertise . Together, the findings from this review present a mixed picture of GP knowledge and experiences in identifying autism and managing care for children with the condition. At one end of the continuum, there were GPs who had not heard of autism or endorsed outmoded aetiological theories. Others, however, demonstrated a sound knowledge of the conditions but had limited confidence in their ability to identify the condition. Many GPs and researchers alike called for more training and this might be effective. However, framing the problem as one of a lack of training risks silences the array of organisational factors that impact on a GP's ability to provide care for these patients.
Factors associated with the prescribing of high-dose opioids in primary care: a systematic review and meta-analysis
The risks of harms from opioids increase substantially at high doses, and high-dose prescribing has increased in primary care. However, little is known about what leads to high-dose prescribing, and studies exploring this have not been synthesized. We, therefore, systematically synthesized factors associated with the prescribing of high-dose opioids in primary care. Methods: We conducted a systematic review of observational studies in high-income countries that used patient-level primary care data and explored any factor(s) in people for whom opioids were prescribed, stratified by oral morphine equivalents (OME). We defined high doses as ≥ 90 OME mg/day. We searched MEDLINE, Embase, Web of Science, reference lists, forward citations, and conference proceedings from database inception to 5 April 2019. Two investigators independently screened studies, extracted data, and appraised the quality of included studies using the Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. We pooled data on factors using random effects meta-analyses and reported relative risks (RR) or mean differences with 95% confidence intervals (CI) where appropriate. We also performed a number needed to harm (NNTH) calculation on factors when applicable. Results: We included six studies with a total of 4,248,119 participants taking opioids, of whom 3.64% (n = 154,749) were taking high doses. The majority of included studies (n = 4) were conducted in the USA, one in Australia and one in the UK. The largest study (n = 4,046,275) was from the USA. Included studies were graded as having fair to good quality evidence. The co-prescription of benzodiazepines (RR 3.27, 95% CI 1.32 to 8.13, I2 = 99.9%), depression (RR 1.38, 95% CI 1.27 to 1.51, I2 = 0%), emergency department visits (RR 1.53, 95% CI 1.46 to 1.61, I2 = 0%, NNTH 15, 95% CI 12 to 20), unemployment (RR 1.44, 95% CI 1.27 to 1.63, I2 = 0%), and male gender (RR 1.21, 95% CI 1.14 to 1.28, I2 = 78.6%) were significantly associated with the prescribing of high-dose opioids in primary care. Conclusions: High doses of opioids are associated with greater risks of harms. Associated factors such as the co-prescription of benzodiazepines and depression identify priority areas that should be considered when selecting, identifying, and managing people taking high-dose opioids in primary care. Coordinated strategies and services that promote the safe prescribing of opioids are needed.
Research priorities in advanced heart failure: James Lind alliance priority setting partnership
Objective: To determine research priorities in advanced heart failure (HF) for patients, carers and healthcare professionals. Methods: Priority setting partnership using the systematic James Lind Alliance method for ranking and setting research priorities. An initial open survey of patients, carers and healthcare professionals identified respondents’ questions, which were categorised to produce a list of summary research questions; questions already answered in existing literature were removed. In a second survey of patients, carers and healthcare professionals, respondents ranked the summary research questions in order of priority. The top 25 unanswered research priorities were then considered at a face-to-face workshop using nominal group technique to agree on a ‘top 10’. Results: 192 respondents submitted 489 responses each containing one or more research uncertainty. Out-of-scope questions (35) were removed, and collating the responses produced 80 summary questions. Questions already answered in the literature (15) were removed. In the second survey, 65 questions were ranked by 128 respondents. The top 10 priorities were developed at a consensus meeting of stakeholders and included a focus on quality of life, psychological support, the impact on carers, role of the charity sector and managing prognostic uncertainty. Ranked priorities by physicians and patients were remarkably divergent. Conclusions: Engaging stakeholders in setting research priorities led to a novel set of research questions that might not have otherwise been considered. These priorities can be used by researchers and funders to direct future research towards the areas which matter most to people living with advanced HF.
Editorial: Context, context, context: how has covid-19 changed implementation globally and how can we ‘lock in’ learning?
In our recent editorial [1] we discussed the importance of knowledge mobilization (KM; defined as ‘a proactive process that involves efforts to transform practice through the circulation of knowledge within and across practice domains’ [2]) to the implementation of best practice to drive up the quality of care for patients. We acknowledged the role and importance of recognizing real-world context, providing examples of individual, organizational and national contextual factors that influence KM. Since the publication of that editorial, the context of healthcare both nationally and internationally has changed substantially. The covid-19 pandemic has, and will continue to have, a significant impact on KM and the design and delivery of healthcare services. The commonly cited conclusion in KM is that ‘context is everything’, and we would like to add to this discussion and build upon our previous editorial in light of the covid-19 situation. This piece explores the impact of covid-19 on KM, in the context of musculoskeletal services, and the ways in which organizations can ‘lock in’ learning, after arguably the biggest challenge that healthcare services have ever experienced.
Anticipatory prescribing in community end-of-life care in the UK and Ireland during the COVID-19 pandemic: online survey
Background: Anticipatory prescribing (AP) of injectable medications in advance of clinical need is established practice in community end-of-life care. Changes to prescribing guidelines and practice have been reported during the COVID-19 pandemic. Aims and objectives: To investigate UK and Ireland clinicians’ experiences concerning changes in AP during the COVID-19 pandemic and their recommendations for change. Methods: Online survey of participants at previous AP national workshops, members of the Association for Palliative Medicine of Great Britain and Ireland and other professional organisations, with snowball sampling. Results: Two hundred and sixty-one replies were received between 9 and 19 April 2020 from clinicians in community, hospice and hospital settings across all areas of the UK and Ireland. Changes to AP local guidance and practice were reported: route of administration (47%), drugs prescribed (38%), total quantities prescribed (35%), doses and ranges (29%). Concerns over shortages of nurses and doctors to administer subcutaneous injections led 37% to consider drug administration by family or social caregivers, often by buccal, sublingual and transdermal routes. Clinical contact and patient assessment were more often remote via telephone or video (63%). Recommendations for regulatory changes to permit drug repurposing and easier community access were made. Conclusions: The challenges of the COVID-19 pandemic for UK community palliative care has stimulated rapid innovation in AP. The extent to which these are implemented and their clinical efficacy need further examination.
Arriving or departing: Primary Care Annual Scientific Meeting
From 3–5 July we attended the Society of Academic Primary Care (SAPC)’s annual scientific meeting (ASM), held at the University of Exeter. SAPC aims to advance primary care through education and research, and their stated goal is ‘to promote understanding of primary care - what it is and why it matters, and why academic primary care is an essential component of strong primary care’. This year’s conference theme was ‘Primary Care: Arriving? Or Departing?’ We are all aware of the challenges facing primary care, with changing socio-demographic population profiles, increased demand, decreased funding and challenges recruiting and retaining a dynamic, motivated workforce. As such, high-quality research is needed to provide evidence to address these challenges and shape the future of primary care. The conference programme reflected this issue, covering a range of research informing the design and delivery of high-quality clinical care as well as addressing organisational and behavioural aspects of primary care service development and delivery. The conference was opened in style by Ukrainian-born international opera singer Irtna Ilnytska, administration assistant at the University of Exeter and graduate of the Academy of Music, Milan; a reminder of how the UK benefits from the diverse talents of international workers. The conference included 128 oral presentations, specialist interest group meetings (https://sapc.ac.uk/special-interest-groups) and workshops, allowing attendees to personalise a programme most relevant for them.
Impact of emergency hospital admissions on patterns of primary care prescribing: a retrospective cohort analysis of electronic records in England
Background: Little is known about the impact of hospitalisation on prescribing in UK clinical practice. Aim: To investigate whether an emergency hospital admission drives increases in polypharmacy and potentially inappropriate prescriptions (PIPs). Design and setting: A retrospective cohort analysis set in primary and secondary care in England. Method: Changes in number of prescriptions and PIPs following an emergency hospital admission in 2014 (at admission and 4 weeks post-discharge), and 6 months post-discharge were calculated among 37 761 adult patients. Regression models were used to investigate changes in prescribing following an admission. Results: Emergency attendees surviving 6 months (N = 32 657) had a mean of 4.4 (standard deviation [SD] = 4.6) prescriptions before admission, and a mean of 4.7 (SD = 4.7; P<0.001) 4 weeks after discharge. Small increases (<0.5) in the number of prescriptions at 4 weeks were observed across most hospital specialties, except for surgery (−0.02; SD = 0.65) and cardiology (2.1; SD = 2.6). The amount of PIPs increased after hospitalisation; 4.0% of patients had ≥1 PIP immediately before pre-admission, increasing to 8.0% 4 weeks post-discharge. Across hospital specialties, increases in the proportion of patients with a PIP ranged from 2.1% in obstetrics and gynaecology to 8.0% in cardiology. Patients were, on average, prescribed fewer medicines at 6 months compared with 4 weeks post-discharge (mean = 4.1; SD = 4.6; P<0.001). PIPs decreased to 5.4% (n = 1751) of patients. Conclusion: Perceptions that hospitalisation is a consistent factor driving rises in polypharmacy are unfounded. Increases in prescribing post-hospitalisation reflect appropriate clinical response to acute illness, whereas decreases are more likely in patients who are multimorbid, reflecting a focus on deprescribing and medicines optimisation in these individuals. Increases in PIPs remain a concern.
Delegating home visits in general practice: a realist review on the impact on GP workload and patient care
Background UK general practice is being shaped by new ways of working. Traditional GP tasks are being delegated to other staff with the intention of reducing GPs’ workload and hospital admissions, and improving patients’ access to care. One such task is patient-requested home visits. However, it is unclear what impact delegated home visits may have, who might benefit, and under what circumstances. Aim To explore how the process of delegating home visits works, for whom, and in what contexts. Design and setting A review of secondary data on home visit delegation processes in UK primary care settings. Method A realist approach was taken to reviewing data, which aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes. A range of data has been used including news items, grey literature, and academic articles. Results Data were synthesised from 70 documents. GPs may believe that delegating home visits is a risky option unless they have trust and experience with the wider multidisciplinary team. Internal systems such as technological infrastructure might help or hinder the delegation process. Healthcare professionals carrying out delegated home visits might benefit from being integrated into general practice but may feel that their clinical autonomy is limited by the delegation process. Patients report short-term satisfaction when visited by a healthcare professional other than a GP. The impact this has on long-term health outcomes and cost is less clear. Conclusion The delegation of home visits may require a shift in patient expectation about who undertakes care. Professional expectations may also require a shift, having implications for the balance of staffing between primary and secondary care, and the training of healthcare professionals.
Antimicrobial resistance associations with national primary care antibiotic stewardship policy: Primary care-based, multilevel analytic study
Background: Recent UK antibiotic stewardship policies have resulted in significant changes in primary care dispensing, but whether this has impacted antimicrobial resistance is unknown. Aim: To evaluate associations between changes in primary care dispensing and antimicrobial resistance in community-acquired urinary Escherichia coli infections. Methods: Multilevel logistic regression modelling investigating relationships between primary care practice level antibiotic dispensing for approximately 1.5 million patients in South West England and resistance in 152,704 community-acquired urinary E. coli between 2013 and 2016. Relationships presented for within and subsequent quarter drug-bug pairs, adjusted for patient age, deprivation, and rurality. Results: In line with national trends, overall antibiotic dispensing per 1000 registered patients fell 11%. Amoxicillin fell 14%, cefalexin 20%, ciprofloxacin 24%, co-amoxiclav 49% and trimethoprim 8%. Nitrofurantoin increased 7%. Antibiotic reductions were associated with reduced within quarter same-antibiotic resistance to: amoxicillin, ciprofloxacin and trimethoprim. Subsequent quarter reduced resistance was observed for trimethoprim and amoxicillin. Antibiotic dispensing reductions were associated with increased within and subsequent quarter resistance to cefalexin and co-amoxiclav. Increased nitrofurantoin dispensing was associated with reduced within and subsequent quarter trimethoprim resistance without affecting nitrofurantoin resistance. Conclusions: This evaluation of a national primary care stewardship policy on antimicrobial resistance in the community suggests both hoped-for benefits and unexpected harms. Some increase in resistance to cefalexin and co-amoxiclav could result from residual confounding. Randomised controlled trials are urgently required to investigate causality.
Contribution of paramedics in primary and urgent care: a systematic review
Background: Within the UK, there are now opportunities for paramedics to work across a variety of healthcare settings away from their traditional ambulance service employer, with many opting to move into primary care. Aim: To provide an overview of the types of clinical roles paramedics are undertaking in primary and urgent care settings within the UK. Design and setting: A systematic review. Method: Searches were conducted of MEDLINE, CINAHL, Embase, the National Institute for Health and Care Excellence, the Journal of Paramedic Practice, and the Cochrane Database from January 2004 to March 2019 for papers detailing the role, scope of practice, clinician and patient satisfaction, and costs of paramedics in primary and urgent care settings. Free-text keywords and subject headings focused on two key concepts: paramedic and general practice/primary care. Results: In total, 6765 references were screened by title and/or abstract. After full-text review, 24 studies were included. Key findings focused on the description of the clinical role, the clinical work environment, the contribution of paramedics to the primary care workforce, the clinical activities they undertook, patient satisfaction, and education and training for paramedics moving from the ambulance service into primary care. Conclusion: Current published research identifies that the role of the paramedic working in primary and urgent care is being advocated and implemented across the UK; however, there is insufficient detail regarding the clinical contribution of paramedics in these clinical settings. More research needs to be done to determine how, why, and in what context paramedics are now working in primary and urgent care, and what their overall contribution is to the primary care workforce.
Development and validation of the DIabetes Severity SCOre (DISSCO) in 139 626 individuals with type 2 diabetes: a retrospective cohort study
Objective: Clinically applicable diabetes severity measures are lacking, with no previous studies comparing their predictive value with glycated hemoglobin (HbA1c). We developed and validated a type 2 diabetes severity score (the DIabetes Severity SCOre, DISSCO) and evaluated its association with risks of hospitalization and mortality, assessing its additional risk information to sociodemographic factors and HbA1c. Research design and methods: We used UK primary and secondary care data for 139 626 individuals with type 2 diabetes between 2007 and 2017, aged ≥35 years, and registered in general practices in England. The study cohort was randomly divided into a training cohort (n=111 748, 80%) to develop the severity tool and a validation cohort (n=27 878). We developed baseline and longitudinal severity scores using 34 diabetes-related domains. Cox regression models (adjusted for age, gender, ethnicity, deprivation, and HbA1c) were used for primary (all-cause mortality) and secondary (hospitalization due to any cause, diabetes, hypoglycemia, or cardiovascular disease or procedures) outcomes. Likelihood ratio (LR) tests were fitted to assess the significance of adding DISSCO to the sociodemographics and HbA1c models. Results: A total of 139 626 patients registered in 400 general practices, aged 63±12 years were included, 45% of whom were women, 83% were White, and 18% were from deprived areas. The mean baseline severity score was 1.3±2.0. Overall, 27 362 (20%) people died and 99 951 (72%) had ≥1 hospitalization. In the training cohort, a one-unit increase in baseline DISSCO was associated with higher hazard of mortality (HR: 1.14, 95% CI 1.13 to 1.15, area under the receiver operating characteristics curve (AUROC)=0.76) and cardiovascular hospitalization (HR: 1.45, 95% CI 1.43 to 1.46, AUROC=0.73). The LR tests showed that adding DISSCO to sociodemographic variables significantly improved the predictive value of survival models, outperforming the added value of HbA1c for all outcomes. Findings were consistent in the validation cohort. Conclusions: Higher levels of DISSCO are associated with higher risks for hospital admissions and mortality. The new severity score had higher predictive value than the proxy used in clinical practice, HbA1c. This reproducible algorithm can help practitioners stratify clinical care of patients with type 2 diabetes.
Exploring how health behaviours are supported and changed in people with severe mental illness: A qualitative study of a cardiovascular risk reducing intervention in Primary Care in England
Objectives: This study explored how health behaviours were supported and changed in people with severe mental illness by primary health care professionals trained in delivering behaviour change techniques (BCTs) within a cardiovascular disease risk reducing intervention. Design: Secondary qualitative analysis of 30 staff and patient interviews. Methods: We mapped coded data to the BCT Taxonomy (version 1) to identify BCT application. Thematic analysis was conducted to explore the barriers and facilitators of supporting and changing health behaviours. Themes were then interpreted using the Capability, Opportunity, Motivation, and Behaviour model to gain greater explanation behind the processes. Results: Twenty BCTs were identified. Staff and patients perceived that health behaviours were commonly affected by both automatic and reflective motivation, sometimes in turn affected by psychological capability, social, and physical opportunity. Staff and patients suggested that motivation was enhanced by both patient and staff ability to observe health benefits, in some cases patients’ health knowledge, mental health status, and social support networks. It was suggested that engaging in/sustaining healthy behaviours was influenced by physical opportunities to engrain behaviours into routine. Conclusions: According to staff and patients, health behaviour change in this population was driven by complex processes. It was suggested that capability, opportunity, and motivation were in some cases enhanced by BCTs, but variable. Behaviour change may be optimized by individualized behavioural assessments, identifying drivers of behaviour and applying a range of BCTs may help to target individual needs. Patient peer‐led approaches, techniques to encourage awareness of visible success, and normalizing health behaviours may increase behaviour change.
Patient and public involvement in general practice research
Patient and public involvement (PPI) in research has become expected practice by funders and Research Ethics Committees (RECs).1–3 Working with public contributors from the outset in designing and undertaking patient-related research aims to ensure that the focus is relevant to, and grounded in, their lived experiences.4 Despite sustained UK research policy advocating the importance of PPI,3 public contributions are often absent or minimal in reports of primary care research.5 In this patient perspectives edition of the BJGP, only two papers report on public contributions to the design and execution of the research.6,7 When PPI input is described, research reports are rarely specific about the input of public contributors along the way; how their concerns, reviews, suggestions, and objections have actually shaped or changed the course of the research.1,4,8 PPI work often remains a ‘black box’. This editorial makes the case that meaningful PPI makes a positive contribution, but the nature and content of PPI work need to be transparent and appropriate. PPI collaboration in research is time consuming and more problematic for both public contributors and researchers than best-practice guidelines suggest.4,9 The reasons why general practice research is not designed and undertaken with public contributors are numerous, including insufficient resources and a desire to avoid complicating a project.2,8 We draw on our experience as three researchers and one PPI group member to highlight some of the key challenges and practicalities involved.
Administration of end-of-life drugs by family caregivers during covid-19 pandemic
Doctors, nurses, and family caregivers worldwide are facing tough decisions concerning the supply and administration of medications to manage symptoms when patients are dying from covid-19 or other conditions in the community or care homes. Proposed changes in practice aimed at ensuring adequate end-of-life symptom control need careful consideration alongside appropriate training and support. Editorial Updated UK advice, including NICE rapid guidance on managing covid-19 symptoms in the community, reiterates the importance of prescribing medications in advance of need for pain, nausea and vomiting, agitation, and respiratory secretions.These drugs may be administered if needed by visiting doctors or nurses, as is already well established in some countries. However, this practice is being overhauled radically in response to the pandemic.
Identifying potential moderators of first-line treatment effect in patients with musculoskeletal shoulder pain: a systematic review
Background: Commonly used conservative shoulder pain treatments include: advice/analgesia, exercise/manual therapy and, corticosteroid injection. Moderators, patient/clinical attributes influencing treatment effect, facilitate clinical decision-making by identifying which patients might respond best to specific treatments. This review summarises results of studies aiming to identify/test treatment effect moderators. Methods: Randomised controlled trials (RCTs) containing some form of, or suggested moderation/subgroup analysis (sample size >20, and >10 subjects in smallest subgroup), comparing above treatments against physical/functional/pain outcomes, in adults with shoulder pain were searched for in Medline, Embase, PsychInfo, CINAHL, AMED, Pedro, Cochrane Database. Cochrane Risk of Bias tool and Pincus criteria for moderation analysis were applied. Results: Six RCTs aiming to identify/test moderators and 16 suggesting potential moderators were included and data narratively synthesised. One trial offered confirmatory level moderation (Pincus criteria). Graded exercise had smaller effect in those with painful arc at baseline, compared against without, although lacked statistical significance (mean difference −14.0 shoulder disability (0–100 scale), 95% CI’s [−28.1, 0.1], p = 0.05). Twenty other factors with insufficient level moderation evidence were identified. Discussion: Review highlights lack of high-quality evidence for moderators of treatment effect of shoulder pain treatments. Future research should address proposed candidate moderators, using robust moderation methodologies to inform clinical decision-making.
The importance of language in engagement between health-care professionals and people living with obesity: a joint consensus statement
Obesity is a chronic condition that requires long-term management and is associated with unprecedented stigma in different settings, including during interactions with the health-care system. This stigma has a negative effect on the mental and physical health of people with obesity and can lead to avoidance of health care and disruption of the doctor–patient relationship. Considerable evidence exists to suggest that simply having a conversation about obesity can lead to weight loss, which translates into health benefits. However, both health-care practitioners and people living with obesity report apprehension in initiating this conversation. We have collaborated with stakeholders from Obesity UK, physicians, dieticians, clinical psychologists, obesity researchers, conversation analysts, nurses, and representatives from National Health Service England Diabetes and Obesity. This group has contributed to the production of this consensus statement, which addresses how people living with obesity wish to have their condition referred to and provides practical guidance for health-care professionals to facilitate collaborative and supportive discussions about obesity. Expert stakeholders consider that changes to language used at the point of care can alleviate the stigma of obesity within the health-care system and support improved outcomes for both people living with obesity and for the health-care system.
Patients’ experiences of alcohol screening and advice in primary care: a qualitative study
Background: Despite evidence supporting the effectiveness of alcohol screening and brief advice to reduce heavy drinking, implementation in primary healthcare remains limited. The challenges that clinicians experience when delivering such interventions are well-known, but we have little understanding of the patient perspective. We used Normalization Process Theory (NPT) informed interviews to explore patients’ views on alcohol screening and brief advice in routine primary healthcare. Methods: Semi-structured qualitative interviews with 22 primary care patients who had been screened for heavy drinking and/or received brief alcohol advice were analysed thematically, informed by Normalisation Process Theory constructs (coherence, cognitive participation, collective action, reflexive monitoring). Results: We found mixed understanding of the adverse health consequences of heavy drinking, particularly longerterm risks. There was some awareness of current alcohol guidelines but these were viewed flexibly, depending on the individual drinker and drinking context. Most described alcohol screening as routine, with clinicians viewed as trustworthy and objective. Patients enacted a range of self-regulatory techniques to limit their drinking but perceived such strategies as learned through experience rather than based on clinical advice. However, most saw alcohol advice as a valuable component of preventative healthcare, especially those experiencing co-occurring health conditions. Conclusions: Despite strong acceptance of the screening role played by primary care clinicians, patients have less confidence in the effectiveness of alcohol advice. Primary care-based alcohol brief advice needs to reflect how individuals actually drink, and harness strategies that patients already commonly employ, such as self-regulation, to boost its relevance.
Impact of electronic palliative care coordination systems (EPaCCS) on care at the end of life across multiple care sectors, in one clinical commissioning group area, in England: a realist evaluation protocol
Introduction: Electronic palliative care coordination systems (EPaCCS) aim to support people approaching the end of life (EOL) to receive consistent care, according to their wishes, that is coordinated effectively across multiple care sectors. They are in use across the UK although empirical evidence into their effectiveness is poor. This paper presents a protocol of a mixed-methods study, to understand how, and by whom, EPaCCS are being used and whether EPaCCS are enabling Healthcare Professionals (HCPs) to coordinate patients’ EOL care. Methods and analysis: This is a mixed-methods study, carried out within a realist paradigm, to evaluate the impact of an EPaCCS on EOL care as provided by a Clinical Commissioning Group (CCG) in England. This study has two aims: (1) Describe the socio-demographic characteristics of patients who die with an EPaCCS record, their underlying cause of death and place of death and compare these with patients who die without an EPaCCS record. (2) Explore the impact of an EPaCCS on the experience of receiving EOL care for patients and their carers, and understand HCPs’ views and experiences of utilising an EPaCCS to coordinate care for their patients. The study will be conducted in five phases: (1) development of the initial programme theory; (2) focus group with CCG stakeholder board; (3) individual interviews with HCPs, patients, current and bereaved carers; (4) retrospective cohort study of routinely collected data on EPaCCS usage and (5) data analysis and synthesis of study findings. Ethics and dissemination: The study has been approved by National Health Service South West–Frenchay Research Ethics Committee (REC reference number: 18/SW/0198). Findings will be published in a wide range of outputs targeted at key audiences.
Non-pharmacological interventions for depression/anxiety in older adults with physical comorbidities affecting functioning: systematic review and meta-analysis
Objective: To review the effectiveness of non-pharmacological interventions in older adults with depression or anxiety and comorbidities affecting functioning. Design: Systematic review and meta-analysis of randomized controlled trials, including searches of 10 databases (inception-Jul 2017). Setting: Home/community. Participants: People aged 60 and over experiencing functional difficulties from physical or cognitive comorbidities and have symptoms or a diagnosis of depression and/or anxiety. Interventions: Non-pharmacological interventions targeted at depression/anxiety. Measurements: We extracted outcome data on depressive symptoms, quality of life, functioning, and service use. We used random effects meta-analysis to pool study data where possible. Two authors assessed the risk of bias using the Cochrane Risk of Bias tool. Results: We identified 14 eligible trials including 2099 randomized participants and two subgroup analyses. Problem-solving therapy (PST) reduced short-term clinician-rated depressive symptoms (n = 5 trials, mean difference in Hamilton Depression Rating Scale score −4.94 [95% CI −7.90 to −1.98]) but not remission, with limited evidence for effects on functioning and quality of life. There was limited high-quality evidence for other intervention types. Collaborative care did not appear to affect depressive symptoms, functioning, or quality of life; and had mixed evidence for effects upon remission. No intervention consistently affected service use, but trials were limited by small sample sizes and short follow-up periods. No anxiety interventions were identified. Conclusion: PST may reduce depressive symptoms post-intervention in older people with depression and functional impairments. Collaborative care appears to have few effects in this population. Future research needs to assess cost-effectiveness, long-term outcomes, and anxiety interventions for this population.
Crossing the Digital Divide in Online Self-Management Support: Analysis of Usage Data From HeLP-Diabetes
Background: Digital health is increasingly recognized as a cost-effective means to support patient self-care. However, there are concerns about whether the “digital divide,” defined as the gap between those who do and do not make regular use of digital technologies, will lead to increased health inequalities. Access to the internet, computer literacy, motivation to use digital health interventions, and fears about internet security are barriers to use of digital health interventions. Some of these barriers disproportionately affect people of older age, black or minority ethnic background, and low socioeconomic status. HeLP-Diabetes (Healthy Living for People with type 2 Diabetes), a theoretically informed online self-management program for adults with type 2 diabetes, was developed to meet the needs of people from a broad demographic background. Objective: This study aimed to determine whether there was evidence of a digital divide when HeLP-Diabetes was integrated into routine care. This was achieved by (1) comparing the characteristics of people who registered for the program against the target population (people with type 2 diabetes in inner London), (2) comparing the characteristics of people who registered for the program and used it with those who did not use it, and (3) comparing sections of the website visited by different demographic groups. Methods: A retrospective analysis of data on the use of HeLP-Diabetes in routine clinical practice in 4 inner London clinical commissioning groups was undertaken. Data were collected from patients who registered for the program as part of routine health services.. Data on gender, age, ethnicity, and educational attainment were collected at registration, and data on webpage visits (user identification number, date, time, and page visited) were collected automatically by software on the server side of the website. Results: The characteristics of people who registered for the program were found to reflect those of the target population. The mean age was 58.4 years (SD=28.0), over 50.0% were from black and minority ethnic backgrounds, and nearly a third (29.8%) had no qualifications beyond school leaving age. There was no association between demographic characteristics and use of the program, apart from weak evidence of less use by the mixed ethnicity group. There was no evidence of the differential use of the program by any demographic group, apart from weak evidence for people with degrees and school leavers being more likely to use the “Living and working with diabetes” (P=.03) and “Treating diabetes” (P=.04) sections of the website. Conclusions: This study is one of the first to provide evidence that a digital health intervention can be integrated into routine health services without widening health inequalities. The relative success of the intervention may be attributed to integration into routine health care, and careful design with extensive user input and consideration of literacy levels. Developers of digital health interventions need to acknowledge barriers to access and use, and collect data on the demographic profile of users, to address inequalities.