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Training needs for staff providing remote services in general practice: a mixed-methods study

Background Contemporary general practice includes many kinds of remote encounter. The rise in telephone, video and online modalities for triage and clinical care requires clinicians and support staff to be trained, both individually and as teams, but evidence-based competencies have not previously been produced for general practice. Aim To identify training needs, core competencies, and learning methods for staff providing remote encounters. Design and setting Mixed-methods study in UK general practice. Method Data were collated from longitudinal ethnographic case studies of 12 general practices; a multi-stakeholder workshop; interviews with policymakers, training providers, and trainees; published research; and grey literature (such as training materials and surveys). Data were coded thematically and analysed using theories of individual and team learning. Results Learning to provide remote services occurred in the context of high workload, understaffing, and complex workflows. Low confidence and perceived unmet training needs were common. Training priorities for novice clinicians included basic technological skills, triage, ethics (for privacy and consent), and communication and clinical skills. Established clinicians’ training priorities include advanced communication skills (for example, maintaining rapport and attentiveness), working within the limits of technologies, making complex judgements, coordinating multi-professional care in a distributed environment, and training others. Much existing training is didactic and technology focused. While basic knowledge was often gained using such methods, the ability and confidence to make complex judgements were usually acquired through experience, informal discussions, and on-the-job methods such as shadowing. Whole-team training was valued but rarely available. A draft set of competencies is offered based on the findings. Conclusion The knowledge needed to deliver high-quality remote encounters to diverse patient groups is complex, collective, and organisationally embedded. The vital role of non-didactic training, for example, joint clinical sessions, case-based discussions, and in-person, whole-team, on-the-job training, needs to be recognised.

Video analysis of communication by physiotherapists and patients in video consultations: a qualitative study using conversation analysis

Objectives: To investigate the challenges of doing physical examinations and exercises by video, and the communication strategies used by physiotherapists and patients to overcome them. Design: A qualitative study of talk and social actions, examining the verbal and non-verbal communication practices used by patients and physiotherapists. Video consultations between physiotherapists and patients were video recorded using MS Teams, transcribed and analysed in detail using Conversation Analysis. Setting: Video consultations were recorded in three specialist settings (long-term pain, orthopaedics, and neuromuscular rehabilitation) across two NHS hospitals. Participants: 15 adult patients (10 female, 5 male; aged 20-77) with a scheduled video consultation. Results: Examinations and exercises retain–>were successfully accomplished in all 15 consultations. Two key challenges were identified for physiotherapists and patients when doing video assessments: (1) managing safety and clinical risk, and (2) making exercises and movements visible. Challenges were addressed by through communication practices that were patient-centred and tailored to the video context (e.g., explaining how to frame the body to the camera or adjust the camera to make the body visible). Conclusions: Video is being used by physiotherapists to consult with their patients. This can work well, but tailored communication strategies are critical to help participants overcome the challenges of remote physical examinations and exercises. Contribution of the Paper: This paper is a first to use video-based analysis to determine the challenges of video consulting for doing remote assessments and exercises in physiotherapy settings. It demonstrates how patients and physiotherapists use communication strategies to raise concerns around safety and visibility and how they overcome these concerns.

Communication in Telehealth: A State-of-the-Art Literature Review of Conversation-Analytic Research

We provide a state-of-the-art review of research on conversation analysis and telehealth. We conducted a systematic review of the literature, focusing on studies that investigate how technology is procedurally consequential for the interaction. We discerned three key topics: the interactional organization, the therapeutic relationship, and the clinical activities of the encounter. The literature on telehealth is highly heterogeneous, with significant differences between text-based care (e.g., via chat or e-mail) and audio(visual) care (e.g., via telephone or video). We discuss the extent to which remote care can be regarded as a demarcated field for study or whether the medium is merely part of the “context,” particularly when investigating hybrid and polymedia forms of care involving multiple technological media.

How Informal Carers Support Video Consulting in Physiotherapy, Heart Failure, and Cancer: Qualitative Study Using Linguistic Ethnography

Background: Informal carers play an important role in the everyday care of patients and the delivery of health care services. They aid patients in transportation to and from appointments, and they provide assistance during the appointments (eg, answering questions on the patient’s behalf). Video consultations are often seen as a way of providing patients with easier access to care. However, few studies have considered how this affects the role of informal carers and how they are needed to make video consultations safe and feasible. Objective: This study aims to identify how informal carers, usually friends or family who provide unpaid assistance, support patients and clinicians during video consultations. Methods: We conducted an in-depth analysis of the communication in a sample of video consultations drawn from 7 clinical settings across 4 National Health Service Trusts in the United Kingdom. The data set consisted of 52 video consultation recordings (of patients with diabetes, gestational diabetes, cancer, heart failure, orthopedic problems, long-term pain, and neuromuscular rehabilitation) and interviews with all participants involved in these consultations. Using Linguistic Ethnography, which embeds detailed analysis of verbal and nonverbal communication in the context of the interaction, we examined the interactional, technological, and clinical work carers did to facilitate video consultations and help patients and clinicians overcome challenges of the remote and video-mediated context. Results: Most patients (40/52, 77%) participated in the video consultation without support from an informal carer. Only 23% (12/52) of the consultations involved an informal carer. In addition to facilitating the clinical interaction (eg, answering questions on behalf of the patient), we identified 3 types of work that informal carers did: facilitating the use of technology; addressing problems when the patient could not hear or understand the clinician; and assisting with physical examinations, acting as the eyes, ears, and hands of the clinician. Carers often stayed in the background, monitoring the consultation to identify situations where they might be needed. In doing so, copresent carers reassured patients and helped them conduct the activities that make up a consultation. However, carers did not necessarily help patients solve all the challenges of a video consultation (eg, aiming the camera while laying hands on the patient during an examination). We compared cases where an informal carer was copresent with cases where the patient was alone, which showed that carers provided an important safety net, particularly for patients who were frail and experienced mobility difficulties. Conclusions: Informal carers play a critical role in making video consultations safe and feasible, particularly for patients with limited technological experience or complex needs. Guidance and research on video consulting need to consider the availability and work done by informal carers and how they can be supported in providing patients access to digital health care services.

How Informal Carers Support Video Consulting in Physiotherapy, Heart Failure, and Cancer: Qualitative Study Using Linguistic Ethnography (Preprint)

Using Linguistic Ethnography to Study Video Consultations: A Call to Action and Future Research Agenda

Video consultations are a rapidly growing service model, particularly in secondary care. Studies, mainly using trials and post-hoc surveys, have routinely documented that they can be a safe and effective means to deliver care at a distance. While video offers new opportunities to provide health services, it also constrains how patients and clinicians can interact, raising questions about feasibility, quality, and safety—questions that cannot be adequately addressed with prevailing methods and approaches. To support successful and appropriate implementation, use and spread of video consultations, we need to investigate how video changes the interaction. In this article, we use two worked examples to demonstrate how Linguistic Ethnography, a methodological approach combining ethnographic with linguistic analysis, enables a detailed understanding of how communication in video consultations works, providing an evidence base to support patients and clinicians with using this service model.

Whose turn is it anyway? Latency and the organization of turn-taking in video-mediated interaction

Latency in video-mediated interaction can frustrate smooth turn-taking: it may cause participants to perceive silence at points where talk should occur, it may cause them to talk in overlap, and it impedes their ability to return to one-speaker-at-a-time. Whilst potentially frustrating for participants, this makes video-mediated interaction a perspicuous setting for the study of social interaction: it is an environment that nurtures the occurrence of turn-taking problems. For this paper, we conducted secondary analysis of 25 video consultations recorded for heart failure, (antenatal) diabetes, and cancer services in the UK. By comparing video recordings of the patient's and clinician's side of the call, we provide a detailed analysis of how latency interferes with the turn-taking system, how participants understand problems, and how they address them. We conclude that in our data latency unnoticed until it becomes problematic: participants act as if they share the same reality.

Video consultations between patients and clinicians in diabetes, cancer, and heart failure services: Linguistic ethnographic study of video-mediated interaction

Background: Video-mediated clinical consultations offer potential benefits over conventional face-to-face in terms of access, convenience, and sometimes cost. The improved technical quality and dependability of video-mediated consultations has opened up the possibility for more widespread use. However, questions remain regarding clinical quality and safety. Video-mediated consultations are sometimes criticized for being not as good as face-to-face, but there has been little previous in-depth research on their interactional dynamics, and no agreement on what a good video consultation looks like. Objective: Using conversation analysis, this study aimed to identify and analyze the communication strategies through which video-mediated consultations are accomplished and to produce recommendations for patients and clinicians to improve the communicative quality of such consultations. Methods: We conducted an in-depth analysis of the clinician-patient interaction in a sample of video-mediated consultations and a comparison sample of face-to-face consultations drawn from 4 clinical settings across 2 trusts (1 community and 1 acute care) in the UK National Health Service. The video dataset consisted of 37 recordings of video-mediated consultations (with diabetes, antenatal diabetes, cancer, and heart failure patients), 28 matched audio recordings of face-to-face consultations, and fieldnotes from before and after each consultation. We also conducted 37 interviews with staff and 26 interviews with patients. Using linguistic ethnography (combining analysis of communication with an appreciation of the context in which it takes place), we examined in detail how video interaction was mediated by 2 software platforms (Skype and FaceTime). Results: Patients had been selected by their clinician as appropriate for video-mediated consultation. Most consultations in our sample were technically and clinically unproblematic. However, we identified 3 interactional challenges: (1) opening the video consultation, (2) dealing with disruption to conversational flow (eg, technical issues with audio and/or video), and (3) conducting an examination. Operational and technological issues were the exception rather than the norm. In all but 1 case, both clinicians and patients (deliberately or intuitively) used established communication strategies to successfully negotiate these challenges. Remote physical examinations required the patient (and, in some cases, a relative) to simultaneously follow instructions and manipulate technology (eg, camera) to make it possible for the clinician to see and hear adequately. Conclusions: A remote video link alters how patients and clinicians interact and may adversely affect the flow of conversation. However, our data suggest that when such problems occur, clinicians and patients can work collaboratively to find ways to overcome them. There is potential for a limited physical examination to be undertaken remotely with some patients and in some conditions, but this appears to need complex interactional work by the patient and/or their relatives. We offer preliminary guidance for patients and clinicians on what is and is not feasible when consulting via a video link.

Video Consultations Between Patients and Clinicians in Diabetes, Cancer, and Heart Failure Services: Linguistic Ethnographic Study of Video-Mediated Interaction (Preprint)

BACKGROUND Video-mediated clinical consultations offer potential benefits over conventional face-to-face in terms of access, convenience, and sometimes cost. The improved technical quality and dependability of video-mediated consultations has opened up the possibility for more widespread use. However, questions remain regarding clinical quality and safety. Video-mediated consultations are sometimes criticized for being not as good as face-to-face, but there has been little previous in-depth research on their interactional dynamics, and no agreement on what a good video consultation looks like. OBJECTIVE Using conversation analysis, this study aimed to identify and analyze the communication strategies through which video-mediated consultations are accomplished and to produce recommendations for patients and clinicians to improve the communicative quality of such consultations. METHODS We conducted an in-depth analysis of the clinician-patient interaction in a sample of video-mediated consultations and a comparison sample of face-to-face consultations drawn from 4 clinical settings across 2 trusts (1 community and 1 acute care) in the UK National Health Service. The video dataset consisted of 37 recordings of video-mediated consultations (with diabetes, antenatal diabetes, cancer, and heart failure patients), 28 matched audio recordings of face-to-face consultations, and fieldnotes from before and after each consultation. We also conducted 37 interviews with staff and 26 interviews with patients. Using linguistic ethnography (combining analysis of communication with an appreciation of the context in which it takes place), we examined in detail how video interaction was mediated by 2 software platforms (Skype and FaceTime). RESULTS Patients had been selected by their clinician as <i>appropriate</i> for video-mediated consultation. Most consultations in our sample were technically and clinically unproblematic. However, we identified 3 interactional challenges: (1) opening the video consultation, (2) dealing with disruption to conversational flow (eg, technical issues with audio and/or video), and (3) conducting an examination. Operational and technological issues were the exception rather than the norm. In all but 1 case, both clinicians and patients (deliberately or intuitively) used established communication strategies to successfully negotiate these challenges. Remote physical examinations required the patient (and, in some cases, a relative) to simultaneously follow instructions and manipulate technology (eg, camera) to make it possible for the clinician to see and hear adequately. CONCLUSIONS A remote video link alters how patients and clinicians interact and may adversely affect the flow of conversation. However, our data suggest that when such problems occur, clinicians and patients can work collaboratively to find ways to overcome them. There is potential for a limited physical examination to be undertaken remotely with some patients and in some conditions, but this appears to need complex interactional work by the patient and/or their relatives. We offer preliminary guidance for patients and clinicians on what is and is not feasible when consulting via a video link. INTERNATIONAL REGISTERED REPORT RR2-10.2196/10913

Physical examinations via video for patients with heart failure: Qualitative study using conversation analysis

Background: Video consultations are increasingly seen as a possible replacement for face-to-face consultations. Direct physical examination of the patient is impossible; however, a limited examination may be undertaken via video (eg, using visual signals or asking a patient to press their lower legs and assess fluid retention). Little is currently known about what such video examinations involve. Objective: This study aimed to explore the opportunities and challenges of remote physical examination of patients with heart failure using video-mediated communication technology. Methods: We conducted a microanalysis of video examinations using conversation analysis (CA), an established approach for studying the details of communication and interaction. In all, seven video consultations (using FaceTime) between patients with heart failure and their community-based specialist nurses were video recorded with consent. We used CA to identify the challenges of remote physical examination over video and the verbal and nonverbal communication strategies used to address them. Results: Apart from a general visual overview, remote physical examination in patients with heart failure was restricted to assessing fluid retention (by the patient or relative feeling for leg edema), blood pressure with pulse rate and rhythm (using a self-inflating blood pressure monitor incorporating an irregular heartbeat indicator and put on by the patient or relative), and oxygen saturation (using a finger clip device). In all seven cases, one or more of these examinations were accomplished via video, generating accurate biometric data for assessment by the clinician. However, video examinations proved challenging for all involved. Participants (patients, clinicians, and, sometimes, relatives) needed to collaboratively negotiate three recurrent challenges: (1) adequate design of instructions to guide video examinations (with nurses required to explain tasks using lay language and to check instructions were followed), (2) accommodation of the patient's desire for autonomy (on the part of nurses and relatives) in light of opportunities for involvement in their own physical assessment, and (3) doing the physical examination while simultaneously making it visible to the nurse (with patients and relatives needing adequate technological knowledge to operate a device and make the examination visible to the nurse as well as basic biomedical knowledge to follow nurses' instructions). Nurses remained responsible for making a clinical judgment of the adequacy of the examination and the trustworthiness of the data. In sum, despite significant challenges, selected participants in heart failure consultations managed to successfully complete video examinations. Conclusions: Video examinations are possible in the context of heart failure services. However, they are limited, time consuming, and challenging for all involved. Guidance and training are needed to support rollout of this new service model, along with research to understand if the challenges identified are relevant to different patients and conditions and how they can be successfully negotiated.

Technology-Enhanced Consultations in Diabetes, Cancer, and Heart Failure: Protocol for the Qualitative Analysis of Remote Consultations (QuARC) Project.

BACKGROUND: Remote videoconsulting is promoted by policy makers as a way of delivering health care efficiently to an aging population with rising rates of chronic illness. As a radically new service model, it brings operational and interactional challenges in using digital technologies. In-depth research on this dynamic is needed before remote consultations are introduced more widely. OBJECTIVE: The objective of this study will be to identify and analyze the communication strategies through which remote consultations are accomplished and to guide patients and clinicians to improve the communicative quality of remote consultations. METHODS: In previous research, we collected and analyzed two separate datasets of remote consultations in a National Institute for Health Research-funded study of clinics in East London using Skype and a Wellcome Trust-funded study of specialist community heart failure teams in Oxford using Skype or FaceTime. The Qualitative Analysis of Remote Consultations (QuARC) study will combine datasets and undertake detailed interactional microanalysis of up to 40 remote consultations undertaken by senior and junior doctors and nurse specialists, including consultations with adults with diabetes, women who have diabetes during pregnancy, people consulting for postoperative cancer surgery and community-based patients having routine heart failure reviews along with up to 25 comparable face-to-face consultations. Drawing on established techniques (eg, conversation analysis), analysis will examine the contextual features in remote consultations (eg, restricted visual field) combined with close analysis of different modes of communication (eg, speech, gesture, and gaze). RESULTS: Our findings will address the current gap in knowledge about how technology shapes the fine detail of communication in remote consultations. Alongside academic outputs, findings will inform the coproduction of information and guidance about communication strategies to support successful remote consultations. CONCLUSIONS: Identifying the communication strategies through which remote consultations are accomplished and producing guidance for patients and clinicians about how to use this kind of technology successfully in consultations is an important and timely goal because roll out of remote consultations is planned across the National Health Service. REGISTERED REPORT IDENTIFIER: RR1-10.2196/10913.

Technology-Enhanced Consultations in Diabetes, Cancer, and Heart Failure: Protocol for the Qualitative Analysis of Remote Consultations (QuARC) Project

Background: Remote videoconsulting is promoted by policy makers as a way of delivering health care efficiently to an aging population with rising rates of chronic illness. As a radically new service model, it brings operational and interactional challenges in using digital technologies. In-depth research on this dynamic is needed before remote consultations are introduced more widely. Objective: The objective of this study will be to identify and analyze the communication strategies through which remote consultations are accomplished and to guide patients and clinicians to improve the communicative quality of remote consultations. Methods: In previous research, we collected and analyzed two separate datasets of remote consultations in a National Institute for Health Research–funded study of clinics in East London using Skype and a Wellcome Trust–funded study of specialist community heart failure teams in Oxford using Skype or FaceTime. The Qualitative Analysis of Remote Consultations (QuARC) study will combine datasets and undertake detailed interactional microanalysis of up to 40 remote consultations undertaken by senior and junior doctors and nurse specialists, including consultations with adults with diabetes, women who have diabetes during pregnancy, people consulting for postoperative cancer surgery and community-based patients having routine heart failure reviews along with up to 25 comparable face-to-face consultations. Drawing on established techniques (eg, conversation analysis), analysis will examine the contextual features in remote consultations (eg, restricted visual field) combined with close analysis of different modes of communication (eg, speech, gesture, and gaze). Results: Our findings will address the current gap in knowledge about how technology shapes the fine detail of communication in remote consultations. Alongside academic outputs, findings will inform the coproduction of information and guidance about communication strategies to support successful remote consultations. Conclusions: Identifying the communication strategies through which remote consultations are accomplished and producing guidance for patients and clinicians about how to use this kind of technology successfully in consultations is an important and timely goal because roll out of remote consultations is planned across the National Health Service.

Pharmaceutical Company Targets and Strategies to Address Climate Change: Content Analysis of Public Reports from 20 Pharmaceutical Companies

The pharmaceutical industry produces a large proportion of health system greenhouse gas (GHG) emissions, contributing to climate change. This urgently needs to be addressed. We aimed to examine pharmaceutical company climate change targets, GHG emissions, and strategies to reduce them. We performed content analysis of the 20 largest pharmaceutical companies' publicly available 2020/2021 reports, focusing on extracting information on their reported climate change targets, GHG emissions (and whether companies had demonstrated any reduction in emissions over their reporting period), and strategies being implemented to reduce company emissions and meet their targets. Nineteen companies have committed to reducing GHG emissions, ten to carbon neutrality and eight to net zero emissions between 2025 and 2050. Companies showed largely favorable reductions in scope 1 (in-house) and scope 2 (purchased energy), with variable results in scope 3 (supply chain) emissions. Strategies to reduce emissions included optimizing manufacturing and distribution, and responsible sourcing of energy, water, and raw materials. Pharmaceutical companies are setting climate change targets and reporting reduced emissions via a range of strategies. This varies, with scope to track actions and accountability to targets, improve consistency of reporting, especially of scope 3 emissions, and collaborate on novel solutions. There is need for further mixed methods research on progress with achieving reported climate change targets, as well as implementation of strategies to reduce emissions within the pharmaceutical industry.

Gender in the consolidated criteria for reporting qualitative research (COREQ) checklist

Adopting and embedding home sensors in social care: findings from a mixed methods, rapid evaluation

Background: The growing pressure faced by adult social care in England has fuelled interest in technology-enabled care (TEC). This includes the use of sensor-based technology to monitor activity patterns for ‘proactive’ interventions and care. However, evidence on its effectiveness and use is limited to feasibility pilots, as opposed to business-as-usual. Working with three local authorities using home sensors, we sought to define good practices and draw transferable lessons on implementing and embedding this technology in routine care practice. Methods Across all sites, we interviewed 51 staff and system stakeholders, 19 service users, and family/informal caregivers. We also used secondary data to determine the feasibility of a full economic study. The analysis was guided by the NASSS (non-adoption, abandonment, and challenges to scale-up, spread and sustainability) framework to explore factors influencing implementation and sustained adoption of the technology in use. Results Home sensors were used across multiple care contexts (assessment, reablement, and long-term care monitoring). Perceived value and impact included an increase in service user independence and safety, family/informal caregiver reassurance, identifying healthcare needs, providing more holistic and objective assessments, and supporting dialogue regarding care needs. However, evidence of the impact across these areas was limited, and we were unable to obtain the data required to undertake an economic analysis. Key issues to consider for sustained adoption include the materiality and dependability of the technology, compatibility with service users and their care networks, workforce knowledge and confidence, inter-organizational routines and coordination work, and strategic alignment. Conclusion Our findings indicate the need to acknowledge the labor-intensive process of embedding and adapting the use of home sensors for proactive care. Decision makers need to focus on how to support and resource incremental and system wide-changes, with particular attention paid to ensuring technology dependability, ‘wrap around’ support, workforce knowledge and skills, co-adaptation of inter-organization routines, cross-stakeholder collaboration, and evaluation capabilities.

Enabling scale and spread of technology-enabled remote monitoring of blood pressure at home: findings from a rapid qualitative evaluation

Background: High blood pressure (BP) is a leading cause of morbidity and mortality. Blood pressure home monitoring improves blood pressure control, but there is limited evidence about the implementation of specifically ‘technology-enabled’ remote monitoring of blood pressure (TERM ) at home. This evaluation aims to improve the evidence base on what constitutes TERM BP services, how they work, and what influences their implementation, impacts, spread, and scale. Methods A multi-method, rapid qualitative evaluation involved four sites that implemented TERM BP. Across sites, we conducted interviews with staff (n=35) and patients (n=15) and analyzed key service documents. Three workshops with site staff, patients, and regional and national stakeholders helped refine the learning process. Thematic analysis and synthesis, and triangulation against existing literature, helped inform recommendations and was guided by the Non-adoption, Abandonment, and challenges to Scale-up, Spread and Sustainability of the technology framework. The patients and public voices informed the evaluation design and conduct. Results TERM BP implementation varies in governance, patient eligibility, technology, workforce, and workflow. Perceived impacts include improved blood pressure control, case-finding, and a more efficient workload distribution. The parallel running of technology-enabled and paper-based pathways mitigates access inequalities, but involves a high administrative workload. Sociotechnical influences on implementation relate to technology user-friendliness and adaptability, health system relationships and resources, practice capabilities and learning cultures, and patient acceptability and enablement. Flexibility within a planned, gradual approach that embeds skills in teams and systems and impacts evidence generation support scale and spread. Conclusions Technology and social forces co-evolve to shape TERM BP pathways and manage co-existing tensions, including planning, emergence, demand, and capacity. Decision makers should establish implementation guidance and commissioning criteria, address regulatory issues, and enable evidence generation and shared learning. Further research is needed on the impact of TERM BP, especially in integrated care and related to inequalities.

Social and Ethical Aspects of Remote and Hybrid Care in the Special Allocation Scheme in general practice (SEARCH): A mixed methods feasibility study protocol

Background: Despite the growing body of research on remote primary care and access for (digitally) excluded groups, very little is known about care for patients who have been deliberately excluded from mainstream services. The ‘Special Allocation Scheme’ (SAS) in England provides GP services to patients who have been excluded from their GP practice after being reported for violent behaviour. Patients registered on SAS are likely to be offered remote services, in part because patients are often placed in an ‘out-of-area’ SAS practice. Our aim is to find out more about the needs of patients on the SAS, whether and when it is appropriate to offer remote options, and who these options might benefit or disadvantage. We also aim to develop safe, ethical, and meaningful ways to involve patients with experience on the scheme in research and service development. Methods Workstream 1 includes a national scoping survey of SAS provision across England. Workstream 2 comprises of three ethnographic case studies of SAS services, including observation and interviews with patients, NHS staff and national/regional decision makers. Workstream 3 involves two codesign workshops with patients, researchers, clinicians, support staff and third sector care providers to co-produce a set of reflections and best practices to inform future research and service redesign in this context. An iterative and participatory-informed PPIE approach is adopted throughout, involving patients and other stakeholders from early conceptualisation to study design, analysis and codesign of outputs. Conclusions Whilst remote solutions can improve access to primary care for some, they are not suitable for every patient population and can widen health inequalities. This is a novel study in a critically under-researched area of service delivery with clear practical and ethical implications for practice. Findings will develop understanding and transferable learning for SAS delivery and inform the design of a future study.

Implementation and use of technology-enabled remote monitoring for chronic obstructive pulmonary disease: a rapid qualitative evaluation.

BACKGROUND: Chronic obstructive pulmonary disease affects around 2% United Kingdom population. Timely identification of patients at risk of deterioration is crucial. Technology-enabled remote monitoring may help prevent deterioration, support chronic obstructive pulmonary disease patients at home and appropriate use of National Health Service services. Evidence on the adoption, use and experience of technology-enabled remote monitoring in the chronic obstructive pulmonary disease pathway is currently limited, impeding efforts to inform effective technology-enabled remote monitoring design and implementation. OBJECTIVE: To understand what supports good practice in the implementation and use of technology-enabled remote monitoring in the chronic obstructive pulmonary disease care pathway and draw transferable lessons that can inform spread and scale up. DESIGN AND METHODS: Rapid evaluation, combining qualitative interviews, focused case studies and stakeholder workshops. Patient and public voices informed evaluation design, conduct and co-design of resources. SETTING AND PARTICIPANTS: Scoping interviews with a purposive sample of 29 national and regional stakeholders informed selection of four case study sites involved in delivering technology-enabled remote monitoring for chronic obstructive pulmonary disease. Case studies combined interviews with 19 staff and review of 18 documents. Analysis was informed by the non-adoption, abandonment and challenges to scale-up, spread and sustainability of technology framework. A stakeholder workshop (n = 23 participants) refined emerging findings. Interviews with respiratory patients and a co-design workshop informed development of patient-facing resources. RESULTS: Technology-enabled remote monitoring for chronic obstructive pulmonary disease occurs along a continuum of scope and scale. Technology-enabled care pathways have some common overarching features, but variation is seen across contexts and patient cohorts. Technology-enabled remote monitoring services influence care provision on a system level. Effective implementation is underpinned by service characteristics affecting its use, technology functionalities and organisational capabilities and capacities. Technology-enabled remote monitoring success also depends on defining the data-driven purpose and value proposition, ensuring buy-in, organising the workforce and workload in sustainable ways, data and IT platform interoperability, support for patients in using the service safely and appropriately, utilising existing resources, team buy-in, financial resourcing and clear policy incentives, and openness to ongoing learning. Patients value technology-enabled remote monitoring services that help them feel more connected to healthcare providers and provide timely information and support. Healthcare staff value high-quality patient care, services value affordability and sustainable workload impact. LIMITATIONS: Small-scale qualitative evaluation conducted at pace. CONCLUSIONS: Technology can support remote monitoring but is only one aspect of an effective technology-enabled remote monitoring service. It needs to be embedded in the chronic obstructive pulmonary disease pathway and align with service needs and existing capacity in cost-effective ways and with proportionate oversight of quality and safety. Decision-makers need to consider which aspects of the technology are essential, how they can be effectively embedded and supported by an appropriately equipped workforce, and needs of different patient cohorts. FUTURE WORK: There is a need for evidence on longer-term effectiveness and cost-effectiveness of technology-enabled remote monitoring for chronic obstructive pulmonary disease, impact on patient and staff experience, and issues of equity of access. Qualitative and quantitative approaches are needed to appreciate varied technology and evolving use in different settings/groups. FUNDING: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR154231.

Adopting and embedding home sensors in social care: findings from a mixed methods, rapid evaluation

Background: The growing pressure faced by adult social care in England has fuelled interest in technology-enabled care (TEC). This includes the use of sensor-based technology to monitor activity patterns for ‘proactive’ interventions and care. However, evidence on its effectiveness and use is limited to feasibility pilots, as opposed to business-as-usual. Working with three local authorities using home sensors, we sought to define good practices and draw transferable lessons on implementing and embedding this technology in routine care practice. Methods: Across all sites, we interviewed 51 staff and system stakeholders, 19 service users and family/informal caregivers. We also used secondary data to determine the feasibility of a full economic study. The analysis was guided by the NASSS (non-adoption, abandonment, and challenges to scale-up, spread and sustainability) framework to explore factors influencing implementation and sustained adoption of the technology in use. Results: Home sensors were used across multiple care contexts (assessment, reablement, and long-term care monitoring). Perceived value and impact included an increase in service user independence and safety, family/informal caregiver reassurance, identifying healthcare needs, providing more holistic and objective assessments, and supporting dialogue regarding care needs. However, evidence of the impact across these areas was limited, and we were unable to obtain the data required to undertake an economic analysis. Key issues to consider for sustained adoption include the materiality and dependability of the technology, compatibility with service users and their care networks, workforce knowledge and confidence, inter-organizational routines and coordination work, and strategic alignment. Conclusion: Our findings indicate the need to acknowledge the labor-intensive process of embedding and adapting the use of home sensors for proactive care. Decision makers need to focus on how to support and resource incremental and system wide-changes, with particular attention paid to ensuring technology dependability, ‘wrap around’ support, workforce knowledge and skills, co-adaptation of inter-organization routines, cross-stakeholder collaboration, and evaluation capabilities.

What is the impact of increasing the prominence of calorie labelling? A stepped wedge randomised controlled pilot trial in worksite cafeterias

Background: Calorie labelling may help to reduce energy consumption, but few well-controlled experimental studies have been conducted in real world settings. In a previous randomised controlled pilot trial we did not observe an effect of calorie labelling on energy purchased in worksite cafeterias. In the present study we sought to enhance the effect by making the labels more prominent, and to address the operational challenges reported previously by worksites. Methods: Three worksite cafeterias were randomised in a stepped wedge design to start the intervention at one of three fortnightly periods between March and July 2018. The intervention comprised introducing prominent calorie labelling for all cafeteria products for which calorie information was available (on average 87% of products offered across the three sites were labelled). Calorie content was displayed in bold capitalised Verdana typeface with a minimum font size of 14 e.g. 120 CALORIES. Feasibility and acceptability were assessed using post-intervention surveys with cafeteria patrons and semi-structured interviews with managers. Effectiveness was assessed using total daily energy (kcal) purchased from intervention items across the three sites, analysed using semi-parametric GAMLSS models. Results: Recruitment and retention of worksite cafeterias proved feasible: all three randomised sites successfully completed the study. Post-intervention feedback suggested high levels of intervention acceptability: 87% of responding patrons wanted calorie labelling to remain in place. No effect of the intervention on daily energy purchased was observed: −0.6% (95%CI -2.5 to 1.2, p = .487). By-site analyses showed similar null effects at each of the three sites, all ps > .110. Conclusions: There was no evidence that prominent calorie labelling changed daily energy purchased across three English-based worksite cafeterias. The intervention was feasible to implement and acceptable to patrons and managers.