Found 9900 matches for
Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity: a realist review
<jats:sec><jats:title>Objectives</jats:title><jats:p>To understand <jats:italic>how</jats:italic> and <jats:italic>why</jats:italic> effective multi-chronic disease management interventions influence health outcomes in older adults 65 years of age or older.</jats:p></jats:sec><jats:sec><jats:title>Design</jats:title><jats:p>A realist review.</jats:p></jats:sec><jats:sec><jats:title>Data sources</jats:title><jats:p>Electronic databases including Medline and Embase (inception to December 2017); and the grey literature.</jats:p></jats:sec><jats:sec><jats:title>Eligibility criteria for selecting studies</jats:title><jats:p>We considered any studies (ie, experimental quasi-experimental, observational, qualitative and mixed-methods studies) as long as they provided data to explain our programme theories and effectiveness review (published elsewhere) findings. The population of interest was older adults (age ≥65 years) with two or more chronic conditions.</jats:p></jats:sec><jats:sec><jats:title>Analysis</jats:title><jats:p>We used the Realist And MEta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and publication criteria for our synthesis aimed at refining our programme theories such that they contained multiple context-mechanism-outcome configurations describing the ways different mechanisms fire to generate outcomes. We created a 3-step synthesis process grounded in meta-ethnography to separate units of data from articles, and to derive explanatory statements across them.</jats:p></jats:sec><jats:sec><jats:title>Results</jats:title><jats:p>106 articles contributed to the analysis. We refined our programme theories to explain multimorbidity management in older adults: (1) care coordination interventions with the best potential for impact are team-based strategies, <jats:italic>disease management</jats:italic> programmes and <jats:italic>case management</jats:italic>; (2) optimised disease prioritisation involves ensuring that clinician work with patients to identify what symptoms are problematic and why, and to explore options that are acceptable to both clinicians and patients and (3) optimised patient self-management is dependent on patients’ capacity for selfcare and to what extent, and establishing what patients need to enable selfcare.</jats:p></jats:sec><jats:sec><jats:title>Conclusions</jats:title><jats:p>To optimise care, both clinical management and patient self-management need to be considered from multiple perspectives (patient, provider and system). To mitigate the complexities of multimorbidity management, patients focus on reducing symptoms and preserving quality of life while providers focus on the condition that most threaten morbidity and mortality.</jats:p></jats:sec><jats:sec><jats:title>PROSPERO registration number</jats:title><jats:p>CRD42014014489.</jats:p></jats:sec>
C-reactive protein and neutrophil count laboratory test requests from primary care: what is the demand and would substitution by point of care technology be viable?
Aims C-reactive protein (CRP) and neutrophil count (NC) are important diagnostic indicators of inflammation. Point of care (POC) technologies for these markers are available but rarely used in community settings in the United Kingdom. To inform the potential for POC tests, it is necessary to understand the demand for testing. We aimed to describe the frequency of CRP and NC test requests from primary care to central laboratory services, describe variability between practices and assess the relationship between the tests. Methods We described the number of patients with either or both laboratory tests, and the volume of testing per individual and per practice, in a retrospective cohort of all adults in general practices in Oxfordshire, 2014-2016. Results 372,017 CRP and 776,581 NC tests in 160,883 and 275,093 patients respectively were requested from 69 practices. CRP was tested mainly in combination with NC, while the latter was more often tested alone. The median (IQR) of CRP and NC tests/person tested was 1 (1-2) and 2 (1-3) respectively. The median (IQR) tests/practice/week was 36 (22-52) and 72 (50-108), and per 1,000 persons registered/practice/ week was 4 (3-5) and 8 (7-9) respectively. The median (IQR) CRP and NC concentrations were 2.7 (0.9-7.9) mg/dl and 4.1 (3.1-5.5) x109/L respectively. Conclusions The high demand for CRP and NC testing in the community, and the range of results falling within the reportable range for current POC technologies highlights the opportunity for laboratory testing to be supplemented by POC testing in general practice.
<jats:p>As antibiotic consumption grows, bacteria are becoming increasingly resistant to treatment. Antibiotic resistance undermines much of modern health care, which relies on access to effective antibiotics to prevent and treat infections associated with routine medical procedures. The resulting challenges have much in common with those posed by climate change, which economists have responded to with research that has informed and shaped public policy. Drawing on economic concepts such as externalities and the principal–agent relationship, we suggest how economics can help to solve the challenges arising from increasing resistance to antibiotics. We discuss solutions to the key economic issues, from incentivizing the development of effective new antibiotics to improving antibiotic stewardship through financial mechanisms and regulation.</jats:p>
© The Author(s) 2018. Using a unique dataset and a nonparametric decomposition, we determine whether immigrants with native names, immigrants with foreign names, and natives have different outcomes in Spain’s housing market. Results suggest that immigrants with native names achieve greater discounts relative to immigrants with non-Spanish names. As a robustness check, we prove that this is not due to the country of birth. We observe that most of the difference in price across immigrant groups remains unexplained, which may imply some form of discrimination (pure or statistical) against immigrants with non-native names.
Limited evidence for diagnosing bacterial skin infections in older adults in primary care: Systematic review 11 Medical and Health Sciences 1103 Clinical Sciences 11 Medical and Health Sciences 1117 Public Health and Health Services
© 2019 The Author(s). Background: Older adults with bacterial skin infections may present with atypical symptoms, making diagnosis difficult. There is limited authoritative guidance on how older adults in the community present with bacterial skin infections. To date there have been no systematic reviews assessing the diagnostic value of symptoms and signs in identifying bacterial skin infections in older adults in the community. Methods: We searched Medline and Medline in process, Embase and Web of Science, from inception to September 2017. We included cohort and cross-sectional studies assessing the diagnostic accuracy of symptoms and signs in predicting bacterial skin infections in adults in primary care aged over 65 years. The QUADAS-2 tool was used to assess study quality. Results: We identified two observational studies of low-moderate quality, with a total of 7991 participants, providing data to calculate the diagnostic accuracy of 5 unique symptoms in predicting bacterial skin infections. The presence of wounds [LR+: 7.93 (CI 4.81-13.1)], pressure sores [LR+: 4.85 (CI 2.18-10.8)] and skin ulcers [LR+: 6.26 (CI 5.49-7.13)] help to diagnose bacterial skin infections. The presence of urinary incontinence does not help to predict bacterial skin infections (LR + 's of 0.99 and 1.04; LR-'s of 0.96 and 1.04). Conclusions: Currently, there is insufficient evidence to inform the diagnosis of bacterial skin infections in older adults in the community; clinicians should therefore rely upon their clinical judgement and experience. Evidence from high quality primary care studies in older adults, including studies assessing symptoms traditionally associated with bacterial skin infections (e.g. erythema and warmth), is urgently needed to guide practice.
© 2016 Massachusetts Medical Society. BACKGROUND The role of image-guided surveillance as compared with planned neck dissection in the treatment of patients with squamous-cell carcinoma of the head and neck who have advanced nodal disease (stage N2 or N3) and who have received chemoradiotherapy for primary treatment is a matter of debate. METHODS In this prospective, randomized, controlled trial, we assessed the noninferiority of positron- emission tomography-computed tomography (PET-CT)-guided surveillance (performed 12 weeks after the end of chemoradiotherapy, with neck dissection performed only if PET-CT showed an incomplete or equivocal response) to planned neck dissection in patients with stage N2 or N3 disease. The primary end point was overall survival. RESULTS From 2007 through 2012, we recruited 564 patients (282 patients in the planned-surgery group and 282 patients in the surveillance group) from 37 centers in the United Kingdom. Among these patients, 17% had nodal stage N2a disease and 61% had stage N2b disease. A total of 84% of the patients had oropharyngeal cancer, and 75% had tumor specimens that stained positive for the p16 protein, an indicator that human papillomavirus had a role in the causation of the cancer. The median follow-up was 36 months. PET-CT-guided surveillance resulted in fewer neck dissections than did planned dissection surgery (54 vs. 221); rates of surgical complications were similar in the two groups (42% and 38%, respectively). The 2-year overall survival rate was 84.9% (95% confidence interval [CI], 80.7 to 89.1) in the surveillance group and 81.5% (95% CI, 76.9 to 86.3) in the planned-surgery group. The hazard ratio for death slightly favored PET-CT-guided surveillance and indicated noninferiority (upper boundary of the 95% CI for the hazard ratio, <1.50; P = 0.004). There was no significant difference between the groups with respect to p16 expression. Quality of life was similar in the two groups. PET-CT-guided surveillance, as compared with neck dissection, resulted in savings of £1,492 (approximately $2,190 in U.S. dollars) per person over the duration of the trial. CONCLUSIONS Survival was similar among patients who underwent PET-CT-guided surveillance and those who underwent planned neck dissection, but surveillance resulted in considerably fewer operations and it was more cost-effective. (Funded by the National Institute for Health Research Health Technology Assessment Programme and Cancer Research UK; PET-NECK Current Controlled Trials number, ISRCTN13735240.).
Relative toxicity of mood stabilisers and antipsychotics: Case fatality and fatal toxicity associated with self-poisoning
© 2018 The Author(s). Background: Bipolar and other psychiatric disorders are associated with considerably increased risk of suicidal behaviour, which may include self-poisoning with medication used to treat the disorder. Therefore, choice of medication for treatment should include consideration of toxicity, especially for patients at risk. The aim of this study was to estimate the relative toxicity of specific drugs within two drug categories, antipsychotics and mood stabilizers, using large-scale databases to provide evidence that could assist clinicians in making decisions about prescribing, especially for patients at risk of suicidal behaviour. Method: Two indices were used to assess relative toxicity of mood stabilisers and antipsychotics: case fatality (the ratio between rates of fatal and non-fatal self-poisoning) and fatal toxicity (the ratio between rates of fatal self-poisoning and prescription). Mood stabilisers assessed included lithium [reference], sodium valproate, carbamazepine, and lamotrigine, while antipsychotics included chlorpromazine [reference], clozapine, olanzapine, quetiapine and risperidone. Fatal self-poisoning (suicide) data were provided by the Office for National Statistics (ONS), non-fatal self-poisoning data by the Multicentre Study of Self-harm in England, and information on prescriptions by the Clinical Practice Research Datalink. The primary analysis focussed on deaths due to a single drug. Cases where the drug of interest was listed as the likely primary toxic agent in multiple drug overdoses were also analysed. The study period was 2005-2012. Results: There appeared to be little difference in toxicity between the mood stabilisers, except that based on case fatality where multiple drug poisonings were considered, carbamazepine was over twice as likely to result in death relative to lithium (OR 2.37 95% CI 1.16-4.85). Of the antipsychotics, clozapine was approximately18 times more likely to result in death when taken in overdose than chlorpromazine (single drug case fatality: OR 18.53 95% CI 8.69-39.52). Otherwise, only risperidone differed from chlorpromazine, being less toxic (OR 0.06 95% CI 0.01-0.47). Conclusions: There was little difference in toxicity of the individual mood stabilisers. Clozapine was far more toxic than the other antipsychotics. The findings are relevant to prescribing policy, especially for patients at particular risk of suicidal behaviour.
Corrigendum to “The feasibility and acceptability of self-testing for proteinuria during pregnancy: A mixed methods approach” [Pregn. Hypertens. 12 (2018) 161–168] (Pregnancy Hypertension: An International Journal of Women's Cardiovascular Health (2018) 12 (161–168), (S2210778917301460), (10.1016/j.preghy.2017.11.009))
© 2019 The Author(s) The authors regret the omission of the following In the Acknowledgements: “Lucy Mackillop was supported by the NIHR Oxford Biomedical Research Centre.” In the Affiliations: “NIHR Oxford Biomedical Research Centre, Oxford University Hospitals NHS Foundation Trust.” The authors would like to apologise for any inconvenience caused.
Acceptability and psychological impact of out-of-office monitoring to diagnose hypertension: an evaluation of survey data from primary care patients.
BACKGROUND: Out-of-office blood pressure (BP) is recommended for diagnosing hypertension in primary care due to its increased accuracy compared to office BP. Moreover, being diagnosed as hypertensive has previously been linked to lower wellbeing. There is limited evidence regarding the acceptability of out-of-office BP and its impact on wellbeing. AIM: To assess the acceptability and psychological impact of out-of-office monitoring in people with suspected hypertension. DESIGN AND SETTING: A pre- and post-evaluation of participants with elevated (≥130 mmHg) systolic BP, assessing the psychological impact of 28 days of self-monitoring followed by ambulatory BP monitoring for 24 hours. METHOD: Participants completed standardised psychological measures pre- and post-monitoring, and a validated acceptability scale post-monitoring. Descriptive data were compared using χ2 tests and binary logistic regression. Pre- and post-monitoring comparisons were made using the paired t-test and Wilcoxon signed rank test. RESULTS: Out-of-office BP monitoring had no impact on depression and anxiety status in 93% and 85% of participants, respectively. Self-monitoring was more acceptable than ambulatory monitoring (n = 183, median 2.4, interquartile range [IQR] 1.9-3.1 versus median 3.2, IQR 2.7-3.7, P<0.01). When asked directly, 48/183 participants (26%, 95% confidence interval [CI] = 20 to 33%) reported that self-monitoring made them anxious, and 55/183 (30%, 95% CI = 24 to 37%) reported that ambulatory monitoring made them anxious. CONCLUSION: Out-of-office monitoring for hypertension diagnosis does not appear to be harmful. However, health professionals should be aware that in some patients it induces feelings of anxiety, and self-monitoring may be preferable to ambulatory monitoring.
Practice variation in the use of tests in UK primary care: A retrospective analysis of 16 million tests performed over 3.3 million patient years in 2015/16
© 2018 The Author(s). Background: The UK's National Health Service (NHS) is currently subject to unprecedented financial strain. The identification of unnecessary healthcare resource use has been suggested to reduce spending. However, there is little very research quantifying wasteful test use, despite the £3 billion annual expenditure. Geographical variation has been suggested as one metric in which to quantify inappropriate use. We set out to identify tests ordered from UK primary care that are subject to the greatest between-practice variation in their use. Methods: We used data from 444 general practices within the Clinical Practice Research Datalink to calculate a coefficient of variation (CoV) for the ordering of 44 specific tests from UK general practices. The coefficient of variation was calculated after adjusting for differences between practice populations. We also determined the tests that had both a higher-than-average CoV and a higher-than-average rate of use. Results: In total, 16,496,218 tests were ordered for 4,078,091 patients over 3,311,050 person-years from April 1, 2015, to March 31, 2016. The tests subject to the greatest variation were drug monitoring 158% (95%CI 153 to 163%), urine microalbumin (52% (95%CI 49.9 to 53.2%)), pelvic CT (51% (95%CI 50 to 53%)) and Pap smear (49% (95%CI 48 to 51%). Seven tests were classified as high variability and high rate (clotting, vitamin D, urine albumin, prostate-specific antigen (PSA), bone profile, urine MCS and C-reactive protein (CRP)). Conclusions: There are wide variations in the use of common tests, which is unlikely to be explained by clinical indications. Since £3 billion annually are spent on tests, this represents considerable variation in the use of resources and inefficient management in the NHS. Our results can be of value to policy makers, researchers, patients and clinicians as the NHS strives towards identifying overuse and underuse of tests.
The internal validation of weight and weight change coding using weight measurement data within the UK primary care electronic health record
© 2019 Nicholson et al. Purpose: To use recorded weight values to internally validate weight status and weight change coding in the primary care Electronic Health Record (EHR). Patients and methods: We included adult patients with weight-related Read codes recorded in the UK’s Clinical Practice Research Datalink EHR between 2000 and 2017. Weight status codes were compared to weight values recorded on the same day and positive predictive values (PPVs) were calculated for commonly used codes. Weight change codes were validated using three methods: the percentage (%) difference in kilograms at the time of the code and 1) the previous weight measurement, 2) the weight predicted using linear regression, and 3) the historic mean weight. Weight change codes were validated if estimates were consistent across two out of three methods. Results: A total of 8,108,481 weight codes were recorded in 1,000,002 patients’ EHR. Twice as many were recorded in females (n=5,208,593, 64%). The mean body mass index for “over-weight” codes ranged from 31.9 kg/m 2 to 46.9 kg/m 2 and from 17.4 kg/m 2 to 19.2 kg/m 2 for “underweight” codes. PPVs for the most commonly used weight status codes ranged from 81.3% (80%–82.5%) to 99.3% (99.2%–99.4%). Across the estimation methods, and using only validated weight change codes, mean weight loss ranged from – 5.2% (SD 5.8%) to –7.9% (SD 7.3%) and mean weight gain from 4.2 % (SD 5.5%) to 7.9 % (SD 8.2%). The previous and predicted weight methods were most consistent. Conclusion: We have developed an internationally applicable methodology to internally validate weight-related EHR coding by using available weight measurement data. We demonstrate the UK Read codes that can be confidently used to classify weight status and weight change in the absence of weight values. We provide the first evidence from primary care that a Read code for unexpected weight loss represents a mean loss of ≥ 5 % in a 6-month period, which was broadly consistent across age groups and gender.
“She’s gone now.” A mixed methods analysis of the experiences and perceptions around the deaths of children who died unexpectedly in health care facilities in Cape Town, South Africa
© 2019 Hodkinson et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. Purpose The sudden death of a child is a catastrophic event for both the family and the healthcare workers involved. Confidential enquiries provide a biomedical depiction of the processes and quality of care delivered and drive improvements in care. However, these rarely include an assessment of the patient/caregiver experience which is increasingly regarded as a key measure of quality of care. Methods A parallel convergent mixed methods design was used to compare and contrast medically-assessed clinical quality of care with caregiver perceptions of quality and care in a cohort of sudden childhood deaths in emergency facilities in Cape Town, South Africa. Results Amongst the 29 sudden childhood deaths, clinical quality of care was assessed as poor in 11 (38%) and the death was considered avoidable or potentially avoidable in 16 (55%). The main themes identified from the caregivers were their perception of the quality of care delivered (driven by perceived healthcare worker effort, empathy and promptness), the way the family was dealt with during the final resuscitation, and communications at the time of and after the death. Ten (35%) caregivers were predominantly negative about the care delivered, of whom four received fair clinical quality of care; 13 (49%) of caregivers had predominantly positive experiences, one of whom received poor clinical quality of care. Conclusions Caregivers’ experiences of the healthcare service around their child’s death are influenced largely by the way healthcare workers communicate with them, as well as the perceived clinical effort. This is not always concordant with the clinically assessed quality of care. Simple interventions such as protocols and education of healthcare workers in dealing with families of a dying or deceased child could improve families’ experiences at a time when they are most vulnerable.