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Our digital devices bring a lot of ‘good’ into our lives, but they also come with heaps of ‘bad.’ This workshop allows you to reflect on your relationship with your digital devices, rather than removing them from your life.
Targeted Interventions to Improve the Systematic Collection of Acute Respiratory Infection Clinical Data from Primary Care Computerised Medical Records.
Data quality in primary care is important for surveillance and research projects based on routinely collected computerised medical records data. We present the results of a targeted intervention of incentives and tools to record specific data about acute respiratory infectious disease. As part of an epidemiological study, practices received a template to code this information, which could also act as a consultation template. Use of the template was not restricted to patients taking part in the epidemiological study. We saw significant increases in coded data for patients in the study in the four areas that we examined; oxygen saturation, body temperature, respiratory rate and history of fever. For patients not included in the study we saw only small differences between study practices and non-study practices. There was an increased frequency of recording of measured body temperature in study practices but the effect was small (1.1%) 95% CI [0.56%,1.66%]. Primary care data quality can be improved with targeted interventions and support, but the effect does not transfer out of the specific patients for which it has been incentivised.
Managing an ageing cystic fibrosis population: challenges and priorities.
The increasing life expectancy of people with cystic fibrosis (pwCF), largely driven by advancements in early diagnosis, multidisciplinary care and the recent introduction of cystic fibrosis transmembrane conductance regulator (CFTR) modulator therapies, is likely to herald a shift in the focus of care toward managing the complexities of ageing. This review highlights key challenges and research priorities for addressing the health needs of an ageing CF population. A growing body of evidence underscores the heightened risks of cancers, cardiovascular diseases and changing nutritional and metabolic profiles as pwCF age. CFTR modulators have improved clinical outcomes, but their effects on inflammation, immunity and long-term disease trajectories remain incompletely understood. Nutritional management, particularly the implications of obesity and body composition, poses new challenges, as does the potential accelerated ageing of immune and pulmonary systems in CF. Emerging issues such as menopause in females with CF, lifetime antimicrobial resistance and the interplay between chronic inflammation and ageing further complicate the care landscape. The review emphasises the urgent need for multidisciplinary research programmes that integrate clinical, patient and community perspectives. Leveraging established CF registries, clinical trial networks and collaborations with ageing research frameworks is critical to addressing these challenges. Ultimately, the goal is to ensure that pwCF not only live longer but also experience improved quality of life and holistic wellbeing as they realise the full benefits of therapeutic advances.
Contrasting cultures of emergency department care: A qualitative study of patients' experiences of attending the emergency department for low back pain in the UK
Objectives This article aimed to explore patients' experiences of attending the emergency department (ED) for low back pain (LBP) and provides a theoretically informed analysis of the ED cultures perceived by patients to inform their experiences of care. Design Multisite, cross-sectional qualitative interview study. Setting Four NHS Emergency Departments located in the UK. Participants 47 adults (aged 23-79 years) who, in the past 6 weeks, had attended the ED for LBP (all types and durations). Purposive sampling was used to gain variation in the recruiting sites, and participants' LBP and demographic characteristics. Interventions Data were collected using individual, semistructured, telephone interviews (median 45 min duration) which were audio-recorded and transcribed verbatim. Analysis was informed using reflexive thematic analysis and ideal type analysis. Cycles of inductive and deductive analysis were undertaken, with Bourdieu's concepts of field and habitus employed to help explain the findings. Results We present three contrasting cultures of ED care for LBP, comprising (1) emergency screening only, (2) 'cynicism and neglect' and (3) appropriate and kind care. Taking each culture (field) in turn, we explore important differences in the content and delivery of care. Drawing on Bourdieu's concepts of field and habitus, we consider the social and institutional norms and misrepresentations likely to underpin the thoughts and behaviours of ED staff (their habitus), and why these tended to vary based on where and by whom the patient was managed in the ED. Conclusions Strategies to improve patients' experience need to review the social and institutional norms that underpin staff habitus, the assumptions informing these norms and the voices that validate and reproduce them. ISRCTN registration number ISRCTN77522923.
People, Place and Innovation: How Organizational Culture and Physical Environment Shaped the Implementation of the NHS TC Programme
This chapter describes the experience of an organizational change in the English National Health Service (NHS) by focusing on the interconnections between culture and place in shaping that change. We use the term ‘place’ to mean space in the sense of the physical environment, architecture and lay-out, rather than location or setting. The idea that culture structures change is familiar, but perhaps the influence of physical environments, architecture and spatial configuration is less well examined. Organizational culture and negotiated order theories have been successfully employed to understand organizational change, and while these perspectives sometimes acknowledge the importance of physical context, few empirical studies have examined the interplay of culture and place in the change process. This chapter therefore focuses on the interaction between people and place in shaping organizational change. It looks at the intersection of culture and place in the context of an ethnography of the development of an innovative form of health care delivery, namely NHS Treatment Centres. Of particular interest are the stories participants in this study told us about the physical environment and the ways in which place influenced their sense-making and decisions around the implementation of this change programme. The chapter considers the possibilities and limitations to organizational change that arise from the powerful structuring effects and interplay of culture, physical and geographical environment, by exploring how Treatment Centres were adapted to the particular local configurations of people and place and then by reflecting on the impact of place on understanding organizational change.
Introduction: Why Focus on Culture and Climate?
This book brings together a series of papers which detail recent international research on the theme of culture and climate in health care organizations. It is the sixth edition in the Palgrave series of edited collections on organizational behaviour in health care and was developed from the highly successful Organizational Behaviour in Health Care Conference held at the University of New South Wales, Sydney in March 2008.
Conclusion: Culture and Climate in Health Care Organizations — Evidentiary, Conceptual and Practical progress
In this final chapter we bring the range of contributions to a conclusion. To accomplish this, we provide a synthesis of the terrain we have covered and offer some suggestions about where this might lead us in the future. Health care organizations involve a diverse mix of managerial, professional and ancillary groups of workers the result of which is that health services are made up of culturally complex organizations. This diversity encapsulates multiple value systems, beliefs and attitudes as well as considerable power differentials. Therefore, health care organizations offer a rich landscape for study. ‘Culture’ and ‘climate’ have been central themes in this volume, which has included broad ranging studies that are of interest to health care professionals, managers, policy makers and the informed public as well as the community of health care organizational researchers.
Chasing Chameleons, Chimeras and Caterpillars: Evaluating an Organizational Innovation in the National Health Service
Although some might argue that too little attention is paid to the evaluation of health service innovations, evaluation research has burgeoned alongside the ubiquitous healthcare reform of the UK NHS which escalated under the Conservative government of the 1980s and has continued under the Labour government since the late 1990s. In terms of funding and activity health service evaluation is something of an industry: to give just one example the NHS Service Delivery and Organization (SDO) R&D Programme has spent some £6m since 2002 funding research to evaluate models of service delivery(http://sdo.lshtm.ac.ukhttp://sdo.lshtm.ac.uk).Evaluative research is a quest for evidence and an answer to ‘what works (or doesn’t) for whom in which context?’ often driven by a desire to inform the change process. This chapter is about one particular evaluative research project which examined an organizational innovation introduced as part of wider NHS reforms undertaken by the New Labour government. Our focus is not on answering the ‘what works’ question per se, but instead we critically examine what makes evaluation research difficult. We draw on our experience of researching one innovation, but the challenges arising from the specifics of this particular project are not unique; indeed we argue that the chameleons, chimeras and caterpillars we encountered may well be persistent features of evaluative research.
Women’s experiences of anal incontinence following vaginal birth: A qualitative study of missed opportunities in routine care contacts
Objectives This study aimed to explore experiences of women with anal incontinence following a childbirth injury, and to identify areas of missed opportunities within care they received. Design This is a qualitative study involving semi-structured interviews. Setting Participants were recruited via five hospitals in the UK, and via social media adverts and communication from charity organisations. Participants Women who have experienced anal incontinence following a childbirth injury, either within 7 years of sustaining the injury, or if they identified new, or worsening symptoms of AI at the time of menopause. Main outcome measures Main outcomes are experiences of women with anal incontinence following childbirth injury, and missed opportunities within the care they received. Results The following main themes were identified: opportunities for diagnosis missed, missed opportunities for information sharing and continuity and timeliness of care. Conclusions Anal Incontinence following a childbirth injury has a profound impact on women. Lack of information and awareness both amongst women and healthcare professionals contributes to delays in accurate diagnosis and appropriate treatment.
Developing prediction models for electrolyte abnormalities in patients indicated for antihypertensive therapy: evidence-based treatment and monitoring recommendations.
OBJECTIVES: Evidence from clinical trials suggests that antihypertensive treatment is associated with an increased risk of common electrolyte abnormalities. We aimed to develop and validate two clinical prediction models to estimate the risk of hyperkalaemia and hyponatraemia, respectively, to facilitate targeted treatment and monitoring strategies for individuals indicated for antihypertensive therapy. DESIGN AND METHODS: Participants aged at least 40 years, registered to an English primary care practice within the Clinical Practice Research Datalink (CPRD), with a systolic blood pressure reading between 130 and 179 mmHg were included the study. The primary outcomes were first hyperkalaemia or hyponatraemia event recorded in primary or secondary care. Model development used a Fine-Gray approach with death from other causes as competing event. Model performance was assessed using C-statistic, D-statistic, and Observed/Expected (O/E) ratio upon external validation. RESULTS: The development cohort included 1 773 224 patients (mean age 59 years, median follow-up 6 years). The hyperkalaemia model contained 23 predictors and the hyponatraemia model contained 29 predictors, with all antihypertensive medications associated with the outcomes. Upon external validation in a cohort of 3 805 366 patients, both models calibrated well (O/E ratio: hyperkalaemia 1.16, 95% CI 1.13-1.19; hyponatraemia 1.00, 95% CI 0.98-1.02) and showed good discrimination at 10 years (C-statistic: 0.69, 95% CI 0.69-0.69; 0.80, 95% CI 0.80-0.80, respectively). CONCLUSION: Current clinical guidelines recommend monitoring serum electrolytes after initiating antihypertensive treatment. These clinical prediction models predicted individuals' risk of electrolyte abnormalities associated with antihypertensive treatment and could be used to target closer monitoring for individuals at a higher risk, where resources are limited.
Withdrawal of antihypertensive drugs in older people
Background: Hypertension is an important risk factor for subsequent cardiovascular events, including ischaemic and haemorrhagic stroke, myocardial infarction, and heart failure, as well as chronic kidney disease, cognitive decline, and premature death. Overall, the use of antihypertensive medications has led to a reduction in cardiovascular disease, morbidity rates, and mortality rates. However, the use of antihypertensive medications is also associated with harms, especially in older people, including the development of adverse drug reactions and drug-drug interactions, and can contribute to increasing medication-related burden. As such, discontinuation of antihypertensives may be considered appropriate in some older people. Objectives: To evaluate the effects of withdrawal of antihypertensive medications used for hypertension or primary prevention of cardiovascular disease in older adults. Search methods: For this update, we searched the Cochrane Hypertension Specialised Register, CENTRAL (2022, Issue 9), Ovid MEDLINE, Ovid Embase, the WHO ICTRP, and ClinicalTrials.gov up to October 2022. We also conducted reference checking and citation searches, and contacted study authors to identify any additional studies when appropriate. There were no language restrictions on the searches. Selection criteria: We included randomised controlled trials (RCTs) of withdrawal versus continuation of antihypertensive medications used for hypertension or primary prevention of cardiovascular disease in older adults (defined as 50 years of age and over). Eligible participants were living in the community, residential aged care facilities, or based in hospital settings. We included trials evaluating the complete withdrawal of all antihypertensive medication, as well as those focusing on a dose reduction of antihypertensive medication. Data collection and analysis: We compared the intervention of discontinuing or reducing the dose of antihypertensive medication to continuing antihypertensive medication using mean differences (MD) and 95% confidence intervals (95% CIs) for continuous variables, and Peto odds ratios (ORs) and 95% CI for binary variables. Our primary outcomes were mortality, myocardial infarction, and the development of adverse drug reactions or adverse drug withdrawal reactions. Secondary outcomes included hospitalisation, stroke, blood pressure (systolic and diastolic), falls, quality of life, and success in withdrawing from antihypertensives. Two review authors independently, and in duplicate, conducted all stages of study selection, data extraction, and quality assessment. Main results: We identified no new studies in this update. Six RCTs from the original review met the inclusion criteria and were included in the review (1073 participants). Study duration and follow-up ranged from 4 weeks to 56 weeks. Meta-analysis of studies showed that discontinuing antihypertensives, compared to continuing, may result in little to no difference in all-cause mortality (OR 2.08, 95% CI 0.79 to 5.46; P = 0.14, I2 = 0%; 4 studies, 630 participants; low certainty of evidence), and that the evidence is very uncertain about the effect on myocardial infarction (OR 1.86, 95% CI 0.19 to 17.98; P = 0.59, I2 = 0%; 2 studies, 447 participants; very low certainty of evidence). Meta-analysis was not possible for the development of adverse drug reactions and withdrawal reactions; the evidence is very uncertain about the effect of antihypertensive discontinuation on the risk of adverse drug reactions (very low certainty of evidence), and the included studies did not assess adverse drug withdrawal reactions specifically. One study reported on hospitalisations; discontinuing antihypertensives may result in little to no difference in hospitalisation (OR 0.83, 95% CI 0.33 to 2.10; P = 0.70; 1 study, 385 participants; low certainty of evidence). Meta-analysis showed that discontinuing antihypertensives may result in little to no difference in stroke (OR 1.44, 95% CI 0.25 to 8.35; P = 0.68, I2 = 6%; 3 studies, 524 participants; low certainty of evidence). Blood pressure may be higher in the discontinuation group than the continuation group (systolic blood pressure: MD 9.75 mmHg, 95% CI 7.33 to 12.18; P < 0.001, I2 = 67%; 5 studies, 767 participants; low certainty of evidence; and diastolic blood pressure: MD 3.5 mmHg, 95% CI 1.82 to 5.18; P < 0.001, I2 = 47%; 5 studies, 768 participants; low certainty of evidence). No studies reported falls. The sources of bias included selective reporting (reporting bias), lack of blinding of outcome assessment (detection bias), incomplete outcome data (attrition bias), and lack of blinding of participants and personnel (performance bias). Authors' conclusions: The main conclusions from the 2020 review still apply. Discontinuing antihypertensives may result in little to no difference in mortality, hospitalisation, and stroke. The evidence is very uncertain about the effect of discontinuing antihypertensives on myocardial infarction and adverse drug reactions and adverse drug withdrawal reactions. Discontinuing antihypertensives may result in an increase in blood pressure. There was no information about the effect on falls. The evidence was of low to very low certainty, mainly due to small studies and low event rates. These limitations mean that we cannot draw any firm conclusions about the effect of deprescribing antihypertensives on these outcomes. Future research should focus on populations with the greatest uncertainty of the benefit:risk ratio for the use of antihypertensive medications, such as those with frailty, older age groups, and those taking polypharmacy, and measure clinically important outcomes such as adverse drug events, falls, and quality of life.