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A blog by Dr Gurpreet Singh Kalra and Shawn D. Mathis, members of cohort 1 of the MSc in Global Healthcare Leadership
Healthcare decision-makers' perspectives on evaluating conflict management training in paediatric healthcare: a utilisation-focused qualitative study.
BackgroundConflict is prevalent across healthcare settings but is especially common in paediatrics, where high emotional stakes and parental expectations often intensify disagreements. Conflict can lead to negative outcomes for hospitals, staff and patients. Effective conflict management training can mitigate these impacts, but evaluating such training programmes remains challenging due to a lack of standardised tools and best practices.MethodsThis qualitative study aimed to explore healthcare decision-makers' perspectives on what key areas should be evaluated in conflict management training programmes in paediatric healthcare settings, employing Patton's utilisation-focused evaluation approach. Semi-structured interviews were conducted with 13 healthcare decision-makers and key stakeholders from various healthcare and charitable organisations. Interviews were analysed using reflexive thematic analysis by Braun and Clarke to identify key themes for evaluation.ResultsFour primary themes were generated regarding the key areas that healthcare decision-makers believe should be evaluated in conflict management training. These were experience of training sessions, staff competency and well-being, patient/family experiences of conflict and impact on staff time and on clinical resources. Interviewees identified that the evaluation of training sessions should focus on participant engagement and satisfaction. Codes relating to staff competency and well-being included the acquisition and long-term retention of conflict management skills. Codes relating to patient/family experience focused on the quality of communication and support during conflicts. The theme of resource utilisation included codes relating to the time and cost implications of conflict.ConclusionThe study identified essential evaluation areas that align with and expand on Kirkpatrick's framework, suggesting the need for both qualitative and quantitative data and long-term follow-up. Tailoring evaluation frameworks to specific programme contexts can enhance their relevance and utility, contributing to improved conflict management in both paediatric and wider healthcare settings.
Defining and Risk-Stratifying Immunosuppression (the DESTINIES Study): Protocol for an Electronic Delphi Study
Background: Globally, there are marked inconsistencies in how immunosuppression is characterized and subdivided into clinical risk groups. This is detrimental to the precision and comparability of disease surveillance efforts—which has negative implications for the care of those who are immunosuppressed and their health outcomes. This was particularly apparent during the COVID-19 pandemic; despite collective motivation to protect these patients, conflicting clinical definitions created international rifts in how those who were immunosuppressed were monitored and managed during this period. We propose that international clinical consensus be built around the conditions that lead to immunosuppression and their gradations of severity concerning COVID-19. Such information can then be formalized into a digital phenotype to enhance disease surveillance and provide much-needed intelligence on risk-prioritizing these patients. Objective: We aim to demonstrate how electronic Delphi objectives, methodology, and statistical approaches will help address this lack of consensus internationally and deliver a COVID-19 risk-stratified phenotype for “adult immunosuppression.” Methods: Leveraging existing evidence for heterogeneous COVID-19 outcomes in adults who are immunosuppressed, this work will recruit over 50 world-leading clinical, research, or policy experts in the area of immunology or clinical risk prioritization. After 2 rounds of clinical consensus building and 1 round of concluding debate, these panelists will confirm the medical conditions that should be classed as immunosuppressed and their differential vulnerability to COVID-19. Consensus statements on the time and dose dependencies of these risks will also be presented. This work will be conducted iteratively, with opportunities for panelists to ask clarifying questions between rounds and provide ongoing feedback to improve questionnaire items. Statistical analysis will focus on levels of agreement between responses. Results: This protocol outlines a robust method for improving consensus on the definition and meaningful subdivision of adult immunosuppression concerning COVID-19. Panelist recruitment took place between April and May of 2024; the target set for over 50 panelists was achieved. The study launched at the end of May and data collection is projected to end in July 2024. Conclusions: This protocol, if fully implemented, will deliver a universally acceptable, clinically relevant, and electronic health record–compatible phenotype for adult immunosuppression. As well as having immediate value for COVID-19 resource prioritization, this exercise and its output hold prospective value for clinical decision-making across all diseases that disproportionately affect those who are immunosuppressed.
Tracking cortical entrainment to stages of optic-flow processing.
In human visual processing, information from the visual field passes through numerous transformations before perceptual attributes such as motion are derived. Determining the sequence of transforms involved in the perception of visual motion has been an active field since the 1940s. One plausible family of models are the spatiotemporal energy models, based on computations of motion energy computed from the spatiotemporal features the visual field. One of the most venerated is that of Heeger (1988), which hypotheses that motion is estimated by matching the predicted spatiotemporal energy in frequency space. In this study, we investigate the plausibility of Heeger's model by testing for evidence of cortical entrainment to its components. Entrainment of cortical activity to these components was estimated using measurements of electro- and magnetoencephalographic (EMEG) activity, recorded while healthy subjects watched videos of dots moving left and right across their visual field. We find entrainment to several components of Heeger's model bilaterally in occipital lobe regions, including representations of motion energy at a latency of 80 ms, overall velocity at 95 ms, and acceleration at 130 ms. We find little evidence of entrainment to displacement. We contrast Heeger's biologically inspired model with alternative baseline models, finding that Heeger's model provides a closer fit to the observed data. These results help shed light on the processes through which perception of motion arises in the visual processing stream.
Prevalence and patterns of testing for anaemia in primary care in England.
Background Despite epidemiological data on anaemia being available on a global scale, its prevalence in the United Kingdom is not well described. Aim To investigate anaemia prevalence and testing patterns for haemoglobin and other blood parameters. Design and Setting A population-based cohort study using data drawn from the Clinical Practice Research Datalink Aurum database in 2019. Method We extracted demographic data for each person who was registered at their current practice during 2019, including linked data on Index of Multiple Deprivation. We calculated anaemia prevalence in 2019 based on World Health Organization specified age and gender thresholds for haemoglobin. We classified anaemia based on mean corpuscular volume and ferritin. We followed up people with anaemia for up to one year to investigate longitudinal testing patterns for haemoglobin. Results The cohort contained 14 million people. Anaemia prevalence in 2019 was 4.1% (5.1 % females and 3.1% males). Prevalence was higher in people aged >65 years, Black and Asian ethnicities, and people living in areas with higher social deprivation. Only half of people with anaemia and a mean corpuscular volume of ≤100 fL had an accompanying ferritin value recorded. About half of people with anaemia had a follow-up haemoglobin test within one-year, most of which still indicated anaemia. Conclusion Anaemia is prevalent in the UK with large disparities between levels of demographic variables. Investigation and follow-up of anaemia is suboptimal in many patients. Health interventions aimed at improving anaemia investigation and treatment are needed, particularly in these at-risk groups.
Acute hepatitis of unknown aetiology in children: evidence for and against causal relationships with SARS-CoV-2, HAdv and AAV2.
BACKGROUND: The cause of acute paediatric hepatitis of unknown aetiology (2022) has not been established despite extensive investigation. OBJECTIVE: To summarise the evidence for and against a causal role for human adenovirus (HAdv), adeno-associated virus 2 (AAV-2) and SARS-CoV-2 in outbreaks of paediatric hepatitis in 2022. METHODS: We appraised and summarised relevant evidence for each of the Bradford Hill criteria for causality using quantitative (statistical modelling) and qualitative (narrative coherence) approaches. Each team member scored the evidence base for each criterion separately for HAdv, AAV-2 and SARS-CoV-2; differences were resolved by discussion. We additionally examined criteria of strength and temporality by examining the lagged association between SARS-CoV-2 positivity, respiratory HAdv positivity, positive faecal HAdv specimens and excess A&E attendances in 1-4 years for liver conditions in England. RESULTS: Assessing criteria using the published literature and our modelling: for HAdv three Bradford Hill criteria (strength, consistency and temporality) were partially met; and five criteria (consistency, coherence, experimental manipulation, analogy and temporality) were minimally met. For AAV-2, the strength of association criterion was fully met, five criteria (consistency, temporality, specificity, biological gradient and plausibility) were partially met and three (coherence, analogy and experimental manipulation) were minimally met. For SARS-CoV-2, five criteria (strength of association, plausibility, temporality, coherence and analogy) were fully met; one (consistency) was partially met and three (specificity, biological gradient and experimental manipulation) were minimally met. CONCLUSION: Based on the Bradford Hill criteria and modelling, HAdv alone is unlikely to be the cause of the recent increase in hepatitis in children. The causal link between SARS-CoV-2, and to a lesser degree AAV-2, appears substantially stronger but remains unproven. Hepatitis is a known complication of multisystem inflammatory syndrome in children following COVID-19, and SARS-CoV-2 has been linked to increased susceptibility to infection post-COVID-19, which may suggest complex causal pathways including a possible interaction with AAV-2 infection/reactivation in hosts that are genetically susceptible or sensitised to infection.
Associations of long-term nitrogen dioxide exposure with a wide spectrum of diseases: a prospective cohort study of 0·5 million Chinese adults
Background: Little evidence is available on the long-term health effects of nitrogen dioxide (NO2) in low-income and middle-income populations. We investigated the associations of long-term NO2 exposure with the incidence of a wide spectrum of disease outcomes, based on data from the China Kadoorie Biobank. Methods: This prospective cohort study involved 512 724 Chinese adults aged 30–79 years recruited from ten areas of China during 2004–08. Time-varying Cox regression models yielded adjusted hazard ratios (HRs) for the associations of long-term NO2 exposure with aggregated disease incidence endpoints classified by 14 ICD-10 chapters, and incidences of 12 specific diseases selected from three key ICD-10 chapters (cardiovascular, respiratory, and musculoskeletal diseases) found to be robustly associated with NO2 in the analyses of aggregated endpoints. All models were stratified by age-at-risk (in 1-year scale), study area, and sex, and were adjusted for education, household income, smoking status, alcohol intake, cooking fuel type, heating fuel type, self-reported health status, BMI, physical activity level, temperature, and relative humidity. Findings: The analysis of 512 709 participants (mean baseline age 52·0 years [SD 10·7]; 59·0% female and 41·0% male) included approximately 6·5 million person-years of follow-up. Between 5285 and 144 852 incident events were recorded for each of the 14 aggregated endpoints. Each 10 μg/m3 higher annual average NO2 exposure was associated with higher risks of chapter-specific endpoints, especially cardiovascular (n=144 852; HR 1·04 [95% CI 1·02–1·05]), respiratory (n=73 232; 1·03 [1·01–1·05]), musculoskeletal (n=54 409; 1·11 [1·09–1·14]), and mental and behavioural (n=5361; 1·12 [1·05–1·21]) disorders. Further in-depth analyses on specific diseases found significant positive supra-linear associations with hypertensive disease (1·08 [1·05–1·11]), lower respiratory tract infection (1·03 [1·01–1·06]), arthrosis (1·15 [1·09–1·21]), intervertebral disc disorders (1·13 [1·09–1·17]), and spondylopathies (1·05 [1·01–1·10]), and linear associations with ischaemic heart disease (1·03 [1·00–1·05]), ischaemic stroke (1·08 [1·06–1·11]), and asthma (1·15 [1·04–1·27]), whereas intracerebral haemorrhage (1·00 [0·95–1·06]), other cerebrovascular disease (0·98 [0·96–1·01]), acute upper respiratory infection (1·03 [0·96–1·09]), and chronic lower respiratory disease (0·98 [0·95–1·02]) showed no significant association. NO2 exposure showed robust null association with external causes (n=32 907; 0·98 [0·95–1·02]) as a negative control. Interpretation: In China, long-term NO2 exposure was associated with a range of diseases, particularly cardiovascular, respiratory, and musculoskeletal diseases. These associations underscore the pressing need to implement the recently tightened WHO air quality guidelines. Funding: Wellcome Trust, UK Medical Research Council, Cancer Research UK, British Heart Foundation, National Natural Science Foundation of China, National Key Research and Development Program of China, Sino-British Fellowship Trust, and Kadoorie Charitable Foundation.
National trends in heart failure mortality in men and women, United Kingdom, 2000–2017
Aims: To understand gender differences in the prognosis of women and men with heart failure, we compared mortality, cause of death and survival trends over time. Methods and results: We analysed UK primary care data for 26 725 women and 29 234 men over age 45 years with a new diagnosis of heart failure between 1 January 2000 and 31 December 2017 using the Clinical Practice Research Datalink, inpatient Hospital Episode Statistics and the Office for National Statistics death registry. Age-specific overall survival and cause-specific mortality rates were calculated by gender and year. During the study period 15 084 women and 15 822 men with heart failure died. Women were on average 5 years older at diagnosis (79.6 vs. 74.8 years). Median survival was lower in women compared to men (3.99 vs. 4.47 years), but women had a 14% age-adjusted lower risk of all-cause mortality [hazard ratio (HR) 0.86, 95% confidence interval (CI) 0.84–0.88]. Heart failure was equally likely to be cause of death in women and men (HR 1.03, 95% CI 0.96–1.12). There were modest improvements in survival for both genders, but these were greater in men. The reduction in mortality risk in women was greatest for those diagnosed in the community (HR 0.83, 95% CI 0.80–0.85). Conclusions: Women are diagnosed with heart failure older than men but have a better age-adjusted prognosis. Survival gains were less in women over the last two decades. Addressing gender differences in heart failure diagnostic and treatment pathways should be a clinical and research priority.
Risk factors for SARS-CoV-2 among patients in the Oxford Royal College of General Practitioners Research and Surveillance Centre primary care network: a cross-sectional study
Background: There are few primary care studies of the COVID-19 pandemic. We aimed to identify demographic and clinical risk factors for testing positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) within the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre primary care network. Methods: We analysed routinely collected, pseudonymised data for patients in the RCGP Research and Surveillance Centre primary care sentinel network who were tested for SARS-CoV-2 between Jan 28 and April 4, 2020. We used multivariable logistic regression models with multiple imputation to identify risk factors for positive SARS-CoV-2 tests within this surveillance network. Findings: We identified 3802 SARS-CoV-2 test results, of which 587 were positive. In multivariable analysis, male sex was independently associated with testing positive for SARS-CoV-2 (296 [18·4%] of 1612 men vs 291 [13·3%] of 2190 women; adjusted odds ratio [OR] 1·55, 95% CI 1·27–1·89). Adults were at increased risk of testing positive for SARS-CoV-2 compared with children, and people aged 40–64 years were at greatest risk in the multivariable model (243 [18·5%] of 1316 adults aged 40–64 years vs 23 [4·6%] of 499 children; adjusted OR 5·36, 95% CI 3·28–8·76). Compared with white people, the adjusted odds of a positive test were greater in black people (388 [15·5%] of 2497 white people vs 36 [62·1%] of 58 black people; adjusted OR 4·75, 95% CI 2·65–8·51). People living in urban areas versus rural areas (476 [26·2%] of 1816 in urban areas vs 111 [5·6%] of 1986 in rural areas; adjusted OR 4·59, 95% CI 3·57–5·90) and in more deprived areas (197 [29·5%] of 668 in most deprived vs 143 [7·7%] of 1855 in least deprived; adjusted OR 2·03, 95% CI 1·51–2·71) were more likely to test positive. People with chronic kidney disease were more likely to test positive in the adjusted analysis (68 [32·9%] of 207 with chronic kidney disease vs 519 [14·4%] of 3595 without; adjusted OR 1·91, 95% CI 1·31–2·78), but there was no significant association with other chronic conditions in that analysis. We found increased odds of a positive test among people who are obese (142 [20·9%] of 680 people with obesity vs 171 [13·2%] of 1296 normal-weight people; adjusted OR 1·41, 95% CI 1·04–1·91). Notably, active smoking was linked with decreased odds of a positive test result (47 [11·4%] of 413 active smokers vs 201 [17·9%] of 1125 non-smokers; adjusted OR 0·49, 95% CI 0·34–0·71). Interpretation: A positive SARS-CoV-2 test result in this primary care cohort was associated with similar risk factors as observed for severe outcomes of COVID-19 in hospital settings, except for smoking. We provide evidence of potential sociodemographic factors associated with a positive test, including deprivation, population density, ethnicity, and chronic kidney disease. Funding: Wellcome Trust.
Low-dose spironolactone and cardiovascular outcomes in moderate stage chronic kidney disease: a randomized controlled trial
Chronic kidney disease (CKD) is associated with a substantial risk of progression to end-stage renal disease and vascular events. The nonsteroidal mineralocorticoid receptor antagonist (MRA), finerenone, offers cardiorenal protection for people with CKD and diabetes, but there is uncertainty if the steroidal MRA, spironolactone, provides the same protection. In this prospective, randomized, open, blinded endpoint trial, we assessed the effectiveness of 25 mg spironolactone in addition to usual care or usual care alone for reducing cardiovascular outcomes in stage 3b CKD among an older community cohort (mean age = 74.8 years and s.d. = 8.1). We recruited 1,434 adults from English primary care, of whom 1,372 (96%) were included in the primary analysis. The primary outcome was time from randomization until the first occurrence of death, hospitalization for heart disease, stroke, heart failure, transient ischemic attack or peripheral arterial disease, or first onset of any condition listed not present at baseline. Across 3 years of follow-up, the primary endpoint occurred in 113 of 677 participants randomized to spironolactone (16.7%) and 111 of 695 participants randomized to usual care (16.0%) with no significant difference between groups (hazard ratio = 1.05, 95% confidence interval: 0.81–1.37). Two-thirds of participants randomized to spironolactone stopped treatment within 6 months, predominantly because they met prespecified safety stop criteria. The most common reason for stopping spironolactone was a decrease in the estimated glomerular filtration rate that met prespecified stop criteria (n = 239, 35.4%), followed by participants being withdrawn due to treatment side effects (n = 128, 18.9%) and hyperkalemia (n = 54, 8.0%). In conclusion, we found that spironolactone was frequently discontinued due to safety concerns, with no evidence that it reduced cardiovascular outcomes in people with stage 3b CKD. Spironolactone should not be used for people with stage 3b CKD without another explicit treatment indication. ClinicalTrials.gov registration: ISRCTN44522369.
Survival of people with valvular heart disease in a large, English community-based cohort study
Objective Valvular heart disease (VHD) is present in half the population aged >65 years but is usually mild and of uncertain importance. We investigated the association between VHD and its phenotypes with all-cause and cause-specific mortality. Methods The OxVALVE (Oxford Valvular Heart Disease) population cohort study screened 4009 participants aged >65 years to establish the presence and severity of VHD. We linked data to a national mortality registry and undertook detailed outcome analysis. Results Mortality data were available for 3511 participants, of whom 361 (10.3%) died (median 6.49 years follow-up). Most had some form of valve abnormality (n=2645, 70.2%). In adjusted analyses, neither mild VHD (prevalence 44.9%) nor clinically significant VHD (moderate or severe stenosis or regurgitation; 5.2%) was associated with increased all-cause mortality (HR 1.20, 95% CI 0.96 to 1.51 and HR 1.47, 95% CI 0.94 to 2.31, respectively). Conversely, advanced aortic sclerosis (prevalence 2.25%) and advanced mitral annular calcification (MAC, 1.31%) were associated with an increased risk of death (HR 2.05, 95% CI 1.28 to 3.30 and HR 2.51, 95% CI 1.41 to 4.49, respectively). Mortality was highest for people with both clinically significant VHD and advanced aortic sclerosis or MAC (HR 4.38, 95% CI 1.99 to 9.67). Conclusions Advanced aortic sclerosis or MAC is associated with a worse outcome, particularly for patients with significant VHD, but also in the absence of other VHD. Older patients with mild VHD can be reassured about their prognosis. The absence of an association between significant VHD and mortality may reflect its relatively low prevalence in our cohort.
Long term trends in natriuretic peptide testing for heart failure in UK primary care: A cohort study
Aims: Heart failure (HF) is a malignant condition with poor outcomes and is often diagnosed on emergency hospital admission. Natriuretic peptide (NP) testing in primary care is recommended in international guidelines to facilitate timely diagnosis. We aimed to report contemporary trends in NP testing and subsequent HF diagnosis rates over time. Methods and results: Cohort study using linked primary and secondary care data of adult (≥45 years) patients in England 2004-18 (n = 7 212 013, 48% male) to report trends in NP testing (over time, by age, sex, ethnicity, and socioeconomic status) and HF diagnosis rates. NP test rates increased from 0.25 per 1000 person-years [95% confidence interval (CI) 0.23-0.26] in 2004 to 16.88 per 1000 person-years (95% CI 16.73-17.03) in 2018, with a significant upward trend in 2010 following publication of national HF guidance. Women and different ethnic groups had similar test rates, and there was more NP testing in older and more socially deprived groups as expected. The HF detection rate was constant over the study period (around 10%) and the proportion of patients without NP testing prior to diagnosis remained high [99.6% (n = 13 484) in 2004 vs. 76.7% (n = 12 978) in 2017]. Conclusion: NP testing in primary care has increased over time, with no evidence of significant inequalities, but most patients with HF still do not have an NP test recorded prior to diagnosis. More NP testing in primary care may be needed to prevent hospitalization and facilitate HF diagnosis at an earlier, more treatable stage.
How should we do racially just research? Learning from a qualitative study on COVID-19 pandemic experiences in the UK
Racialised social inequalities were exposed and exacerbated during the COVID-19 pandemic. The methods health researchers employ in designing and conducting research can replicate the same inequalities, with important implications for the creation of new knowledge. In this paper, we retrospectively and critically analyse the thinking and methods we employed during two qualitative studies about the diverse experiences of people and families during the COVID-19 pandemic in the UK. Set within a wider literature on engaging with race and ethnicity in health research, we present an analysis based on reflexive accounts and testimonies from researchers, and close-up examinations of different stages of the research. By illustrating these ideological, practical and interactional components of research, including some uncomfortable reflections, we hope to encourage more open conversations among researchers and research funders. Through this process, we can strengthen efforts that dismantle unhelpful historical research orthodoxies and move towards re-formulating ways of research practice that are more explicitly anti-racist and inclusive.
Implementation and Evaluation of Automated, Online Study Recruitment from Computerised Medical Records in a Primary Care Sentinel Surveillance Network
Infectious intestinal disease (IID) is a syndrome consisting of diarrhoea and vomiting symptoms linked to a causative pathogen. The Third Study of IID (IID3) will report its incidence in the community within the UK and assess how it has changed since the second IID study (IID2) in 2012. We implemented an automated, online patient recruitment process within a national sentinel surveillance network and compared its performance versus IID2 in terms of: Patient recruitment rates and demographic characteristics of recruited participants. We utilised a text messaging system (TMS) running off a computerised medical record systems (CMR) application programme interface (API). Demographic analysis showed that the majority of those recruited to IID3/IID2 studies were >65 years and female. However, the recruitment of participants of non-white ethnicity was statistically significantly different between IID3/IID2. Further work is required to improve recruitment in the younger patient demographic and in ethnic minority populations.
Digging for Literature on Tailoring Cultural Offers With and for Older People From Ethnic Minority Groups: A Scoping Review
Introduction: Social prescribing addresses non-medical issues (e.g., loneliness, financial worries, housing problems) affecting physical and/or mental health. It involves connecting people to external support or services, including ‘cultural offers’–events, groups and activities run within or by cultural organisations. Such offers need to be acceptable and accessible to diverse populations if forming part of a social prescription. Methods: A scoping review was conducted to identify what existing literature, conducted in the United Kingdom, tells us about tailoring cultural offers for older people (aged 60+ years) from ethnic minority groups. Relevant literature was searched for on electronic databases, through Google, via a questionnaire to cultural organisations and by contacting the study's advisory group. Results: Screening of 906 references–59 of which were read as full documents–resulted in six sources being included in the review. Some cultural activities described within them were run in traditional cultural spaces (e.g., museums, art galleries). Others were held in community centres. Data suggested that attending with others could reduce concerns about belonging. Barriers to engagement included low energy, language, poor confidence, accessing transport and unfamiliarity with a setting and/or activities. Provision of familiar food could help make people feel welcomed. Conclusions: Reviewed papers showed that consulting with target groups is important to ensure that activities are inclusive and sympathetically delivered. The review also highlighted a paucity of published research on the topic; this means that cultural providers have little evidence to draw on when developing cultural offers for older people from ethnic minority groups.