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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Access systems in general practice: a systematic scoping review
Background Access to GP appointments is increasingly challenging in many high-income countries, with an overstretched workforce and rising demand. Various access systems have been developed and evaluated internationally. Aim To systematically consolidate the current international evidence base related to different types of GP access systems. Design and setting Scoping review examining international literature. Method Literature searches were run across relevant databases in May 2022. Title, abstract, and full-text screenings were carried out. Data from included studies were extracted and mapped to synthesise the components and aims within different GP access systems. Results In total, 49 studies were included in the review. The majority of these were set in the UK. Some access systems featured heavily in the literature, such as Advanced Access, telephone triage, and online consultations, and others less so. There were two key strategies adopted by systems that related to either changing appointment capacity or modifying patient pathways. Components related to these strategies are summarised and illustrated as a schematic representation. Most rationales behind access systems were practice, rather than patient, focused. ‘Add-on’ systems and aims for efficiency have become more popular in recent years. Conclusion This synthesis provides a useful tool in understanding access systems’ aims, design, and implementation. With focus on alleviating demand, patient-focused outcomes appear to be underinvestigated and potentially overlooked during design and implementation. More recently, digital services have been promoted as offering patient choice and convenience. But a context where demand outweighs resources challenges the premise that extending choice is possible.
Emergence of Acquired Dolutegravir Resistance in Treatment-experienced People With HIV in Lesotho
Background: Since 2019, the World Health Organization has recommended dolutegravir-based antiretroviral therapy (ART) as the preferred regimen for human immunodeficiency virus management. Large-scale programmatic transitioning to dolutegravir-based ART was subsequently implemented across Africa, often in the absence of recent viral load testing and without access to genotypic resistance testing (GRT) in case of viremia. Methods: This study assessed emerging dolutegravir resistance in the routine care of the Viral Load Cohort North-East Lesotho. We included pediatric and adult participants who changed from nonnucleoside reverse transcriptase inhibitor- to dolutegravir-based ART and had at least 1 viral load assessment before and after the change. We sequenced available samples of participants fulfilling the additional virological criteria of having 2 viremic episodes while taking dolutegravir, with at least 1 viral load ≥500 copies/mL taken ≥18 months after changing to dolutegravir. Results: Among 15 349 participants, 157 (1.0%) met the virological criteria, and GRT was successful for 85 (0.6%). Among these 85, 8 (9.4%) had dolutegravir resistance, with 2 (2.4%) and 6 (7.1%) predicted to have intermediate- and high-level dolutegravir resistance, respectively. One participant had 2, 2 had 1, and 5 had 0 active drugs in their regimen. A GRT from before the change to dolutegravir was available for 5 of these 8 participants: 4 had 0 and 1 had 1 active drug in their nonnucleoside transcriptase inhibitor-based regimen. Conclusions: Nine percent of people with persistent or recurring human immunodeficiency virus viremia ≥18 months after changing to dolutegravir-based ART had dolutegravir resistance. Detection and management of emerging dolutegravir resistance must be addressed across Africa.
Integrating homelessness support – developing a relational understanding
PurposePeople experiencing homelessness often have multiple health and other support needs, requiring complex, coordinated support. Admission to hospital is potentially an opportunity to address these needs and begin integrating care, but so often it is a missed one. Our purpose in this research was to evaluate an ongoing, roll-out programme that offered government funding to 17 “test sites” across England to develop integrated care as part of post-discharge “step-down” support. In this paper, we examine senior stakeholder experiences of seeking to implement integrated care as part of specialist step-down care.Design/methodology/approachIn this paper, we focus on data collected in interviews with key stakeholders (N = 10) who managed the mobilisation of local out of hospital care models for people experiencing homelessness. Interviews were conducted and analysed from a relational perspective, that is focusing on relationships between interactants, through which, for example, identities, understanding and integrating practice emerge.FindingsA relational perspective on the data provides insights to better understand the complexity of integrating care at the point of hospital discharge for people experiencing homelessness.Research limitations/implicationsAlthough in depth, the data were limited to certain perspectives on the issues. Other perspectives and data collection from in-depth study of case sites would be invaluable in developing the empirical evidence base for a relational understanding of integrating care.Practical implicationsA relational perspective highlights the emergent and ongoing nature of integrating care in this context of support for people experiencing homelessness. The need for different system agents to work to be constantly enacting the desired support is crucial to understanding future system changes for integrating care.Originality/valueThis is the first paper developing a relational analysis of integrating care. It highlights a different theoretical perspective on the issues and important insights.
How to establish and sustain a disease registry: insights from a qualitative study of six disease registries in the UK
Background: The advent of new chronic conditions such as long COVID-19 raises the question of whether and, if so, how best to establish new disease registries for such conditions. Prompted by the potential need for a long COVID-19 registry, we examined experiences of existing UK disease registries to understand barriers and enablers to establishing and sustaining a register, and how these have changed over time. Methods: We undertook semi-structured interviews between November 2022 and April 2023 with individuals representing six disease registries that collect individual-level longitudinal data on people diagnosed with a chronic condition. Results: Registries examined were developed by a few individuals, usually clinicians, to gain a greater understanding of the disease. Patient voices were largely absent from initial agenda setting processes, but, over time, all registries sought to increase patient involvement. Securing long-term funding was cited as the biggest challenge; due to limited funds, one of the registries examined no longer actively recruits patients. Charities devoted to the diseases in question were key funders, though most registries also sought commercial opportunities. Inclusion on the NIHR Clinical Research Network Portfolio was also considered a vital resource to support recruitment and follow-up of participants. All registries have sought to minimise the primary data collected to reduce the burden on clinicians and patients, increasingly relying on linkage to other data sources. Several registries have developed consent procedures that enable participants to be contacted for additional data collection. In some cases, the initial patient consent and data sharing permissions obtained had limited the flexibility to adapt the registry to changing data needs. Finally, there was a need to foster buy-in from the community of patients and clinicians who provide and/or use the data. Conclusion: We identified six key considerations when establishing a sustainable disease registry: (1) include a diverse set of stakeholders; (2) involve patients at every stage; (3) collect a core data set for all participants; (4) ensure the data system is flexible and interoperable with the wider data landscape; (5) anticipate changing data needs over time; and (6) identify financial opportunities to sustain the registry’s activities for the long term.
Longitudinal patterns in smoking abstinence in trials of e-cigarettes for smoking cessation: secondary analysis of data from a systematic review, with meta-analyses.
INTRODUCTION: We set out to better understand patterns of smoking abstinence and relapse in trials of e-cigarettes for smoking cessation. METHODS: Secondary analysis of studies from a Cochrane review. Studies had to test any type of e-cigarette intervention for smoking cessation. They had to follow-up for at least 6 months and report either: abstinence at multiple time points; abstinence using multiple definitions; relapse. We narratively synthesized data and conducted meta-analyses. RESULTS: We included 15 studies (n=7,233 participants). Using the Cochrane risk of bias tool v1, 5 were judged to be at high risk of bias, 8 were at low risk, and 2 at unclear risk. Absolute continuous abstinence rates tended to decline over time, but varying slopes. For absolute point prevalence abstinence, three studies demonstrated a shallow decline over time, two a steep decline, and three the opposite - an increase in abstinence over time. Data on relative abstinence rates (e-cigarettes versus control) were mixed. There were multiple instances of differences between point prevalence and continuous/sustained abstinence rates, both in trajectories over time and in terms of relative abstinence. The few studies addressing relapse highlighted mixed demographic and behavioural characteristics associated with relapse rates. CONCLUSIONS: Smoking trajectories vary between trials of e-cigarettes for smoking cessation. Risk ratios may not be stable over time and may increase or decrease in favor of e-cigarettes depending on the study. Further data are needed, especially on relapse rates in early quitters who use e-cigarettes versus those who use other or no stop-smoking aids. IMPLICATIONS: While some have posited e-cigarettes might increase smoking relapse when used as a cessation tool, others have posited that combustible cigarette quit rates may increase over time in the same studies due to 'accidental quitting'. We set out to investigate this empirically and found considerable variation in smoking trajectories in e-cigarette trials. Data suggest risk ratios may not be stable over time and may increase or decrease in favor of e-cigarettes depending on the study. Further data are needed, especially on relapse rates in early quitters who use e-cigarettes versus those who use other or no stop-smoking aids.
E-cigarette (EC) and heated tobacco product (HTP) use in the United Arab Emirates, an emerging EC and HTP market: A cross-sectional analysis of the International Tobacco Control (ITC) UAE Survey.
INTRODUCTION: E-cigarettes (ECs) and heated tobacco products (HTPs) are recent arrivals to the nicotine product market in the Middle East, which are rapidly growing in popularity in the region. There is a lack of surveillance data at the country-level on use of these products and factors associated with their use. METHODS: This study analyzed a subset of data from the UAE Healthy Future Study, a population-based cohort study of the Emirati population, to determine the factors associated with EC and HTP use among a sample of Emirati adults (≥ 18 years). The baseline assessment and supplementary questionnaires, conducted from 2016 to 2023, included data on combustible tobacco use, EC, and HTP use and sociodemographic characteristics. RESULTS: Of the 2,041 individuals who answered questions on EC use, 32% reported ever using them. Of 521 people providing data on HTP, 30% reported ever using them. After adjusting for age, sex, education, perceived harms and perceived addictiveness of EC, current EC use was associated with baseline combustible tobacco smoking (aOR = 27.63, 95% confidence interval [CI] 14.39, 53.06), users of a younger age (aOR=0.91, 95%CI 0.88, 0.95), and users of male sex (OR = 2.15, 95% CI 1.21, 3.81). Current HTP use was less common, but was also associated with baseline combustible tobacco use. CONCLUSIONS: Use of ECs and HTPs was more common among those who used combustible tobacco. Future research should examine use trajectories among those who do and do not smoke, as well as uptake of these products among youth. IMPLICATIONS: Non-combustible nicotine products are growing in popularity in the Middle East Region. Our study found that EC and HTP use is associated with baseline combustible tobacco use and that concurrent users may use them to cut down on their combustible tobacco use. Continued comprehensive population-based monitoring of all tobacco and nicotine products, especially EC and HTP use, will provide current data to aid in appropriately informing public health and harm reduction messages and programming.
Exploring the GP-patient relationship: a historical narration
The relationship between patients and their doctor is a fundamental concept-particularly within general practice. Many patients and general practitioners (GPs) have a'common-sense' recognition of the interpersonal connection, usually over time, that makes a relationship meaningful. GPs have consistently striven to emphasise the importance of this connection. While much research has explored the components and influences affecting intersubjective connections, less attention has focused on how the historical, professional, sociopolitical and philosophical contexts have influenced their experience and portrayal. However, recent claims of a crisis in UK general practice resulting from declining relational encounters suggest these are important considerations. In this paper, episodic narration (chronicling) is used to explore five different ages of UK general practice: the emergent period (1815-1948); the expansion of coverage (1949-1965); the professionalisation of general practice (1966-1988); the age of marketisation and neoliberalisation (1989-2004); and the age of technology and fragmentation (2004-present day). A range of sources illustrate micro and macro viewpoints within each period-personal reflections, professional publications, political directives or policies, and representations from the fields of art and literature. This allows for a deeper exploration of contextual influences on the codification and enactment of GP-patient relationships over time and their interpretation and perception. Significant epidemiological and biomedical realities and their respective social interpretation(s), the socioprofessional nature of the GP, that is, their role, societal position and framework of practice, and broader sociopolitical and philosophical factors are explored. Ideological frameworks (from socialism to free market policies and neoliberalism) were particularly important. These determine approaches to funding, service/provider structures, and regulation and governance, which incentivise, enable, or inhibit choices and behaviours among individuals and society, thus impacting the enactment of the GP-patient relationship. If meaningful GP-patient connections are valuable and desirable-as GPs consistently claim they are-we require an honest discussion about the contexts necessary to enable and retain them.
Recommendations for the recognition, diagnosis, and management of long COVID: A Delphi study
Background In the absence of research into therapies and care pathways for long COVID, guidance based on emerging experience is needed. Aim To provide a rapid expert guide for GPs and long COVID clinical services. Design and setting A Delphi study was conducted with a panel of primary and secondary care doctors. Method Recommendations were generated relating to the investigation and management of long COVID. These were distributed online to a panel of UK doctors (any specialty) with an interest in, lived experience of, and/or experience treating long COVID. Over two rounds of Delphi testing, panellists indicated their agreement with each recommendation (using a five-point Likert scale) and provided comments. Recommendations eliciting a response of strongly agree , agree , or neither agree nor disagree from 90% or more of responders were taken as showing consensus. Results Thirty-Three clinicians representing 14 specialties reached consensus on 35 recommendations. Chiefly, GPs should consider long COVID in the presence of a wide range of presenting features (not limited to fatigue and breathlessness) and exclude differential diagnoses where appropriate. Detailed history and examination with baseline investigations should be conducted in primary care. Indications for further investigation and specific therapies (for myocarditis, postural tachycardia syndrome, mast cell disorder) include hypoxia/desaturation, chest pain, palpitations, and histamine-related symptoms. Rehabilitation should be individualised, with careful activity pacing (to avoid relapse) and multidisciplinary support. Conclusion Long COVID clinics should operate as part of an integrated care system, with GPs playing a key role in the multidisciplinary team. Holistic care pathways, investigation of specific complications, management of potential symptom clusters, and tailored rehabilitation are needed.
The impact of low-energy total diet replacement with behavioural support for remission of type 2 diabetes on disordered eating (ARIADNE): Protocol for a non-inferiority randomised controlled trial
Introduction: The National Health Service (NHS) in England is currently piloting a weight loss programme for remission of newly diagnosed type 2 diabetes (T2D), where participants replace all food with low-energy nutritionally complete formula products for 12 weeks (total diet replacement, TDR) and receive behavioural support. In a clinical trial, this programme led to remission in nearly half the participants. However, this weight loss programme might also worsen disordered eating and prompt eating disorders in susceptible people. We aim to investigate if the TDR programme is non-inferior to standard care in terms of disordered eating in susceptible individuals. Methods: Fifty six people with newly diagnosed T2D, BMI ≥ 27 kg/m2, and medium to high scores of disordered eating based on the Eating Disorders Examination questionnaire (EDE-Q) will be randomised 1:1 to TDR receiving remote weekly/bi-weekly dietetic support or standard care. Participants will be re-assessed remotely at 1, 3, 4, 6, and 12 months. The primary outcome will be the between-group difference in the score of the EDE-Q. If the sample size can be expanded to 150, we will reduce the non-inferiority boundary. Weight, glycated haemoglobin (HbA1c), impairment from disordered eating, and distress will be secondary outcomes. Using the recorded consultations, we will evaluate the process in observed changes in eating behaviour and disordered eating. Conclusions: If TDR for T2D remission is deemed non-inferior to standard care, more people may enrol and benefit from T2D remission. If TDR exacerbates disordered eating, screening may reduce unintended harm. Trial Registration: NCT05744232 (ClinicalTrials.gov, prospectively registered).
Ethnicity and health at work during the COVID-19
This paper explores how health-work-related illnesses and injuries have changed during the COVID-19 pandemic for different ethnic groups and by gender. We find that not all groups were affected in the same way. While almost all men in all ethnic groups were on average less likely to work during the pandemic period, women were more likely to work. We also find that Mixed Ethnic and Pakistani women who reported a higher probability of working in the reference week had a higher risk of illness/injuries at work. Meanwhile, White men and Other ethnic groups with a reduced probability of working during the pandemic had a lower risk of illness/injuries at work. Long-term illness varied by ethnicity and gender, with men experiencing a reduction and women an increase in physical and mental health issues. This research provides valuable insights into the multifaceted impact of the COVID-19 pandemic on the health and work patterns of different ethnic groups and gender. Understanding and identifying these disparities is crucial for formulating targeted policies aimed at mitigating adverse effects and promoting equitable outcomes in regional studies and urban economics.
The association between experiences of racism and mental health on children and young people in the UK: rapid scoping review.
BACKGROUND: Racism is increasingly recognised as a key contributor to poor mental health. However, the existing literature primarily focuses on its effects on adults. AIM: To identify literature on the association between experiences of racism and mental health in children and young people in the UK. METHOD: Inclusion criteria were: (a) peer-reviewed publications containing original data; (b) UK-based research; (c) included examination of associations between mental health and experiences of direct or indirect racism (quantitative or qualitative); (d) inclusion of an assessment of mental health outcomes; (e) participant ages up to and including 18 years of age or (if the range went beyond 18) with a mean age of 17 years or less. Six databases were searched between 2000 and 2022; an initial 11 522 studies were identified with only eight meeting the inclusion criteria. RESULTS: Five of the identified studies provided quantitative data and three provided qualitative data. The majority of studies (7/8) focused on children and young people aged 10 years and over; only one focused on children under the age of 10 years. Measurements of racism varied among the studies providing quantitative data. Only four studies directly focused on the effects of racism on the mental health of children and young people. CONCLUSION: Although the included studies highlighted potential negative impacts of experiences of racism on children and young people in the UK, this review shows the lack of available literature to inform policy and practice. No studies examined the impact of internalised racism, systemic and institutional racism, or intersectionality.
Coziness in Games: Second Homes, Audiences, and Esthetics
The “Cozy” game has gained traction as a concept in contemporary game culture as a set of formal generic features. While we examine the way that Cozy Games are often now defined as a genre, we demonstrate that “coziness in games” has widespread formal and engagement functions and can be experienced in a whole range of games, not simply those defined by the Cozy genre. In focusing on the player–text relationship, and in using a literary model, we seek to widen the discourse and range of meanings of coziness in, as well as of, games. This approach enables us to think about our own lived experience of playing games in terms of the generation of affect, as well as opening the way for renewed analysis of representation, ideology, and cognition.
The contested zone: interviews with GPs about their beliefs about treatment-resistant depression
BACKGROUND: Treatment-resistant depression (TRD) is when antidepressants do not work and affects 55% of British primary care users with depression. People with TRD should be referred to secondary care but there are long wait times. This means most people are managed by GPs, but primary care guidelines are not standardised. Thus, how GPs manage people with TRD may vary, and there is limited evidence for how quality care may look. As a result of this variation, an investigation into how GPs manage people might be valuable. AIM: To understand and interpret how GPs make decisions about treatment for people with potential TRD. METHOD: Fourteen GPs were interviewed by AT, patient-led researcher with bipolar, and LH, a GP. Interviews started with a vignette where someone did not respond to antidepressants. We followed up with semi-structured questions. Data were transcribed verbatim and analysed thematically. RESULTS: GPs gave eleven explanations for antidepressant ineffectiveness before and instead of TRD. Explanations included misdiagnosis, medicalised misery, not yet found the right antidepressant, believing too much in antidepressants, and not engaging with psychological interventions. We interpreted that the prioritisation of these explanations suggests that TRD can be contested diagnosis. This interpretation was not only latent but overt in our data: 'I think if we call things TRD, we undermine the impact of those other changes.' CONCLUSION: TRD can be a contested diagnosis in the same way as ADHD, ME, and long-COVID. GP training and continuing professional development may support GP awareness of TRD and help them in confidently making the diagnosis.