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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.
Towards Equitable and Resilient Digital Primary Care Systems: An International Comparison and Insight for Moving Forward
Objective: While the COVID-19 pandemic provided a global stimulus for digital health capacity, its development has often been inequitable, short-term in planning, and lacking in health system coherence. Inclusive digital health and the development of resilient health systems are broad outcomes that require a systematic approach to achieving them. This paper from the IMIA Primary Care Informatics Working Group (WG) provides necessary first steps for the design of a digital primary care system that can support system equity and resilience. Methods: We report on digital capability and growth in maturity in four key areas: (1) Vaccination/Prevention, (2) Disease management, (3) Surveillance, and (4) Pandemic preparedness for Australia, Canada, and the United Kingdom (data from England). Our comparison looks at seasonal influenza management prior to COVID-19 (2019-20) compared to COVID-19 (winter 2020 onwards). Results: All three countries showed growth in digital maturity from the 2019-20 management of influenza to the 2020-21 year and the management of the COVID-19 pandemic. However, the degree of progress was sporadic and uneven and has led to issues of system inequity across populations. Conclusion: The opportunity to use the lessons learned from COVID-19 should not be wasted. A digital health infrastructure is not enough on its own to drive health system transformation and to achieve desired outcomes such as system equity and resilience. We must define specific measures to track the growth of digital maturity, including standardized and fit-for-context data that is shared accurately across the health and socioeconomic sectors.
Stratification of diabetes in the context of comorbidities, using representation learning and topological data analysis
Diabetes is a heterogenous, multimorbid disorder with a large variation in manifestations, trajectories, and outcomes. The aim of this study is to validate a novel machine learning method for the phenotyping of diabetes in the context of comorbidities. Data from 9967 multimorbid patients with a new diagnosis of diabetes were extracted from Clinical Practice Research Datalink. First, using BEHRT (a transformer-based deep learning architecture), the embeddings corresponding to diabetes were learned. Next, topological data analysis (TDA) was carried out to test how different areas in high-dimensional manifold correspond to different risk profiles. The following endpoints were considered when profiling risk trajectories: major adverse cardiovascular events (MACE), coronary artery disease (CAD), stroke (CVA), heart failure (HF), renal failure (RF), diabetic neuropathy, peripheral arterial disease, reduced visual acuity and all-cause mortality. Kaplan Meier curves were plotted for each derived phenotype. Finally, we tested the performance of an established risk prediction model (QRISK) by adding TDA-derived features. We identified four subgroups of patients with diabetes and divergent comorbidity patterns differing in their risk of future cardiovascular, renal, and other microvascular outcomes. Phenotype 1 (young with chronic inflammatory conditions) and phenotype 2 (young with CAD) included relatively younger patients with diabetes compared to phenotypes 3 (older with hypertension and renal disease) and 4 (older with previous CVA), and those subgroups had a higher frequency of pre-existing cardio-renal diseases. Within ten years of follow-up, 2592 patients (26%) experienced MACE, 2515 patients (25%) died, and 2020 patients (20%) suffered RF. QRISK3 model’s AUC was augmented from 67.26% (CI 67.25–67.28%) to 67.67% (CI 67.66–67.69%) by adding specific TDA-derived phenotype and the distances to both extremities of the TDA graph improving its performance in the prediction of CV outcomes. We confirmed the importance of accounting for multimorbidity when risk stratifying heterogenous cohort of patients with new diagnosis of diabetes. Our unsupervised machine learning method improved the prediction of clinical outcomes.
The drivers of non-adherence to albuminuria testing guidelines and the clinical and economic impact of not identifying chronic kidney disease.
BACKGROUND: Regular monitoring is required to ensure that patients who have, or are at risk of, chronic kidney disease (CKD) receive appropriate management. Guidelines recommend regular testing of estimated glomerular filtration rate (GFR) and albuminuria. However, evidence suggests that albuminuria testing rates, specifically urine albumin-to-creatinine ratio (UACR), are suboptimal. AIM: To assess published evidence relating to the drivers of non-adherence to albuminuria testing guidelines and the impact of not identifying CKD across the course of progression. MATERIALS AND METHODS: A systematic review of five bibliographic databases was conducted, supplemented by hand searches of relevant conference abstracts. RESULTS: One study was identified that reported drivers of non-adherence to albuminuria testing guidelines. The largest barrier was the perception that testing does not impact patient management. Thirteen studies were identified that evaluated the impact of not identifying CKD patients. All included studies analyzed the effect of not identifying worsening CKD severity leading to late referral (LR). 12/13 studies reported only on clinical impact, and 1/13 reported on clinical and economic impact. LR led to higher costs and worse outcomes than early referral, including higher rates of mortality and worsened kidney replacement therapy preparation. CONCLUSION: This systematic review demonstrates a gap in evidence exploring the drivers of non-adherence to albuminuria testing guidelines and the impact of not identifying patients in the early stages of CKD. Guideline-recommended testing allows timely identification, referral, and treatment for patients with, or at risk of, CKD, providing the best chance of avoiding the worsened outcomes identified in this review.
Influence of research evidence on the use of cardiovascular clinical prediction rules in primary care: an exploratory qualitative interview study
Background: Cardiovascular clinical prediction rules (CPRs) are widely used in primary care. They accumulate research evidence through derivation, external validation, and impact studies. However, existing knowledge about the influence of research evidence on the use of CPRs is limited. Therefore, we explored how primary care clinicians’ perceptions of and experiences with research influence their use of cardiovascular CPRs. Methods: We conducted an exploratory qualitative interview study with thematic analysis. Primary care clinicians were recruited from the WWAMI (Washington, Wyoming, Alaska, Montana and Idaho) region Practice and Research Network (WPRN). We used purposeful sampling to ensure maximum variation within the participant group. Data were collected by conducting semi-structured online interviews. We analyzed data using inductive thematic analysis to identify commonalities and differences within themes. Results: Of 29 primary care clinicians who completed the questionnaire, 15 participated in the interview. We identified two main themes relating to the influence of clinicians’ perceptions of and experiences with cardiovascular CPR research on their decisions about using cardiovascular CPRs: “Seek and judge” and “be acquainted and assume.” When clinicians are familiar with, trust, and feel confident in using research evidence, they might actively search and assess the evidence, which may then influence their decisions about using cardiovascular CPRs. However, clinicians, who are unfamiliar with, distrust, or find it challenging to use research evidence, might be passively acquainted with evidence but do not make their own judgment on the trustworthiness of such evidence. Therefore, these clinicians might not rely on research evidence when making decisions about using cardiovascular CPRs. Conclusions: Clinicians’ perceptions and experiences could influence how they use research evidence in decisions about using cardiovascular CPRs. This implies, when promoting evidence-based decisions, it might be useful to target clinicians’ unfamiliarity, distrust, and challenges regarding the use of research evidence rather than focusing only on their knowledge and skills. Further, because clinicians often rely on evidence-unrelated factors, guideline developers and policymakers should recommend cardiovascular CPRs supported by high-quality evidence.
Gut microbiology of UK care home residents: a cross-sectional analysis from a randomised controlled trial
Objective: To describe the prevalence of potentially clinically relevant gut pathogens and associations with the carriage of resistant organisms in UK care home residents. Methods: Stool samples were collected pre-randomisation from care home residents participating in a randomised placebo-controlled trial. Cultivable clinically relevant bacteria were analysed. Antimicrobial susceptibility testing was performed by agar dilution (amoxicillin, co-amoxiclav, gentamicin, trimethoprim, nitrofurantoin, and ciprofloxacin). We also aimed to detect resistance to third-generation cephalosporins, carbapenems, and vancomycin. Results: Stool samples were available for 159/310 residents participating in the trial (51%) from 23 care homes between 2016 and 2018. In total, 402 bacterial isolates were cultured from 158 stool samples and 29 different species were cultured. The five most common species were Escherichia coli (155/158, 98%), Pseudomonas aeruginosa (40/158, 25%), Enterococcus faecalis (35/158, 22%), Enterococcus faecium (30/158, 19%), and Proteus mirabilis (25/158, 16%). Enterobacterales isolates were cultured from 157 samples (99%), and resistance to at least one of the tested antimicrobials was found in 119 of these (76%). There were high levels of variation in outcomes by care home. Discussion: We demonstrated that care home residents harbour significant levels of antimicrobial-resistant organisms in their stool. This work emphasises the importance of both enhanced infection control practices and antimicrobial stewardship programmes to support the appropriate use of antimicrobials in this setting.
Tailoring CONSORT‐SPI to improve the reporting of smoking cessation intervention trials: An expert consensus study
AbstractBackground and AimsInadequate reporting of smoking cessation intervention trials is common and leads to significant challenges for researchers. The aim of this study was to tailor CONSORT (Consolidated Standards of Reporting Trials)‐SPI (Social and Psychological Interventions) guidelines to improve reporting of trials of behavioural interventions to promote smoking cessation.MethodInformed by missing data from the IC‐SMOKE (Intervention and Comparison group support provided in SMOKing cEssation) systematic review project, this study used a multi‐stage Delphi process to examine which items could be added or modified to improve the reporting of smoking cessation trials. The first stage involved an on‐line survey of 17 international experts in smoking cessation and trial methodology voting on the importance of items for inclusion in the updated guidelines. This was followed by a face‐to‐face expert consensus meeting attended by 15 of these experts, where the final inclusion and exclusion of new items and modifications were agreed upon. A nine‐point Likert scale was used to establish consensus, with suggested modifications requiring agreement of 75% or more. Disagreements in the first stage were presented again at the second stage for discussion and a second round of voting. Only items which reached the threshold for agreement were included.ResultsThe experts agreed on the inclusion of 10 new items and the specification of 12 existing items. This included modifications that could apply to trials more widely (e.g. the rationale for the comparator), but also modifications that were very specific to smoking cessation trials (e.g. the reporting of smoking cessation outcomes).ConclusionsA Delphi study has developed a modified CONSORT‐SPI guideline (CONSORT‐SPI‐SMOKE) to improve the reporting of trials of behavioural interventions to promote smoking cessation.
Impact of Long Covid on the school experiences of children and young people: a qualitative study.
OBJECTIVES: To explore the impact of Long Covid (LC) on the school experiences of children and young people (CYP). DESIGN: Qualitative study using narrative interviews. PARTICIPANTS: 22 CYP (aged 10-18 years, 15 female) with LC and 15 parents/caregivers (13 female) of CYP (aged 5-18 years) with LC. SETTING: Interviews were conducted between October 2021 and July 2022 via online video call or telephone. Recruitment routes included social media, LC support groups, clinicians, community groups and snowballing. RESULTS: Three key findings were identified. Finding 1: Going to school is a valued part of CYP's lives and participants viewed educational attainment as important for their future trajectories. Returning to school full time was highlighted as a key part of regaining 'normal life'. Finding 2: Attending school (in-person or online) with LC is extremely difficult; even a gradual return required CYP to balance the impact of being at and engaging with school, with the need to manage symptoms to prevent relapse. Often this meant prioritising school and rest over other aspects of their lives. Finding 3: School responses to CYP with LC were reported to be mixed and hampered by difficulties communicating with healthcare professionals during the pandemic and a lack of awareness of LC among healthcare and education professionals. Participants viewed supportive school responses as staff believing, understanding and taking them seriously, alongside schools offering tailored and flexible adaptations which allowed engagement with school while limiting any deterioration of symptoms. CONCLUSIONS: This study describes how LC affects the school experiences of CYP and generates recommendations for supportive school responses alongside supportive healthcare professionals. Further research could explore the approaches that facilitate a successful return to school for CYP with LC and investigate education professionals' perspectives on support they require to positively engage with returning pupils.
Infant feeding as a transgressive practice in the context of HIV in the UK: A qualitative interview study
HIV transmission risk via breastfeeding is greatly reduced by antiretroviral therapy but is not zero. Current UK guidelines recommend exclusive formula feeding; however, women can breastfeed if they meet certain criteria. We examine the narrative accounts of mothers with HIV (pregnant or recently given birth) who navigated divergent cultural and national policy norms regarding infant feeding. Mothers with HIV, the majority of whom in the UK are of Black African ethnicity, face a complex decision regarding infant feeding, which has implications for their sense of identity, belonging and citizenship. While the UK has one of the lowest breastfeeding rates globally, breastfeeding is normalised across African and Asian cultures. However, HIV remains stigmatised and formula feeding could signal one's HIV-positive status. Our participants made difficult trade-offs to mitigate the variety of threats they faced, and both feeding options (breast or formula) felt transgressive, with immense hazards involved for these intersectionally-disadvantaged women.
[Effectiveness evaluation of health belief model-based health education intervention for patients with hypertension in community settings].
Objective: To evaluate the effectiveness of health belief model-based health education intervention in improving blood pressure control of patients with hypertension in community settings. Methods: From September 2016 to September 2017, 400 newly diagnosed patients with hypertension were recruited from 6 community healthcare centers with comparable population size and health services in the Shunyi District of Beijing. All community healthcare centers were randomly assigned to the intervention group (206 patients) and the control group (194 patients). Patients in the intervention group received 3 lectures (20-30 min for each) of health belief model-based health education. Patients in the control group received usual care. The basic characteristics, health beliefs, and health literacy were collected, and blood pressure was measured before and after the intervention, respectively. The difference-in-difference model was used to analyze the change of blood pressure and the influencing factors between two groups before and after the intervention. Results: A total of 134 patients in the intervention group and 129 patients in the control group completed the study. After adjusting for the age, gender, family income, medical insurance, chronic diseases and family history, the score of perceived barriers was increased by 1.65 (P=0.016), and perceived seriousness was decreased by 0.73 (P=0.018). The systolic blood pressure of patients was decreased by 7.37 mmHg (1 mmHg=0.133 kPa, P=0.001) and diastolic blood pressure was decreased by 4.07 mmHg (P=0.014), respectively. The β (95%CI) values were -7.37 (-11.88,-2.86) and -4.07 (-7.30, -0.84). The perceived susceptibility and self-efficacy had a significant influence on the blood pressure of patients (P<0.05). Conclusion: Health belief model-based health education intervention could significantly improve the blood pressure control of patients with hypertension in the community settings.