Can-Pain-a digital intervention to optimise cancer pain control in the community: development and feasibility testing.

PURPOSE: To develop a novel digital intervention to optimise cancer pain control in the community. This paper describes intervention development, content/rationale and initial feasibility testing. METHODS: Determinants of suboptimal cancer pain management were characterised through two systematic reviews; patient, caregiver and healthcare professional (HCP) interviews (n = 39); and two HCP focus groups (n = 12). Intervention mapping was used to translate results into theory-based content, creating the app "Can-Pain". Patients with/without a linked caregiver, their general practitioners and community palliative care nurses were recruited to feasibility test Can-Pain over 4 weeks. RESULTS: Patients on strong opioids described challenges balancing pain levels with opioid intake, side effects and activities and communicating about pain management problems with HCPs. Can-Pain addresses these challenges through educational resources, contemporaneous short-acting opioid tracking and weekly patient-reported outcome monitoring. Novel aspects of Can-Pain include the use of contemporaneous breakthrough analgesic reports as a surrogate measure of pain control and measuring the level at which pain becomes bothersome to the individual. Patients were unwell due to advanced cancer, making recruitment to feasibility testing difficult. Two patients and one caregiver used Can-Pain for 4 weeks, sharing weekly reports with four HCPs. Can-Pain highlighted unrecognised problems, promoted shared understanding about symptoms between patients and HCPs and supported shared decision-making. CONCLUSIONS: Preliminary testing suggests that Can-Pain is feasible and could promote patient-centred pain management. We will conduct further small-scale evaluations to inform a future randomised, stepped-wedge trial. TRIAL REGISTRATION: Qualitative research: ClinicalTrials.gov , reference NCT02341846 Feasibility study: NIHR CPMS database ID 34172.

Antibiotic prescribing for respiratory tract infection: exploring drivers of cognitive effort and factors associated with inappropriate prescribing.

BACKGROUND: Antibiotics are over-prescribed for upper respiratory tract infection (URTI). It is unclear how factors known to influence prescribing decisions operate 'in the moment': dual process theories, which propose two systems of thought ('automatic' and 'analytical'), may inform this. OBJECTIVE(S): Investigate cognitive processes underlying antibiotic prescribing for URTI and the factors associated with inappropriate prescribing. METHODS: We conducted a mixed methods study. Primary care physicians in Scotland (n = 158) made prescribing decisions for patient scenarios describing sore throat or otitis media delivered online. Decision difficulty and decision time were recorded. Decisions were categorized as appropriate or inappropriate based on clinical guidelines. Regression analyses explored relationships between scenario and physician characteristics and decision difficulty, time and appropriateness. A subgroup (n = 5) verbalized their thoughts (think aloud) whilst making decisions for a subset of scenarios. Interviews were analysed inductively. RESULTS: Illness duration of 4+ days was associated with greater difficulty. Inappropriate prescribing was associated with clinical factors suggesting viral cause and with patient preference against antibiotics. In interviews, physicians made appropriate decisions quickly for easier cases, with little deliberation, reflecting automatic-type processes. For more difficult cases, physicians deliberated over information in some instances, but not in others, with inappropriate prescribing occurring in both instances. Some interpretations of illness duration and unilateral ear examination findings (for otitis media) were associated with inappropriate prescribing. CONCLUSION: Both automatic and analytical processes may lead to inappropriate prescribing. Interventions to support appropriate prescribing may benefit from targeting interpretation of illness duration and otitis media ear exam findings and facilitating appropriate use of both modes of thinking.

Antibiotics are often used to treat the common cold and ear/nose/throat infections but typically do not work for these issues. We explored the reasons why this prescribing may happen and some of the difficulties doctors might experience when making these treatment decisions. Doctors reviewed written descriptions of patients and decided whether or not to prescribe antibiotics. Some of these doctors also took part in an interview where they 'thought aloud' (said what they were thinking as they were thinking it) while considering the patient descriptions. When the patient had been ill for four or more days, this made decisions more difficult. Sometimes decisions to prescribe due to this illness duration and due to findings from an ear exam were not in line with guidelines for prescribing. Some decisions to prescribe seemed to be more related to automatic habits, while others occurred after careful deliberation over the information. Doctors need more support to make decisions involving these factors and may benefit from strategies to help them use their automatic/habitual thinking and their deliberative thinking in the best ways.

The use, quality and effectiveness of pelvic examination in primary care for the detection of gynaecological cancer: a systematic review.

BACKGROUND: Urgent suspected cancer referral guidelines recommend that women with gynaecological cancer symptoms should have a pelvic examination (PE) prior to referral. We do not know to what extent GPs comply, their competency at PE, or if PE shortens the diagnostic interval. OBJECTIVES: We conducted a systematic review of the use, quality and effectiveness of PE in primary care for women with suspected gynaecological cancer. METHOD: PRISMA guidelines were followed. Three databases were searched using four terms: PE, primary care, competency and gynaecological cancer. Citation lists of all identified papers were screened independently for eligibility by two reviewers. Data extraction was performed in duplicate and independently. Paper quality was assessed using the relevant Critical Appraisal Skills Programme checklist. Emergent themes and contrasting issues were explored in a narrative ecological synthesis. MAIN FINDINGS: Twenty papers met the inclusion criteria. 52% or less of women with suspicious symptoms had a PE. No papers directly explored GPs' competence at performing PE. Pre-referral PE was associated with reduced diagnostic delay and earlier stage diagnosis. Ecological synthesis demonstrated a complex interplay between patient and practitioner factors and the environment in which examination is performed. Presenting symptoms are commonly misattributed by patients and practitioners resulting in misdiagnosis and lack of PE. CONCLUSION: We do not know if pre-referral PE leads to better outcomes for patients. PE is often not performed for women with gynaecological cancer symptoms, and evidence that it may result in earlier stage of diagnosis is weak. More research is needed.

Negotiating explanations: doctor-patient communication with patients with medically unexplained symptoms-a qualitative analysis.

BACKGROUND: Patients with medically unexplained physical symptoms (MUPS) seek explanations for their symptoms, but often find general practitioners (GPs) unable to deliver these. Different methods of explaining MUPS have been proposed. Little is known about how communication evolves around these explanations. OBJECTIVE: To examine the dialogue between GPs and patients related to explanations in a community-based clinic for MUPS. We categorized dialogue types and dialogue outcomes. METHODS: Patients were ≥18 years with inclusion criteria for moderate MUPS: ≥2 referrals to specialists, ≥1 functional syndrome/symptoms, ≥10 on the Patient Health Questionnaire-15 and GP's judgement that symptoms were unexplained. We analysed transcripts of 112 audio-recorded consultations (39 patients and 5 GPs) from two studies on the Symptoms Clinic Intervention, a consultation intervention for MUPS in primary care. We used constant comparative analysis to code and classify dialogue types and outcomes. RESULTS: We extracted 115 explanation sequences. We identified four dialogue types, differing in the extent to which the GP or patient controlled the dialogue. We categorized eight outcomes of the sequences, ranging from acceptance to rejection by the patient. The most common outcome was holding (conversation suspended in an unresolved state), followed by acceptance. Few explanations were rejected by the patient. Co-created explanations by patient and GP were most likely to be accepted. CONCLUSION: We developed a classification of dialogue types and outcomes in relation to explanations offered by GPs for MUPS patients. While it requires further validation, it provides a framework, which can be used for teaching, evaluation of practice and research.

Physical disease and resilient outcomes: a systematic review of resilience definitions and study methods.

BACKGROUND: Findings from physical disease resilience research may be used to develop approaches to reduce the burden of disease. However, there is no consensus on the definition and measurement of resilience in the context of physical disease. OBJECTIVE: The aim was to summarize the range of definitions of physical disease resilience and the approaches taken to study it in studies examining physical disease and its relationship to resilient outcomes. METHODS: Electronic databases were searched from inception to March 2013 for studies in which physical disease was assessed for its association with resilient outcomes. Article screening, data extraction, and quality assessment were carried out independently by 2 reviewers, with disagreements being resolved by a third reviewer. The results were combined using a narrative technique. RESULTS: Of 2280 articles, 12 met the inclusion criteria. Of these studies, 1 was of high quality, 9 were of moderate quality, and 2 were low quality. The common findings were that resilience involves maintaining healthy levels of functioning following adversity and that it is a dynamic process not a personality trait. Studies either assessed resilience based on observed outcomes or via resilience measurement scales. They either considered physical disease as an adversity leading to resilience or as a variable modifying the relationship between adversity and resilience. CONCLUSION: This work begins building consensus as to the approach to take when defining and measuring physical disease resilience. Resilience should be considered as a dynamic process that varies across the life-course and across different domains, therefore the choice of a resilience measure should reflect this.

Engaging the citizenship of the homeless-a qualitative study of specialist primary care providers.

BACKGROUND: Homeless patients have complex health needs. They also often describe difficulty accessing and maintaining access to clinical services. Although engagement with health care has been explored from the patient perspective, little is known about how health care professionals conceptualize, assess and promote engagement with health care among homeless persons. AIM: To examine how health professionals working in services for homeless persons view their patients' engagement with health care and explore how these views influence their practice. METHODS: Semi-structured phone interviews were conducted with health professionals who had experience working with homeless patients. Purposive sampling aimed to cover a range of location, practice type and duration of professional experience. Thematic analysis was undertaken on interview transcripts. RESULTS: Thirteen interviews were conducted. Four themes were explored relating to engagement of homeless persons with health care: (i) systematic barriers to engagement; (ii) difficulties engaging with professionals; (iii) system approaches to facilitate engagement and (iv) relationship approaches to facilitate engagement. In addition, a fifth theme emerged relating to the interaction between practices and networks of homeless persons in which practices were perceived as a key resource for a citizenship of the homeless. CONCLUSION: Primary care practices providing services for homeless people aim to promote engagement with health care by maximizing flexibility and fostering relationships between patients and the clinical team. In doing so they produce a paradox, whereby they function as a key hub within a citizenship of homeless persons while simultaneously aiming to help people move out of homelessness into a more settled state.

What influences GPs' use of pelvic examination? A qualitative investigation in primary care.

BACKGROUND: Omission of pelvic examination (PE) has been associated with diagnostic delay in women diagnosed with gynaecological cancer. However, PEs are often not carried out by GPs. AIM: To determine the perceptions of GPs about the role of PEs, the barriers to and facilitators of PEs, and GPs' experience of PEs in practice. DESIGN AND SETTING: Qualitative semi-structured interview study conducted in one health board in Scotland (mixed urban and rural) with an approximate population of 500 000. METHOD: Interviews were conducted face-to-face or by telephone between March and June 2019. Framework analysis used the COM-B behaviour change model concepts of capability, opportunity, and motivation. RESULTS: Data was compatible with all three domains of the COM-B framework. Capability related to training in and maintenance of skills. These went beyond carrying out the examination to interpreting it reliably. Opportunity related to the clinical environment and the provision of chaperones for intimate examination. Interviewees described a range of motivations towards or against PEs that were unrelated to either capability or opportunity. These all related to providing high-quality care, but this was defined in different ways: 'doing what is best for the individual', 'doctors examine', and 'GPs as pragmatists'. CONCLUSION: GPs' reasons for carrying out, or not carrying out, PEs in women with symptoms potentially indicating cancer are complex. The COM-B framework provides a way of understanding this complexity. Interventions to increase the use of PEs, and critics of its non-use, need to consider these multiple factors.

Study protocol for the Multiple Symptoms Study 3: a pragmatic, randomised controlled trial of a clinic for patients with persistent (medically unexplained) physical symptoms.

INTRODUCTION: Persistent physical symptoms (which cannot be adequately attributed to physical disease) affect around 1 million people (2% of adults) in the UK. They affect patients' quality of life and account for at least one third of referrals from General Practitioners (GPs) to specialists. These referrals give patients little benefit but have a real cost to health services time and diagnostic resources. The symptoms clinic has been designed to help people make sense of persistent physical symptoms (especially if medical tests have been negative) and to reduce the impact of symptoms on daily life. METHODS AND ANALYSIS: This pragmatic, multicentre, randomised controlled trial will assess the clinical and cost-effectiveness of the symptoms clinic intervention plus usual care compared with usual care alone. Patients were identified through GP searches and mail-outs and recruited by the central research team. 354 participants were recruited and individually randomised (1:1). The primary outcome is the self-reported Physical Health Questionnaire-15 at 52 weeks postrandomisation. Secondary outcome measures include the EuroQol 5 dimension 5 level and healthcare resource use. Outcome measures will also be collected at 13 and 26 weeks postrandomisation. A process evaluation will be conducted including consultation content analysis and interviews with participants and key stakeholders. ETHICS AND DISSEMINATION: Ethics approval has been obtained via Greater Manchester Central Research Ethics Committee (Reference 18/NW/0422). The results of the trial will be submitted for publication in peer-reviewed journals, presented at relevant conferences and disseminated to trial participants and patient interest groups. TRIAL REGISTRATION NUMBER: ISRCTN57050216.

Distinguishing variation in referral accuracy from referral threshold: analysis of a national dataset of referrals for suspected cancer.

OBJECTIVES: To distinguish between variation in referral threshold and variation in accurate selection of patients for referral in fast-track referrals for possible cancer. To examine factors associated with threshold and accuracy and model the effects of changing thresholds. DESIGN: Analysis of national data on cancer referrals from general practices in England over a 5-year period. We developed a new method to estimate specificity of referral to complement existing sensitivity. We used bivariate meta-analysis to produce summary measures and described practices in relation to these. SETTING: 5479 general practitioner (GP) practices with data relating to more than 50 cancer cases diagnosed over the 5 years. OUTCOMES: Number of practices whose 95% confidence regions for sensitivity and specificity indicated that they were outliers in terms of either referral threshold or decision accuracy. RESULTS: 2019 practices (36.8%) were outliers in relation to referral threshold compared with 1205 practices (22%) in relation to decision accuracy. Practice age profile, cancer incidence and deprivation showed a modest association with decision accuracy but not with thresholds. If all practices shared the referral behaviour of those in the highest quintile of age-standardised referral rate, there would be a 3.3% increase in cancers detected through fast-track pathways at the cost of a 36.9% increase in urgent referrals. CONCLUSION: This new method permits variation in referral to be described more precisely and quality improvement activities to be targeted. Changing referral thresholds without increasing accuracy will result in modest effects on detection rates and a large increase in demand on diagnostic services.

The value of different aspects of person-centred care: a series of discrete choice experiments in people with long-term conditions.

OBJECTIVE: To measure the value the patients place on different aspects of person-centred care. DESIGN: We systematically identified four attributes of person-centred care. We then measured their value to 923 people with either chronic pain or chronic lung disease over three discrete choice experiments (DCEs) about services to support self-management. We calculated the value of each attribute for all respondents and identified groups of people with similar preferences using latent class modelling. SETTING: DCEs conducted online via a commercial survey company. PARTICIPANTS: Adults with either chronic pain (two DCEs, n=517 and 206, respectively) or breathlessness due to chronic respiratory disease (n=200). RESULTS: Participants were more likely to choose services with higher level person-centred attributes. They most valued services that took account of a person's current situation likelihood of selection increased by 16.9% (95% CI=15.4 to 18.3) and worked with the person on what they wanted to get from life (15.8%; 14.5 to 17.1). More personally relevant information was valued less than these (12.3%; 11.0 to 13.6). A friendly and personal communicative style was valued least (3.8%; 2.7 to 4.8). Latent class models indicated that a substantial minority of participants valued personally relevant information over the other attributes. CONCLUSION: This is the first study to measure the value patients place on different aspects of person-centred care. Professional training needs to emphasise the substance of clinical communication-working responsively with individuals on what matters to them-as well as the style of its delivery.

Can patient-reported measurements of pain be used to improve cancer pain management? A systematic review and meta-analysis.

PURPOSE: Cancer pain is a distressing and complex experience. It is feasible that the systematic collection and feedback of patient-reported outcome measurements (PROMs) relating to pain could enhance cancer pain management. We aimed to conduct a systematic review of interventions in which patient-reported pain data were collected and fed back to patients and/or professionals in order to improve cancer pain control. METHODS: MEDLINE, EMBASE and CINAHL databases were searched for randomised and non-randomised controlled trials in which patient-reported data were collected and fed back with the intention of improving pain management by adult patients or professionals. We conducted a narrative synthesis. We also conducted a meta-analysis of studies reporting pain intensity. RESULTS: 29 reports from 22 trials of 20 interventions were included. PROM measures were used to alert physicians to poorly controlled pain, to target pain education and to link treatment to management algorithms. Few interventions were underpinned by explicit behavioural theories. Interventions were inconsistently applied or infrequently led to changes in treatment. Narrative synthesis suggested that feedback of PROM data tended to increase discussions between patients and professionals about pain and/or symptoms overall. Meta-analysis of 12 studies showed a reduction in average pain intensity in intervention group participants compared with controls (mean difference=-0.59 (95% CI -0.87 to -0.30)). CONCLUSIONS: Interventions that assess and feedback cancer pain data to patients and/or professionals have so far led to modest reductions in cancer pain intensity. Suggestions are given to inform and enhance future PROM feedback interventions.

Resilience does matter: evidence from a 10-year cohort record linkage study.

OBJECTIVES: To examine 10-year mortality and hospital use among individuals categorised as resilient and vulnerable to the impact of chronic pain. DESIGN: A cohort record linkage study. SETTING: Grampian, Scotland. PARTICIPANTS: 5858 individuals from the Grampian Pain Cohort, established in 1996, were linked, by probability matching, with national routinely collected datasets. MAIN OUTCOME MEASURES: HRs for subsequent 10-year mortality and ORs/incidence rate ratios for subsequent 10-year hospital use, each with adjustment for potential confounding variables. RESULTS: 36.5% of those with high pain intensity reported a low pain-related disability (categorised resilient) and 7.1% of those reporting low pain intensity reported a high pain-related disability (categorised vulnerable). Sex, age, housing, employment and long-term limiting illness were independently associated with being vulnerable or resilient. After adjustment for these variables, individuals in the resilient group were 25% less likely to die within 10 years of the survey compared with non-resilient individuals: HR 0.75, 95% CI 0.62 to 0.91 and vulnerable individuals were 45% more likely to die than non-vulnerable individuals: HR 1.45, 95% CI 1.01 to 2.11. Resilient individuals were less likely to have had an outpatient or day-case visit for anaesthetics: OR 0.46, 95% CI 0.27 to 0.79, but no other clinical specialities. Vulnerable individuals were significantly less likely to have had any outpatient or day-case visit (OR 0.43, 0.25 to 0.75); but more likely to have had a psychiatric visit (OR 1.96, 1.06 to 3.61). No significant differences in likelihood of any inpatient visits were found. CONCLUSIONS: Resilient individuals have a better 10-year survival than non-resilient individuals indicating that resilience is a phenomenon worth researching. Further research is needed to explore who is likely to become resilient, why and how, as well as to tease out the internal and external factors that influence resilience.