General practitioners' role in improving health care in care homes: a realist review.

BACKGROUND: Despite recent focus on improving health care in care homes, it is unclear what role general practitioners (GPs) should play. To provide evidence for future practice we set out to explore how GPs have been involved in such improvements. METHODS: Realist review incorporated theory-driven literature searches and stakeholder interviews, supplemented by focussed searches on GP-led medication reviews and end-of-life care. Medline, Embase, CINAHL, PsycInfo, Web of Science, and the Cochrane library were searched. Grey literature was identified through internet searches and professional networks. Studies were included based upon relevance. Data were coded to develop and test contexts, mechanisms, and outcomes for improvements involving GPs. RESULTS: Evidence was synthesized from 30 articles. Programme theories described: (i) "negotiated working with GPs," where other professionals led improvement and GPs provided expertise; and (ii) "GP involvement in national/regional improvement programmes." The expertise of GPs was vital to many improvement programmes, with their medical expertise or role as coordinators of primary care proving pivotal. GPs had limited training in quality improvement (QI) and care home improvement work had to be negotiated in the context of wider primary care commitments. CONCLUSIONS: GPs are central to QI in health care in care homes. Their contributions relate to their specialist expertise and recognition as leaders of primary care but are challenged by available time and resources to develop this role.

How quality improvement collaboratives work to improve healthcare in care homes: a realist evaluation.

BACKGROUND: Quality improvement collaboratives (QICs) bring together multidisciplinary teams in a structured process to improve care quality. How QICs can be used to support healthcare improvement in care homes is not fully understood. METHODS: A realist evaluation to develop and test a programme theory of how QICs work to improve healthcare in care homes. A multiple case study design considered implementation across 4 sites and 29 care homes. Observations, interviews and focus groups captured contexts and mechanisms operating within QICs. Data analysis classified emerging themes using context-mechanism-outcome configurations to explain how NHS and care home staff work together to design and implement improvement. RESULTS: QICs will be able to implement and iterate improvements in care homes where they have a broad and easily understandable remit; recruit staff with established partnership working between the NHS and care homes; use strategies to build relationships and minimise hierarchy; protect and pay for staff time; enable staff to implement improvements aligned with existing work; help members develop plans in manageable chunks through QI coaching; encourage QIC members to recruit multidisciplinary support through existing networks; facilitate meetings in care homes and use shared learning events to build multidisciplinary interventions stepwise. Teams did not use measurement for change, citing difficulties integrating this into pre-existing and QI-related workload. CONCLUSIONS: These findings outline what needs to be in place for health and social care staff to work together to effect change. Further research needs to consider ways to work alongside staff to incorporate measurement for change into QI.

Ethnic disparity in access to the memory assessment service between South Asian and white British older adults in the United Kingdom: A cohort study.

BACKGROUND: Equality of access to memory assessment services by older adults from ethnic minorities is both an ethical imperative and a public health priority. OBJECTIVE: To investigate whether timeliness of access to memory assessment service differs between older people of white British and South Asian ethnicity. DESIGN: Longitudinal cohort. SETTING: Nottingham Memory Study; outpatient secondary mental healthcare. SUBJECTS: Our cohort comprised 3654 white British and 32 South Asian older outpatients. METHODS: The criterion for timely access to memory assessment service was set at 90 days from referral. Relationships between ethnicity and likelihood of timely access to memory assessment service were analysed using binary logistic regression. Analyses were adjusted for socio-demographic factors, deprivation and previous access to rapid response mental health services. RESULTS: Among white British outpatients, 2272 people (62.2%) achieved timely access to memory assessment service. Among South Asian outpatients, fourteen people (43.8%) achieved timely access to memory assessment service. After full adjustment, South Asian outpatients had a 0.47-fold reduced likelihood of timely access, compared to white British outpatients (odds ratio 0.47, 95% confidence interval 0.23-0.95, P value = .035). The difference became non-significant when restricting analyses to outpatients reporting British nationality or English as first language. Older age, lower index of deprivation and previous access to rapid response mental health services were associated with reduced likelihood of timely access, while gender was not. CONCLUSIONS: In a UK mental healthcare service, older South Asian outpatients are less likely to access dementia diagnostic services in a timely way, compared to white British outpatients.

Quality improvement in long-term care settings: a scoping review of effective strategies used in care homes.

PURPOSE: We conducted a scoping review of quality improvement in care homes. We aimed to identify participating occupational groups and methods for evaluation. Secondly, we aimed to describe resident-level interventions and which outcomes were measured. METHODS: Following extended PRISMA guideline for scoping reviews, we conducted systematic searches of Medline, CINAHL, Psychinfo, and ASSIA (2000-2019). Furthermore, we searched systematic reviews databases including Cochrane Library and JBI, and the grey literature database, Greylit. Four co-authors contributed to selection and data extraction. RESULTS: Sixty five studies were included, 6 of which had multiple publications (75 articles overall). A range of quality improvement strategies were implemented, including audit feedback and quality improvement collaboratives. Methods consisted of controlled trials, quantitative time series and qualitative interview and observational studies. Process evaluations, involving staff of various occupational groups, described experiences and implementation measures. Many studies measured resident-level outputs and health outcomes. 14 studies reported improvements to a clinical measure; however, four of these articles were of low quality. Larger randomised controlled studies did not show statistically significant benefits to resident health outcomes. CONCLUSION: In care homes, quality improvement has been applied with several different strategies, being evaluated by a variety of measures. In terms of measuring benefits to residents, process outputs and health outcomes have been reported. There was no pattern of which quality improvement strategy was used for which clinical problem. Further development of reporting of quality improvement projects and outcomes could facilitate implementation.

Protocol for a realist review of General Practitioners' Role in Advancing Practice in Care Homes (GRAPE study).

INTRODUCTION: Older people who live in care homes have a high level of need with complex health conditions. In addition to providing medical care to residents, general practitioners (GPs) play a role as gatekeeper for access to services, as well as leadership within healthcare provision. This review will describe how GPs were involved in initiatives to change arrangements of healthcare services in order to improve quality and experience of care. METHODS AND ANALYSIS: Following RAMESES quality and publication guidelines standards, we will proceed with realist review to develop theories of how GPs work with care home staff to bring about improvements. We identify when improvement in outcomes does not occur and why this may be the case. The first stage will include interviews with GPs to ask their views on improvement in care homes. These interviews will enable development of initial theories and give direction for the literature searches. In the second stage, we will use iterative literature searches to add depth and context to the early theories; databases will include Medline, Embase, CINAHL, PsycINFO and ASSIA. In stage 3, evidence that is judged as rigorous and relevant will be used to test the initial theories, and through the process, refine the theory statements. In the final stage, we will synthesise findings and provide recommendations for practice and policy-making.During the review, we will invite a context expert group to reflect on our findings. This group will have expertise in current trends in primary care and the care home sector both in UK and internationally. ETHICS AND DISSEMINATION: The study was approved by University of Nottingham Faculty of Medicine and Health Sciences Research Ethics Committee: 354-1907. Findings will be shared through stakeholder networks, published in National Institute for Health Research journal and submitted for peer-reviewed journal publication.

Role of comprehensive geriatric assessment in healthcare of older people in UK care homes: realist review.

OBJECTIVES: Comprehensive geriatric assessment (CGA) may be a way to deliver optimal care for care home residents. We used realist review to develop a theory-driven account of how CGA works in care homes. DESIGN: Realist review. SETTING: Care homes. METHODS: The review had three stages: first, interviews with expert stakeholders and scoping of the literature to develop programme theories for CGA; second, iterative searches with structured retrieval and extraction of the literature; third, synthesis to refine the programme theory of how CGA works in care homes.We used the following databases: Medline, CINAHL, Scopus, PsychInfo, PubMed, Google Scholar, Greylit, Cochrane Library and Joanna Briggs Institute. RESULTS: 130 articles informed a programme theory which suggested CGA had three main components: structured comprehensive assessment, developing a care plan and working towards patient-centred goals. Each of these required engagement of a multidisciplinary team (MDT). Most evidence was available around assessment, with tension between structured assessment led by a single professional and less structured assessment involving multiple members of an MDT. Care planning needed to accommodate visiting clinicians and there was evidence that a core MDT often used care planning as a mechanism to seek external specialist support. Goal-setting processes were not always sufficiently patient-centred and did not always accommodate the views of care home staff. Studies reported improved outcomes from CGA affecting resident satisfaction, prescribing, healthcare resource use and objective measures of quality of care. CONCLUSION: The programme theory described here provides a framework for understanding how CGA could be effective in care homes. It will be of use to teams developing, implementing or auditing CGA in care homes. All three components are required to make CGA work-this may explain why attempts to implement CGA by interventions focused solely on assessment or care planning have failed in some long-term care settings. TRIAL REGISTRATION NUMBER: CRD42017062601.

Citizens' Juries: When Older Adults Deliberate on the Benefits and Risks of Smart Health and Smart Homes.

: Background: Technology-enabled healthcare or smart health has provided a wealth of products and services to enable older people to monitor and manage their own health conditions at home, thereby maintaining independence, whilst also reducing healthcare costs. However, despite the growing ubiquity of smart health, innovations are often technically driven, and the older user does not often have input into design. The purpose of the current study was to facilitate a debate about the positive and negative perceptions and attitudes towards digital health technologies. Methods: We conducted citizens' juries to enable a deliberative inquiry into the benefits and risks of smart health technologies and systems. Transcriptions of group discussions were interpreted from a perspective of life-worlds versus systems-worlds. Results: Twenty-three participants of diverse demographics contributed to the debate. Views of older people were felt to be frequently ignored by organisations implementing systems and technologies. Participants demonstrated diverse levels of digital literacy and a range of concerns about misuse of technology. Conclusion: Our interpretation contrasted the life-world of experiences, hopes, and fears with the systems-world of surveillance, efficiencies, and risks. This interpretation offers new perspectives on involving older people in co-design and governance of smart health and smart homes.

Using comprehensive geriatric assessment for quality improvements in healthcare of older people in UK care homes: protocol for realist review within Proactive Healthcare of Older People in Care Homes (PEACH) study.

INTRODUCTION: Care home residents are relatively high users of healthcare resources and may have complex needs. Comprehensive geriatric assessment (CGA) may benefit care home residents and improve efficiency of care delivery. This is an approach to care in which there is a thorough multidisciplinary assessment (physical and mental health, functioning and physical and social environments) and a care plan based on this assessment, usually delivered by a multidisciplinary team. The CGA process is known to improve outcomes for community-dwelling older people and those in receipt of hospital care, but less is known about its efficacy in care home residents. METHODS AND ANALYSIS: Realist review was selected as the most appropriate method to explore the complex nature of the care home setting and multidisciplinary delivery of care. The aim of the realist review is to identify and characterise a programme theory that underpins the CGA intervention. The realist review will extract data from research articles which describe the causal mechanisms through which the practice of CGA generates outcomes. The focus of the intervention is care homes, and the outcomes of interest are health-related quality of life and satisfaction with services; for both residents and staff. Further outcomes may include appropriate use of National Health Service services and resources of older care home residents. The review will proceed through three stages: (1) identifying the candidate programme theories that underpin CGA through interviews with key stakeholders, systematic search of the peer-reviewed and non-peer-reviewed evidence, (2) identifying the evidence relevant to CGA in UK care homes and refining the programme theories through refining and iterating the systematic search, lateral searches and seeking further information from study authors and (3) analysis and synthesis of evidence, involving the testing of the programme theories. ETHICS AND DISSEMINATION: The PEACH project was identified as service development following submission to the UK Health Research Authority and subsequent review by the University of Nottingham Research Ethics Committee. The study protocols have been reviewed as part of good governance by the Nottinghamshire Healthcare Foundation Trust. We aim to publish this realist review in a peer-reviewed journal with international readership. We will disseminate findings to public and stakeholders using knowledge mobilisation techniques. Stakeholders will include the Quality Improvement Collaboratives within PEACH study. National networks, such as British Society of Gerontology and National Care Association will be approached for wider dissemination. TRIAL REGISTRATION NUMBER: The realist review has been registered on International Prospective Register of Systematic Reviews (PROSPERO 2017: CRD42017062601).

Competing autocrine pathways involving alternative neuropilin-1 ligands regulate chemotaxis of carcinoma cells.

Neuropilin-1 (NP1), in conjunction with plexins, promotes axon repulsion by binding to semaphorin 3A (SEMA3A). Although NP1 is expressed in carcinoma cells, its functions have remained elusive, and neither SEMA3A nor plexin expression has been explored in cancer. Here we provide evidence that breast carcinoma cells support an autocrine pathway involving SEMA3A, plexin-A1, and NP1 that impedes their ability to chemotax. Reducing SEMA3A or NP1 expression by RNA interference or inhibiting plexin-A1 signaling enhanced migration. Conversely, expression of constitutively active plexin-A1 impaired chemotaxis. The paradox of how breast carcinoma cells expressing these endogenous chemotaxis inhibitors are able to migrate is explained by their expression of vascular endothelial growth factor (VEGF), a NP1 ligand that competes with SEMA3A for receptor binding. Finally, we establish that the ratio of endogenous VEGF and SEMA3A concentrations in carcinoma cells determines their chemotactic rate. Our findings lead to the surprising conclusion that opposing autocrine loops involving NP1 regulate the chemotaxis of breast carcinoma cells. Moreover, our data indicate a novel autocrine function for VEGF in chemotaxis.

PTEN couples Sema3A signalling to growth cone collapse.

Distinct changes in glycogen synthase kinase-3 (GSK-3) signalling can regulate neuronal morphogenesis including the determination and maintenance of axonal identity, and are required for neurotrophin-mediated axon elongation. In addition, we have previously shown a dependency on GSK-3 activation in the semaphorin 3A (Sema3A)-mediated growth-cone-collapse response of sensory neurons. Regulation of GSK-3 activity involves the intermediate signalling lipid phosphatidylinositol 3,4,5-trisphosphate, which can be modulated by phosphatidylinositol 3-kinase (PI3K) and the tumour suppressor PTEN. We report here the involvement of PTEN in the Sema3A-mediated growth cone collapse. Sema3A suppresses PI3K signalling concomitant with the activation of GSK-3, which depends on the phosphatase activity of PTEN. PTEN is highly enriched in the axonal compartment and the central domain of sensory growth cones during axonal extension, where it colocalises with microtubules. Following exposure to Sema3A, PTEN accumulates rapidly at the growth cone membrane suggesting a mechanism by which PTEN couples Sema3A signalling to growth cone collapse. These findings demonstrate a dependency on PTEN to regulate GSK-3 signalling in response to Sema3A and highlight the importance of subcellular distributions of PTEN to control growth cone behaviour.