Integrating health promotion with and for older people - eHealth (IHOPe) - evaluating remote integrated person-centred care : Protocol of a randomised controlled trial with effectiveness, health economic, and process evaluation.

BACKGROUND: Healthcare and welfare systems worldwide are unprepared to accommodate the growing population of older people. Simultaneously, the cost of reactive care for older people is increasing. However, healthcare systems in many countries are reforming towards integrated and person-centred care with a focus on health promotion and proactive actions. The Integrating Health Promotion with and for Older People - eHealth (IHOPe) project aims to describe and evaluate a person-centred e-support intervention that promotes a sustainable partnership between community-dwelling frail older people and health and social care professionals. METHODS: The IHOPe project is designed as a randomised controlled trial comparing a control group receiving standard care with an intervention group receiving standard care and add-on person-centred care through telephone support and a digital platform. The primary outcome measure is a composite score of changes in general self-efficacy and the need for unscheduled hospital care. The project is conducted in Gothenburg, Sweden. At least 220 participants aged ≥ 75 years will be included after being screened using a frailty instrument. The study design, intervention components, digital platform, and questionnaires were developed in close collaboration with an advisory group of inter-professional researchers, stakeholders, clinicians, and older representatives. Data will mainly be collected through questionnaires at baseline and 3, 6, and 12 months after inclusion in the study. Recruitment is ongoing and should be completed during 2023. Data will be analysed using quantitative and qualitative methods. The evaluation will include effectiveness, process, and health economics. The study was approved by the Regional Ethical Review Board in Gothenburg, Sweden (Dnr 2019-05364, Dnr 2020-03550, Dnr 2021-03255). DISCUSSION: The findings will expand our knowledge of remotely integrated person-centred care for frail older people. Thereby, the IHOPe project is expected to fill highlighted knowledge gaps on intervention evaluations including the triad of person-centred, digital, and integrated care elements, as well as economic evaluations of remote health services for frail older people. The study is ongoing, and the results are not completed but if they turn out to be positive, implementation is not limited to time or location. TRIAL REGISTRATION: ClinicalTrial.gov: NCT04416815. Registered 07/06/2021.

Meaningful use of a digital platform and structured telephone support to facilitate remote person-centred care - a mixed-method study on patient perspectives.

BACKGROUND: Process evaluations are useful in clarifying results obtained from randomised controlled trials (RCTs). Traditionally, the degree of intervention usage in process evaluations is monitored by measuring dose or evaluating implementation fidelity. From a person-centred perspective, such evaluations should be supplemented with patients' experiences of meaningful use, given that intervention use should be agreed upon between interested parties and tailored to each patient. This study aimed to elucidate patients' experiences of a remote person-centred care (PCC) intervention by deepening the understanding of, if, how and for whom the intervention contributed to meaningful use. METHODS: Patients (n = 86) were recruited from the RCT PROTECT intervention group. A convergent mixed-method approach was implemented. Data were collected in parallel with the ongoing RCT via a survey, including ratings and written comments on meaningful or non-meaningful use. Also, interviews were performed with twelve purposefully selected participants. Descriptive statistics, logistic regression and content analysis were employed. Data sources were integrated in the results. RESULTS: Most participants rated the overall intervention as meaningful to use, with the telephone support rated as most meaningful. Interviews and written comments showed that patient ratings on meaningful use were explained by four categories: Not in need, Communication deficiency, Benefits in everyday life and A personal boost. Meaningful use of rating symptoms on the digital platform was predicted by living alone (adjusted odds ratio [aOR] = 2.8 P = .044). A diagnosis of chronic obstructive pulmonary disease (COPD) predicted meaningful use of digital platform direct messaging (aOR = 3.5, P = .045). Moreover, having access to direct-dial telephone contact explained meaningful use among participants with low ratings of technical competence (aOR = 3.6, P = .014). CONCLUSIONS: The combined digital platform and structured telephone support could be helpful in identifying preventive actions to maintain health for people diagnosed with COPD and chronic heart failure but tends to be more meaningful for those diagnosed with COPD. Overall, lower adoption of the digital platform was seen compared to telephone support. Shortcomings were noted in the digital platform's implementation that negatively influences experiences of meaningful use. When used, the intervention proved to be an easily applicable and valued tool to support preventive actions in a person-centred manner.

Commentary: how person-centred is pharmaceutical care?

Health systems in many countries are currently undergoing an evolution towards more person-centred care. However, an overview of the literature shows that there is little or no guidance available on how to apply person-centred care to pharmaceutical care and clinical pharmacy practices. In this paper we apply a model for person-centred care created by a national multidisciplinary research centre in Gothenburg, Sweden, to the clinical work tasks of outpatient and inpatient pharmacists and describe how pharmaceutical care can become more person-centred.

Why do patients struggle with their medicines?-A phenomenological hermeneutical study of how patients experience medicines in their everyday lives.

Why do so many people struggle with their medicines despite decades of research on medicines taking? Research into how people experience medicines in their everyday life remains scarce with the majority of research in this area of focusing on whether or not people take their medicines as prescribed. Hence, this study used a phenomenological hermeneutical qualitative design to gain a deeper understanding of individuals' perspectives on the lived experience of medicine-taking. Findings from this study highlight five main themes where participants experience medicines as: 1) life-saving and indispensable, 2) normal and a daily routine, 3) confusing and concerning, 4) unsuitable without adjustment, and 5) intrusive and unwelcome. These results can be the basis for mutually agreed prescribing through a co-creative approach that aims at enhancing open and honest dialogues between patients and healthcare professionals in partnership about medicines.

Testing evidence routine practice: Using an implementation framework to embed a clinically proven asthma service in Australian community pharmacy.

INTRODUCTION: Community pharmacists are well placed and evidence clearly demonstrates that they can be suitably trained to deliver professional services that improve the management of asthma patients in clinical, economic and humanistic terms. However the gap between this evidence and practice reality remains wide. In this study we measure the implementation process as well as the service benefits of an asthma service model. METHODS: Using an effectiveness-implementation hybrid design, a defined implementation process (progression from Exploration through Preparation and Testing to Operation stages) supporting an asthma service (promoting asthma control and inhaler technique) was tested in 17 community pharmacies across metropolitan Sydney. RESULTS: Seven pharmacies reached the Operation stage of implementation. Eight pharmacies reached the Testing stage of implementation and two pharmacies did not progress beyond the Preparation stage of implementation. A total of 128 patients were enrolled in the asthma service with 110 patients remaining enrolled at the close of the study. Asthma control showed a positive trend throughout the service with the overall proportion of patients with 'poor' asthma control at baseline decreasing from 72% to 57% at study close. There was a statistically significant increase in the proportion of patients with correct inhaler technique from 12% at Baseline (Visit 1) to 33% at Visit 2 and 57% at study close. CONCLUSION: Implementation of the asthma service varied across pharmacies. Different strategies specific to practice sites at different stages of the implementation model may result in greater uptake of professional services. The asthma service led to improved patient outcomes overall with a positive trend in asthma control and significant change in inhaler technique.

Dispensing good sleep health behaviours not pills--a cluster-randomized controlled trial to test the feasibility and efficacy of pharmacist-provided brief behavioural treatment for insomnia.

Behavioural therapies are recommended as the first-line treatment of insomnia; however, sedatives and hypnotics constitute the main treatment modality used in primary care. Community pharmacies provide a unique conduit for identifying and providing appropriate treatment for those with insomnia either purchasing prescription sedatives or seeking over-the-counter treatments. A feasibility study using a cluster-randomized controlled trial, testing the efficacy of trained pharmacists providing behavioural interventions such as stimulus control and sleep restriction to patients with insomnia, in improving insomnia severity was conducted. The intervention involved three pharmacy visits (baseline, 1 and 3 months follow-up). The control group received usual care and information sheets on insomnia. The primary outcome was the Insomnia Severity Index. Twelve community pharmacists (five control, seven intervention) in New South Wales, Australia were recruited and trained. These pharmacists, in turn, recruited 46 patients (22 control, 24 intervention (mean age 53.7 ± 18.4, 72% females) and delivered a brief behavioural therapy intervention. The overall decrease in Insomnia Severity Index from baseline to the 3-month follow-up in the intervention group, n = 17 (7.6 ± 4.3 points), was significantly greater than for the control group, n = 19 (2.9 ± 8.8 points) (mean difference 4.6, 95% confidence interval: 0.005-9.2, P = 0.05). However, when the effect of clustering was taken into account using a mixed-effects model, the estimated difference in Insomnia Severity Index (change from baseline to visit 3) between the intervention and control groups was not significant (group difference in Insomnia Severity Index change = 3.78, 95% confidence interval: -0.81 to 8.37, P = 0.11; intracluster correlation = 0.18). The study highlights the use of a novel venue to deliver brief behavioural therapies for insomnia using trained non-psychologist health professionals. Although, when cluster effect was taken into account, the difference in Insomnia Severity Index reduction between the intervention versus control groups was non-significant, the results highlight that reductions in insomnia severity can be gained using trained pharmacists providing brief behavioural interventions. Future research in this area is warranted, with appropriately sized studies using the conventional, robust randomized trial design.

A comparison of screening methods for sleep disorders in Australian community pharmacies: a randomized controlled trial.

BACKGROUND: Community pharmacies may potentially assist in screening for chronic conditions such as sleep disorders, which remain both under-diagnosed and untreated. We aimed to compare a subjective risk-assessment-only questionnaire (RAO) for common sleep disorder screening against the same risk-assessment questionnaire plus a nasal flow monitor as an objective marker of possible underlying obstructive sleep apnea (OSA) (RA+) in a community pharmacy setting. The primary outcome was the number of participants identified in RAO or RA+ group who were likely to have and consequently be diagnosed with OSA. Further outcomes included the number of participants identified as being at risk for, referred for, taking-up referral for, and then diagnosed with OSA, insomnia, and/or restless legs syndrome (RLS) in either group. METHODS: In a cluster-randomized trial, participants were recruited through 23 community pharmacies. Using validated instruments, 325 (RAO = 152, RA+ = 173) participants were screened for OSA, insomnia, and RLS. FINDINGS: 218 (67%) participants were at risk of OSA, insomnia or RLS and these participants were referred to their primary physician. The proportion of screened participants identified as being at risk of OSA was significantly higher in the RA+ group (36% in RAO vs. 66% in RA+, OR 3.4, 95% CI (1.8-6.5), p<0.001). A 12-month follow-up was completed in 125 RAO and 155 RA+ participants. Actual referral uptake was 34% RAO, 26% RA+, OR 4.4, 95% CI (1.4-19.2), p = 0.31. The OSA diagnosis rate was higher in the RA+ arm (p = 0.01). To yield a single additional confirmed OSA diagnosis, 16 people would need to be screened using the RA+ protocol. CONCLUSIONS: These results demonstrate that utilising either screening method is feasible in identifying individuals in the community pharmacy setting who are likely to have OSA, insomnia and/or RLS. Secondly, adding an objective marker of OSA to a questionnaire-based prediction tool resulted in more confirmed OSA diagnoses. TRIAL REGISTRATION: ACTR.org.au ACTRN12608000628347.

Sleep disorders screening, sleep health awareness, and patient follow-up by community pharmacists in Australia.

INTRODUCTION: Community pharmacies are well placed to deliver education and counseling to improve sleep health. OBJECTIVE: To develop, implement and evaluate a pharmacist led sleep health program. METHODS: Participating pharmacists (n=23) were trained to screen, counsel and follow up patients at risk of sleep disorders. Patients were screened for specific sleep disorders, counseled, provided written information and/or referred to physicians. Patient outcomes were evaluated by questionnaire at 3 or 12 months post screening. RESULTS: A total of 325 patients were screened, with 142 (44%) patients at risk of one or more sleep disorders. A total of 847 interventions were recorded by pharmacists: verbal counseling (49%), written information (34%), and referrals (16%). A total of 63 patients (of 99 recalling being referred) reported acting on their referral. Positive changes were made with smoking (4%), caffeine intake (10%), alcohol intake (9%) and improved sleep environment (19%). CONCLUSION: Pharmacists can raise awareness through educating patients on sleep health, and through counseling initiate behavior change in those at risk of having or developing a sleep disorder. PRACTICE IMPLICATIONS: Further research using this feasibility study can help in understanding the utility of pharmacists screening patients for sleep disorders and educating the public in sleep health.

Standardizing care in medical oncology: are Web-based systems the answer?

BACKGROUND: Medical oncology is embracing information technology to standardize care and improve patient outcomes, with a range of Web-based systems used internationally. The authors' aim was to determine the factors affecting the uptake and use of a Web-based protocol system for medical oncology in the Australian setting. METHODS: The authors conducted 50 interviews and observed medical oncology physicians, nurses, and pharmacists in their treatment setting at 6 hospitals in different geographic locations. RESULTS: The Web-based system plays a major role in guiding oncology treatment across participating sites. However, its use varies according to hospital location, clinician roles, and experience. A range of issues impact on clinicians' attitudes toward and use of the Web-based system. Important factors are clinician-specific (eg, their need for autonomy and perceptions of lack of time) or environmental (eg, hospital policy on protocol use, endorsement of the system, and the availability of appropriate infrastructure, such as sufficient computers). The level of education received regarding the system was also found to be integral to its ongoing use. CONCLUSIONS: Although the provision of high-quality evidence-based resources, electronic or otherwise, is essential for standardizing care and improving patient outcomes, the authors' findings demonstrate that this alone does not ensure uptake. It is important to understand end-users, the environment in which they operate, and the basic infrastructure required to implement such a system. Implementation must also be accompanied by continuing education and endorsement to ensure both long-term sustainability and use of the system to its full potential.

The development of a sleep disorder screening program in Australian community pharmacies.

OBJECTIVE: To develop, pilot and determine the feasibility of a sleep-specific screening and awareness program in community pharmacies. SETTING: The screening was piloted in five Australian community pharmacies. METHOD: The Pharmacy Tool for Assessment of Sleep Health was constructed by drawing on known relationships between sleep disorders, and lifestyle factors, medical conditions and medications. Four validated instruments were used in the screening tool: the Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), Multivariable Apnea Prediction Index (MAPI) and International Restless Legs Syndrome Study Group Screening Criteria (IRLS). These instruments were used to predict the participant's risk of a sleep disorder and the results were compared with reported lifestyle, medical and medication factors. On-site training of consenting pharmacists was provided, followed by an eight week client recruiting and screening period. Feedback was elicited from participating pharmacists and clients. MAIN OUTCOME MEASURE: The feasibility of, and trends found from, the developed screening tool and protocol. RESULTS: Of 167 clients who requested or were invited to participate by pharmacists, 84 (50.3%) were screened. Analysis of collected data indicated that 33.3%, 21.4% and 27.4% of participants were at risk of having or developing insomnia, obstructive sleep apnea (OSA) and restless legs syndrome (RLS) respectively, while 38.1% were not at risk of any of the screened disorders. OSA odds increased 12.8 times (95% CI: 3.2-50.4) with diabetes and 4.9 times (1.2-20.9) with opioid use, while shift workers were 8.4 times (1.6-43.2) more likely to have insomnia. Participants and pharmacists reported the screening protocol and instrument was user friendly and feasible. CONCLUSION: The development and pilot of this screening tool was successful. The prevalence of sleep disorders in the sampled population was high but generally consistent with previous studies on the general population. Furthermore, associations found may form a foundation for a clinical algorithm to identify those at a higher risk of having or developing a sleep disorder. Further work is required to validate this screening tool in the community pharmacy context.