Identifying barriers to outpatient appointment attendance in patient groups at risk of inequity: a mixed methods study in a London NHS trust.

BACKGROUND: There is significant health inequity in the United Kingdom (U.K.), with different populations facing challenges accessing health services, which can impact health outcomes. At one London National Health Service (NHS) Trust, data showed that patients from deprived areas and minority ethnic groups had a higher likelihood of missing their first outpatient appointment. This study's objectives were to understand barriers to specific patient populations attending first outpatient appointments, explore systemic factors and assess appointment awareness. METHODS: Five high-volume specialties identified as having inequitable access based on ethnicity and deprivation were selected as the study setting. Mixed methods were employed to understand barriers to outpatient attendance, including qualitative semi-structured interviews with patients and staff, observations of staff workflows and interrogation of quantitative data on appointment communication. To identify barriers, semi-structured interviews were conducted with patients who missed their appointment and were from a minority ethnic group or deprived area. Staff interviews and observations were carried out to further understand attendance barriers. Patient interview data were analysed using inductive thematic analysis to create a thematic framework and triangulated with staff data. Subthemes were mapped onto a behavioural science framework highlighting behaviours that could be targeted. Quantitative data from patient interviews were analysed to assess appointment awareness and communication. RESULTS: Twenty-six patients and 11 staff were interviewed, with four staff observed. Seven themes were identified as barriers - communication factors, communication methods, healthcare system, system errors, transport, appointment, and personal factors. Knowledge about appointments was an important identified behaviour, supported by eight out of 26 patients answering that they were unaware of their missed appointment. Environmental context and resources were other strongly represented behavioural factors, highlighting systemic barriers that prevent attendance. CONCLUSION: This study showed the barriers preventing patients from minority ethnic groups or living in deprived areas from attending their outpatient appointment. These barriers included communication factors, communication methods, healthcare the system, system errors, transport, appointment, and personal factors. Healthcare services should acknowledge this and work with public members from these communities to co-design solutions supporting attendance. Our work provides a basis for future intervention design, informed by behavioural science and community involvement.

Implementing behavioural science informed letter interventions to increase COVID-19 vaccination uptake in uncontactable London residents: a difference-in-difference study in London, UK.

BACKGROUND: The UK COVID-19 vaccination programme began in December, 2020. By February, 2021, eight North West London Clinical Commissioning Groups (CCGs) had the lowest vaccination rates nationally. This study evaluated the impact of behavioural science-informed (BI) letters on vaccination uptake. METHODS: Unvaccinated residents of the Central London CCG who were deemed uncontactable (through text messaging and phone calls) were identified with the whole systems integrated care database. BI letters were sent to residents in the intervention CCG between May and June, 2021. Three neighbouring CCGs in London with similar non-responder data were used as control groups. A linear difference-in-difference analysis was undertaken to assess change in vaccine uptake rate across all four CCGs. Percentage point change was adjusted for selected covariates including ethnicity, age, gender, and index of multiple deprivation (IMD) quintiles. Approval was obtained from the quality improvement and audit office of Imperial College Healthcare NHS Trust (London, UK). FINDINGS: Within the intervention Central London CCG, 10 161 residents received the BI letter. The control CCGs contained 27 383 uncontactable residents. All CCGs showed an increase in vaccination rates in this population. The linear difference-in-difference analysis showed an increase in vaccination uptake in the intervention CCG (relative change 31·9% (95% CI 30·5-33·3; p<0·0001). Residents in IMD quintile 5 (least deprived) showed the largest rate of change (4·1%; p<0·0001). Residents with a mixed or multiple ethnic background were less likely to receive a COVID-19 vaccine (-4·1%, p<0·0001). INTERPRETATION: BI letters improved the rate of vaccine uptake. The percentage point increase of 31·9% equates to 436 additional previously uncontactable residents being vaccinated. Our data highlighted differences in the effect of BI-informed interventions in population subgroups. BI letters are a cost-effective and trusted communication tool, effectively engaging residents where other communication strategies did not work. FUNDING: None.

Understanding the facilitators and barriers to barcode medication administration by nursing staff using behavioural science frameworks. A mixed methods study.

INTRODUCTION: Barcode medication administration (BCMA) technology helps ensure correct medications are administered by nursing staff through scanning of patient and medication barcodes. In many hospitals scanning rates are low, limiting the potential safety benefits. We aimed to explore the barriers and facilitators to BCMA use in a London hospital. METHODS: In this mixed methods study we used local quantitative data on BCMA scanning rates to identify clinically similar wards (in terms of patient acuity and workload) with different scanning rates for qualitative exploration. Interviews designed to elicit barriers to using BCMA technology were conducted with nursing staff, supported by observations of medication administration. Qualitative data were analysed inductively and a thematic framework constructed housing key themes, subsequently categorised into barriers and facilitators. To explore patient perspectives of BCMA scanning, a purposive sample of patients were also interviewed. These patient data were analysed deductively according to the thematic framework. Themes were mapped to behavioural science frameworks to further understand the behaviours involved. RESULTS: BCMA was operational on 15 wards, with only six having medication scan rates of more than 10% of scannable doses. Of three wards selected for qualitative investigation, the lowest scan rate was 6.7%. Twenty-seven nurses and 15 patients were interviewed. Eleven key themes were identified, encompassing both barriers and facilitators to BCMA use. Barriers included poor trolley ergonomics and perceived time inefficiency. Facilitators included a streamlined process and thorough training. All nurses described BCMA as positive for patient safety. Patients described BCMA as making them "feel safer". Behavioural science frameworks highlighted the importance of professional role and an individual's belief in their capability. CONCLUSION: We present a novel exploration of facilitators and barriers to BCMA use from the viewpoint of both patients and nursing staff, highlighting a strong perception that BCMA enhances safety. Barriers were reported on both high and low usage wards, demonstrating the importance of behaviours and motivations. These findings provide a detailed understanding from which to design interventions to support behaviour change and increase BCMA use.

A population survey on beliefs around cervical cancer screening: determining the barriers and facilitators associated with attendance.

BACKGROUND: Cervical screening saves approximately 5000 lives annually in England. However, screening rates have been falling continuously, and coverage in London is particularly low (64.7%). While demographic predictors of uptake have been well researched, there has been less thorough investigation of the individual barriers and facilitators which predict cervical screening attendance. Understanding modifiable factors influencing attendance can guide the design of effective interventions to increase cervical screening uptake. The aim of this study was to understand the demographic, and individual factors associated with self-reported attendance at cervical screening in London. METHODS: The study used an online survey of 500 women in London (June-July 2017). The survey included self-reported measures of past attendance, demographic variables (including age, household income, ethnicity), past experience variables, and individual variables (list of potential barriers and facilitators developed based on the Theoretical Domains Framework and existing literature, which included: environmental context and resources, perceived risk, anticipated pain/embarrassment). Participants were categorised into regular attenders and non-regular attenders. Backwards stepwise logistic regression investigated the barriers and facilitators predicting past attendance. Demographic variables with significant differences between regular and non-regular attenders were added to the final regression model. RESULTS: Of women who had previously been invited (n = 461, age range: 25-65), 34.5% (n = 159) were classified as non-regular attenders, and 65.5% (n = 302) as regular attenders. The individual barriers and facilitators predicting attendance were: cervical screening priority, memory, environmental context and resources, and intention. The only demographic variables related to regular attendance were relationship status (married/civil partnership having higher rates than single) and higher household income. Relationship status was not significant when adjusting for barriers and facilitators. Those who have ever been sexually active or who have had an STI in the past were significantly more likely to be regular attenders. CONCLUSIONS: The study shows the importance of individual barriers and facilitators in predicting self-reported cervical screening attendance. Household income was the only significant demographic variable when combined with the individual variables. Interventions targeting priority, memory, and practical barriers affecting environmental context may be expected to be effective an increasing attendance.

Text Messaging and Opt-out Mailed Outreach in Colorectal Cancer Screening: a Randomized Clinical Trial.

BACKGROUND: Routine screening reduces colorectal cancer mortality, but screening rates fall below national targets and are particularly low in underserved populations. OBJECTIVE: To compare the effectiveness of a single text message outreach to serial text messaging and mailed fecal home test kits on colorectal cancer screening rates. DESIGN: A two-armed randomized clinical trial. PARTICIPANTS: An urban community health center in Philadelphia. Adults aged 50-74 who were due for colorectal cancer screening had at least one visit to the practice in the previously year, and had a cell phone number recorded. INTERVENTIONS: Participants were randomized (1:1 ratio). Individuals in the control arm were sent a simple text message reminder as per usual practice. Those in the intervention arm were sent a pre-alert text message offering the options to opt-out of receiving a mailed fecal immunochemical test (FIT) kit, followed by up to three behaviorally informed text message reminders. MAIN MEASURES: The primary outcome was participation in colorectal cancer screening at 12 weeks. The secondary outcome was the FIT kit return rate at 12 weeks. KEY RESULTS: Four hundred forty participants were included. The mean age was 57.4 years (SD ± 6.1). 63.4% were women, 87.7% were Black, 19.1% were uninsured, and 49.6% were Medicaid beneficiaries. At 12 weeks, there was an absolute 17.3 percentage point increase in colorectal cancer screening in the intervention arm (19.6%), compared to the control arm (2.3%, p < 0.001). There was an absolute 17.7 percentage point increase in FIT kit return in the intervention arm (19.1%) compared to the control arm (1.4%, p < 0.001). CONCLUSIONS: Serial text messaging with opt-out mailed FIT kit outreach can substantially improve colorectal cancer screening rates in an underserved population. TRIAL REGISTRATION: clinicaltrials.gov ( https://clinicaltrials.gov/ct2/show/NCT03479645 ).

Behavioral economics informed message content in text message reminders to improve cervical screening participation: Two pragmatic randomized controlled trials.

The objective of the reported research was to assess the impact of text message (SMS) reminders and their content on cervical screening rates. Women invited for cervical screening in Northwest London from February-October 2015 were eligible. 3133 women aged 24-29 (Study 1) were randomized (1, 1) to 'no SMS' (control), or a primary care physician (PCP) endorsed SMS (SMS-PCP). 11,405 women aged 30-64 (Study 2), were randomized (1, 1:1:1:1:1:1) to either: no SMS, an SMS without manipulation (SMS), the SMS-PCP, an SMS with a total or proportionate social norm (SMS-SNT or SMS-SNP), or an SMS with a gain-framed or loss-framed message (SMS-GF and SMS-LF). The primary outcome was participation at 18 weeks. In Study 1 participation was significantly higher in the SMS-PCP arm (31.4%) compared to control (26.4%, aOR, 1.29, 95%CI: 1.09-1·51; p = 0.002). In Study 2 participation was highest in the SMS-PCP (38.4%) and SMS (38.1%) arms compared to control (34.4%), (aOR: 1.19, 95%CI: 1.03-1.38; p = 0.02 and aOR: 1.18, 95%CI: 1.02-1.37; p = 0.03, respectively). The results demonstrate that behavioral SMSs improve cervical screening participation. The message content plays an important role in the impact of SMS. The results from this trial have already been used to designing effective policy for cervical cancer screening. The NHS Cervical Screening Programme started running a London-wide screening SMS campaign which was based on the cervical screening trial described here. According to figures published by Public Health England, after six months attendance increased by 4.8%, which is the equivalent of 13,400 more women being screened at 18 weeks.

Raising the barcode: improving medication safety behaviours through a behavioural science-informed feedback intervention. A quality improvement project and difference-in-difference analysis.

Barcode medication administration (BCMA) technology can improve patient safety by using scanning technology to ensure the right drug and dose are given to the right patient. Implementation can be challenging, requiring adoption of different workflows by nursing staff. In one London National Health Service trust scanning rates were lower than desired at around 0-20% of doses per ward. Our objective was to encourage patient safety behaviours in the form of medication scanning through implementation of a feedback intervention. This was informed by behavioural science, codesigned with nurses and informed by known barriers to use. Five wards were selected to trial the intervention over an 18-week period beginning August 2021. The remaining 14 hospital wards acted as controls. Intervention wards had varying uptake of BCMA at baseline and represented a range of specialties. A bespoke feedback intervention comprising three behavioural science constructs (gamification, the messenger effect and framing) was delivered to each intervention ward each week. A linear difference-in-difference analysis was used to evaluate the impact of our intervention on scan rates, both for the overall 18-week period and at two weekly intervals within this timeframe. We identified a 23.1 percentage point increase in medication scan rates (from an average baseline of 15.0% to 38.1%) on the intervention wards compared with control (p<0.001) following implementation of the intervention. Feedback had most impact in the first 6 weeks, with an initial percentage point increase of 26.3 (p<0.001), which subsequently plateaued. Neither clinical specialty nor number of beds on each ward were significant factors in our models. Our study demonstrated that a feedback intervention, codesigned with end users and incorporating behavioural science constructs, can lead to a significant increase in the adoption of BCMA scanning.

Testing the impact of differing behavioural science informed text message content in COVID-19 vaccination invitations on vaccine uptake: A randomised clinical trial.

Behavioural science constructs can be incorporated into messaging strategies to enhance the effectiveness of public health campaigns by increasing the occurrence of desired behaviours. This study investigated the impact of behavioural science-informed text message strategies on COVID-19 vaccination rates in 18-39-year-olds in an area of low uptake in London during the first vaccination offer round in the United Kingdom. This three-armed randomised trial recruited unvaccinated residents of an urban Central London suburb being offered their first vaccination between May and June 2021. Participants were randomised to receive the control (current practice) text message or one of two different behavioural science-informed COVID-19 vaccine invitation strategies. Both intervention strategies contained the phrase "your vaccine is ready and waiting for you", aiming to evoke a sense of ownership, with one strategy also including a pre-alert message. The main outcome measures were vaccination rates at 3 and 8 weeks after message delivery. A total of 88,820 residents were randomly assigned to one of the three trial arms. Each arm had a vaccine uptake rate of 27.2 %, 27.4 % and 27.3 % respectively. The mean age of participants was 28.2 years (SD ± 5.7), the mean index of multiple deprivation was 4.3 (SD ± 2.0) and 50.4 % were women. Vaccine uptake varied by demographics, however there was no significant difference between trial arms (p = 0.872). Delivery was successful for 53.6 % of text messages. Our choice of behavioural science informed messaging strategies did not improve vaccination rates above the rate seen for the current practice message. This likely reflects the wide exposure to public health campaigns during the pandemic, as such text messages nudges were unlikely to alter existing informed decision-making processes. Text message delivery was relatively low, indicating a need for accurate mobile phone number records and multi-modal approaches to reach eligible patients for vaccination. The protocol was registered at clinicaltrials.gov (NCT04895683) on 20/05/2021.

Association of Medicaid Healthy Behavior Incentive Programs With Smoking Cessation, Weight Loss, and Annual Preventive Health Visits.

Importance: Several states have implemented Healthy Behavior Incentive Programs (HBIPs) in Medicaid through Section 1115 demonstration waivers. These programs use financial incentives to encourage positive behavior changes, such as greater use of preventive services, smoking cessation, and weight loss. Objective: To test for an association between the introduction of HBIPs and the rates of smoking cessation, weight loss, and annual preventive health visits in states that have adopted behavior-specific programs compared with states that have not. Design, Setting, and Participants: A cohort study using a difference-in-differences analysis of the 2011-2016 Behavioral Risk Factor Surveillance Survey Interview Results data, adjusting for demographic conditions, state unemployment rates, state Medicaid expansion, national secular trends, and time invariant state-specific factors, was conducted. Two sets of participants were considered: adults aged 18 to 64 years who had a reported annual household income of less than $25 000 (n = 442 089) or adults aged 18 to 64 years who had completed high school education or less (n = 676 883). Exposures: Changes in health behavior outcomes in 4 states (Florida, Indiana, Iowa, and Michigan) that implemented behavior-specific HBIPs targeting smoking, obesity, and annual health checkups through a Section 1115 waiver, against changes in control states, including Washington, DC, that did not introduce an HBIP (n = 44). Main Outcomes and Measures: Rate of smoking, obesity, and attendance at annual preventive health visits. Results: Of Behavioral Risk Factor Surveillance Service respondents used for the less than $25 000 annual household income cohort (n = 442 089), the mean (SD) age was 43.1 (0.8) years, and the mean (SD) percentage of women was 58.4% (2.5%). For the cohort of high school education or less (n = 676 883) population, the mean (SD) age was 41.6 (1.1) years, and the mean (SD) percentage of women was 46.6% (0.9%). During a 2-year period after implementation, there were no improvements in smoking and obesity in individuals with a household income of less than $25 000 (2.49 percentage points, 95% CI, 1.75-3.23 percentage points; P < .001 and -1.94 percentage points, 95% CI, -4.42 to 0.55 percentage points; P = .12, respectively) as well as in the population holding a high school education or less (1.74 percentage points, 95% CI, 0.64-2.85 percentage points; P = .003 and -0.73 percentage points, 95% CI, -1.84 to 0.38 percentage points; P = .19). An association was noted between an increase in preventive health visit rates among states adopting behavior-specific HBIPs relative to control states in the less than $25 000 household income population (3.89 percentage points, 95% CI, 2.64-5.14 percentage points; P < .001). However, these associations were substantively small and not robust across the high school education or less population (1.8 percentage points, 95% CI, -0.12 to 3.71 percentage points; P = .07). Conclusions and Relevance: Early postimplementation assessment may indicate that HBIPs were not associated with substantive improvements in incentivized healthy behaviors among populations likely to be Medicaid beneficiaries. The value, format, and timing of the incentive, complexity in delivery, and lack of awareness of incentives among target beneficiaries and clinicians may limit the usefulness of programs even over a longer follow-up period.

Regulation of CD38 in proliferating chronic lymphocytic leukemia cells stimulated with CD154 and interleukin-4.

BACKGROUND AND OBJECTIVES: Chronic lymphocytic leukemia (CLL) cells, like normal B-cells, exist in two populations in vivo: quiescent cells in the peripheral circulation and proliferating cells in lymph nodes. The surface marker CD38 has roles in cell adhesion and signaling. Its expression correlates with poor clinical outcome and is associated with expression of the signaling intermediate ZAP-70, which is also a marker of poor prognosis. We investigated the regulation of CD38 and ZAP-70 in proliferating CLL cells. DESIGN AND METHODS: We cultured CLL cells on a stromal cell layer that maintains viability and also with some stromal cells expressing CD40 ligand (CD154) in order to measure changes in expression of CD38 and ZAP-70. RESULTS: We demonstrated up-regulation of CD38 expression by CD154. The degree of up-regulation did not correlate with clinical stage or mutational status. In addition in the majority of cases tested ZAP-70 expression increased in parallel with up-regulation of CD38 although discordant cases were also observed. INTERPRETATION AND CONCLUSIONS: Overall we demonstrated that regulation of CD38 in CLL is dynamic and dependent on signals from CD154 and a stromal cell layer. We speculate that CD38 and ZAP-70 are expressed in lymph node leukemic cells in both good and poor prognosis patients, but, in cases with good clinical outcome, these molecules are down-regulated in the peripheral blood whereas in cases with poor prognosis their expression is maintained.

Central round block repair of large breast resection defects: oncologic and aesthetic outcomes.

BACKGROUND: The central round block repair is a volume displacement technique to reconstruct large wide local excision (WLE) defects in breasts with moderate ptosis or hypertrophy. There are limited published data on the outcomes of this technique. METHODS: Data were collected prospectively for 57 consecutive patients and follow up information obtained from patient records. The volume of breast resection was estimated geometrically from mammography. Aesthetic outcomes were assessed from clinical measurements and panel review of patient photographs. RESULTS: The median age was 51 [22-86] years and follow-up 5 (1.9-8.4) years. The median specimen resection weight was 50 [25-361] g and tumour size 25 [10-75] mm. Estimated volume of breast excised was 17.8% (6-31%). In total, 12/57 patients had incomplete margins: five patients had re-excision to achieve clear margins and seven required mastectomy. Two patients had local recurrence during the follow-up period, five developed distant metastases. Aesthetic data were completed for 35/50 patients. Twelve (34%) had no measurable asymmetry and 31 (89%) had a nipple position within 2 cm of the original height. Only two patients requested symmetrising surgery. CONCLUSIONS: Central round block reconstruction of large defects after WLE is a safe technique with good aesthetic outcomes. Contralateral symmetrising surgery is not usually required.

Symptomatic myositis ossificans following computer navigated total knee replacement: a complication of fixed femoral marker placement.

Myositis ossificans is a rare cause of pain following knee arthroplasty. We describe a 72-year-old woman who developed symptomatic early onset myositis ossificans at the femoral marker pin site following navigated knee arthroplasty.