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INTRODUCTION: The adoption of remote healthcare methods has been accelerated by the COVID-19 pandemic, but evidence suggests that some patients need additional support to engage remotely, potentially increasing health disparities if needs are not met. This study of COVID-19 remote home monitoring services across England explores experiences of and engagement with the service across different patient groups. METHODS: This was a mixed-methods study with survey and interview data collected from 28 services across England between February and June 2021. Surveys were conducted with staff and patients and carers receiving the service. Interviews with staff service leads, patients and carers were conducted in 17 sites. Quantitative data were analysed using univariate and multivariate methods, and qualitative data were analysed using thematic analysis. FINDINGS: Survey responses were received from 292 staff and 1069 patients and carers. Twenty-three staff service leads, 59 patients and 3 carers were interviewed. Many service leads reported that they had considered inclusivity when adapting the service for their local population; strategies included widening the eligibility criteria, prioritising vulnerable groups and creating referral pathways. However, disparities were reported across patient groups in their experiences and engagement. Older patients reported the service to be less helpful (p = 0.004), were more likely to report a problem (p < 0.001) and had more difficulty in understanding information (p = 0.005). Health status (p = 0.004), ethnicity (p < 0.001), gender (p < 0.001) and employment (p = 0.007) were associated with differential engagement with monitoring, and minority ethnic groups reported more difficulty understanding service information (p = 0.001). Qualitative data found illness severity to be an important factor in the support required, and patients' living situation and social network affected whether they found the service reassuring. CONCLUSION: Addressing health disparities must be a key focus in the design and delivery of remote care. Services should be tailored to match the needs of their local population, encourage access through collaboration and referral pathways with other services and monitor their inclusiveness. Involving patients and staff in service design can illuminate the diversity of patients' needs and experiences of care. PATIENT OR PUBLIC CONTRIBUTION: The study team met with service user and public members of the BRACE PPI group and patient representatives from RSET in a series of workshops. Workshops informed study design, data collection tools, data interpretation and dissemination activities. Study documents (such as consent forms, topic guides, surveys and information sheets) were reviewed by PPI members; patient surveys and interview guides were piloted, and members also commented on the manuscript.
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COVID-19 , Serviços de Assistência Domiciliar , Telemedicina , Humanos , COVID-19/terapia , Masculino , Feminino , Pessoa de Meia-Idade , Idoso , Inglaterra , Adulto , Serviços de Assistência Domiciliar/organização & administração , SARS-CoV-2 , Disparidades em Assistência à Saúde , Inquéritos e Questionários , Idoso de 80 Anos ou maisRESUMO
This initial article delves into the methodology, methods and theories, while the subsequent article will centre on the discoveries, discussion and conclusion. The study aimed to address the research question: how do men perceive their engagement in the self-management of non-cancer-related lymphoedema? An interpretivist qualitative methodology was employed, utilising an online survey based on the validated lymphoedema quality of life tool (LYMQoL). The data underwent inductive narrative inquiry. The study incorporated theories such as hegemonic masculinity and the health, illness, men and masculinities (HIMM) framework. The findings will be detailed in the second article in this series. This article has delineated the objective, methodologyand methods, employing a qualitative interpretivist approach through narrative inquiry. The study incorporated masculinity theories, including hegemonic masculinity and HIMM. The second article will present the findings and their significance within the broader literature.
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Masculinidade , Qualidade de Vida , Masculino , Humanos , Reino Unido , Pesquisa QualitativaRESUMO
BACKGROUND: People need high-quality information to make decisions about research participation. Providing information in written format alone is conventional but may not be the most effective and acceptable approach. We developed a structure for the presentation of information using multimedia which included generic and trial-specific content. Our aim was to embed 'Studies Within A Trial' (SWATs) across multiple ongoing trials to test whether multimedia presentation of patient information led to better rates of recruitment. METHODS: Five trials included a SWAT and randomised their participants to receive a multimedia presentation alongside standard information, or standard written information alone. We collected data on trial recruitment, acceptance and retention and analysed the pooled results using random effects meta-analysis, with the primary outcome defined as the proportion of participants randomised following an invitation to take part. RESULTS: Five SWATs provided data on the primary outcome of proportion of participants randomised. Multimedia alongside written information results in little or no difference in recruitment rates (pooled odds ratio = 0.96, 95% CI: 0.79 to 1.17, p-value = 0.671, I2 = 0%). There was no effect on any other outcomes. CONCLUSIONS: Multimedia alongside written information did not improve trial recruitment rates. TRIAL REGISTRATION: ISRCTN71952900, ISRCTN 06710391, ISRCTN 17160087, ISRCTN05926847, ISRCTN62869767.
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Multimídia , Projetos de Pesquisa , Humanos , Seleção de Pacientes , Razão de ChancesRESUMO
Background: Between 2018 and 2025, a national implementation programme is funding more than 500 new mental health support teams (MHSTs) in England, to work in education settings to deliver evidence-based interventions to children with mild to moderate mental health problems and support emotional wellbeing for all pupils. A new role, education mental health practitioner (EMHP), has been created for the programme.Aims: A national evaluation explored the development, implementation and early progress of 58 MHSTs in the programme's first 25 'Trailblazer' sites. This paper reports the views and experiences of people involved in MHST design, implementation and service delivery at a local, regional and national level.Methods: Data are reported from in-depth interviews with staff in five Trailblazer sites (n = 71), and the programme's regional (n = 52) and national leads (n = 21).Results: Interviewees universally welcomed the creation of MHSTs, but there was a lack of clarity about their purpose, concerns that the standardised CBT interventions being offered were not working well for some children, and challenges retaining EMHPs.Conclusions: This study raises questions about MHSTs' service scope, what role they should play in addressing remaining gaps in mental health provision, and how EMHPs can develop the skills to work effectively with diverse groups.
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AIMS: To review and synthesise the contemporary qualitative evidence, relating to the individual, healthcare professional and system-level barriers and facilitators to injectable therapies in people with type 2 diabetes, and evaluate (using an intersectional approach to explore the diverse perspectives of different identities) whether views have changed with treatment and guideline advancements. METHODS: A meta-ethnography approach used. Eight databases searched from the years 2006 (GLP-1 analogues introduced) to February 2021. Study selection (using a pre-defined inclusion criteria), quality appraisal and data extraction, conducted independently by two reviewers. RESULTS: Screened 7143 abstracts, assessed 93 full-text papers for eligibility and included 42 studies-using data from 818 individuals with type 2 diabetes and 160 healthcare professionals. Studies covered a diverse range of views from healthcare professionals and individuals, including those relating to older adults and people from ethnic migrant backgrounds, and 10 studies rated moderate to strong research value. Key themes abstracted: barriers (physical/psychological/social) and facilitators (motivation/capability/opportunity). CONCLUSIONS: The first synthesis of contemporary qualitative data to adopt an intersectionality approach and explore diverse views relating to barriers and facilitators that influence engagement with injectable treatments for type 2 diabetes. A model is presented to help patients, health practitioners and policy makers identify barriers and facilitators and understand the complex interplay of physical, psychological and social factors involved when prescribing injectable therapies. Despite advances in injectable treatments and guidelines, findings highlight the many barriers that still exist and show how strongly held culturally-specific health beliefs of people from diverse socio-economic and ethnic backgrounds can become substantial obstacles to treatment.
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Antropologia Cultural/métodos , Atenção à Saúde/métodos , Diabetes Mellitus Tipo 2/tratamento farmacológico , Pessoal de Saúde/psicologia , Hipoglicemiantes/administração & dosagem , Pesquisa Qualitativa , Humanos , Injeções , MotivaçãoRESUMO
INTRODUCTION: Remote home monitoring models were implemented during the COVID-19 pandemic to shorten hospital length of stay, reduce unnecessary hospital admission, readmission and infection and appropriately escalate care. Within these models, patients are asked to take and record readings and escalate care if advised. There is limited evidence on how patients and carers experience these services. This study aimed to evaluate patient experiences of, and engagement with, remote home monitoring models for COVID-19. METHODS: A rapid mixed-methods study was carried out in England (conducted from March to June 2021). We remotely conducted a cross-sectional survey and semi-structured interviews with patients and carers. Interview findings were summarized using rapid assessment procedures sheets and data were grouped into themes (using thematic analysis). Survey data were analysed using descriptive statistics. RESULTS: We received 1069 surveys (18% response rate) and conducted interviews with patients (n = 59) or their carers (n = 3). 'Care' relied on support from staff members and family/friends. Patients and carers reported positive experiences and felt that the service and human contact reassured them and was easy to engage with. Yet, some patients and carers identified problems with engagement (e.g., hesitancy to self-escalate care). Engagement was influenced by patient factors such as health and knowledge, support from family/friends and staff, availability and ease of use of informational and material resources (e.g., equipment) and service factors. CONCLUSION: Remote home monitoring models place responsibility on patients to self-manage symptoms in partnership with staff; yet, many patients required support and preferred human contact (especially for identifying problems). Caring burden and experiences of those living alone and barriers to engagement should be considered when designing and implementing remote home monitoring services. PATIENT OR PUBLIC CONTRIBUTION: The study team met with service users and public members of the evaluation teams throughout the project in a series of workshops. Workshops informed study design, data collection tools and data interpretation and were conducted to also discuss study dissemination. Public patient involvement (PPI) members helped to pilot patient surveys and interview guides with the research team. Some members of the public also piloted the patient survey. Members of the PPI group were given the opportunity to comment on the manuscript, and the manuscript was amended accordingly.
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COVID-19 , Assistência ao Paciente , Participação do Paciente , Telemedicina , Humanos , Cuidadores , Estudos Transversais , PandemiasRESUMO
BACKGROUND: Prioritisation processes are widely used in healthcare research and increasingly in social care research. Previous research has recommended using consensus development methods for inclusive research agenda setting. This research has highlighted the need for transparent and systematic methods for priority setting. Yet there has been little research on how to conduct prioritisation processes using rapid methods. This is a particular concern when prioritisation needs to happen rapidly. This paper aims to describe and discuss a process of rapidly identifying and prioritising a shortlist of innovations for rapid evaluation applied in the field of adult social care and social work. METHOD: We adapted the James Lind Alliance approach to priority setting for rapid use. We followed four stages: (1) Identified a long list of innovations, (2) Developed shortlisting criteria, (3) Grouped and sifted innovations, and (4) Prioritised innovations in a multi-stakeholder workshop (n = 23). Project initiation through to completion of the final report took four months. RESULTS: Twenty innovations were included in the final shortlist (out of 158 suggested innovations). The top five innovations for evaluation were identified and findings highlighted key themes which influenced prioritisation. The top five priorities (listed here in alphabetical order) were: Care coordination for dementia in the community, family group conferencing, Greenwich prisons social care, local area coordination and MySense.Ai. Feedback from workshop participants (n = 15) highlighted tensions from using a rapid process (e.g. challenges of reaching consensus in one workshop). CONCLUSION: The method outlined in this manuscript can be used to rapidly prioritise innovations for evaluation in a feasible and robust way. We outline some implications and compromises of rapid prioritisation processes for future users of this approach to consider.
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Prioridades em Saúde , Apoio Social , Adulto , Consenso , Humanos , Inovação Organizacional , Projetos de Pesquisa , Serviço SocialRESUMO
BACKGROUND: Migrants from South Asia living in developed countries have an increased risk for developing cardiovascular disease (CVD), with limited research into underlying social causes. METHODS: We used social capital as an interpretive lens to undertake analysis of exploratory qualitative interviews with three generations of at-risk migrant Pakistani men from the West Midlands, UK. Perceptions of social networks, trust, and cultural norms associated with access to healthcare (support and information) were the primary area of exploration. RESULTS: Findings highlighted the role of social networks within religious or community spaces embedded as part of ethnic enclaves. Local Mosques and gyms remained key social spaces, where culturally specific gender differences played out within the context of a diaspora community, defined ways in which individuals navigated their social spheres and influenced members of their family and community on health and social behaviours. CONCLUSIONS: There are generational and age-based differences in how members use locations to access and develop social support for particular lifestyle choices. The pursuit of a healthier lifestyle varies across the diverse migrant community, determined by social hierarchies and socio-cultural factors. Living close to similar others can limit exposure to novel lifestyle choices and efforts need to be made to promote wider integration between communities and variety of locations catering to health and lifestyle.
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Masculinidade , Rede Social , Humanos , Masculino , Paquistão , Pesquisa Qualitativa , Reino UnidoRESUMO
Health coaching is a novel population intervention to support self-management but it is untested in people with mild disease. People with chronic obstructive pulmonary disease with mild dyspnea are a population excluded from supported self-management and whose illness might progress without intervention. We explored participants' experiences about how health coaching motivated behavior change. Interviews were conducted with 21 intervention and 10 control participants at 6 months, and 20 intervention participants at 12 months. Participants were identified from a randomized controlled trial of telephone health coaching. Data were analyzed using the framework method. Participants positively enacted behavior change to become more physically active. Participants took advantage of environmental affordances to pull themselves toward activity targets, or relied on being pushed to be more active by the health coach or significant others. Behavior change was maintained where efforts to be more active were built into the everyday lifeworld of participants.
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Conhecimentos, Atitudes e Prática em Saúde , Tutoria/métodos , Motivação , Doença Pulmonar Obstrutiva Crônica/psicologia , Autogestão/métodos , Idoso , Idoso de 80 Anos ou mais , Feminino , Comportamentos Relacionados com a Saúde , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Enfermeiras e Enfermeiros , Doença Pulmonar Obstrutiva Crônica/terapia , Ensaios Clínicos Controlados Aleatórios como Assunto , Autocuidado/métodos , TelefoneRESUMO
BACKGROUND: Many overweight people find it difficult to maintain weight loss after attending a weight reduction programme. Self-weighing and telephone support are known to be useful methods for self-monitoring for weight loss. We examined the effectiveness of an SMS-text messaging based weight maintenance programme to encourage regular self-weighing in adults who had completed a 12 week commercial weight loss programme. METHODS: Randomised controlled trial of 380 obese or overweight men and women. The intervention group (N = 190) received a single maintenance support phone call and SMS-text based weight maintenance messages over 12 weeks to encourage regular self-weighing after completing their weight loss programme. The primary outcome was change in weight at 9 months follow up. RESULTS: Our sample (N = 380) had a mean age of 47.4 years (SD 13.4), mean baseline weight and BMI of 93.1 kg (16.1) and 34.4 kg/m(2) (5.0) respectively, as well as majority female (87.3%) and White British (80.0%). Using intention to treat analysis both groups regained weight at 9 months follow up; the intervention group regained an average of 1.36 kg while the control group regained 1.81 kg. Adjusting for covariates resulted in a mean difference of 0.45 kg (95% CI -0.78, 1.67) favouring the intervention group at 9 month follow up. CONCLUSIONS: We found no evidence that an SMS based weight maintenance intervention encouraging adults to weigh themselves weekly prevented weight regain at 3 or 9 months after completing a commercial weight loss programme. TRIAL REGISTRATION: Current Controlled Trials ISRCTN47845106 .
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Manutenção do Peso Corporal , Obesidade , Avaliação de Programas e Projetos de Saúde , Envio de Mensagens de Texto , Programas de Redução de Peso , Adulto , Índice de Massa Corporal , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Obesidade/prevenção & controle , Obesidade/terapia , Sobrepeso , Telefone , Reino Unido , Aumento de Peso , Redução de PesoRESUMO
OBJECTIVE: The global prevalence of non-communicable diseases (NCDs), such as diabetes mellitus and coronary heart disease, continues to rise. Internationally, people of South Asian origin (i.e. by birth or heritage) are much more likely to develop and live with NCDs compared to the general population. The South Asian diaspora population is highly heterogeneous, varying by socioeconomic status, migration history, religion and ethnicity. This article reports the findings of a study to explore the types of support accessed by Punjabi Sikhs living in Birmingham and the Black Country, UK, who were living with NCDs. DESIGN: The study sought to develop a greater understanding of past experiences of accessing support and the importance of relationships in the mobilisation of resources for self-management. It was nested within a larger programme of research which explored attitudes to prevention of chronic diseases in local communities in the region. Seventeen Punjabi Sikh men and women were recruited through purposive sampling. Narrative interviews were conducted and analysed by the research team. Sociological theories on systems of support and social relations were consulted to inform the interpretation of data. RESULTS: The study findings suggest that participants interpreted chronic disease self-management in relation to four primary systems of support: health services for disease management; multiple sources of care, including traditional Indian medicines and the Internet, for symptom management; community groups for lifestyle management; and the family for emotional and physical care. Within these systems of support, participants identified barriers and facilitators to the maintenance of a healthy lifestyle. We focus on intra-group diversity; exploring the intersection of views and experiences by age, gender, generation and caste. CONCLUSION: The findings have implications for the design and delivery of primary care and community services which support the prevention and management of NCDs in an increasingly diverse population.
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Doença Crônica/psicologia , Conhecimentos, Atitudes e Prática em Saúde/etnologia , Autogestão/métodos , Autogestão/psicologia , Apoio Social , Adolescente , Adulto , Idoso , Doença Crônica/terapia , Terapias Complementares , Emigrantes e Imigrantes , Família/psicologia , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Siquim/etnologia , Medicina Estatal , Reino Unido , Adulto JovemRESUMO
BACKGROUND: The prevalence of diagnosed chronic obstructive pulmonary disease (COPD) in the UK is 1.8%, although it is estimated that this represents less than half of the total disease in the population as much remains undiagnosed. Case finding initiatives in primary care will identify people with mild disease and symptoms. The majority of self-management trials have identified patients from secondary care clinics or following a hospital admission for exacerbation of their condition. This trial will recruit a primary care population with mild symptoms of COPD and use telephone health coaching to encourage self-management. METHODS/DESIGN: In this study, using a multi-centred randomised controlled trial (RCT) across at least 70 general practices in England, we plan to establish the effectiveness of nurse-led telephone health coaching to support self-management in primary care for people who report only mild symptoms of their COPD (MRC grade 1 and 2) compared to usual care. The intervention focuses on taking up smoking cessation services, increasing physical activity, medication management and action planning and is underpinned by behavioural change theory. In total, we aim to recruit 556 patients with COPD confirmed by spirometry with follow up at six and 12 months. The primary outcome is health related quality of life using the St Georges Respiratory Questionnaire (SGRQ). Spirometry and BMI are measured at baseline. Secondary outcomes include self-reported health behaviours (smoking and physical activity), physical activity measured by accelerometery (at 12 months), psychological morbidity, self-efficacy and cost-effectiveness of the intervention. Longitudinal qualitative interviews will explore how engaged participants were with the intervention and how embedded behaviour change was in every day practices. DISCUSSION: This trial will provide robust evidence about the effectiveness of a novel telephone health coaching intervention to promote behaviour change and prevent disease progression in patients with mild symptoms of dyspnoea in primary care. TRIAL REGISTRATION: Current controlled trials ISRCTN06710391 .
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Broncodilatadores/uso terapêutico , Aconselhamento/métodos , Dispneia/terapia , Atividade Motora , Atenção Primária à Saúde , Doença Pulmonar Obstrutiva Crônica/terapia , Abandono do Hábito de Fumar , Telefone , Dispneia/etiologia , Inglaterra , Humanos , Padrões de Prática em Enfermagem , Doença Pulmonar Obstrutiva Crônica/complicações , Comportamento de Redução do Risco , Autocuidado/métodos , Índice de Gravidade de DoençaRESUMO
BACKGROUND: Self-management education is at the forefront of addressing the increasing prevalence of chronic diseases. For those at greatest risk, such as minority-ethnic and/or socio-economically deprived groups, self-management education can be culturally-tailored to encourage behavioural change. Yet, the application of culturally appropriate material and expertise within health promotion services continues to be debated. We critique the design, implementation, and delivery of a culturally-tailored self-management intervention, with particular focus on the experiences of lay educators. METHODS: A mixed methods qualitative evaluation was undertaken to understand self-management service provision to culturally diverse communities (i.e. how components such as lay workers, group-based design, and culturally-appropriate educational material are intended to encourage behavioural change). We interviewed lay educators delivering the Chronic Disease Educator programme along with attendees, whilst observing workshops. Data were thematically analysed using a content-based constant comparison approach through a number of interpretative analytical stages. RESULTS: Lay educators felt part of the local community, relating to attendees from different races and ethnicities. However, lay educators faced challenges when addressing health beliefs and changing lifestyle practices. Culturally-tailored components aided communication, with educator's cultural awareness leading to close relationships with attendees, while the group-based design facilitated discussions of the emotional impact of illness. CONCLUSIONS: Lay educators bring with them a number of nuanced skills and knowledge when delivering self-management education. The development and training required for this role is inhibited by financial constraints at policy-level. The interpretation of being from the 'community' links with the identity and status of the lay role, overlapping notions of race, ethnicity, and language.
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Competência Cultural , Educação de Pacientes como Assunto , Autocuidado , Adulto , Idoso , Doença Crônica , Comunicação , Parto Obstétrico , Gerenciamento Clínico , Feminino , Humanos , Entrevistas como Assunto , Masculino , Pessoa de Meia-Idade , Grupos Minoritários , Gravidez , Pesquisa Qualitativa , Adulto JovemRESUMO
Background: General practices are facing challenges such as rising patient demand and difficulties recruiting and retaining general practitioners. Greater use of digital technology has been advocated as a way of mitigating some of these challenges and improving patient access. This includes Digital First Primary Care, when a patient's first contact with primary care is through a digital route, either through a laptop or smartphone. The use of Digital First Primary Care has been expedited since COVID-19. There is little evidence of staff experiences of using Digital First Primary Care with more complex patients, such as those with multiple long-term conditions. Objective: To understand the experiences of those with multiple long-term conditions of Digital First Primary Care from the perspectives of healthcare professionals and stakeholders. Design: This was a qualitative evaluation, comprised of four distinct work packages: Work package 1: Locating the study within the wider context, engaging with literature, and co-designing the study approach and research questions with patients. Work package 2: Interviews with health professionals working across general practice and key expert topic stakeholders, including academics and policy-makers. Work package 3: Analysis of data and generation of themes, and testing findings with patients. Work package 4: Synthesis, reporting and dissemination. Results: The study commenced in January 2021 and in total 28 interviews were conducted with 14 health professionals and 15 stakeholders between January and August 2022. From the perspective of health professionals, Digital First Primary Care approaches could enable patients to speak with a clinician more quickly than traditional approaches. Those with multiple long-term conditions could submit healthcare readings from home, though health professionals felt patients may struggle navigating digital systems not designed to capture the nuances associated with living with multiple conditions. Clinicians expressed preferences for seeing patients face-to-face, particularly those with multiple long-term conditions, to identify non-verbal cues about a patient's health. Digital First Primary Care approaches provided an opportunity for clinicians to engage with the carers of patients living with multiple long-term conditions, yet there were concerns around obtaining consent and confidentiality. There remain debates among stakeholders about the nature and extent to which Digital First Primary Care impacts on staff workload. Limitations: At the time of data collection, general practices were facing considerable pressure to deliver care and respond to the COVID-19 pandemic. While it was originally intended that the study would include interviews with patients with multiple long-term conditions and their carers, none of the general practices that took part in the study were willing and/or able to recruit patients and carers in the time available. Conclusions: The rapid implementation of Digital First Primary Care, at a time of immense pressures, meant there has been little time for considering the impact on patients, including those with multiple long-term conditions. The impacts on care continuity depended largely on how surgeries implemented their approaches. Staff and stakeholders felt that Digital First Primary Care, as an additional route for accessing primary care, could be useful for patients with multiple long-term conditions but not at the expense of face-to-face consultations. Future work: Future research obtaining patient and carer views of digital-first approaches, understanding the impacts on carers and how approaches are designed with patients with more complex conditions in mind, is essential. Funding: This award was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: 16/138/31) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 21. See the NIHR Funding and Awards website for further award information.
Healthcare professionals want to provide the best primary care in the face of increasing pressures, as well as improve access to care for patients. Digital First Primary Care is one response to this situation, when a patients' first contact with primary care is through a digital route, either through a laptop or smartphone. Online systems allow the patient to provide information to their practice about their symptoms or needs and request a response from a health professional. Our study aimed to understand how Digital First Primary Care works for healthcare professionals providing care to increasing numbers of patients with multiple long-term conditions and their carers. Firstly, we examined the relatively limited existing findings and then interviewed healthcare professionals and key stakeholders experienced in digital approaches within primary care (e.g. from policy organisations, universities and the National Health Service). While we attempted to speak to patients and carers directly, unfortunately the pressures in general practice meant we were unable to do so. However, the study was co-designed with patients. Healthcare professionals and stakeholders felt that patients with multiple long-term conditions faced additional challenges with the use of Digital First Primary Care compared to other patients. For example, they reported difficulties navigating online forms and not being able to speak with a general practitioner who knew them well. There were differing views from healthcare professionals and stakeholders about how far Digital First Primary Care could help staff in general practice and enhance care. For some clinicians, the workload was easier to manage and some simple tasks (e.g. sick notes) could be completed quickly. This could reduce stress for staff and mean more patients could be seen per day. Others felt that the digital system had shortcomings. This could be important for patients with multiple long-term conditions; for example, when a digital form may not fully inform the general practitioner as to the exact nature of the problem, potentially requiring a further follow-up appointment. Health professionals reported that carers of patients with multiple long-term conditions generally liked the new systems as they helped to improve contact with general practice staff. The summary was co-authored by members of the BRACE Patient and Public Involvement group.
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Saúde Digital , Múltiplas Afecções Crônicas , Relações Médico-Paciente , Inglaterra , Múltiplas Afecções Crônicas/terapia , Saúde Digital/normas , Saúde Digital/tendências , Humanos , Medicina Estatal/organização & administração , Medicina Estatal/normas , Medicina Estatal/tendências , Satisfação do Paciente/estatística & dados numéricos , Engajamento do Médico/estatística & dados numéricos , Entrevistas como AssuntoRESUMO
BACKGROUND: Debate surrounding the organisation and sustainability of primary care in England highlights the desirability of a more integrated approach to patient care across all settings. One such approach is 'vertical integration', where a provider of specialist care, such as a hospital, also runs general practices. AIM: To quantify the impact of vertical integration on hospital use in England. DESIGN & SETTING: Analysis of activity data for NHS hospitals in England between April 2013 and February 2020. METHOD: Analysis of NHS England data on hospital activity, which looked at the following seven outcome measures: accident and emergency (A&E) department attendances; outpatient attendances; total inpatient admissions; inpatient admissions for ambulatory care sensitive conditions; emergency admissions; emergency readmissions; and length of stay. Rates of hospital use by patients of vertically integrated practices and controls were compared, before and after the former were vertically integrated. RESULTS: In the 2 years after a GP practice changes, for the population registered at that practice, compared with controls, vertical integration is associated with modest reductions in rates of A&E attendances (2% reduction [incidence rate ratio {IRR} 0.98, 95% confidence interval {CI} = 0.96 to 0.99, P<0.0001]), outpatient attendances (1% reduction [IRR 0.99, 95% CI = 0.99 to 1.00, P = 0.0061]), emergency inpatient admissions (3% reduction [IRR 0.97, 95% CI = 0.95 to 0.99, P = 0.0062]), and emergency readmissions within 30 days (5% reduction [IRR 0.95, 95% CI = 0.91 to 1.00, P = 0.039]), with no impact on length of stay, overall inpatient admissions, or inpatient admissions for ambulatory care sensitive conditions. CONCLUSION: Vertical integration is associated with modest reductions in use of some hospital services and no change in others.
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BACKGROUND: Organisations providing secondary care in the NHS in England have historically not also provided primary health care, but this is changing. Data on where this kind of 'vertical integration' is happening are lacking, making it difficult to evaluate its impact. AIM: To compile a comprehensive list of instances of secondary care trusts running general practices in England, to enable evaluation of the impact of such arrangements. DESIGN & SETTING: This service mapping study comprises review, collation, synthesis, and analysis of published information describing secondary and primary care provision in the NHS in England in March 2021. METHOD: Desk-based collection, including hand-searching, of secondary care organisations' statutory annual reports. Triangulation via comparison with national data on general practices, the general practice workforce and practice contracts. RESULTS: It was possible to construct a database of all instances of trusts running general practices in England as of 31 March 2021. We have identified 26 trusts running a total of 85 general practices, operating across a total of 116 practice sites. These practices have on average fewer patients and fewer GP full-time equivalents than other general practices, and before becoming vertically integrated were performing less well in the Quality and Outcomes Framework. CONCLUSION: We recommend that national statistics recording the details of general practices contracting with the NHS should include whether each practice is owned by another organisation and whether that is an NHS trust, another public body, or a private organisation. Such data are required to enable evaluation of the impacts of this kind of vertical integration.
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BACKGROUND: Remote home monitoring services emerged as critical components of health care delivery from NHS England during the COVID-19 pandemic, aiming to provide timely interventions and reduce health care system burden. Two types of service were offered: referral by community health services to home-based care to ensure the right people were admitted to the hospital at the right time (called COVID Oximetry@home, CO@h); and referral by hospital to support patients' transition from hospital to home (called COVID-19 Virtual Ward, CVW). The information collected for the oxygen levels and other symptoms was provided via digital means (technology-enabled) or over the phone (analogue-only submission mode). This study aimed to evaluate the costs of implementing remote home monitoring for COVID-19 patients across 26 sites in England during wave 2 of the pandemic. Understanding the operational and financial implications of these services from the NHS perspective is essential for effective resource allocation and service planning. METHODS: We used a bottom-up costing approach at the intervention level to describe the costs of setting up and running the services. Twenty-six implementation sites reported the numbers of patients and staff involved in the service and other resources used. Descriptive statistics and multivariable regression analysis were used to assess cost variations and quantify the relationship between the number of users and costs while adjusting for other service characteristics. RESULTS: The mean cost per patient monitored was lower in the CO@h service compared with the CVW service (£527 vs £599). The mean cost per patient was lower for implementation sites using technology-enabled and analogue data submission modes compared with implementation sites using analogue-only modes for both CO@h (£515 vs £561) and CVW (£584 vs £612) services. The number of patients enrolled in the services and the service type significantly affected the mean cost per patient. CONCLUSIONS: Our analysis provides a framework for evaluating the costs of similar services in the future and shows that the implementation of these services benefit from the employment of tech-enabled data submission modes.
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Background: Vertical integration means merging organisations that operate at different stages along the patient pathway. We focus on acute hospitals running primary care medical practices. Evidence is scarce concerning the impact on use of health-care services and patient experience. Objectives: To assess the impact of vertical integration on use of hospital services, service delivery and patient experience and whether patients with multiple long-term conditions are affected differently from others. Design: Rapid, mixed methods evaluation with four work packages: (1) review of NHS trust annual reports and other sources to understand the scale of vertical integration across England; (2) development of the statistical analysis; (3) analysis of national survey data on patient experience, and national data on use of hospital services over the 2 years preceding and following vertical integration, comparing vertically integrated practices with a variety of control practices; and (4) focus groups and interviews with staff and patients across three case study sites to explore the impact of vertical integration on patient experience of care. Results: At 31 March 2021, 26 NHS trusts were in vertically integrated organisations, running 85 general practices across 116 practice sites. The earliest vertical integration between trusts and general practices was in 2015; a mean of 3.3 practices run by each trust (range 1-12). On average, integrated practices have fewer patients, are slightly more likely to be in the most deprived decile of areas, are more likely to hold an alternative provider medical services contract and have worse Quality and Outcomes Framework scores compared with non-integrated practices. Vertical integration is associated with statistically significant, modest reductions in rates of accident and emergency department attendances: 2% reduction (incidence rate ratio 0.98, 95% confidence interval 0.96 to 0.99; pâ <â 0.0001); outpatient attendances: 1% reduction (incidence rate ratio 0.99, 95% confidence interval 0.99 to 1.00; pâ =â 0.0061), emergency inpatient admissions: 3% reduction (incidence rate ratio 0.97, 95% confidence interval 0.95 to 0.99; pâ =â 0.0062) and emergency readmissions: 5% reduction (incidence rate ratio 0.95, 95% confidence interval 0.91 to 1.00; pâ =â 0.039), with no impact on length of stay, overall inpatient admissions or inpatient admissions for ambulatory care sensitive conditions. The falls in accident and emergency department and outpatient attendance rates are temporary. Focus groups and interviews with staff (Nâ =â 22) and interviews with patients (Nâ =â 14) showed that with vertical integration, health service improvements are introduced following a period of cultural interchange. Patients with multiple long-term conditions continue to encounter 'navigation work' choosing and accessing health-care provision, with diminishing continuity of care. Limitations: In the quantitative analysis, we could not replicate the counterfactual of what would have happened in those specific locations had practices not merged with trusts. There was imbalance across three case study sites with regard to staff and patients recruited for interview, and the latter were drawn from patient participation groups who may not be representative of local populations. Conclusions: Vertical integration can lead to modest reductions in use of hospital services and has minor or no impact on patient experience of care. Our analysis does not reveal a case for widespread roll-out of the approach. Future research: Further quantitative follow-up of the longer-term impact of vertical integration on hospital usage and more extensive interviewing of patients and their carers about patient experiences of navigating care. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (BRACE Project no. 16/138/31) and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 17. See the NIHR Journals Library website for further project information.
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Pacientes Internados , Pacientes Ambulatoriais , Humanos , Inglaterra , Academias e Institutos , HospitaisRESUMO
OBJECTIVES: Remote home monitoring services for patients at risk of rapid deterioration introduced during the COVID-19 pandemic had important implications for the health workforce. This study explored the nature of 'work' that health care staff in England undertook to manage patients with COVID-19 remotely, how they were supported to deliver these new services, and the factors that influenced delivery of COVID-19 remote home monitoring services for staff. METHODS: We conducted a rapid mixed-methods evaluation of COVID-19 remote home monitoring services during November 2020 to July 2021 using a cross-sectional survey of a purposive sample of staff involved in delivering the service (clinical leads, frontline delivery staff and those involved in data collection and management) from 28 sites across England. We also conducted interviews with 58 staff in a subsample of 17 sites. Data collection and analysis were carried out in parallel. We used thematic analysis to analyse qualitative data while quantitative survey data were analysed using descriptive statistics. RESULTS: A total of 292 staff responded to the surveys (39% response rate). We found that prior experience of remote monitoring had some, albeit limited benefit for delivering similar services for patients diagnosed with COVID-19. Staff received a range of locally specific training and clinical oversight along with bespoke materials and resources. Staff reported feeling uncertain about using their own judgement and being reliant on seeking clinical oversight. The experience of transitioning from face-to-face to remote service delivery led some frontline delivery staff to reconsider their professional role, as well as their beliefs around their own capabilities. There was a general perception of staff being able to adapt, acquire new skills and knowledge and they demonstrated a commitment to continuity of care for patients, although there were reports of struggling with the increased accountability and responsibility attached to their adapted roles at times. CONCLUSIONS: Remote home monitoring models can play an important role in managing a large number of patients for COVID-19 and possibly a range of other conditions. Successful delivery of such service models depends on staff competency and the nature of training received to facilitate effective care and patient engagement.
Assuntos
COVID-19 , Humanos , COVID-19/epidemiologia , Pandemias , Estudos Transversais , Atenção à Saúde , InglaterraRESUMO
Background: Remote home monitoring services were developed and implemented for patients with COVID-19 during the pandemic. Patients monitored blood oxygen saturation and other readings (e.g. temperature) at home and were escalated as necessary. Objective: To evaluate effectiveness, costs, implementation, and staff and patient experiences (including disparities and mode) of COVID-19 remote home monitoring services in England during the COVID-19 pandemic (waves 1 and 2). Methods: A rapid mixed-methods evaluation, conducted in two phases. Phase 1 (July-August 2020) comprised a rapid systematic review, implementation and economic analysis study (in eight sites). Phase 2 (January-June 2021) comprised a large-scale, multisite, mixed-methods study of effectiveness, costs, implementation and patient/staff experience, using national data sets, surveys (28 sites) and interviews (17 sites). Results: Phase 1 Findings from the review and empirical study indicated that these services have been implemented worldwide and vary substantially. Empirical findings highlighted that communication, appropriate information and multiple modes of monitoring facilitated implementation; barriers included unclear referral processes, workforce availability and lack of administrative support. Phase 2 We received surveys from 292 staff (39% response rate) and 1069 patients/carers (18% response rate). We conducted interviews with 58 staff, 62 patients/carers and 5 national leads. Despite national roll-out, enrolment to services was lower than expected (average enrolment across 37 clinical commissioning groups judged to have completed data was 8.7%). There was large variability in implementation of services, influenced by patient (e.g. local population needs), workforce (e.g. workload), organisational (e.g. collaboration) and resource (e.g. software) factors. We found that for every 10% increase in enrolment to the programme, mortality was reduced by 2% (95% confidence interval: 4% reduction to 1% increase), admissions increased by 3% (-1% to 7%), in-hospital mortality fell by 3% (-8% to 3%) and lengths of stay increased by 1.8% (-1.2% to 4.9%). None of these results are statistically significant. We found slightly longer hospital lengths of stay associated with virtual ward services (adjusted incidence rate ratio 1.05, 95% confidence interval 1.01 to 1.09), and no statistically significant impact on subsequent COVID-19 readmissions (adjusted odds ratio 0.95, 95% confidence interval 0.89 to 1.02). Low patient enrolment rates and incomplete data may have affected chances of detecting possible impact. The mean running cost per patient varied for different types of service and mode; and was driven by the number and grade of staff. Staff, patients and carers generally reported positive experiences of services. Services were easy to deliver but staff needed additional training. Staff knowledge/confidence, NHS resources/workload, dynamics between multidisciplinary team members and patients' engagement with the service (e.g. using the oximeter to record and submit readings) influenced delivery. Patients and carers felt services and human contact received reassured them and were easy to engage with. Engagement was conditional on patient, support, resource and service factors. Many sites designed services to suit the needs of their local population. Despite adaptations, disparities were reported across some patient groups. For example, older adults and patients from ethnic minorities reported more difficulties engaging with the service. Tech-enabled models helped to manage large patient groups but did not completely replace phone calls. Limitations: Limitations included data completeness, inability to link data on service use to outcomes at a patient level, low survey response rates and under-representation of some patient groups. Future work: Further research should consider the long-term impact and cost-effectiveness of these services and the appropriateness of different models for different groups of patients. Conclusions: We were not able to find quantitative evidence that COVID-19 remote home monitoring services have been effective. However, low enrolment rates, incomplete data and varied implementation reduced our chances of detecting any impact that may have existed. While services were viewed positively by staff and patients, barriers to implementation, delivery and engagement should be considered. Study registration: This study is registered with the ISRCTN (14962466). Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme (RSET: 16/138/17; BRACE: 16/138/31) and NHSEI and will be published in full in Health and Social Care Delivery Research; Vol. 11, No. 13. See the NIHR Journals Library website for further project information. The views expressed in this publication are those of the authors and not necessarily those of the National Institute for Health and Care Research or the Department of Health and Social Care.
COVID-19 patients can experience very low oxygen levels, without feeling breathless. Patients may not realise there is a problem until they become extremely unwell, risking being admitted to hospital too late. To address this, COVID-19 remote home monitoring services were developed and later rolled out across England. Patients monitored oxygen levels at home using an 'oximeter' (a small device which clips on to your finger) and sent these readings to providers via phone or technology (e.g. an app). Patients could access further care if needed. We did not know whether these services worked, or what people felt about them. ⢠How services were set up and used in England. ⢠Whether services work (e.g. by reducing deaths and length of hospital stay). ⢠How much they cost. ⢠What patients, carers and staff think about these services (including differences between groups and telephone vs. technology). We looked at available existing evidence and collected data from eight services operating in the first wave of the pandemic. During the second wave of the pandemic, we used data available at a national level and conducted surveys (28 sites) and interviews (17 sites) with staff, patients and individuals involved in developing/leading services nationally. These services have been used worldwide, but they vary considerably. We found many things that help these services to be used (e.g. good communication) but also things that get in the way (e.g. unclear referrals). Our findings did not show that services reduce deaths or time in hospital. But these findings are limited by a lack of data. Staff and patients liked these services, but we found some barriers to delivering and using the service. Some groups found services harder to use (e.g. older patients, those with disabilities and ethnic minorities). Using technology helped with large patient groups, but it did not completely replace phone calls. Better information is needed to know whether these services work. Staff and patients liked these services. However, improvements may make them easier to deliver and use (e.g. further staff training and giving additional support to patients who need it).