Staff and patient experience of the implementation and delivery of a virtual health care home monitoring service for COVID-19 in Melbourne, Australia.

BACKGROUND: Provision of virtual health care (VHC) home monitoring for patients who are experiencing mild to moderate COVID-19 illness is emerging as a central strategy for reducing pressure on acute health systems. Understanding the enablers and challenges in implementation and delivery of these programs is important for future implementation and re-design. The aim of this study was to explore the perspectives of staff involved with the implementation and delivery, and the experience of patients managed by, a VHC monitoring service in Melbourne, Australia during the COVID-19 pandemic. METHODS: A descriptive qualitative approach informed by naturalist inquiry was used. Staff interviews were analysed using the Consolidated Framework for Implementation Research (CFIR). Patient experience was captured using a survey and descriptive statistics were used to describe categorical responses while content analysis was used to analyse free text responses as they related to the CFIR. Finally, data from the interviews and patient experience were triangulated to see if patient experience validated data from staff interviews. RESULTS: All 15 staff were interviewed, and 271 patients were surveyed (42%). A total of four final overarching themes emerged: service implementation enablers, service delivery benefits for patients, fragmentation of care, and workforce strengths. 19 subthemes aligned with 18 CFIR constructs from staff and patient data. CONCLUSION: Rapid implementation was enabled through shared resources, dividing implementation tasks between senior personnel, engaging furloughed healthcare staff in design and delivery, and having a flexible approach that allowed for ongoing improvements. Benefits for patients included early identification of COVID-19 deterioration, as well as provision of accurate and trustworthy information to isolate safely at home. The main challenges were the multiple agencies involved in patient monitoring, which may be addressed in the future by attributing responsibility for monitoring to a single agency.

Type 2 diabetes mellitus in people with severe mental illness: inequalities by ethnicity and age. Cross-sectional analysis of 588 408 records from the UK.

AIMS: To investigate whether the association of severe mental illness with Type 2 diabetes varies by ethnicity and age. METHODS: We conducted a cross-sectional analysis of data from an ethnically diverse sample of 588 408 individuals aged ≥18 years, registered to 98% of general practices (primary care) in London, UK. The outcome of interest was prevalent Type 2 diabetes. RESULTS: Relative to people without severe mental illness, the relative risk of Type 2 diabetes in people with severe mental illness was greatest in the youngest age groups. In the white British group the relative risks were 9.99 (95% CI 5.34, 18.69) in those aged 18-34 years, 2.89 (95% CI 2.43, 3.45) in those aged 35-54 years and 1.16 (95% CI 1.04, 1.30) in those aged ≥55 years, with similar trends across all ethnic minority groups. Additional adjustment for anti-psychotic prescriptions only marginally attenuated the associations. Assessment of estimated prevalence of Type 2 diabetes in severe mental illness by ethnicity (absolute measures of effect) indicated that the association between severe mental illness and Type 2 diabetes was more marked in ethnic minorities than in the white British group with severe mental illness, especially for Indian, Pakistani and Bangladeshi individuals with severe mental illness. CONCLUSIONS: The relative risk of Type 2 diabetes is elevated in younger populations. Most associations persisted despite adjustment for anti-psychotic prescriptions. Ethnic minority groups had a higher prevalence of Type 2 diabetes in the presence of severe mental illness. Future research and policy, particularly with respect to screening and clinical care for Type 2 diabetes in populations with severe mental illness, should take these findings into account.

Ethnicity and cardiovascular health inequalities in people with severe mental illnesses: protocol for the E-CHASM study.

PURPOSE: People with severe mental illnesses (SMI) experience a 17- to 20-year reduction in life expectancy. One-third of deaths are due to cardiovascular disease. This study will establish the relationship of SMI with cardiovascular disease in ethnic minority groups (Indian, Pakistani, Bangladeshi, black Caribbean, black African and Irish), in the UK. METHODS: E-CHASM is a mixed methods study utilising data from 1.25 million electronic patient records. Secondary analysis of routine patient records will establish if differences in cause-specific mortality, cardiovascular disease prevalence and disparities in accessing healthcare for ethnic minority people living with SMI exist. A nested qualitative study will be used to assess barriers to accessing healthcare, both from the perspectives of service users and providers. RESULTS: In primary care, 993,116 individuals, aged 18+, provided data from 186/189 (98 %) practices in four inner-city boroughs (local government areas) in London. Prevalence of SMI according to primary care records, ranged from 1.3-1.7 %, across boroughs. The primary care sample included Bangladeshi [n = 94,643 (10 %)], Indian [n = 6086 (6 %)], Pakistani [n = 35,596 (4 %)], black Caribbean [n = 45,013 (5 %)], black African [n = 75,454 (8 %)] and Irish people [n = 13,745 (1 %)]. In the secondary care database, 12,432 individuals with SMI over 2007-2013 contributed information; prevalent diagnoses were schizophrenia [n = 6805 (55 %)], schizoaffective disorders [n = 1438 (12 %)] and bipolar affective disorder [n = 4112 (33 %)]. Largest ethnic minority groups in this sample were black Caribbean [1432 (12 %)] and black African (1393 (11 %)). CONCLUSIONS: There is a dearth of research examining cardiovascular disease in minority ethnic groups with severe mental illnesses. The E-CHASM study will address this knowledge gap.

Neutron powder diffraction and molecular dynamics study of superionic SrBr2.

The nature of the dynamic ionic disorder within the high-temperature superionic phase of strontium bromide, ß-SrBr2, has been investigated using reverse Monte Carlo (RMC) modelling of neutron powder diffraction data and complementary ab initio molecular dynamics (MD) simulations. The RMC and MD results are in good agreement and indicate the presence of extensive dynamic disorder within the Br(-) sublattice of the cubic fluorite structure. Rapid anion diffusion predominantly occurs as hops between nearest neighbour sites in the 〈100〉 directions, though the trajectories are markedly curved and pass through the peripheries of the octahedral voids in the cation sublattice. In addition, there are extensive correlations between the motions of individual Br(-), often leading to the formation of a short-lived square antiprism co-ordination environment around the Sr(2+). Such polyhedra are observed within the (ambient temperature) ordered tetragonal crystal structure of α-SrBr2. The nature of the ionic disorder in SrBr2 is of particular interest because it is the only known example of a Br(-)-ion superionic. Owing to the large size of this anion, a comparison with the behaviour of other superionic phases gives an insight into the role of ionic size on the conducting properties within these materials.

Total scattering analysis of cation coordination and vacancy pair distribution in Yb substituted δ-Bi2O3.

Reverse Monte Carlo (RMC) modelling of neutron total scattering data, combined with conventional Rietveld analysis of x-ray and neutron data, has been used to describe the cation coordination environments and vacancy pair distribution in the oxide ion conducting electrolyte Bi3YbO6. The thermal variation of the cubic fluorite unit cell volume, monitored by variable temperature x-ray and neutron experiments, reveals significant curvature, which is explained by changes in the oxide ion distribution. There is a significant increase in tetrahedral oxide ion vacancy concentration relative to δ-Bi2O3, due to the creation of Frenkel defects associated with the Yb(3+) cation. The tetrahedral oxide ion vacancy concentration increases from room temperature to 800 °C, but little change is observed in the vacancy pair distribution with temperature. The vacancy pair distributions at both temperatures are consistent with a favouring of [100] vacancy pairs.

Characteristics of general practices involved in undergraduate medical teaching.

BACKGROUND: The movement of medical education into the community has accelerated the development of a new model of general practice in which core clinical services are complemented by educational and research activities involving the whole primary care team. AIM: To compare quality indicators, workload characteristics, and health authority income of general practices involved in undergraduate medical education in east London with those of other practices in the area and national figures where available. DESIGN OF STUDY: A comprehensive survey of undergraduate and postgraduate clinical placements and practice-based research activity within general practice. SETTING: One-hundred and sixty-one practices based in East London and the City Health Authority (ELCHA). METHOD: Cross-sectional survey comparing routinely-collected information on practice resources, workload, income, and performance between teaching and non-teaching practices. RESULTS: In east London, teaching practices are larger partnerships with smaller list sizes, higher staff costs, and better quality premises than non-teaching practices. Teaching practices demonstrate significantly better performance on quality indicators, such as cervical cytology coverage and prescribing indicators. Patient-related health authority income per whole time equivalent (WTE) general practitioner (GP) is significantly lower among teaching practices. A multiple regression analysis was used to explore the association between teaching status and income. Eighty-eight per cent of the variation in patient-related income could be explained by the combination of list size, list turnover, removals at doctor's request, quality of premises, and immunisation and cytology rates. CONCLUSION: This study demonstrates that practice involvement in undergraduate education in east London is associated with higher scores on a range of organisational and performance quality indicators. The lower patient-related income of teaching practices is associated with smaller list sizes and may only be partially replaced by teaching income. Lower vacancy rates suggest that teaching practices are more attractive to doctors seeking partnerships in east London.

Lessons from the London Initiative Zone Educational Incentives funding: associations between practice characteristics, funding, and courses undertaken.

BACKGROUND: Following the Tomlinson report of 1992, London Initiative Zone Educational Incentives (LIZEI) funding was introduced for a three-year period to improve recruitment, retention, and educational opportunities for general practitioners working within inner London. AIM: To test the hypothesis that general practices that show evidence of good organisation achieved better access to LIZEI funding than less organised practices. METHOD: Observational practice-based study involving all 164 general practices in EAst London and the City Health Authority during the first two years of the scheme, April 1995 to March 1997. RESULTS: Univariate analysis showed that higher levels of LIZEI funding were associated with practices where there was evidence of good organisation, including higher targets for cervical cytology screening and immunisation rates for under two-year-olds, better asthma prescribing, and training status. Using ten practice and population explanatory variables, multiple regression models were developed for fundholding and non-fundholding practices. Among non-fundholding practices, the asthma prescribing ratio was the variable with the greatest predictive value, explaining 14.7% of the variation in LIZEI funding between practices. Strong positive associations existed between taking further degrees and diplomas, practice size, training, and non-fundholding status. CONCLUSION: Larger practices, training practices, and those that demonstrated aspects of good practice organisation gained more LIZEI funding: an example of the 'inverse funding law'. Practices within a multifund, based in the Newham locality, gained LIZEI funding regardless of practice organisation. Networks of practices, and, potentially, primary care groups, have a role in equalising the opportunities for education and development between practices in east London.

Factors influencing the attendance rate at accident and emergency departments in East London: the contributions of practice organization, population characteristics and distance.

OBJECTIVES: To examine the contribution of general practice organisation, population characteristics and distance to practice attendance rates at four local accident and emergency departments. DESIGN: Practice-based study examining variations in accident and emergency department attendance rates in 105 practices, using routine data from the Family Health Services Authority (FHSA), the District Health Authority and the 1991 Census. SETTING: East London and the City Health Authority, covering practices based in the inner city boroughs of Hackney, Tower Hamlets and Newham, and the City of London. MAIN OUTCOME MEASURE: Practice-based, age-standardized, adult attendance rates at accident and emergency departments in the year to 31 March 1994. RESULTS: Annual age-standardized practice accident and emergency department attendance rates ranged from 10.3 to 29.4 per 100 population. The mean practice attendance rate was 17.6 per 100 (95% CI 16.8-18.4). No significant relationship was found between attendance rates and practice characteristics (number and sex of general practitioner (GP) principals, presence of practice manager or nurse, computerization and training status). There were strong positive relationships between attendance rates and households not owner-occupied (R = 0.55, P < 0.001) and pensioners living alone (R = 0.55, P < 0.001). There were negative correlations with Asian ethnicity (R = -0.31, P = 0.002) and residents lacking amenities (R = -0.26, P = 0.007). The distance to the nearest accident and emergency department also correlated negatively with attendance (R = -0.27, P = 0.006). A backwards multiple regression model showed that 48% of the variation in attendance rates could be accounted for by six factors: percentage of households not owner occupied, percentage living in households without a car, percentage living in households lacking amenities, percentage of pensioners living alone, percentage of Asian ethnicity, and percentage living in households with a head born in the New Commonwealth and Pakistan. Optimal subsets regression identified a number of alternative models with similar explanatory value. CONCLUSIONS: Social deprivation is strongly linked with attendance rates at accident and emergency departments in East London. In contrast, the organizational characteristics of general practices appear to have no bearing on the rates. Both purchasers and providers need to take account of these findings when planning accident and emergency provision.

When patterns are broken, new patterns emerge. A story of community collaboration for health.

The Bridge Community Health Clinic (BCHC) is the result of a multifaceted community effort that persevered though seven years of analysis and planning to achieve a community health center that met the entire community need. An influx of Southeast Asian emigrants who held different beliefs regarding medical care showed how the established health system was not meeting the needs of the changing population. This article describes how the Wausau community came together with the help of health care businesses and formed BCHC, promoting community health.

The questionable value of medical screening in the small-group health insurance market.

Insurers perform medical screening to assess risk for health insurance in the small-group market. Most reform proposals eliminate screening because it denies coverage to those who need it. This DataWatch empirically analyzes the value of medical screening to insurers. We analyzed claims of two employed populations covered by a large insurer--one screened and the other not screened. We found no significant difference in the amounts claimed by these two populations over six years. This suggests that medical screening could be eliminated in the small-group market without an increase in premiums.

Economic impact of malnutrition: a model system for hospitalized patients.

A retrospective review of 771 patients' charts in two acute care hospitals was performed to determine likelihood of malnutrition (LOM) at admission and to assess the effect of LOM on costs and charges. Using accepted criteria, LOM was present in 59 and 48% of medical and surgical patients, respectively. Patients with LOM were 2.6 or 3.4 times as likely to have a predefined minor or major complication, respectively; and 3.8 times as likely to die as patients without LOM (all p less than 0.001). In every diagnosis-related group, the mean length of stay was longer for LOM patients (range 1.1-12.8 excess days). Accountants converted charges to direct variable costs using departmental cost-to-charge ratios. LOM status increased excess costs and charges per patient by $1738 and $3557, respectively (p less than 0.0001). When complications occurred, LOM patients incurred $2996 or $6157 excess costs and charges per patient (p less than 0.01). Serum albumin was the strongest clinical predictor of cost. The hospitals' cost of providing enteral or parenteral nutrition support was $18 or $102 per day, respectively. Too few patients received early nutrition support to assess efficacy. Nonetheless, the costs associated with malnutrition warrant early detection and aggressive treatment.