Improving Collaborative Behaviour Planning in Adult Auditory Rehabilitation: Development of the I-PLAN Intervention Using the Behaviour Change Wheel.

Background: The consequences of poorly managed hearing loss can be ameliorated with hearing aid use but rates of use are sub-optimal. The impact of audiologist behaviour on subsequent use, particularly over the long term, is unknown. Purpose: This study aimed to describe the role of the behaviour change wheel in developing an intervention to introduce and embed particular clinical behaviours into adult hearing aid fitting consultations, within the framework of the Medical Research Council guidance on complex interventions. Methods: Following the steps of the behaviour change wheel, audiologist behaviours that might influence hearing aid use were identified based on a systematic review and qualitative work with audiologists. An analysis, using the COM-B model, identified potential drivers of the target behaviours. This was used to select intervention functions and behaviour change techniques likely to influence behaviour in this context. Results: The target behaviours were as follows: giving information about the benefits of hearing aid use and the negative consequences of non-use, providing prompts for use and engaging in collaborative behavioural planning for use. The behavioural analysis suggested that psychological capability, opportunity and motivation were potential drivers of these behaviours. The intervention functions of education, coercion, training, environmental restructuring, modelling and enablement were selected and combined to develop a single complex intervention that seeks to address the target behaviours.

Hearing aids for mild to moderate hearing loss in adults.

BACKGROUND: The main clinical intervention for mild to moderate hearing loss is the provision of hearing aids. These are routinely offered and fitted to those who seek help for hearing difficulties. By amplifying and improving access to sounds, and speech sounds in particular, the aim of hearing aid use is to reduce the negative consequences of hearing loss and improve participation in everyday life. OBJECTIVES: To evaluate the effects of hearing aids for mild to moderate hearing loss in adults. SEARCH METHODS: The Cochrane ENT Information Specialist searched the ENT Trials Register; the Cochrane Register of Studies Online; MEDLINE; PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 23 March 2017. SELECTION CRITERIA: Randomised controlled trials (RCTs) of hearing aids compared to a passive or active control in adults with mild to moderate hearing loss. DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. The primary outcomes in this review were hearing-specific health-related quality of life and the adverse effect pain. Secondary outcomes were health-related quality of life, listening ability and the adverse effect noise-induced hearing loss. We used GRADE to assess the quality of the evidence for each outcome; this is indicated in italics. MAIN RESULTS: We included five RCTs involving 825 participants. The studies were carried out in the USA and Europe, and were published between 1987 and 2017. Risk of bias across the studies varied. Most had low risk for selection, reporting and attrition bias, and a high risk for performance and detection bias because blinding was inadequate or absent.All participants had mild to moderate hearing loss. The average age across all five studies was between 69 and 83 years. The duration of the studies ranged between six weeks and six months.There was a large beneficial effect of hearing aids on hearing-specific health-related quality of life associated with participation in daily life as measured using the Hearing Handicap Inventory for the Elderly (HHIE, scale range 1 to 100) compared to the unaided/placebo condition (mean difference (MD) -26.47, 95% confidence interval (CI) -42.16 to -10.77; 722 participants; three studies) (moderate-quality evidence).There was a small beneficial effect of hearing aids on general health-related quality of life (standardised mean difference (SMD) -0.38, 95% CI -0.55 to -0.21; 568 participants; two studies) (moderate-quality evidence). There was a large beneficial effect of hearing aids on listening ability (SMD -1.88, 95% CI -3.24 to -0.52; 534 participants; two studies) (moderate-quality evidence).Adverse effects were measured in only one study (48 participants) and none were reported (very low-quality evidence). AUTHORS' CONCLUSIONS: The available evidence concurs that hearing aids are effective at improving hearing-specific health-related quality of life, general health-related quality of life and listening ability in adults with mild to moderate hearing loss. The evidence is compatible with the widespread provision of hearing aids as the first-line clinical management in those who seek help for hearing difficulties. Greater consistency is needed in the choice of outcome measures used to assess benefits from hearing aids. Further placebo-controlled studies would increase our confidence in the estimates of these effects and ascertain whether they vary according to age, gender, degree of hearing loss and type of hearing aid.

Cochrane Corner: interventions to improve hearing aid use in adult auditory rehabilitation.

This "Cochrane Corner" will be a recurring feature in the journal that highlights systematic reviews relevant to audiology, with invited commentary to aid clinical decision making. This first instalment features the Cochrane review "Interventions to Improve Hearing Aid Use in Adult Auditory Rehabilitation," published in 2016. In their review, Barker et al identified 37 randomised controlled trials (RCTs) and concluded that there is low-quality evidence using self-management support and complex interventions (support plus delivery system design) in adult auditory rehabilitation. The review highlights the need for well-conducted studies in this area.

Interventions to improve hearing aid use in adult auditory rehabilitation.

BACKGROUND: Acquired adult-onset hearing loss is a common long-term condition for which the most common intervention is hearing aid fitting. However, up to 40% of people fitted with a hearing aid either fail to use it or may not gain optimal benefit from it. This is an update of a review first published in The Cochrane Library in 2014. OBJECTIVES: To assess the long-term effectiveness of interventions to promote the use of hearing aids in adults with acquired hearing loss fitted with at least one hearing aid. SEARCH METHODS: The Cochrane ENT Information Specialist searched the Cochrane ENT Trials Register; Central Register of Controlled Trials (CENTRAL 2016, Issue 5); PubMed; EMBASE; CINAHL; Web of Science; ClinicalTrials.gov; ICTRP and additional sources for published and unpublished trials. The date of the search was 13 June 2016. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of interventions designed to improve or promote hearing aid use in adults with acquired hearing loss compared with usual care or another intervention. We excluded interventions that compared hearing aid technology. We classified interventions according to the 'chronic care model' (CCM). The primary outcomes were hearing aid use (measured as adherence or daily hours of use) and adverse effects (inappropriate advice or clinical practice, or patient complaints). Secondary patient-reported outcomes included quality of life, hearing handicap, hearing aid benefit and communication. Outcomes were measured over the short ( 12 to < 52 weeks) and long term (one year plus). DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by Cochrane. MAIN RESULTS: We included 37 studies involving a total of 4129 participants. Risk of bias across the included studies was variable. We judged the GRADE quality of evidence to be very low or low for the primary outcomes where data were available.The majority of participants were over 65 years of age with mild to moderate adult-onset hearing loss. There was a mix of new and experienced hearing aid users. Six of the studies (287 participants) assessed long-term outcomes.All 37 studies tested interventions that could be classified using the CCM as self-management support (ways to help someone to manage their hearing loss and hearing aid(s) better by giving information, practice and experience at listening/communicating or by asking people to practise tasks at home) and/or delivery system design interventions (just changing how the service was delivered). Self-management support interventions We found no studies that investigated the effect of these interventions on adherence, adverse effects or hearing aid benefit. Two studies reported daily hours of hearing aid use but we were unable to combine these in a meta-analysis. There was no evidence of a statistically significant effect on quality of life over the medium term. Self-management support reduced short- to medium-term hearing handicap (two studies, 87 participants; mean difference (MD) -12.80, 95% confidence interval (CI) -23.11 to -2.48 (0 to 100 scale)) and increased the use of verbal communication strategies in the short to medium term (one study, 52 participants; MD 0.72, 95% CI 0.21 to 1.23 (0 to 5 scale)). The clinical significance of these statistical findings is uncertain. It is likely that the outcomes were clinically significant for some, but not all, participants. Our confidence in the quality of this evidence was very low. No self-management support studies reported long-term outcomes. Delivery system design interventionsThese interventions did not significantly affect adherence or daily hours of hearing aid use in the short to medium term, or adverse effects in the long term. We found no studies that investigated the effect of these interventions on quality of life. There was no evidence of a statistically or clinically significant effect on hearing handicap, hearing aid benefit or the use of verbal communication strategies in the short to medium term. Our confidence in the quality of this evidence was low or very low. Long-term outcome measurement was rare. Combined self-management support/delivery system design interventionsOne combined intervention showed evidence of a statistically significant effect on adherence in the short term (one study, 167 participants, risk ratio (RR) 1.06, 95% CI 1.00 to 1.12). However, there was no evidence of a statistically or clinically significant effect on daily hours of hearing aid use over the long term, or the short to medium term. No studies of this type investigated adverse effects. There was no evidence of an effect on quality of life over the long term, or short to medium term. These combined interventions reduced hearing handicap in the short to medium term (15 studies, 728 participants; standardised mean difference (SMD) -0.26, 95% CI -0.48 to -0.04). This represents a small-moderate effect size but there is no evidence of a statistically significant effect over the long term. There was evidence of a statistically, but not clinically, significant effect on long-term hearing aid benefit (two studies, 69 participants, MD 0.30, 95% CI 0.02 to 0.58 (1 to 5 scale)), but no evidence of an effect over the short to medium term. There was evidence of a statistically, but not clinically, significant effect on the use of verbal communication strategies in the short term (four studies, 223 participants, MD 0.45, 95% CI 0.15 to 0.74 (0 to 5 scale)), but not the long term. Our confidence in the quality of this evidence was low or very low.We found no studies that assessed the effect of other CCM interventions (decision support, the clinical information system, community resources or health system changes). AUTHORS' CONCLUSIONS: There is some low to very low quality evidence to support the use of self-management support and complex interventions combining self-management support and delivery system design in adult auditory rehabilitation. However, effect sizes are small. The range of interventions that have been tested is relatively limited. Future research should prioritise: long-term outcome assessment; development of a core outcome set for adult auditory rehabilitation; and study designs and outcome measures that are powered to detect incremental effects of rehabilitative healthcare system changes.

Applying the COM-B behaviour model and behaviour change wheel to develop an intervention to improve hearing-aid use in adult auditory rehabilitation.

OBJECTIVES: To introduce a psychological model of behaviour; the COM-B model and describe how this has been used in combination with the behaviour change wheel (BCW) in developing an intervention which aims to promote regular, long-term use of hearing aids by adults with acquired hearing loss. DESIGN: Qualitative structured interview study using the COM-B model to identify the determinants of behavioural planning on the part of audiologists; a potentially important factor in encouraging long-term hearing-aid use. STUDY SAMPLE: Ten audiologists drawn from a random sample of five English audiology departments. RESULTS: The analysis suggests that behavioural planning might be more likely to occur if audiologists' psychological capability, physical and social opportunity, and reflective and automatic motivation were addressed. This analysis forms the basis of an intervention design, using the BCW, to encourage behavioural planning by audiologists and subsequent hearing-aid use by people with hearing loss. CONCLUSIONS: The COM-B model and BCW can be applied successfully in the context of audiology to analyse the behaviour of both people with hearing loss and professionals working with them, supplying information that is being used in intervention design. The effectiveness of the intervention will be tested in a clinical trial.

Current process in hearing-aid fitting appointments: An analysis of audiologists' use of behaviour change techniques using the behaviour change technique taxonomy (v1).

OBJECTIVES: To observe and analyse the range and nature of behaviour change techniques (BCTs) employed by audiologists during hearing-aid fitting consultations to encourage and enable hearing-aid use. DESIGN: Non-participant observation and qualitative thematic analysis using the behaviour change technique taxonomy (version 1) (BCTTv1). STUDY SAMPLE: Ten consultations across five English NHS audiology departments. RESULTS: Audiologists engage in behaviours to ensure the hearing-aid is fitted to prescription and is comfortable to wear. They provide information, equipment, and training in how to use a hearing-aid including changing batteries, cleaning, and maintenance. There is scope for audiologists to use additional BCTs: collaborating with patients to develop a behavioural plan for hearing-aid use that includes goal-setting, action-planning and problem-solving; involving significant others; providing information on the benefits of hearing-aid use or the consequences of non-use and giving advice about using prompts/cues for hearing-aid use. CONCLUSIONS: This observational study of audiologist behaviour in hearing-aid fitting consultations has identified opportunities to use additional behaviour change techniques that might encourage hearing-aid use. This information defines potential intervention targets for further research with the aim of improving hearing-aid use amongst adults with acquired hearing loss.

Outcome Measurement in Adult Auditory Rehabilitation: A Scoping Review of Measures Used in Randomized Controlled Trials.

OBJECTIVES: This review documented the range and nature of reported outcome measures in the context of adult auditory rehabilitative research. DESIGN: A scoping review conducted as a part of the development of a systematic review of the effect of interventions to improve hearing aid use. The authors searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP; and additional sources for published and unpublished randomized control trials. The date of the search was November 6, 2013. Outcomes were grouped using a framework suggested by the Cochrane Effective Practice and Organization of Care group. RESULTS: Patient outcomes included adherence to hearing aid use, daily hours of aid use, hearing handicap, hearing aid benefit, quality of life, and communication and psychological outcome. Satisfaction and speech perception were frequent secondary outcomes. There was diversity in measures used to report patient outcomes. Outcome categories other than patient health status and behavior were rarely reported. The timing of outcome measurement was often short term (<12 weeks), with a relative lack of evidence on long-term outcomes (>1 year). CONCLUSIONS: This review has highlighted considerable diversity in patient-reported outcome measurements in randomized control trials in the context of adult auditory rehabilitation. In addition, there are gaps in the literature with respect to measurement of other outcome types of potential interest to stakeholders, including policymakers and commissioners. Long-term outcome assessment is rare.

A study of the relationship between the video head impulse test and air calorics.

The video head impulse test (vHIT) has been proposed as an objective approach to detect peripheral vestibular disorder in a clinical setting. Data from several studies indicate that the vHIT is a useful addition to the vestibular test battery and can give complementary information to caloric testing. This study explores the relationship between lateral canal vestibular occular reflex gain measured using the vHIT system and canal paresis indicated using air calorics in a sample of patients attending a clinic for balance disorder. Sensitivity and specificity of the vHIT test relative to calorics was studied for a clinical sample of 51 patients (20 male, 31 female) who attended a private clinic for balance disorders. vHIT gains were compared to the manufacturer's normative range and to data from a normative study using 30 young volunteers. Of 14 patients in the clinical sample that had significant canal paresis indicated by air calorics, only 4 showed a significant abnormality in either canal using a measurement of vHIT gain. vHIT gain does not correlate with canal paresis as indicated by air caloric testing. vHIT gain appears relatively insensitive to peripheral vestibular disorder as indicated by air caloric testing, although patients that had no caloric response on one side showed abnormal vHIT gain. vHIT testing may be a useful addition to the existing vestibular test battery, but it does not appear to be an alternative to it.

Supporting living well with hearing loss: A Delphi review of self-management support.

OBJECTIVES: To assess consensus amongst stakeholders in adult auditory rehabilitation on what processes might support self-management. DESIGN: A three-round Delphi review was conducted online. Participants responded to five questions relating to living well with a hearing loss and the clinical processes that might support living well. Responses were analysed using thematic analysis. In further rounds, statements arising from the analysis were scored using a nine-point Likert scale, independently and then in the light of the collated panel responses. Statements reaching pre-defined criteria for consensus were identified. STUDY SAMPLE: A panel of 26 stakeholders in adult auditory rehabilitation were consulted, including people with hearing loss and researchers and professionals who design and implement process change. RESULTS: There was consensus on clinical skills and behaviours that might help individuals live well, including processes that inform and involve the individual with the hearing loss (e.g. providing information about hearing and collaborative goal setting, respectively). The panel identified potential emotional, cognitive, and behavioural markers for living well with a hearing loss. CONCLUSIONS: The results of this review provide a rationale for the development and evaluation of interventions that include collaborative clinical behaviours as part of self-management support.

Interventions to improve hearing aid use in adult auditory rehabilitation.

BACKGROUND: Acquired adult-onset hearing loss is a common long-term condition for which the most common intervention is hearing aid fitting. However, up to 40% of people fitted with a hearing aid either fail to use it or may not gain optimal benefit from it. OBJECTIVES: To assess the long-term effectiveness of interventions to promote the use of hearing aids in adults with acquired hearing loss fitted with at least one hearing aid. SEARCH METHODS: We searched the Cochrane ENT Disorders Group Trials Register; CENTRAL; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP and additional sources for published and unpublished trials. The date of the search was 6 November 2013. SELECTION CRITERIA: We included randomised controlled trials (RCTs) of interventions designed to improve or promote hearing aid use in adults with acquired hearing loss compared with usual care or another intervention. We excluded interventions that compared hearing aid technology. We classified interventions according to the 'chronic care model' (CCM). The primary outcomes were hearing aid use (measured as adherence or daily hours of use) and adverse effects (inappropriate advice or clinical practice, or patient complaints). Secondary patient-reported outcomes included quality of life, hearing handicap, hearing aid benefit and communication. Outcomes were measured over the short ( 12 to < 52 weeks) and long term (one year plus). DATA COLLECTION AND ANALYSIS: We used the standard methodological procedures expected by The Cochrane Collaboration. MAIN RESULTS: We included 32 studies involving a total of 2072 participants. The risk of bias across the included studies was variable. We judged the GRADE quality of evidence to be very low or low for the primary outcomes where data were available.The majority of participants were over 65 years of age with mild to moderate adult-onset hearing loss. There was a mix of new and experienced hearing aid users. Six of the studies (1018 participants) were conducted in a military veteran population. Six of the studies (287 participants) assessed long-term outcomes.All 32 studies tested interventions that could be classified as self management support (ways to help someone to manage their hearing loss and hearing aid(s) better by giving information, practice and experience at listening/communicating or by asking people to practise tasks at home) and/or delivery system design interventions (just changing how the service was delivered) according to the CCM. Self management support interventions We found no studies that investigated the effect of these interventions on adherence, adverse effects or hearing aid benefit. Two studies reported daily hours of hearing aid use but we were unable to combine these in a meta-analysis. There was no evidence of a statistically significant effect on quality of life over the medium term. Self management support reduced short- to medium-term hearing handicap (two studies, 87 participants; mean difference (MD) -12.80, 95% confidence interval (CI) -23.11 to -2.48 (0 to 100 scale)) and increased the use of verbal communication strategies in the short to medium term (one study, 52 participants; MD 0.72, 95% CI 0.21 to 1.23 (0 to 5 scale)). The clinical significance of these statistical findings is uncertain but it is likely that the outcomes were clinically significant for some, but not all, participants. Our confidence in the quality of this evidence was very low. No self management support studies reported long-term outcomes. Delivery system design interventions These interventions did not significantly affect adherence or daily hours of hearing aid use in the short to medium term, or adverse effects in the long term. We found no studies that investigated the effect of these interventions on quality of life. There was no evidence of a statistically or clinically significant effect on hearing handicap, hearing aid benefit or the use of verbal communication strategies in the short to medium term. Our confidence in the quality of this evidence was low or very low. Long-term outcome measurement was rare. Combined self management support/delivery system design interventions We found no studies that investigated the effect of complex interventions combining components of self management support and delivery system design on adherence or adverse effects. There was no evidence of a statistically or clinically significant effect on daily hours of hearing aid use over the long term, or the short to medium term. Similarly, there was no evidence of an effect on quality of life over the long term, or short to medium term. These combined interventions reduced hearing handicap in the short to medium term (13 studies, 485 participants, standardised mean difference (SMD) -0.27, 95% CI -0.49 to -0.06). This represents a small-moderate effect size but there is no evidence of a statistically significant effect over the long term. There was evidence of a statistically, but not clinically, significant effect on long-term hearing aid benefit (two studies, 69 participants, MD 0.30, 95% CI 0.02 to 0.58 (1 to 5 scale)), but no evidence of effect over the short to medium term. There was evidence of a statistically, but not clinically, significant effect on the use of verbal communication strategies in the short term (four studies, 223 participants, MD 0.45, 95% CI 0.15 to 0.74 (0 to 5 scale)), but not the long term. Our confidence in the quality of this evidence was low or very low.We found no studies that assessed the effect of other CCM interventions (decision support, the clinical information system, community resources or health system changes). AUTHORS' CONCLUSIONS: There is some low to very low quality evidence to support the use of self management support and complex interventions combining self management support and delivery system design in adult auditory rehabilitation. However, effect sizes are small and the range of interventions that have been tested is relatively limited. Priorities for future research should be assessment of long-term outcome a year or more after the intervention, development of a core outcome set for adult auditory rehabilitation and development of study designs and outcome measures that are powered to detect incremental effects of rehabilitative healthcare system changes over and above the provision of a hearing aid.

An evaluation of audiology service improvement documentation in England using the chronic care model and content analysis.

OBJECTIVE: Implementation of the chronic care model (CCM) is associated with improved outcomes for patients. It follows that any proposed policy or implementation plan that maps highly onto the CCM is more likely to lead to improved outcomes. The aim of this study was to compare long-term condition (LTC) policy documents and audiology quality standard documents with the CCM and to highlight the need for further research in service implementation and clinical outcome. DESIGN: We carried out a keyword-in-context content analysis of relevant documents. STUDY SAMPLE: Documents relating to health department policy on LTCs, audiology service improvement initiatives in England and the CCM. RESULTS: This analysis shows that current audiology implementation documents in England map poorly onto the CCM compared to health policy documents relating to the management of LTCs. The biggest discrepancies occur in self-management support, delivery system design, and decision support. These elements are supported by the best evidence of potential improvements in clinical outcome. CONCLUSIONS: Our content analysis of audiology service quality improvement documents in England suggests they compare poorly to some elements of the CCM. We discuss the implications this might have for future research.

The provision and impact of online patient access to their electronic health records (EHR) and transactional services on the quality and safety of health care: systematic review protocol.

BACKGROUND: Innovators have piloted improvements in communication, changed patterns of practice and patient empowerment from online access to electronic health records (EHR). International studies of online services, such as prescription ordering, online appointment booking and secure communications with primary care, show good uptake of email consultations, accessing test results and booking appointments; when technologies and business process are in place. Online access and transactional services are due to be rolled out across England by 2015; this review seeks to explore the impact of online access to health records and other online services on the quality and safety of primary health care. OBJECTIVE: To assess the factors that may affect the provision of online patient access to their EHR and transactional services, and the impact of such access on the quality and safety of health care. METHOD: Two reviewers independently searched 11 international databases during the period 1999-2012. A range of papers including descriptive studies using qualitative or quantitative methods, hypothesis-testing studies and systematic reviews were included. A detailed eligibility criterion will be used to shape study inclusion. A team of experts will review these papers for eligibility, extract data using a customised extraction form and use the Grading of Recommendations Assessment, Development and Evaluation (GRADE) instrument to determine the quality of the evidence and the strengths of any recommendation. Data will then be descriptively summarised and thematically synthesised. Where feasible, we will perform a quantitative meta-analysis. Prospero (International Prospective Register of Systematic Reviews) registration number: crd42012003091.

Does social isolation, social support or loneliness influence health or well-being after a cardiovascular disease event? A narrative thematic systematic review.

Identification of factors which influence health after a cardiovascular disease (CVD) event will assist with reducing the high health and economic burden of CVD. We undertook a systematic review to investigate the association between social health (lower social isolation, higher social support and lower loneliness) and health and well-being after a CVD event among people living in Australia and New Zealand. Four electronic databases were systematically searched until June 2020. Two reviewers undertook title/abstract screen. One reviewer undertook full-text screen and data extraction. A second author either independently extracted or checked data. Narrative thematic analysis was undertaken. Of the 752 unique records retrieved, 39 papers from 29 studies met our inclusion criteria. Included studies recruited between 10 and 1,455 participants, aged 12-96 years, and the majority were male. Greater social health was consistently associated with better mental health outcomes (lower depressive symptoms, anxiety symptoms and psychological distress). Lower social isolation and higher social support were associated with the extent to which patient needs were being met. Living situation was not associated with mental health outcomes, and being married or living with someone was associated with greater medication adherence. Our systematic review demonstrates that greater social health is associated with better mental health outcomes and met patient needs among cardiac patients. As partner status and living status did not align with social isolation and social support findings in this review, we recommend they not be used as social health proxies when assessing health outcomes among CVD patients. Our review highlights the need for more research focused on women and the importance of gender-disaggregated reporting. Further assessment is required to evaluate whether loneliness is associated with health and well-being outcomes after a CVD event.

PC-based note taking in patient-centred diagnostic interviews: a thematic analysis of patient opinion elicited using a pilot survey instrument.

BACKGROUND: Computers are used increasingly in patient-clinician consultations. There is the potential for PC use to have an effect on the communication process. OBJECTIVE: The aim of this preliminary study was to investigate patient opinion regarding the use of PC-based note taking during diagnostic vestibular assessments. METHOD: We gave a simple four-item questionnaire to 100 consecutive patients attending for vestibular assessment at a secondary referral level primary care trust audiology service. Written responses to two of the questionnaire items were subject to an inductive thematic analysis. RESULTS: The questionnaire was acceptable to patients, none refused to complete it. Dominant themes identified suggest that patients do perceive consistent positive benefits from the use of PC-based note taking. CONCLUSION: This pilot study's short survey instrument is usable and may provide insights into patients' perceptions of computer use in a clinical setting.

The derivation of optimum criteria for use in the monothermal caloric screening test.

OBJECTIVE: The aim of this study was to determine whether it is possible to predict a normal outcome of the bithermal caloric test by testing at a single temperature and if so, what criteria are most appropriate to use. DESIGN: A total of 490 patients were considered candidates for the bithermal test and 414 completed the four necessary components, their nystagmus being measured using videonystagmography. RESULTS: Clinical decision analysis revealed that the cool monothermal test does not provide an adequate combination of sensitivity and specificity for us to recommend its clinical use. However, the warm monothermal test offers a sensitivity of 95% with 29% of patients with normal bithermal results having to undergo the bithermal test (specificity = 71%) if a combination of three criteria are used: a normal bithermal caloric test outcome can be anticipated and testing curtailed after the first temperature if (a) the warm monothermal caloric asymmetry (MCA) is <15% and (b) the two warm results are each >8 degrees per sec ( degrees /sec), and (c) any spontaneous nystagmus is <4 degrees /sec. CONCLUSIONS: When appropriate criteria are used, the warm monothermal caloric test offers a performance that is acceptable for routine clinical use, sparing a considerable proportion of patients from unnecessary tests at the cool temperature. We believe that the warm/cool monothermal test difference is probably a consequence of the interrelationship between canal paresis and directional preponderance.

An evaluation of the cost-effectiveness of booklet-based self-management of dizziness in primary care, with and without expert telephone support.

BACKGROUND: Dizziness is a very common symptom that often leads to reduced quality of life, anxiety and emotional distress, loss of fitness, lack of confidence in balance, unsteadiness and an increased risk of falling. Most dizzy patients are managed in primary care by reassurance and medication to suppress symptoms. Trials have shown that chronic dizziness can be treated effectively in primary care using a self-help booklet to teach patients vestibular rehabilitation exercises that promote neurological adaptation and skill and confidence in balance. However, brief support from a trained nurse was provided in these trials, and this model of managing dizzy patients has not been taken up due to a lack of skills and resources in primary care. The aim of this trial is to evaluate two new alternative models of delivery that may be more feasible and cost-effective. METHODS/DESIGN: In a single blind two-centre pragmatic controlled trial, we will randomise 330 patients from 30 practices to a) self-help booklet with telephone support from a vestibular therapist, b) self-help booklet alone, c) routine medical care. Symptoms, disability, handicap and quality of life will be assessed by validated questionnaires administered by post at baseline, immediately post-treatment (3 months), and at one year follow-up. The study is powered to test our primary hypothesis, that the self-help booklet with telephone support will be more effective than routine care. We will also explore the effectiveness of the booklet without any support, and calculate the costs of treatment in each arm. DISCUSSION: If our trial indicates that patients can cost-effectively manage their dizziness in primary care, then it can be easily rolled out to relieve the symptoms of the many patients in primary care who currently have chronic, untreated, disabling dizziness. Treatment in primary care may reduce the development of psychological and physical sequelae that cause handicap and require treatment. There is also the potential to reduce the cost to the NHS of treating dizziness by reducing demand for referral to secondary care for specialist assessment and treatment. TRIAL REGISTRATION: ClinicalTrials.gov trial registration ID number: NCT00732797.

Minimally disruptive medicine is needed for patients with multimorbidity: time to develop computerised medical record systems to meet this requirement.

BACKGROUND: Minimally disruptive medicine (MDM) is proposed as a method for more appropriately managing people with multiple chronic disease. Much clinical management is currently single disease focussed, with people with multimorbidity being managed according to multiple single disease guidelines. Current initiatives to improve care include education about individual conditions and creating an environment where multiple guidelines might be simultaneously supported. The patient-centred medical home (PCMH) is an example of the latter. However, educational programmes and PCMH may increase the burden on patients. PROBLEM: The cumulative workload for patients in managing the impact of multiple disease-specific guidelines is only relatively recently recognised. There is an intellectual vacuum as to how best to manage multimorbidity and how informatics might support implementing MDM. There is currently no alternative to multiple single-condition- specific guidelines and a lack of certainty, should the treatment burden need to be reduced, as to which guideline might be 'dropped'. ACTION: The best information about multimorbidity is recorded in primary care computerised medical record (CMR) systems and in an increasing number of integrated care organisations. CMR systems have the potential to flag individuals who might be in greatest need. However, CMR systems may also provide insights into whether there are ameliorating factors that might make it easier for them to be resilient to the burden of care. Data from such CMR systems might be used to develop the evidence base about how to better manage multimorbidity. CONCLUSIONS: There is potential for these information systems to help reduce the management burden on patients and clinicians. However, substantial investment in research-driven CMR development is needed if we are to achieve this.

Patients' online access to their electronic health records and linked online services: a systematic interpretative review.

OBJECTIVES: To investigate the effect of providing patients online access to their electronic health record (EHR) and linked transactional services on the provision, quality and safety of healthcare. The objectives are also to identify and understand: barriers and facilitators for providing online access to their records and services for primary care workers; and their association with organisational/IT system issues. SETTING: Primary care. PARTICIPANTS: A total of 143 studies were included. 17 were experimental in design and subject to risk of bias assessment, which is reported in a separate paper. Detailed inclusion and exclusion criteria have also been published elsewhere in the protocol. PRIMARY AND SECONDARY OUTCOME MEASURES: Our primary outcome measure was change in quality or safety as a result of implementation or utilisation of online records/transactional services. RESULTS: No studies reported changes in health outcomes; though eight detected medication errors and seven reported improved uptake of preventative care. Professional concerns over privacy were reported in 14 studies. 18 studies reported concern over potential increased workload; with some showing an increase workload in email or online messaging; telephone contact remaining unchanged, and face-to face contact staying the same or falling. Owing to heterogeneity in reporting overall workload change was hard to predict. 10 studies reported how online access offered convenience, primarily for more advantaged patients, who were largely highly satisfied with the process when clinician responses were prompt. CONCLUSIONS: Patient online access and services offer increased convenience and satisfaction. However, professionals were concerned about impact on workload and risk to privacy. Studies correcting medication errors may improve patient safety. There may need to be a redesign of the business process to engage health professionals in online access and of the EHR to make it friendlier and provide equity of access to a wider group of patients. A1 SYSTEMATIC REVIEW REGISTRATION NUMBER: PROSPERO CRD42012003091.

Clinical and cost effectiveness of booklet based vestibular rehabilitation for chronic dizziness in primary care: single blind, parallel group, pragmatic, randomised controlled trial.

OBJECTIVE: To determine the clinical and cost effectiveness of booklet based vestibular rehabilitation with and without telephone support for chronic dizziness, compared with routine care. DESIGN: Single blind, parallel group, pragmatic, randomised controlled trial. SETTING: 35 general practices across southern England between October 2008 and January 2011. PARTICIPANTS: Patients aged 18 years or over with chronic dizziness (mean duration >five years) not attributable to non-vestibular causes (confirmed by general practitioner) and that could be aggravated by head movement (confirmed by patient). INTERVENTIONS: Participants randomly allocated to receive routine medical care, booklet based vestibular rehabilitation only, or booklet based vestibular rehabilitation with telephone support. For the booklet approach, participants received self management booklets providing comprehensive advice on undertaking vestibular rehabilitation exercises at home daily for up to 12 weeks and using cognitive behavioural techniques to promote positive beliefs and treatment adherence. Participants receiving telephone support were offered up to three brief sessions of structured support from a vestibular therapist. MAIN OUTCOME MEASURES: Vertigo symptom scale-short form and total healthcare costs related to dizziness per quality adjusted life year (QALY). RESULTS: Of 337 randomised participants, 276 (82%) completed all clinical measures at the primary endpoint, 12 weeks, and 263 (78%) at one year follow-up. We analysed clinical effectiveness by intention to treat, using analysis of covariance to compare groups after intervention, controlling for baseline symptom scores. At 12 weeks, scores on the vertigo symptom scale in the telephone support group did not differ significantly from those in the routine care group (adjusted mean difference -1.79 (95% confidence interval -3.69 to 0.11), P=0.064). At one year, both intervention groups improved significantly relative to routine care (telephone support -2.52 (-4.52 to -0.51), P=0.014; booklet only -2.43 (-4.27 to -0.60), P=0.010). Analysis of cost effectiveness acceptability curves showed that both interventions were highly cost effective; at very low QALY values, the booklet only approach was most likely to be cost effective, but the approach with additional telephone support was most likely to be cost effective at QALY values more than £1200 (€1488; $1932). Using the booklet approach with telephone support, five (three to 12) patients would need to be treated for one patient to report subjective improvement at one year. CONCLUSIONS: Booklet based vestibular rehabilitation for chronic dizziness is a simple and cost effective means of improving patient reported outcomes in primary care. TRIAL REGISTRATION: ClinicalTrials.gov NCT00732797.