Peripheral artery disease (PAD) in primary care-educational experiences for PAD primary care in England-a mixed-method study.

BACKGROUND: Peripheral artery disease (PAD), the pathophysiologic narrowing of arterial blood vessels of the lower leg due to atherosclerosis, is a highly prevalent disease, with sharp increases in prevalence with age. Primary care is ideally located to identify and manage PAD. OBJECTIVES: This study aims to identify the educational experiences, opinions, and confidence of primary care clinicians (PCCs) regarding PAD. METHOD: This mixed-method study was conducted within primary care in England. An online survey was completed with follow-on semistructured interviews, between January and September 2021, with PCCs, namely GPs, practice nurses, and allied professionals (survey n = 874, interviews n = 50). RESULTS: PCCs report variation in PAD education received, where the content could not often be recalled. Patient-focussed experiential and self-directed learning, formed the largest method to gain PAD education. All PCCs recognized that they have an important role in recognizing PAD yet confidence in recognizing and diagnosing PAD was lacking. PCCs acknowledged that late or missed PAD diagnosis resulted in significant patient morbidity and mortality. Yet many did not recognize PAD as a common disease. CONCLUSION: As "specialist-generalists" with finite resources, education provided to primary care needs to be applicable for the multimorbid patient presentations often seen, utilizing resources available in primary care, with consideration to the time constraints endured.

A scoping review of international virtual knowledge exchanges for healthcare professionals.

International knowledge exchanges within healthcare have historically been a popular method to provide exposure to practice in other national and international healthcare settings. As the COVID-19 pandemic forced many countries into lockdowns, knowledge exchanges in healthcare were forced into a period of suspension. This provided an opportunity to consider alternative methods of delivery. This scoping review explores virtual knowledge exchanges in healthcare professional education, including their format and related outcomes. Thirty-four virtual knowledge exchanges were identified. These demonstrated viability and subjective participant satisfaction. Virtual methods removed barriers of time, distance and finance associated with traditional exchanges, while still facilitating engagement with other international healthcare colleagues. However these exchanges were heterogeneous in their aims, structure and theoretical underpinnings. An understanding of educational outcomes and their measurement was not always obvious. Applying an overlay of robust pedagogical theory would strengthen and provide structure to the clearly well valued activity of international exchange.

Prevalence of Cognitive Impairment in Individuals with Vascular Surgical Pathology: a Systematic Review and Meta-Analysis.

OBJECTIVE: A significant proportion of vascular surgery patients may have undiagnosed cognitive impairment; however, its true prevalence and impact on outcomes are unknown. The aim of this review was to estimate the prevalence of cognitive impairment among individuals with clinically significant vascular surgical pathology and investigate its associations with post-operative outcomes in those undergoing vascular surgery. METHODS: MEDLINE, EMBASE, EMCare, CINAHL, PsycINFO, and Scopus were searched for relevant studies. Included studies assessed cognitive function among individuals with either symptomatic vascular surgical pathology, or disease above threshold for intervention, using a validated cognitive assessment tool. The primary outcome measure was prevalence of cognitive impairment. Secondary outcomes included incidence of post-operative delirium (POD). Two reviewers independently extracted relevant study data and assessed risk of bias (ROBINS-E or RoB 2 tool). Prevalence (%) of cognitive impairment was calculated for individual studies and presented with 95% confidence intervals (CI). Prevalence data from comparable studies were pooled using the Mantel-Haenszel method (random effects model) for separate vascular disease types. Certainty of effect estimates was assessed using the GRADE criteria. RESULTS: Twenty-four studies (2 564 participants) were included in the systematic review, and nine studies (1 310 participants) were included in the meta-analyses. The prevalence of cognitive impairment was 61% (95% CI 48 - 74; 391 participants; low certainty) in studies including multiple vascular surgical pathologies, 38% (95% CI 32 - 44; 278 participants; very low certainty) in carotid artery disease, and 19% (95% CI 10 - 33; 641 participants; low certainty) in those with intermittent claudication. Lower cognitive assessment scores were associated with POD (five studies; 841 participants), but data were not suitable for pooling. CONCLUSION: Screening elective vascular surgery patients for cognitive impairment may be appropriate given its high prevalence, and the association of worse cognition with POD, among individuals with clinically significant vascular surgical pathology.

A systematic review investigating the identification, causes, and outcomes of delays in the management of chronic limb-threatening ischemia and diabetic foot ulceration.

OBJECTIVE: Patients presenting with chronic limb-threatening ischemia and diabetic foot ulceration (DFU) are at high risk of major lower limb amputation. Long-standing concern exists regarding late presentation and delayed management contributing to increased amputation rates. Despite multiple guidelines existing on the management of both conditions, there is currently no accepted time frame in which to enact specialist care and treatment. This systematic review aimed to investigate potential time delays in the identification, referral, and management of both chronic limb-threatening ischemia and DFU. METHODS: A systematic review conforming to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement standards was performed searching MEDLINE, Embase, The Cochrane Library, and Cumulative Index to Nursing and Allied Health Literature from inception to November 14, 2018. All English-language qualitative and quantitative articles investigating or reporting the identification, causes, and outcomes of time delays within "high-income" countries (annual gross domestic product per person >$15,000) were included. Data were extracted independently by the investigators. Given the clinical crossover, both conditions were investigated together. A study protocol was designed and registered at the International Prospective Register of Systematic Reviews. RESULTS: A total of 4780 articles were screened, of which 32 articles, involving 71,310 patients and 1388 health care professionals, were included. Twenty-three articles focused predominantly on DFU. Considerable heterogeneity was noted, and only 12 articles were deemed of high quality. Only four articles defined a delay, but this was not consistent between studies. Median times from symptom onset to specialist health care assessment ranged from 15 to 126 days, with subsequent median times from assessment to treatment ranging from 1 to 91 days. A number of patient and health care factors were consistently reported as potentially causative, including poor symptom recognition by the patient, inaccurate health care assessment, and difficulties in accessing specialist services. Twenty articles reported outcomes of delays, namely, rates of major amputation, ulcer healing, and all-cause mortality. Although results were heterogeneous, they allude to delays being associated with detrimental outcomes for patients. CONCLUSIONS: Time delays exist in all aspects of the management pathway, which are in some cases considerable in length. The causes of these are complex but reflect poor patient health-seeking behaviors, inaccurate health care assessment, and barriers to referral and treatment within the care pathway. The adoption of standardized limits for referral and treatment times, exploration of missed opportunities for diagnosis, and investigation of novel strategies for providing specialist care are required to help reduce delays.

Knowledge of peripheral artery disease: What do the public, healthcare practitioners, and trainees know?

This systematic review evaluated the knowledge and awareness of peripheral artery disease (PAD) within the general public (including patients with peripheral vascular disease), nonspecialist healthcare professionals (nsHCP), and trainees (medical students and trainee doctors). Relevant articles were identified from electronic databases using key search terms: 'peripheral artery disease'; 'limb ischaemia'; 'intermittent claudication'; 'knowledge'; 'understanding'; 'public'; 'medical professional'. The heterogeneous results were described narratively. A lack of knowledge and understanding of PAD (disease awareness) were identified in all groups. Among nsHCPs, factors which affect knowledge include the level of training, early clinical exposure and the presence of family members with cardiovascular/vascular disease. Within the general public, knowledge and awareness was improved if a family member/friend had a diagnosis, or following a patient-centred consultation with any HCP. Public campaigns are proven effective in improving disease knowledge/awareness in conditions such as stroke alongside sustained patient education. These may provide future avenues to improve PAD knowledge and awareness, in order to effectively manage risk factors and minimise delayed or missed diagnosis of PAD. (PROSPERO registration number: CRD42018117304).

Understanding TIA: an ethnographic study of TIA consultations.

BACKGROUND: Transient ischaemic attack (TIA) is a transient episode of neurological dysfunction. Rapid access TIA clinics have been set up as integrated 'one-stop' clinics that aim to investigate, diagnose, educate and implement treatment to reduce the risk of further TIA/stroke. OBJECTIVE: This study aimed to examine how TIA consultations were conducted by observing the consultations and then interviewing patients. METHODS: This ethnographic study observed fifteen patient-clinician consultations where a diagnosis of TIA was made within three different TIA outpatient clinics in the East Midlands. All fifteen patients, their accompanying family-members/carers and three stroke clinicians were interviewed. Data analysis was informed by the constant comparative approach. RESULTS: There was considerable variation in the conduct of these consultations across sites and clinicians. This resulted in variation in patient experience and knowledge after the consultation including the ability to recognize TIA-associated risk factors and their management. As TIA symptoms resolve, patients may reduce their need to seek health care services in addition to demonstrating reduced concordance with secondary stroke prevention. Health professionals recognize that this single appointment provides patients with a large amount of information which may be difficult to process. Importantly, there was little discussion about future symptoms and how to respond. A management plan, which considered a patient's health belief, knowledge and encouraged the involvement of family members, improved information recall. CONCLUSIONS: TIA is a complex medical diagnosis with multiple risk factors that may make the management complex and hence difficult for patients to undertake. Our findings found variability in the conduct, provision of information and patient understanding. Guidance on nationally agreed consultation framework may prove useful. Improved patient education may include individualized/sustained education utilizing multidisciplinary team members across family/primary and secondary care, video or greater online education and improved general public education.

Interventions for improving modifiable risk factor control in the secondary prevention of stroke.

BACKGROUND: People with stroke or transient ischaemic attack (TIA) are at increased risk of future stroke and other cardiovascular events. Stroke services need to be configured to maximise the adoption of evidence-based strategies for secondary stroke prevention. Smoking-related interventions were examined in a separate review so were not considered in this review. This is an update of our 2014 review. OBJECTIVES: To assess the effects of stroke service interventions for implementing secondary stroke prevention strategies on modifiable risk factor control, including patient adherence to prescribed medications, and the occurrence of secondary cardiovascular events. SEARCH METHODS: We searched the Cochrane Stroke Group Trials Register (April 2017), the Cochrane Effective Practice and Organisation of Care Group Trials Register (April 2017), CENTRAL (the Cochrane Library 2017, issue 3), MEDLINE (1950 to April 2017), Embase (1981 to April 2017) and 10 additional databases including clinical trials registers. We located further studies by searching reference lists of articles and contacting authors of included studies. SELECTION CRITERIA: We included randomised controlled trials (RCTs) that evaluated the effects of organisational or educational and behavioural interventions (compared with usual care) on modifiable risk factor control for secondary stroke prevention. DATA COLLECTION AND ANALYSIS: Four review authors selected studies for inclusion and independently extracted data. The quality of the evidence as 'high', 'moderate', 'low' or 'very low' according to the GRADE approach (GRADEpro GDT).Three review authors assessed the risk of bias for the included studies. We sought missing data from trialists.The results are presented in 'Summary of findings' tables. MAIN RESULTS: The updated review included 16 new studies involving 25,819 participants, resulting in a total of 42 studies including 33,840 participants. We used the Cochrane risk of bias tool and assessed three studies at high risk of bias; the remainder were considered to have a low risk of bias. We included 26 studies that predominantly evaluated organisational interventions and 16 that evaluated educational and behavioural interventions for participants. We pooled results where appropriate, although some clinical and methodological heterogeneity was present.Educational and behavioural interventions showed no clear differences on any of the review outcomes, which include mean systolic and diastolic blood pressure, mean body mass index, achievement of HbA1c target, lipid profile, mean HbA1c level, medication adherence, or recurrent cardiovascular events. There was moderate-quality evidence that organisational interventions resulted in improved blood pressure control, in particular an improvement in achieving target blood pressure (odds ratio (OR) 1.44, 95% confidence interval (CI) 1.09 to1.90; 13 studies; 23,631 participants). However, there were no significant changes in mean systolic blood pressure (mean difference (MD), -1.58 mmHg 95% CI -4.66 to 1.51; 16 studies; 17,490 participants) and mean diastolic blood pressure (MD -0.91 mmHg 95% CI -2.75 to 0.93; 14 studies; 17,178 participants). There were no significant changes in the remaining review outcomes. AUTHORS' CONCLUSIONS: We found that organisational interventions may be associated with an improvement in achieving blood pressure target but we did not find any clear evidence that these interventions improve other modifiable risk factors (lipid profile, HbA1c, medication adherence) or reduce the incidence of recurrent cardiovascular events. Interventions, including patient education alone, did not lead to improvements in modifiable risk factor control or the prevention of recurrent cardiovascular events.

International exchanges in primary care-learning from thy neighbour.

This systematic review describes how international exchange programmes in primary care have been received and evaluated. Electronic databases (MEDLINE, Embase, PsycINFO, EBM reviews, CAB abstracts and PubMED) were searched to identify articles where the main focus of the study was exchanges undertaken in primary care/family medicine until March 2016. Articles were included if they (i) discussed participant exchanges in primary care; (ii) presented associated outcome data-this included (a) individual/group experience of exchange; (b) mechanism of exchange and (c) observations during the exchange. A narrative synthesis was performed of the heterogeneous data identified. Twenty-nine studies were included. Exchange locations varied across the world with the largest number in Europe. Participants came from a range of backgrounds including medical students, nurses, General Practitioners (GP), GP trainees (GPTs) and visiting scholars/professors. Exchange duration ranged from 3 days to 2 years. Key themes were identified from analysis of the studies with illustrative quotes from the included studies provided. Four key areas were discussed in relation to exchange experience: learning opportunities and new knowledge; comparative observation; knowledge gained and translational learning. Primary care international exchanges provide a rich source of cross-country learning. This review identified that exchange participants benefit both personally and professionally, equipping them with translatable skills to improve the care provided to their patients.

The value of European exchange programs for early career family doctors.

The Hippokrates Exchange programme (HEP) is designed to give early career General Practitioners (Associates in Training (AITs)/First5s) first-hand experience into concepts of a primary healthcare system outside of their host country. The aim is to improve GP knowledge and skills, inspire professional development and promote a global approach to primary care. Although an increasing number are taking up this opportunity, their views and experiences of international exchanges are not well described. The aim of the study was to explore the experiences of AITs/First5s following their HEP exchanges. This qualitative study analysed 16 post-exchange reports of UK participants visiting 10 European countries via the HEP, using a thematic approach. Participants were unanimously positive about their exchange experiences. The themes that emerged were (1) Comparison of primary care practice (2) Infrastructure of host primary care (3) Motivation and experience of exchanges and (4) Learning and reflection. Participants displayed considerable benefits from these exchanges by broadening their experience in different primary care systems and identifying improvements to be incorporated into their UK practice.

Workplace-based knowledge exchange programmes between academics, policy-makers and providers of healthcare: a qualitative study.

BACKGROUND: Workplace-based knowledge exchange programmes (WKEPs), such as job shadowing or secondments, offer potential for health and care providers, academics, and policy-makers to foster partnerships, develop local solutions and overcome key differences in practices. Yet opportunities for exchange can be hard to find and are poorly reported in the literature. OBJECTIVES: To understand the views of providers, academics and policy-makers regarding WKEPs, in particular, their motivations to participate in such exchanges and the perceived barriers and facilitators to participation. METHODS: A qualitative study involving semistructured interviews with 20 healthcare providers, academics and policy-makers in England. Rapid data collection and analysis techniques were employed. Interviews formed part of a wider scoping study that mapped the characteristics and existing literature related to WKEPs. RESULTS: Interviewees reported being motivated to develop, sponsor and/or participate in WKEPs with a clear purpose and defined outcomes that could demonstrate the value of the time out of work to their organisations. Perceived barriers included competitive application processes for national fellowships, a lack of knowing how to identify with whom to undertake an exchange (varying 'tribes'), and the burdens of time, costs and administration regarding arranging exchanges. WKEPs were reported to work best where there was a perceived sense of shared purpose, long-standing relationship and trust between organisations. Facilitators included existing confidentiality agreements and/or shared professional standards, as well as funding. CONCLUSION: WKEPs were reported to be valuable experiences but required significant organisational buy-in and cooperation to arrange and sustain. To benefit emerging partnerships, such as the new integrated care systems in England, more outcomes evaluations of existing WKEPs are needed, and research focused on overcoming barriers to participation, such as time and costs.

Factors that influence the feasibility and implementation of a complex intervention to improve the treatment of peripheral arterial disease in primary and secondary care: a qualitative exploration of patient and provider perspectives.

OBJECTIVES: Our aim was to examine the feasibility and implementation of a complex intervention to improve the care of patients with peripheral arterial disease (the LEGS intervention) from the perspective of patients, general practitioners and secondary care clinicians. DESIGN: A qualitative study involving semistructured individual interviews with patients and providers to gain an understanding of the feasibility of the LEGS intervention as well the barriers and facilitators to implementation in secondary and primary care. SETTING: Primary and secondary care settings across two National Health Service Trusts. PARTICIPANTS: Twenty-five semistructured telephone interviews were conducted with (1) patients who had received the intervention (n=11), (2) secondary care clinicians responsible for delivering the intervention (n=8) and (3) general practitioners (n=6). ANALYSIS: Data were initially analysed using inductive descriptive thematic analysis. The consolidated framework for implementation research was then used as a matrix to explore patterns in the data and to map connections between the three participant groups. Lastly, interpretive analysis allowed for refining, and a final coding frame was developed. RESULTS: Four overarching themes were identified: (1) the potential to make a difference, (2) a solution to address the gap in no man's land, (3), prioritising and making it happen and (4) personalised information and supportive conversations for taking on the advice. The impetus for prioritising and delivering the intervention was further driven by its flexibility and adaptability to be tailored to the individual and to the environment. CONCLUSIONS: The LEGS intervention can be tailored for use at early and late stages of peripheral arterial disease, provides an opportunity to meet patient needs and can be used to promote shared working across the primary-secondary care interface.

A Community and Hospital cAre Bundle to improve the medical treatment of severe cLaudIcation and critical limb iSchaemia (CHABLIS).

Background: Patients with peripheral artery disease (PAD) often do not receive optimal best medical therapy (BMT). Through interaction with patients and healthcare-professionals (HCPs) we developed the LEaflet Gp letter Structured checklist (LEGS) complex clinical intervention to support HCPs in providing guideline-compliant PAD BMT. Methods: This was a prospective multicentre study assessing the feasibility and fidelity of delivering the LEGS intervention in primary and secondary care over six months. Intervention fidelity was scored based on the proportion of intervention components used correctly at discharge, 30 days, and six months. Results: Overall, 129 individuals were screened and 120 took part (33% female, 74% with chronic limb threatening ischaemia; 93% recruitment rate). Of those, 118 (98% retention rate) completed follow-up. Mean intervention fidelity score at discharge (primary outcome measure) was 63% [95% Confidence Interval (CI): 39-68%, SD: 5%], exceeding the success criteria set at 60% by a panel of HCPs and patients. This, however, declined to 51% at six months. Eight patients (6.7%) died (all cardiovascular deaths), four (3.3%) had a major lower limb amputation, 12 (10%) had a cardiovascular event, and 13 (11%) were admitted due to limb ischaemia at six months. Incomplete lipid therapy prescriptions and LEGS intervention documents not received by primary care CHPs were the most common reasons for not complying with the LEGS intervention. Conclusions: The LEGS intervention can be delivered in PAD care pathways across different hospitals, primary, and community healthcare settings with acceptable fidelity, to streamline and improve PAD BMT short- and medium-term.

Medical Education in a Post COVID-19 era - remote teaching methods for cardiovascular knowledge and skills.

This article was migrated. The article was marked as recommended. Introduction As traditional clinical teaching faces major obstacles during the COVID-19 pandemic, medical educators look toward remote teaching methods to provide solutions to allow continuation of teaching. Remote methods, teaching delivered other than face-to-face, align with the transformation seen within pedagogy over the last 20 years. Aim The aim of this scoping review was to i) identify existing teaching methods available to remotely teach cardiovascular knowledge or skills and ii) identify if they have been evaluated. Methods A scoping review of the literature was undertaken to synthesise available evidence and examine remote teaching methods for application to undergraduate medical education. Results Forty-two articles were identified which presented remote teaching methods using either teaching based online, computer-programs, digital resources, mobile-phone technology, podcasts, serious gaming, social media or resources to aid self-directed learning. Although results were heterogenous, they gave an indication of the method's usefulness. However, evaluations were not consistent and if they were, would have strengthened the value of the findings. Conclusion Various remote teaching methods are available to replace face-to-face cardiovascular teaching where this is not possible. Evidence for effectiveness and engagement of individual platforms are variable. Given the ongoing COVID-19 pandemic, medical educators should prioritise ongoing evaluation of remote teaching methods and share best practice.

Development of entrepreneurial activity in nurse education.

The provision of health care and healthcare education in the UK is undergoing rapid change and development, and is subject to intense market forces. A reduction in the amount of money being spent on nurses' education and training, together with changes in working practices in health care, are affecting the provision of healthcare education significantly. This article gives an overview of the changes influencing providers of pre and post-registration healthcare education, and describes how education providers are generating income through enterprise activity.