GP trainee responses to using SHERPA for multimorbidity consultations.

UK general practitioner (GP) trainees are taught a consultation model which elicits the patients' main reason for consulting 'today'. This approach will often miss important issues for the increasing number of patients with multimorbidity. We developed the SHERPA model as a person-centred biopsychosocial framework for consulting patients with multimorbidity to address this. We aimed to examine GPs trainees' responses to SHERPA when integrated into their vocational training. The research design was qualitative and participants were GPs trainees in vocational training from one UK training location. GP trainees were introduced to the SHERPA model through interactive workshops. Qualitative data were collected from 16 participants, through four hours of teaching observation, 24 feedback templates, six practical applications of SHERPA and eight one-to-one interviews. Data were transcribed, and, using the Framework approach, systematically analysed, focussing on trainees' learning and application of the model. The results demonstrated that all participants engaged well with the teaching sessions, brought observations from their own experience, and reflected on particularly complex consultations. Half of the participants applied SHERPA successfully with their patients, particularly repeat attenders. Barriers to this approach were: selecting appropriate patients; perceived time pressure; lack of familiarity using the model; viewing SHERPA as 'additional', rather than integral, to shared decision-making in complex situations. The SHERPA model was viewed as helpful by these GP trainees for patients with whom they had established a relationship. Earlier introduction and regular support from trainers, where trainees reflect on experience of SHERPA, could increase confidence in using this method.

Knowledge, skills and attitudes of older people and staff about getting up from the floor following a fall: a qualitative investigation.

BACKGROUND: Falls are the most common reason for ambulance callouts resulting in non-conveyance. Even in the absence of injury, only half of those who fall can get themselves up off the floor, often remaining there over an hour, increasing risk of complications. There are recognized techniques for older people to learn how to get up after a fall, but these are rarely taught. The aim of this study was to develop an understanding of attitudes of older people, carers and health professionals on getting up following a fall. METHODS: A qualitative focus group and semi-structured interviews were conducted with 28 participants, including community-dwelling older people with experience of a non-injurious fall, carers, physiotherapists, occupational therapists, paramedics and first responders. Data were transcribed and analysed systematically using the Framework approach. A stakeholder group of falls experts and service users advised during analysis. RESULTS: The data highlighted three areas contributing to an individual's capability to get-up following a fall: the environment (physical and social); physical ability; and degree of self-efficacy (attitude and beliefs about their own ability). These factors fell within the wider context of making a decision about needing help, which included what training and knowledge each person already had to manage their fall response. Staff described how they balance their responsibilities, prioritising the individual's immediate needs; this leaves limited time to address capability in the aforementioned three areas. Paramedics, routinely responding to falls, only receive training on getting-up techniques from within their peer-group. Therapists are aware of the skillset to breakdown the getting-up process, but, with limited time, select who to teach these techniques to. CONCLUSION: Neither therapists nor ambulance service staff routinely teach strategies on how to get up, meaning that healthcare professionals largely have a reactive role in managing falls. Interventions that address the environment, physical ability and self-efficacy could positively impact on peoples' capability to get up following a fall. Therefore, a more proactive approach would be to teach people techniques to manage these aspects of future falls and to provide them easily accessible information.

Not all waits are equal: an exploratory investigation of emergency care patient pathways.

BACKGROUND: Increasing pressure in the United Kingdom (UK) urgent care system has led to Emergency Departments (EDs) failing to meet the national requirement that 95% of patients are admitted, discharged or transferred within 4-h of arrival. Despite the target being the same for all acute hospitals, individual Trusts organise their services in different ways. The impact of this variation on patient journey time and waiting is unknown. Our study aimed to apply the Lean technique of Value Stream Mapping (VSM) to investigate care processes and delays in patient journeys at four contrasting hospitals. METHODS: VSM timing data were collected for patients accessing acute care at four hospitals in South West England. Data were categorised according to waits and activities, which were compared across sites to identify variations in practice from the patient viewpoint. We included Public and Patient Involvement (PPI) to fully interpret our findings; observations and initial findings were considered in a PPI workshop. RESULTS: One hundred eight patients were recruited, comprising 25,432 min of patient time containing 4098 episodes of care or waiting. The median patient journey was 223 min (3 h, 43 min); just within the 4-h target. Although total patient journey times were similar between sites, the stage where the greatest proportion of waiting occurred varied. Reasons for waiting were dominated by waits for beds, investigations or results to be available. From our sample we observed that EDs without a discharge/clinical decision area exhibited a greater proportion of waiting time following an admission or discharge decision. PPI interpretation indicated that patients who experience waits at the beginning of their journey feel more anxious because they are 'not in the system yet'. CONCLUSIONS: The novel application of VSM analysis across different hospitals, coupled with PPI interpretation, provides important insight into the impact of care provision on patient experience. Measures that could reduce patient waiting include automatic notification of test results, and the option of discharge/clinical decision areas for patients awaiting results or departure. To enhance patient experience, good communication with patients and relatives about reasons for waits is essential.

Which components of behavioral weight management programs are essential for weight loss in people living with obesity? A rapid review of systematic reviews.

The optimal treatment and organization of care for people with obesity is one of the greatest challenges facing today's health services. While surgery and pharmacotherapy offer effective treatment options for some people with obesity, behavioral interventions are important to support long-term behavioral change. However, little is known about the most effective components of behavioral interventions, and this is especially the case for people with complex or severe obesity (i.e. body mass index [BMI] > 35 kg/m2). Accordingly, the current rapid review aimed to identify which behavior change techniques (BCTs) are effective for weight loss in adults with (severe) obesity. A secondary aim was to review the effects of BCTs on dietary behaviors and physical activity, and psychological outcomes, recognizing that behavioral interventions commonly target these. A search of Scopus, Ovid Medline, and Web of Science resulted in 1227 results, with 22 reviews eligible for inclusion. The most commonly reported BCTs were self-monitoring and goal setting, but these had variable effects on weight in adults with obesity. Combining these BCTs with other self-regulatory techniques led to increased weight loss. Further, for adults with severe obesity, so-called 'nudge' techniques and self-regulatory techniques were associated with greater weight loss. Three reviews also found that while self-monitoring increased physical activity, behavioral commitments increased changes to dietary behaviors. BCTs were not associated with psychological well-being. The review confirms that behavioral interventions have an impact in weight management, including for individuals with more complex or severe obesity, but highlights the need for further investigation of their use within clinical settings.

Development of a group-based behaviour change intervention for people with severe obesity informed by the social identity approach to health.

INTRODUCTION: Interventions to support behaviour change in people living with chronic health conditions increasingly use patient groups as the mode of delivery, but these are often designed without consideration of the group processes that can shape intervention outcomes. This article outlines a new approach to designing group-based behaviour change interventions that prioritizes recipients' shared social identity as group members in facilitating the adoption of established behaviour change techniques (BCTs). The approach is illustrated through an example drawn from research focused on people living with severe obesity. METHODS: A prioritization process was undertaken in collaboration with stakeholders, including behaviour change experts, clinicians, and a former patient to develop an evidence-based, group intervention informed by the social identity approach to health. Three phases of development are reported: (1) identification of the health problem; (2) delineation of intervention mechanisms and operationalization of BCTs for group delivery and (3) intervention manualization. The fourth phase, intervention testing and optimization, is reported elsewhere. RESULTS: A group-based behaviour change intervention was developed, consisting of 12 group sessions and 3 one-to-one consultations. The intervention aimed to support the development of shared social identity among recipients, alongside the delivery of evidence-based BCTs, to improve the likelihood of successful intervention and health outcomes among people living with severe obesity. CONCLUSIONS: A manualized intervention, informed by the social identity approach to health, was systematically designed with input from stakeholders. The development approach employed can inform the design of behavioural interventions in other health contexts where group-based delivery is planned.

A Qualitative Exploration of Patient and Staff Experiences of the Receipt and Delivery of Specialist Weight Management Services in the UK.

BACKGROUND: Addressing the increasing prevalence of obesity is a global public health priority. Severe obesity (body mass index > 40) reduces life expectancy, due to its association with people developing complications (e.g. diabetes, cancer, cardiovascular disease), and greatly impairs quality of life. The National Health Service (NHS) in the UK provides specialist weight management services (SWMS) for people with severe obesity, but key uncertainties remain around patient access to and engagement with weight management services, as well as pathways beyond the service. METHODS: In this multiple methods study, using online forum data and semi-structured interviews, stakeholders' experiences of delivering and receiving SWMS were explored. Using the web search engine Google with keywords and web address (URL) identifiers, relevant public online platforms were sourced with snowball sampling and search strings used to identify threads related to people's experiences of accessing SWMS (n = 57). Interviews were conducted with 24 participants (nine patients, 15 staff), and data from all sources were analysed thematically using the framework approach. RESULTS: Six themes related to access to and engagement with SWMS emerged during data analysis: (1) making the first move, (2) uncertainty and confusion, (3) resource issues, (4) respect and understanding, (5) mode of delivery, and (6) desire for ongoing support. CONCLUSION: There is a mixed and varied picture of SWMS provision across the UK. The service offered is based on local clinical decision making and available resources, resulting in a range of patient experiences and perspectives. Whilst service capacity issues and patient anxiety were seen as barriers to accessing care, peer support and positive clinical and group interactions (connectedness between individuals) were considered to increase engagement.

Using qualitative methods for attribute development for discrete choice experiments: issues and recommendations.

Attribute generation for discrete choice experiments (DCEs) is often poorly reported, and it is unclear whether this element of research is conducted rigorously. This paper explores issues associated with developing attributes for DCEs and contrasts different qualitative approaches. The paper draws on eight studies, four developed attributes for measures, and four developed attributes for more ad hoc policy questions. Issues that have become apparent through these studies include the following: the theoretical framework for random utility theory and the need for attributes that are neither too close to the latent construct nor too intrinsic to people's personality; the need to think about attribute development as a two-stage process involving conceptual development followed by refinement of language to convey the intended meaning; and the difficulty in resolving tensions inherent in the reductiveness of condensing complex and nuanced qualitative findings into precise terms. The comparison of alternative qualitative approaches suggests that the nature of data collection will depend both on the characteristics of the question (its sensitivity, for example) and the availability of existing qualitative information. An iterative, constant comparative approach to analysis is recommended. Finally, the paper provides a series of recommendations for improving the reporting of this element of DCE studies.

A group-based behavioural intervention for weight management (PROGROUP) versus usual care in adults with severe obesity: a feasibility randomised controlled trial protocol.

BACKGROUND: Approximately 15 million people in the UK live with obesity, around 5 million of whom have severe obesity (body mass index (BMI) ≥35kg/m2). Having severe obesity markedly compromises health, well-being and quality of life, and substantially reduces life expectancy. These adverse outcomes are prevented or ameliorated by weight loss, for which sustained behavioural change is the cornerstone of treatment. Although NHS specialist 'Tier 3' Weight Management Services (T3WMS) support people with severe obesity, using individual and group-based treatment, the current evidence on optimal intervention design and outcomes is limited. Due to heterogeneity of severe obesity, there is a need to tailor treatment to address individual needs. Despite this heterogeneity, there are good reasons to suspect that a structured group-based behavioural intervention may be more effective and cost-effective for the treatment of severe obesity compared to usual care. The aims of this study are to test the feasibility of establishing and delivering a multi-centre randomised controlled clinical trial to compare a group-based behavioural intervention versus usual care in people with severe obesity. METHODS: This feasibility randomised controlled study is a partially clustered multi-centre trial of PROGROUP (a novel group-based behavioural intervention) versus usual care. Adults ≥18 years of age who have been newly referred to and accepted by NHS T3WMS will be eligible if they have a BMI ≥40, or ≥35 kg/m2 with comorbidity, are suitable for group-based care and are willing to be randomised. Exclusion criteria are participation in another weight management study, planned bariatric surgery during the trial, and unwillingness or inability to attend group sessions. Outcome assessors will be blinded to treatment allocation and success of blinding will be evaluated. Clinical measures will be collected at baseline, 6 and 12 months post-randomisation. Secondary outcome measures will be self-reported and collected remotely. Process and economic evaluations will be conducted. DISCUSSION: This randomised feasibility study has been designed to test all the required research procedures and additionally explore three key issues; the feasibility of implementing a complex trial at participating NHS T3WMS, training the multidisciplinary healthcare teams in a standard intervention, and the acceptability of a group intervention for these particularly complex patients. TRIAL REGISTRATION: ISRCTN number 22088800.

Women's experience of colposcopy: a qualitative investigation.

BACKGROUND: The last comprehensive investigation of women's experience of the colposcopy service in the UK was conducted in the 1980's. It highlighted women's anxiety and lack of information, resulting in recommendations for improvements. Since then the colposcopy service has changed substantially. It is therefore time to re-visit women's experience of this service and reflect upon the success of service changes in improving experience and reducing anxiety. The aim of this study was to investigate women's experience of being referred for, and attending, colposcopy appointments, and identify potential service improvements. METHODS: Qualitative in-depth interviews were conducted with 18 women newly referred for colposcopy in the West Midlands, UK. The interviews were designed to elicit the experience of colposcopy from the patients' perspective. RESULTS: The eight emerging themes were categorised as three overarching concepts, which were: feelings of emotional reaction, choices being accommodated and time delays. Women felt very apprehensive before their appointment, but when attending, appreciated being consulted about their preferences. Delays in referral and feeling 'rushed' by staff impacted negatively on women's experience. CONCLUSIONS: Service changes in information provision and increased respect for dignity seem to have improved the experience that women have of colposcopy, however, this does not appear to have translated into decreased anxiety. Women still have strong emotional reactions to being referred for, and attending, colposcopy appointments. Staff taking time to explain the diagnosis fully, and discuss their preferences about aspects of their consultation can alleviate their anxiety.

The Effectiveness and Usability of Online, Group-Based Interventions for People With Severe Obesity: Protocol for a Systematic Review.

BACKGROUND: Globally, obesity is a growing crisis. Despite obesity being preventable, over a quarter of the UK adult population is currently considered clinically obese (typically body mass index ≥35 kg/m2). Access to treatment for people with severe obesity is limited by long wait times and local availability. Online and group-based interventions provide means of increasing the accessibility of obesity prevention and treatment services. However, there has been no prior review of the effectiveness of group-based interventions delivered online for people with severe obesity. OBJECTIVE: The purpose of this systematic review protocol is to provide an evaluation of the effectiveness and usability of different types of online, group-based interventions for people with severe obesity. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocols (PRISMA-P) and the Population, Intervention, Comparator, Outcome, and Study (PICOS) frameworks were used to structure this review. The review will systematically search 7 databases: MEDLINE, Embase, the Cumulative Index of Nursing and Allied Health Literature, APA PsycNet, Web of Science, CENTRAL, and the ProQuest Dissertations and Theses databases. Two authors (MM-I and LB) will independently screen the titles and abstracts of identified articles, select studies for inclusion based on the eligibility criteria, and extract data into a standardized form. Any disagreements will be discussed and resolved by a third reviewer (EM) if necessary. Risk of bias will be assessed using the Cochrane Collaboration Risk of Bias 2 tool and a descriptive analysis will be used to evaluate effectiveness and usability. RESULTS: The systematic review has not yet been started. It is expected to be completed and submitted for publication by December 2021. CONCLUSIONS: This systematic review will summarize the effectiveness and usability of online, group-based interventions for people with obesity. It will identify the types of online delivery that have the strongest support to help inform the development of more useful and engaging interventions for people with severe obesity. TRIAL REGISTRATION: National Institute for Health Research, PROSPERO CRD42021227101; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021227101. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/26619.

How Group-Based Interventions Can Improve Services for People with Severe Obesity.

PURPOSE OF REVIEW: Rising demand for specialised "Tier 3" weight management services in England is exceeding capacity, leading many services to offer group-based care programmes. This review considers the organisation of current provision, exploring how group programmes may enhance services and how these could be scaled up for wider implementation. RECENT FINDINGS: Existing group-based programmes mainly focus on providing patients with information and education about their condition. Evidence suggests that groups themselves offer therapeutic benefits beyond this, by underpinning patients' engagement with programme materials and contributing to wider health and well-being. To maximise these benefits, there is a need to attend to the group processes that emerge in treatment groups which, left unchecked, may limit or even adversely impact programme outcomes. Group-based interventions may be of benefit to patients in Tier 3 specialist weight management services, although their format is complex and reliant on facilitators' expertise.

Women's colposcopy experience and preferences: a mixed methods study.

BACKGROUND: The colposcopy service is a key component in the UK Cervical Screening Programme. Over 120,000 women are referred to the service annually, however up to 25% of women fail to attend their appointment. Little is known about patients' preferences for colposcopic investigation and treatment. This study aims to investigate women's experience of colposcopy, to identify patients' preferences for aspects of appointments within the colposcopy service, and to make suggestions for service improvement. METHODS/DESIGN: This study has been designed as a two stage, mixed method project. Stage one will involve in-depth interviews with new colposcopy patients to ascertain their experience of colposcopy services. This qualitative stage will generate factors thought to be important by service users in their experience. Stage two will utilise a choice based quantitative technique to identify women's preferences and determine the representativeness of factors generated through the interviews. The initial stage of in-depth interviews will be conducted with patients who are newly referred to colposcopy clinics to investigate the experience that they have of the referral process and appointment attendance. The outcome of these interviews will be analysed qualitatively using Framework analysis. Factors found to be important in women's experience will be extracted and used to construct a choice based questionnaire. The discrete choice experiment (questionnaire) will apply a best-worst technique through scenario-based questions to find women's relative preferences for different aspects of the service. It will be offered to women attending follow-up appointments at two colposcopy clinics in the West Midlands. Women will complete the questionnaire whilst they wait for their appointment, or, if they prefer, will take it home to complete in private. Women who do not attend their appointment will be posted the research information and questionnaire. The questionnaire analysis will use a weighted least squares regression technique for each best/worst pair. The accept/reject 'would you attend this appointment' question will be analysed using a random effects logit model. DISCUSSION: Colposcopy is a common procedure and one that is associated with raised anxiety among women experiencing the service. Little is known about women's experience of the service or their preferences for service delivery. The outcomes of the study will comprise a description of women's experience of colposcopy and establishing their preferences for how aspects of the service should be provided. Women's preferences will be fed back to service providers to enable improvements to the service to be made.

A randomised controlled trial and cost effectiveness study of systematic screening (targeted and total population screening) versus routine practice for the detection of atrial fibrillation in the over 65s: (SAFE) [ISRCTN19633732].

BACKGROUND: Atrial fibrillation (AF) has been recognised as an important independent risk factor for thromboembolic disease, particularly stroke for which it provides a five-fold increase in risk. This study aimed to determine the baseline prevalence and the incidence of AF based on a variety of screening strategies and in doing so to evaluate the incremental cost-effectiveness of different screening strategies, including targeted or whole population screening, compared with routine clinical practice, for detection of AF in people aged 65 and over. The value of clinical assessment and echocardiography as additional methods of risk stratification for thromboembolic disease in patients with AF were also evaluated. METHODS: The study design was a multi-centre randomised controlled trial with a study population of patients aged 65 and over from 50 General Practices in the West Midlands. These purposefully selected general practices were randomly allocated to 25 intervention practices and 25 control practices. GPs and practice nurses within the intervention practices received education on the importance of AF detection and ECG interpretation. Patients in the intervention practices were randomly allocated to systematic (n = 5000) or opportunistic screening (n = 5000). Prospective identification of pre-existing risk factors for AF within the screened population enabled comparison between high risk targeted screening and total population screening. AF detection rates in systematically screened and opportunistically screened populations in the intervention practices were compared to AF detection rate in 5,000 patients in the control practices.

Factors affecting patients' trust and confidence in GPs: evidence from the English national GP patient survey.

OBJECTIVES: Patients' trust in general practitioners (GPs) is fundamental to effective clinical encounters. Associations between patients' trust and their perceptions of communication within the consultation have been identified, but the influence of patients' demographic characteristics on these associations is unknown. We aimed to investigate the relative contribution of the patient's age, gender and ethnicity in any association between patients' ratings of interpersonal aspects of the consultation and their confidence and trust in the doctor. DESIGN: Secondary analysis of English national GP patient survey data (2009). SETTING: Primary Care, England, UK. PARTICIPANTS: Data from year 3 of the GP patient survey: 5 660 217 questionnaires sent to patients aged 18 and over, registered with a GP in England for at least 6 months; overall response rate was 42% after adjustment for sampling design. OUTCOME MEASURES: We used binary logistic regression analysis to investigate patients' reported confidence and trust in the GP, analysing ratings of 7 interpersonal aspects of the consultation, controlling for patients' sociodemographic characteristics. Further modelling examined moderating effects of age, gender and ethnicity on the relative importance of these 7 predictors. RESULTS: Among 1.5 million respondents (adjusted response rate 42%), the sense of 'being taken seriously' had the strongest association with confidence and trust. The relative importance of the 7 interpersonal aspects of care was similar for men and women. Non-white patients accorded higher priority to being given enough time than did white patients. Involvement in decisions regarding their care was more strongly associated with reports of confidence and trust for older patients than for younger patients. CONCLUSIONS: Associations between patients' ratings of interpersonal aspects of care and their confidence and trust in their GP are influenced by patients' demographic characteristics. Taking account of these findings could inform patient-centred service design and delivery and potentially enhance patients' confidence and trust in their doctor.