The Parent PrU: A measure to assess personal utility of pediatric genomic results.

PURPOSE: We aimed to adapt and validate an existing patient-reported outcome measure, the personal-utility (PrU) scale, for use in the pediatric genomic context. METHODS: We adapted the adult version of the PrU and obtained feedback from 6 parents whose child had undergone sequencing. The resulting measure, the Parent PrU, was administered to parents of children in 4 pediatric cohorts of the Clinical Sequencing Evidence-Generating Research consortium after they received their children's genomic results. We investigated the measure's structural validity and internal consistency. RESULTS: We conducted a principal-axis factor analysis with oblimin rotation on data from 755 participants to determine structural validity. These analyses yielded a 3-factor solution, accounting for 76% of the variance in the 16 items. We used Cronbach's α to assess the internal consistency of each factor: (1) child benefits (α = .95), (2) affective parent benefits (α = .90), and (3) parent control (α = .94). CONCLUSION: Our evidence suggests that the Parent PrU scale has potential as a measure for assessing parent-reported personal utility of their children's genomic results. Additional research is needed to further validate the Parent PrU scale, including by comparing its findings with utility assessments reported by clinicians and children themselves.

Care quality and safety in long-term aged care settings: A systematic review and narrative analysis of missed care measurements.

AIM: To critically evaluate missed care measurement approaches and their application in long-term aged care (LTAC) settings. DESIGN: Systematic review using Tawfik's guideline. DATA SOURCES: PubMed, Scopus, Web of Science, CINAHL and ProQuest were searched. Supplemental searching was from reference lists of retrieved records, first authors' ORCID homepages and Google advanced search for grey literature. Search limitations were English language, published between 1 January 2001 and 31 December 2022. REVIEW METHOD: COVIDENCE was utilized for screening, data extraction and quality appraisal. JBI Critical Appraisal Tools and COSMIN Risk of Bias Tool were used for quality appraisal. Data were summarized and synthesized using narrative analysis. RESULTS: Twenty-four publications across 11 regions were included, with two principal methods of missed care measurement: modified standard scales and tailored specific approaches. They were applied inconsistently and generated diverse measurement outcomes. There were challenges even with the most commonly used tool, the BERNCA-NH, including absence of high-quality verification through comparative analysis against an established 'gold standard', reliance on self-administration, incomplete assessment of constructs and inadequate exploration of psychometric properties. CONCLUSION: Globally, there are deficiencies in the effectiveness and comprehensiveness of the instruments measuring missed care in LTAC settings. Further research on theoretical and practical perspectives is required. IMPLICATIONS: Findings highlighted a critical need to establish a standardized, validated approach to measure missed care in LTAC settings. This review calls for collaborative efforts by researchers, clinical staff and policymakers to develop and implement evidence-based practices as a way of safeguarding the well-being of older clients living in LTAC settings. IMPACT: Measurements of missed care in LTAC settings rely on adapting acute care tools. There is a critical gap in measuring missed care in LTAC settings. Developing a new tool could improve care quality and safety in LTAC settings globally. REPORTING METHOD: Adhered to PRISMA guideline. PATIENT OR PUBLIC CONTRIBUTION: No patient or public contribution.

The PrU: Development and validation of a measure to assess personal utility of genomic results.

PURPOSE: People report experiencing value from learning genomic results even in the absence of clinically actionable information. Such personal utility has emerged as a key concept in genomic medicine. The lack of a validated patient-reported outcome measure of personal utility has impeded the ability to assess this concept among those receiving genomic results and evaluate the patient-perceived value of genomics. We aimed to construct and psychometrically evaluate a scale to measure personal utility of genomic results-the Personal Utility (PrU) scale. METHODS: We used an evidence-based, operational definition of personal utility, with data from a systematic literature review and Delphi survey to build a novel scale. After piloting with 24 adults, the PrU was administered to healthy adults in a Clinical Sequencing Evidence-Generating Research Consortium study after receiving results. We investigated the responses using exploratory factor analysis. RESULTS: The exploratory factor analysis (N = 841 participants) resulted in a 3-factor solution, accounting for 74% of the variance in items: (1) self-knowledge (α = 0.92), (2) reproductive planning (α = 0.89), and (3) practical benefits (α = 0.91). CONCLUSION: Our findings support the use of the 3-factor PrU to assess personal utility of genomic results. Validation of the PrU in other samples will be important for more wide-spread application.

Community-based outpatient cancer rehabilitation services for women with gynecologic cancer: acceptability and impact on patient-reported outcomes.

OBJECTIVE: Women with gynecologic cancers often experience functional impairments impacting quality of life. Physical and occupational therapy (PT/OT) treat functional impairment; however, the acceptability and impact of these services for women with gynecologic cancer are unknown. METHODS: We reviewed rehabilitation charts of women with gynecologic cancer who received PT/OT (i.e., patients) in 2019 and completed patient-reported outcome measures (PROMs) selected by their therapist at intake (pre) and discharge (post). We calculated descriptive statistics for patient, rehabilitation, and acceptability (0-10) data. For PROM data, we used paired samples t-tests to evaluate pre-post change, and then calculated effect size (Hedge's g) and the proportion who achieved a minimal detectable change (MDC). RESULTS: PT/OT patients (N = 84) were 64.63 ± 11.04 years old with predominant diagnoses of ovarian (41.7%) or endometrial (32.1%) cancer. They attended a median of 13 sessions (IQR = 8.0-19.0). Sessions were predominantly PT (86%) vs. OT (14%). Median acceptability was 10 (IQR = 9.8-10.0). Pre-post improvement was observed for each of the 17 PROMs used by therapists. Significant improvement (p < .05) was observed for four PROMs: the Patient-Specific Functional Scale (M∆ = 2.93 ± 2.31, g = 1.47, 71% achieved MDC), the Lower Extremity Functional Scale (M∆ = 12.88 ± 12.31, g = 0.61, 60% achieved MDC), the Lymphedema Life Impact Scale (M∆ = 20.50 ± 20.61, g = 1.18, 58% achieved MDC), and the Modified Fatigue Impact Scale (M∆ = 6.55 ± 9.69, g = 0.33, 7% achieved MDC). CONCLUSION: PT/OT was acceptable and improved patient-reported outcomes for women with gynecologic cancers. Future research is needed to establish gynecologic-specific guidelines for referral and PT/OT practice.

Healthcare needs, experiences and treatment burden in primary care patients with multimorbidity: An evaluation of process of care from patients' perspectives.

BACKGROUND: Patients with multimorbidity often experience treatment burden as a result of fragmented, specialist-driven healthcare. The 'family doctor team' is an emerging service model in China to address the increasing need for high-quality routine primary care. OBJECTIVE: This study aimed to explore the extent to which treatment burden was associated with healthcare needs and patients' experiences. METHODS: Multisite surveys were conducted in primary care facilities in Guangdong province, southern China. Interviewer-administered questionnaires were used to collect data from patients (N = 2160) who had ≥2 clinically diagnosed long-term conditions (multimorbidity) and had ≥1 clinical encounter in the past 12 months since enrolment registration with the family doctor team. Patients' experiences and treatment burden were measured using a previously validated Chinese version of the Primary Care Assessment Tool (PCAT) and the Treatment Burden Questionnaire, respectively. RESULTS: The mean age of the patients was 61.4 years, and slightly over half were females. Patients who had a family doctor team as the primary source of care reported significantly higher PCAT scores (mean difference 7.2 points, p < .001) and lower treatment burden scores (mean difference -6.4 points, p < .001) when compared to those who often bypassed primary care. Greater healthcare needs were significantly correlated with increased treatment burden (ß-coefficient 1.965, p < .001), whilst better patients' experiences were associated with lower treatment burden (ß-coefficient -0.252, p < .001) after adjusting for confounders. CONCLUSION: The inverse association between patients' experiences and treatment burden supports the importance of primary care in managing patients with multimorbidity. PATIENT CONTRIBUTION: Primary care service users were involved in the instrument development and data collection.

[Relationship between the use of home-visit nursing services and family caregivers' experience of interprofessional care].

AIM: To examine the relationship between the use of home-visit nursing services (VNS) for patients and their family caregivers' experience of interprofessional care, which is an indicator of the care process. METHODS: We used data from a cross-sectional survey in Japan, 2020. Family caregivers 40-74 years old and caring for community-dwelling patients with chronic conditions were recruited. The outcome variable was family caregivers' experience, reflecting the quality of interprofessional care for patients and their caregivers. We used the Japanese version of the Caregivers' Experience Instrument (J-IEXPAC CAREGIVERS), which includes two domains: attention for the patient and attention for the caregiver. The main factor was the use of VNS, and covariates were socioeconomic factors of the caregivers and the use of other health and social care services. J-IEXPAC CAREGIVERS scores were divided into two groups by median values and analyzed by multivariate logistic regression analyses. RESULTS: A total of 566 caregivers were included in the analysis. The median age was 62 years old. VNS was used in 86 cases (15.2%). Logistic regression analyses revealed that the use of VNS was significantly associated with a higher total score group for J-IEXPAC CAREGIVERS (odds ratio = 3.02; 95% confidence interval 1.54-5.91). Of the J-IEXPAC CAREGIVERS domains, attention for the patient was significant. CONCLUSIONS: We found that the use of VNS was likely to provide a better experience among family caregivers. Our findings suggest that visiting nurses fulfill their expected role as core members of a multidisciplinary team.

Measuring family caregivers' experience of interprofessional care for patients and families: development of the Japanese version of the Caregivers' Experience Instrument.

BACKGROUND: Improving individuals' experience of care is now a critical goal of health care systems. Although a number of instruments have been developed to measure experience of care, few instruments measure family caregivers' experience of interprofessional care for patients and families. OBJECTIVE: To develop the Japanese version of the Caregivers' Experience Instrument (J-IEXPAC CAREGIVERS) and to investigate its validity in assessing quality of integrated care for both patients with chronic conditions and their family caregivers, from the caregivers' perspective, in Japan. METHODS: We used a cross-sectional questionnaire survey to test the validity and internal consistency of J-IEXPAC CAREGIVERS. Four hundred family caregivers were recruited in three municipalities. We evaluated the feasibility, structural validity, internal consistency and hypothesis testing for construct validity of the scale. RESULTS: A total of 274 (68.5%) questionnaires were analysed. Confirmatory factor analysis showed acceptable model fit for the hypothesized two-factor model according to fit indices, as identified for the original version: attention for the patient and attention for the caregiver. Cronbach's alpha for score in J-IEXPAC CAREGIVERS with 12 items was high (0.92). Spearman's rank correlation coefficient between overall caregiver satisfaction and J-IEXPAC CAREGIVERS score was 0.71. Family caregivers who experienced home-visit services had significantly (P = 0.001) higher total scores than those who did not. CONCLUSIONS: This pilot study showed that the J-IEXPAC CAREGIVERS is valid and reliable. This scale can be useful for evaluating quality of integrated care, with focus on family caregivers and patients with chronic conditions in Japan.

System-Wide Accelerated Implementation of Telemedicine in Response to COVID-19: Mixed Methods Evaluation.

BACKGROUND: As the COVID-19 pandemic disrupted medical practice, telemedicine emerged as an alternative to outpatient visits. However, it is not known how patients and physicians responded to an accelerated implementation of this model of medical care. OBJECTIVE: The aim of this study is to report the system-wide accelerated implementation of telemedicine, compare patient satisfaction between telemedicine and in-person visits, and report provider perceptions. METHODS: This study was conducted at the UC Christus Health Network, a large private academic health network in Santiago, Chile. The satisfaction of patients receiving telemedicine care in March and April 2020 was compared to those receiving in-person care during the same period (concurrent control group) as well as in March and April 2019 (retrospective control group). Patient satisfaction with in-person care was measured using the Net Promoter Score (NPS) survey. Patient satisfaction with telemedicine was assessed with an online survey assessing similar domains. Providers rated their satisfaction and responded to open-ended questions assessing challenges, strategies used to address challenges, the diagnostic process, treatment, and the patient-provider relationship. RESULTS: A total of 3962 patients receiving telemedicine, 1187 patients from the concurrent control group, and 1848 patients from the retrospective control group completed the surveys. Satisfaction was very high with both telemedicine and in-person services. Overall, 263 physicians from over 41 specialties responded to the survey. During telemedicine visits, most providers felt their clinical skills were challenged (61.8%). Female providers felt more challenged than male providers (70.7% versus 50.9%, P=.002). Surgeons, obstetricians, and gynecologists felt their clinical skills were challenged the least, compared to providers from nonsurgical specialties (P<.001). Challenges related to the delivery modality, diagnostic process, and patient-provider relationship differed by provider specialty (P=.046, P<.001, and P=.02, respectively). CONCLUSIONS: Telemedicine implemented in response to the COVID-19 pandemic produced high patient and provider satisfaction. Specialty groups perceived the impact of this new mode of clinical practice differently.

An evaluation of a multifaceted, local Quality Improvement Framework for long-term conditions in UK primary care.

BACKGROUND: The evidence that large pay-for-performance schemes improve the health of populations is mixed-evidence regarding locally implemented schemes is limited. OBJECTIVE: This study evaluates the effects in Stoke-on-Trent of a local, multifaceted Quality Improvement Framework including pay for performance in general practice introduced in 2009 in the context of the national Quality and Outcomes Framework that operated from 2004. METHODS: We compared age-standardized mortality data from all 326 local authorities in England with the rates in Stoke-on-Trent using Difference-in-Differences, estimating a fixed-effects linear regression model with an interaction effect. RESULTS: In addition to the existing downward trend in cardiovascular deaths, we find an additional annual reduction of 36 deaths compared with the national mean for coronary heart disease and 13 deaths per 100000 from stroke in Stoke-on-Trent. Compared with the national mean, there was an additional reduction of 9 deaths per 100000 people per annum for coronary heart disease and 14 deaths per 100000 people per annum for stroke following the introduction of the 2009 Stoke-on-Trent Quality Improvement Framework. CONCLUSION: There are concerns about the unintended consequences of large pay-for-performance schemes in health care, but in a population with a high prevalence of disease, they may at least initially be beneficial. This study also provides evidence that a local, additional scheme may further improve the health of populations. Such schemes, whether national or local, require periodic review to evaluate the balance of their benefits and risks.

Implementing new care models: learning from the Greater Manchester demonstrator pilot experience.

BACKGROUND: Current health policy focuses on improving accessibility, increasing integration and shifting resources from hospitals to community and primary care. Initiatives aimed at achieving these policy aims have supported the implementation of various 'new models of care', including general practice offering 'additional availability' appointments during evenings and at weekends. In Greater Manchester, six 'demonstrator sites' were funded: four sites delivered additional availability appointments, other services included case management and rapid response. The aim of this paper is to explore the factors influencing the implementation of services within a programme designed to improve access to primary care. The paper consists of a qualitative process evaluation undertaken within provider organisations, including general practices, hospitals and care homes. METHODS: Semi-structured interviews, with the data subjected to thematic analysis. RESULTS: Ninety-one people participated in interviews. Six key factors were identified as important for the establishment and running of the demonstrators: information technology; information governance; workforce and organisational development; communications and engagement; supporting infrastructure; federations and alliances. These factors brought to light challenges in the attempt to provide new or modify existing services. Underpinning all factors was the issue of trust; there was consensus amongst our participants that trusting relationships, particularly between general practices, were vital for collaboration. It was also crucial that general practices trusted in the integrity of anyone external who was to work with the practice, particularly if they were to access data on the practice computer system. A dialogical approach was required, which enabled staff to see themselves as active rather than passive participants. CONCLUSIONS: The research highlights various challenges presented by the context within which extended access is implemented. Trust was the fundamental underlying issue; there was consensus amongst participants that trusting relationships were vital for effective collaboration in primary care.

Expectations and perceptions of clients concerning the quality of care provided at a Brazilian hospital facility.

PURPOSE: To identify the expectations and perceptions of clients concerning the quality of hospital care provided to them and their respective companions at a private Brazilian hospital using SERVQUAL. The SERVQUAL questionnaire can provide information concerning expectations and perceptions of clients. In addition, it is able to identify the participation of frontline employees and how they contribute to the organization's end product (service delivery). METHODS: In total, 172 inpatients for surgical reasons answered the SERVQUAL questionnaire. It consists of 23 pairs of statements, 22 of which are distributed into the dimensions of tangibles, reliability, responsiveness, assurance and empathy. Statement 23 refers to the overall quality of care. Exploratory analysis, internal consistency (Cronbach's alpha) and the kappa Coefficient were calculated using the Statistical Package for Social Sciences and SAS 9.2. Ethical approval was obtained from the Institutional Review Board at the Hospital das Clínicas at the University of São Paulo at Ribeirao Preto Medical School. RESULTS: Most participants had a bachelor's degree and were over than 60years old. Cronbach's alpha coefficients indicated good internal consistency (α=0.93) and high levels of agreement were observed (91.10%). CONCLUSION: The SERVQUAL questionnaire was sensitive to items in each dimension for which clients' perceptions surpassed their expectations. IMPLICATIONS FOR NURSING MANAGEMENT: The continuous quality assessment of health services is mandatory for nursing leadership. The nursing leadership can further explore the SERVQUAL with a view to better attending to the clients' expectations.

Integration and activity of hospital-based palliative care consultation teams: the INSIGHT multicentric cohort study.

BACKGROUND: Hospital-based Palliative Care Consultation Teams (PCCTs) have a consulting role to specialist services at their request. Referral of patients is often late. Early palliative care in oncology has shown its effectiveness in improving quality of life, thereby questioning the "on request" model of PCCTs. Whether this evidence changed practice is unknown. This multicentre prospective cohort study aims to describe the activity and integration of PCCTs at the patient level. METHODS: For consecutive patients newly referred to participating PCCTs, the team collected the following data: circumstances of first referral, problems identified, number of interventions, patient's survival after first evaluation and place of death. RESULTS: Seventeen PCCTs based in university hospitals in Paris area, recruited 744 newly referred adult patients, aged 72 ± 15 years, 52% males, and 504(68%) with cancer as primary diagnosis. After 6 months, 548(74%) had died. At first evaluation, 12% patients were outpatients, 88% were inpatients. Symptoms represented the main reasons for referral and problems identified; 79% of patients had altered performance status; 24% encountered the PCCT only once. Median survival (1st-3rd quartile) after first evaluation by the PCCT was 22 (5-82) days for overall patients, and respectively 31 (8-107) days and 9 (3-34) days for cancer versus noncancer patients (p < 0.0001). Place of death was acute care hospital for 51.7% patients, and home or Palliative Care Unit for 35%. Patients referred earlier died more often in PCU. CONCLUSION: The study provides original data showing a still late referral to the PCCTs in France. Cancer patients represent their predominant activity. The integrated palliative care model seems to emerge besides the "on request" model which originally characterised their missions.

Clinical Outcomes in a Large Cohort of Musculoskeletal Patients Undergoing Chiropractic Care in the United Kingdom: A Comparison of Self- and National Health Service-Referred Routes.

OBJECTIVE: An innovative commissioning pathway has recently been introduced in the United Kingdom allowing chiropractic organizations to provide state-funded chiropractic care to patients through referral from National Health Service (NHS) primary care physicians. The purpose of this study was to examine the outcomes of NHS and private patient groups presenting with musculoskeletal conditions to chiropractors under the Any Qualified Provider scheme and compare the clinical outcomes of these patients with those presenting privately. METHODS: A prospective cohort design monitoring patient outcomes comparing self-referring and NHS-referred patients undergoing chiropractic care was used. The primary outcome was the change in Bournemouth Questionnaire scores. Within- and between-group analyses were performed to explore differences between outcomes with additional analysis of subgroups as categorized by the STarT back tool. RESULTS: A total of 8222 patients filled in baseline questionnaires. Of these, NHS patients (41%) had more adverse health measures at baseline and went on to receive more treatment. Using percent change in Bournemouth Questionnaire scores categorized at minimal clinical change cutoffs and adjusting for baseline differences, patients with low back and neck pain presenting privately are more likely to report improvement within 2 weeks and to have slightly better outcomes at 90 days. However, these patients were more likely to be attending consultations beyond 30 days. CONCLUSIONS: This study supports the contention that chiropractic services as provided in United Kingdom are appropriate for both private and NHS-referred patient groups and should be considered when general medical physicians make decisions concerning referral routes and pain pathways for patients with musculoskeletal conditions.

Women's Health Hubs: a rapid mixed-methods evaluation.

Background: Women's sexual and reproductive health needs are complex and vary across the life course. They are met by a range of providers, professionals and venues. Provision is not well integrated, with inequalities in access. In some areas of the United Kingdom Women's Health Hubs have been established to improve provision, experience and outcomes for women, and to address inequalities and reduce costs. These models were established prior to the national implementation of Women's Health Hubs announced in the English 2022 Women's Health Strategy. Objective: To explore the 'current state of the art', mapping the United Kingdom landscape, and studying experiences of delivering and using Women's Health Hubs across England, defining key features and early markers of success to inform policy and practice. Design: A mixed-methods evaluation, comprising three work packages: Mapping the Women's Health Hub landscape and context and developing a definition of Women's Health Hubs, informed by an online national survey of Women's Health Hub leaders, and interviews with regional stakeholders. In-depth evaluation in four hub sites, including interviews with staff and women, focus groups in local communities and documentary analysis. Interviews with national stakeholders and consolidation of findings from work packages 1 and 2. Fieldwork was undertaken from May 2022 to March 2023. The evaluation was initiated prior to the national scale-up of Women's Health Hubs announced in the 2022 Women's Health Strategy. Results: Most areas of the United Kingdom did not have a Women's Health Hub. Seventeen active services were identified, established between 2001 and 2022. Women's Health Hubs were diverse, predominantly GP-led, with different perspectives of the role and definition of a hub. Women using hubs reported positive experiences, finding services caring and convenient. Implementation facilitators included committed, collaborative leaders working across boundaries, sufficient workforce capacity and a supportive policy context. Challenges included access to funding, commissioning, workforce issues, facilities and equipment, stakeholder engagement and wider system integration, priorities and pressures. Leaders were committed to addressing inequalities, but evidence of impact was still emerging. Limitations: It was challenging to locate models; therefore, some may have been missed. Data availability limited assessment of impact, including inequalities. Some population groups were not represented in the data, and the evaluation was more provider-oriented. It was not possible to develop a typology of Women's Health Hubs as planned due to heterogeneity in models. Conclusions: Existing Women's Health Hub models were providing integrated approaches to meet local needs. Many were at an early stage of development. Evidence of system-level impact and costs was still emerging. Women's Health Hubs may widen inequalities if models are more accessible to advantaged groups. The important role of committed leaders in existing 'bottom-up' models may limit scalability and sustainability. Findings suggest that national scale-up will take time and requires funding and that it is necessary to design models according to local needs and resources. In 2023, the Department of Health and Social Care announced funding to establish a Women's Health Hub in every Integrated Care System in England. Future work: Future evaluation should consider system-level impact and costs, explore unintended consequences and test assumptions. Funding: This award was funded by the National Institute of Health and Care Research (NIHR) Health and Social Care Delivery Research programme (NIHR award ref: NIHR135589) and is published in full in Health and Social Care Delivery Research; Vol. 12, No. 30. See the NIHR Funding and Awards website for further award information.

In the National Health Service, care for women's health issues such as heavy periods, menopause, contraception and abortion is provided by different services, such as GPs and hospital gynaecology and sexual health clinics. Services are not always joined up and often women find it hard to access care. To improve care, United Kingdom National Health Service teams have set up Women's Health Hubs. Women's Health Hubs involve a group of health professionals working together to provide more joined-up community-based services to women throughout their lives. This evaluation aimed to explore why, where and how Women's Health Hubs have been set up and what they have achieved and to understand staff and patient experiences. The results will be shared with the government and National Health Service as new Women's Health Hubs are set up. The evaluation included a survey of people who have set up hubs across the United Kingdom and interviews with women's health leaders in England. In four hubs in England, we talked to local women and staff, and reviewed documents. We found 17 hubs, and most areas of the United Kingdom did not have one. Every hub was different, with different views about how hubs should work. Most were set up to improve access and experiences for women, and reduce pressure on other services. Six hubs had involved women in developing their service but most had not. Hubs offered appointments with health professionals, usually in GP or community clinics. The most common services were for coil fitting, menopause and heavy periods. The set-up of hubs was helped by passionate leaders who involved the right people, and identified funding and time. Challenges included National Health Service pressures and a lack of funding, clinic space and staff. Women who have used hubs report a good experience, with caring and convenient services. More work is needed to understand how hubs can improve care for all women, including unfair differences in care.

A social network analysis approach to assess COVID19-related disruption to substance use treatment and informal social interactions among people who use drugs in Scotland.

AIMS: To assess the extent of Coronavirus-related disruption to health and social care treatment and social interactions among people with lived or living experience of substance use in Scotland, and explore potential reasons for variations in disruption. DESIGN: Cross sectional mixed methods interview, incorporating a social network 'egonet interview' approach asking about whether participants had interactions with a range of substance use, health, social care or third sector organisations, or informal social interactions. SETTING: Five Alcohol and Drug Partnership Areas in Scotland. PARTICIPANTS: 57 (42% women) participants were involved in the study, on average 42 years old. MEASUREMENTS: Five-point Likert scale reporting whether interactions with a range of services and people had gotten much better, better, no different (or no change), worse, or much worse since COVID19 and lockdown. Ratings were nested within participants (Individuals provided multiple ratings) and some ratings were also nested within treatment service (services received multiple ratings). The nested structure was accounted for using cross classified ordinal logistic multilevel models. FINDINGS: While the overall average suggested only a slight negative change in interactions (mean rating 2.93), there were substantial variations according to type of interaction, and between individuals. Reported change was more often negative for mental health services (Adjusted OR = 0.93 95% CI 0.17,0.90), and positive for pharmacies (3.03 95% CI 1.36, 5.93). The models found between-participant variation of around 10%, and negligible between-service variation of around 1% in ratings. Ratings didn't vary by individual age or gender but there was variation between areas. CONCLUSIONS: Substance use treatment service adaptations due to COVID19 lockdown led to both positive and negative service user experiences. Social network methods provide an effective way to describe complex system-wide interaction patterns, and to measure variations at the individual, service, and area level.

Interrupted time series evaluation of the impact of a dementia wellbeing service on avoidable hospital admissions for people with dementia in Bristol, England.

OBJECTIVES: To determine whether a dementia wellbeing service (DWS) signposting people with dementia to community services decreases the rate of avoidable hospital admissions, in-hospital mortality, complexity of admissions (number of comorbidities) or length of stay. METHODS: Interrupted time series analysis to estimate the effects of the DWS on hospital outcomes. We included all unplanned admissions for ambulatory care sensitive conditions ('avoidable hospital admissions') with a dementia diagnosis recorded in the Hospital Episode Statistics. The intervention region was compared with a demographically similar control region in the 2 years before and 3 years after the implementation of the new service (October 2013 to September 2018). RESULTS: There was no strong evidence that admission rates reduced and only weak evidence that the trend in average length of stay reduced slowly over time. In-hospital mortality decreased immediately after the introduction of the dementia wellbeing service compared to comparator areas (x0.64, 95% CI 0.42, 0.97, p = 0.037) but attenuated over the following years. The rate of increase in comorbidities also appeared to slow after the service began; they were similar to comparator areas by September 2018. CONCLUSIONS: We found no major impact of the DWS on avoidable hospital admissions, although there was weak evidence for slightly shorter length of stay and reduced complexity of hospital admissions. These findings may or may not reflect a true benefit of the service and require further investigation. The DWS was established to improve quality of dementia care; reducing hospital admissions was never its sole purpose. More targeted interventions may be required to reduce hospital admissions for people with dementia.

Feedback for Emergency Ambulance Staff: A National Review of Current Practice Informed by Realist Evaluation Methodology.

Research suggests that feedback in Emergency Medical Services (EMS) positively affects quality of care and professional development. However, the mechanisms by which feedback achieves its effects still need to be better understood across healthcare settings. This study aimed to understand how United Kingdom (UK) ambulance services provide feedback for EMS professionals and develop a programme theory of how feedback works within EMS, using a mixed-methods, realist evaluation framework. A national cross-sectional survey was conducted to identify feedback initiatives in UK ambulance services, followed by four in-depth case studies involving qualitative interviews and documentary analysis. We used qualitative content analysis and descriptive statistics to analyse survey responses from 40 prehospital feedback initiatives, alongside retroductive analysis of 17 interviews and six documents from case study sites. Feedback initiatives mainly provided individual patient outcome feedback through "pull" initiatives triggered by staff requests. Challenges related to information governance were identified. Our programme theory of feedback to EMS professionals encompassed context (healthcare professional and organisational characteristics), mechanisms (feedback and implementation characteristics, psychological reasoning) and outcomes (implementation, staff and service outcomes). This study suggests that most UK ambulance services use a range of feedback initiatives and provides 24 empirically based testable hypotheses for future research.

Family caregivers' experience with healthcare and social care professionals and their participation in health checkups: A cross sectional study in Japan.

Background: For family caregivers, who are generally regarded as a vulnerable population, having regular checkups is a desirable health behavior. This study examined family caregivers' habit of having regular checkups prior to becoming involved with professionals who care for patients, and whether they had had recent checkups. We then examined the association between family caregivers' experience with professionals and their participation in checkups after adjusting for the past habit. Methods: We conducted a cross sectional survey in Japan between November and December 2020. We recruited family caregivers who were aged 40-74 years and caring for community-dwelling adult patients. The outcome variable was whether family caregivers had undergone any health checkups since April 2019. We assessed family caregivers' experience using the Japanese version of the Caregivers' Experience Instrument (J-IEXPAC CAREGIVERS). Results: Of the 1091 recruited family caregivers, 629 were included in the analysis. Of these, 358 had previously undergone regular checkups, and 158 had no checkups or selected the option "unknown." Outcome rates in each group were 74.6% and 43.0%, respectively, and 62.0% for all 629 caregivers. Multivariate modified Poisson regression analysis revealed that among the J-IEXPAC CAREGIVERS scores, only the domain score for attention for the caregiver was significantly associated with family caregivers' participation in checkups (adjusted prevalence ratio per 1 SD increase = 1.07; 95% CI 1.01-1.14). Conclusions: Among family caregivers' experience with professionals, the factor that focused on caregivers themselves was significantly associated with their participation in checkups. This finding underscores the significance of caregiver-focused care.

Cochlear implant eligibility in an adult hearing aid population: a multi-perspective service evaluation of a patient referral pathway at a British district general hospital.

OBJECTIVES: To quantify patient eligibility for cochlear implantation following National Institute for Health and Care Excellence 2019 guidelines (TA566) over five years at our institution, and identify factors influencing patients' decisions surrounding cochlear implantation referral. METHODS: A multi-perspective service evaluation was conducted at a district general hospital, comprising cochlear implantation eligible patients. The main outcome measures were: eligibility numbers for 2014-2019, comparing application of TA566 versus 2009 (TA166) guidelines; and patient interview transcripts and questionnaires. RESULTS: There was a 259 per cent average increase in cochlear implantation eligibility from 2014 to 2019. Most patients' thresholds were 80 dB HL or more at 3 kHz and 4 kHz. There are several cochlear implantation barriers, including patient-centred issues (e.g. health-related anxieties, implantation misperceptions) and external barriers (difficulty getting to regional implant centres). Motivating factors for cochlear implantation include improved quality of life and access to local cochlear implantation services. CONCLUSION: The TA566 guidelines have increased cochlear implantation eligibility, putting pressure on cochlear implantation centres and referring hospitals. Current referral systems have external and patient-centred implantation barriers. British cochlear implantation delivery may need rethinking to meet increasing populational demands and improve accessibility for those most vulnerable to these barriers.

Community-based outpatient rehabilitation for the treatment of breast cancer-related upper extremity disability: an evaluation of practice-based evidence.

PURPOSE: To evaluate the impact and acceptability of outpatient physical or occupational therapy (PT/OT) for breast cancer survivors (BCS) with varying levels of upper extremity disability (UED). METHODS: We retrospectively extracted patient and therapy characteristics, UED measured by quick-disabilities of the arm, shoulder and hand (QuickDASH, 0-100 pts.), and patient-rated acceptability (1-item, 0-10 pts) from rehabilitation charts of BCS who completed cancer-specialized PT/OT provided by a single national institution in 2019. We summarized characteristics and acceptability using descriptive statistics, then used established parameters to group BCS by baseline UED severity: high- (QuickDASH > 31.5), moderate- (QuickDASH = 18.5-31.5), or low-UED (QuickDASH = 13-18.5). To evaluate within-group pre-to-post QuickDASH change, we used paired samples t test (p < 0.01), then calculated the proportion who achieved the minimally clinical important difference (MCID, 15.9 points). To compare between-groups difference in QuickDASH improvement, we used Kruskal-Wallis test and Chi-squared test. RESULTS: Patients (N = 417) were 59.89 ± 12.06 years old, 99% female, and attended approximately 10 PT/OT sessions (IQR = 6.0-16.0). Most had high baseline UED (62%), followed by moderate (25%) or low UED (13%). For each severity group, mean pre-to-post change in QuickDASH was significant: high-UED (M∆ = 25.13 ± 20.33, d = 1.24, p < 0.01), moderate-UED (M∆ = 11.36 ± 11.9, d = 0.95, p < 0.01), and low-UED (M∆ = 4.84 ± 9.15, d = 0.53, p < 0.01). Most with high UED achieved the MCID (n = 176, 68.2%). In the moderate- and low-UED groups 44% (n = 46) and 4% (n = 2) achieved the MCID, respectively. Acceptability was high (n = 167, Median = 10). CONCLUSION: Outpatient cancer rehabilitation is associated with significant improvement in UED for BCS and was acceptable to patients regardless of UED severity at baseline.