Does proactive care in care homes improve survival? A quality improvement project.

BACKGROUND: NHS England's 'Enhanced Health in Care Homes' specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered. AIM: To determine whether a proactive healthcare model could improve healthcare outcomes for care home residents. DESIGN AND SETTING: Quality improvement project involving 429 residents in 40 care homes in a non-randomised crossover cohort design. The headline outcome was 2-year survival. METHOD: All care home residents had healthcare coordinated by the PCN's Older Peoples' Hub. A daily MDT managed the urgent healthcare needs of residents. Proactive healthcare, comprising information technology-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), were completed by residents, with prioritisation based on clinical needs.Time-dependent Cox regression analysis was used with patients divided into two groups:Control group: received routine and urgent (reactive) care only.Intervention group: additional proactive i-CGA and ACP. RESULTS: By 2 years, control group survival was 8.6% (n=108), compared with 48.1% in the intervention group (n=321), p<0.001. This represented a 39.6% absolute risk reduction in mortality, 70.2% relative risk reduction and the number needed to treat of 2.5, with little changes when adjusting for confounding variables. CONCLUSION: A PCN with an MDT-hub offering additional proactive care (with an i-CGA and ACP) in addition to routine and urgent/reactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.

What is the volume, quality and characteristics of evidence relating to the effectiveness and cost-effectiveness of multi-disciplinary occupational health interventions aiming to improve work-related outcomes for employed adults? An evidence and gap map of systematic reviews.

Background: In the UK, tens of millions of working days are lost due to work-related ill health every year, costing billions of pounds. The role of Occupational Health (OH) services is vital in helping workers to maintain employment when they encounter injury or illness. OH providers traditionally rely on a clinical workforce to deliver these services, particularly doctors and nurses with OH qualifications. However, the increasing demand for OH services is unlikely to be met in the future using this traditional model, due to the declining number of OH-trained doctors and nurses in the UK. Multi-disciplinary models of OH delivery, including a more varied range of healthcare and non-healthcare professionals, could provide a way to meet this new demand for OH services. There is a need to identify collaborative models of OH service delivery and review their effectiveness on return-to work outcomes. There is an existing pool of systematic review evidence evaluating workplace based, multi-disciplinary OH interventions, but it is difficult to identify which aspects of the content and/or delivery of these interventions may be associated with improved work-related outcomes. Objectives: The aim of this evidence and gap map (EGM) was to provide an overview of the systematic review evidence that evaluates the effectiveness and cost-effectiveness of multi-disciplinary OH interventions intending to improve work-related outcomes. Search Methods: In June 2021 we searched a selection of bibliographic databases and other academic literature resources covering a range of relevant disciplines, including health care and business studies, to identify systematic review evidence from a variety of sectors of employment. We also searched Google Search and a selection of topically relevant websites and consulted with stakeholders to identify reports already known to them. Searches were updated in February 2023. Selection Criteria: Systematic reviews needed to be about adults (16 years or over) in employment, who have had absence from work for any medical reason. Interventions needed to be multi-disciplinary (including professionals from different backgrounds in clinical and non-clinical professions) and designed to support employees and employers to manage health conditions in the workplace and/or to help employees with health conditions retain and/or return to work following medical absence. Effectiveness needed to be measured in terms of return to work, work retention or measures of absence, or economic evaluation outcomes. These criteria were applied to the title and abstract and full text of each systematic review independently by two reviewers, with disagreements resolved through discussion. We awarded each systematic review a rating of 'High', 'Medium' or 'Low' relevance to indicate the extent to which the populations, interventions and their contexts synthesised within the review were consistent with our research question. We also recorded the number of primary studies included within each of the 'High' and 'Medium' reviews that were relevant to research question using the same screening process applied at review level. Data Collection and Analysis: Summary data for each eligible review was extracted. The quality of the systematic reviews, rated as 'High' or 'Medium' relevance following full text screening, was appraised using the AMSTAR-2 quality appraisal tool. All data were extracted by one reviewer and checked by a second, with disagreements being settled through discussion. Summary data for all eligible systematic reviews were tabulated and described narratively. The data extracted from reviews of 'High' and 'Medium' relevance was imported into EPPI-Mapper software to create an EGM. Stakeholder Involvement: We worked alongside commissioners and policy makers from the Department of Health and Social Care (DHSC) and Department of Work and Pensions (DWP), OH personnel, and people with lived experience of accessing OH services themselves and/or supporting employees to access OH services. Individuals contributed to decision making at all stages of the project. This ensured our EGM reflects the needs of individuals who will use it. Main Results: We identified 98 systematic reviews that contained relevant interventions, which involved a variety of professionals and workplaces, and which measured effectiveness in terms of return to work (RTW). Of these, we focused on the 30 reviews where the population and intervention characteristics within the systematic reviews were considered to be of high or medium relevance to our research questions. The 30 reviews were of varying quality, split evenly between High/Moderate quality and Low/Critically-Low quality ratings. We did not identify any relevant systematic review evidence on any other work-related outcome of interest. Interventions were heterogenous, both within and across included systematic reviews. The EGM is structured according to the health condition experienced by participants, and the effectiveness of the interventions being evaluated, as reported within the included systematic reviews. It is possible to view (i) the quality and quantity of systematic review evidence for a given health condition, (ii) how review authors assessed the effectiveness or cost-effectiveness of the interventions evaluated. The EGM also details the primary studies relevant to our research aim included within each review. Authors' Conclusions: This EGM map highlights the array of systematic review evidence that exists in relation to the effectiveness or cost-effectiveness of multi-disciplinary, workplace-based OH interventions in supporting RTW. This evidence will allow policy makers and commissioners of services to determine which OH interventions may be most useful for supporting different population groups in different contexts. OH professionals may find the content of the EGM useful in identifying systematic review evidence to support their practice. The EGM also identifies where systematic review evidence in this area is lacking, or where existing evidence is of poor quality. These may represent areas where it may be particularly useful to conduct further systematic reviews.

Theory protection: Do humans protect existing associative links?

Theories of associative learning often propose that learning is proportional to prediction error, or the difference between expected events and those that occur. Spicer et al. (2020) suggested an alternative, that humans might instead selectively attribute surprising outcomes to cues that they are not confident about, to maintain cue-outcome associations about which they are more confident. Spicer et al. reported three predictive learning experiments, the results of which were consistent with their proposal ("theory protection") rather than a prediction error account (Rescorla, 2001). The four experiments reported here further test theory protection against a prediction error account. Experiments 3 and 4 also test the proposals of Holmes et al. (2019), who suggested a function mapping learning to performance that can explain Spicer et al.'s results using a prediction-error framework. In contrast to the previous study, these experiments were based on inhibition rather than excitation. Participants were trained with a set of cues (represented by letters), each of which was followed by the presence or absence of an outcome (represented by + or -). Following this, a cue that previously caused the outcome (A+) was placed in compound with another cue (B) with an ambiguous causal status (e.g., a novel cue in Experiment 1). This compound (AB-) did not cause the outcome. Participants always learned more about B in the second training phase, despite A always having the greater prediction error. In Experiments 3 and 4, a cue with no apparent prediction error was learned about more than a cue with a large prediction error. Experiment 4 tested participants' relative confidence about the causal status of cues A and B prior to the AB- stage, producing findings that are consistent with theory protection and inconsistent with the predictions of Rescorla, and Holmes et al. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Similarities and differences: Comment on Chan et al. (2021).

Spicer et al. (2020) reported a series of causal learning experiments in which participants appeared to learn most readily about cues when they were not certain of their causal status and proposed that their results were a consequence of participants' use of theory protection. In the present issue, Chan et al. (2021) present an alternative view, using a modification of Rescorla and Wagner's (1972) influential model of learning. Although the explanation offered by Chan et al. appears very different from that suggested by Spicer et al., there are conceptual commonalities. Here we briefly discuss the similarities and differences of the 2 approaches and agree with Chan et al.'s proposal that the best way to advance the debate will be to test situations in which the 2 theories make differing predictions. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Theory protection in associative learning: Humans maintain certain beliefs in a manner that violates prediction error.

Three experiments were conducted to investigate a possible role for certainty in human causal learning. In these experiments, human participants were initially trained with a set of cues, each of which was followed by the presence or absence of an outcome. In a subsequent training stage, 2 of these cues were trained in a causal compound, and the change in associative strength for each of the cues was compared, using a procedure based on Rescorla (2001). In each experiment, the cues differed in both their causal certainty (on the part of participants) and size of their prediction error (with respect to the outcome). The cue with the larger prediction error was always the cue with the more certain causal status. According to established prediction error models (Bush & Mosteller, 1951; Rescorla, 2001; Rescorla & Wagner, 1972), a larger prediction error should result in a greater updating of associative strength. However, the opposite was observed, as participants always learned more about the cue with the smaller prediction error. A plausible explanation is that participants engaged in a form of theory protection, in which they were resistant to updating their existing beliefs about cues with a certain causal status. Instead, participants appeared to attribute outcomes to cues with a comparatively uncertain causal status, in an apparent violation of prediction error. The potential role of attentional processes (Mackintosh, 1975; Pearce & Hall, 1980) in explaining these results is also discussed. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Crossing boundaries: Global reorientation following transfer from the inside to the outside of an arena.

In 2 spatial navigation experiments, human participants were asked to find a hidden goal (a WiFi signal) that was located in 1 of the right-angled corners of a kite-shaped (Experiment 1) or a cross-shaped (Experiment 2) virtual environment. Goal location was defined solely with respect to the geometry of the environment. Following this training, in a test conducted in extinction, participants were placed onto the outside of the same environments and asked to locate the WiFi signal. The results of both experiments revealed that participants spent more time searching in regions on the outside of the environments that were closest to where the WiFi signal was located during training. These results are difficult to explain in terms of analyses of spatial navigation and reorientation that emphasize the role of local representational encoding or view matching. Instead, we suggest that these results are better understood in terms of a global representation of the shape of the environment. (PsycINFO Database Record (c) 2019 APA, all rights reserved).