Development of a Tool to Determine Excellence in the Provision of Physical Therapist Clinical Education: A Modified Delphi Study.

OBJECTIVE: The purpose of this study was to create a Site of Excellence in Clinical Education (SECE-PT) tool with the essential criteria used to determine excellence in the provision of physical therapist clinical education at a clinical site using a consensus-building approach. METHODS: The development of the SECE-PT tool was divided into 2 parts. Part 1 involved the development of an initial set of proposed criteria, whereas part 2 employed a modified Delphi approach for consensus building. Purposive selection and snowball sampling techniques were used to recruit clinical instructors, recent graduates, site coordinators of clinical education, and directors of clinical education who met the inclusion criteria for the modified Delphi study. Three web-based survey rounds were used to achieve consensus, defined as a mean score of ≥7 on the 11-point Likert scale. The first round gathered demographic information on participants and collected information about clarity and redundancy in the criteria provided, the second gathered information once again about clarity and redundancy on the revised criteria provided, and the third asked participants to rate how essential it was for a site of excellence to demonstrate each of the final criteria. RESULTS: A total of 123 participants, equally representing clinical and academic perspectives, completed the demographic survey and round 1. Ninety-four participants completed round 2, and 80 participants completed the third and final round. Consensus revealed that 44 criteria were deemed essential for a SECE-PT to demonstrate. CONCLUSION: This study provides a measure to evaluate clinical sites providing clinical education. The SECE-PT tool should be widely adopted to evaluate the quality of the clinical site providing the education to student physical therapists. IMPACT: The SECE-PT tool can be used by clinical sites for self-assessment to examine aspects of their clinical education programs and determine whether parts of their program should be further developed. This can provide a framework for discussion and collaboration between clinical and academic partners, as well as regional consortia.

Ecosystem Conditions That Influence the Viability of an Old-Forest Species with Limited Vagility: The Red Tree Vole.

We evaluated ecosystem conditions known to influence the viability of a strictly arboreal species (the red tree vole, Arborimus longicaudus) endemic and historically distributed in the forests across the Coast Range, Cascades, and Klamath Mountains ecoregions in the Western United States of America. We found widespread reductions in ecosystem conditions needed to support the long-term viability of the red tree vole. This was particularly evident in the Coast Range where the weighted watershed index (WWI) was 26% of its historical value, and the current probability of maintaining viability departed the most from historical viability probabilities in ecoregions that were evaluated. In contrast, in the Cascades and Klamath Mountains, the WWI was 42% and 52% of their respective historical values, and the current probabilities of maintaining viability departed less from historical conditions than in the Coast Range. Habitat loss from timber harvest represented the most immediate threat in the Coast Range, while habitat loss from wildfires represented the most risk to the red tree vole in the Cascades and Klamath Mountains. Reducing the risks to the viability of the red tree vole will depend largely on the implementation of conservation practices designed to protect remaining habitat and restore degraded ecosystems in the Coast Range. However, the risk of large, high-severity wildfires will require the protection and increased resilience of existing ecosystems. Our results indicate that considerable adaptation to climate change will be required to conserve the red tree vole in the long term. Conservation may be accomplished by revising land and resource management plans to include standards and guidelines relevant to red tree vole management and persistence, the identification of priority areas for conservation and restoration, and in assessing how management alternatives influence ecosystem resiliency and red tree vole viability.

Primary care heart failure service identifies a missed cohort of heart failure patients with reduced ejection fraction.

AIMS: We explored whether a missed cohort of patients in the community with heart failure (HF) and left ventricular systolic dysfunction (LVSD) could be identified and receive treatment optimization through a primary care heart failure (PCHF) service. METHODS AND RESULTS: PCHF is a partnership between Inspira Health, National Health Service Cardiologists and Medtronic. The PCHF service uses retrospective clinical audit to identify patients requiring a prospective face-to-face consultation with a consultant cardiologist for clinical review of their HF management within primary care. The service is delivered via five phases: (i) system interrogation of general practitioner (GP) systems; (ii) clinical audit of medical records; (iii) patient invitation; (iv) consultant reviews; and (v) follow-up. A total of 78 GP practices (864 194 population) have participated. In total, 19 393 patients' records were audited. HF register was 9668 (prevalence 1.1%) with 6162 patients coded with LVSD (prevalence 0.7%). HF case finder identified 9725 additional patients to be audited of whom 2916 patients required LVSD codes adding to the patient medical record (47% increase in LVSD). Prevalence of HF with LVSD increased from 0.7% to 1.05%. A total of 662 patients were invited for consultant cardiologist review at their local GP practice. The service found that within primary care, 27% of HF patients identified for a cardiologist consultation were eligible for complex device therapy, 45% required medicines optimization, and 47% of patients audited required diagnosis codes adding to their GP record. CONCLUSION: A PCHF service can identify a missed cohort of patients with HF and LVSD, enabling the optimization of prognostic medication and an increase in device prescription.

A consultant-led anticoagulation review of all patients in one clinical commissioning group to prevent atrial fibrillation related stroke.

OBJECTIVE: Ensuring patients with Atrial fibrillation (AF) are appropriately anticoagulated across NHS Bedfordshire Clinical Commissioning Group (BCCG) with the primary goal of reducing AF-related strokes. METHODS: With Inspira Health, BCCG adopted the Primary Care Atrial Fibrillation (PCAF) Service which is led by Consultant Cardiologists. PCAF uses retrospective clinical audit to identify patients who require prospective face-to-face review on the need for anticoagulation. RESULTS: 34 GP practices participated covering a 376 311 population (80% of BCCG). 12 573 patients' medical records were audited. The initial AF register was 7301 patients (AF prevalence 1.9%) and an additional 265 patients were identified through AF casefinder resulting in an AF prevalence of 2.0%. From 7566 patients with AF, 5831 were already on anticoagulants (77.1%), with 50.5% (n = 2947) on VKA medications and 49.5% (n = 2884) on direct oral anticoagulants (DOACs). Of the DOAC patients, 595 (20.6%) required dosage review or up to date blood tests. Case notes were reviewed for 1735 patients not on anticoagulation, with 901 (51.9%) patients deemed not eligible for anticoagulation. This left 834 (48.1%) patients who were eligible for, but not on, anticoagulation. A further 407 (13.8%) patients currently taking VKA medications were deemed sup-optimal with regards to INR control with TTR < 65%. In total 1241 patients were invited for review by a Consultant Cardiologist at their local GP practice, with an attendance rate of 90%. From all face to face and virtual consultations, 908 patients had anticoagulants prescribed, changed, management of INRs improved or were in the process of being anticoagulated at the time of follow-up. From this we would expect 36.3 AF related strokes prevented and a cost saving to the NHS of £470 200 per year. CONCLUSION: Through comprehensive audit, BCCG have been able to ensure that patients with AF are appropriately anticoagulated in 80% of their catchment population. This has improved anticoagulation to prevent AF-related stroke.

Retrospective observational study of the impact on emergency admission of telehealth at scale delivered in community care in Liverpool, UK.

OBJECTIVE: To assess the effect of a real world, ongoing telehealth service on the use of secondary healthcare. DESIGN: A retrospective observational study with anonymous matched controls. SETTING: Primary and community healthcare. Patients were recruited over 4 years in 89 general practices in Liverpool, UK and remotely managed by a dedicated clinical team in Liverpool Community Health. PARTICIPANTS: 5154 patients with chronic obstructive pulmonary disease, heart failure or diabetes were enrolled in the programme, of whom 3562 satisfied the inclusion criteria of this study. INTERVENTION: At least 9 weeks of telehealth including vital sign collection, questionnaires, education, support and informal coaching by clinical staff. PRIMARY OUTCOME: Reduction in the number of emergency admissions in the 12 months after start, compared with the year before start. Secondary subgroup analysis to improve future targeting and personalisation of the service. RESULT: The average number of emergency admissions for the intervention group at baseline is 0.35, 95% CI 0.32 to 0.38. The differential decrease in emergency admissions in the intervention group in comparison with the control group, the average treatment effect, is 0.08, 95 CI 0.05 to 0.11, corresponding to an average percentage decrease of 22.7%. In subgroup analysis, a score is calculated that can be used prospectively to predict individual benefit from the intervention. Patients with an above median score (37%) are predicted average reduction in emergency admissions of 0.15, 95% CI 0.09 to 0.2, corresponding to a percentage decrease in admissions of 25.3%. CONCLUSION: The telehealth intervention has a positive impact across a wide cohort of patients with different diseases. Prospective scoring of patients and allocation to targeted telehealth interventions is likely to improve the effectiveness and efficiency of the service.

Necessary but not sufficient? Engaging young people in the development of an avatar-based online intervention designed to provide psychosocial support to young people affected by their own or a family member's cancer diagnosis.

OBJECTIVE: This study discusses the challenges and successes of engaging young people in a project aimed at developing an online counselling intervention for young people affected by cancer. CONTEXT: For younger people with a diagnosis of cancer or who are caring for someone with cancer, the psychosocial consequences can create significant challenges for their social and educational development. Whilst young people have been shown to be reluctant to make use of traditional face-to-face counselling, research is beginning to suggest that effective therapeutic relationships can be formed with young people online. DESIGN: The first phase of the study involved working with a 'Young Persons' Panel' of healthy school pupils and university students to develop and pilot an online counselling intervention and study materials in preparation for a pilot evaluation of the intervention. INTERVENTION: An avatar-based virtual reality counselling world was created where young people can create their own avatar and receive counselling over the Internet from a qualified counsellor via an avatar in a virtual reality world. FINDINGS: The process of engaging young people in the C:EVOLVE project enabled a unique intervention to be developed and demonstrated positive developmental opportunities. However, despite the rigorous approach to the development of the intervention, initial attempts within the pilot evaluation phase of the study showed difficulties recruiting to the study, and this phase of the study has currently ceased whilst further exploratory work takes place. CONCLUSION: This study has demonstrated the complexities of intervention development and evaluation research targeted at young people and the challenges created when attempting to bring clinical practice and research evaluation together.

Working together to shape the endometrial cancer research agenda: The top ten unanswered research questions.

BACKGROUND: Endometrial cancer (EC) is the most common gynaecological cancer in developed nations and its incidence is rising. As a direct consequence, more women are dying from EC despite advances in care and improved survivorship. There is a lack of research activity and funding, as well as public awareness about EC. We sought to engage patients, carers and healthcare professionals to identify the most important unanswered research questions in EC. METHODOLOGY: The priority setting methodology was developed by the James Lind Alliance and involved four key stages: gathering research questions; checking these against existing evidence; interim prioritisation; and a final consensus meeting during which the top ten unanswered research questions were agreed using modified nominal group methodology. RESULTS: Our first online survey yielded 786 individual submissions from 413 respondents, of whom 211 were EC survivors or carers, and from which 202 unique unanswered research questions were generated. 253 individuals, including 108 EC survivors and carers, completed an online interim prioritisation survey. The resulting top 30 questions were ranked in a final consensus meeting. Our top ten spanned the breadth of patient experience of this disease and included developing personalised risk scoring, refining criteria for specialist referral, understanding the underlying biology of different types of EC, developing novel personalised treatment and prevention strategies, prognostic and predictive biomarkers, increasing public awareness and interventions for psychological issues. CONCLUSION: Having established the top ten unanswered research questions in EC, we hope this galvanises researchers, healthcare professionals and the public to collaborate, coordinate and invest in research to improve the lives of women affected by EC.

Sowing the seeds or failing to blossom? A feasibility study of a simple ecotherapy-based intervention in women affected by breast cancer.

Engaging in nature-based activities is recognised as providing the basis for easily accessible, cost-effective interventions which can have other important physical and psychological health outcomes. The aim of the reported feasibility study was to explore the acceptability and potential psychological benefits of a simple ecotherapy-based intervention for individuals affected by cancer. A total of seven women from an existing breast cancer support group agreed to take part in the study by cultivating and customising a garden bowl for three months, maintaining a diary, and participating in a focus group at the end of the project. The analysis of the focus group data revealed four main themes that suggested that the women found engaging with the intervention to be therapeutic on a number of different levels: reflecting their cancer journey, a source of positivity, making meaning through memories, and a sense of control provided by engagement with the intervention. Engagement with the diary-writing element of the intervention, however, was not as widely endorsed by the group, as participants were even reluctant to make use of an online forum to share experiences of engaging with the intervention. Overall, the study suggests that the flexibility of level of engagement with an intervention is an important factor in developing acceptable interventions, and that the value of targeted recruitment to improve engagement with novel interventions is paramount.

Is a nurse-led telephone intervention a viable alternative to nurse-led home care and standard care for patients receiving oral capecitabine? Results from a large prospective audit in patients with colorectal cancer.

Home care nursing has been shown to be a valuable service for patients receiving oral chemotherapy; however, associated costs can be high and telephone-based services may be more cost-effective options. This prospective audit explored the usefulness of a nurse-led telephone intervention for supporting cancer patients treated with Capecitabine, comparing historical findings from a randomised trial evaluating a home-based intervention over standard care with a modified nurse-led telephone follow-up intervention. Self-reported toxicity and service use were assessed in 298 patients who received nurse-led telephone follow-up, compared with historical data from 164 patients (81 receiving standard care and 83 home care intervention). Findings suggested that nurse-led telephone follow-up can potentially lead to reduced toxicity (chest pain, vomiting, oral mucositis, nausea, insomnia) when compared with standard care, and that it has a similar impact on the management of some symptoms when compared with home care (i.e. vomiting, oral mucositis), although it was not as effective as the home care intervention for other toxicities (diarrhoea and insomnia). These encouraging findings need to be explored further using a randomised trial design before we reach any conclusions. Further research should also include a health economics study to assess the cost-effectiveness of the telephone-based services for patients receiving oral chemotherapy.

Psychodynamic psychotherapy as treatment for depression in adolescence.

This article presents a psychodynamic approach to understanding and treating adolescent depression, based largely on the manual for short-term psychoanalytic psychotherapy (STPP) for adolescents (11-17 years old) with moderate to severe depression, developed for the IMPACT Study from Great Britain. Although the authors make reference to longer-term psychodynamic treatments, the 28-session model (plus 7 sessions of parent/carer work) used in the IMPACT Study informs the psychodynamic approach presented herein. In the course of discussing the analytical framework for depression and the treatment, a single case study is presented throughout to graphically illustrate the clinical course and outcomes.

The frequency of detection of unexpected diabetes mellitus during haemoglobinopathy investigations.

AIMS: To establish the frequency of detection of previously undiagnosed diabetes mellitus as a result of detection of an increased glycated fraction of haemoglobin during high performance liquid chromatography (HPLC) for haemoglobinopathy diagnosis. METHODS: A prospective study was carried out over a 3-month period. During that period a total of 2094 patient samples were received for haemoglobinopathy investigation and were included in the study. RESULTS: Fifty samples were found to have an apparent increase in the glycated haemoglobin fraction and of these 38 were found to be from patients with known diabetes. Previously undiagnosed diabetes was discovered in 11 patients and it is likely that the twelfth patient also had diabetes. CONCLUSIONS: The detection of evidence of undiagnosed diabetes during HPLC haemoglobinopathy investigations is not rare, there being four cases per month in this study. This incidental observation should be reported to clinical staff.

Pilot evaluation of a biopsychosocial integrated standardized patient examination in a family medicine clerkship.

OBJECTIVE: A new biopsychosocial Integrated Standardized Patient Examination (ISPE) was implemented to assess communication skills for medical students participating in a family medicine clerkship. METHOD: Mixed method, multi-level evaluation. RESULTS: Pilot ISPE scores were significantly higher than previous Objective Structured Clinical Examination (OSCE) (p < .01). Family Physician and Social/Behavioral Scientist rater scores were correlated (p < .001), and Cronbach's alpha statistics were acceptable (FM: alpha = .837; BH: alpha = .768). Preceptor scores on "relations with professionals" (beta = .694, p = .008) significantly predicted ISPE scores, but other clerkship assignment grades were inversely associated with ISPE. Qualitative focus group themes included lack of readiness, divergence in beliefs on scope of physician practice, and focus on grade. CONCLUSIONS: This pilot project describes the process and demonstrates the possibility of implementing a complex standardized patient case to assess students' management of complicated primary care patients with medical, psychological, and social issues.

What is a 'normal' midwife?

When you look through job advertisements these days, there are many different titles for midwifery roles. From Consultant to Research & Development Midwife, breastfeeding specialist to Sure Start ... it makes me wonder what has happened to the 'normal' midwife. Last year (June 2001) we had a focus on Normal Birth--this time we are asking, what is a 'normal' midwife? What skills does she/he have? What does she/he do to keep things 'normal'? A clinical midwife, a researcher, an educationalist and a consumer give us their views.