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1.
BMC Public Health ; 21(1): 1631, 2021 09 06.
Artigo em Inglês | MEDLINE | ID: mdl-34488695

RESUMO

BACKGROUND: Hot weather leads to increased illness and deaths. The Heatwave Plan for England (HWP) aims to protect the population by raising awareness of the dangers of hot weather, especially for those most vulnerable. Individuals at increased risk to the effects of heat include older adults, particularly 75+, and those with specific chronic conditions, such as diabetes, respiratory and heart conditions. The HWP recommends specific protective actions which relate to five heat-health alert levels (levels 0-4). This study examines the attitudes to hot weather of adults in England, and the protective measures taken during a heatwave. METHODS: As part of a wider evaluation of the implementation and effects of the HWP, a survey (n = 3153) and focus groups, a form of group interview facilitated by a researcher, were carried out after the June 2017 level 3 heat-health alert. Survey respondents were categorised into three groups based on their age and health status: 'vulnerable' (aged 75+), 'potentially vulnerable' (aged 18-74 in poor health) and 'not vulnerable' (rest of the adult population) to hot weather. Multivariable logistic regression models identified factors associated with these groups taking protective measures. In-person group discussion, focused on heat-health, were carried out with 25 people, mostly aged 75 + . RESULTS: Most vulnerable and potentially vulnerable adults do not consider themselves at risk of hot weather and are unaware of the effectiveness of important protective behaviours. Only one-quarter of (potentially) vulnerable adults reported changing their behaviour as a result of hearing hot weather-related health advice during the level 3 alert period. Focus group findings showed many vulnerable adults were more concerned about the effects of the sun's ultra-violet radiation on the skin than on the effects of hot temperatures on health. CONCLUSIONS: Current public health messages appear to be insufficient, given the low level of (potentially) vulnerable adults changing their behaviour during hot weather. In the context of increasingly warmer summers in England due to climate change, public health messaging needs to convince (potentially) vulnerable adults of all the risks of hot weather (not just effects of sunlight on the skin) and of the importance of heat protective measures.


Assuntos
Mudança Climática , Temperatura Alta , Idoso , Atitude , Inglaterra/epidemiologia , Humanos , Estações do Ano , Tempo (Meteorologia)
2.
BMJ Open Qual ; 10(2)2021 05.
Artigo em Inglês | MEDLINE | ID: mdl-34049868

RESUMO

BACKGROUND: This paper presents the results of the first UK-wide survey of National Health Service (NHS) general practitioners (GPs) and practice managers (PMs) designed to explore the service improvement activities being undertaken in practices, and the factors that facilitated or obstructed that work. The research was prompted by growing policy and professional interest in the quality of general practice and its improvement. The analysis compares GP and PM involvement in, and experience of, quality improvement activities. METHODS: This was a mixed-method study comprising 26 semistructured interviews, a focus group and two surveys. The qualitative data supported the design of the surveys, which were sent to all 46 238 GPs on the Royal College of General Practitioners (RCGP) database and the PM at every practice across the UK (n=9153) in July 2017. RESULTS: Responses from 2377 GPs and 1424 PMs were received and were broadly representative of each group. Ninety-nine per cent reported having planned or undertaken improvement activities in the previous 12 months. The most frequent related to prescribing and access. Key facilitators of improvement included 'good clinical leadership'. The two main barriers were 'too many demands from external stakeholders' and a lack of protected time. Audit and significant event audit were the most common improvement tools used, but respondents were interested in training on other quality improvement tools. CONCLUSION: GPs and PMs are interested in improving service quality. As such, the new quality improvement domain in the Quality and Outcomes Framework used in the payment of practices is likely to be relatively easily accepted by GPs in England. However, if improving quality is to become routine work for practices, it will be important for the NHS in the four UK countries to work with practices to mitigate some of the barriers that they face, in particular the lack of protected time.


Assuntos
Medicina Geral , Clínicos Gerais , Atitude do Pessoal de Saúde , Humanos , Melhoria de Qualidade , Medicina Estatal , Inquéritos e Questionários , Reino Unido
3.
BMJ Open ; 10(10): e037625, 2020 10 23.
Artigo em Inglês | MEDLINE | ID: mdl-33099494

RESUMO

OBJECTIVES: To measure the provision of evidence-based preventive and promotive interventions to women, and subsequently their newborns, during childbirth in a high-mortality setting. DESIGN AND PARTICIPANTS: Cross-sectional observations of care provided to women, and their newborns during the intrapartum and immediate postpartum period using a standardised checklist capturing healthcare worker behaviours regarding lifesaving and respectful care. SETTING: Ten primary healthcare facilities in Gombe state, northeast Nigeria. The northeast region of Nigeria has some of the highest maternal and newborn death rates globally. MAIN OUTCOME MEASURES: Data on 50 measures of internationally recommended evidence-based interventions and good practice. RESULTS: 1875 women were admitted to a health facility during the observation period; of these, 1804 gave birth in the facility and did not experience an adverse event or death. Many clinical interventions around the time of birth were routinely implemented, including provision of uterotonic (96% (95% CI 93% to 98%)), whereas risk-assessment measures, such as history-taking or checking vital signs were rarely completed: just 2% (95% CI 2% to 7%) of women had their temperature taken and 12% (95% CI 9% to 16%) were asked about complications during the pregnancy. CONCLUSIONS: The majority of women did not receive the recommended routine processes of childbirth care they and their newborns needed to benefit from their choice to deliver in a health facility. In particular, few benefited from even basic risk assessments, leading to missed opportunities to identify risks. To continue with the recommendation of childbirth care in primary healthcare facilities in high mortality settings like Gombe, it is crucial that birth attendant capacity, capability and prioritisation processes are addressed.


Assuntos
Parto Obstétrico , Parto , Criança , Estudos Transversais , Medicina Baseada em Evidências , Feminino , Humanos , Recém-Nascido , Nigéria , Gravidez
4.
BMJ Glob Health ; 5(3): e002135, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32201626

RESUMO

Introduction: There is a limited understanding of the importance of respectful maternity care on utilisation of maternal and newborn health services. This study aimed to determine how specific hypothetical facility birth experience of care attributes influenced rural Nigerian women's stated preferences for hypothetical place of delivery. Methods: Attributes were identified through a comprehensive review of the literature. These attributes and their respective levels were further investigated in a qualitative study. We then developed and implemented a cross-sectional discrete choice experiment with a random sample of 426 women who had facility-based childbirth to elicit their stated preferences for facility birth experience of care attributes. Women were asked to choose between two hypothetical health facilities or home birth for future delivery. Choice data were analysed using multinomial logit and mixed multinomial logit models. Results: Complete data for the discrete choice experiment were available for 425 of 426 women. The majority belonged to Fulani ethnic group (60%) and were married (95%). Almost half (45%) had no formal education. Parameter estimates were all of expected signs suggesting internal validity. The most important influence on choice of place of delivery was good health system condition, followed by absence of sexual abuse, then absence of physical and verbal abuse. Poor facility culture, including an unclean birth environment with no privacy and unclear user fee, was associated with the most disutility and had the most negative impact on preferences for facility-based childbirth. Conclusion: The likelihood of poor facility birth experiences had a significant impact on stated preferences for place of delivery among rural women in northeast Nigeria. The study findings further underline the important relationship between facility birth experience and utilisation. Achieving universal health coverage would require efforts toward addressing poor facility birth experiences and promoting respectful maternity care, to ensure women want to access the services available.


Assuntos
Parto Obstétrico , Serviços de Saúde Materna , Respeito , Comportamento de Escolha , Estudos Transversais , Parto Obstétrico/estatística & dados numéricos , Feminino , Humanos , Serviços de Saúde Materna/organização & administração , Nigéria , Gravidez , População Rural
5.
Br J Gen Pract ; 69(682): e321-e328, 2019 May.
Artigo em Inglês | MEDLINE | ID: mdl-31015225

RESUMO

BACKGROUND: To better manage patient demand, some general practices have implemented a 'telephone first' approach in which all patients seeking a face-to-face appointment first have to speak to a GP on the telephone. Previous studies have suggested that there is considerable scope for this new approach, but there remain significant concerns. AIM: To understand the views of GPs and practice staff of the telephone first approach, and to identify enablers and barriers to successful adoption of the approach. DESIGN AND SETTING: A qualitative study of the telephone first approach in 12 general practices that have adopted it, and two general practices that have tried the approach but reverted to their previous system. METHOD: A total of 53 qualitative interviews with GPs and practice staff were conducted. Transcriptions of the interviews were systematically analysed. RESULTS: Staff in the majority of practices reported that the approach was an improvement on their previous system, but all practices experienced challenges; for example, where practices did not have the capacity to meet the increase in demand for telephone consultations. Staff were also aware that the new system suited some patients better than others. Adoption of the telephone first approach could be very stressful, with a negative impact on morale, especially reported in interviews with the two practices that had tried but stopped the approach. Interviewees identified enablers and barriers to the successful adoption of a telephone first approach in primary care. Enablers to successful adoption were: understanding demand, practice staff as pivotal, making modifications to the approach, and educating patients. CONCLUSION: Practices considering adopting or clinical commissioning groups considering funding a telephone first approach should consider carefully a practice's capacity and capability before launching.


Assuntos
Atitude do Pessoal de Saúde , Clínicos Gerais/organização & administração , Entrevistas como Assunto , Preferência do Paciente , Atenção Primária à Saúde , Consulta Remota , Agendamento de Consultas , Humanos , Avaliação de Processos e Resultados em Cuidados de Saúde , Atenção Primária à Saúde/métodos , Atenção Primária à Saúde/organização & administração , Pesquisa Qualitativa , Consulta Remota/métodos , Consulta Remota/organização & administração , Reino Unido , Carga de Trabalho
6.
BMJ Open ; 9(3): e024220, 2019 03 03.
Artigo em Inglês | MEDLINE | ID: mdl-30833317

RESUMO

OBJECTIVES: To estimate the impact on hospital utilisation and costs of a multi-faceted primary care intervention for older people identified as being at risk of avoidable hospitalisation. DESIGN: Observational study: controlled time series analysis and estimation of costs and cost consequences of the Programme. General practitioner (GP)'s practice level data were analysed from 2009 to 2016 (intervention operated from 2012 to 2016). Mixed-effect Poisson regression models of hospital utilisation included comparisons with control practices and background trends in addition to within-practice comparisons. Cost estimation used standard tariff values. SETTING: 94 practices in Southwark and Lambeth and 263 control practices from other parts of England. MAIN OUTCOME MEASURES: Hospital utilisation: emergency department attendance, emergency admissions, emergency admissions for ambulatory sensitive conditions, outpatient attendance, elective admission and length of stay. RESULTS: By the fourth year of the Programme, there were reductions in accident and emergency (A&E) attendance (rate ratio 0.944, 95% CI 0.913 to 0.976), outpatient attendances (rate ratio 0.938, 95% CI 0.902 to 0.975) and elective admissions (rate ratio 0.921, 95% CI 0.908 to 0.935) but there was no evidence of reduced emergency admissions. The costs of the Programme were £149 per resident aged 65 and above but savings in hospital costs were only £86 per resident aged 65 and above, equivalent to a net increase in health service expenditure of £64 per resident though the Programme was nearly cost neutral if set-up costs were excluded. Holistic assessments carried out by GPs and consequent Integrated Care Management (ICM) plans were associated with increases in elective activity and costs; £126 increase in outpatient attendance and £936 in elective admission costs per holistic assessment carried out, and £576 increase in outpatient and £5858 in elective admission costs per patient receiving ICM. CONCLUSIONS: The Older People's Programme was not cost saving. Some aspects of the Programme were associated with increased costs of elective care, possibly through the identification of unmet need.


Assuntos
Prestação Integrada de Cuidados de Saúde/economia , Prestação Integrada de Cuidados de Saúde/estatística & dados numéricos , Serviços de Saúde para Idosos/economia , Serviços de Saúde para Idosos/estatística & dados numéricos , Hospitalização/economia , Hospitalização/estatística & dados numéricos , Atenção Primária à Saúde , Idoso , Idoso de 80 Anos ou mais , Análise Custo-Benefício , Inglaterra/epidemiologia , Avaliação Geriátrica/estatística & dados numéricos , Humanos , Análise de Séries Temporais Interrompida , Alta do Paciente , Readmissão do Paciente/economia , Readmissão do Paciente/estatística & dados numéricos , Avaliação de Programas e Projetos de Saúde
7.
J Glob Health ; 8(2): 020420, 2018 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-30410739

RESUMO

Background: Basic newborn resuscitation for babies not breathing at birth is a highly effective intervention and its scale-up identified as a top research priority. However, tracking progress on the scale-up and coverage of this intervention is compromised by limitations in measuring both the number of newborns receiving the intervention and the number of newborns requiring the intervention. Using data from a facility and birth attendant survey in Gombe State, Nigeria, we aimed to advance the measurement agenda by developing a proxy indicator defined as the "percent of newborns born in a facility with the potential to provide newborn resuscitation". Methods: The indicator's denominator was defined as: the total number of births in facilities during a defined time period (facility records). The numerator was constructed from the number of those births that occurred in appropriately equipped facilities (facility inventory), where a birth attendant demonstrated basic resuscitation competence (assessed by a simulation exercise). The proportion of facility-births that took place in a setting with the potential to provide newborn resuscitation was then calculated. Results: The analysis included 17 383 births that occurred during May-October 2015 in 117 primary and referral facilities surveyed in November 2015. Overall 81% of the facilities did not have all items of essential equipment required for resuscitation; the items of equipment least frequently present included a timing device and resuscitation bag with two sizes of neonatal face mask. Only 3% of 117 birth attendants interviewed demonstrated competence to undertake resuscitation, all of whom were classified as skilled attendants and worked in referral facilities. We found that 20% of the 17 383 births took place in a facility with the potential to provide lifesaving resuscitation care. Conclusions: The indicator definition of neonatal resuscitation presented here responds to the need to advance the measurement agenda for newborn care and importantly adjusts for the volume of births occurring in different facilities. Its application in this setting revealed substantial missed opportunities to providing lifesaving care and highlights the need for a greater focus on input as well as process quality in all levels of health facilities.


Assuntos
Asfixia Neonatal/terapia , Instalações de Saúde/estatística & dados numéricos , Ressuscitação , Competência Clínica/estatística & dados numéricos , Parto Obstétrico , Equipamentos e Provisões/provisão & distribuição , Feminino , Pesquisas sobre Serviços de Saúde , Humanos , Recém-Nascido , Masculino , Nigéria , Gravidez
8.
Br J Gen Pract ; 68(669): e286-e292, 2018 04.
Artigo em Inglês | MEDLINE | ID: mdl-29530921

RESUMO

BACKGROUND: Long-term conditions place a substantial burden on primary care services, with drug therapy being a core aspect of clinical management. However, the ideal frequency for issuing repeat prescriptions for these medications is unknown. AIM: To examine the impact of longer-duration (2-4 months) versus shorter-duration (28-day) prescriptions. DESIGN AND SETTING: Systematic review of primary care studies. METHOD: Scientific and grey literature databases were searched from inception until 21 October 2015. Eligible studies were randomised controlled trials and observational studies that examined longer prescriptions (2-4 months) compared with shorter prescriptions (28 days) in patients with stable, chronic conditions being treated in primary care. Outcomes of interest were: health outcomes, adverse events, medication adherence, medication wastage, professional administration time, pharmacists' time and/or costs, patient experience, and patient out-of-pocket costs. RESULTS: From a search total of 24 876 records across all databases, 13 studies were eligible for review. Evidence of moderate quality from nine studies suggested that longer prescriptions are associated with increased medication adherence. Evidence from six studies suggested that longer prescriptions may increase medication waste, but results were not always statistically significant and were of very low quality. No eligible studies were identified that measured any of the other outcomes of interest, including health outcomes and adverse events. CONCLUSION: There is insufficient evidence relating to the overall impact of differing prescription lengths on clinical and health service outcomes, although studies do suggest medication adherence may improve with longer prescriptions. UK recommendations to provide shorter prescriptions are not substantiated by the current evidence base.


Assuntos
Doença Crônica/tratamento farmacológico , Serviços Comunitários de Farmácia , Prescrições de Medicamentos/economia , Padrões de Prática Médica/estatística & dados numéricos , Atenção Primária à Saúde , Doença Crônica/economia , Serviços Comunitários de Farmácia/economia , Serviços Comunitários de Farmácia/estatística & dados numéricos , Análise Custo-Benefício , Humanos , Padrões de Prática Médica/economia , Atenção Primária à Saúde/economia , Atenção Primária à Saúde/estatística & dados numéricos , Ensaios Clínicos Controlados Aleatórios como Assunto , Resultado do Tratamento , Reino Unido
9.
Int J Technol Assess Health Care ; 34(1): 27-37, 2018 Jan.
Artigo em Inglês | MEDLINE | ID: mdl-29338794

RESUMO

BACKGROUND: Walking is a good way to meet physical activity guidelines. We examined the effectiveness of walking in groups compared with walking alone or inactive controls in physically healthy adults on physical activity and quality of life. (PROSPERO CRD42016033752). METHODS: We searched Medline, Embase, Cinahl, Web of Knowledge Science Citation Index, and Cochrane CENTRAL until March 2016, for any comparative studies, in physically healthy adults, of walking in groups compared with inactive controls or walking alone, reporting any measure of physical activity. We searched references from recent relevant systematic reviews. Two reviewers checked study eligibility and independently extracted data. Disagreements were resolved through discussion. Quality was assessed using likelihood of selection, performance, attrition, and detection biases. Meta-analysis was conducted using Review Manager 5.3. RESULTS: From 1,404 citations, 18 studies were included in qualitative synthesis and 10 in meta-analyses. Fourteen compared group walking to inactive controls and four to walking alone. Eight reported more than one measure of physical activity, none reported according to current guidelines. Group walking compared with inactive controls increased follow-up physical activity (9 randomized controlled trials, standardized mean difference [SMD] 0.58 [95 percent confidence interval {CI}, 0.34-0.82] to SMD 0.43 [95 percent CI, 0.20-0.66]). Compared with walking alone, studies were too few and too heterogeneous to conduct meta-analysis, but the trend was improved physical activity at follow-up for group walking participants. Seven (all inactive control) reported quality-of-life: five showed statistically significantly improved scores. DISCUSSION: Better evidence may encourage government policy to promote walking in groups. Standardized physical activity outcomes need to be reported in research.


Assuntos
Processos Grupais , Qualidade de Vida , Caminhada/fisiologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Exercício Físico/fisiologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Pacientes Desistentes do Tratamento , Ensaios Clínicos Controlados Aleatórios como Assunto , Adulto Jovem
10.
BMJ Open ; 8(12): e026197, 2018 12 31.
Artigo em Inglês | MEDLINE | ID: mdl-30598491

RESUMO

OBJECTIVE: To understand patients' views on a 'telephone-first' approach, in which all appointment requests in general practice are followed by a telephone call from the general practitioner (GP). DESIGN: Qualitative interviews with patients and carers. SETTING: Twelve general practices in England. PARTICIPANTS: 43 patients, including 30 women, nine aged over 75 years, four parents of young children, five carers, five patients with hearing impairment and two whose first language was not English. RESULTS: Patients expressed varied views, often strongly held, ranging from enthusiasm for to hostility towards the 'telephone-first' approach. The new system suited some patients, avoiding the need to come into the surgery but was problematic for others, for example, when it was difficult for someone working in an open plan office to take a call-back. A substantial proportion of negative comments were about the operation of the scheme itself rather than the principles behind it, for example, difficulty getting through on the phone or being unable to schedule when the GP would phone back. Some practices were able to operate the scheme in a way that met their patients' needs better than others and practices varied significantly in how they had implemented the approach. CONCLUSIONS: The 'telephone-first' approach appears to work well for some patients, but others find it much less acceptable. Some of the reported problems related to how the approach had been implemented rather than the 'telephone-first' approach in principle and suggests there may be potential for some of the challenges experienced by patients to be overcome.


Assuntos
Agendamento de Consultas , Medicina Geral/métodos , Consulta Remota/métodos , Telefone , Atitude do Pessoal de Saúde , Inglaterra , Feminino , Medicina Geral/organização & administração , Clínicos Gerais , Humanos , Entrevistas como Assunto , Masculino , Satisfação do Paciente , Pesquisa Qualitativa , Encaminhamento e Consulta , Consulta Remota/organização & administração , Carga de Trabalho
11.
Health Technol Assess ; 21(78): 1-128, 2017 12.
Artigo em Inglês | MEDLINE | ID: mdl-29268843

RESUMO

BACKGROUND: To reduce expenditure on, and wastage of, drugs, some commissioners have encouraged general practitioners to issue shorter prescriptions, typically 28 days in length; however, the evidence base for this recommendation is uncertain. OBJECTIVE: To evaluate the evidence of the clinical effectiveness and cost-effectiveness of shorter versus longer prescriptions for people with stable chronic conditions treated in primary care. DESIGN/DATA SOURCES: The design of the study comprised three elements. First, a systematic review comparing 28-day prescriptions with longer prescriptions in patients with chronic conditions treated in primary care, evaluating any relevant clinical outcomes, adherence to treatment, costs and cost-effectiveness. Databases searched included MEDLINE (PubMed), EMBASE, Cumulative Index to Nursing and Allied Health Literature, Web of Science and Cochrane Central Register of Controlled Trials. Searches were from database inception to October 2015 (updated search to June 2016 in PubMed). Second, a cost analysis of medication wastage associated with < 60-day and ≥ 60-day prescriptions for five patient cohorts over an 11-year period from the Clinical Practice Research Datalink. Third, a decision model adapting three existing models to predict costs and effects of differing adherence levels associated with 28-day versus 3-month prescriptions in three clinical scenarios. REVIEW METHODS: In the systematic review, from 15,257 unique citations, 54 full-text papers were reviewed and 16 studies were included, five of which were abstracts and one of which was an extended conference abstract. None was a randomised controlled trial: 11 were retrospective cohort studies, three were cross-sectional surveys and two were cost studies. No information on health outcomes was available. RESULTS: An exploratory meta-analysis based on six retrospective cohort studies suggested that lower adherence was associated with 28-day prescriptions (standardised mean difference -0.45, 95% confidence interval -0.65 to -0.26). The cost analysis showed that a statistically significant increase in medication waste was associated with longer prescription lengths. However, when accounting for dispensing fees and prescriber time, longer prescriptions were found to be cost saving compared with shorter prescriptions. Prescriber time was the largest component of the calculated cost savings to the NHS. The decision modelling suggested that, in all three clinical scenarios, longer prescription lengths were associated with lower costs and higher quality-adjusted life-years. LIMITATIONS: The available evidence was found to be at a moderate to serious risk of bias. All of the studies were conducted in the USA, which was a cause for concern in terms of generalisability to the UK. No evidence of the direct impact of prescription length on health outcomes was found. The cost study could investigate prescriptions issued only; it could not assess patient adherence to those prescriptions. Additionally, the cost study was based on products issued only and did not account for underlying patient diagnoses. A lack of good-quality evidence affected our decision modelling strategy. CONCLUSIONS: Although the quality of the evidence was poor, this study found that longer prescriptions may be less costly overall, and may be associated with better adherence than 28-day prescriptions in patients with chronic conditions being treated in primary care. FUTURE WORK: There is a need to more reliably evaluate the impact of differing prescription lengths on adherence, on patient health outcomes and on total costs to the NHS. The priority should be to identify patients with particular conditions or characteristics who should receive shorter or longer prescriptions. To determine the need for any further research, an expected value of perfect information analysis should be performed. STUDY REGISTRATION: This study is registered as PROSPERO CRD42015027042. FUNDING: The National Institute for Health Research Health Technology Assessment programme.


Assuntos
Doença Crônica , Análise Custo-Benefício , Prescrições de Medicamentos/economia , Modelos Econômicos , Avaliação da Tecnologia Biomédica , Resultado do Tratamento , Humanos , Atenção Primária à Saúde , Fatores de Tempo
12.
BMJ ; 358: j4197, 2017 Sep 27.
Artigo em Inglês | MEDLINE | ID: mdl-28954741

RESUMO

Objective To evaluate a "telephone first" approach, in which all patients wanting to see a general practitioner (GP) are asked to speak to a GP on the phone before being given an appointment for a face to face consultation.Design Time series and cross sectional analysis of routine healthcare data, data from national surveys, and primary survey data.Participants 147 general practices adopting the telephone first approach compared with a 10% random sample of other practices in England.Intervention Management support for workload planning and introduction of the telephone first approach provided by two commercial companies.Main outcome measures Number of consultations, total time consulting (59 telephone first practices, no controls). Patient experience (GP Patient Survey, telephone first practices plus controls). Use and costs of secondary care (hospital episode statistics, telephone first practices plus controls). The main analysis was intention to treat, with sensitivity analyses restricted to practices thought to be closely following the companies' protocols.Results After the introduction of the telephone first approach, face to face consultations decreased considerably (adjusted change within practices -38%, 95% confidence interval -45% to -29%; P<0.001). An average practice experienced a 12-fold increase in telephone consultations (1204%, 633% to 2290%; P<0.001). The average duration of both telephone and face to face consultations decreased, but there was an overall increase of 8% in the mean time spent consulting by GPs, albeit with large uncertainty on this estimate (95% confidence interval -1% to 17%; P=0.088). These average workload figures mask wide variation between practices, with some practices experiencing a substantial reduction in workload and others a large increase. Compared with other English practices in the national GP Patient Survey, in practices using the telephone first approach there was a large (20.0 percentage points, 95% confidence interval 18.2 to 21.9; P<0.001) improvement in length of time to be seen. In contrast, other scores on the GP Patient Survey were slightly more negative. Introduction of the telephone first approach was followed by a small (2.0%) increase in hospital admissions (95% confidence interval 1% to 3%; P=0.006), no initial change in emergency department attendance, but a small (2% per year) decrease in the subsequent rate of rise of emergency department attendance (1% to 3%; P=0.005). There was a small net increase in secondary care costs.Conclusions The telephone first approach shows that many problems in general practice can be dealt with over the phone. The approach does not suit all patients or practices and is not a panacea for meeting demand. There was no evidence to support claims that the approach would, on average, save costs or reduce use of secondary care.


Assuntos
Agendamento de Consultas , Medicina Geral , Gerenciamento da Prática Profissional/organização & administração , Consulta Remota , Atitude do Pessoal de Saúde , Análise Custo-Benefício , Feminino , Medicina Geral/métodos , Medicina Geral/organização & administração , Medicina Geral/estatística & dados numéricos , Clínicos Gerais/psicologia , Clínicos Gerais/estatística & dados numéricos , Humanos , Entrevistas como Assunto/métodos , Masculino , Pessoa de Meia-Idade , Avaliação de Processos e Resultados em Cuidados de Saúde , Preferência do Paciente , Padrões de Prática Médica/organização & administração , Consulta Remota/métodos , Consulta Remota/organização & administração , Consulta Remota/estatística & dados numéricos , Reino Unido , Carga de Trabalho/estatística & dados numéricos
13.
BMC Health Serv Res ; 17(1): 356, 2017 05 18.
Artigo em Inglês | MEDLINE | ID: mdl-28521740

RESUMO

BACKGROUND: The lack of availability of skilled providers in low- and middle- income countries is considered to be an important barrier to achieving reductions in maternal and child mortality. However, there is limited research on programs increasing the availability of skilled birth attendants in developing countries. We study the implementation of the Nigeria Midwives Service Scheme, a government program that recruited and deployed nearly 2,500 midwives to rural primary health care facilities across Nigeria in 2010. An outcome evaluation carried out by this team found only a modest impact on the use of antenatal care and no measurable impact on skilled birth attendance. This paper draws on perspectives of policymakers, program midwives, and community residents to understand why the program failed to have the desired impact. METHODS: We conducted semi-structured interviews with federal, state and local government policy makers and with MSS midwives. We also conducted focus groups with community stakeholders including community leaders and male and female residents. RESULTS: Our data reveal a range of design, implementation and operational challenges ranging from insufficient buy-in by key stakeholders at state and local levels, to irregular and in some cases total non-provision of agreed midwife benefits that likely contributed to the program's lack of impact. These challenges not only created a deep sense of dissatisfaction with the program but also had practical impacts on service delivery likely affecting households' uptake of services. CONCLUSION: This paper highlights the challenge of effectively scaling up maternal and child health interventions. Our findings emphasize the critical importance of program design, particularly when programs are implemented at scale; the need to identify and involve key stakeholders during planning and implementation; the importance of clearly defining lines of authority and responsibility that align with existing structures; and the necessity for multi-faceted interventions that address multiple barriers at the same time.


Assuntos
Pessoal Técnico de Saúde/provisão & distribuição , Acesso aos Serviços de Saúde , Tocologia , Serviços de Saúde Rural , Países em Desenvolvimento , Grupos Focais , Humanos , Serviços de Saúde Materna , Tocologia/economia , Nigéria , Equipe de Assistência ao Paciente , Participação dos Interessados , Recursos Humanos
14.
BMC Health Serv Res ; 16: 425, 2016 08 23.
Artigo em Inglês | MEDLINE | ID: mdl-27613502

RESUMO

BACKGROUND: Limited availability of skilled health providers in developing countries is thought to be an important barrier to achieving maternal and child health-related MDG goals. Little is known, however, about the extent to which scaling-up supply of health providers will lead to improved pregnancy and birth outcomes. We study the effects of the Midwives Service Scheme (MSS), a public sector program in Nigeria that increased the supply of skilled midwives in rural communities on pregnancy and birth outcomes. METHODS: We surveyed 7,104 women with a birth within the preceding five years across 12 states in Nigeria and compared changes in birth outcomes in MSS communities to changes in non-MSS communities over the same period. RESULTS: The main measured effect of the scheme was a 7.3-percentage point increase in antenatal care use in program clinics and a 5-percentage point increase in overall use of antenatal care, both within the first year of the program. We found no statistically significant effect of the scheme on skilled birth attendance or on maternal delivery complications. CONCLUSION: This study highlights the complexity of improving maternal and child health outcomes in developing countries, and shows that scaling up supply of midwives may not be sufficient on its own.


Assuntos
Serviços de Saúde Materna , Tocologia , Resultado da Gravidez , Cuidado Pré-Natal/estatística & dados numéricos , Países em Desenvolvimento , Feminino , Humanos , Masculino , Serviços de Saúde Materna/estatística & dados numéricos , Nigéria , Gravidez , Serviços de Saúde Rural , Inquéritos e Questionários , Recursos Humanos
15.
BMC Pregnancy Childbirth ; 16: 232, 2016 08 19.
Artigo em Inglês | MEDLINE | ID: mdl-27538806

RESUMO

BACKGROUND: The Nigerian Midwives Service Scheme (MSS) is an ambitious human resources project created in 2009 to address supply side barriers to accessing care. Key features include the recruitment and deployment of newly qualified, unemployed and retired midwives to rural primary healthcare centres (PHCs) to ensure improved access to skilled care. This study aimed to understand, from multiple perspectives, the views and experiences of childbearing women living in areas where it has been implemented. METHODS: A qualitative study was undertaken as part of an impact evaluation of the MSS in three states from three geo-political regions of Nigeria. Semi-structured interviews were conducted around nine MSS PHCs with women who had given birth in the past six months, midwives working in the PHCs and policy makers. Focus group discussions were held with wider community members. Coding and analysis of the data was performed in NVivo10 based on the constant comparative approach. RESULTS: The majority of participants reported that there had been positive improvements in maternity care as a result of an increasing number of midwives. However, despite improvements in the perceived quality of care and an apparent willingness to give birth in a PHC, more women gave birth at home than intended. There were some notable differences between states, with a majority of women in one northern state favouring home birth, which midwives and community members commented stemmed from low levels of awareness. The principle reason cited by women for home birth was the sudden onset of labour. Financial barriers, the lack of essential drugs and equipment, lack of transportation and the absence of staff, particularly at night, were also identified as barriers to accessing care. CONCLUSIONS: Our research highlights a number of barriers to accessing care exist, which are likely to have limited the potential for the MSS to have an impact. It suggests that in addition to scaling up the workforce through the MSS, efforts are also needed to address the determinants of care seeking. For the MSS this means that the while the supply side, through the provision of skilled attendance, still needs to be strengthened, this should not be in isolation of addressing demand-side factors.


Assuntos
Acesso aos Serviços de Saúde/estatística & dados numéricos , Serviços de Saúde Materna/estatística & dados numéricos , Tocologia/métodos , Aceitação pelo Paciente de Cuidados de Saúde/psicologia , Atenção Primária à Saúde/métodos , Adolescente , Adulto , Parto Obstétrico/psicologia , Parto Obstétrico/estatística & dados numéricos , Feminino , Grupos Focais , Parto Domiciliar/psicologia , Parto Domiciliar/estatística & dados numéricos , Humanos , Nigéria , Aceitação pelo Paciente de Cuidados de Saúde/estatística & dados numéricos , Gravidez , Pesquisa Qualitativa , População Rural/estatística & dados numéricos , Fatores Socioeconômicos , Adulto Jovem
16.
Qual Life Res ; 25(9): 2245-56, 2016 09.
Artigo em Inglês | MEDLINE | ID: mdl-27039304

RESUMO

PURPOSE: Patient-reported data are playing an increasing role in health care. In oncology, data from quality of life (QoL) assessment tools may be particularly important for those with limited survival prospects, where treatments aim to prolong survival while maintaining or improving QoL. This paper examines the use and impact of using QoL measures on health care of cancer patients within a clinical setting, particularly those with brain cancer. It also examines facilitators and challenges, and provides implications for policy and practice. DESIGN: We conducted a systematic literature review, 15 expert interviews and a consultation at an international summit. RESULTS: The systematic review found no relevant intervention studies specifically in brain cancer patients, and after expanding our search to include other cancers, 15 relevant studies were identified. The evidence on the effectiveness of using QoL tools was inconsistent for patient management, but somewhat more consistent in favour of improving patient-physician communication. Interviews identified unharnessed potential and growing interest in QoL tool use and associated challenges to address. CONCLUSION: Our findings suggest that the use of QoL tools in cancer patients may improve patient-physician communication and have the potential to improve care, but the tools are not currently widely used in clinical practice (in brain cancer nor some other cancer contexts) although they are in clinical trials. There is a need for further research and stakeholder engagement on how QoL tools can achieve most impact across cancer and patient contexts. There is also a need for policy, health professional, research and patient communities to strengthen information exchange and debate, support awareness raising and provide training on tool design, use and interpretation.


Assuntos
Neoplasias Encefálicas/psicologia , Serviços de Saúde/normas , Perfil de Impacto da Doença , Humanos
17.
Rand Health Q ; 5(3): 2, 2016 Jan 29.
Artigo em Inglês | MEDLINE | ID: mdl-28083399

RESUMO

RAND Europe undertook a systematic review of the evidence of effectiveness and cost effectiveness on changing the public's risk related behaviour pertaining to antimicrobial use to inform the development of a NICE public health guideline aimed at delaying antimicrobial resistance (AMR). The review considered educational interventions targeting individuals, communities or the general public delivered via any mode. Specifically, it aimed to address: 1. Which educational interventions are effective and cost-effective in changing the public's behaviour to ensure they only ask for antimicrobials when appropriate and use them correctly? 2. Which educational interventions are effective and cost-effective in changing the public's behaviour to prevent infection and reduce the spread of antimicrobial resistance? Overall, 60 studies met the inclusion criteria; 29 related to research question 1, and 36 related to research question 2 (five studies were applicable to both). The key findings are summarised in "Evidence Statements" in accordance with NICE guidelines. Evidence Statements provide a high level overview of the key features of the evidence including: the number of studies, the quality of evidence, and the direction of the estimated effect followed by a brief summary of each of the supporting studies. Studies are grouped into Evidence Statements by setting and intervention.

18.
Rand Health Q ; 6(1): 7, 2016 Jun 20.
Artigo em Inglês | MEDLINE | ID: mdl-28083435

RESUMO

The Department of Health's Innovation, Health and Wealth (IHW) strategy aimed to introduce a more strategic approach to the spread of innovation across the NHS. This study represents the first phase of a three-year evaluation and aims to map progress towards the IHW strategy and its component actions. This evaluation used a combination of quantitative and qualitative methods: document review, key informant interviews and stakeholder survey. This study also forms the basis for selecting case studies for phase two of the evaluation. Our findings from the interviews and survey suggest broad stakeholder support for the overarching ambitions of the IHW strategy. However, we found variable progress towards the overarching objectives of the eight IHW themes and an ambiguous relationship between many of the themes' objectives and their actions. It was difficult to assess progress on IHW's actions as commitment to the actions, implementation guidance and expected outcomes of the actions were not clearly articulated. The Academic Health Science Networks (AHSNs) and the Small Business Research Initiative (SBRI) were reported to be working well, which may be attributed to their clear structures of accountability and earmarked budgets. However, survey respondents and interviewees raised concerns that budgetary pressures may limit the impact of both AHSNs and the SBRI. The main challenges identified for ongoing action were the resources available for their implementation (e.g. Medtech Briefings), lack of awareness of the initiative (e.g. the NICE Implementation Collaborative) and the design of the actions (e.g. the Innovation Scorecard, web portal and High Impact Innovations).

19.
Rand Health Q ; 4(4): 5, 2015 Mar 20.
Artigo em Inglês | MEDLINE | ID: mdl-28083352

RESUMO

The European Bathing Directive (2006/7/EC) stipulates water quality standards for recreational bathing waters based on specified limits of faecal indicator organisms (FIOs). Presence of FIOs above the limits is considered to be indicative of poor water quality and to present a risk to bathers' health. The European Bathing Directive (2006) is to be reviewed in 2020. We conducted a rapid evidence assessment on recreational bathing waters and gastrointestinal illness (GI) to identify the extent of the literature published since the previous review period in 2003 and to determine whether there is any new evidence which may indicate that a revision to the Directive would be justified. Overall, 21 papers (from 16 studies), including two RCTs, met the inclusion criteria; 12 were conducted in marine waters and four were conducted in freshwater. Considerable heterogeneity existed between study protocols and the majority had significant methodological limitations, including self-selection and misclassification biases. Moreover, there was limited variation in water quality among studies, providing a limited evidence base on which to assess the classification standards. Overall, there appears to be a consistent significant relationship between faecal indicator organisms and GI in freshwater, but not marine water studies. Given the apparent lack of relationship between GI and water quality, it is unclear whether the boundaries of the Bathing Waters Directive are supported by studies published in the post-2003 period. We suggest that more epidemiological evidence is needed to disprove or confirm the original work that was used to derive these boundaries for marine waters.

20.
Environ Sci Technol ; 49(2): 1086-94, 2015 Jan 20.
Artigo em Inglês | MEDLINE | ID: mdl-25513885

RESUMO

This study aimed to assess whether the MDG classifications and JMP sanitation ladder corresponded to hygienic proxies. Latrines were purposefully sampled in urban and rural Tanzania. Three hygienic proxies were measured: E. coli on points of hand contact, helminth at point of foot contact, and number of flies. Additionally, samples were collected from comparable surfaces in the household, and a questionnaire on management and use, combined with a visual inspection of the latrine's design was conducted. In total, 341 latrines were sampled. The MDG classifications "improved" vs "unimproved" did not describe the observed differences in E. coli concentrations. Disaggregating the data into the JMP sanitation ladder, on average "shared" facilities were the least contaminated: 9.2 vs 17.7 ("improved") and 137 E. coli/100 mL ("unimproved") (p = 0.04, p < 0.001). Logistic regression analysis suggests that both the presence of a slab and sharing a facility is protective against faecal-oral exposure (OR 0.18 95% CI 0.10, 0.34 and OR 0.52, 95% CI 0.29, 0.92). The findings do not support the current assumption that shared facilities of an adequate technology should be classified for MDG purposes as "unimproved".


Assuntos
Saneamento/instrumentação , Saneamento/métodos , Toaletes , Administração Oral , Animais , Escherichia coli , Características da Família , Fezes/microbiologia , Helmintos , Humanos , Higiene , Análise de Regressão , População Rural , Tamanho da Amostra , Poluentes do Solo , Inquéritos e Questionários , Tanzânia , População Urbana
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