Tools for measuring individual self-care capability: a scoping review.

BACKGROUND: Our ability to self-care can play a crucial role in the prevention, management and rehabilitation of diverse conditions, including chronic non-communicable diseases. Various tools have been developed to support the measurement of self-care capabilities of healthy individuals, those experiencing everyday self-limiting conditions, or one or more multiple long-term conditions. We sought to characterise the various non-mono-disease specific self-care measurement tools for adults as such a review was lacking. OBJECTIVE: The aim of the review was to identify and characterise the various non-mono-disease specific self-care measurement tools for adults. Secondary objectives were to characterise these tools in terms of their content, structure and psychometric properties. DESIGN: Scoping review with content assessment. METHODS: The search was conducted in Embase, PubMed, PsycINFO and CINAHL databases using a variety of MeSH terms and keywords covering 1 January 1950 to 30 November 2022. Inclusion criteria included tools assessing health literacy, capability and/or performance of general health self-care practices and targeting adults. We excluded tools targeting self-care in the context of disease management only or indicated to a specific medical setting or theme. We used the Seven Pillars of Self-Care framework to inform the qualitative content assessment of each tool. RESULTS: We screened 26,304 reports to identify 38 relevant tools which were described in 42 primary reference studies. Descriptive analysis highlighted a temporal shift in the overall emphasis from rehabilitation-focused to prevention-focused tools. The intended method of administration also transitioned from observe-and-interview style methods to the utilisation of self-reporting tools. Only five tools incorporated questions relevant to the seven pillars of self-care. CONCLUSIONS: Various tools exist to measure individual self-care capability, but few consider assessing capability against all seven pillars of self-care. There is a need to develop a comprehensive, validated tool and easily accessible tool to measure individual self-care capability including the assessment of a wide range of self-care practices. Such a tool could be used to inform targeted health and social care interventions.

Evaluating the impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in patients with COVID-19 assessed in emergency departments in England: a retrospective matched cohort study.

BACKGROUND: To identify the impact of enrolment onto a national pulse oximetry remote monitoring programme for COVID-19 (COVID-19 Oximetry @home; CO@h) on health service use and mortality in patients attending Emergency Departments (EDs). METHODS: We conducted a retrospective matched cohort study of patients enrolled onto the CO@h pathway from EDs in England. We included all patients with a positive COVID-19 test from 1 October 2020 to 3 May 2021 who attended ED from 3 days before to 10 days after the date of the test. All patients who were admitted or died on the same or following day to the first ED attendance within the time window were excluded. In the primary analysis, participants enrolled onto CO@h were matched using demographic and clinical criteria to participants who were not enrolled. Five outcome measures were examined within 28 days of first ED attendance: (1) Death from any cause; (2) Any subsequent ED attendance; (3) Any emergency hospital admission; (4) Critical care admission; and (5) Length of stay. RESULTS: 15 621 participants were included in the primary analysis, of whom 639 were enrolled onto CO@h and 14 982 were controls. Odds of death were 52% lower in those enrolled (95% CI 7% to 75%) compared with those not enrolled onto CO@h. Odds of any ED attendance or admission were 37% (95% CI 16% to 63%) and 59% (95% CI 32% to 91%) higher, respectively, in those enrolled. Of those admitted, those enrolled had 53% (95% CI 7% to 76%) lower odds of critical care admission. There was no significant impact on length of stay. CONCLUSIONS: These findings indicate that for patients assessed in ED, pulse oximetry remote monitoring may be a clinically effective and safe model for early detection of hypoxia and escalation. However, possible selection biases might limit the generalisability to other populations.

Population-level impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in the people with COVID-19 in England: a national analysis using a stepped wedge design.

BACKGROUND: To identify the population-level impact of a national pulse oximetry remote monitoring programme for COVID-19 (COVID Oximetry @home (CO@h)) in England on mortality and health service use. METHODS: We conducted a retrospective cohort study using a stepped wedge pre-implementation and post-implementation design, including all 106 Clinical Commissioning Groups (CCGs) in England implementing a local CO@h programme. All symptomatic people with a positive COVID-19 PCR test result from 1 October 2020 to 3 May 2021, and who were aged ≥65 years or identified as clinically extremely vulnerable were included. Care home residents were excluded. A pre-intervention period before implementation of the CO@h programme in each CCG was compared with a post-intervention period after implementation. Five outcome measures within 28 days of a positive COVID-19 test: (i) death from any cause; (ii) any ED attendance; (iii) any emergency hospital admission; (iv) critical care admission and (v) total length of hospital stay. RESULTS: 217 650 people were eligible and included in the analysis. Total enrolment onto the programme was low, with enrolment data received for only 5527 (2.5%) of the eligible population. The period of implementation of the programme was not associated with mortality or length of hospital stay. The period of implementation was associated with increased health service utilisation with a 12% increase in the odds of ED attendance (95% CI: 6% to 18%) and emergency hospital admission (95% CI: 5% to 20%) and a 24% increase in the odds of critical care admission in those admitted (95% CI: 5% to 47%). In a secondary analysis of CO@h sites with at least 10% or 20% of eligible people enrolled, there was no significant association with any outcome measure. CONCLUSION: At a population level, there was no association with mortality before and after the implementation period of the CO@h programme, and small increases in health service utilisation were observed. However, lower than expected enrolment is likely to have diluted the effects of the programme at a population level.

Operational failures in general practice: a consensus-building study on the priorities for improvement.

BACKGROUND: System problems, known as operational failures, can greatly affect the work of GPs, with negative consequences for patient and professional experience, efficiency, and effectiveness. Many operational failures are tractable to improvement, but which ones should be prioritised is less clear. AIM: To build consensus among GPs and patients on the operational failures that should be prioritised to improve NHS general practice. DESIGN AND SETTING: Two modified Delphi exercises were conducted online among NHS GPs and patients in several regions across England. METHOD: Between February and October 2021, two modified Delphi exercises were conducted online: one with NHS GPs, and a subsequent exercise with patients. Over two rounds, GPs rated the importance of a list of operational failures (n = 45) that had been compiled using existing evidence. The resulting shortlist was presented to patients for rating over two rounds. Data were analysed using median scores and interquartile ranges. Consensus was defined as 80% of responses falling within one value below and above the median. RESULTS: Sixty-two GPs responded to the first Delphi exercise, and 53.2% (n = 33) were retained through to round two. This exercise yielded consensus on 14 failures as a priority for improvement, which were presented to patients. Thirty-seven patients responded to the first patient Delphi exercise, and 89.2% (n = 33) were retained through to round two. Patients identified 13 failures as priorities. The highest scoring failures included inaccuracies in patients' medical notes, missing test results, and difficulties referring patients to other providers because of problems with referral forms. CONCLUSION: This study identified the highest-priority operational failures in general practice according to GPs and patients, and indicates where improvement efforts relating to operational failures in general practice should be focused.

Factors associated with enrolment into a national COVID-19 pulse oximetry remote monitoring programme in England: a retrospective observational study.

BACKGROUND: Hypoxaemia is an important predictor of severity in individuals with COVID-19 and can present without symptoms. The COVID Oximetry @home (CO@h) programme was implemented across England in November, 2020, providing pulse oximeters to higher-risk people with COVID-19 to enable early detection of deterioration and the need for escalation of care. We aimed to describe the clinical and demographic characteristics of individuals enrolled onto the programme and to assess whether there were any inequalities in enrolment. METHODS: This retrospective observational study was based on data from a cohort of people resident in England recorded as having a positive COVID-19 test between Oct 1, 2020, and May 3, 2021. The proportion of participants enrolled onto the CO@h programmes in the 7 days before and 28 days after a positive COVID-19 test was calculated for each clinical commissioning group (CCG) in England. Two-level hierarchical multivariable logistic regression with random intercepts for each CCG was run to identify factors predictive of being enrolled onto the CO@h programme. FINDINGS: CO@h programme sites were reported by NHS England as becoming operational between Nov 21 and Dec 31, 2020. 1 227 405 people resident in 72 CCGs had a positive COVID-19 test between the date of programme implementation and May 3, 2021, of whom 19 932 (1·6%) were enrolled onto the CO@h programme. Of those enrolled, 14 441 (72·5%) were aged 50 years or older or were identified as clinically extremely vulnerable (ie, having a high-risk medical condition). Higher odds of enrolment onto the CO@h programme were found in older individuals (adjusted odds ratio 2·21 [95% CI 2·19-2·23], p<0·001, for those aged 50-64 years; 3·48 [3·33-3·63], p<0·001, for those aged 65-79 years; and 2·50 [2·34-2·68], p<0·001, for those aged ≥80 years), in individuals of non-White ethnicity (1·35 [1·28-1·43], p<0·001, for Asian individuals; 1·13 [1·04-1·22], p=0·005, for Black individuals; and 1·17 [1·03-1·32], p=0·015, for those of mixed ethnicity), in those who were overweight (1·31 [1·26-1·37], p<0·001) or obese (1·69 [1·63-1·77], p<0·001), or in those identified as clinically extremely vulnerable (1·58 [1·51-1·65], p<0·001), and lower odds were reported in those from the least socioeconomically deprived areas compared with those from the most socioeconomically deprived areas (0·75 [0·69-0·81]; p<0·001). INTERPRETATION: Nationally, uptake of the CO@h programme was low, with clinical judgment used to determine eligibility. Preferential enrolment onto the pulse oximetry monitoring programme was observed in people known to be at the highest risk of developing severe COVID-19. FUNDING: NHS England, National Institute for Health Research, and The Wellcome Trust.

Effectiveness and safety of pulse oximetry in remote patient monitoring of patients with COVID-19: a systematic review.

The COVID-19 pandemic has led health systems to increase the use of tools for monitoring and triaging patients remotely. In this systematic review, we aim to assess the effectiveness and safety of pulse oximetry in remote patient monitoring (RPM) of patients at home with COVID-19. We searched five databases (MEDLINE, Embase, Global Health, medRxiv, and bioRxiv) from database inception to April 15, 2021, and included feasibility studies, clinical trials, and observational studies, including preprints. We found 561 studies, of which 13 were included in our narrative synthesis. These 13 studies were all observational cohorts and involved a total of 2908 participants. A meta-analysis was not feasible owing to the heterogeneity of the outcomes reported in the included studies. Our systematic review substantiates the safety and potential of pulse oximetry for monitoring patients at home with COVID-19, identifying the risk of deterioration and the need for advanced care. The use of pulse oximetry can potentially save hospital resources for patients who might benefit the most from care escalation; however, we could not identify explicit evidence for the effect of RPM with pulse oximetry on health outcomes compared with other monitoring models such as virtual wards, regular monitoring consultations, and online or paper diaries to monitor changes in symptoms and vital signs. Based on our findings, we make 11 recommendations across the three Donabedian model domains and highlight three specific measurements for setting up an RPM system with pulse oximetry.

Management and patient safety of complex elderly patients in primary care during the COVID-19 pandemic in the UK-Qualitative assessment.

OBJECTIVES: The study aims to investigate GPs' experiences of how UK COVID-19 policies have affected the management and safety of complex elderly patients, who suffer from multimorbidity, at the primary care level in North West London (NWL). DESIGN: This is a service evaluation adopting a qualitative approach. SETTING: Individual semi-structured interviews were conducted between 6 and 22 May 2020, 2 months after the introduction of the UK COVID-19 Action Plan, allowing GPs to adapt to the new changes and reflect on their impact. PARTICIPANTS: Fourteen GPs working in NWL were interviewed, until data saturation was reached. OUTCOME MEASURES: The impact of COVID-19 policies on the management and safety of complex elderly patients in primary care from the GPs' perspective. RESULTS: Participants' average experience was fourteen years working in primary care for the NHS. They stated that COVID-19 policies have affected primary care at three levels, patients' behaviour, work conditions, and clinical practice. GPs reflected on the impact through five major themes; four of which have been adapted from the Safety Attitudes Questionnaire (SAQ) framework, changes in primary care (at the three levels mentioned above), involvement of GPs in policy making, communication and coordination (with patients and in between medical teams), stressors and worries; in addition to a fifth theme to conclude the GPs' suggestions for improvement (either proposed mitigation strategies, or existing actions that showed relative success). A participant used an expression of "infodemic" to describe the GPs' everyday pressure of receiving new policy updates with their subsequent changes in practice. CONCLUSION: The COVID-19 pandemic has affected all levels of the health system in the UK, particularly primary care. Based on the GPs' perspective in NWL, changes to practice have offered opportunities to maintain safe healthcare as well as possible drawbacks that should be of concern.

Quality of health care and patient safety in extreme adversity settings in the Eastern Mediterranean Region: a qualitative multicountry assessment.

BACKGROUND: Quality and patient safety are essential for the provision of effective health care services. Research on these aspects is lacking in settings of extreme adversity. AIMS: This study aimed to explore the perception of health care stakeholders working in extreme adversity settings of the quality of health care and patient safety. METHODS: This was a qualitative study conducted through semistructured interviews with 26 health care stakeholders from seven countries of the World Health Organization's Eastern Mediterranean Region which are experiencing emergencies. The interviews explored the respondents' perspectives of four aspects of quality and patient safety: definition of the quality of health care, challenges to the provision of good quality health care in emergency settings, priority health services and populations in emergency settings, and interventions to improve health care quality and patient safety. RESULTS: The participants emphasized that saving lives was the main priority in extreme adversity settings. While all people living in emergency situations were vulnerable and at risk, the respondents considered women and children, poor and disabled people, and those living in hard-to-reach areas the priority populations to be targeted by improvement interventions. The challenges to quality of health care were: financing problems, service inaccessibility, insecurity of health workers, break down in health systems, and inadequate infrastructure. Respondents proposed interventions to improve quality, however, their effective implementation remains challenging in these exceptional settings. CONCLUSIONS: The interventions identified can serve as a basis for improvements in health care quality that could be adapted to extreme adversity settings.

A digital solution to streamline access to smoking cessation interventions in England; findings from a primary care pilot (STOPNOW study).

Objectives: Despite the proven efficacy of several smoking cessation medications that have been shown to improve long-term abstinence rates, approximately two-thirds of smokers report not having used medication in their most recent quit attempt. A main barrier could be delayed access to pharmacological interventions. This study investigated the utility of a primary care linked online portal to streamline timely access to pharmacological support to patients who want to quit smoking by making an asynchronous request for treatment to their general practitioner. Study design: Prospective cohort study. Methods: An online portal with added functionality was developed, which allowed patients with a unique link to make an asynchronous request for treatment. Two GP practices identified a total of 4337 eligible patients who received an SMS or email invite to engage with an online portal including an electronic survey to capture information about smoking behaviours and to request treatment. Portal informatics and patient level data were analysed to measure the efficacy of the online system in reducing the time between making a formal request to treatment and access to pharmacological support. The primary outcome measure was the time between making a formal request for treatment and access to pharmacological support from a designated community pharmacy. Results: 323 patients (7.4%) initiated the survey, but only 56 patients completed the survey and made a formal request for treatment. 94% of participants did not return to use the portal to make a second or follow-up request for treatment. Only 3 participants completed the 12-week pathway. A total of 75 medication items were prescribed and collected by 56 patients. The time difference between the formal request to treatment and GP review ranged between 20 h and 1 week. The time difference between approval of prescription by the GP and access to medication was 5 days ± 2.1 days (range = 1.9-7.0 days). Conclusion: The widespread adoption and diffusion of an IT enabled and asynchronous primary care led remote consultation pathway can streamline timely access to smoking cessation support without the need for the patient to see a GP or an independent prescriber in the first instance.

Prevalence and determinants of cigarette smoking relapse among US adult smokers: a longitudinal study.

OBJECTIVES: This research project aims at estimating the prevalence of cigarette smoking relapse and determining its predictors among adult former smokers in the USA. SETTING: This research analysed secondary data retrieved from the Tobacco Use Supplement-Current Population Survey 2010-2011 cohort in the USA. PARTICIPANTS: Out of 18 499 participants who responded to the survey in 2010 and 2011, the analysis included a total sample size of 3258 ever smokers, who were living in the USA and reported quitting smoking in 2010. The survey's respondents who never smoked or reported current smoking in 2010 were excluded from the study sample. PRIMARY AND SECONDARY OUTCOME MEASURES: Smoking relapse was defined as picking up smoking in 2011 after reporting smoking abstinence in 2010. The prevalence of relapse over the 12-month follow-up period was estimated among different subgroups. Multivariable logistic regression models were applied to determine factors associated with relapse. RESULTS: A total of 184 former smokers reported smoking relapse by 2011 (weighted prevalence 6.8%; 95% CI 5.7% to 8.1%). Prevalence and odds of relapse were higher among young people compared with elders. Former smokers living in smoke-free homes (SFHs) had 60% lower odds of relapse compared with those living in homes that allowed smoking inside (adjusted OR 0.40; 95% CI 0.25 to 0.64). Regarding race/ethnicity, only Hispanics showed significantly higher odds of relapse compared with Whites (non-Hispanics). Odds of relapse were higher among never married, widowed, divorced and separated individuals, compared with the married group. Continuous smoking cessation for 6 months or more significantly decreased odds of relapse. CONCLUSIONS: Wider health determinants, such as race and age, but also living in SFHs showed significant associations with smoking relapse, which could inform the development of more targeted programmes to support those smokers who successfully quit, although further longitudinal studies are required to confirm our findings.