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Carrie S, Fouweather T, Homer T, O'Hara J, Rousseau N, Rooshenas L, Bray A, Stocken DD, Ternent L, Rennie K, Clark E, Waugh N, Steel AJ, Dooley J, Drinnan M, Hamilton D, Lloyd K, Oluboyede Y, Wilson C, Gardiner Q, Kara N, Khwaja S, Leong SC, Maini S, Morrison J, Nix P, Wilson JA, Teare MD. Effectiveness of septoplasty compared to medical management in adults with obstruction associated with a deviated nasal septum: the NAIROS RCT. Health Technol Assess 2024; 28:1-213. [PMID: 38477237 PMCID: PMC11017631 DOI: 10.3310/mvfr4028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2024] Open
Abstract
Background The indications for septoplasty are practice-based, rather than evidence-based. In addition, internationally accepted guidelines for the management of nasal obstruction associated with nasal septal deviation are lacking. Objective The objective was to determine the clinical effectiveness and cost-effectiveness of septoplasty, with or without turbinate reduction, compared with medical management, in the management of nasal obstruction associated with a deviated nasal septum. Design This was a multicentre randomised controlled trial comparing septoplasty, with or without turbinate reduction, with defined medical management; it incorporated a mixed-methods process evaluation and an economic evaluation. Setting The trial was set in 17 NHS secondary care hospitals in the UK. Participants A total of 378 eligible participants aged > 18 years were recruited. Interventions Participants were randomised on a 1: 1 basis and stratified by baseline severity and gender to either (1) septoplasty, with or without turbinate surgery (n = 188) or (2) medical management with intranasal steroid spray and saline spray (n = 190). Main outcome measures The primary outcome was the Sino-nasal Outcome Test-22 items score at 6 months (patient-reported outcome). The secondary outcomes were as follows: patient-reported outcomes - Nasal Obstruction Symptom Evaluation score at 6 and 12 months, Sino-nasal Outcome Test-22 items subscales at 12 months, Double Ordinal Airway Subjective Scale at 6 and 12 months, the Short Form questionnaire-36 items and costs; objective measurements - peak nasal inspiratory flow and rhinospirometry. The number of adverse events experienced was also recorded. A within-trial economic evaluation from an NHS and Personal Social Services perspective estimated the incremental cost per (1) improvement (of ≥ 9 points) in Sino-nasal Outcome Test-22 items score, (2) adverse event avoided and (3) quality-adjusted life-year gained at 12 months. An economic model estimated the incremental cost per quality-adjusted life-year gained at 24 and 36 months. A mixed-methods process evaluation was undertaken to understand/address recruitment issues and examine the acceptability of trial processes and treatment arms. Results At the 6-month time point, 307 participants provided primary outcome data (septoplasty, n = 152; medical management, n = 155). An intention-to-treat analysis revealed a greater and more sustained improvement in the primary outcome measure in the surgical arm. The 6-month mean Sino-nasal Outcome Test-22 items scores were -20.0 points lower (better) for participants randomised to septoplasty than for those randomised to medical management [the score for the septoplasty arm was 19.9 and the score for the medical management arm was 39.5 (95% confidence interval -23.6 to -16.4; p < 0.0001)]. This was confirmed by sensitivity analyses and through the analysis of secondary outcomes. Outcomes were statistically significantly related to baseline severity, but not to gender or turbinate reduction. In the surgical and medical management arms, 132 and 95 adverse events occurred, respectively; 14 serious adverse events occurred in the surgical arm and nine in the medical management arm. On average, septoplasty was more costly and more effective in improving Sino-nasal Outcome Test-22 items scores and quality-adjusted life-years than medical management, but incurred a larger number of adverse events. Septoplasty had a 15% probability of being considered cost-effective at 12 months at a £20,000 willingness-to-pay threshold for an additional quality-adjusted life-year. This probability increased to 99% and 100% at 24 and 36 months, respectively. Limitations COVID-19 had an impact on participant-facing data collection from March 2020. Conclusions Septoplasty, with or without turbinate reduction, is more effective than medical management with a nasal steroid and saline spray. Baseline severity predicts the degree of improvement in symptoms. Septoplasty has a low probability of cost-effectiveness at 12 months, but may be considered cost-effective at 24 months. Future work should focus on developing a septoplasty patient decision aid. Trial registration This trial is registered as ISRCTN16168569 and EudraCT 2017-000893-12. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/226/07) and is published in full in Health Technology Assessment; Vol. 28, No. 10. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Sean Carrie
- Ear, Nose and Throat Department, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
- Honorary affiliation with Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tony Fouweather
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tara Homer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - James O'Hara
- Ear, Nose and Throat Department, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Nikki Rousseau
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Leila Rooshenas
- Bristol Population Health Science Institute, University of Bristol, Bristol, UK
| | - Alison Bray
- Honorary affiliation with Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Northern Medical Physics and Clinical Engineering, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Laura Ternent
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Katherine Rennie
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Emma Clark
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Nichola Waugh
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Alison J Steel
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Jemima Dooley
- Centre for Academic Primary Care, University of Bristol, Bristol, UK
| | - Michael Drinnan
- Honorary affiliation with Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- Northern Medical Physics and Clinical Engineering, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - David Hamilton
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Kelly Lloyd
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Yemi Oluboyede
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Caroline Wilson
- Bristol Population Health Science Institute, University of Bristol, Bristol, UK
| | - Quentin Gardiner
- Ear, Nose and Throat Department, Ninewells Hospital, NHS Tayside, Dundee, UK
| | - Naveed Kara
- Ear, Nose and Throat Department, Darlington Memorial Hospital, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Sadie Khwaja
- Ear, Nose and Throat Department, Manchester Royal Infirmary, Manchester University Foundation NHS Trust, Manchester, UK
| | - Samuel Chee Leong
- Ear, Nose and Throat Department, Aintree Hospital, Aintree University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Sangeeta Maini
- Ear, Nose and Throat Department, Aberdeen Royal Infirmary, NHS Grampian, Aberdeen, UK
| | | | - Paul Nix
- Ear, Nose and Throat Department, Leeds General Infirmary, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Janet A Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - M Dawn Teare
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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O'Leary AB, Scally A, Moore N, Maiorino-Groeneveld C, McEntee MF. Radiographers' knowledge and attitudes toward dementia. Radiography (Lond) 2023; 29:456-461. [PMID: 36827791 DOI: 10.1016/j.radi.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 01/19/2023] [Accepted: 02/08/2023] [Indexed: 02/24/2023]
Abstract
INTRODUCTION Dementia is a syndrome associated with a decline in brain function, impacting how we speak, think, feel, and behave. Misunderstanding of dementia and how it affects patients and their carers is common. There is limited research on how radiographers provide adequate care to those with dementia. Radiographers with knowledge and positive attitudes can reduce stigma and fear, improving the quality of care. This study aimed to assess radiographers' knowledge and attitudes towards dementia. METHODS A cohort of registered radiographers in Ireland participated in an online survey. Two pre-existing validated questionnaires: The Alzheimer's Disease Knowledge Scale (ADKS) and the Dementia Attitudes Scale (DAS), assessed radiographers' knowledge and attitudes towards dementia and people with dementia. Scores were compared across variables such as gender, age, grade, qualification, work setting, and the number of years qualified. RESULTS A total of 123 radiographers responded. Knowledge scores did not significantly differ across demographic groups (p > 0.05). Total knowledge scores ranged from 60% to 100%. Total attitude scores ranged from 50% to 100%. Participants with a BSc, MSc, and other post-graduate degrees scored higher on the attitude scale than those with a diploma qualification (p = 0.027). Those with less than 20 years' experience scored higher than those with more. Knowledge had little correlation with attitude (r = 0.0522; p = 0.5667). CONCLUSION Findings indicate variations in attitudes linked to age and experience, and some misconceptions can be observed across varying groups. Interventions to improve attitudes and raise awareness are needed. IMPLICATIONS FOR PRACTICE There is a need for further research and education on dementia care in the imaging department. We have identified areas requiring further education.
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Affiliation(s)
- A B O'Leary
- The Discipline of Medical Imaging and Radiation Therapy, Brookfield Science Building, University College Cork, College Road, Cork, T12 AK54, Ireland
| | - A Scally
- The Discipline of Medical Imaging and Radiation Therapy, Brookfield Science Building, University College Cork, College Road, Cork, T12 AK54, Ireland
| | - N Moore
- The Discipline of Medical Imaging and Radiation Therapy, Brookfield Science Building, University College Cork, College Road, Cork, T12 AK54, Ireland
| | - C Maiorino-Groeneveld
- The Discipline of Medical Imaging and Radiation Therapy, Brookfield Science Building, University College Cork, College Road, Cork, T12 AK54, Ireland
| | - M F McEntee
- The Discipline of Medical Imaging and Radiation Therapy, Brookfield Science Building, University College Cork, College Road, Cork, T12 AK54, Ireland.
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Bamford C, Wilcock J, Brunskill G, Wheatley A, Harrison Dening K, Manthorpe J, Allan L, Banerjee S, Booi L, Griffiths S, Rait G, Walters K, Robinson L. Improving primary care based post-diagnostic support for people living with dementia and carers: Developing a complex intervention using the Theory of Change. PLoS One 2023; 18:e0283818. [PMID: 37134099 PMCID: PMC10155958 DOI: 10.1371/journal.pone.0283818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/17/2023] [Indexed: 05/04/2023] Open
Abstract
BACKGROUND The need to improve support following a diagnosis of dementia is widely recognised, but it is unclear how this can best be achieved within UK health and social care systems. A task-shared and task-shifted approach has been recommended, but there is limited guidance on how to achieve this in practice. As part of a programme of research, we developed an intervention to enhance the role of primary care in post-diagnostic care and support for people living with dementia and carers. METHODS We used the Theory of Change to develop a complex intervention informed by initial literature reviews and qualitative work. The intervention was developed through an iterative series of workshops, meetings and task groups with a range of stakeholders, including the multidisciplinary project team, people living with dementia and carers, service managers, frontline practitioners, and commissioners. RESULTS 142 participants contributed to intervention development through face-to-face or virtual meetings. The intervention comprises three complementary strands of work focusing on: developing systems, delivering tailored care and support, and building capacity and capability. Clinical dementia leads, based in primary care networks, will facilitate the intervention providing tailored expertise and support. CONCLUSION The Theory of Change proved useful in providing structure and engaging stakeholders. The process was challenging, took longer and was less participative than intended due to restrictions caused by the COVID-19 pandemic. We will next conduct a feasibility and implementation study to explore whether the intervention can be successfully delivered within primary care. If successful, the intervention offers practical strategies for delivering a task-shared and task-shifted approach to post-diagnostic support that could be adapted for similar health and social care contexts internationally.
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Affiliation(s)
- Claire Bamford
- Population Health Sciences Institute, Faculty of Medical Sciences, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Jane Wilcock
- Research Department of Primary Care & Population Health, University College London, London, United Kingdom
| | - Greta Brunskill
- Voluntary Organisations Network North East, Newcastle, United Kingdom
| | - Alison Wheatley
- Population Health Sciences Institute, Faculty of Medical Sciences, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Jill Manthorpe
- NIHR Policy Research Unit in Health and Social Care Workforce, The Policy Institute at King's, King's College London, London, United Kingdom
| | - Louise Allan
- South Cloisters, University of Exeter, Exeter, United Kingdom
| | - Sube Banerjee
- Faculty of Health, University of Plymouth, Plymouth, United Kingdom
| | - Laura Booi
- Centre for Dementia Research, Leeds Beckett University, Leeds, United Kingdom
| | - Sarah Griffiths
- Research Department of Primary Care & Population Health, University College London, London, United Kingdom
| | - Greta Rait
- Research Department of Primary Care & Population Health, University College London, London, United Kingdom
| | - Kate Walters
- Research Department of Primary Care & Population Health, University College London, London, United Kingdom
| | - Louise Robinson
- Population Health Sciences Institute, Faculty of Medical Sciences, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne, United Kingdom
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Reuland C, Shi G, Deatras M, Ang M, Evangelista PPG, Shilkofski N. A qualitative study of barriers and facilitators to pediatric early warning score (PEWS) implementation in a resource-limited setting. Front Pediatr 2023; 11:1127752. [PMID: 37009287 PMCID: PMC10050749 DOI: 10.3389/fped.2023.1127752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 02/06/2023] [Indexed: 04/04/2023] Open
Abstract
Objectives Globally, pediatric hospitals have implemented Pediatric Early Warning Scores (PEWS) to standardize escalation of care and improve detection of clinical deterioration in pediatric patients. This study aims to utilize qualitative methodology to understand barriers and facilitators of PEWS implementation at Philippine Children's Medical Center (PCMC), a tertiary care hospital in Manila, Philippines. Methods Semi-structured interviews querying current processes for clinical monitoring, Pediatric Intensive Care Unit (PICU) transfer, and clinician attitudes towards PEWS implementation were audio recorded. In-person hospital observations served to triangulate interview findings. The Systems Engineering Initiative for Patient Safety (SEIPS) framework guided content coding of interviews to characterize work systems, processes, and outcomes related to patient monitoring and care escalation. Thematic coding was performed using Dedoose software. This model allowed identification of barriers and facilitators to PEWS implementation. Results Barriers within PCMC workflow included: limited bed capacity, delay in referral, patient overflow, limited monitoring equipment, and high patient to staff ratio. Facilitators of PEWS implementation included support for PEWS adaptation and existence of systems for vital sign monitoring. Observations by study personnel confirmed validity of themes. Conclusion Utilizing qualitative methodology to understand barriers and facilitators to PEWS in specific contexts can guide implementation at resource-limited hospitals.
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Affiliation(s)
- Carolyn Reuland
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
- Correspondence: Carolyn Reuland
| | - Galen Shi
- Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Mark Deatras
- Philippine Children’s Medical Center Department of Pediatric Critical Care, Quezon, Philippines
| | - Mellinor Ang
- Philippine Children’s Medical Center Department of Pediatric Critical Care, Quezon, Philippines
| | | | - Nicole Shilkofski
- Johns Hopkins University School of Medicine Department of Pediatrics, Baltimore, MD, United States
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Couturier Y, Lanoue S, Karam M, Guillette M, Hudon C. Social workers coordination in primary healthcare for patients with complex needs: A scoping review. INTERNATIONAL JOURNAL OF CARE COORDINATION 2022. [DOI: 10.1177/20534345221122952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction Care coordination has been part of social work for some time. It has been recognized as contributing to care coordination for long-term care for the elderly and mental health but less is known about their contribution in primary care with patients with complex health and social needs. As social workers are increasingly present in primary healthcare, this scoping review aims to provide a synthesis of social workers’ coordination activities for patients with complex needs in primary healthcare. Methods CINAHL, Medline, Scopus, SocioIndex, Social Work Abstracts, and ProQuest databases were searched, from 2004 to 2020 for peer-reviewed literature. A thematic analysis using deductive and inductive approaches was used to conduct this scoping review. Results Eighteen studies on 11 different care coordination interventions were included. The care coordination activities have been classified into four categories: 1) activities that target the patient, family, and caregivers; 2) activities that target health and social care professionals and services; 3) activities that link the patient and family with health and social professionals and services; and 4) cross-cutting activities that support and enhance other activity. Discussion A variety of care coordination interventions conducted by social workers were identified, all of which included related but different activities. Still, the common aim is to reduce fragmentation of care. Social workers, because of their disciplinary skills characterized by linkages to nonmedical services, can make a significant contribution to the coordination of care in primary health care, in collaboration with nurses.
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Affiliation(s)
- Yves Couturier
- Department of Social Work, University of Sherbrooke, Sherbrooke, Québec, Canada
| | - Sèverine Lanoue
- Department of Education, University of Sherbrooke, Sherbrooke, Québec, Canada
| | - Marlène Karam
- Faculty of Nursing, University of Montréal, Montréal, Québec, Canada
| | - Maxime Guillette
- Department of Education, University of Sherbrooke, Sherbrooke, Québec, Canada
| | - Catherine Hudon
- Family Medicine and Emergency Medicine Department, Université de Sherbrooke, Sherbrooke, Québec, Canada
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Jerez-Barranco D, Gutiérrez-Rodríguez L, Morilla-Herrera JC, Cuevas Fernandez-Gallego M, Rojano-Perez R, Camuñez-Gomez MD, Sanchez-Del Campo JL, García-Mayor S. Components of case management in caring for patients with dementia: a mixed-methods study. BMC Nurs 2022; 21:163. [PMID: 35739550 PMCID: PMC9219194 DOI: 10.1186/s12912-022-00935-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 06/10/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Case management has shown improvements in some health outcomes for dementia patients and their families. However, despite its benefits the components of case management in order to provide effective patient and family care remain unknown at present. Thus, the aim of this study is to identify the specific components of case management in caring for patients with dementia and to determine the necessary intensity of its deployment to enhance outcomes for these patients and their caregivers. METHODS Mixed-methods study with a qualitative phase to characterise forms of service provision, according to the case management components involved, followed by a quantitative phase to analyse the correlations between different patterns of service provision, adverse events in patients and caregiver overload. This study will be based on the variables described in the RANGE.COM register. DISCUSSION This research is expected to achieve a reproducible, evaluable set of interventions that can be modelled to optimise case management effectiveness for patients with dementia. Interactions between patients with dementia, their family caregivers and case management healthcare services, the components of these interactions and their association with the conditions of the individuals concerned are issues of great interest in the field of case management, which is constantly evolving.
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Affiliation(s)
- Desirée Jerez-Barranco
- Faculty of Health Sciences, Department of Nursing (Spain), University of Málaga, C/Arquitecto Francisco Peñalosa, 3, Campus Universitario de Teatinos, 29071, Málaga, Spain
- Andalusian Health Service, District Costa del Sol, Málaga, Spain
| | - Laura Gutiérrez-Rodríguez
- Faculty of Health Sciences, Department of Nursing (Spain), University of Málaga, C/Arquitecto Francisco Peñalosa, 3, Campus Universitario de Teatinos, 29071, Málaga, Spain.
- Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain.
| | - Juan Carlos Morilla-Herrera
- Faculty of Health Sciences, Department of Nursing (Spain), University of Málaga, C/Arquitecto Francisco Peñalosa, 3, Campus Universitario de Teatinos, 29071, Málaga, Spain
- Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain
- Andalusian Health Service, District Málaga-Guadalhorce, Málaga, Spain
| | - Magdalena Cuevas Fernandez-Gallego
- Faculty of Health Sciences, Department of Nursing (Spain), University of Málaga, C/Arquitecto Francisco Peñalosa, 3, Campus Universitario de Teatinos, 29071, Málaga, Spain
- Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain
- Andalusian Health Service, District Málaga-Guadalhorce, Málaga, Spain
| | | | | | | | - Silvia García-Mayor
- Faculty of Health Sciences, Department of Nursing (Spain), University of Málaga, C/Arquitecto Francisco Peñalosa, 3, Campus Universitario de Teatinos, 29071, Málaga, Spain
- Institute of Biomedical Research in Malaga (IBIMA), Málaga, Spain
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May CR, Albers B, Bracher M, Finch TL, Gilbert A, Girling M, Greenwood K, MacFarlane A, Mair FS, May CM, Murray E, Potthoff S, Rapley T. Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development. Implement Sci 2022; 17:19. [PMID: 35193611 PMCID: PMC8861599 DOI: 10.1186/s13012-022-01191-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2021] [Accepted: 01/18/2022] [Indexed: 04/03/2023] Open
Abstract
Background Normalisation Process Theory (NPT) is frequently used to inform qualitative research that aims to explain and evaluate processes that shape late-stage translation of innovations in the organisation and delivery of healthcare. A coding manual for qualitative researchers using NPT will facilitate transparent data analysis processes and will also reduce the cognitive and practical burden on researchers. Objectives (a) To simplify the theory for the user. (b) To describe the purposes, methods of development, and potential application of a coding manual that translates normalisation process theory (NPT) into an easily usable framework for qualitative analysis. (c) To present an NPT coding manual that is ready for use. Method Qualitative content analysis of papers and chapters that developed normalisation process theory, selection and structuring of theory constructs, and testing constructs against interview data and published empirical studies using NPT. Results A coding manual for NPT was developed. It consists of 12 primary NPT constructs and conforms to the Context-Mechanism-Outcome configuration of realist evaluation studies. Contexts are defined as settings in which implementation work is done, in which strategic intentions, adaptive execution, negotiating capability, and reframing organisational logics are enacted. Mechanisms are defined as the work that people do when they participate in implementation processes and include coherence-building, cognitive participation, collective action, and reflexive monitoring. Outcomes are defined as effects that make visible how things change as implementation processes proceed and include intervention mobilisation, normative restructuring, relational restructuring, and sustainment. Conclusion The coding manual is ready to use and performs three important tasks. It consolidates several iterations of theory development, makes the application of NPT simpler for the user, and links NPT constructs to realist evaluation methods. The coding manual forms the core of a translational framework for implementation research and evaluation. Supplementary Information The online version contains supplementary material available at 10.1186/s13012-022-01191-x.
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May CR, Albers B, Bracher M, Finch TL, Gilbert A, Girling M, Greenwood K, MacFarlane A, Mair FS, May CM, Murray E, Potthoff S, Rapley T. Translational framework for implementation evaluation and research: a normalisation process theory coding manual for qualitative research and instrument development. Implement Sci 2022. [PMID: 35193611 DOI: 10.1186/s13012-022-01191-x.pmid:35193611;pmcid:pmc8861599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/19/2023] Open
Abstract
BACKGROUND Normalisation Process Theory (NPT) is frequently used to inform qualitative research that aims to explain and evaluate processes that shape late-stage translation of innovations in the organisation and delivery of healthcare. A coding manual for qualitative researchers using NPT will facilitate transparent data analysis processes and will also reduce the cognitive and practical burden on researchers. OBJECTIVES (a) To simplify the theory for the user. (b) To describe the purposes, methods of development, and potential application of a coding manual that translates normalisation process theory (NPT) into an easily usable framework for qualitative analysis. (c) To present an NPT coding manual that is ready for use. METHOD Qualitative content analysis of papers and chapters that developed normalisation process theory, selection and structuring of theory constructs, and testing constructs against interview data and published empirical studies using NPT. RESULTS A coding manual for NPT was developed. It consists of 12 primary NPT constructs and conforms to the Context-Mechanism-Outcome configuration of realist evaluation studies. Contexts are defined as settings in which implementation work is done, in which strategic intentions, adaptive execution, negotiating capability, and reframing organisational logics are enacted. Mechanisms are defined as the work that people do when they participate in implementation processes and include coherence-building, cognitive participation, collective action, and reflexive monitoring. Outcomes are defined as effects that make visible how things change as implementation processes proceed and include intervention mobilisation, normative restructuring, relational restructuring, and sustainment. CONCLUSION The coding manual is ready to use and performs three important tasks. It consolidates several iterations of theory development, makes the application of NPT simpler for the user, and links NPT constructs to realist evaluation methods. The coding manual forms the core of a translational framework for implementation research and evaluation.
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Affiliation(s)
- Carl R May
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine & NIHR North Thames ARC, London, UK.
| | - Bianca Albers
- Institute for Implementation Science in Healthcare, Zurich, Switzerland
| | - Mike Bracher
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Tracy L Finch
- Department of Nursing, Midwifery & Health, Northumbria University & NIHR ARC North East-North Cumbria, Newcastle, UK
| | - Anthony Gilbert
- Royal National Orthopaedic Hospital, London & NIHR North Thames ARC, London, UK
| | - Melissa Girling
- Department of Nursing, Midwifery & Health, Northumbria University & NIHR ARC North East-North Cumbria, Newcastle, UK
| | | | - Anne MacFarlane
- School of Medicine and Health Research Institute, University of Limerick, Limerick, Ireland
| | - Frances S Mair
- Institute of Health and Wellbeing, Glasgow University, Glasgow, UK
| | | | - Elizabeth Murray
- Research Department of Primary Care and Population Health, University College London & NIHR North Thames ARC, London, UK
| | - Sebastian Potthoff
- Department of Social Work, Education and Community Wellbeing, Northumbria University & NIHR ARC North East- North Cumbria, Newcastle, UK
| | - Tim Rapley
- Department of Social Work, Education and Community Wellbeing, Northumbria University & NIHR ARC North East- North Cumbria, Newcastle, UK
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Michalko D, Plichtová J, Šestáková A. Network analysis approach for exploring dementia representations in the Slovak media. DEMENTIA 2022; 21:781-793. [DOI: 10.1177/14713012211054971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objectives The aim of the present study is to test the network analysis method on a corpus of media texts with the aim of systematically analysing media representations of dementia in the Slovak media. Methods A word-network was modelled from the corpus of media documents using social network analysis. 244 text-documents (web, print, TV and radio) from 2015 to 2018 (inclusive) were retrieved from the Newton media database using the search words ‘dementia’ and ‘Alzheimer’s disease’. Results Twelve clusters of co-occurring concepts corresponding to individual themes were identified. The results of the analysis provide evidence that biomedical themes such as ‘medical diagnosis’, ‘prevalence of dementia’ and ‘memory disorders’ possess the greatest representational strength and centrality and account for roughly two-thirds of the whole corpus. Conclusion Results of the present study provide valuable insights into the representation of dementia in the Slovak media but also demonstrate how media representations can be studied using the innovative approach of network analysis.
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Affiliation(s)
- Drahomír Michalko
- Department of Behavioural Neuroscience, Centre of Experimental Medicine, Slovak Academy of Sciences, Bratislava, Slovak Republic
| | - Jana Plichtová
- Faculty of Social and Economic Sciences, Institute of Applied Psychology, University of Comenius, Bratislava, Slovak Republic,
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Needs Detection for Carers of Family Members with Dementia. Healthcare (Basel) 2021; 10:healthcare10010045. [PMID: 35052209 PMCID: PMC8775551 DOI: 10.3390/healthcare10010045] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 12/20/2021] [Accepted: 12/24/2021] [Indexed: 11/29/2022] Open
Abstract
Aim: To determine the perceived needs of carers of non-institutionalized family members that suffer from dementia. Methods: Two-steps qualitative study by focus groups of relatives in three centres of different characteristics from the Girona Health Region (step 1) and two in-depth interviews with significant professionals in dementia care (step 2). The analysis was performed based on the interpretation of the transcribed data and the bottom-up coding of categories and themes. The information was triangulated and coding was agreed upon. Results: There were three groups, 26 main carers of community-dwelling relatives with dementia in step 1 and two in-depth interviews with dementia-specialised healthcare and social care professionals in step 2. The demands were categorised according to three main themes: whether they were addressed to the members of care services for more direct and close care, to the agencies for a better joint working and less fragmented system, or to society for better comprehension and social recognition. We emphasize the need for a consultation-liaison reference figure throughout the process both for aspects of greater efficiency in the management of resources and for greater empowerment of carers.
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Frost R, Rait G, Aw S, Brunskill G, Wilcock J, Robinson L, Knapp M, Hogan N, Harrison Dening K, Allan L, Manthorpe J, Walters K. Implementing post diagnostic dementia care in primary care: a mixed-methods systematic review. Aging Ment Health 2021; 25:1381-1394. [PMID: 32911966 DOI: 10.1080/13607863.2020.1818182] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVES Concentrating post-diagnostic dementia care in primary care may lead to better and more cost-effective care closer to home. We aimed to assess which intervention components and contextual factors may contribute to the successful delivery and implementation of primary care-led post-diagnostic dementia care. METHODS Mixed-methods systematic review. We searched five databases (inception-March 2019) with reference list screening and citation tracking. We included studies evaluating post-diagnostic dementia care interventions where primary care had a significant role in dementia care, which assessed one or more implementation elements (acceptability, feasibility, adoption, sustainability, reach, costs, appropriateness or fidelity). Two authors independently critically appraised studies. RESULTS Out of 4528 unique references, we screened 380 full texts and included 49 evaluations of services collecting implementation process data. Most services had high acceptability ratings. The most acceptable components were information provision, social and emotional support and links to community organisations. Feasibility was chiefly influenced by provider engagement and leadership, building dementia care capacity, sufficient resources/funding and collaboration. Care quality was maximised through adding capacity from a dementia-specific health professional. On the basis of limited data, costs for various primary care-led models did not substantially differ from each other. CONCLUSION A range of primary care-led dementia care models appear feasible and acceptable. Future services should: add dementia-focussed health professionals into primary care, develop primary care leadership and provide sufficient funding and collaboration opportunities. Information, community service links and social and ongoing support should be part of services. Further exploration of service reach and formalised fidelity assessment are needed.
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Affiliation(s)
- Rachael Frost
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Greta Rait
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Su Aw
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
| | - Greta Brunskill
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Jane Wilcock
- Research Department of Primary Care and Population Health, University College London, London, UK
| | - Louise Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, UK
| | - Martin Knapp
- 4Care Policy and Evaluation Centre (CPEC), Department of Health Policy, London School of Economics and Political Science, London, UK
| | - Nicole Hogan
- 4Care Policy and Evaluation Centre (CPEC), Department of Health Policy, London School of Economics and Political Science, London, UK
| | | | - Louise Allan
- Institute of Health Research, University of Exeter Medical School, Exeter, UK
| | - Jill Manthorpe
- NIHR Policy Research Unit on Health and Social Care Workforce, Kings College London, London, UK
| | - Kate Walters
- Research Department of Primary Care and Population Health, University College London, London, UK
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12
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Smith R, Martin A, Wright T, Hulbert S, Hatzidimitriadou E. Integrated dementia care: A qualitative evidence synthesis of the experiences of people living with dementia, informal carers and healthcare professionals. Arch Gerontol Geriatr 2021; 97:104471. [PMID: 34289415 DOI: 10.1016/j.archger.2021.104471] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 06/17/2021] [Accepted: 06/25/2021] [Indexed: 11/18/2022]
Abstract
BACKGROUND In order to provide improved care provision, integrated care services are being developed. However, little is known about how people living with dementia, their families and healthcare professionals experience integrated care. Therefore, the purpose of this review of the qualitative literature was to examine the experiences and perceptions of integrated dementia care. METHODS This qualitative review synthesised findings from included studies identified from a comprehensive literature search. Searches included: five electronic databases, journal handsearching, and reference list searching of relevant literature reviews and the final included studies. FINDINGS Three overarching themes were identified: 1) Ways of working which facilitate the delivery of integrated dementia care; 2) Informal carers as equal partners in care provision and decision making; and 3) Challenges leading to fragmented and disjointed integrated dementia care. For integrated care to be successful, communication and collaboration between healthcare professionals, and the involvement of informal carers is needed. Multidisciplinary teams and employing case managers to coordinate care provision can improve communication and collaboration. However, distrust between healthcare professionals and a lack of a central database to access and share information often hinders the development of integrated dementia care service provision. CONCLUSION Integrated dementia care can be successful and well received by people living with dementia and their families when certain conditions are met. However, given the negative consequences fragmented and disjointed care can have on people living with dementia and their families, action is needed to further support the development of integrated dementia care services.
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Affiliation(s)
- Raymond Smith
- Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, North Holmes Road, Canterbury, Kent, CT1 1QU, UK.
| | - Anne Martin
- Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, North Holmes Road, Canterbury, Kent, CT1 1QU, UK.
| | - Toni Wright
- Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, North Holmes Road, Canterbury, Kent, CT1 1QU, UK.
| | - Sabina Hulbert
- Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, North Holmes Road, Canterbury, Kent, CT1 1QU, UK.
| | - Eleni Hatzidimitriadou
- Faculty of Medicine, Health and Social Care, Canterbury Christ Church University, North Holmes Road, Canterbury, Kent, CT1 1QU, UK.
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13
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Gibson C, Goeman D, Pond D. What is the role of the practice nurse in the care of people living with dementia, or cognitive impairment, and their support person(s)?: a systematic review. BMC FAMILY PRACTICE 2020; 21:141. [PMID: 32660419 PMCID: PMC7359614 DOI: 10.1186/s12875-020-01177-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Accepted: 05/28/2020] [Indexed: 01/09/2023]
Abstract
Background The potential value of expanding the Practice Nurse role to include the recognition and management of dementia has been acknowledged. Practice Nurses are well-positioned to provide comprehensive dementia information and support so that people living with dementia are better equipped to self-manage their health and live well with dementia. The purpose of this review was to systematically examine published literature to identify existing and potential roles of Practice Nurse’s in the delivery of care to people affected by dementia and to describe the characteristics and effectiveness of nurse interventions in dementia models of care. Methods The PRISMA statement guided the systematic review of the quantitative and qualitative evidence for roles and characteristics of the Practice Nurse in the delivery of dementia care. A comprehensive literature search of seven electronic databases and Google scholar identified relevant original research published in English between January 2000 and January 2019. Thirteen articles met the inclusion criteria and were extracted into the Covidence software for analysis. Results The heterogeneity of the included studies purpose, design and outcomes measures and the diversity in health systems and primary care nurses scope of practice made it difficult to synthesise the findings and draw conclusions. The heterogeneity did, however, provide important insights into the characteristics of roles undertaken by nurses working in the general practice setting, which were potentially beneficial to people living with dementia and their support person. These included patient accessibility to the Practice Nurse, early recognition and management of cognitive changes, care management and collaboration with the General Practitioner. Limitations of the provision of dementia care by Practice Nurses included a lack of definition of the role, inadequate dementia specific training, time constraints and poor communication with General Practitioners. Conclusions Embedding an evidence-based model that describes the role of the Practice Nurse in dementia care provision has the potential to increase early recognition of cognitive impairment and more appropriate primary care management of dementia. Systematic review registration PROSPERO 2018 CRD42018088191.
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Affiliation(s)
- Caroline Gibson
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.
| | - Dianne Goeman
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia.,Central Clinical School, Monash University; Kolling Institute, the University of Sydney, Sydney, Australia
| | - Dimity Pond
- Faculty of Health and Medicine, School of Medicine and Public Health, University of Newcastle, Callaghan, Australia
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Wang M, Xu X, Huang Y, Shao S, Chen X, Li J, Du J. Knowledge, attitudes and skills of dementia care in general practice: a cross-sectional study in primary health settings in Beijing, China. BMC FAMILY PRACTICE 2020; 21:89. [PMID: 32416731 PMCID: PMC7231407 DOI: 10.1186/s12875-020-01164-3] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 05/10/2020] [Indexed: 12/25/2022]
Abstract
Background General practitioners (GPs) play a significant role in dementia care. However, the knowledge and attitudes of them towards dementia care are poorly characterized. The present study aimed to investigate GPs’ knowledge, attitudes and skills of dementia care in primary health settings in Beijing. Methods A cross-sectional survey was conducted in 27 community health service centers (CHSCs) in Beijing. The GPs’ knowledge, attitudes and skills were assessed utilizing the Alzheimer’s Disease Knowledge Scale (ADKS), Dementia Care Attitude Scale (DCAS) and self-designed questionnaire, respectively. Results A total of 341 participants returned the questionnaire. The overall mean score of GPs’ dementia knowledge measured by the ADKS was 21.42 (SD = 2.73) out of 30 (71.4%), GPs’ attitudes to dementia care was 36.25 (SD = 5.12) out of 50 (72.5%), and GPs’ self-confidence on dementia care skills was 53.93 (SD = 9.57) out of 75 (71.9%). GPs’ overall knowledge towards dementia care was limited and the attitudes were generally positive. They had low level recognition of their roles towards dementia care. The majority of GPs believed that dementia care was within a specialist’s domain not that of general practice. Conclusion GPs demonstrate low levels of dementia knowledge and skills, but express generally positive attitudes towards dementia in this study. It is much needed to translate detailed dementia care handbook, and adequate dementia knowledge training for GPs into practice to improve care outcomes for people with dementia in China. In addition, dementia management should be covered in the national basic package of public health services in primary care.
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Affiliation(s)
- Meirong Wang
- School of General Practice and Continuing Education, Capital Medical University, No. 10, You An Men Wai Xi Tou Tiao, Beijing, 100069, China
| | - Xiaojingyuan Xu
- School of General Practice and Continuing Education, Capital Medical University, No. 10, You An Men Wai Xi Tou Tiao, Beijing, 100069, China
| | - Yafang Huang
- School of General Practice and Continuing Education, Capital Medical University, No. 10, You An Men Wai Xi Tou Tiao, Beijing, 100069, China
| | - Shuang Shao
- School of General Practice and Continuing Education, Capital Medical University, No. 10, You An Men Wai Xi Tou Tiao, Beijing, 100069, China
| | - Xiaolei Chen
- School of General Practice and Continuing Education, Capital Medical University, No. 10, You An Men Wai Xi Tou Tiao, Beijing, 100069, China
| | - Jing Li
- Dongfeng Community Health Service Center, Chaoyang district, Nan Shi Li Ju, Beijing, 100016, China.
| | - Juan Du
- School of General Practice and Continuing Education, Capital Medical University, No. 10, You An Men Wai Xi Tou Tiao, Beijing, 100069, China.
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15
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Norrie C, Woolham J, Samsi K, Manthorpe J. Skill mix: The potential for personal assistants to undertake health-related tasks for people with personal health budgets. HEALTH & SOCIAL CARE IN THE COMMUNITY 2020; 28:922-931. [PMID: 31854059 DOI: 10.1111/hsc.12923] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Revised: 10/17/2019] [Accepted: 11/25/2019] [Indexed: 06/10/2023]
Abstract
Personal health budgets (PHBs) are being promoted in England as expanding the benefits of choice and control to individuals with healthcare needs. National Health Service (NHS) money is provided to eligible people to use as set out in approved care plans, including direct employment of personal assistants (PAs). The government plans to increase NHS-funded PHBs and to further introduce integrated personal budgets (IPBs). This potentially creates more demand for directly employed or self-employed PAs with health-related skills. The objective of this paper is to report findings from interviews with PAs (n = 105) and key informants (n = 26) from across England, undertaken between October 2016 and August 2017, about the potential for the PA workforce to undertake 'health-related' tasks as facilitated by the introduction of PHBs. PAs were purposefully recruited to ensure the sample included participants from different geographical locations. Key informants were purposefully selected based on their knowledge of policy and community services. Data were analysed quantitatively and qualitatively. This paper focuses on reporting qualitative findings, which are set within the theoretical framework of normalisation process theory to explore implementation challenges of PHBs. The majority (64%) of PAs confirmed that they saw their current roles as congruent with PHBs, were willing to engage with PHBs and undertake health-related tasks. However, 74% of PAs said they would need additional training if enacting such roles. Key informant interviews appraised the development of PHBs as complex, noting incongruences arising from NHS and social care-funded PAs carrying out similar roles within different organisational systems. We conclude the current PA workforce is willing to take on PHB work and is likely to interweave this with work funded by PBs and self-funding care users. Implications include the need for careful consideration of training requirements and delivery for PHB-funded PAs.
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Affiliation(s)
- Caroline Norrie
- Health and Social Care Workforce Research Unit, The Policy Institute, King's College London, London, UK
| | - John Woolham
- Health and Social Care Workforce Research Unit, The Policy Institute, King's College London, London, UK
| | - Kritika Samsi
- Health and Social Care Workforce Research Unit, The Policy Institute, King's College London, London, UK
| | - Jill Manthorpe
- Health and Social Care Workforce Research Unit, The Policy Institute, King's College London, London, UK
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16
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Iliffe S, Gallo JJ. Perspectives From the Primary Care Setting on Managing Dementia: Commentary on Heintz et al. American Journal of Geriatric Psychiatry. Am J Geriatr Psychiatry 2020; 28:334-336. [PMID: 31606275 DOI: 10.1016/j.jagp.2019.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/09/2019] [Indexed: 10/26/2022]
Affiliation(s)
- Steve Iliffe
- Research Department of Primary Care & Population Health (SI), University College London, United Kingdom
| | - Joseph J Gallo
- Department of Mental Health (JJG), Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD.
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17
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Mann C, Shaw ARG, Guthrie B, Wye L, Man MS, Chaplin K, Salisbury C. Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice: mixed-methods process evaluation. BMJ Open 2019; 9:e031438. [PMID: 31699734 PMCID: PMC6858134 DOI: 10.1136/bmjopen-2019-031438] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES During a cluster randomised trial, (the 3D study) of an intervention enacting recommended care for people with multimorbidity, including continuity of care and comprehensive biennial reviews, we examined implementation fidelity to interpret the trial outcome and inform future implementation decisions. DESIGN Mixed-methods process evaluation using cross-trial data and a sample of practices, clinicians, administrators and patients. Interviews, focus groups and review observations were analysed thematically and integrated with quantitative data about implementation. Analysis was blind to trial outcomes and examined context, intervention adoption, reach and maintenance, and delivery of reviews to patients. SETTING Thirty-three UK general practices in three areas. PARTICIPANTS The trial included 1546 people with multimorbidity. 11 general practitioners, 14 nurses, 7 administrators and 38 patients from 9 of 16 intervention practices were sampled for an interview. RESULTS Staff loss, practice size and different administrative strategies influenced implementation fidelity. Practices with whole administrative team involvement and good alignment between the intervention and usual care generally implemented better. Fewer reviews than intended were delivered (49% of patients receiving both intended reviews, 30% partially reviewed). In completed reviews >90% of intended components were delivered, but review observations and interviews with patients and clinicians found variation in style of component delivery, from 'tick-box' to patient-centred approaches. Implementation barriers included inadequate skills training to implement patient-centred care planning, but patients reported increased patient-centredness due to comprehensive reviews, extra time and being asked about their health concerns. CONCLUSIONS Implementation failure contributed to lack of impact of the 3D intervention on the trial primary outcome (quality of life), but so did intervention failure since modifiable elements of intervention design were partially responsible. When a decisive distinction between implementation failure and intervention failure cannot be made, identifying potentially modifiable reasons for suboptimal implementation is important to enhance potential for impact and effectiveness of a redesigned intervention. TRIAL REGISTRATION NUMBER ISRCTN06180958.
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Affiliation(s)
- Cindy Mann
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Ali R G Shaw
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Bruce Guthrie
- Division of Population Health Sciences, University of Dundee, Dundee, UK
| | - Lesley Wye
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Mei-See Man
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Katherine Chaplin
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
| | - Chris Salisbury
- Centre for Academic Primary Care, School of Population Health Sciences, University of Bristol, Bristol, UK
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18
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Jones S, Hamilton S, Bell R, Araújo-Soares V, Glinianaia SV, Milne EMG, White M, Willmore M, Shucksmith J. What helped and hindered implementation of an intervention package to reduce smoking in pregnancy: process evaluation guided by normalization process theory. BMC Health Serv Res 2019; 19:297. [PMID: 31072363 PMCID: PMC6509824 DOI: 10.1186/s12913-019-4122-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Accepted: 04/24/2019] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Smoking in pregnancy causes harm to mother and baby. Despite evidence from trials of what helps women quit, implementation in the real world has been hard to achieve. An evidence-based intervention, babyClear©, involving staff training, universal carbon monoxide monitoring, opt-out referral to smoking cessation services, enhanced follow-up protocols and a risk perception tool was introduced across North East England. This paper presents the results of the qualitative analyses, reporting acceptability of the system changes to staff, as well as aids and hindrances to implementation and normalization of this complex intervention. METHODS Process evaluation was used to complement an effectiveness study. Interviews with maternity and smoking cessation services staff and observations of training were undertaken. Normalization Process Theory (NPT) was used to frame the interview guides and analysis. NPT is an empirically-derived theory, developed by sociologists, that uses four concepts to understand the process of routinising new practices. RESULTS Staff interviews took place across eight National Health Service trusts at a time of widespread restructuring in smoking cessation services. Principally interviewees worked in maternity (n = 63) and smoking cessation services (n = 35). Five main themes, identified inductively, influenced the implementation: 1) initial preparedness of the organisations; 2) staff training; 3) managing partnership working; 4) resources; 5) review and planning for sustainability. CONCLUSIONS NPT was used to show that the babyClear© package was acceptable to staff in a range of organisations. Illustrated in Themes 1, 2 & 3, staff welcomed ways to approach pregnant women about their smoking, without damaging their professional relationship with them. Predicated on producing individual behaviour change in women, the intervention does this largely through reorganising and standardising healthcare systems that are required to implement best practice guidelines. Changing organisational systems requires belief and commitment from staff, so that they set up and maintain practical adjustments to their practice and are reflective about adapting themselves and the work context as new challenges are encountered. The ongoing challenge is to identify and maintain the elements of the intervention package which are essential for its effectiveness and how to tailor them to local circumstances and resources without compromising its core ingredients.
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Affiliation(s)
- Susan Jones
- School of Health and Social Care, Teesside University, Borough Road, Middlesbrough, TS1 3BX UK
| | - Sharon Hamilton
- School of Health and Social Care, Teesside University, Borough Road, Middlesbrough, TS1 3BX UK
| | - Ruth Bell
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Vera Araújo-Soares
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Martin White
- School of Health and Social Care, Teesside University, Borough Road, Middlesbrough, TS1 3BX UK
- MRC Epidemiology Unit, School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Martyn Willmore
- Fresh, Smoke Free North East, Durham, UK
- PHE North East, Floor 2, Citygate, Gallowgate, Newcastle upon Tyne, UK
| | - Janet Shucksmith
- School of Health and Social Care, Teesside University, Borough Road, Middlesbrough, TS1 3BX UK
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19
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Wang M, Shao S, Li J, Liu Y, Xu X, Du J. The needs of informal caregivers and barriers of primary care workers toward dementia management in primary care: a qualitative study in Beijing. BMC FAMILY PRACTICE 2018; 19:201. [PMID: 30572842 PMCID: PMC6302289 DOI: 10.1186/s12875-018-0890-7] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/11/2018] [Indexed: 11/23/2022]
Abstract
BACKGROUND Informal caregivers of people with dementia in Beijing are increasingly called upon to provide home-based care for their patients due to the increasing number of dementia patients and the shortage of standardized institutional solutions of care for patients in China. This study aimed to clarify the needs of informal caregivers and barriers of primary care workers toward dementia management in primary care in Beijing to provide references that may help to improve the care and services provided to individuals with dementia and their family caregivers residing in urban China. METHODS A mixed-methods approach was used in this study. We performed individual in-depth interviews with 10 informal caregivers. Moreover, we carried out focus group interviews with 29 primary care workers. Content analysis was used to separately identify themes and codes. Discrepancies were discussed until final agreement was achieved. RESULTS Three themes representing the core attitudes of informal caregivers and primary care workers were identified: care knowledge and skills, psychological counseling, and collaborative management. Most primary care workers believed that the management of dementia patients in primary care was necessary. However, due to the heavy work load and different medical specialties involved, these workers were unable to manage it. CONCLUSIONS Professional training focused on dementia for primary care workers should be strengthened. At the same time, the establishment of a community-based dementia team management model that includes specialists, community health service centers (CHSCs), and community committees should be explored.
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Affiliation(s)
- Meirong Wang
- School of General Practice and Continuing Education, Capital Medical University, No.10 Xitoutiao, You An Men, Beijing, 100069 China
| | - Shuang Shao
- School of General Practice and Continuing Education, Capital Medical University, No.10 Xitoutiao, You An Men, Beijing, 100069 China
| | - Jing Li
- Dongfeng Community Health Service Center, Chaoyang District, Beijing, China
| | - Yingjie Liu
- School of General Practice and Continuing Education, Capital Medical University, No.10 Xitoutiao, You An Men, Beijing, 100069 China
| | - Xiaojingyuan Xu
- School of General Practice and Continuing Education, Capital Medical University, No.10 Xitoutiao, You An Men, Beijing, 100069 China
| | - Juan Du
- School of General Practice and Continuing Education, Capital Medical University, No.10 Xitoutiao, You An Men, Beijing, 100069 China
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20
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Allan LM, Wheatley A, Flynn E, Smith A, Fox C, Howel D, Barber R, Homer TM, Robinson L, Parry SW, Corner L, Connolly JA, Rochester L, Bamford C. Is it feasible to deliver a complex intervention to improve the outcome of falls in people with dementia? A protocol for the DIFRID feasibility study. Pilot Feasibility Stud 2018; 4:170. [PMID: 30455976 PMCID: PMC6230281 DOI: 10.1186/s40814-018-0364-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Accepted: 10/29/2018] [Indexed: 11/25/2022] Open
Abstract
Background People with dementia (PWD) experience ten times as many incident falls as people without dementia. Little is known about how best to deliver services to people with dementia following a fall. We used an integrated, mixed-methods approach to develop a new intervention which combines theory generated via a realist synthesis and data on current provision and pathways, gathered through a prospective observational study as well as qualitative interviews, focus groups and ethnographic observation. This intervention is to be tested in a feasibility study in the UK National Health Service. Methods People living with dementia in one of three geographical areas will be eligible for the study if they experience a fall requiring healthcare attention and have an informal carer. Potential participants will be identified by community services (primary care, paramedics, telecare), secondary care (ED, facilitated discharge services, rehabilitation outreach teams) and research case registers. Participants will receive a complex multidisciplinary intervention focused on their goals and interests for up to 12 weeks. The intervention will be delivered by occupational therapists, physiotherapists and rehabilitation support workers. Feasibility outcomes will include recruitment and retention, suitability and acceptability of outcome measures and acceptability, feasibility and fidelity of intervention components. PWD outcome measures will include number of falls, Montreal Cognitive Assessment (MOCA), European Quality of Life Instrument (EQ-5D-5L), Quality of Life–Alzheimer’s Disease Scale (QOL-AD), Modified Falls Efficacy Scale (MFES) and Goal Attainment Scaling (GAS). PWD outcome measures completed by an informal carer will include Disability Assessment for Dementia (DAD), EQ-5D-5L Proxy, QoL-AD Proxy and a Health Utilisation Questionnaire (HUQ). The carer outcome measure will be the Zarit Burden Interview (ZBI). An embedded process evaluation will explore barriers and facilitators to recruitment and intervention delivery. Discussion The study results will inform whether and how a larger multicentre RCT should be undertaken. A full RCT would have the potential to show how outcomes can be improved for people with dementia who have fallen. Ethics and dissemination The National Research Ethics Service Committee Newcastle and North Tyneside 2 approved the feasibility study. Trial registration International Standard Randomised Controlled Trial Registry. Registration number: ISRCTN41760734. Date of registration: 16/11/2015. Electronic supplementary material The online version of this article (10.1186/s40814-018-0364-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Louise M Allan
- 1Institute of Health Research, University of Exeter, South Cloisters, St Luke's Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Alison Wheatley
- 2Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Elizabeth Flynn
- 3The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Amy Smith
- 4Tees, Esk and Wear Valleys NHS Foundation Trust, Stockton-on-Tees, UK
| | - Chris Fox
- 5University of East Anglia, Norwich, UK
| | - Denise Howel
- 2Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Robert Barber
- 6Northumberland Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Tara Marie Homer
- 2Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Louise Robinson
- 2Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | | | - Jim Anthony Connolly
- 3The Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Lynn Rochester
- 8Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - Claire Bamford
- 2Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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Piercy H, Fowler-Davis S, Dunham M, Cooper C. Evaluation of an integrated service delivering post diagnostic care and support for people living with dementia and their families. HEALTH & SOCIAL CARE IN THE COMMUNITY 2018; 26:819-828. [PMID: 30033620 DOI: 10.1111/hsc.12592] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2018] [Revised: 05/01/2018] [Accepted: 05/22/2018] [Indexed: 06/08/2023]
Abstract
Greater integration of health and social care services is considered vital to ensure sustainable long-term quality provision for the growing numbers of people living with dementia and their families. Integration of services is at the heart of government policy in England. We evaluated a new integrated service for post diagnostic dementia care, funded as a pilot and delivered through a partnership of statutory and voluntary sector health and social care organisations. The service used an adapted Admiral Nursing service model with a workforce of Admiral Nurses (ANs) and Dementia Advisers (DAs). A mixed method approach was used to assess implementation and outcomes. It involved collection of service activity data, carer reported experience survey data, focus group discussions and interviews with the service delivery team, and the management group. Qualitative data was analysed using a framework approach. About 37.8% of the eligible population registered with the service over the 14-month pilot period. The self-referral route accounted for the majority of referrals, and had enabled those not currently receiving specialist dementia care to engage with the service. Carer satisfaction surveys indicated high levels of satisfaction with the service. The caseload management system offered specific benefits. Individual caseloads ensured continuity of care while the integrated structure facilitated seamless transfer between or shared working across AN and DA caseloads. The skill mix facilitated development of the DA role increasing their potential contribution to dementia care. Challenges included managing large workloads and agreeing responsibilities across the skill mix of staff. This model of fully integrated service offers a novel approach to address the problems of fragmented provision by enabling joined-up working across health and social care.
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Affiliation(s)
- Hilary Piercy
- Department of Nursing & Midwifery, Sheffield Hallam University, Sheffield, UK
| | - Sally Fowler-Davis
- Department of Nursing & Midwifery, Sheffield Hallam University, Sheffield, UK
| | - Margaret Dunham
- Department of Nursing & Midwifery, Sheffield Hallam University, Sheffield, UK
| | - Carol Cooper
- Department of Nursing & Midwifery, Sheffield Hallam University, Sheffield, UK
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May CR, Cummings A, Girling M, Bracher M, Mair FS, May CM, Murray E, Myall M, Rapley T, Finch T. Using Normalization Process Theory in feasibility studies and process evaluations of complex healthcare interventions: a systematic review. Implement Sci 2018; 13:80. [PMID: 29879986 PMCID: PMC5992634 DOI: 10.1186/s13012-018-0758-1] [Citation(s) in RCA: 297] [Impact Index Per Article: 49.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2017] [Accepted: 04/24/2018] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Normalization Process Theory (NPT) identifies, characterises and explains key mechanisms that promote and inhibit the implementation, embedding and integration of new health techniques, technologies and other complex interventions. A large body of literature that employs NPT to inform feasibility studies and process evaluations of complex healthcare interventions has now emerged. The aims of this review were to review this literature; to identify and characterise the uses and limits of NPT in research on the implementation and integration of healthcare interventions; and to explore NPT's contribution to understanding the dynamics of these processes. METHODS A qualitative systematic review was conducted. We searched Web of Science, Scopus and Google Scholar for articles with empirical data in peer-reviewed journals that cited either key papers presenting and developing NPT, or the NPT Online Toolkit ( www.normalizationprocess.org ). We included in the review only articles that used NPT as the primary approach to collection, analysis or reporting of data in studies of the implementation of healthcare techniques, technologies or other interventions. A structured data extraction instrument was used, and data were analysed qualitatively. RESULTS Searches revealed 3322 citations. We show that after eliminating 2337 duplicates and broken or junk URLs, 985 were screened as titles and abstracts. Of these, 101 were excluded because they did not fit the inclusion criteria for the review. This left 884 articles for full-text screening. Of these, 754 did not fit the inclusion criteria for the review. This left 130 papers presenting results from 108 identifiable studies to be included in the review. NPT appears to provide researchers and practitioners with a conceptual vocabulary for rigorous studies of implementation processes. It identifies, characterises and explains empirically identifiable mechanisms that motivate and shape implementation processes. Taken together, these mean that analyses using NPT can effectively assist in the explanation of the success or failure of specific implementation projects. Ten percent of papers included critiques of some aspect of NPT, with those that did mainly focusing on its terminology. However, two studies critiqued NPT emphasis on agency, and one study critiqued NPT for its normative focus. CONCLUSIONS This review demonstrates that researchers found NPT useful and applied it across a wide range of interventions. It has been effectively used to aid intervention development and implementation planning as well as evaluating and understanding implementation processes themselves. In particular, NPT appears to have offered a valuable set of conceptual tools to aid understanding of implementation as a dynamic process.
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Affiliation(s)
- Carl R. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Amanda Cummings
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Melissa Girling
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Bracher
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Frances S. Mair
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Christine M. May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Elizabeth Murray
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Michelle Myall
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tim Rapley
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
| | - Tracy Finch
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
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Backhouse A, Richards DA, McCabe R, Watkins R, Dickens C. Stakeholders perspectives on the key components of community-based interventions coordinating care in dementia: a qualitative systematic review. BMC Health Serv Res 2017; 17:767. [PMID: 29166898 PMCID: PMC5700484 DOI: 10.1186/s12913-017-2725-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2017] [Accepted: 11/13/2017] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Interventions aiming to coordinate services for the community-based dementia population vary in components, organisation and implementation. In this review we aimed to investigate the views of stakeholders on the key components of community-based interventions coordinating care in dementia. METHODS We searched four databases from inception to June 2015; Medline, The Cochrane Library, EMBASE and PsycINFO, this was aided by a search of four grey literature databases, and backward and forward citation tracking of included papers. Title and abstract screening was followed by a full text screen by two independent reviewers, and quality was assessed using the CASP appraisal tool. We then conducted thematic synthesis on extracted data. RESULTS A total of seven papers from five independent studies were included in the review, and encompassed the views of over 100 participants from three countries. Through thematic synthesis we identified 32 initial codes that were grouped into 5 second-order themes: (1) case manager had four associated codes and described preferences for the case manager personal and professional attributes, including a sound knowledge in dementia and availability of local services; (2) communication had five associated codes and emphasized the importance stakeholders placed on multichannel communication with service users, as well as between multidisciplinary teams and across organisations; (3) intervention had 11 associated codes which focused primarily on the practicalities of implementation such as the contact type and frequency between case managers and service users, and the importance of case manager training and service evaluation; (4) resources had five associated codes which outlined stakeholder views on the required resources for coordinating interventions and potential overlap with existing resources, as well as arising issues when available resources do not meet those required for successful implementation; and (5) support had seven associated codes that reflect the importance that was placed on the support network around the case manager and the investment of professionals involved directly in care as well as the wider professional network. CONCLUSION The synthesis of relevant qualitative studies has shown how various stakeholder groups considered dementia care coordination interventions to be acceptable, useful and appropriate for dementia care, and have clear preferences for components, implementation methods and settings of these interventions. By incorporating stakeholders' perspectives and preferences when planning and developing coordinating interventions we may increase the likelihood of successful implementation and patient benefits.
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Affiliation(s)
- Amy Backhouse
- University of Exeter Medical School, College House, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
- National Institute for Health Research (NIHR) South West Peninsula Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Exeter, UK
| | - David A. Richards
- University of Exeter Medical School, College House, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
- National Institute for Health Research (NIHR) South West Peninsula Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Exeter, UK
| | - Rose McCabe
- University of Exeter Medical School, College House, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
| | - Ross Watkins
- University of Exeter Medical School, College House, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
- National Institute for Health Research (NIHR) South West Peninsula Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Exeter, UK
| | - Chris Dickens
- University of Exeter Medical School, College House, St Luke’s Campus, Heavitree Road, Exeter, EX1 2LU UK
- National Institute for Health Research (NIHR) South West Peninsula Collaboration for Leadership in Applied Health Research and Care (CLAHRC), Exeter, UK
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Cognitive stimulation therapy in dementia care: exploring the views and experiences of service providers on the barriers and facilitators to implementation in practice using Normalization Process Theory. Int Psychogeriatr 2017; 29:1869-1878. [PMID: 28701238 DOI: 10.1017/s1041610217001272] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Cognitive stimulation therapy (CST) is an evidence-based, cost-effective psychosocial intervention for people with dementia but is currently not a standard part of post-diagnostic care. This qualitative study explored the views and experiences of dementia care providers on the barriers and facilitators to its implementation in usual care. METHOD Thirty four semi-structured interviews (24 participants) were conducted across four dementia care sites in the North of England; ten were follow-up interviews. Data were analyzed using thematic analysis and then mapped to the Normalization Process Theory framework. RESULTS Participants considered CST a "good fit" with their "preferred" ways of working and goals of dementia care namely the provision of person-centered services. For facilitators delivering the intervention, compared to other behavioral interventions, CST was seen to offer benefits to their work and was easy to understand as an intervention. Training in CST and seeing benefits for clients were important motivators. Time and resources were crucial for the successful implementation of CST. Participants were keen to objectively measure benefits to participants but unsure how to do this. CONCLUSIONS CST is a cost-effective psychosocial intervention for people with dementia, recommended by national guidance. Despite our findings which show that, using the NPT framework, there are more facilitators than barriers to the implementation of CST, it is still not a standard part of post-diagnostic dementia care. Further research is needed to explore the reasons for this implementation gap in ensuring evidence-based care in translated into practice.
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Dreier-Wolfgramm A, Michalowsky B, Austrom MG, van der Marck MA, Iliffe S, Alder C, Vollmar HC, Thyrian JR, Wucherer D, Zwingmann I, Hoffmann W. Dementia care management in primary care : Current collaborative care models and the case for interprofessional education. Z Gerontol Geriatr 2017; 50:68-77. [PMID: 28364258 DOI: 10.1007/s00391-017-1220-8] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Revised: 02/27/2017] [Accepted: 03/03/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Dementia is one of the most prevalent diseases in the older population. Various dementia care models have been developed to address patient's healthcare needs. They can be described as "collaborative care" or "person-centered care". Referring to the needs of the workforce working with persons with dementia, a key element is the use of interprofessional education (IPE). OBJECTIVE The purpose of this article is to describe different international collaborative care models to define a minimum standard of healthcare professions for collaborative dementia care in primary care. This helps to identify requirements for IPE to optimize care of people with dementia and to support informal caregivers in the future. MATERIAL AND METHODS In this article six dementia care models from 4 different countries (Germany, USA, UK and Netherlands) are described and compared regarding aims, interventions and healthcare professionals involved. RESULTS Care teams are minimally comprised of general practitioners or primary care providers, nurses, and social workers. Additional healthcare disciplines may be involved for specific interventions. Mostly, care team members received specific training but such training did not necessarily incorporate the IPE approach. To ensure successful collaboration of professions, IPE training programs should at least consist of the following core topics: (1) early diagnosis, (2) postdiagnostic support, (3) advanced care planning for patients and caregivers and (4) effective collaborative care. CONCLUSION The IPE programs for dementia should be expanded and must be widely implemented in order to assess the impact on collaborative practice. This study will provide the knowledge base for structuring IPE trainings developing educational agendas and adapting existing guidelines to improve collaborative dementia care in the future.
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Affiliation(s)
- Adina Dreier-Wolfgramm
- Institute for Community Medicine, Dept. Epidemiology of Health Care and Community Health, University Medicine Greifswald, Greifswald, Germany.
| | - Bernhard Michalowsky
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
| | - Mary Guerriero Austrom
- Department of Psychiatry, Indiana Alzheimer Disease Center, Indiana University Center for Aging Research (IU-CAR), Indiana University School of Medicine (IUSM), Indianapolis, USA
| | - Marjolein A van der Marck
- Radboud Institute for Health Sciences, Department of Geriatric Medicine/Radboudumc Alzheimer Centre, Radboud university medical centre, Nijmegen, Netherlands
| | - Steve Iliffe
- Research Department of Primary Care & Population Health, University College London, London, UK
| | - Catherine Alder
- USA Regenstrief Institute, Inc., Eskenazi Health, Indianapolis, USA
| | - Horst Christian Vollmar
- Institute of General Practice and Family Medicine, Jena University Hospital, Friedrich-Schiller-University, Jena, Germany.,Institute of General Practice and Family Medicine, University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Jochen René Thyrian
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
| | - Diana Wucherer
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
| | - Ina Zwingmann
- German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
| | - Wolfgang Hoffmann
- Institute for Community Medicine, Dept. Epidemiology of Health Care and Community Health, University Medicine Greifswald, Greifswald, Germany.,German Center for Neurodegenerative Diseases (DZNE), Rostock/Greifswald, Germany
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O'Brien JT, Holmes C, Jones M, Jones R, Livingston G, McKeith I, Mittler P, Passmore P, Ritchie C, Robinson L, Sampson EL, Taylor JP, Thomas A, Burns A. Clinical practice with anti-dementia drugs: A revised (third) consensus statement from the British Association for Psychopharmacology. J Psychopharmacol 2017; 31:147-168. [PMID: 28103749 DOI: 10.1177/0269881116680924] [Citation(s) in RCA: 119] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The British Association for Psychopharmacology coordinated a meeting of experts to review and revise its previous 2011 guidelines for clinical practice with anti-dementia drugs. As before, levels of evidence were rated using accepted standards which were then translated into grades of recommendation A-D, with A having the strongest evidence base (from randomised controlled trials) and D the weakest (case studies or expert opinion). Current clinical diagnostic criteria for dementia have sufficient accuracy to be applied in clinical practice (B) and both structural (computed tomography and magnetic resonance imaging) and functional (positron emission tomography and single photon emission computerised tomography) brain imaging can improve diagnostic accuracy in particular situations (B). Cholinesterase inhibitors (donepezil, rivastigmine, and galantamine) are effective for cognition in mild to moderate Alzheimer's disease (A), memantine for moderate to severe Alzheimer's disease (A) and combination therapy (cholinesterase inhibitors and memantine) may be beneficial (B). Drugs should not be stopped just because dementia severity increases (A). Until further evidence is available other drugs, including statins, anti-inflammatory drugs, vitamin E, nutritional supplements and Ginkgo biloba, cannot be recommended either for the treatment or prevention of Alzheimer's disease (A). Neither cholinesterase inhibitors nor memantine are effective in those with mild cognitive impairment (A). Cholinesterase inhibitors are not effective in frontotemporal dementia and may cause agitation (A), though selective serotonin reuptake inhibitors may help behavioural (but not cognitive) features (B). Cholinesterase inhibitors should be used for the treatment of people with Lewy body dementias (both Parkinson's disease dementia and dementia with Lewy bodies), and memantine may be helpful (A). No drugs are clearly effective in vascular dementia, though cholinesterase inhibitors are beneficial in mixed dementia (B). Early evidence suggests multifactorial interventions may have potential to prevent or delay the onset of dementia (B). Though the consensus statement focuses on medication, psychological interventions can be effective in addition to pharmacotherapy, both for cognitive and non-cognitive symptoms. Many novel pharmacological approaches involving strategies to reduce amyloid and/or tau deposition in those with or at high risk of Alzheimer's disease are in progress. Though results of pivotal studies in early (prodromal/mild) Alzheimer's disease are awaited, results to date in more established (mild to moderate) Alzheimer's disease have been equivocal and no disease modifying agents are either licensed or can be currently recommended for clinical use.
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Affiliation(s)
| | | | - Matthew Jones
- 3 Salford Royal NHS Foundation Trust, Salford, UK.,4 University of Manchester, Manchester, UK
| | - Roy Jones
- 5 The Research Institute for the Care of Older People, Bath, UK.,6 University of Bath, Bath, UK
| | | | | | | | | | - Craig Ritchie
- 10 Centre for Dementia Prevention, University of Edinburgh, Edinburgh, UK
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Overbeck G, Davidsen AS, Kousgaard MB. Enablers and barriers to implementing collaborative care for anxiety and depression: a systematic qualitative review. Implement Sci 2016; 11:165. [PMID: 28031028 PMCID: PMC5192575 DOI: 10.1186/s13012-016-0519-y] [Citation(s) in RCA: 79] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2016] [Accepted: 11/01/2016] [Indexed: 12/26/2022] Open
Abstract
Background Collaborative care is an increasingly popular approach for improving quality of care for people with mental health problems through an intensified and structured collaboration between primary care providers and health professionals with specialized psychiatric expertise. Trials have shown significant positive effects for patients suffering from depression, but since collaborative care is a complex intervention, it is important to understand the factors which affect its implementation. We present a qualitative systematic review of the enablers and barriers to implementing collaborative care for patients with anxiety and depression. Methods We developed a comprehensive search strategy in cooperation with a research librarian and performed a search in five databases (EMBASE, PubMed, PsycINFO, ProQuest, and CINAHL). All authors independently screened titles and abstracts and reviewed full-text articles. Studies were included if they were published in English and based on the original qualitative data on the implementation of a collaborative care intervention targeted at depression or anxiety in an adult patient population in a high-income country. Our subsequent analysis employed the normalization process theory (NPT). Results We included 17 studies in our review of which 11 were conducted in the USA, five in the UK, and one in Canada. We identified several barriers and enablers within the four major analytical dimensions of NPT. Securing buy-in among primary care providers was found to be critical but sometimes difficult. Enablers included physician champions, reimbursement for extra work, and feedback on the effectiveness of collaborative care. The social and professional skills of the care managers seemed critical for integrating collaborative care in the primary health care clinic. Day-to-day implementation was also found to be facilitated by the care managers being located in the clinic since this supports regular face-to-face interactions between physicians and care managers. Conclusions The following areas require special attention when planning collaborative care interventions: effective educational programs, especially for care managers; issues of reimbursement in relation to primary care providers; good systems for communication and monitoring; and promoting face-to-face interaction between care managers and physicians, preferably through co-location. There is a need for well-sampled, in-depth qualitative studies on the implementation of collaborative care in settings outside the USA and the UK. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0519-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Gritt Overbeck
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, København, Denmark.
| | - Annette Sofie Davidsen
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, København, Denmark
| | - Marius Brostrøm Kousgaard
- The Research Unit for General Practice and Section of General Practice, Institute of Public Health, University of Copenhagen, København, Denmark
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Balard F, Gely-Nargeot MC, Corvol A, Saint-Jean O, Somme D. Case management for the elderly with complex needs: cross-linking the views of their role held by elderly people, their informal caregivers and the case managers. BMC Health Serv Res 2016; 16:635. [PMID: 27825342 PMCID: PMC5101789 DOI: 10.1186/s12913-016-1892-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2016] [Accepted: 11/01/2016] [Indexed: 11/22/2022] Open
Abstract
Background In 2009, case management interventions were a new social service in France implemented within the framework of the PRISMA-France program (2006–2010). People who had benefitted from case management intervention were individuals, over 60 years old living at home in situations deemed complex by professionals. Their informal caregivers were also considered as users of the service. This research accompanied the interventions during the implementation of PRISMA-France attempting to explore the users’ (old people and their informal caregivers) and case managers’ first experiences of case management. Its aim is to provide a thorough knowledge of the dispositive in order to reveal any initial failings and to ensure optimum conditions for the onset of full implementation. Methods The study had a qualitative explorative design. Cross-linked representations of case-management were obtained through opened-ended and guided interviews with three types of informants: old people (19), their informal caregivers (11) and the case managers (5) who participated in the program during the first 6 months. Thematic analysis of the data was carried out. Results The analysis revealed that each group of people generated its own representations of the case manager’s role, even though the three groups of informants shared the idea that the case manager is first and foremost a helper. The case managers insisted on their proximity to the old people and their role as coordinators. The informal caregivers saw the professional as a partner and potential provider of assistance in accompanying old people. The old people focused on the personal connections established with the case manager. Conclusion The innovative and experimental dimension of case management in France and the flexible nature of the role generated a broad spectrum of representations by those involved. These different representations are, in part, the fruit of each individual’s projected expectations of this social service. Analyzing the first representations of the case manager’s role during the implementation phase of the CM service appears as a necessary step before considering the effects of the services. The implementation and the success of a case management model have to be evaluated regarding the previous healthcare context and the expectations of the people involved.
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Affiliation(s)
- Frédéric Balard
- Laboratoire Lorrain de sciences sociales, Université de Lorraine, Nancy, France.
| | | | - Aline Corvol
- Centre Hospitalier de Rennes, Service de Gériatrie, Rennes, France
| | | | - Dominique Somme
- Université de Rennes 1, Centre Hospitalier de Rennes, Service de Gériatrie, Laboratoire CRAPE Centre de Recherches sur l'Action Politique en Europe, UMR 6051, Rennes, France
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Abstract
BACKGROUND Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice. DISCUSSION We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems. CONCLUSION Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of 'real world' contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants' discretion over resource mobilisation and actors' contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.
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Affiliation(s)
- Carl R May
- Faculty of Health Sciences, University of Southampton, Building 67 (Nightingale), University Road, Highfield, Southampton, SO17 1BJ, UK. .,University Hospital Southampton NHS Foundation Trust, Southampton, UK. .,NIHR CLAHRC Wessex, University of Southampton, Southampton, UK.
| | - Mark Johnson
- University Hospital Southampton NHS Foundation Trust, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust and University of Southampton, Southampton, UK
| | - Tracy Finch
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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30
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Abstract
BACKGROUND Context is a problem in research on health behaviour change, knowledge translation, practice implementation and health improvement. This is because many intervention and evaluation designs seek to eliminate contextual confounders, when these represent the normal conditions into which interventions must be integrated if they are to be workable in practice. DISCUSSION We present an ecological model of the ways that participants in implementation and health improvement processes interact with contexts. The paper addresses the problem of context as it affects processes of implementation, scaling up and diffusion of interventions. We extend our earlier work to develop Normalisation Process Theory and show how these processes involve interactions between mechanisms of resource mobilisation, collective action and negotiations with context. These mechanisms are adaptive. They contribute to self-organisation in complex adaptive systems. CONCLUSION Implementation includes the translational efforts that take healthcare interventions beyond the closed systems of evaluation studies into the open systems of 'real world' contexts. The outcome of these processes depends on interactions and negotiations between their participants and contexts. In these negotiations, the plasticity of intervention components, the degree of participants' discretion over resource mobilisation and actors' contributions, and the elasticity of contexts, all play important parts. Understanding these processes in terms of feedback loops, adaptive mechanisms and the practical compromises that stem from them enables us to see the mechanisms specified by NPT as core elements of self-organisation in complex systems.
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Abstract
Purpose
– The purpose of this paper is to report the preliminary evaluation findings of an integration programme in the children’s health care sector in the North West of England. The programme was led by the local Clinical Commissioning Group (CCG) utilising a semi-autonomous working group model. It comprised horizontal and vertical integration. The evaluation reflects the emerging policy context of CCG leadership in the field of health care planning and commissioning.
Design/methodology/approach
– The evaluation used a mixed method observational study design to obtain the views and opinions of stakeholders and measured their change over time. A series of initial semi-structured interviews was conducted with purposively selected key professionals in strategic positions to assist in designing a survey instrument. An online survey was launched at programme inception and repeated at five months. Respondents were members of five implementation working groups. Survey responses were subjected to a descriptive analysis and tests of correlation.
Findings
– The data showed high levels of commitment and perceptions of shared vision and goals amongst respondents which were relatively stable over time. Responses also indicated that the programme was perceived to have a considerable impact on collaborative work but that this initial effect decreased over time. There were no significant attitudinal differences across sectors or professional groups.
Originality/value
– The study demonstrates the strengths and weaknesses of the multi-agency working group model to implement change. Whilst confirming initial positive effects of integration programmes on collaborative work, over time this appears to wear off to be replaced by increased levels of skepticism amongst participants. The author findings have implications for service commissioners and service planners engaging in vertical or horizontal integration of children’s services.
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Long Term Effect on Professionals' Knowledge, Practice and Attitudes towards User Involvement Four Years after Implementing an Organisational Development Plan: A Controlled Study. PLoS One 2016; 11:e0150742. [PMID: 26974971 PMCID: PMC4790889 DOI: 10.1371/journal.pone.0150742] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Accepted: 02/18/2016] [Indexed: 11/23/2022] Open
Abstract
Background Health service organisations are increasingly implementing user involvement initiatives according to requirements from governments, such as user representation in administrational boards, better information to users, and more involvement of the users during treatment. Professionals are vital in all initiatives to enhance user involvement, and initiatives to increase involvement should influence the professionals’ practice and attitudes. The implementation of a development plan intending to enhance user involvement in a mental health hospital in Central Norway had no effect on the professionals after 16 months. The objective was therefore to investigate the long term effect on the professionals’ knowledge, practice and attitudes towards user involvement after four years. Methods This was a non-randomized controlled study including professionals from three mental health hospitals in Central Norway. A development plan intended to enhance user participation was implemented in one of the hospitals, including establishing a patient education centre and a user office, purchasing of user expertise, appointing contact professionals for next of kin, and improving of the centre’s information and the professional culture. The professionals at two other hospitals constituted the control group. All professionals were invited to answer the Consumer Participation Questionnaire (CPQ) and additional questions, at a four year interval. Results A total of 399 professionals participated (43% response rate). Comparing the changes in the intervention group with the changes in the control group, the results showed that the plan had improved some aspects of the professionals’ knowledge about the user involvement taking place in the hospital. In addition, some parts of the professionals’ practice of providing information to the service users was improved, and the development plan might have raised their awareness about insufficient involvement of next of kin. Conclusions This is the first controlled study on the long term effect on professionals from implementing a development plan to enhance user participation in a mental health hospital. Since there was more effect after four years than after 16 months, this study indicates that it takes time before the effect of complex interventions to enhance patient participation in organisations can be detected among the professionals. More long-term studies are thus warranted.
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Khanassov V, Vedel I. Family Physician-Case Manager Collaboration and Needs of Patients With Dementia and Their Caregivers: A Systematic Mixed Studies Review. Ann Fam Med 2016; 14:166-77. [PMID: 26951593 PMCID: PMC4781521 DOI: 10.1370/afm.1898] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2015] [Revised: 10/15/2015] [Accepted: 11/08/2015] [Indexed: 11/09/2022] Open
Abstract
PURPOSE Dementia case management (CM) in primary care is a complex intervention aimed at identifying the various needs of patients with dementia and their caregivers, as well as the organization and coordination of care. A key element of CM is the collaboration of family physicians with case managers. We conducted a systematic mixed-studies review to identify the needs of the patient-caregiver dyad and the effects of CM. METHODS We searched MEDLINE, PsycINFO, and EMBASE up to October 2014, regardless of the study design. Our main outcomes were needs of patients and their caregivers and the effects of CM on these needs. We used narrative syntheses to develop a taxonomy of needs and to describe the effects of CM on those needs. We used meta-analysis to calculate the prevalence of needs and the standardized mean differences to evaluate the effects of CM on the needs identified. RESULTS Fifty-four studies were included. We identified needs of the patient-caregiver dyad and needs of the patient and caregiver individually. CM addressed the majority of the identified needs. Still, some very common needs (eg, early diagnosis) are overlooked while other needs (eg, education on the disease) are well addressed. Fully establishing the value of CM is difficult given the small number of studies of CM in primary care. CONCLUSIONS There is good evidence that case managers, in collaboration with family physicians, have a pivotal role in addressing the needs of the patient-caregiver dyad.
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Affiliation(s)
| | - Isabelle Vedel
- Department of Family Medicine, McGill University, Montreal, Canada
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de Lange J, Deusing E, van Asch IFM, Peeters J, Zwaanswijk M, Pot AM, Francke AL. Factors facilitating dementia case management: Results of online focus groups. DEMENTIA 2016; 17:110-125. [DOI: 10.1177/1471301216634959] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
To obtain insight into facilitating factors for case management in dementia care, we conducted a qualitative study with 13 online focus groups (OFGs). Participants were professionals involved in dementia case management ( N = 99). We used mind-maps and the method of constant comparison for analysis. Participants perceived OFGs as a useful tool to explore their perspectives. The perceived advantage of OFGs was the flexibility and convenience of logging in at any time or place preferred. Five facilitating factors for case management were identified in the OFGs: 1. Good cooperation between partners; 2. Organisational embedding with an independent position of case managers; 3. Structural funding; 4. Competent case managers; 5. Familiarity with case management in the region. Good cooperation was essential for successful dementia case management and should thus be a primary concern for care providers.
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Affiliation(s)
- Jacomine de Lange
- Program on Aging, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands; Research Centre Innovations in Care, Rotterdam University of Applied Sciences, Rotterdam, the Netherlands
| | - Eline Deusing
- Program on Aging, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
| | - Iris FM van Asch
- Program on Aging, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands
| | - José Peeters
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Marieke Zwaanswijk
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands
| | - Anne Margriet Pot
- Program on Aging, Netherlands Institute of Mental Health and Addiction, Utrecht, the Netherlands; Department of Clinical Psychology, EMGO+, VU University Amsterdam, the Netherlands
| | - Anneke L Francke
- NIVEL, Netherlands Institute for Health Services Research, Utrecht, the Netherlands; Department of Public and Occupational Health, EMGO+, VU University Medical Center Amsterdam, the Netherlands
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Bunn F, Burn AM, Goodman C, Robinson L, Rait G, Norton S, Bennett H, Poole M, Schoeman J, Brayne C. Comorbidity and dementia: a mixed-method study on improving health care for people with dementia (CoDem). HEALTH SERVICES AND DELIVERY RESEARCH 2016. [DOI: 10.3310/hsdr04080] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundAmong people living with dementia (PLWD) there is a high prevalence of comorbid medical conditions but little is known about the effects of comorbidity on processes and quality of care and patient needs or how services are adapting to address the particular needs of this population.ObjectivesTo explore the impact of dementia on access to non-dementia services and identify ways of improving the integration of services for this population.DesignWe undertook a scoping review, cross-sectional analysis of a population cohort database, interviews with PLWD and comorbidity and their family carers and focus groups or interviews with health-care professionals (HCPs). We focused specifically on three conditions: diabetes, stroke and vision impairment (VI). The analysis was informed by theories of continuity of care and access to care.ParticipantsThe study included 28 community-dwelling PLWD with one of our target comorbidities, 33 family carers and 56 HCPs specialising in diabetes, stroke, VI or primary care.ResultsThe scoping review (n = 76 studies or reports) found a lack of continuity in health-care systems for PLWD and comorbidity, with little integration or communication between different teams and specialities. PLWD had poorer access to services than those without dementia. Analysis of a population cohort database found that 17% of PLWD had diabetes, 18% had had a stroke and 17% had some form of VI. There has been an increase in the use of unpaid care for PLWD and comorbidity over the last decade. Our qualitative data supported the findings of the scoping review: communication was often poor, with an absence of a standardised approach to sharing information about a person’s dementia and how it might affect the management of other conditions. Although HCPs acknowledged the vital role that family carers play in managing health-care conditions of PLWD and facilitating continuity and access to care, this recognition did not translate into their routine involvement in appointments or decision-making about their family member. Although we found examples of good practice, these tended to be about the behaviour of individual practitioners rather than system-based approaches; current systems may unintentionally block access to care for PLWD. Pathways and guidelines for our three target conditions do not address the possibility of a dementia diagnosis or provide decision-making support for practitioners trying to weigh up the risks and benefits of treatment for PLWD.ConclusionsSignificant numbers of PLWD have comorbid conditions such as stroke, diabetes and VI. The presence of dementia complicates the delivery of health and social care and magnifies the difficulties that people with long-term conditions experience. Key elements of good care for PLWD and comorbidity include having the PLWD and family carer at the centre, flexibility around processes and good communication which ensures that all services are aware when someone has a diagnosis of dementia. The impact of a diagnosis of dementia on pre-existing conditions should be incorporated into guidelines and care planning. Future work needs to focus on the development and evaluation of interventions to improve continuity of care and access to services for PLWD with comorbidity.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Frances Bunn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Anne-Marie Burn
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Claire Goodman
- Centre for Research in Primary and Community Care, University of Hertfordshire, Hatfield, UK
| | - Louise Robinson
- Institute for Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Greta Rait
- PRIMENT Clinical Trials Unit, Research Department of Primary Care and Population Health, University College London Medical School, London, UK
| | - Sam Norton
- Department of Psychology, Institute of Psychiatry, King’s College London, London, UK
| | - Holly Bennett
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
| | - Marie Poole
- Institute for Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Carol Brayne
- Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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Chronic Kidney Disease Guideline Implementation in Primary Care: A Qualitative Report from the TRANSLATE CKD Study. J Am Board Fam Med 2015; 28:624-31. [PMID: 26355134 PMCID: PMC4815897 DOI: 10.3122/jabfm.2015.05.150070] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
BACKGROUND Primary care physicians (PCPs) are optimally situated to identify and manage early stage chronic kidney disease (CKD). Nonetheless, studies have documented suboptimal PCP understanding, awareness, and management of early CKD. The TRANSLATE CKD study is an ongoing national, mixed-methods, cluster randomized control trial that examines the implementation of evidence-based guidelines for CKD into primary care practice. METHODS As part of the mixed-methods process evaluation, semistructured interviews were conducted by phone with 27 providers participating in the study. Interviews were audio-taped and transcribed. Thematic content analysis was used to identify themes. Themes were categorized according to the 4 domains of Normalization Process Theory (NPT). RESULTS Identified themes illuminated the complex work undertaken to manage CKD in primary care practices. Barriers to guideline implementation were identified in each of the 4 NPT domains, including (1) lack of knowledge and understanding around CKD (coherence), (2) difficulties engaging providers and patients in CKD management (cognitive participation), (3) limited time and competing demands (collective action), and (4) challenges obtaining and using data to monitor progress (reflexive monitoring). CONCLUSIONS Addressing the barriers to implementation with concrete interventions at the levels at which they occur, informed by NPT, will ultimately improve the quality of CKD patient care.
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Drew S, Judge A, May C, Farmer A, Cooper C, Javaid MK, Gooberman-Hill R. Implementation of secondary fracture prevention services after hip fracture: a qualitative study using extended Normalization Process Theory. Implement Sci 2015; 10:57. [PMID: 25903563 PMCID: PMC4470053 DOI: 10.1186/s13012-015-0243-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Accepted: 04/07/2015] [Indexed: 01/21/2023] Open
Abstract
Background National and international guidance emphasizes the need for hospitals to have effective secondary fracture prevention services, to reduce the risk of future fractures in hip fracture patients. Variation exists in how hospitals organize these services, and there remain significant gaps in care. No research has systematically explored reasons for this to understand how to successfully implement these services. The objective of this study was to use extended Normalization Process Theory to understand how secondary fracture prevention services can be successfully implemented. Methods Forty-three semi-structured interviews were conducted with healthcare professionals involved in delivering secondary fracture prevention within 11 hospitals that receive patients with acute hip fracture in one region in England. These included orthogeriatricians, fracture prevention nurses and service managers. Extended Normalization Process Theory was used to inform study design and analysis. Results Extended Normalization Process Theory specifies four constructs relating to collective action in service implementation: capacity, potential, capability and contribution. The capacity of healthcare professionals to co-operate and co-ordinate their actions was achieved using dedicated fracture prevention co-ordinators to organize important processes of care. However, participants described effective communication with GPs as challenging. Individual potential and commitment to operationalize services was generally high. Shared commitments were promoted through multi-disciplinary team working, facilitated by fracture prevention co-ordinators. Healthcare professionals had capacity to deliver multiple components of services when co-ordinators ‘freed up’ time. As key agents in its intervention, fracture prevention coordinators were therefore indispensable to effective implementation. Aside from difficulty of co-ordination with primary care, the intervention was highly workable and easily integrated into practice. Nevertheless, implementation was threatened by under-staffed and under-resourced services, lack of capacity to administer scans and poor patient access. To ensure ongoing service delivery, the contributions of healthcare professionals were shaped by planning, in multi-disciplinary team meetings, the use of clinical databases to identify patients and define the composition of clinical work and monitoring to improve clinical practice. Conclusions Findings identify and describe elements needed to implement secondary fracture prevention services successfully. The study highlights the value of Normalization Process Theory to achieve comprehensive understanding of healthcare professionals’ experiences in enacting a complex intervention. Electronic supplementary material The online version of this article (doi:10.1186/s13012-015-0243-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Sarah Drew
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK.
| | - Andrew Judge
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK. .,MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, SO16 6YD, UK.
| | - Carl May
- Faculty of Health Sciences, University of Southampton, Highfield, Southampton, SO17 1BJ, UK.
| | - Andrew Farmer
- Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory Quarter, Oxford, OX2 6GG, UK.
| | - Cyrus Cooper
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK. .,MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, SO16 6YD, UK.
| | - M Kassim Javaid
- Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, Oxford NIHR Musculoskeletal Biomedical Research Unit, University of Oxford, Windmill Road, Headington, Oxford, OX3 7LD, UK. .,MRC Lifecourse Epidemiology Unit, Southampton General Hospital, University of Southampton, Southampton, SO16 6YD, UK.
| | - Rachael Gooberman-Hill
- School of Clinical Sciences, University of Bristol, Learning and Research Building, Level 1, Southmead Hospital, Bristol, BS10 5NB, UK.
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