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Tyler N, Hodkinson A, Planner C, Angelakis I, Keyworth C, Hall A, Jones PP, Wright OG, Keers R, Blakeman T, Panagioti M. Transitional Care Interventions From Hospital to Community to Reduce Health Care Use and Improve Patient Outcomes: A Systematic Review and Network Meta-Analysis. JAMA Netw Open 2023; 6:e2344825. [PMID: 38032642 PMCID: PMC10690480 DOI: 10.1001/jamanetworkopen.2023.44825] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 10/03/2023] [Indexed: 12/01/2023] Open
Abstract
Importance Discharge from the hospital to the community has been associated with serious patient risks and excess service costs. Objective To evaluate the comparative effectiveness associated with transitional care interventions with different complexity levels at improving health care utilization and patient outcomes in the transition from the hospital to the community. Data Sources CENTRAL, Embase, MEDLINE, and PsycINFO were searched from inception until August 2022. Study Selection Randomized clinical trials evaluating transitional care interventions from hospitals to the community were identified. Data Extraction and Synthesis At least 2 reviewers were involved in all data screening and extraction. Random-effects network meta-analyses and meta-regressions were applied. The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed. Main Outcomes and Measures The primary outcomes were readmission at 30, 90, and 180 days after discharge. Secondary outcomes included emergency department visits, mortality, quality of life, patient satisfaction, medication adherence, length of stay, primary care and outpatient visits, and intervention uptake. Results Overall, 126 trials with 97 408 participants were included, 86 (68%) of which were of low risk of bias. Low-complexity interventions were associated with the most efficacy for reducing hospital readmissions at 30 days (odds ratio [OR], 0.78; 95% CI, 0.66 to 0.92) and 180 days (OR, 0.45; 95% CI, 0.30 to 0.66) and emergency department visits (OR, 0.68; 95% CI, 0.48 to 0.96). Medium-complexity interventions were associated with the most efficacy at reducing hospital readmissions at 90 days (OR, 0.64; 95% CI, 0.45 to 0.92), reducing adverse events (OR, 0.42; 95% CI, 0.24 to 0.75), and improving medication adherence (standardized mean difference [SMD], 0.49; 95% CI, 0.30 to 0.67) but were associated with less efficacy than low-complexity interventions for reducing readmissions at 30 and 180 days. High-complexity interventions were most effective for reducing length of hospital stay (SMD, -0.20; 95% CI, -0.38 to -0.03) and increasing patient satisfaction (SMD, 0.52; 95% CI, 0.22 to 0.82) but were least effective for reducing readmissions at all time periods. None of the interventions were associated with improved uptake, quality of life (general, mental, or physical), or primary care and outpatient visits. Conclusions and Relevance These findings suggest that low- and medium-complexity transitional care interventions were associated with reducing health care utilization for patients transitioning from hospitals to the community. Comprehensive and consistent outcome measures are needed to capture the patient benefits of transitional care interventions.
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Affiliation(s)
- Natasha Tyler
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Alexander Hodkinson
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Claire Planner
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Ioannis Angelakis
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- Institute of Population Health, Department of Primary Care & Mental Health, University of Liverpool, Liverpool, United Kingdom
| | | | - Alex Hall
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, United Kingdom
| | | | | | - Richard Keers
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
- Pharmacy Department, Pennine Care NHS Foundation Trust, Aston-Under-Lyne, United Kingdom
- Centre for Pharmacoepidemiology and Drug Safety, Division of Pharmacy and Optometry, School of Health Sciences, University of Manchester, Manchester, United Kingdom
| | - Tom Blakeman
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
| | - Maria Panagioti
- National Institute for Health Research School for Primary Care Research, Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, University of Manchester, Manchester, United Kingdom
- National Institute for Health and Care Research Greater Manchester Patient Safety Translational Research Centre, Division of Population Health, Health Services Research & Primary Care, University of Manchester, Manchester, United Kingdom
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Tyler N, Angelakis I, Keers RN, Planner C, Hodkinson A, Giles SJ, Grundy A, Kapur N, Armitage C, Blakeman T, Campbell SM, Robinson C, Leather J, Panagioti M. Evaluating a co-designed care bundle to improve patient safety at discharge from adult and adolescent mental health services (SAFER-MH and SAFER-YMH): protocol for a non-randomised feasibility study. BMJ Open 2023; 13:e069216. [PMID: 37041053 PMCID: PMC10106061 DOI: 10.1136/bmjopen-2022-069216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/13/2023] Open
Abstract
INTRODUCTION Patients being discharged from inpatient mental wards often describe safety risks in terms of inadequate information sharing and involvement in discharge decisions. Through stakeholder engagement, we co-designed, developed and adapted two versions of a care bundle intervention, the SAFER Mental Health care bundle for adult and youth inpatient mental health settings (SAFER-MH and SAFER-YMH, respectively), that look to address these concerns through the introduction of new or improved processes of care. METHODS AND ANALYSIS Two uncontrolled before-and-after feasibility studies, where all participants will receive the intervention. We will examine the feasibility and acceptability of the SAFER-MH in inpatient mental health settings in patients aged 18 years or older who are being discharged and the feasibility and acceptability of the SAFER-YMH intervention in inpatient mental health settings in patients aged between 14 and 18 years who are being discharged. The baseline period and intervention periods are both 6 weeks. SAFER-MH will be implemented in three wards and SAFER-YMH in one or two wards, ideally across different trusts within England. We will use quantitative (eg, questionnaires, completion forms) and qualitative (eg, interviews, process evaluation) methods to assess the acceptability and feasibility of the two versions of the intervention. The findings will inform whether a main effectiveness trial is feasible and, if so, how it should be designed, and how many patients/wards should be included. ETHICS AND DISSEMINATION Ethical approval was obtained from the National Health Service Cornwall and Plymouth Research Ethics Committee and Surrey Research Ethics Committee (reference: 22/SW/0096 and 22/LO/0404). Research findings will be disseminated with participating sites and shared in various ways to engage different audiences. We will present findings at international and national conferences, and publish in open-access, peer-reviewed journals.
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Affiliation(s)
- Natasha Tyler
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Ioannis Angelakis
- Department of Primary Care and Mental Health, University of Liverpool, Liverpool, UK
| | - Richard Neil Keers
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety Research, University of Manchester, Manchester, UK
| | - Claire Planner
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | | | - Sally J Giles
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Andrew Grundy
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | - Navneet Kapur
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- Centre for Suicide Prevention, University of Manchester, Manchester, UK
| | - Chris Armitage
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- Manchester Centre for Health Psychology, University of Manchester, Manchester, UK
| | - Tom Blakeman
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, University of Manchester, Manchester, UK
| | - Stephen M Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Catherine Robinson
- Division of Nursing, Midwifery & Social Work, University of Manchester, Manchester, UK
| | - Jessica Leather
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
| | - Maria Panagioti
- NIHR Greater Manchester Patient Safety Translational Research Centre, University of Manchester, Manchester, UK
- NIHR School for Primary Care Research, University of Manchester, Manchester, UK
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Sawhney S, Blakeman T, Blana D, Boyers D, Fluck N, Nath M, Methven S, Rzewuska M, Black C. Care processes and outcomes of deprivation across the clinical course of kidney disease: findings from a high-income country with universal healthcare. Nephrol Dial Transplant 2022; 38:1170-1182. [PMID: 35869974 PMCID: PMC10157789 DOI: 10.1093/ndt/gfac224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND No single study contrasts the extent and consequences of inequity of kidney care across the clinical course of kidney disease. METHODS This population study of Grampian (UK) followed incident presentations of AKI, and incident eGFR thresholds of < 60, <45 and < 30 in separate cohorts (2011-2021). The key exposure was area-level deprivation (lowest quintile of the Scottish Index of Multiple Deprivation). Outcomes were care processes (monitoring, prescribing, appointments, unscheduled care); long-term mortality; and kidney failure. Modelling involved multivariable logistic regression, negative binomial regression, and cause specific Cox models with/without adjustment of comorbidities. RESULTS There were 41 313, 51 190, 32 171, and 17 781 new presentations of AKI, and eGFR thresholds < 60, <45 and < 30. 6.1-7.8% were from deprived areas, and (vs all others) presented on average five years younger, with more diabetes, pulmonary and liver disease. Those from deprived areas were more likely to present initially in hospital, less likely to receive community monitoring, less likely to attend appointments, and more likely to have an unplanned emergency department or hospital admission episode. Deprivation had greatest association with long-term kidney failure at the eGFR < 60 threshold (adjusted HR 1.48, 1.17-1.87), and this association attenuated with advancing disease severity (HR 1.09, 0.93-1.28 at eGFR < 30); with a similar pattern for mortality. Across all analyses the most detrimental associations of deprivation were at an eGFR < 60 threshold, AKI, males, and those aged < 65 years. CONCLUSIONS Even in a high-income country with universal healthcare, serious and consistent inequities of kidney care exist. The poorer care and outcomes with area-level deprivation were greater earlier in the disease course.
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Affiliation(s)
| | | | | | | | - Nick Fluck
- University of Aberdeen, UK.,NHS Grampian, UK
| | | | | | | | - Corri Black
- University of Aberdeen, UK.,NHS Grampian, UK
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Hossain MZ, Chew-Graham CA, Sowden E, Blakeman T, Wellwood I, Tierney S, Deaton C. Challenges in the management of people with heart failure with preserved ejection fraction (HFpEF) in primary care: A qualitative study of general practitioner perspectives. Chronic Illn 2022; 18:410-425. [PMID: 33401942 PMCID: PMC9163769 DOI: 10.1177/1742395320983871] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To explore the perspectives of general practitioners (GPs) on the identification and management of people, including those from ethnic minority groups, with Heart Failure with Preserved Ejection Fraction (HFpEF). METHODS Qualitative study. Semi-structured, face-to-face or telephone interviews and focus groups were conducted with 35 GPs in England, which were audio-recorded and transcribed verbatim. Framework analysis was used to manage and interpret data. RESULTS Themes presented reflect four inter-related challenges: GPs' 1) lack of understanding HFpEF, impacting on 2) difficulties in communicating the diagnosis, leading to 3) uncertainty in managing people with HFpEF, further hindered by (4) discontinuity across the primary/secondary interface. All were considered more challenging by GPs when managing people from different cultures and languages. DISCUSSION HFpEF is not well understood by GPs, leading to diagnostic difficulty, management uncertainty and potential inequity in care offered. People with HFpEF are seen as complex, with multiple long-term conditions and requiring personalised care. Challenges in their management occur across the healthcare system. This study has identified learning needs for GPs around identification and on-going support for people with HFpEF in primary care. It will contribute to the development of more flexible and patient-centred pathways across the primary/secondary care interface.
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Affiliation(s)
- Muhammad Z Hossain
- Faculty of Medicine and Health Sciences, School of Medicine, Keele University, Keele, UK
| | - Carolyn A Chew-Graham
- Faculty of Medicine and Health Sciences, School of Medicine, Keele University, Keele, UK
| | - Emma Sowden
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Tom Blakeman
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, University of Manchester, Manchester, UK
| | - Ian Wellwood
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, School of Clinical Medicine, Cambridge, UK
| | - Stephanie Tierney
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Christi Deaton
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, School of Clinical Medicine, Cambridge, UK
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Howells K, Burrows M, Amp M, Brennan R, Yeung WL, Jackson S, Dickinson J, Draper J, Campbell S, Ashcroft D, Blakeman T, Sanders C. Exploring the experiences of changes to support access to primary health care services and the impact on the quality and safety of care for homeless people during the COVID-19 pandemic: a study protocol for a qualitative mixed methods approach. Int J Equity Health 2021; 20:29. [PMID: 33423682 PMCID: PMC7797179 DOI: 10.1186/s12939-020-01364-4] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2020] [Accepted: 12/16/2020] [Indexed: 11/16/2022] Open
Abstract
Background Despite high level of health care need amongst people experiencing homelessness, poor access is a major concern. This is sometimes due to organisational and bureaucratic barriers, but also because they often feel stigmatised and treated badly when they do seek health care. The COVID-19 pandemic and the required social distancing measures have caused unprecedented disruption and change for the organisation of primary care, particularly for people experiencing homelessness. Against this backdrop there are many questions to address regarding whether the recent changes required to deliver services to people experiencing homelessness in the context of COVID-19 will help to address or compound problems in accessing care and inequalities in health outcomes. Methods An action led and participatory research methodology will be employed to address the study objectives. Interviews with people experiencing homelessness were will be conducted by a researcher with lived experience of homelessness. Researchers with lived experience are able to engage with vulnerable communities in an empathetic, non-judgemental way as their shared experience promotes a sense of trust and integrity, which in turn encourages participation in research and may help people speak more openly about their experience. The experiences of health professionals and stakeholders delivering and facilitating care for people experiencing homelessness during the pandemic will also be explored. Discussion It is important to explore whether recent changes to the delivery of primary care in response to the COVID-19 pandemic compromise the safety of people experiencing homelessness and exacerbate health inequalities. This could have implications for how primary healthcare is delivered to those experiencing homelessness not only for the duration of the pandemic but in the future.
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Affiliation(s)
- Kelly Howells
- NIHR Greater Manchester Patient Safety Translational Research Centre, 6th Floor Williamson Building, Oxford Road, Manchester, M13 9PL, Centre for Primary Care, The University of Manchester, Manchester, UK.
| | | | | | | | | | | | | | - Julie Draper
- Bolton Homeless and Vulnerable Adults Service, Bolton, UK
| | - Stephen Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre, 6th Floor Williamson Building, Oxford Road, Manchester, M13 9PL, Centre for Primary Care, The University of Manchester, Manchester, UK
| | - Darren Ashcroft
- NIHR Greater Manchester Patient Safety Translational Research Centre, 6th Floor Williamson Building, Oxford Road, Manchester, M13 9PL, Centre for Primary Care, The University of Manchester, Manchester, UK
| | - Tom Blakeman
- NIHR Greater Manchester Patient Safety Translational Research Centre, 6th Floor Williamson Building, Oxford Road, Manchester, M13 9PL, Centre for Primary Care, The University of Manchester, Manchester, UK
| | - Caroline Sanders
- NIHR Greater Manchester Patient Safety Translational Research Centre, 6th Floor Williamson Building, Oxford Road, Manchester, M13 9PL, Centre for Primary Care, The University of Manchester, Manchester, UK
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Howard SJ, Elvey R, Ohrnberger J, Turner AJ, Anselmi L, Martindale AM, Blakeman T. Post-discharge care following acute kidney injury: quality improvement in primary care. BMJ Open Qual 2020; 9:e000891. [PMID: 33328317 PMCID: PMC7745694 DOI: 10.1136/bmjoq-2019-000891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Revised: 10/27/2020] [Accepted: 11/03/2020] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Over the past decade, targeting acute kidney injury (AKI) has become a priority to improve patient safety and health outcomes. Illness complicated by AKI is common and is associated with adverse outcomes including high rates of unplanned hospital readmission. Through national patient safety directives, NHS England has mandated the implementation of an AKI clinical decision support system in hospitals. In order to improve care following AKI, hospitals have also been incentivised to improve discharge summaries and general practices are recommended to establish registers of people who have had an episode of illness complicated by AKI. However, to date, there is limited evidence surrounding the development and impact of interventions following AKI. DESIGN We conducted a quality improvement project in primary care aiming to improve the management of patients following an episode of hospital care complicated by AKI. All 31 general practices within a single NHS Clinical Commissioning Group were incentivised by a locally commissioned service to engage in audit and feedback, education training and to develop an action plan at each practice to improve management of AKI. RESULTS AKI coding in general practice increased from 28% of cases in 2015/2016 to 50% in 2017/2018. Coding of AKI was associated with significant improvements in downstream patient management in terms of conducting a medication review within 1 month of hospital discharge, monitoring kidney function within 3 months and providing written information about AKI to patients. However, there was no effect on unplanned hospitalisation and mortality. CONCLUSION The findings suggest that the quality improvement intervention successfully engaged a primary care workforce in AKI-related care, but that a higher intensity intervention is likely to be required to improve health outcomes. Development of a real-time audit tool is necessary to better understand and minimise the impact of the high mortality rate following AKI.
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Affiliation(s)
- Susan J Howard
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
| | - Rebecca Elvey
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
| | - Julius Ohrnberger
- Department of Infectious Disease Epidemiology, Imperial College London, London, UK
| | - Alex J Turner
- Health Organisation, Policy and Economics (HOPE) group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Laura Anselmi
- Health Organisation, Policy and Economics (HOPE) group, Centre for Primary Care and Health Services Research, The University of Manchester, Manchester, UK
| | - Anne-Marie Martindale
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
| | - Tom Blakeman
- NIHR Applied Research Collaboration Greater Manchester (ARC-GM), Health Innovation Manchester, Manchester, UK
- Centre for Primary Care and Health Services Research, Division of Population Health, Health Services Research and Primary Care; School of Health Sciences, Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK, The University of Manchester, Manchester, UK
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Tsang JY, Murray J, Kingdon E, Tomson C, Hallas K, Campbell S, Blakeman T. Guidance for post-discharge care following acute kidney injury: an appropriateness ratings evaluation. BJGP Open 2020; 4:bjgpopen20X101054. [PMID: 32546580 PMCID: PMC7465579 DOI: 10.3399/bjgpopen20x101054] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Accepted: 02/10/2020] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute kidney injury (AKI) is associated with poor health outcomes, including increased mortality and rehospitalisation. National policy and patient safety drivers have targeted AKI as an example to ensure safer transitions of care. AIM To establish guidance to promote high-quality transitions of care for adults following episodes of illness complicated by AKI. DESIGN & SETTING An appropriateness ratings evaluation was undertaken using the RAND/UCLA Appropriateness Method (RAM). The Royal College of General Practitioners (RCGP) AKI working group developed a range of clinical scenarios to help identify the necessary steps to be taken following discharge of a patient from secondary care into primary care in the UK. METHOD A 10-person expert panel was convened to rate 819 clinical scenarios, testing the most appropriate time and action following hospital discharge. Specifically, the scenarios focused on determining the appropriateness and urgency for planning: an initial medication review; monitoring of kidney function; and assessment for albuminuria. RESULTS Taking no action (that is, no medication review; no kidney monitoring; or no albuminuria testing) was rated inappropriate in all cases. In most scenarios, there was consensus that both the initial medication review and kidney function monitoring should take place within 1-2 weeks or 1 month, depending on clinical context. However, patients with heart failure and poor kidney recovery were rated to require expedited review. There was consensus that assessment for albuminuria should take place at 3 months after discharge following AKI. CONCLUSION Systems to support tailored and timely post-AKI discharge care are required, especially in high-risk populations, such as people with heart failure.
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Affiliation(s)
- Jung Yin Tsang
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care and Health Services Research, Institute of Population Health, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre (PTSRC), University of Manchester, Manchester, UK
| | - Jonathan Murray
- Renal Unit, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
- Academic Health Science Network for the North East and North Cumbria (AHSN NENC), Newcastle upon Tyne, UK
| | - Edward Kingdon
- Brighton & Sussex University Hospitals NHS Trust, Brighton, UK
- Kent Surrey Sussex Academic Health Science Network (KSS AHSN), Crawley, UK
| | - Charlie Tomson
- Department of Renal Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Kyle Hallas
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care and Health Services Research, Institute of Population Health, University of Manchester, Manchester, UK
| | - Stephen Campbell
- NIHR Greater Manchester Patient Safety Translational Research Centre (PTSRC), University of Manchester, Manchester, UK
| | - Tom Blakeman
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care and Health Services Research, Institute of Population Health, University of Manchester, Manchester, UK
- NIHR Greater Manchester Patient Safety Translational Research Centre (PTSRC), University of Manchester, Manchester, UK
- RCGP Clinical Champion for Kidney Care, Royal College of General Practitioners, London, UK
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Reeves D, Pye S, Ashcroft DM, Clegg A, Kontopantelis E, Blakeman T, van Marwijk H. The challenge of ageing populations and patient frailty: can primary care adapt? BMJ 2018; 362:k3349. [PMID: 30154082 DOI: 10.1136/bmj.k3349] [Citation(s) in RCA: 66] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- David Reeves
- University of Manchester-NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Manchester, UK
- University of Manchester, Division of Population Health, Health Services Research and Primary Care, Manchester, UK
| | - Stephen Pye
- University of Manchester-NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Manchester, UK
- University of Manchester, Division of Population Health, Health Services Research and Primary Care, Manchester, UK
| | - Darren M Ashcroft
- University of Manchester-School of Pharmacy and Pharmaceutical Sciences, Manchester, UK
| | - Andrew Clegg
- University of Leeds-Academic Unit of Elderly Care and Rehabilitation, Leeds, UK
| | - Evangelos Kontopantelis
- University of Manchester-NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Manchester, UK
- University of Manchester, Division of Population Health, Health Services Research and Primary Care, Manchester, UK
| | - Tom Blakeman
- University of Manchester-NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Manchester, UK
- University of Manchester, Division of Population Health, Health Services Research and Primary Care, Manchester, UK
| | - Harm van Marwijk
- University of Manchester-NIHR School for Primary Care Research, Manchester Academic Health Science Centre, Manchester, UK
- Brighton and Sussex Medical School-Division of Primary Care and Public Health, Brighton, UK
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Martindale AM, Elvey R, Howard SJ, McCorkindale S, Sinha S, Blakeman T. Understanding the implementation of 'sick day guidance' to prevent acute kidney injury across a primary care setting in England: a qualitative evaluation. BMJ Open 2017; 7:e017241. [PMID: 29122792 PMCID: PMC5695520 DOI: 10.1136/bmjopen-2017-017241] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVES The study sought to examine the implementation of sick day guidance cards designed to prevent acute kidney injury (AKI), in primary care settings. DESIGN Qualitative semistructured interviews were conducted and comparative analysis informed by normalisation process theory was undertaken to understand sense-making, implementation and appraisal of the cards and associated guidance. SETTING A single primary care health setting in the North of England. PARTICIPANTS 29 participants took part in the qualitative evaluation: seven general practitioners, five practice nurses, five community pharmacists, four practice pharmacists, two administrators, one healthcare assistant and five patients. INTERVENTION The sick day guidance intervention was rolled out (2015-2016) in general practices (n=48) and community pharmacies (n=60). The materials consisted of a 'medicine sick day guidance' card, provided to patients who were taking the listed drugs. The card provided advice about medicines management during episodes of acute illness. An information leaflet was provided to healthcare practitioners and administrators suggesting how to use and give the cards. RESULTS Implementation of sick day guidance cards to prevent AKI entailed a new set of working practises across primary care. A tension existed between ensuring reach in administration of the cards to at risk populations while being confident to ensure patient understanding of their purpose and use. Communicating the concept of temporary cessation of medicines was a particular challenge and limited their administration to patient populations at higher risk of AKI, particularly those with less capacity to self-manage. CONCLUSIONS Sick day guidance cards that focus solely on medicines management may be of limited patient benefit without adequate resourcing or if delivered as a standalone intervention. Development and evaluation of primary care interventions is urgently warranted to tackle the harm associated with AKI.
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Affiliation(s)
- Anne-Marie Martindale
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Salford Royal NHS Foundation Trust, Salford, UK
| | - Rebecca Elvey
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Salford Royal NHS Foundation Trust, Salford, UK
| | | | | | | | - Tom Blakeman
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care, Salford Royal NHS Foundation Trust, Salford, UK
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Phipps DL, Morris RL, Blakeman T, Ashcroft DM. What is involved in medicines management across care boundaries? A qualitative study of healthcare practitioners' experiences in the case of acute kidney injury. BMJ Open 2017; 7:e011765. [PMID: 28100559 PMCID: PMC5253539 DOI: 10.1136/bmjopen-2016-011765] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
OBJECTIVES To examine the role of individual and collective cognitive work in managing medicines for acute kidney injury (AKI), this being an example of a clinical scenario that crosses the boundaries of care organisations and specialties. DESIGN Qualitative design, informed by a realist perspective and using semistructured interviews as the data source. The data were analysed using template analysis. SETTING Primary, secondary and intermediate care in England. PARTICIPANTS 12 General practitioners, 10 community pharmacists, 7 hospital doctors and 7 hospital pharmacists, all with experience of involvement in preventing or treating AKI. RESULTS We identified three main themes concerning participants' experiences of managing medicines in AKI. In the first theme, challenges arising from the clinical context, AKI is identified as a technically complex condition to identify and treat, often requiring judgements to be made about renal functioning against the context of the patient's general well-being. In the second theme, challenges arising from the organisational context, the crossing of professional and organisational boundaries is seen to introduce problems for the coordination of clinical activities, for example by disrupting information flows. In the third theme, meeting the challenges, participants identify ways in which they overcome the challenges they face in order to ensure effective medicines management, for example by adapting their work practices and tools. CONCLUSIONS These themes indicate the critical role of cognitive work on the part of healthcare practitioners, as individuals and as teams, in ensuring effective medicines management during AKI. Our findings suggest that the capabilities underlying this work, for example decision-making, communication and team coordination, should be the focus of training and work design interventions to improve medicines management for AKI or for other conditions.
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Affiliation(s)
- Denham L Phipps
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety Research, Manchester Pharmacy School, The University of Manchester, Manchester, UK
| | - Rebecca L Morris
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
- Centre for Primary Care, Institute of Population Health, The University of Manchester, Manchester, UK
| | - Tom Blakeman
- Centre for Primary Care, Institute of Population Health, The University of Manchester, Manchester, UK
- NIHR Greater Manchester Collaborative for Leadership in Applied Health Reserach and Care, The University of Manchester, Manchester, UK
| | - Darren M Ashcroft
- NIHR Greater Manchester Patient Safety Translational Research Centre, The University of Manchester, Manchester, UK
- Centre for Pharmacoepidemiology and Drug Safety Research, Manchester Pharmacy School, The University of Manchester, Manchester, UK
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Blakeman T, Griffith K, Lasserson D, Lopez B, Tsang JY, Campbell S, Tomson C. Development of guidance on the timeliness in response to acute kidney injury warning stage test results for adults in primary care: an appropriateness ratings evaluation. BMJ Open 2016; 6:e012865. [PMID: 27729353 PMCID: PMC5073517 DOI: 10.1136/bmjopen-2016-012865] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Revised: 08/19/2016] [Accepted: 09/12/2016] [Indexed: 02/01/2023] Open
Abstract
OBJECTIVES Tackling the harm associated with acute kidney injury (AKI) is a global priority. In England, a national computerised AKI algorithm is being introduced across the National Health Service (NHS) to drive this change. The study sought to maximise its clinical utility and minimise the potential for burden on clinicians and patients in primary care. DESIGN An appropriateness ratings evaluation using the RAND/UCLA Appropriateness Method. SETTING Clinical scenarios were developed to test the timeliness in (1) communication of AKI warning stage test results from clinical pathology services to primary care, and (2) primary care clinician response to an AKI warning stage test result. PARTICIPANTS A 10-person panel was purposively sampled with representation from clinical biochemistry, acute and emergency medicine and general practice. General practitioners (GPs) represented typical practice in relation to rural and urban practice, out of hours care, GP commissioning and those interested in reducing the impact of medicalisation and 'overdiagnosis'. RESULTS There was agreement that delivery of AKI warning stage test results through interruptive methods of communication (ie, telephone) from laboratories to primary care was the appropriate next step for patients with an AKI warning stage 3 test result. In the context of acute illness, waiting up to 72 hours to respond to an AKI warning stage test result was deemed an inappropriate action in 62 out of the 65 (94.5%) cases. There was agreement that a clinician response was required within 6 hours, or less, in 39 out of 40 (97.5%) clinical cases relating AKI warning stage test results in the presence of moderate hyperkalaemia. CONCLUSIONS The study has informed national guidance to support a timely and calibrated response to AKI warning stage test results for adults in primary care. Further research is needed to support effective implementation, with a view to examine the effect on health outcomes and costs.
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Affiliation(s)
- Tom Blakeman
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, The University of Manchester, Manchester, UK
| | - Kathryn Griffith
- RCGP Clinical champion for Kidney Care, Royal College of General Practitioners, London, UK
| | - Dan Lasserson
- Department of Geratology, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Berenice Lopez
- Department of Clinical Biochemistry, Norfolk and Norwich University Hospitals Foundation Trust, Norwich, UK
| | - Jung Y Tsang
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, The University of Manchester, Manchester, UK
| | - Stephen Campbell
- NIHR Greater Manchester Primary Care Patient Safety, Translational Research Centre, Institute of Population Health, Centre for Primary Care, University of Manchester, Manchester, UK
| | - Charles Tomson
- Department of Renal Medicine, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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Abstract
Chronic kidney disease (CKD) is an important and common noncommunicable condition globally. In national and international guidelines, CKD is defined and staged according to measures of kidney function that allow for a degree of risk stratification using commonly available markers. It is often asymptomatic in its early stages, and early detection is important to reduce future risk. The risk of cardiovascular outcomes is greater than the risk of progression to end-stage kidney disease for most people with CKD. CKD also predisposes to acute kidney injury – a major cause of morbidity and mortality worldwide. Although only a small proportion of people with CKD progress to end-stage kidney disease, renal replacement therapy (dialysis or transplantation) represents major costs for health care systems and burden for patients. Efforts in primary care to reduce the risks of cardiovascular disease, acute kidney injury, and progression are therefore required. Monitoring renal function is an important task, and primary care clinicians are well placed to oversee this aspect of care along with the management of modifiable risk factors, particularly blood pressure and proteinuria. Good primary care judgment is also essential in making decisions about referral for specialist nephrology opinion. As CKD commonly occurs alongside other conditions, consideration of comorbidities and patient wishes is important, and primary care clinicians have a key role in coordinating care while adopting a holistic, patient-centered approach and providing continuity. This review aims to summarize the vital role that primary care plays in predialysis CKD care and to outline the main considerations in its identification, monitoring, and clinical management in this context.
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Affiliation(s)
- Simon Ds Fraser
- Academic Unit of Primary Care and Population Sciences, Faculty of Medicine, Southampton General Hospital, University of Southampton, Southampton
| | - Tom Blakeman
- National Institute for Health Research Collaboration for Leadership in Applied Health Research Greater Manchester, Centre for Primary Care, Institute of Population Health, The University of Manchester, Manchester, UK
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Tsang JY, Blakeman T, Hegarty J, Humphreys J, Harvey G. Understanding the implementation of interventions to improve the management of chronic kidney disease in primary care: a rapid realist review. Implement Sci 2016; 11:47. [PMID: 27044401 PMCID: PMC4820872 DOI: 10.1186/s13012-016-0413-7] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2015] [Accepted: 03/24/2016] [Indexed: 12/25/2022] Open
Abstract
Background Chronic kidney disease (CKD) is common and a significant marker of morbidity and mortality. Its management in primary care is essential for maintenance of cardiovascular health, avoidance of acute kidney injury (AKI) and delay in progression to end-stage renal disease. Although many guidelines and interventions have been established, there is global evidence of an implementation gap, including variable identification rates and low patient communication and awareness. The objective of this study is to understand the factors enabling and constraining the implementation of CKD interventions in primary care. Methods A rapid realist review was conducted that involved a primary literature search of three databases to identify existing CKD interventions in primary care between the years 2000 and 2014. A secondary search was performed as an iterative process and included bibliographic and grey literature searches of reference lists, authors and research groups. A systematic approach to data extraction using Normalisation Process Theory (NPT) illuminated key mechanisms and contextual factors that affected implementation. Results Our primary search returned 710 articles that were narrowed down to 18 relevant CKD interventions in primary care. Our findings suggested that effective management of resources (encompassing many types) was a significant contextual factor enabling or constraining the functioning of mechanisms. Three key intervention features were identified from the many that contributed to successful implementation. Firstly, it was important to frame CKD interventions appropriately, such as within the context of cardiovascular health and diabetes. This enabled buy-in and facilitated an understanding of the significance of CKD and the need for intervention. Secondly, interventions that were compatible with existing practices or patients’ everyday lives were readily accepted. In contrast, new systems that could not be integrated were abandoned as they were viewed as inconvenient, generating more work. Thirdly, ownership of the feedback process allowed users to make individualised improvements to the intervention to suit their needs. Conclusions Our rapid realist review identified mechanisms that need to be considered in order to optimise the implementation of interventions to improve the management of CKD in primary care. Further research into the factors that enable prolonged sustainability and cost-effectiveness is required for efficient resource utilisation. Electronic supplementary material The online version of this article (doi:10.1186/s13012-016-0413-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jung Yin Tsang
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester (GM), Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, M13 9PL, UK.
| | - Tom Blakeman
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester (GM), Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, M13 9PL, UK
| | - Janet Hegarty
- Renal Department, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - John Humphreys
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester (GM), Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, M13 9PL, UK.,Renal Department, Salford Royal NHS Foundation Trust, Stott Lane, Salford, M6 8HD, UK
| | - Gill Harvey
- Alliance Manchester Business School, University of Manchester, Booth Street West, Manchester, M15 6PB, UK.,School of Nursing, University of Adelaide, Eleanor Harrald Building, Frome Road, Adelaide, SA5005, Australia
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Simmonds R, Evans J, Feder G, Blakeman T, Lasserson D, Murray E, Bennert K, Locock L, Horwood J. Understanding tensions and identifying clinician agreement on improvements to early-stage chronic kidney disease monitoring in primary care: a qualitative study. BMJ Open 2016; 6:e010337. [PMID: 26988353 PMCID: PMC4800136 DOI: 10.1136/bmjopen-2015-010337] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
OBJECTIVES Since 2006, general practitioners (GPs) in England, UK, have been incentivised to keep a register and monitor patients with chronic kidney disease (CKD) stages 3-5. Despite tensions and debate around the merit of this activity, there has been little qualitative research exploring clinician perspectives on monitoring early-stage CKD in primary care. This study aimed to examine and understand a range of different healthcare professional views and experiences of identification and monitoring in primary care of early-stage CKD, in particular stage 3. DESIGN Qualitative design using semistructured interviews. SETTING National Health Service (NHS) settings across primary and secondary care in South West England, UK. PARTICIPANTS 25 clinicians: 16 GPs, 3 practice nurses, 4 renal consultants and 2 public health physicians. RESULTS We identified two related overarching themes of dissonance and consonance in clinician perspectives on early-stage CKD monitoring in primary care. Clinician dissonance around clinical guidelines for CKD monitoring emanated from different interpretations of CKD and different philosophies of healthcare and moral decision-making. Clinician consonance centred on the need for greater understanding of renal decline and increasing proteinuria testing to reduce overdiagnosis and identify those patients who were at risk of progression and further morbidity and who would benefit from early intervention. Clinicians recommended adopting a holistic approach for patients with CKD representing a barometer of overall health. CONCLUSIONS The introduction of new National Institute for Health and Care Excellence (NICE) CKD guidelines in 2014, which focus the meaning and purpose of CKD monitoring by increased proteinuria testing and assessment of risk, may help to resolve some of the ethical and moral tensions clinicians expressed regarding the overmedicalisation of patients with a CKD diagnosis.
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Affiliation(s)
- Rosemary Simmonds
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, UK
| | - Julie Evans
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
| | - Gene Feder
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, UK
| | - Tom Blakeman
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK
| | - Dan Lasserson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Elizabeth Murray
- e-Health Unit, Research Department of Primary Care and Population Health, UCL, UK
| | - Kristina Bennert
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, UK
| | - Louise Locock
- Nuffield Department of Primary Care Health Sciences, University of Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Jeremy Horwood
- Centre for Academic Primary Care, School of Social and Community Medicine, University of Bristol, UK
- National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care (NIHR CLAHRC) West at University Hospitals Bristol NHS Foundation Trust
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Humphreys J, Entwhistle V, Burey L, O'Donoghue D, Blakeman T, Harvey G, Hegarty J. FP341FAILURE TO ACHIEVE NICE BP TARGETS IN PATIENTS WITH CKD AND PROTEINURIA WITHIN THE CLAHRC GM CKD PROGRAMME. Nephrol Dial Transplant 2015. [DOI: 10.1093/ndt/gfv175.23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Blakeman T, Blickem C, Kennedy A, Reeves D, Bower P, Gaffney H, Gardner C, Lee V, Jariwala P, Dawson S, Mossabir R, Brooks H, Richardson G, Spackman E, Vassilev I, Chew-Graham C, Rogers A. Effect of information and telephone-guided access to community support for people with chronic kidney disease: randomised controlled trial. PLoS One 2014; 9:e109135. [PMID: 25330169 PMCID: PMC4199782 DOI: 10.1371/journal.pone.0109135] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 09/02/2014] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Implementation of self-management support in traditional primary care settings has proved difficult, encouraging the development of alternative models which actively link to community resources. Chronic kidney disease (CKD) is a common condition usually diagnosed in the presence of other co-morbidities. This trial aimed to determine the effectiveness of an intervention to provide information and telephone-guided access to community support versus usual care for patients with stage 3 CKD. METHODS AND FINDINGS In a pragmatic, two-arm, patient level randomised controlled trial 436 patients with a diagnosis of stage 3 CKD were recruited from 24 general practices in Greater Manchester. Patients were randomised to intervention (215) or usual care (221). Primary outcome measures were health related quality of life (EQ-5D health questionnaire), blood pressure control, and positive and active engagement in life (heiQ) at 6 months. At 6 months, mean health related quality of life was significantly higher for the intervention group (adjusted mean difference = 0.05; 95% CI = 0.01, 0.08) and blood pressure was controlled for a significantly greater proportion of patients in the intervention group (adjusted odds-ratio = 1.85; 95% CI = 1.25, 2.72). Patients did not differ significantly in positive and active engagement in life. The intervention group reported a reduction in costs compared with control. CONCLUSIONS An intervention to provide tailored information and telephone-guided access to community resources was associated with modest but significant improvements in health related quality of life and better maintenance of blood pressure control for patients with stage 3 CKD compared with usual care. However, further research is required to identify the mechanisms of action of the intervention. TRIAL REGISTRATION Controlled-Trials.com ISRCTN45433299.
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Affiliation(s)
- Tom Blakeman
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Christian Blickem
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Anne Kennedy
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - David Reeves
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Hannah Gaffney
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Caroline Gardner
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Victoria Lee
- NIHR School for Primary Care Research, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Praksha Jariwala
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Shoba Dawson
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Rahena Mossabir
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Helen Brooks
- NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, United Kingdom
| | - Gerry Richardson
- Centre for Health Economics, University of York, Heslington, York, United Kingdom
| | - Eldon Spackman
- Centre for Health Economics, University of York, Heslington, York, United Kingdom
| | - Ivaylo Vassilev
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
| | - Carolyn Chew-Graham
- Primary Care & Health Services, University of Keele, Staffordshire, United Kingdom
| | - Anne Rogers
- NIHR CLAHRC Wessex, Health Sciences, University of Southampton, Highfield Campus, Southampton, United Kingdom
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Abstract
The prevalence and impact of long-term conditions continues to rise. Care planning for people with long-term conditions has been a policy priority for chronic disease management in a number of health-care systems. However, patients and providers appear unclear about the formulation and implementation of care planning. Further work in this area is therefore required to inform the development, implementation and evaluation of future care planning initiatives. We distinguish between 'care planning' (the process by which health-care professionals and patients discuss, agree and review an action plan to achieve the goals or behaviour change of most relevance and concern to the patient) and a 'care plan' (a written document recording the outcome of a care planning process). We propose a typology of care planning and care plans with three core dimensions: perspective (patient or professional), scope (a focus on goals or on behaviours) and networks (confined to the professional-patient dyad or extending to the entire care network). In addition, we draw on psychological models of mediation and moderation to outline potential mechanisms through which care planning and care plans may lead to improved outcomes for both patients and the wider health-care system. The proposed typology of care planning and care plans offered here, along with the model of the process by which care planning may influence outcomes, provide a useful framework for future policy developments and evaluations. Empirical work is required to explore the degree to which current care planning approaches and care plans can be described according to these dimensions, and the factors that determine which types of patients and professionals use which type of care plans.
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Affiliation(s)
- J Burt
- Corresponding author: Jenni Burt, Cambridge Centre for Health Services Research, Institute of Public Health, University of Cambridge, Forvie Site, Robinson Way, Cambridge CB2 0SR. Phone 01223 330596. Fax 01223 762515.
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Reeves D, Hann M, Rick J, Rowe K, Small N, Burt J, Roland M, Protheroe J, Blakeman T, Richardson G, Kennedy A, Bower P. Care plans and care planning in the management of long-term conditions in the UK: a controlled prospective cohort study. Br J Gen Pract 2014; 64:e568-75. [PMID: 25179071 PMCID: PMC4141614 DOI: 10.3399/bjgp14x681385] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Accepted: 04/11/2014] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND In the UK, the use of care planning and written care plans has been proposed to improve the management of long-term conditions, yet there is limited evidence concerning their uptake and benefits. AIM To explore the implementation of care plans and care planning in the UK and associations with the process and outcome of care. DESIGN AND SETTING A controlled prospective cohort study among two groups of patients with long-term conditions who were similar in demographic and clinical characteristics, but who were registered with general practices varying in their implementation of care plans and care planning. METHOD Implementation of care plans and care planning in general practice was assessed using the 2009-2010 GP Patient Survey, and relationships with patient outcomes (self-management and vitality) were examined using multilevel, mixed effects linear regression modelling. RESULTS The study recruited 38 practices and 2439 patients. Practices in the two groups (high and low users of written documents) were similar in structural and population characteristics. Patients in the two groups of practices were similar in demographics and baseline health. Patients did demonstrate significant differences in reported experiences of care planning, although the differences were modest. Very few patients in the cohort reported a written plan that could be confirmed. Analysis of outcomes suggested that most patients show limited change over time in vitality and self-management. Variation in the use of care plans at the practice level was very limited and not related to patient outcomes over time. CONCLUSION The use of written care plans in patients with long-term conditions is uncommon and unlikely to explain a substantive amount of variation in the process and outcome of care. More proactive efforts at implementation may be required to provide a rigorous test of the potential of care plans and care planning.
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Affiliation(s)
- David Reeves
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester
| | - Mark Hann
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester
| | - Jo Rick
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester
| | - Kelly Rowe
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester
| | - Nicola Small
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester
| | - Jenni Burt
- Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Martin Roland
- Department of Public Health and Primary Care, University of Cambridge, Cambridge
| | - Joanne Protheroe
- Institute of Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Keele University, Keele
| | - Tom Blakeman
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester
| | | | - Anne Kennedy
- Faculty of Health Sciences, University of Southampton, Southampton
| | - Peter Bower
- NIHR School for Primary Care Research, Centre for Primary Care, University of Manchester, Manchester
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Kennedy A, Rogers A, Bowen R, Lee V, Blakeman T, Gardner C, Morris R, Protheroe J, Chew-Graham C. Implementing, embedding and integrating self-management support tools for people with long-term conditions in primary care nursing: A qualitative study. Int J Nurs Stud 2014; 51:1103-13. [DOI: 10.1016/j.ijnurstu.2013.11.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Revised: 11/18/2013] [Accepted: 11/19/2013] [Indexed: 11/28/2022]
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Blickem C, Kennedy A, Jariwala P, Morris R, Bowen R, Vassilev I, Brooks H, Blakeman T, Rogers A. Aligning everyday life priorities with people's self-management support networks: an exploration of the work and implementation of a needs-led telephone support system. BMC Health Serv Res 2014; 14:262. [PMID: 24938492 PMCID: PMC4071856 DOI: 10.1186/1472-6963-14-262] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Accepted: 06/10/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Recent initiatives to target the personal, social and clinical needs of people with long-term health conditions have had limited impact within primary care. Evidence of the importance of social networks to support people with long-term conditions points to the need for self-management approaches which align personal circumstances with valued activities. The Patient-Led Assessment for Network Support (PLANS) intervention is a needs-led assessment for patients to prioritise their health and social needs and provide access to local community services and activities. Exploring the work and practices of patients and telephone workers are important for understanding and evaluating the workability and implementation of new interventions. METHODS Qualitative methods (interviews, focus group, observations) were used to explore the experience of PLANS from the perspectives of participants and the telephone support workers who delivered it (as part of an RCT) and the reasons why the intervention worked or not. Normalisation Process Theory (NPT) was used as a sensitising tool to evaluate: the relevance of PLANS to patients (coherence); the processes of engagement (cognitive participation); the work done for PLANS to happen (collective action); the perceived benefits and costs of PLANS (reflexive monitoring). 20 patients in the intervention arm of a clinical trial were interviewed and their telephone support calls were recorded and a focus group with 3 telephone support workers was conducted. RESULTS Analysis of the interviews, support calls and focus group identified three themes in relation to the delivery and experience of PLANS. These are: formulation of 'health' in the context of everyday life; trajectories and tipping points: disrupting everyday routines; precarious trust in networks. The relevance of these themes are considered using NPT constructs in terms of the work that is entailed in engaging with PLANS, taking action, and who is implicated this process. CONCLUSIONS PLANS gives scope to align long-term condition management to everyday life priorities and valued aspects of life. This approach can improve engagement with health-relevant practices by situating them within everyday contexts. This has potential to increase utilisation of local resources with potential cost-saving benefits for the NHS. TRIAL REGISTRATION ISRCTN45433299.
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Affiliation(s)
- Christian Blickem
- NIHR Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Greater Manchester, Centre for Primary Care, Institute of Population Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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Small N, Blickem C, Blakeman T, Panagioti M, Chew-Graham CA, Bower P. Telephone based self-management support by 'lay health workers' and 'peer support workers' to prevent and manage vascular diseases: a systematic review and meta-analysis. BMC Health Serv Res 2013; 13:533. [PMID: 24370214 PMCID: PMC3880982 DOI: 10.1186/1472-6963-13-533] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2013] [Accepted: 12/10/2013] [Indexed: 11/13/2022] Open
Abstract
Background Improved prevention and management of vascular disease is a global priority. Non-health care professionals (such as, ‘lay health workers’ and ‘peer support workers’) are increasingly being used to offer telephone support alongside that offered by conventional services, to reach disadvantaged populations and to provide more efficient delivery of care. However, questions remain over the impact of such interventions, particularly on a wider range of vascular related conditions (such as, chronic kidney disease), and it is unclear how different types of telephone support impact on outcome. This study assessed the evidence on the effectiveness and cost-effectiveness of telephone self-management interventions led by ‘lay health workers’ and ‘peer support workers’ for patients with vascular disease and long-term conditions associated with vascular disease. Methods Systematic review of randomised controlled trials. Three electronic databases were searched. Two authors independently extracted data according to the Cochrane risk of bias tool. Random effects meta-analysis was used to pool outcome measures. Results Ten studies were included, primarily based in community settings in the United States; with participants who had diabetes; and used ‘peer support workers’ that shared characteristics with patients. The included studies were generally rated at risk of bias, as many methodological criteria were rated as ‘unclear’ because of a lack of information. Overall, peer telephone support was associated with small but significant improvements in self-management behaviour (SMD = 0.19, 95% CI 0.05 to 0.33, I2 = 20.4%) and significant reductions in HbA1c level (SMD = -0.26, 95% CI −0.41 to −0.11, I2 = 47.6%). There was no significant effect on mental health quality of life (SMD = 0.03, 95% CI −0.12 to 0.18, I2 = 0%). Data on health care utilisation were very limited and no studies reported cost effectiveness analyses. Conclusions Positive effects were found for telephone self-management interventions via ‘lay workers’ and ‘peer support workers’ for patients on diabetes control and self-management outcomes, but the overall evidence base was limited in scope and quality. Well designed trials assessing non-healthcare professional delivered telephone support for the prevention and management of vascular disease are needed to identify the content of effective components on health outcomes, and to assess cost effectiveness, to determine if such interventions are potentially useful alternatives to professionally delivered care.
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Affiliation(s)
- Nicola Small
- Greater Manchester Collaboration for Leadership in Applied Health Research and Care, Centre for Primary Care, and Manchester Academic Health Science Centre, University of Manchester, Manchester, UK.
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Blickem C, Kennedy A, Vassilev I, Morris R, Brooks H, Jariwala P, Blakeman T, Rogers A. Linking people with long-term health conditions to healthy community activities: development of Patient-Led Assessment for Network Support (PLANS). Health Expect 2013; 16:e48-59. [PMID: 23731452 PMCID: PMC3908360 DOI: 10.1111/hex.12088] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/01/2013] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVE To combine insights from service users with long-term conditions (LTCs) to assist the development of a community referral intervention designed to promote engagement and improve access to health-relevant resources. BACKGROUND Social deprivation and reduced access to resources have been causally linked with social isolation and the ability to manage LTCs. Participation in meaningful activity has been associated with positive health benefits, and strategies to promote access to community activities have shown some potential to improve outcomes for people with LTCs. This suggests the need to develop an engagement and referral intervention in partnership with service users and community groups as part of mainstream self-care support. METHOD A series of focus groups and interviews with members of community groups in Greater Manchester designed as an iterative and collaborative approach to elicit the role of personal and community networks that support long-term condition management (LTCM) to develop a community referral tool. RESULTS Participants reported a broad range of resources relevant to LTCM that often went beyond the usual concerns associated with self-care. This helped to inform a tool (PLANS) to tailor access to types of community-based resources which can support LTCM. CONCLUSIONS Understanding the everyday challenges of living with a LTC highlighted the importance of connecting and engaging with localized support for people. In response to this, we developed an intervention (PLANS) which tailors access to local resources based on personal preferences, needs and acceptability to encourage service users to engage with sustainable health choices.
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Affiliation(s)
- Christian Blickem
- Centre for Primary Care, Institute of Population Health, University of Manchester, Manchester, UK.
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Reeve J, Blakeman T, Freeman GK, Green LA, James PA, Lucassen P, Martin CM, Sturmberg JP, van Weel C. Generalist solutions to complex problems: generating practice-based evidence--the example of managing multi-morbidity. BMC Fam Pract 2013; 14:112. [PMID: 23919296 PMCID: PMC3750615 DOI: 10.1186/1471-2296-14-112] [Citation(s) in RCA: 50] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2013] [Accepted: 08/02/2013] [Indexed: 11/14/2022]
Abstract
Background A growing proportion of people are living with long term conditions. The majority have more than one. Dealing with multi-morbidity is a complex problem for health systems: for those designing and implementing healthcare as well as for those providing the evidence informing practice. Yet the concept of multi-morbidity (the presence of >2 diseases) is a product of the design of health care systems which define health care need on the basis of disease status. So does the solution lie in an alternative model of healthcare? Discussion Strengthening generalist practice has been proposed as part of the solution to tackling multi-morbidity. Generalism is a professional philosophy of practice, deeply known to many practitioners, and described as expertise in whole person medicine. But generalism lacks the evidence base needed by policy makers and planners to support service redesign. The challenge is to fill this practice-research gap in order to critically explore if and when generalist care offers a robust alternative to management of this complex problem. We need practice-based evidence to fill this gap. By recognising generalist practice as a ‘complex intervention’ (intervening in a complex system), we outline an approach to evaluate impact using action-research principles. We highlight the implications for those who both commission and undertake research in order to tackle this problem. Summary Answers to the complex problem of multi-morbidity won’t come from doing more of the same. We need to change systems of care, and so the systems for generating evidence to support that care. This paper contributes to that work through outlining a process for generating practice-based evidence of generalist solutions to the complex problem of person-centred care for people with multi-morbidity.
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Affiliation(s)
- Joanne Reeve
- University of Liverpool, B122 Waterhouse Buildings, 1-5 Brownlow St, Liverpool L693GL, UK.
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Kennedy A, Bower P, Reeves D, Blakeman T, Bowen R, Chew-Graham C, Eden M, Fullwood C, Gaffney H, Gardner C, Lee V, Morris R, Protheroe J, Richardson G, Sanders C, Swallow A, Thompson D, Rogers A. Implementation of self management support for long term conditions in routine primary care settings: cluster randomised controlled trial. BMJ 2013; 346:f2882. [PMID: 23670660 PMCID: PMC3652644 DOI: 10.1136/bmj.f2882] [Citation(s) in RCA: 177] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVE To determine the effectiveness of an intervention to enhance self management support for patients with chronic conditions in UK primary care. DESIGN Pragmatic, two arm, cluster randomised controlled trial. SETTING General practices, serving a population in northwest England with high levels of deprivation. PARTICIPANTS 5599 patients with a diagnosis of diabetes (n=2546), chronic obstructive pulmonary disease (n=1634), and irritable bowel syndrome (n=1419) from 43 practices (19 intervention and 22 control practices). INTERVENTION Practice level training in a whole systems approach to self management support. Practices were trained to use a range of resources: a tool to assess the support needs of patients, guidebooks on self management, and a web based directory of local self management resources. Training facilitators were employed by the health management organisation. MAIN OUTCOME MEASURES Primary outcomes were shared decision making, self efficacy, and generic health related quality of life measured at 12 months. Secondary outcomes were general health, social or role limitations, energy and vitality, psychological wellbeing, self care activity, and enablement. RESULTS We randomised 44 practices and recruited 5599 patients, representing 43% of the eligible population on the practice lists. 4533 patients (81.0%) completed the six month follow-up and 4076 (72.8%) the 12 month follow-up. No statistically significant differences were found between patients attending trained practices and those attending control practices on any of the primary or secondary outcomes. All effect size estimates were well below the prespecified threshold of clinically important difference. CONCLUSIONS An intervention to enhance self management support in routine primary care did not add noticeable value to existing care for long term conditions. The active components required for effective self management support need to be better understood, both within primary care and in patients' everyday lives. TRIAL REGISTRATION Current Controlled Trials ISRCTN90940049.
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Affiliation(s)
- Anne Kennedy
- Faculty of Health Sciences, University of Southampton, Highfield Campus, Southampton SO17 1BJ, UK.
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25
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Blickem C, Blakeman T, Kennedy A, Bower P, Reeves D, Gardner C, Lee V, Chew-Graham C, Richardson G, Brooks H, Dawson S, Mossabir R, Jariwala P, Swallow A, Kontopantelis E, Gaffney H, Small N, Spackman E, Rogers A. The clinical and cost-effectiveness of the BRinging Information and Guided Help Together (BRIGHT) intervention for the self-management support of people with stage 3 chronic kidney disease in primary care: study protocol for a randomized controlled trial. Trials 2013; 14:28. [PMID: 23356861 PMCID: PMC3599273 DOI: 10.1186/1745-6215-14-28] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2012] [Accepted: 01/11/2013] [Indexed: 12/31/2022] Open
Abstract
Background Improving the quality of care for people with vascular disease is a key priority. Chronic kidney disease (CKD) has recently been included as a target condition for general practices to add to registers of chronic conditions as part of the Quality and Outcome Framework. This paper outlines the implementation and evaluation of a self-management intervention involving an information guidebook, tailored access to local resources and telephone support for people with stage 3 chronic kidney disease. Methods/Design The study involves a multi-site, longitudinal patient-level randomized controlled trial. The study will evaluate the clinical use and cost-effectiveness of a complex self-management intervention for people with stage 3 chronic kidney disease in terms of self-management capacity, health-related quality of life and blood pressure control compared to care as usual. We describe the methods of the patient-level randomized controlled trial. Discussion The management of chronic kidney disease is a developing area of research. The BRinging Information and Guided Help Together (BRIGHT) trial aims to provide evidence that a complementary package of support for people with vascular disease that targets both clinical and social need broadens the opportunities of self-management support by addressing problems related to social disadvantage. Trial registration Trial registration reference: ISRCTN45433299
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Affiliation(s)
- Christian Blickem
- Centre for Primary Care, Institute of Population Health, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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Newbould J, Burt J, Bower P, Blakeman T, Kennedy A, Rogers A, Roland M. Experiences of care planning in England: interviews with patients with long term conditions. BMC Fam Pract 2012; 13:71. [PMID: 22831570 PMCID: PMC3436749 DOI: 10.1186/1471-2296-13-71] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Accepted: 07/25/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND The prevalence and impact of long term conditions continues to rise. Care planning for people with long term conditions has been a policy priority in England for chronic disease management. However, it is not clear how care planning is currently understood, translated and implemented in primary care. This study explores experience of care planning in patients with long term conditions in three areas in England. METHODS We conducted semi-structured interviews with 23 predominantly elderly patients with multiple long term conditions. The interviews were designed to explore variations in and emergent experiences of care planning. Qualitative analysis of interview transcripts involved reflexively coding and re-coding data into categories and themes. RESULTS No participants reported experiencing explicit care planning discussions or receiving written documentation setting out a negotiated care plan and they were unfamiliar with the term 'care planning'. However, most described some components of care planning which occurred over a number of contacts with health care professionals which we term "reactive" care planning. Here, key elements of care planning including goal setting and action planning were rare. Additionally, poor continuity and coordination of care, lack of time in consultations, and patient concerns about what was legitimate to discuss with the doctor were described. CONCLUSIONS Amongst this population, elements of care planning were present in their accounts, but a structured, comprehensive process and consequent written record (as outlined in English Department of Health policy) was not evident. Further research needs to explore the advantages and disadvantages of different approaches to care planning for different patient groups.
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Affiliation(s)
- Jenny Newbould
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Jenni Burt
- Cambridge Centre for Health Services Research, University of Cambridge, Cambridge, UK
| | - Peter Bower
- Health Sciences Research Group, University of Manchester, Manchester, UK
| | - Tom Blakeman
- Health Sciences Research Group, University of Manchester, Manchester, UK
| | - Anne Kennedy
- Health Sciences Research Group, University of Manchester, Manchester, UK
| | - Anne Rogers
- Health Sciences Research Group, University of Manchester, Manchester, UK
| | - Martin Roland
- Health Sciences Research Group, University of Manchester, Manchester, UK
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Blakeman T, Protheroe J, Chew-Graham C, Rogers A, Kennedy A. Understanding the management of early-stage chronic kidney disease in primary care: a qualitative study. Br J Gen Pract 2012; 62:e233-42. [PMID: 22520910 PMCID: PMC3310029 DOI: 10.3399/bjgp12x636056] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2011] [Revised: 10/19/2011] [Accepted: 12/01/2011] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Primary care is recognised to have an important role in the delivery of care for people with chronic kidney disease (CKD). However, there is evidence that CKD management is currently suboptimal, with a range of practitioner concerns about its management. AIM To explore processes underpinning the implementation of CKD management in primary care. DESIGN AND SETTING Qualitative study in general practices participating in a chronic kidney disease collaborative undertaken as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester. METHOD Semi-structured interviews were conducted with GPs and practice nurses (n = 21). Normalisation Process Theory provided a framework for generation and analysis of the data. RESULTS A predominant theme was anxiety about the disclosure of early-stage CKD with patients. The tensions experienced related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team. Participants provided accounts of work undertaken to resolve the difficulties encountered, with efforts having tended to focus on reassuring patients. Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions. CONCLUSION Offering reassurance alone may be of limited benefit, and current management of early-stage CKD in primary care may miss opportunities to address susceptibility to kidney injury, improve self-management of vascular conditions, and improve the management of multimorbidity.
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Affiliation(s)
- Tom Blakeman
- Health Sciences Research Group, and Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester, School for Community Based Medicine, University of Manchester, Manchester.
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Bower P, Kennedy A, Reeves D, Rogers A, Blakeman T, Chew-Graham C, Bowen R, Eden M, Gardner C, Hann M, Lee V, Morris R, Protheroe J, Richardson G, Sanders C, Swallow A, Thompson D. A cluster randomised controlled trial of the clinical and cost-effectiveness of a 'whole systems' model of self-management support for the management of long- term conditions in primary care: trial protocol. Implement Sci 2012; 7:7. [PMID: 22280501 PMCID: PMC3274470 DOI: 10.1186/1748-5908-7-7] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2011] [Accepted: 01/26/2012] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care. METHODS The evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial. DISCUSSION If the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population. TRIAL REGISTRATION NUMBER ISRCTN: ISRCTN90940049.
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Affiliation(s)
- Peter Bower
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Anne Kennedy
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - David Reeves
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Anne Rogers
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Tom Blakeman
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Carolyn Chew-Graham
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Robert Bowen
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Martin Eden
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Caroline Gardner
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Mark Hann
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Victoria Lee
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Rebecca Morris
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Joanne Protheroe
- Institute of Primary Care and Health Sciences, Arthritis Research UK Primary Care Centre, Keele University, UK
| | - Gerry Richardson
- Centre for Health Economics, University of York, York YO10 5DD, UK
| | - Caroline Sanders
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - Angela Swallow
- Primary Care Research Group, Community Based Medicine, University of Manchester, 5th Floor Williamson Building, Oxford Road, Manchester M13 9PL, UK
| | - David Thompson
- Section GI Science, School of Translational Medicine- Hope, Clinical Sciences Building, Hope Hospital, Salford M6 8HD, UK
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Bower P, Macdonald W, Harkness E, Gask L, Kendrick T, Valderas JM, Dickens C, Blakeman T, Sibbald B. Multimorbidity, service organization and clinical decision making in primary care: a qualitative study. Fam Pract 2011; 28:579-87. [PMID: 21613378 DOI: 10.1093/fampra/cmr018] [Citation(s) in RCA: 125] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND Primary care professionals often manage patients with multiple long-term health conditions, but managing multimorbidity is challenging given time and resource constraints and interactions between conditions. OBJECTIVE To explore GP and nurse perceptions of multimorbidity and the influence on service organization and clinical decision making. METHODS A qualitative interview study with primary care professionals in practices in Greater Manchester, U.K. Interviews were conducted with 15 GPs and 10 practice nurses. RESULTS Primary care professionals identified tensions between delivering care to meet quality targets and fulfilling the patient's agenda, tensions which are exacerbated in multimorbidity. They were aware of the inconvenience suffered by patients through attendance at multiple clinic appointments when care was structured around individual conditions. They reported difficulties managing patients with multimorbidity in limited consultation time, which led to adoption of an 'additive-sequential' decision-making model which dealt with problems in priority order until consultation resources were exhausted, when further management was deferred. Other challenges included the need for patients to co-ordinate their care, the difficulties of self-management support in multimorbidity and problems of making sense of the relationships between physical and mental health. Doctor and nurse accounts included limited consideration of multimorbidity in terms of the interactions between conditions or synergies between management of different conditions. CONCLUSIONS Primary care professionals identify a number of challenges in care for multimorbidity and adopt a particular model of decision making to deliver care for multiple individual conditions. However, they did not describe specific decision making around managing multimorbidity per se.
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Affiliation(s)
- Peter Bower
- National Institute for Health Research School for Primary Care Research, Manchester Academic Health Science Centre, Health Sciences Research Group, University of Manchester, Oxford Road, Manchester M13 9PL, UK.
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Protheroe J, Blakeman T, Bower P, Chew-Graham C, Kennedy A. An intervention to promote patient participation and self-management in long term conditions: development and feasibility testing. BMC Health Serv Res 2010; 10:206. [PMID: 20630053 PMCID: PMC2912900 DOI: 10.1186/1472-6963-10-206] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2009] [Accepted: 07/14/2010] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND There is worldwide interest in managing the global burden of long-term conditions. Current health policy places emphasis on self-management and supporting patient participation as ways of improving patient outcomes and reducing costs. However, achieving genuine participation is difficult. This paper describes the development of an intervention designed to promote participation in the consultation and facilitate self-management in long-term conditions. In line with current guidance on the development of complex interventions, our aim was to develop and refine the initial intervention using qualitative methods, prior to more formal evaluation. METHODS We based the intervention on published evidence on effective ways of improving participation. The intervention was developed, piloted and evaluated using a range of qualitative methods. Firstly, focus groups with stakeholders (5 patients and 3 clinicians) were held to introduce the prototype and elucidate how it could be improved. Then individual 'think aloud' and qualitative interviews (n = 10) were used to explore how patients responded to and understood the form and provide further refinement. RESULTS The literature highlighted that effective methods of increasing participation include the use of patient reported outcome measures and values clarification exercises. The intervention (called PRISMS) integrated these processes, using a structured form which required patients to identify problems, rate their magnitude and identify their priority. PRISMS was well received by patients and professionals. In the individual qualitative interviews the main themes that emerged from the data related to (a) the content of the PRISMS (b) the process of completing PRISMS and how it could be operationalised in practice and (c) the outcomes of completing PRISMS for the patient. A number of different functions of PRISMS were identified by patients including its use as an aide-memoire, to provide a focus to consultations, to give permission to discuss certain issues, and to provide greater tailoring for the patient. CONCLUSIONS There was evidence that patients found the PRISMS form acceptable and potentially useful. The challenge encountered by patients in completing PRISMS may encourage exploration of these issues within the consultation, complementing the more 'task focussed' aspects of consultations resulting from introduction of clinical guidelines and financial incentives. Further research is required to provide a rigorous assessment of the ability of tools like PRISMS to achieve genuine change in the process and outcome of consultations.
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Affiliation(s)
- Joanne Protheroe
- National Primary Care Research and Development Centre, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Tom Blakeman
- National Primary Care Research and Development Centre, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Peter Bower
- National Primary Care Research and Development Centre, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Carolyn Chew-Graham
- National Primary Care Research and Development Centre, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
| | - Anne Kennedy
- National Primary Care Research and Development Centre, University of Manchester, Oxford Road, Manchester, M13 9PL, UK
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Blakeman T, Bower P, Reeves D, Chew-Graham C. Bringing self-management into clinical view: a qualitative study of long-term condition management in primary care consultations. Chronic Illn 2010; 6:136-50. [PMID: 20444765 DOI: 10.1177/1742395309358333] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES To understand social processes underpinning support for self-management of long-term conditions in primary care. METHODS Comparative analysis of observational and interview data concerning the management of long-term conditions in UK primary-care consultations. Analysis of recordings of primary care consultations (n = 86) was conducted in conjunction with analysis of semi-structured interviews with health professionals (n = 17) and patients (n = 12) living with a long-term condition. RESULTS A key finding was the infrequency with which self-management topics became legitimate objects for discussion in consultations. Analysis suggested that the maintenance of self-other relations was a prime objective for both patients and professionals, and the introduction of self-management topics threatened this process. Technology and the division of labour among primary-care professionals reinforced this tension. DISCUSSION In order for self-management support to become embedded and integrated into primary care, interventions concerning long-term condition management need to take into account this tension underpinning care.
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Affiliation(s)
- Tom Blakeman
- NPCRDC, The University of Manchester Williamson Building, Manchester, UK.
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Abstract
AIM This paper is a report of a study to explore practice nurse involvement in facilitation of self-management for long-term conditions. BACKGROUND In the United Kingdom chronic disease services have shifted from secondary care to general practice and from general practitioners to practice nurses. A new United Kingdom General Practice contract requires adherence to chronic disease management protocols, and facilitating self-management is recognized as an important component. However, improving self-management is a relatively new focus and little is known about the ways in which nurses engage with patient self-management and how they view work with patients in chronic disease clinics. METHOD Semi-structured interviews with 25 practice nurses were carried out in 2004-2005. Interviews were audio-taped and transcribed verbatim. Analysis was informed by the 'trajectory model' and 'personal construct' theories. FINDINGS Main themes in the early stages of work with patients were: categorization of patients, diagnosis, and patient education. First impressions appeared to determine expectations of self-management abilities, although these were amenable to change. Intermediate stages were 'ways of working' (breaking the task down, cognitive restructuring and addressing dissonance, modelling 'good' behaviour, encouragement, listening, involving carers and referral) and maintaining relationships with patients. However, in the longer-term nurses seemed to lack resources beyond personal experience and intuitive ways of working for encouraging effective self-care. CONCLUSION The ways of working identified are unlikely to be sufficient to support patients' self-management, pointing to a need for education to equip nurses with techniques to work effectively with patients dealing with longer-term effects of chronic illness.
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Affiliation(s)
- Wendy Macdonald
- National Primary Care Research and Development Centre, Manchester, UK.
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Blakeman T, Macdonald W, Bower P, Gately C, Chew-Graham C. A qualitative study of GPs' attitudes to self-management of chronic disease. Br J Gen Pract 2006; 56:407-14. [PMID: 16762121 PMCID: PMC1839014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/10/2023] Open
Abstract
BACKGROUND Improving the quality of care for patients living with a chronic illness is a key policy goal. Alongside systems to ensure care is delivered according to evidence-based guidelines, an essential component of these new models of care is the facilitation of self-management. However, changes to the way professionals deliver care is complex, and it is important to understand the key drivers and barriers that may operate in the primary care setting. AIM To explore GPs' perspectives on their involvement in the facilitation of chronic disease self-management. DESIGN OF STUDY Qualitative study. SETTING General practices located in two primary care trusts in northern England. METHOD Data were collected through in-depth, semi-structured interviews with a purposive sample of GPs. During analysis, categories of response were organised into themes that relate to Howie's theoretical model for understanding general practice consultations: content, values, context. RESULTS The GPs' responses highlighted tensions and trade-offs regarding their role in facilitating self-management. Although GPs valued increased patient involvement in their health care, this was in conflict with other values concerning professional responsibility. Furthermore, contextual factors also limited the degree to which they could assist in encouraging self-management. CONCLUSIONS Providing GPs with training in consultation skills is required in order to encourage the delivery of effective self-management. In addition, the context in which GPs work also needs to be modified for this to be achieved.
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Affiliation(s)
- Tom Blakeman
- The National Primary Care Research and Development Centre, Manchester.
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Coulson ML, Blakeman T, Shortus T, Zwar NA. Using a division based diabetes register to target patients for enhanced primary care care planning. Aust Fam Physician 2002; 31:1064. [PMID: 12516505] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/28/2023]
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Harris M, Blakeman T. Enhanced primary care items. Their use in diabetes management. Aust Fam Physician 2001; 30:1134-40. [PMID: 11838391] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Abstract
BACKGROUND The Enhanced Primary Care (EPC) items for care planning and case conferencing provide an opportunity for better quality care for people with chronic disease. OBJECTIVE To explore the use of the EPC items in the structured care of diabetes based on evidenced based guidelines in general practice. DISCUSSION Care planning and case conferencing are useful, especially in the structured care of patients who have poor control. The achievement of better health outcome for these patients depends upon a patient oriented and structured approach in collaboration with other health professionals. This needs to be supported by systems within the practice, Division and local community.
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Affiliation(s)
- M Harris
- School of Community Medicine, University of New South Wales.
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Blakeman T, Harris MF, Comino E, Zwar N. Implementation of the enhanced primary care items requires ongoing education and evaluation. Aust Fam Physician 2001; 30:75-7. [PMID: 11211719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
OBJECTIVE The study aimed to evaluate the uptake and usage of the Federal Government's Enhanced Primary Care (EPC) items by general practitioners in outer urban general practice. METHOD Faxed questionnaire with telephone follow up of a random sample of 347 GPs in South West Sydney, in March and April 2000. RESULTS There was a response rate of 70.6%. Seventy-three percent of respondents reported they had heard of the EPC package and 27% of all the respondents had used one or more of the items. Twenty-three percent had claimed for health assessments (median number 3), 4.5% for care plans (median number 3) and 4% for case conferences (median number 1). Just under half of the GPs who had claimed for health assessments had conducted them in the patient's home. Most GPs either had no system for the use of the items or planned to use them opportunistically. Forty-nine percent of GPs had an age-sex register and those who did were more likely to have claimed for an EPC item and to have specific plans for their use. CONCLUSION While most GPs had heard of the EPC items, only a minority had used them and few planned to use them systematically within their practice. There is a need to address barriers to the uptake of the EPC items and to provide greater support to GPs and health professionals involved with their implementation, especially for care plans and case conferences. Evaluation of the EPC items needs to be an integral part of the implementation process.
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Affiliation(s)
- T Blakeman
- Department of General Practice, South West Sydney Area Health Service, School of Community Medicine, University of New South Wales
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