scholarly journals Improving the Care of People with Long-Term Conditions in Primary Care: Protocol for the Enhance Pilot Trial

2015 ◽  
Vol 5 (1) ◽  
pp. 135-149 ◽  
Author(s):  
Emma L. Healey ◽  
Clare Jinks ◽  
Valerie A. Tan ◽  
Carolyn A. Chew-Graham ◽  
Sarah A. Lawton ◽  
...  
Keyword(s):  
Primary Care ◽  
Controlled Trial ◽  
Qualitative Interviews ◽  
Pilot Trial ◽  
Integrated Approach ◽  
Long Term Conditions ◽  
Delivery Of Care ◽  
Care Protocol ◽  
Engagement Assessment

Background Long-term conditions (LTCs) are important determinants of quality of life and healthcare expenditure worldwide. Whilst multimorbidity is increasingly the norm in primary care, clinical guidelines and the delivery of care remain focused on single diseases, resulting in poorer clinical outcomes. Osteoarthritis, and anxiety and/or depression frequently co-occur with other LTCs, yet are seldom prioritized by the patient or clinician, resulting in higher levels of disability, poorer prognosis, and increased healthcare costs. Objective To examine the feasibility and acceptability of an integrated approach to LTC management, tackling the under-diagnosis and under-management of osteoarthritis-related pain and anxiety and/or depression in older adults with other LTCs in primary care. Design The ENHANCE study is a pilot stepped-wedge cluster randomized controlled trial to test the feasibility and acceptability of a nurse-led ENAHNCE LTC review consultation for identifying, assessing, and managing joint pain, and anxiety and/or depression in patients attending LTC reviews. Specific objectives (process evaluation and research outcomes) will be achieved through a theoretically informed mixed-methods approach using participant self-reported questionnaires, a medical record review, an ENHANCE EMIS template, qualitative interviews, and audio recordings of the ENHANCE LTC review. Discussion Success of the pilot trial will be measured against the level of the primary care team engagement, assessment of training delivery, and degree of patient recruitment and retention. Patient satisfaction and treatment fidelity will also be explored. ISRCTN registry number: 12154418.

scholarly journals The INCLUDE study

2018 ◽  
Vol 8 (1) ◽  
pp. 2235042X1879237 ◽  
Author(s):  
Samantha L Hider ◽  
Milica Bucknall ◽  
Kelly Cooke ◽  
Kendra Cooke ◽  
Andrew G Finney ◽  
...  
Keyword(s):  
Cardiovascular Disease ◽  
Primary Care ◽  
Process Evaluation ◽  
Controlled Trial ◽  
Qualitative Interviews ◽  
Retention Rates ◽  
Anxiety And Depression ◽  
Long Term Conditions ◽  
Inflammatory Conditions ◽  
Increased Risk

Background: Patients with inflammatory rheumatic conditions such as rheumatoid arthritis, polymyalgia rheumatica and ankylosing spondylitis are at increased risk of common comorbidities such as cardiovascular disease, osteoporosis and anxiety and depression which lead to increased morbidity and mortality. These associated morbidities are often un-recognized and under-treated. While patients with other long-term conditions such as diabetes are invited for routine reviews in primary care, which may include identification and management of co-morbidities, at present this does not occur for patients with inflammatory conditions, and thus, opportunities to diagnose and optimally manage these comorbidities are missed. Objective: To evaluate the feasibility and acceptability of a nurse-led integrated care review (the INtegrating and improving Care for patients with infLammatory rheUmatological DisordErs in the community (INCLUDE) review) for people with inflammatory rheumatological conditions in primary care. Design: A pilot cluster randomized controlled trial will be undertaken to test the feasibility and acceptability of a nurse-led integrated primary care review for identification, assessment and initial management of common comorbidities including cardiovascular disease, osteoporosis and anxiety and depression. A process evaluation will be undertaken using a mixed methods approach including participant self-reported questionnaires, a medical record review, an INCLUDE EMIS template, intervention fidelity checking using audio-recordings of the INCLUDE review consultation and qualitative interviews with patient participants, study nurses and study general practitioners (GPs) Discussion: Success of the pilot study will be measured against the engagement, recruitment and study retention rates of both general practices and participants. Acceptability of the INCLUDE review to patients and practitioners and treatment fidelity will be explored using a parallel process evaluation. Trial Registration: ISRCTN12765345.

scholarly journals General practitioners’ views and experiences in caring for patients after sepsis: a qualitative interview study

BMJ Open ◽  
2021 ◽  
Vol 11 (2) ◽  
pp. e040533
Author(s):  
Sabine Gehrke-Beck ◽  
Jochen Gensichen ◽  
Katrina M Turner ◽  
Christoph Heintze ◽  
Konrad FR Schmidt
Keyword(s):  
Primary Care ◽  
Critical Illness ◽  
General Practitioners ◽  
Continuity Of Care ◽  
Controlled Trial ◽  
Qualitative Interviews ◽  
Daily Practice ◽  
Training Programme ◽  
Qualitative Interview Study

BackgroundPatients surviving critical illnesses, such as sepsis, often suffer from long-term complications. After discharge from hospital, most patients are treated in primary care. Little is known how general practitioners (GPs) perform critical illness aftercare and how it can be improved. Within a randomised controlled trial, an outreach training programme has been developed and applied.ObjectivesThe aim of this study is to describe GPs’ views and experiences of caring for postsepsis patients and of participating a specific outreach training.DesignSemistructured qualitative interviews.Setting14 primary care practices in the metropolitan area of Berlin, Germany.Participants14 GPs who had participated in a structured sepsis aftercare programme in primary care.ResultsThemes identified in sepsis aftercare were: continuity of care and good relationship with patients, GP’s experiences during their patient’s critical illness and impact of persisting symptoms. An outreach education as part of the intervention was considered by the GPs to be acceptable, helpful to improve knowledge of the management of postintensive care complications and useful for sepsis aftercare in daily practice.ConclusionsGPs provide continuity of care to patients surviving sepsis. Better communication at the intensive care unit–GP interface and training in management of long-term complications of sepsis may be helpful to improve sepsis aftercare.Trial registration numberISRCTN61744782.

scholarly journals A randomised controlled trial, cost-effectiveness and process evaluation of the implementation of self-management for chronic gastrointestinal disorders in primary care, and linked projects on identification and risk assessment

2018 ◽  
Vol 6 (1) ◽  
pp. 1-154 ◽  
Author(s):  
David G Thompson ◽  
Sarah O’Brien ◽  
Anne Kennedy ◽  
Anne Rogers ◽  
Peter Whorwell ◽  
...  
Keyword(s):  
Risk Assessment ◽  
Primary Care ◽  
Assessment Tool ◽  
Controlled Trial ◽  
Self Management ◽  
Gastrointestinal Disorders ◽  
Management Support ◽  
Long Term Conditions

BackgroundChronic gastrointestinal disorders are major burdens in primary care. Although there is some evidence that enhancing self-management can improve outcomes, it is not known if such models of care can be implemented at scale in routine NHS settings and whether or not it is possible to develop effective risk assessment procedures to identify patients who are likely to become chronically ill.ObjectivesWhat is the clinical effectiveness and cost-effectiveness of an intervention to enhance self-management support for patients with chronic conditions when translated from research settings into routine care? What are the barriers and facilitators that affect the implementation of an intervention to enhance self-management support among patients, clinicians and organisations? Is it possible to develop methods to identify patients at risk of long-term problems with functional gastrointestinal disorders in primary care? Data sources included professional and patient interviews, patient self-report measures and data on service utilisation.DesignA pragmatic, two-arm, practice-level cluster Phase IV randomised controlled trial evaluating outcomes and costs associated with the intervention, with associated process evaluation using interviews and other methods. Four studies around identification and risk assessment: (1) a general practitioner (GP) database study to describe how clinicians in primary care record consultations with patients who experience functional lower gastrointestinal symptoms; (2) a validation of a risk assessment tool; (3) a qualitative study to explore GPs’ views and experiences; and (4) a second GP database study to investigate patient profiles in irritable bowel syndrome, inflammatory bowel disease and abdominal pain.SettingSalford, UK.ParticipantsPeople with long-term conditions and professionals in primary care.InterventionsA practice-level intervention to train practitioners to assess patient self-management capabilities and involve them in a choice of self-management options.Main outcome measuresPatient self-management, care experience and quality of life, health-care utilisation and costs.ResultsNo statistically significant differences were found between patients attending the trained practices and those attending control practices on any of the primary or secondary outcomes. The intervention had little impact on either costs or effects within the time period of the trial. In the practices, self-management tools failed to be normalised in routine care. Full assessment of the predictive tool was not possible because of variable case definitions used in practices. There was a lack of perceived clinical benefit among GPs.LimitationsThe intervention was not implemented fully in practice. Assessment of the risk assessment tool faced barriers in terms of the quality of codting in GP databases and poor recruitment of patients.ConclusionsThe Whole system Informing Self-management Engagement self-management (WISE) model did not add value to existing care for any of the long-term conditions studied.Future workThe active components required for effective self-management support need further study. The results highlight the challenge of delivering improvements to quality of care for long-term conditions. There is a need to develop interventions that are feasible to deliver at scale, yet demonstrably clinically effective and cost-effective. This may have implications for the piloting of interventions and linking implementation more clearly to local commissioning strategies.Trial registrationCurrent Controlled Trial ISRCTN90940049.FundingThis project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full inProgramme Grants for Applied Research; Vol. 6, No. 1. See the NIHR Journals Library website for further project information.

scholarly journals Behavioural activation to prevent depression and loneliness among socially isolated older people with long-term conditions: The BASIL COVID-19 pilot randomised controlled trial

PLoS Medicine ◽  
2021 ◽  
Vol 18 (10) ◽  
pp. e1003779
Author(s):  
Simon Gilbody ◽  
Elizabeth Littlewood ◽  
Dean McMillan ◽  
Carolyn A. Chew-Graham ◽  
Della Bailey ◽  
...  
Keyword(s):  
Older Adults ◽  
Primary Care ◽  
Primary Outcome ◽  
Controlled Trial ◽  
Behavioural Activation ◽  
Long Term Conditions ◽  
Socially Isolated ◽  
Randomised Controlled

Background Older adults, including those with long-term conditions (LTCs), are vulnerable to social isolation. They are likely to have become more socially isolated during the Coronavirus Disease 2019 (COVID-19) pandemic, often due to advice to “shield” to protect them from infection. This places them at particular risk of depression and loneliness. There is a need for brief scalable psychosocial interventions to mitigate the psychological impacts of social isolation. Behavioural activation (BA) is a credible candidate intervention, but a trial is needed. Methods and findings We undertook an external pilot parallel randomised trial (ISRCTN94091479) designed to test recruitment, retention and engagement with, and the acceptability and preliminary effects of the intervention. Participants aged ≥65 years with 2 or more LTCs were recruited in primary care and randomised by computer and with concealed allocation between June and October 2020. BA was offered to intervention participants (n = 47), and control participants received usual primary care (n = 49). Assessment of outcome was made blind to treatment allocation. The primary outcome was depression severity (measured using the Patient Health Questionnaire 9 (PHQ-9)). We also measured health-related quality of life (measured by the Short Form (SF)-12v2 mental component scale (MCS) and physical component scale (PCS)), anxiety (measured by the Generalised Anxiety Disorder 7 (GAD-7)), perceived social and emotional loneliness (measured by the De Jong Gierveld Scale: 11-item loneliness scale). Outcome was measured at 1 and 3 months. The mean age of participants was aged 74 years (standard deviation (SD) 5.5) and they were mostly White (n = 92, 95.8%), and approximately two-thirds of the sample were female (n = 59, 61.5%). Remote recruitment was possible, and 45/47 (95.7%) randomised to the intervention completed 1 or more sessions (median 6 sessions) out of 8. A total of 90 (93.8%) completed the 1-month follow-up, and 86 (89.6%) completed the 3-month follow-up, with similar rates for control (1 month: 45/49 and 3 months 44/49) and intervention (1 month: 45/47and 3 months: 42/47) follow-up. Between-group comparisons were made using a confidence interval (CI) approach, and by adjusting for the covariate of interest at baseline. At 1 month (the primary clinical outcome point), the median number of completed sessions for people receiving the BA intervention was 3, and almost all participants were still receiving the BA intervention. The between-group comparison for the primary clinical outcome at 1 month was an adjusted between-group mean difference of −0.50 PHQ-9 points (95% CI −2.01 to 1.01), but only a small number of participants had completed the intervention at this point. At 3 months, the PHQ-9 adjusted mean difference (AMD) was 0.19 (95% CI −1.36 to 1.75). When we examined loneliness, the adjusted between-group difference in the De Jong Gierveld Loneliness Scale at 1 month was 0.28 (95% CI −0.51 to 1.06) and at 3 months −0.87 (95% CI −1.56 to −0.18), suggesting evidence of benefit of the intervention at this time point. For anxiety, the GAD adjusted between-group difference at 1 month was 0.20 (−1.33, 1.73) and at 3 months 0.31 (−1.08, 1.70). For the SF-12 (physical component score), the adjusted between-group difference at 1 month was 0.34 (−4.17, 4.85) and at 3 months 0.11 (−4.46, 4.67). For the SF-12 (mental component score), the adjusted between-group difference at 1 month was 1.91 (−2.64, 5.15) and at 3 months 1.26 (−2.64, 5.15). Participants who withdrew had minimal depressive symptoms at entry. There were no adverse events. The Behavioural Activation in Social Isolation (BASIL) study had 2 main limitations. First, we found that the intervention was still being delivered at the prespecified primary outcome point, and this fed into the design of the main trial where a primary outcome of 3 months is now collected. Second, this was a pilot trial and was not designed to test between-group differences with high levels of statistical power. Type 2 errors are likely to have occurred, and a larger trial is now underway to test for robust effects and replicate signals of effectiveness in important secondary outcomes such as loneliness. Conclusions In this study, we observed that BA is a credible intervention to mitigate the psychological impacts of COVID-19 isolation for older adults. We demonstrated that it is feasible to undertake a trial of BA. The intervention can be delivered remotely and at scale, but should be reserved for older adults with evidence of depressive symptoms. The significant reduction in loneliness is unlikely to be a chance finding, and replication will be explored in a fully powered randomised controlled trial (RCT). Trial registration ISRCTN94091479.

scholarly journals Developing a digital intervention for primary care practitioners to support antidepressant discontinuation (Preprint)

2021 ◽  
Author(s):  
Hannah Bowers ◽  
Tony Kendrick ◽  
Nadja van Ginneken ◽  
Marta Glowacka ◽  
Samantha Williams ◽  
...  
Keyword(s):  
Primary Care ◽  
Health Professionals ◽  
Controlled Trial ◽  
Qualitative Interviews ◽  
Think Aloud ◽  
Design Elements ◽  
Digital Intervention ◽  
Long Term Treatment ◽  
Antidepressant Use

BACKGROUND The number of people on antidepressants has increased in the past three decades, mainly due to people staying on them longer, but in many cases long-term treatment is not evidence-based and risks increasing side effects. Prompting GPs to review medication does not improve rates of appropriate discontinuation. GPs and other health professionals may need help to support patients discontinuing antidepressants in primary care. OBJECTIVE To develop a digital intervention to support practitioners to help patients discontinue inappropriate long-term antidepressants, as part of a wider intervention package including a patient digital intervention and patient telephone support. METHODS A prototype digital intervention (called ‘ADvisor for Health Professionals’) was planned and developed using a theory, evidence and person-based approach. The following elements informed development: a literature review and qualitative synthesis, an in-depth qualitative study, development of guiding principles for design elements, and theoretical behavioural analyses. The intervention was then optimised through think-aloud qualitative interviews with health professionals while using the prototype intervention. RESULTS Think-aloud qualitative interviews with 19 health professionals suggested that the digital intervention contained useful information and was readily accessible for practitioners. The development work highlighted a need for further guidance on drug tapering schedules for practitioners, as well as clarity around who is responsible for broaching the subject of discontinuation. Practitioners highlighted the need to have information in easily and quickly accessible formats due to time constraints in day-to-day practice. Some GPs felt that some information was already known to them but understood why this was included. Practitioners differed in their ideas about how it would be used in practice, with some preferring to read the resource in its entirety and others wanting to ‘dip in and out’ as needed. Changes were made to the wording and structure of the intervention in response to the feedback provided. CONCLUSIONS ADvisor for Health Professionals is a digital intervention which has been developed using theory, evidence and a person-based approach. The optimisation work suggests that practitioners may find this tool useful in supporting reduction of long-term antidepressant use. Further quantitative and qualitative evaluation through a randomised controlled trial is needed to examine the feasibility, effectiveness and cost-effectiveness of the intervention.

scholarly journals Long-term condition management for prisoners: improving the processes between community and prison

2021 ◽  
Vol 22 (1) ◽  
Author(s):  
NMJ Wright ◽  
F Hankins ◽  
P Hearty
Keyword(s):  
Qualitative Interviews ◽  
Electronic Record ◽  
Medicines Management ◽  
Long Term Conditions ◽  
Police Custody ◽  
Barriers To Screening ◽  
High Prevalence ◽  
Facilitators And Barriers ◽  
Ongoing Monitoring

Abstract Background Prisoner populations have a disproportionately high prevalence of risk factors for long-term conditions (LTCs), and movement between community and prisons is a period of potential disruption in the ongoing monitoring and management of LTCs. Method Nineteen qualitative interviews with staff, recruited by purposive sampling for professional background, were conducted to explore facilitators and barriers to screening, monitoring and medicines management for LTCs. Results There is variability in prisoner behaviours regarding bringing community GP-prescribed medication to prison following arrest and detention in police custody, which affects service ability regarding seamless continuation of community prescribing actions. Systems for actively inputting clinical data into existing, nationally agreed, electronic record templates for QOF monitoring are under-developed in prisons and such activity is dependent upon individual “enthusiast(s)”. Conclusion There is a pressing need to embed standardised QOF monitoring systems within an integrated community/prison commissioning framework, supported by connectivity between prison and community primary care records, including all activity related to QOF compliance.

FRAILTY AND SARCOPAENIA TRIALS IN PRIMARY CARE – IDENTIFYING AND OVERCOMING KEY BARRIERS TO SUCCESSFUL CLINICIAN PARTICIPATION

2015 ◽  
pp. 1-2
Author(s):  
A. SINCLAIR
Keyword(s):  
Primary Care ◽  
Target Population ◽  
Population Based ◽  
Care Staff ◽  
Long Term Conditions ◽  
Primary Care Research ◽  
Wide Range ◽  
Primary Care Practitioners ◽  
Primary Care Staff

Primary care research involving older people brings together a wide range of primary care practitioners. Key areas of activity include: health promotion, disease prevention, screening and early diagnosis, as well as the management of common and long-term conditions such as frailty and sarcopaenia which are under-researched domains of health in this setting. Few interventional studies have identified frail or sarcopaenic patients as the target population based on recent definitions of either condition. Several barriers to successful research in the primary care area exist and overcoming such barriers is not straightforward but involves a multidimensional approach that attempts to enhance the confidence and opportunity to engage in research of primary care staff and the consideration of factors that allow external leads of research to coordinate their programme.

scholarly journals Acceptability of a vocational advice service for patients consulting in primary care with musculoskeletal pain: A qualitative exploration of the experiences of general practitioners, vocational advisers and patients

2017 ◽  
Vol 47 (1) ◽  
pp. 78-85 ◽  
Author(s):  
Tom Sanders ◽  
Gwenllian Wynne-Jones ◽  
Bie Nio Ong ◽  
Majid Artus ◽  
Nadine Foster
Keyword(s):  
Primary Care ◽  
Controlled Trial ◽  
Comparative Method ◽  
Qualitative Interviews ◽  
Cluster Randomised Controlled Trial ◽  
Key Factors ◽  
Constant Comparative Method ◽  
General Practices ◽  
Randomised Controlled ◽  
Qualitative Exploration

Aims: Using qualitative interviews, this study explored the experiences of GPs, vocational advisers and patients towards a new vocational advice (VA) service in primary care. Methods: This study was nested within the Study of Work and Pain (SWAP) cluster randomised controlled trial. The SWAP trial located a VA service within three general practices in Staffordshire. Interviews took place with 10 GPs 12 months after the introduction of the VA service, four vocational advisers whilst the VA service was running and 20 patients on discharge from the VA service. The data were analysed using the constant comparative method, which is a variation of grounded theory. Results: The key factors determining the acceptability and perceived effectiveness of the VA service from the perspective of the three groups of stakeholders were (1) the timing of referrals to the VA, (2) the perceived lack of patient demand for the service and (3) role uncertainty experienced by VAs. Conclusions: Early vocational intervention may not be appropriate for all musculoskeletal patients with work difficulties. Indeed, many patients felt they did not require the support of a VA, either because they had self-limiting work difficulties and/or already had support mechanisms in place to return to work. Future VA interventions may be better implemented in a targeted way so that appropriate patients are identified with characteristics which can best be addressed by the VA service.

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