Pathways of Teach-Back Communication to Health Outcomes Among Individuals With Diabetes: A Pathway Modeling

Teach-back method can help promote interactive communication between patients and providers. However, the mechanism of how teach-back operates in routine care is uninvestigated. Using pathway analysis, we explored the potential pathways of patient teach-back to health outcomes among individuals with diabetes. Study sample included 2901 US adults with diabetes ascertained from the 2011 to 2016 Longitudinal Medical Expenditure Panel Survey. Our pathway model analysis showed that patient teach-back was associated with better interaction with providers, shared decision-making, and receiving lifestyle advice. Teach-back had a direct negative effect on condition-specific hospitalization and indirect negative effects through lifestyle advice and diabetic complication. Teach-back method may promote active interactions between patients and providers by creating an opportunity to be more engaged in shared decision-making and receive additional health advice from providers. These improvements seem to be associated with a reduction in risks for complications and related hospitalization.

Feasibility study to assess the delivery of a novel isometric exercise intervention for people with stage 1 hypertension in the NHS: protocol for the IsoFIT-BP study including amendments to mitigate the risk of COVID-19

Background Hypertension (HTN) affects approximately 25% of the UK population and is a leading cause of mortality. Associated annual health care costs run into billions. National treatment guidance includes initial lifestyle advice, followed by anti-hypertensive medication if blood pressure (BP) remains high. However, adoption and adherence to recommended exercise guidelines, dietary advice and anti-hypertensive medication is poor. Four short bouts of isometric exercise (IE) performed 3 days per week (d/wk) at home elicits clinically significant reductions in BP in those with normal to high-normal BP. This study will determine the feasibility of delivering personalised IE to patients with stage 1 hypertension for whom lifestyle changes would be recommended before medication within NHS primary care. Methods This is a randomised controlled feasibility study. Participants were 18+ years, with stage 1 hypertension, not on anti-hypertensive medication and without significant medical contraindications. Trial arms will be standard lifestyle advice (control) or isometric wall squat exercise and standard lifestyle advice. Primary outcomes include the feasibility of healthcare professionals to deliver isometric exercise prescriptions in a primary care NHS setting and estimation of the variance of change in systolic BP. Secondary outcomes include accuracy of protocol delivery, execution of and adherence to protocol, recruitment rate, attrition, perception of intervention viability, cost, participant experience and accuracy of home BP. The study will last 18 months. Sample size of 100 participants (50 per arm) allows for 20% attrition and 6.5% incomplete data, based upon 74 (37 each arm) participants (two-sided 95% confidence interval, width of 1.33 and standard deviation of 4) completing 4 weeks. Ethical approval IRAS ID is 274676. Discussion Before the efficacy of this novel intervention to treat stage 1 hypertension can be investigated in any large randomised controlled trial, it is necessary to ascertain if it can be delivered and carried out in a NHS primary care setting. Findings could support IE viability as a prophylactic/alternative treatment option. Trial registration ISRCTN13472393, registered 18 August 2020

Core health-components, contextual factors and program elements of community-based interventions in Southeast Asia – a realist synthesis regarding hypertension and diabetes

Background In Southeast Asia, diabetes and hypertension are on the rise and have become major causes of death. Community-based interventions can achieve the required behavioural change for better prevention. The aims of this review are 1) to assess the core health-components of community-based interventions and 2) to assess which contextual factors and program elements affect their impact in Southeast Asia. Methods A realist review was conducted, combining empirical evidence with theoretical understanding. Documents published between 2009 and 2019 were systematically searched in PubMed/Medline, Web of Science, Cochrane Library, Google Scholar and PsycINFO and local databases. Documents were included if they reported on community-based interventions aimed at hypertension and/or diabetes in Southeast Asian context; and had a health-related outcome; and/or described contextual factors and/or program elements. Results We retrieved 67 scientific documents and 12 grey literature documents. We identified twelve core health-components: community health workers, family support, educational activities, comprehensive programs, physical exercise, telehealth, peer support, empowerment, activities to achieve self-efficacy, lifestyle advice, activities aimed at establishing trust, and storytelling. In addition, we found ten contextual factors and program elements that may affect the impact: implementation problems, organized in groups, cultural sensitivity, synergy, access, family health/worker support, gender, involvement of stakeholders, and referral and education services when giving lifestyle advice. Conclusions We identified a considerable number of core health-components, contextual influences and program elements of community-based interventions to improve diabetes and hypertension prevention. The main innovative outcomes were, that telehealth can substitute primary healthcare in rural areas, storytelling is a useful context-adaptable component, and comprehensive interventions can improve health-related outcomes. This extends the understanding of promising core health-components, including which elements and in what Southeast Asian context.

Prevention of Gestational Diabetes in Pregnant Women with Obesity: Protocol for a Pilot Randomised Controlled Trial

BackgroundObesity in pregnancy increases the risk of gestational diabetes mellitus (GDM) and associated adverse outcomes. Despite metabolic differences, all pregnant women with obesity are considered to have the same risk of developing GDM. Improved risk stratification is required to enable targeted intervention in women with obesity who would benefit the most. The aim of this study is to identify pregnant women with obesity at higher risk of developing GDM and in a pilot randomised controlled trial (RCT), show efficacy of a lifestyle intervention and/or metformin to improve glycaemic control.MethodsWomen aged 18 years or older with a singleton pregnancy and body mass index (BMI) ≥30kg/m2 will be recruited from one maternity unit in London, UK. Risk of GDM will be assessed using a multivariable GDM prediction model combining maternal age, mid-arm circumference, systolic blood pressure, serum triglycerides and whole blood HbA1c. Women identified at higher risk of developing GDM will be randomly allocated to one of two intervention groups (lifestyle advice with or without metformin) or standard antenatal care. Primary outcome; reduction in mean glucose/24hr of 0.5mmol/l as assessed by continuous glucose monitoring. A sample of 60 high risk women is required.DiscussionEarly risk stratification of GDM in pregnant women with obesity and targeted intervention using lifestyle advice with or without metformin could improve glucose tolerance compared to standard antenatal care. If successful, an adequately powered RCT will be performed to investigate whether this strategy is effective in preventing GDM in women with obesity. Ethics and trial registrationThis study has been approved by the NHS Research Ethics Committee (UK IRAS integrated research application system; reference 18/LO/1500). EudraCT Number 2018-000003-16.

1454 The Challenges of Consent and COVID-19: Analysis of Documentation of Risk of Hospital Acquired COVID-19 Infection in a District General Hospital

Background The COVID-19 pandemic has been a challenging time for society and raised further challenges for medical practice. It poses a new material risk to any hospital admission or procedure, and consenting practice must modify to accommodate this. Aim To assess the documentation of the risk of COVID-19 infection and associated morbidity in consenting practice, using the existing consent form as benchmark, for patient’s undergoing general surgical procedures under general anaesthesia. Method Retrospective case-note analysis of 41 general surgical inpatient consent forms and operation notes during April 2020. Data were gathered on multiple points mentioned in Royal College of Surgeons (RCS) guidance. This includes documentation of risk of COVID-19 infection, the patient’s diagnosis, other risk documentation, peri-operative lifestyle advice and likelihood of success. Results Of 41 cases, 16 (39%) had risk of chest infection documented. Of these 16, 10 (63%) specified COVID-19 in the risk documentation. Further, morbidity related to COVID-19 was documented in 4 out of 41 (10%) cases identified. Conclusions A material risk is classified as anything that poses substantial risk to a patient, and it is vital that they are made aware of this prior to undertaking any form of medical intervention. This study demonstrates deviation from RCS guidance, and the results have been discussed and distributed within the general surgical department. Advice has been communicated regarding improvements required in consenting practice from the clinical lead. We aim to re-audit practice in the coming months.

An audit to assess whether patients under the care of a community mental health team who are taking clozapine are having their lipid profile checked annually and are given lifestyle advice and have had a QRISK3 assessment

Aims‘All cause’ mortality is higher among patients with serious mental illness than the general population and a significant contributor from this is cardiovascular disease. Mean triglyceride levels have been shown to double and cholesterol levels to increase by at least 10% after 5 years’ treatment with clozapine. NICE guidelines state all patients should have their lipids measured at baseline, 3 months after starting treatment with a new antipsychotic, and then annually.The first aim of our audit was to identify whether patients who had been on clozapine for at least 3 months from our community mental health team (CMHT) who were not taking cholesterol lowering medication are having their lipid profile checked annually. The second aim was to see whether these patients have high total cholesterol levels and whether they had had a documented discussion about exercise, diet or lifestyle and a QRISK3 assessment.MethodWe constructed a list of 56 patients who were taking clozapine from the CMHT. We excluded 17 patients who were on cholesterol lowering medication and would have excluded any patients who had been on clozapine for less than 3 months. We then looked at whether the patients had had a lipid profile and identified patients with a cholesterol level >5.0 to indicate a ‘high cholesterol level.’ We then searched through the last year of each of the patient's case notes to see whether they had had a QRISK assessment or lifestyle advice by searching for the words ‘diet, exercise, lifestyle and QRISK’.Result36 of the 39 (92%) patients had lipid levels checked in the last 12 months. 21 of the 39 (54%) patients had a cholesterol over 5.0. 9 of the 39 (23%) patients had a documented discussion regarding lifestyle, diet or exercise in the last year. 0 of the 39 (0%) patients had a documented QRISK3 assessment.ConclusionMost (92%) patients from the CMHT had their lipid profile checked in the last year. 54% had total cholesterol level over 5.0. Only a small proportion (23%) had documented lifestyle discussion and none of the patients had a QRISK3 assessment. The results will be presented to the CMHT and we will organise teaching on giving lifestyle advice and QRISK3 assessments.