A review of trial and real-world data applying a realist approach to identify behavioural mechanisms supporting practitioners to taper opioids

This realist enquiry applying behavioural theory aimed to identify behavioural mechanisms and contexts that facilitate prescribers tapering opioids. We identified relevant opioid tapering interventions and services from a 2018 international systematic review and a 2019 England-wide survey, respectively. Interventions and services were eligible if they provided information about contexts and/or behavioural mechanisms influencing opioid tapering success. A stakeholder group (n=23) generated draft programme theories based around the 14 domains of the theoretical domains framework. We refined these using the trial and service data. From 71 articles and 21 survey responses, 56 and 16 respectively were included, representing primary care, hospital, specialist pain facilities and prison services. We identified six programme theories that included five behavioural mechanisms: prescribers’ knowledge about how to taper; build prescribers’ beliefs about capabilities to initiate tapering discussions and manage psychological consequences of tapering; perceived professional role in tapering; the environmental context enabling referral to specialists; and facilitating positive social influence by aligning patient: prescriber expectations of tapering. No interventions are addressing all six mechanisms supportive of tapering. Work is required to operationalise programme theories according to organisational structures and resources. An example operationalisation is combining tapering guidelines with information about local excess opioid problems and endorsing these with organisational branding. Prescribers being given the skills and confidence to initiate tapering discussions by training them in cognitive-based interventions and incorporating access to psychological and physical support in the patient pathway. Patients being provided with leaflets about the tapering process and informed about the patient pathway.

Drug prescriptions and dementia incidence: a medication-wide association study of 17000 dementia cases among half a million participants

BackgroundPrevious studies have suggested that some medications may influence dementia risk. We conducted a hypothesis-generating medication-wide association study to investigate systematically the association between all prescription medications and incident dementia.MethodsWe used a population-based cohort within the Secure Anonymised Information Linkage (SAIL) databank, comprising routinely-collected primary care, hospital admissions and mortality data from Wales, UK. We included all participants born after 1910 and registered with a SAIL general practice at ≤60 years old. Follow-up was from each participant’s 60th birthday to the earliest of dementia diagnosis, deregistration from a SAIL general practice, death or the end of 2018. We considered participants exposed to a medication if they received ≥1 prescription for any of 744 medications before or during follow-up. We adjusted for sex, smoking and socioeconomic status. The outcome was any all-cause dementia code in primary care, hospital or mortality data during follow-up. We used Cox regression to calculate hazard ratios and Bonferroni-corrected p values.ResultsOf 551 344 participants, 16 998 (3%) developed dementia (median follow-up was 17 years for people who developed dementia, 10 years for those without dementia). Of 744 medications, 221 (30%) were associated with dementia. Of these, 217 (98%) were associated with increased dementia incidence, many clustering around certain indications. Four medications (all vaccines) were associated with a lower dementia incidence.ConclusionsAlmost a third of medications were associated with dementia. The clustering of many drugs around certain indications may provide insights into early manifestations of dementia. We encourage further investigation of hypotheses generated by these results.

EP.FRI.650 Are we calculating and documenting the NELA Score pre-operatively?

Aim Emergency laparotomy is a common procedure associated with high risk of mortality and morbidity. NELA risk score calculation for patients undergoing emergency laparotomy improves the quality of patient care and compares the organisation of patient care provided to the outcomes following surgery. The aim of this study was to determine if NELA score was calculated and documented pre-laparotomy. Methods A retrospective analysis was conducted for patients who had emergency laparotomy at a primary care hospital in England. This study included reviewing the case notes and consent forms to assess if NELA risk score was calculated. Following further education of the surgical team, the audit loop was closed.The primary outcome was to identify not only calculation but also that the score was documented. Results Measures taken to enhance NELA risk calculation included theatre co-ordinator asking for NELA risk score while booking for laparotomy and documentation on the booking form and posters on surgical ward. Consequently, 40% notes included Scoring which improved to 70% after making the above changes. Conclusion The NELA risk score should be calculated for all patients undergoing emergency laparotomy as it estimates an individual’s risk of death within 30 days of surgery. It also standardises the risk calculation among all laparotomy patients and aids in clinical decision making, therefore is vital to be calculated in pre-operative phase. To ensure it is correctly calculated at all times, regular teaching and updates of NELA score is recommended.

1302 Ratio of Adenoma Detection Rate to Polyp Detection Rate

Introduction Colorectal cancer is the 3rd most common cancer in the UK. The higher Adenoma Detection Rate during colonoscopy is associated with reduction in the mortality incidence of colorectal cancer. Endoscopists with less than 20% ADR is directly proportional to higher risk of the development of an interval Colorectal cancer. The aim of this study was to calculate the Adenoma Detection Rate and Polyp Detection Rate for each endoscopist to assess the performance of the unit as well as individuals. Method A retrospective analysis was conducted for patients who had colonoscopy in a period of 3 consecutive months at a primary care hospital in England. This study included collecting the data through patient’s histology reports and medical records. The primary outcome was total Adenoma Detection Rate and Polyp Detection Rate and its ratio for each endoscopist. Results 913 colonoscopies were done by 16 different endoscopists out of which 279 patients with polyps were considered for the study. It was observed that half of the total endoscopists were found to have ADR more than 20%. 4 endoscopists had ADR between 15-20% whereas below minimal rate (less than 15%) ADR was recorded by the other 4 endoscopists. Conclusions Lower ADRs are associated with higher rates of interval cancers. An improvement of the ADR of 1% prevents 3% people from colon cancer which can be achieved by maintaining the aspirational adenoma detection rate more than 20%.

The Effectiveness of Health Education in Improving Knowledge about Hypoglycemia and Insulin Pen Use among Outpatients with Type 2 Diabetes Mellitus at a Primary Care Hospital in Vietnam

Background. Patients with type 2 diabetes mellitus (T2DM) who have limited knowledge about hypoglycemia and insulin pen use are likely to have hypoglycemia and other complications. Objective. This study aimed to evaluate the effectiveness of health education on knowledge about hypoglycemia and insulin pen use among outpatients with T2DM at a primary care hospital in Vietnam. Methods. A pretest–posttest study was conducted among 80 patients with T2DM at District 11 Hospital in Ho Chi Minh City, Vietnam. At baseline, patients were interviewed through a predefined, structural questionnaire to assess their knowledge about hypoglycemia and insulin pen use. After that, patients underwent an individual health education session about hypoglycemia and insulin pen. One month and two months after this intervention, knowledge about hypoglycemia and insulin pen use were recorded again. Results. The majority were males (65.0%) and the mean age was 59.6 (standard deviation 8.1, range 35-75) years. Very few patients had good knowledge and proper insulin pen use, with percentages ranging from 13.8% to 60%. There was a significant improvement of knowledge and practice after the intervention. Such improvement remained high one month and two months after the intervention. Conclusions. The health education intervention is effective in improving knowledge and practice in this population. There is a pressing need for such intervention at primary care hospitals to optimize treatment for patients with T2DM, possibly focusing on those who had characteristics to have the best effectiveness found in this study.

Suicidal ideation, distress, and related factors in a population of cancer patients treated in a general acute hospital

Purpose Suicidality and suicidal ideation (SI) in oncology has long been an underestimated danger. Although there are cancer-specific distress screening tools available, none of these specifically incorporates items for SI. We examined the prevalence of SI in cancer patients, investigated the relation between SI and distress, and tried to identify additional associated factors. Methods A cross-sectional study with patients treated for cancer in a primary care hospital was conducted. Psychosocial distress and SI in 226 patients was assessed. An expert rating scale (PO-Bado-SF) and a self-assessment instrument (QSC-R23) were used to measure distress. SI was assessed with item 9 of the PHQ-9. Data was descriptively analyzed, and correlations and group comparisons between clinically distressed and non-distressed patients were calculated. Results SI was reported by 15% of patients. Classified as clinically distressed were 24.8% (QSC-R23) to 36.7% (PO-Bado-SF). SI was correlated with externally (rτ = 0.19, p < 0.001) and self-rated distress (rτ = 0.31, p < 0.001). Symptoms sufficiently severe for at least a medium major depressive episode were recorded in 23.5% of patients (PHQ-9). Factors associated with SI were feeling bad about oneself, feeling down, depressed, and hopeless, deficits in activities of daily life, psycho-somatic afflictions, social restrictions, and restrictions in daily life. Being in a steady relationship seemed to have a protective effect. Conclusions SI is common in cancer patients. Distress and associated factors are increased in patients with SI. A distress screening with the ability to assess SI could be an important step in prevention, but more research is necessary.

Concordance and timing in recording cancer events in primary care, hospital and mortality records for patients with and without psoriasis: A population-based cohort study

Background The association between psoriasis and the risk of cancer has been investigated in numerous studies utilising electronic health records (EHRs), with conflicting results in the extent of the association. Objectives To assess concordance and timing of cancer recording between primary care, hospital and death registration data for people with and without psoriasis. Methods Cohort studies delineated using primary care EHRs from the Clinical Practice Research Datalink (CPRD) GOLD and Aurum databases, with linkage to hospital episode statistics (HES), Office for National Statistics (ONS) mortality data and indices of multiple deprivation (IMD). People with psoriasis were matched to those without psoriasis by age, sex and general practice. Cancer recording between databases was investigated by proportion concordant, that being the presence of cancer record in both source and comparator datasets. Delay in recording cancer diagnoses between CPRD and HES records and predictors of discordance were also assessed. Results 58,904 people with psoriasis and 350,592 comparison patients were included using CPRD GOLD; whereas 213,400 people with psoriasis and 1,268,998 comparison patients were included in CPRD Aurum. For all cancer records (excluding keratinocyte), concordance between CPRD and HES was greater than 80%. Concordance for same-site cancer records was markedly lower (<68% GOLD-linked data; <72% Aurum-linked data). Concordance of non-Hodgkin lymphoma and liver cancer recording between CPRD and HES was lower for people with psoriasis compared to those without. Conclusions Concordance between CPRD and HES is poor when restricted to cancers of the same site, with greater discordance in people with psoriasis for some cancers of specific sites. The use of linked patient-level data is an important step in reducing misclassification of cancer outcomes in epidemiological studies using routinely collected electronic health records.

Regularity of contact with general practitioners and diabetes-related hospitalisation through a period of policy change: A retrospective cohort study

Background This study evaluated changes in regularity of general practitioner (GP) contact (the pattern of visits over time) and the impact of regularity on diabetes-related hospitalisation following introduction of care co-ordination incentives. Methods Linked primary care, hospital and death records covered West Australian adults from 1991–2004. Different eras were evaluated based on incentive program changes and model fit, to assess changes in regularity. Changes in regularity, derived from the variance in the number of days between GP contacts, were evaluated using ordered logistic regression. The impact of regularity on hospitalisation rates and costs were evaluated. Results Two eras prior to program introduction (1991/92–1994/9 and 1995/96–1998/99), and one after (1999/2000–2002/03) were assessed. Among 153,455 at risk of diabetes-related hospitalisation GP contact became slightly less regular in the second era, though there was no change from the second to third era. The most regular decile had 5.5% fewer hospitalisations (95% CI -0.9% to -9.9%) and lower per-patient costs (difference AU$115, CI -$63 to -$167) than the least regular. Associations were similar in each era. Conclusions Ongoing relationships between GPs and patients are important to maintaining health. Historical data provide the opportunity to assess the impact of care co-ordination incentives on relationships.

The COVID-19 Pandemic in Spain: Experiences of Midwives on the Healthcare Frontline

Background: Midwives look after women during pregnancy, childbirth and puerperium. In Spain, the first wave of COVID was particularly virulent. There are few studies about the experiences of midwives providing care during the COVID pandemic and very few have been undertaken in the countries of southern Europe such as Spain. This article sets out to take a more in-depth look at the experiences of midwives who were on the frontline of care during the early months of the COVID-19 pandemic as well as to identify new needs and resilience strategies that can help midwives. Methods: A qualitative methodology of phenomenological tradition was used, interviewing 10 midwives from primary care, hospital and independent care. Results: After content analysis, three central categories emerged: (a) cascade of emotions; (b) professional occupation and concern for the women; (c) resisting the day-to-day; resilience and resistance strategies. Conclusions: Despite the difficulties, midwives are concerned about the loss of rights and autonomy and about the increased vulnerability of women. Midwives have become aware of the power they have in their actions both in health management and administration, as well as in the care of women, creating strategies to provide dignified care to their users.