Michael Allen, C. James, J. Frost, K. Liabo, K. Pearn, T. Monks, Z. Zhelev, S. Logan, R. Everson, M. James, Ken Stein
Stroke is a common cause of adult disability. Expert opinion is that about 20% of patients should receive thrombolysis to break up a clot causing the stroke. Currently, 11–12% of patients in England and Wales receive this treatment, ranging between 2% and 24% between hospitals. We sought to enhance the national stroke audit by providing further analysis of the key sources of inter-hospital variation to determine how a target of 20% of stroke patients receiving thrombolysis may be reached. We modelled three aspects of the thrombolysis pathway, using machine learning and clinical pathway simulation. In addition, the project had a qualitative research arm, with the objective of understanding clinicians’ attitudes to use of modelling and machine learning applied to the national stroke audit. Anonymised data were collected for 246,676 emergency stroke admissions to acute stroke teams in England and Wales between 2016 and 2018, obtained from the Sentinel Stroke National Audit Programme. Use of thrombolysis could be predicted with 85% accuracy for those patients with a chance of receiving thrombolysis (i.e. those arriving within 4 hours of stroke onset). Machine learning models allowed prediction of likely treatment choice for each patient at all hospitals. A clinical pathway simulation predicted hospital thrombolysis use with an average absolute error of 0.5 percentage points. We found that about half of the inter-hospital variation in thrombolysis use came from differences in local patient populations, and half from in-hospital processes and decision-making. Three changes were applied to all hospitals in the model: (1) arrival to treatment in 30 minutes, (2) proportion of patients with determined stroke onset times set to at least the national upper quartile and (3) thrombolysis decisions made based on majority vote of a benchmark set of 30 hospitals. Any single change alone was predicted to increase national thrombolysis use from 11.6% to between 12.3% and 14.5% (with clinical decision-making having the most effect). Combined, these changes would be expected to increase thrombolysis to 18.3% (and to double the clinical benefit of thrombolysis, as speed increases also improve clinical benefit independently of the proportion of patients receiving thrombolysis); however, there would still be significant variation between hospitals depending on local patient population. For each hospital, the effect of each change could be predicted alone or in combination. Qualitative research with 19 clinicians showed that engagement with, and trust in, the model was greatest in physicians from units with higher thrombolysis rates. Physicians also wanted to see a machine learning model predicting outcome with probability of adverse effect of thrombolysis to counter a fear that driving thrombolysis use up may cause more harm than good. Models may be built using data available in the Sentinel Stroke National Audit Programme only. No
{"title":"Using simulation and machine learning to maximise the benefit of intravenous thrombolysis in acute stroke in England and Wales: the SAMueL modelling and qualitative study","authors":"Michael Allen, C. James, J. Frost, K. Liabo, K. Pearn, T. Monks, Z. Zhelev, S. Logan, R. Everson, M. James, Ken Stein","doi":"10.3310/gvzl5699","DOIUrl":"https://doi.org/10.3310/gvzl5699","url":null,"abstract":"\u0000 \u0000 Stroke is a common cause of adult disability. Expert opinion is that about 20% of patients should receive thrombolysis to break up a clot causing the stroke. Currently, 11–12% of patients in England and Wales receive this treatment, ranging between 2% and 24% between hospitals.\u0000 \u0000 \u0000 \u0000 We sought to enhance the national stroke audit by providing further analysis of the key sources of inter-hospital variation to determine how a target of 20% of stroke patients receiving thrombolysis may be reached.\u0000 \u0000 \u0000 \u0000 We modelled three aspects of the thrombolysis pathway, using machine learning and clinical pathway simulation. In addition, the project had a qualitative research arm, with the objective of understanding clinicians’ attitudes to use of modelling and machine learning applied to the national stroke audit.\u0000 \u0000 \u0000 \u0000 Anonymised data were collected for 246,676 emergency stroke admissions to acute stroke teams in England and Wales between 2016 and 2018, obtained from the Sentinel Stroke National Audit Programme.\u0000 \u0000 \u0000 \u0000 Use of thrombolysis could be predicted with 85% accuracy for those patients with a chance of receiving thrombolysis (i.e. those arriving within 4 hours of stroke onset). Machine learning models allowed prediction of likely treatment choice for each patient at all hospitals. A clinical pathway simulation predicted hospital thrombolysis use with an average absolute error of 0.5 percentage points. We found that about half of the inter-hospital variation in thrombolysis use came from differences in local patient populations, and half from in-hospital processes and decision-making. Three changes were applied to all hospitals in the model: (1) arrival to treatment in 30 minutes, (2) proportion of patients with determined stroke onset times set to at least the national upper quartile and (3) thrombolysis decisions made based on majority vote of a benchmark set of 30 hospitals. Any single change alone was predicted to increase national thrombolysis use from 11.6% to between 12.3% and 14.5% (with clinical decision-making having the most effect). Combined, these changes would be expected to increase thrombolysis to 18.3% (and to double the clinical benefit of thrombolysis, as speed increases also improve clinical benefit independently of the proportion of patients receiving thrombolysis); however, there would still be significant variation between hospitals depending on local patient population. For each hospital, the effect of each change could be predicted alone or in combination. Qualitative research with 19 clinicians showed that engagement with, and trust in, the model was greatest in physicians from units with higher thrombolysis rates. Physicians also wanted to see a machine learning model predicting outcome with probability of adverse effect of thrombolysis to counter a fear that driving thrombolysis use up may cause more harm than good.\u0000 \u0000 \u0000 \u0000 Models may be built using data available in the Sentinel Stroke National Audit Programme only. No","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42101868","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
J. Glasby, I. Litchfield, S. Parkinson, L. Hocking, Denise Tanner, B. Roe, J. Bousfield
Background Digital technology is a focus within the NHS and social care as a way to improve care and address pressures. Sensor-based technology with artificial intelligence capabilities is one type of technology that may be useful, although there are gaps in evidence that need to be addressed. Objective This study evaluates how one example of a technology using home-based sensors with artificial intelligence capabilities (pseudonymised as 'IndependencePlus') was implemented in three case study sites across England. The focus of this study was on decision-making processes and implementation. Design Stage 1 consisted of a rapid literature review, nine interviews and three project design groups. Stage 2 involved qualitative data collection from three social care sites (20 interviews), and three interviews with technology providers and regulators. Results • It was expected that the technology would improve care planning and reduce costs for the social care system, aid in prevention and responding to needs, support independent living and provide reassurance for those who draw on care and their carers. • The sensors were not able to collect the necessary data to create anticipated benefits. Several technological aspects of the system reduced its flexibility and were complex for staff to use. • There appeared to be no systematic decision-making process in deciding whether to adopt artificial intelligence. In its absence, a number of contextual factors influenced procurement decisions. • Incorporating artificial intelligence-based technology into existing models of social care provision requires alterations to existing funding models and care pathways, as well as workforce training. • Technology-enabled care solutions require robust digital infrastructure, which is lacking for many of those who draw on care and support. • Short-term service pressures and a sense of crisis management are not conducive to the culture that is needed to reap the potential longer-term benefits of artificial intelligence. Limitations Significant recruitment challenges (especially regarding people who draw on care and carers) were faced, particularly in relation to pressures from COVID-19. Conclusions This study confirmed a number of common implementation challenges, and adds insight around the specific decision-making processes for a technology that has been implemented in social care. We have also identified issues related to managing and analysing data, and introducing a technology focused on prevention into an environment which is focused on dealing with crises. This has helped to fill gaps in the literature and share practical lessons with commissioners, social care providers, technology providers and policy-makers. Future work We have highlighted the implications of our findings for future practice and shared these with case study sites. We have also developed a toolkit for others implementing new technology into adult social care based on our findings (https:
{"title":"New and emerging technology for adult social care - the example of home sensors with artificial intelligence (AI) technology.","authors":"J. Glasby, I. Litchfield, S. Parkinson, L. Hocking, Denise Tanner, B. Roe, J. Bousfield","doi":"10.3310/hsdr-tr-134314","DOIUrl":"https://doi.org/10.3310/hsdr-tr-134314","url":null,"abstract":"Background\u0000Digital technology is a focus within the NHS and social care as a way to improve care and address pressures. Sensor-based technology with artificial intelligence capabilities is one type of technology that may be useful, although there are gaps in evidence that need to be addressed.\u0000\u0000\u0000Objective\u0000This study evaluates how one example of a technology using home-based sensors with artificial intelligence capabilities (pseudonymised as 'IndependencePlus') was implemented in three case study sites across England. The focus of this study was on decision-making processes and implementation.\u0000\u0000\u0000Design\u0000Stage 1 consisted of a rapid literature review, nine interviews and three project design groups. Stage 2 involved qualitative data collection from three social care sites (20 interviews), and three interviews with technology providers and regulators.\u0000\u0000\u0000Results\u0000• It was expected that the technology would improve care planning and reduce costs for the social care system, aid in prevention and responding to needs, support independent living and provide reassurance for those who draw on care and their carers. • The sensors were not able to collect the necessary data to create anticipated benefits. Several technological aspects of the system reduced its flexibility and were complex for staff to use. • There appeared to be no systematic decision-making process in deciding whether to adopt artificial intelligence. In its absence, a number of contextual factors influenced procurement decisions. • Incorporating artificial intelligence-based technology into existing models of social care provision requires alterations to existing funding models and care pathways, as well as workforce training. • Technology-enabled care solutions require robust digital infrastructure, which is lacking for many of those who draw on care and support. • Short-term service pressures and a sense of crisis management are not conducive to the culture that is needed to reap the potential longer-term benefits of artificial intelligence.\u0000\u0000\u0000Limitations\u0000Significant recruitment challenges (especially regarding people who draw on care and carers) were faced, particularly in relation to pressures from COVID-19.\u0000\u0000\u0000Conclusions\u0000This study confirmed a number of common implementation challenges, and adds insight around the specific decision-making processes for a technology that has been implemented in social care. We have also identified issues related to managing and analysing data, and introducing a technology focused on prevention into an environment which is focused on dealing with crises. This has helped to fill gaps in the literature and share practical lessons with commissioners, social care providers, technology providers and policy-makers.\u0000\u0000\u0000Future work\u0000We have highlighted the implications of our findings for future practice and shared these with case study sites. We have also developed a toolkit for others implementing new technology into adult social care based on our findings (https:","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":"11 9 1","pages":"1-64"},"PeriodicalIF":0.0,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47964364","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Background There is a considerable body of systematic review evidence considering the effectiveness of rehabilitation programmes on clinical outcomes. However, much less is known about effectively engaging and sustaining patients in rehabilitation. There is a need to understand the full range of potential intervention strategies. Methods We conducted a mapping review of UK review-level evidence published 2017-21. We searched MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health (CINAHL) and conducted a narrative synthesis. Included reviews reported factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation, or an intervention to facilitate these factors. Study selection was undertaken independently by two reviewers. Results In total, we identified 20 review papers that met our inclusion criteria. There was a bias towards reviews considering cardiac rehabilitation, with these numbering 16. An additional 11 unpublished interventions were also identified through internet searching of key websites. The reviews included 60 identifiable UK primary studies that considered factors which affected attendance at rehabilitation; 42 considered cardiac rehabilitation and 18 considering pulmonary rehabilitation. They reported on factors from the patients' point of view, as well as the views of professionals involved in referral or treatment. It was more common for factors to be reported as impeding attendance at rehabilitation rather than facilitating it. We grouped the factors into patient perspective (support, culture, demographics, practical, health, emotions, knowledge/beliefs and service factors) and professional perspective (knowledge: staff and patient, staffing, adequacy of service provision and referral from other services, including support and wait times). We found considerably fewer reviews (n = 3) looking at interventions to facilitate participation in rehabilitation. Although most of the factors affecting participation were reported from a patient perspective, most of the identified interventions were implemented to address barriers to access in terms of the provider perspective. The majority of access challenges identified by patients would not therefore be addressed by the identified interventions. The more recent unevaluated interventions implemented during the COVID-19 pandemic may have the potential to act on some of the patient barriers in access to services, including travel and inconvenient timing of services. Conclusions The factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation consist of a web of complex and interlinked factors taking into consideration the perspectives of the patients and the service providers. The small number of published interventions we identified that aim to improve access are unlikely to address the majority of these factors, especially those identified by patients as limiting their access. Better understanding
{"title":"Factors which facilitate or impede patient engagement with pulmonary and cardiac rehabilitation: a rapid evaluation mapping review.","authors":"L. Blank, A. Cantrell, K. Sworn, A. Booth","doi":"10.3310/hsdr-tr-135449","DOIUrl":"https://doi.org/10.3310/hsdr-tr-135449","url":null,"abstract":"Background\u0000There is a considerable body of systematic review evidence considering the effectiveness of rehabilitation programmes on clinical outcomes. However, much less is known about effectively engaging and sustaining patients in rehabilitation. There is a need to understand the full range of potential intervention strategies.\u0000\u0000\u0000Methods\u0000We conducted a mapping review of UK review-level evidence published 2017-21. We searched MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health (CINAHL) and conducted a narrative synthesis. Included reviews reported factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation, or an intervention to facilitate these factors. Study selection was undertaken independently by two reviewers.\u0000\u0000\u0000Results\u0000In total, we identified 20 review papers that met our inclusion criteria. There was a bias towards reviews considering cardiac rehabilitation, with these numbering 16. An additional 11 unpublished interventions were also identified through internet searching of key websites. The reviews included 60 identifiable UK primary studies that considered factors which affected attendance at rehabilitation; 42 considered cardiac rehabilitation and 18 considering pulmonary rehabilitation. They reported on factors from the patients' point of view, as well as the views of professionals involved in referral or treatment. It was more common for factors to be reported as impeding attendance at rehabilitation rather than facilitating it. We grouped the factors into patient perspective (support, culture, demographics, practical, health, emotions, knowledge/beliefs and service factors) and professional perspective (knowledge: staff and patient, staffing, adequacy of service provision and referral from other services, including support and wait times). We found considerably fewer reviews (n = 3) looking at interventions to facilitate participation in rehabilitation. Although most of the factors affecting participation were reported from a patient perspective, most of the identified interventions were implemented to address barriers to access in terms of the provider perspective. The majority of access challenges identified by patients would not therefore be addressed by the identified interventions. The more recent unevaluated interventions implemented during the COVID-19 pandemic may have the potential to act on some of the patient barriers in access to services, including travel and inconvenient timing of services.\u0000\u0000\u0000Conclusions\u0000The factors affecting commencement, continuation or completion of cardiac or pulmonary rehabilitation consist of a web of complex and interlinked factors taking into consideration the perspectives of the patients and the service providers. The small number of published interventions we identified that aim to improve access are unlikely to address the majority of these factors, especially those identified by patients as limiting their access. Better understanding","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":"11 4 1","pages":"1-59"},"PeriodicalIF":0.0,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46118552","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Giulia Zoccatelli, Amit Desai, G. Robert, G. Martin, S. Brearley
Local Healthwatch organisations are an important part of the landscape of health and care commissioning and provision in England. In addition, local Healthwatch organisations are a key means by which users of services are given voice to influence decisions about health and care commissioning and provision. We aimed to explore and enhance the operation and impact of local Healthwatch in ensuring effective patient and public voice in the commissioning and provision of NHS services. We used mixed methods, including a national survey (96/150 responses, 68%); actor network theory-inspired ethnographic data collection in five local Healthwatch organisations (made up of 75 days’ fieldwork, 84 semistructured interviews, 114 virtual interviews, observations during the COVID-19 pandemic and documentary analysis) and serial interviews about experiences during the pandemic with 11 Healthwatch staff and four volunteers who were members of a Healthwatch Involvement Panel (which also guided data collection and analysis). Finally, we ran five joint interpretive forums to help make sense of our data. Our five Healthwatch case study organisations are of varying size and organisational form and are located in different parts of England. We found significant variation in the organisation and work of Healthwatch organisations nationally, including hosting arrangements, scale of operations, complexity of relationships with health and care bodies, and sources of income beyond core funding. Key points of divergence that were consequential for Healthwatch activities included the degree of autonomy from host organisations and local understandings of accountability to various constituencies. These points of divergence gave rise to very different modes of operation and different priorities for enacting the nationally prescribed responsibilities of Healthwatch organisations locally. Large variations in funding levels created Healthwatch organisations that diverged not just in scale but in focus. As the COVID-19 pandemic unfolded, Healthwatch found new approaches to giving voice to the views of the public and formed effective relationships with other agencies. We identified generalisable principles of good practice regarding the collection and communication of evidence. Policy implications relate to (1) the overall funding regime for Healthwatch and potential inequalities in what is available to local populations and (2) the development of Healthwatch’s role given the evolution of local health and care systems since 2012. Future studies should explore (1) the consequences of the development of integrated care systems for local Healthwatch organisations, (2) Healthwatch in an international comparative perspective, (3) how the response to the COVID-19 pandemic has reconfigured the voluntary sector locally and (4) how Healthwatch responds formally and informally to a newly emerging focus on public health and health inequalities.
{"title":"Exploring the work and organisation of local Healthwatch in England: a mixed-methods ethnographic study","authors":"Giulia Zoccatelli, Amit Desai, G. Robert, G. Martin, S. Brearley","doi":"10.3310/yuti9128","DOIUrl":"https://doi.org/10.3310/yuti9128","url":null,"abstract":"\u0000 \u0000 Local Healthwatch organisations are an important part of the landscape of health and care commissioning and provision in England. In addition, local Healthwatch organisations are a key means by which users of services are given voice to influence decisions about health and care commissioning and provision.\u0000 \u0000 \u0000 \u0000 We aimed to explore and enhance the operation and impact of local Healthwatch in ensuring effective patient and public voice in the commissioning and provision of NHS services.\u0000 \u0000 \u0000 \u0000 We used mixed methods, including a national survey (96/150 responses, 68%); actor network theory-inspired ethnographic data collection in five local Healthwatch organisations (made up of 75 days’ fieldwork, 84 semistructured interviews, 114 virtual interviews, observations during the COVID-19 pandemic and documentary analysis) and serial interviews about experiences during the pandemic with 11 Healthwatch staff and four volunteers who were members of a Healthwatch Involvement Panel (which also guided data collection and analysis). Finally, we ran five joint interpretive forums to help make sense of our data.\u0000 \u0000 \u0000 \u0000 Our five Healthwatch case study organisations are of varying size and organisational form and are located in different parts of England.\u0000 \u0000 \u0000 \u0000 We found significant variation in the organisation and work of Healthwatch organisations nationally, including hosting arrangements, scale of operations, complexity of relationships with health and care bodies, and sources of income beyond core funding. Key points of divergence that were consequential for Healthwatch activities included the degree of autonomy from host organisations and local understandings of accountability to various constituencies. These points of divergence gave rise to very different modes of operation and different priorities for enacting the nationally prescribed responsibilities of Healthwatch organisations locally. Large variations in funding levels created Healthwatch organisations that diverged not just in scale but in focus. As the COVID-19 pandemic unfolded, Healthwatch found new approaches to giving voice to the views of the public and formed effective relationships with other agencies.\u0000 \u0000 \u0000 \u0000 We identified generalisable principles of good practice regarding the collection and communication of evidence. Policy implications relate to (1) the overall funding regime for Healthwatch and potential inequalities in what is available to local populations and (2) the development of Healthwatch’s role given the evolution of local health and care systems since 2012.\u0000 \u0000 \u0000 \u0000 Future studies should explore (1) the consequences of the development of integrated care systems for local Healthwatch organisations, (2) Healthwatch in an international comparative perspective, (3) how the response to the COVID-19 pandemic has reconfigured the voluntary sector locally and (4) how Healthwatch responds formally and informally to a newly emerging focus on public health and health inequalities.\u0000 \u0000 \u0000","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-10-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48415991","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
A. Ramsay, J. Ledger, S. Tomini, C. Hall, D. Hargroves, P. Hunter, Simon Payne, Rajeshwari R. Mehta, R. Simister, Fola Tayo, N. Fulop
In response to COVID-19, alongside other service changes, North Central London and East Kent implemented prehospital video triage: this involved stroke and ambulance clinicians communicating over FaceTime (Apple Inc., Cupertino, CA, USA) to assess suspected stroke patients while still on scene. To evaluate the implementation, experience and impact of prehospital video triage in North Central London and East Kent. A rapid mixed-methods service evaluation (July 2020 to September 2021) using the following methods. (1) Evidence reviews: scoping review (15 reviews included) and rapid systematic review (47 papers included) on prehospital video triage for stroke, covering usability (audio-visual and signal quality); acceptability (whether or not clinicians want to use it); impact (on outcomes, safety, experience and cost-effectiveness); and factors influencing implementation. (2) Clinician views of prehospital video triage in North Central London and East Kent, covering usability, acceptability, patient safety and implementation: qualitative analysis of interviews with ambulance and stroke clinicians (n = 27), observations (n = 12) and documents (n = 23); a survey of ambulance clinicians (n = 233). (3) Impact on safety and quality: analysis of local ambulance conveyance times (n = 1400; April to September 2020). Analysis of national stroke audit data on ambulance conveyance and stroke unit delivery of clinical interventions in North Central London, East Kent and the rest of England (n = 137,650; July 2018 to December 2020). (1) Evidence: limited but growing, and sparse in UK settings. Prehospital video triage can be usable and acceptable, requiring clear network connection and audio-visual signal, clinician training and communication. Key knowledge gaps included impact on patient conveyance, patient outcomes and cost-effectiveness. (2) Clinician views. Usability – relied on stable Wi-Fi and audio-visual signals, and back-up processes for when signals failed. Clinicians described training as important for confidence in using prehospital video triage services, noting potential for ‘refresher’ courses and joint training events. Ambulance clinicians preferred more active training, as used in North Central London. Acceptability – most clinicians felt that prehospital video triage improved on previous processes and wanted it to continue or expand. Ambulance clinicians reported increased confidence in decisions. Stroke clinicians found doing assessments alongside their standard duties a source of pressure. Safety – clinical leaders monitored and managed potential patient safety issues; clinicians felt strongly that services were safe. Implementation – several factors enabled prehospital video triage at a system level (e.g. COVID-19) and more locally (e.g. facilitative governance, receptive clinicians). Clinical leaders reached across and beyond their organisations to engage clinicians, senior managers and the wider system. (3) Impact o
{"title":"Prehospital video triage of potential stroke patients in North Central London and East Kent: rapid mixed-methods service evaluation","authors":"A. Ramsay, J. Ledger, S. Tomini, C. Hall, D. Hargroves, P. Hunter, Simon Payne, Rajeshwari R. Mehta, R. Simister, Fola Tayo, N. Fulop","doi":"10.3310/iqzn1725","DOIUrl":"https://doi.org/10.3310/iqzn1725","url":null,"abstract":"\u0000 \u0000 In response to COVID-19, alongside other service changes, North Central London and East Kent implemented prehospital video triage: this involved stroke and ambulance clinicians communicating over FaceTime (Apple Inc., Cupertino, CA, USA) to assess suspected stroke patients while still on scene.\u0000 \u0000 \u0000 \u0000 To evaluate the implementation, experience and impact of prehospital video triage in North Central London and East Kent.\u0000 \u0000 \u0000 \u0000 A rapid mixed-methods service evaluation (July 2020 to September 2021) using the following methods. (1) Evidence reviews: scoping review (15 reviews included) and rapid systematic review (47 papers included) on prehospital video triage for stroke, covering usability (audio-visual and signal quality); acceptability (whether or not clinicians want to use it); impact (on outcomes, safety, experience and cost-effectiveness); and factors influencing implementation. (2) Clinician views of prehospital video triage in North Central London and East Kent, covering usability, acceptability, patient safety and implementation: qualitative analysis of interviews with ambulance and stroke clinicians (n = 27), observations (n = 12) and documents (n = 23); a survey of ambulance clinicians (n = 233). (3) Impact on safety and quality: analysis of local ambulance conveyance times (n = 1400; April to September 2020). Analysis of national stroke audit data on ambulance conveyance and stroke unit delivery of clinical interventions in North Central London, East Kent and the rest of England (n = 137,650; July 2018 to December 2020).\u0000 \u0000 \u0000 \u0000 (1) Evidence: limited but growing, and sparse in UK settings. Prehospital video triage can be usable and acceptable, requiring clear network connection and audio-visual signal, clinician training and communication. Key knowledge gaps included impact on patient conveyance, patient outcomes and cost-effectiveness. (2) Clinician views. Usability – relied on stable Wi-Fi and audio-visual signals, and back-up processes for when signals failed. Clinicians described training as important for confidence in using prehospital video triage services, noting potential for ‘refresher’ courses and joint training events. Ambulance clinicians preferred more active training, as used in North Central London. Acceptability – most clinicians felt that prehospital video triage improved on previous processes and wanted it to continue or expand. Ambulance clinicians reported increased confidence in decisions. Stroke clinicians found doing assessments alongside their standard duties a source of pressure. Safety – clinical leaders monitored and managed potential patient safety issues; clinicians felt strongly that services were safe. Implementation – several factors enabled prehospital video triage at a system level (e.g. COVID-19) and more locally (e.g. facilitative governance, receptive clinicians). Clinical leaders reached across and beyond their organisations to engage clinicians, senior managers and the wider system. (3) Impact o","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45693202","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
L. Al-Khudairy, A. Ayorinde, Iman Ghosh, A. Grove, J. Harlock, Edward Meehan, Adam Briggs, R. Court, A. Clarke
Social prescribing encourages health-care and other professionals to refer patients to a link worker, who will develop a personalised plan to improve the patient’s health and well-being. We explore the feasibility of evaluating the service. The objective was to answer the following research questions. (1) What are the most important evaluation questions that an impact study could investigate? (2) What data are already available at a local or national level and what else would be needed? (3) Are there sites delivering at a large enough scale and in a position to take part in an impact study? (4) How could the known challenges to evaluation (e.g. information governance and identifying a control group) be addressed? Data sources included MEDLINE ALL (via Ovid), searched from inception to 14 February 2019, and the first 100 hits of a Google (Google Inc., Mountain View, CA, USA) search. Rapid systematic review – electronic searches up to February 2019. Studies included any study design or outcomes. Screening was conducted by one reviewer; eligibility assessment and data extraction were undertaken by two reviewers. Data were synthesised narratively. Qualitative interviews – data from 25 participants in different regions of England were analysed using a pragmatic framework approach across 12 areas including prior data collection, delivery sites, scale and processes of current service delivery, and known challenges to evaluation. Views of key stakeholders (i.e. patients and academics) were captured. Rapid systematic review – 27 out of 124 studies were included. We identified outcomes and highlighted research challenges. Important evaluation questions included identification of the most appropriate (1) outcomes and (2) methods for dealing with heterogeneity. Qualitative interviews – social prescribing programmes are holistic in nature, covering domains such as social isolation and finance. Service provision is heterogeneous. The follow-on services that patients access are often underfunded or short term. Available data – there was significant heterogeneity in data availability, format and follow-up. Data were collected using a range of tools in ad hoc databases across sites. Non-attendance data were frequently not captured. Service users are more deprived and vulnerable than the overall practice population. Feasibility and potential limitations of an evaluation – current data collection is limited in determining the effectiveness of the link worker social prescribing model; therefore, uniform data collection across sites is needed. Standardised outcomes and process measures are required. Cost–utility analysis could provide comparative values for assessment alongside other NHS interventions. This was a rapid systematic review that did not include a systematic quality assessment of studies. COVID-19 had an impact on the shape of the service. We were not able to examine the potential causal mechanisms in any detail.
{"title":"Evidence and methods required to evaluate the impact for patients who use social prescribing: a rapid systematic review and qualitative interviews","authors":"L. Al-Khudairy, A. Ayorinde, Iman Ghosh, A. Grove, J. Harlock, Edward Meehan, Adam Briggs, R. Court, A. Clarke","doi":"10.3310/rmjh0230","DOIUrl":"https://doi.org/10.3310/rmjh0230","url":null,"abstract":"\u0000 \u0000 Social prescribing encourages health-care and other professionals to refer patients to a link worker, who will develop a personalised plan to improve the patient’s health and well-being. We explore the feasibility of evaluating the service.\u0000 \u0000 \u0000 \u0000 The objective was to answer the following research questions. (1) What are the most important evaluation questions that an impact study could investigate? (2) What data are already available at a local or national level and what else would be needed? (3) Are there sites delivering at a large enough scale and in a position to take part in an impact study? (4) How could the known challenges to evaluation (e.g. information governance and identifying a control group) be addressed?\u0000 \u0000 \u0000 \u0000 Data sources included MEDLINE ALL (via Ovid), searched from inception to 14 February 2019, and the first 100 hits of a Google (Google Inc., Mountain View, CA, USA) search.\u0000 \u0000 \u0000 \u0000 Rapid systematic review – electronic searches up to February 2019. Studies included any study design or outcomes. Screening was conducted by one reviewer; eligibility assessment and data extraction were undertaken by two reviewers. Data were synthesised narratively. Qualitative interviews – data from 25 participants in different regions of England were analysed using a pragmatic framework approach across 12 areas including prior data collection, delivery sites, scale and processes of current service delivery, and known challenges to evaluation. Views of key stakeholders (i.e. patients and academics) were captured.\u0000 \u0000 \u0000 \u0000 Rapid systematic review – 27 out of 124 studies were included. We identified outcomes and highlighted research challenges. Important evaluation questions included identification of the most appropriate (1) outcomes and (2) methods for dealing with heterogeneity. Qualitative interviews – social prescribing programmes are holistic in nature, covering domains such as social isolation and finance. Service provision is heterogeneous. The follow-on services that patients access are often underfunded or short term. Available data – there was significant heterogeneity in data availability, format and follow-up. Data were collected using a range of tools in ad hoc databases across sites. Non-attendance data were frequently not captured. Service users are more deprived and vulnerable than the overall practice population. Feasibility and potential limitations of an evaluation – current data collection is limited in determining the effectiveness of the link worker social prescribing model; therefore, uniform data collection across sites is needed. Standardised outcomes and process measures are required. Cost–utility analysis could provide comparative values for assessment alongside other NHS interventions.\u0000 \u0000 \u0000 \u0000 This was a rapid systematic review that did not include a systematic quality assessment of studies. COVID-19 had an impact on the shape of the service. We were not able to examine the potential causal mechanisms in any detail.\u0000 \u0000 ","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43029758","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
M. Brady, Myzoon Ali, Kathryn VandenBerg, L. Williams, Louise R. Williams, M. Abo, F. Becker, A. Bowen, C. Brandenburg, C. Breitenstein, S. Bruehl, D. Copland, Tamara B. Cranfill, Marie di Pietro-Bachmann, P. Enderby, J. Fillingham, F. Galli, M. Gandolfi, B. Glize, E. Godecke, N. Hawkins, K. Hilari, J. Hinckley, S. Horton, David Mark Howard, Petra Jaecks, E. Jefferies, L. Jesus, M. Kambanaros, Eun Kyoung Kang, E. Khedr, A. Kong, T. Kukkonen, M. Laganaro, M. L. Lambon Ralph, A. Laska, B. Leemann, A. Leff, R. R. Lima, Antje Lorenz, B. MacWhinney, Rebecca Shisler Marshall, F. Mattioli, I. Mavis, M. Meinzer, R. Nilipour, E. Noé, N. Paik, Rebecca L Palmer, I. Papathanasiou, Brígida F Patrício, I. Martins, Cathy Price, T. Jakovac, E. Rochon, M. Rose, C. Rosso, I. Rubi-Fessen, M. Ruiter, C. Snell, B. Stahl, J. Szaflarski, Shirley A. Thomas, Mieke van de Sandt-Koenderman, Ineke van der Meulen, E. Visch-Brink, L. Worrall, H. Wright
People with language problems following stroke (aphasia) benefit from speech and language therapy. Optimising speech and language therapy for aphasia recovery is a research priority. The objectives were to explore patterns and predictors of language and communication recovery, optimum speech and language therapy intervention provision, and whether or not effectiveness varies by participant subgroup or language domain. This research comprised a systematic review, a meta-analysis and a network meta-analysis of individual participant data. Participant data were collected in research and clinical settings. The intervention under investigation was speech and language therapy for aphasia after stroke. The main outcome measures were absolute changes in language scores from baseline on overall language ability, auditory comprehension, spoken language, reading comprehension, writing and functional communication. Electronic databases were systematically searched, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Linguistic and Language Behavior Abstracts and SpeechBITE (searched from inception to 2015). The results were screened for eligibility, and published and unpublished data sets (randomised controlled trials, non-randomised controlled trials, cohort studies, case series, registries) with at least 10 individual participant data reporting aphasia duration and severity were identified. Existing collaborators and primary researchers named in identified records were invited to contribute electronic data sets. Individual participant data in the public domain were extracted. Data on demographics, speech and language therapy interventions, outcomes and quality criteria were independently extracted by two reviewers, or available as individual participant data data sets. Meta-analysis and network meta-analysis were used to generate hypotheses. We retrieved 5928 individual participant data from 174 data sets across 28 countries, comprising 75 electronic (3940 individual participant data), 47 randomised controlled trial (1778 individual participant data) and 91 speech and language therapy intervention (2746 individual participant data) data sets. The median participant age was 63 years (interquartile range 53–72 years). We identified 53 unavailable, but potentially eligible, randomised controlled trials (46 of these appeared to include speech and language therapy). Relevant individual participant data were filtered into each analysis. Statistically significant predictors of recovery included age (functional communication, individual participant data: 532, n = 14 randomised controlled trials) and sex (overall language ability, individual participant data: 482, n = 11 randomised controlled trials; functional communication, individual participant data: 532, n = 14 randomised controlled trials). Older age and being a longer time since aphasia onset predicted poorer recover
{"title":"Complex speech-language therapy interventions for stroke-related aphasia: the RELEASE study incorporating a systematic review and individual participant data network meta-analysis","authors":"M. Brady, Myzoon Ali, Kathryn VandenBerg, L. Williams, Louise R. Williams, M. Abo, F. Becker, A. Bowen, C. Brandenburg, C. Breitenstein, S. Bruehl, D. Copland, Tamara B. Cranfill, Marie di Pietro-Bachmann, P. Enderby, J. Fillingham, F. Galli, M. Gandolfi, B. Glize, E. Godecke, N. Hawkins, K. Hilari, J. Hinckley, S. Horton, David Mark Howard, Petra Jaecks, E. Jefferies, L. Jesus, M. Kambanaros, Eun Kyoung Kang, E. Khedr, A. Kong, T. Kukkonen, M. Laganaro, M. L. Lambon Ralph, A. Laska, B. Leemann, A. Leff, R. R. Lima, Antje Lorenz, B. MacWhinney, Rebecca Shisler Marshall, F. Mattioli, I. Mavis, M. Meinzer, R. Nilipour, E. Noé, N. Paik, Rebecca L Palmer, I. Papathanasiou, Brígida F Patrício, I. Martins, Cathy Price, T. Jakovac, E. Rochon, M. Rose, C. Rosso, I. Rubi-Fessen, M. Ruiter, C. Snell, B. Stahl, J. Szaflarski, Shirley A. Thomas, Mieke van de Sandt-Koenderman, Ineke van der Meulen, E. Visch-Brink, L. Worrall, H. Wright","doi":"10.3310/rtlh7522","DOIUrl":"https://doi.org/10.3310/rtlh7522","url":null,"abstract":"\u0000 \u0000 People with language problems following stroke (aphasia) benefit from speech and language therapy. Optimising speech and language therapy for aphasia recovery is a research priority.\u0000 \u0000 \u0000 \u0000 The objectives were to explore patterns and predictors of language and communication recovery, optimum speech and language therapy intervention provision, and whether or not effectiveness varies by participant subgroup or language domain.\u0000 \u0000 \u0000 \u0000 This research comprised a systematic review, a meta-analysis and a network meta-analysis of individual participant data.\u0000 \u0000 \u0000 \u0000 Participant data were collected in research and clinical settings.\u0000 \u0000 \u0000 \u0000 The intervention under investigation was speech and language therapy for aphasia after stroke.\u0000 \u0000 \u0000 \u0000 The main outcome measures were absolute changes in language scores from baseline on overall language ability, auditory comprehension, spoken language, reading comprehension, writing and functional communication.\u0000 \u0000 \u0000 \u0000 Electronic databases were systematically searched, including MEDLINE, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Linguistic and Language Behavior Abstracts and SpeechBITE (searched from inception to 2015). The results were screened for eligibility, and published and unpublished data sets (randomised controlled trials, non-randomised controlled trials, cohort studies, case series, registries) with at least 10 individual participant data reporting aphasia duration and severity were identified. Existing collaborators and primary researchers named in identified records were invited to contribute electronic data sets. Individual participant data in the public domain were extracted.\u0000 \u0000 \u0000 \u0000 Data on demographics, speech and language therapy interventions, outcomes and quality criteria were independently extracted by two reviewers, or available as individual participant data data sets. Meta-analysis and network meta-analysis were used to generate hypotheses.\u0000 \u0000 \u0000 \u0000 We retrieved 5928 individual participant data from 174 data sets across 28 countries, comprising 75 electronic (3940 individual participant data), 47 randomised controlled trial (1778 individual participant data) and 91 speech and language therapy intervention (2746 individual participant data) data sets. The median participant age was 63 years (interquartile range 53–72 years). We identified 53 unavailable, but potentially eligible, randomised controlled trials (46 of these appeared to include speech and language therapy). Relevant individual participant data were filtered into each analysis. Statistically significant predictors of recovery included age (functional communication, individual participant data: 532, n = 14 randomised controlled trials) and sex (overall language ability, individual participant data: 482, n = 11 randomised controlled trials; functional communication, individual participant data: 532, n = 14 randomised controlled trials). Older age and being a longer time since aphasia onset predicted poorer recover","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47043182","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Papoutsi, D. Hargreaves, A. Hagell, N. Hounsome, H. Skirrow, K. Muralidhara, G. Colligan, S. Vijayaraghavan, T. Greenhalgh, S. Finer
Our research was based on the expressed need to evaluate the potential for group clinics to enhance care within the NHS for people with long-term conditions. We aimed to explore the scope, feasibility, impact and potential scalability of group clinics for young adults with diabetes who have poor experiences of care and clinical outcomes. We applied a participatory approach to the entire research process, where appropriate. Four NHS trusts delivering diabetes care to young adults in ethnically diverse and socioeconomically deprived communities. We involved 135 young adults as participants in our research (73 at two intervention sites and 62 at two control sites). A realist review synthesised existing evidence for group clinics to understand ‘what works, for whom, under what circumstances’. Using the realist review findings and a scoping exercise, we used co-design to develop a model of group clinic-based care, which we then implemented and evaluated using primarily qualitative methods, with quantitative and costs analyses to inform future evaluations. Young adults reported positive experiences from the group clinics. However, across the group clinics delivered, only one-third (on average) of those invited to specific clinics attended, despite substantial efforts to encourage attendance, and only 37 out of 73 (51%) participants attended any group clinics. Social learning helped the acquisition of new knowledge and normalisation of experiences. Group clinics met previously unreached emotional needs, and the relationships that formed between young adults, and between them and the staff facilitating the clinics, were key. Clinical staff delivered the clinics using a facilitatory approach, and a youth worker helped to ensure that the care model was developmentally appropriate. Existing organisational structures presented substantial challenges to the delivery of group clinics, and there was considerable hidden work required by the staff delivering them. Group clinics may augment one-to-one care but do not necessarily replace it. The average cost of each group clinic, per participant, was £127–58. Engagement in co-design and the research process and participation in the group clinics was challenging, and limited our quantitative data analysis. These limitations had implications for the fidelity of the intervention and generalisability of our findings. During the research, we established that group clinics would not replace existing care, and that further work is required to understand the theoretical base of ‘blended’ models of care, and the potential of digital offers, before a definitive evaluation (a cluster-randomised trial) can be designed. Our findings show that young adults with diabetes, including those in deprived and ethnically diverse settings, have positive experiences of group-based care, and it may augment existing one-to-one care. However, engagement with group-based care is challenging
{"title":"Group clinics for young adults living with diabetes in an ethnically diverse, socioeconomically deprived population: mixed-methods evaluation","authors":"C. Papoutsi, D. Hargreaves, A. Hagell, N. Hounsome, H. Skirrow, K. Muralidhara, G. Colligan, S. Vijayaraghavan, T. Greenhalgh, S. Finer","doi":"10.3310/nkcr8246","DOIUrl":"https://doi.org/10.3310/nkcr8246","url":null,"abstract":"\u0000 \u0000 Our research was based on the expressed need to evaluate the potential for group clinics to enhance care within the NHS for people with long-term conditions.\u0000 \u0000 \u0000 \u0000 We aimed to explore the scope, feasibility, impact and potential scalability of group clinics for young adults with diabetes who have poor experiences of care and clinical outcomes. We applied a participatory approach to the entire research process, where appropriate.\u0000 \u0000 \u0000 \u0000 Four NHS trusts delivering diabetes care to young adults in ethnically diverse and socioeconomically deprived communities.\u0000 \u0000 \u0000 \u0000 We involved 135 young adults as participants in our research (73 at two intervention sites and 62 at two control sites).\u0000 \u0000 \u0000 \u0000 A realist review synthesised existing evidence for group clinics to understand ‘what works, for whom, under what circumstances’. Using the realist review findings and a scoping exercise, we used co-design to develop a model of group clinic-based care, which we then implemented and evaluated using primarily qualitative methods, with quantitative and costs analyses to inform future evaluations.\u0000 \u0000 \u0000 \u0000 Young adults reported positive experiences from the group clinics. However, across the group clinics delivered, only one-third (on average) of those invited to specific clinics attended, despite substantial efforts to encourage attendance, and only 37 out of 73 (51%) participants attended any group clinics. Social learning helped the acquisition of new knowledge and normalisation of experiences. Group clinics met previously unreached emotional needs, and the relationships that formed between young adults, and between them and the staff facilitating the clinics, were key. Clinical staff delivered the clinics using a facilitatory approach, and a youth worker helped to ensure that the care model was developmentally appropriate. Existing organisational structures presented substantial challenges to the delivery of group clinics, and there was considerable hidden work required by the staff delivering them. Group clinics may augment one-to-one care but do not necessarily replace it. The average cost of each group clinic, per participant, was £127–58.\u0000 \u0000 \u0000 \u0000 Engagement in co-design and the research process and participation in the group clinics was challenging, and limited our quantitative data analysis. These limitations had implications for the fidelity of the intervention and generalisability of our findings. During the research, we established that group clinics would not replace existing care, and that further work is required to understand the theoretical base of ‘blended’ models of care, and the potential of digital offers, before a definitive evaluation (a cluster-randomised trial) can be designed.\u0000 \u0000 \u0000 \u0000 Our findings show that young adults with diabetes, including those in deprived and ethnically diverse settings, have positive experiences of group-based care, and it may augment existing one-to-one care. However, engagement with group-based care is challenging","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46757597","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
C. Butler, P. Wilson, V. Abrahamson, Rasa Mikelyte, H. Gage, Peter Williams, Charlotte Brigden, Brooke Swash, M. Rees-Roberts, G. Silsbury, Mary Goodwin, Kay Greene, B. Wee, S. Barclay
Many people prefer to die at home when the time comes. Hospice at home services aim to support patients to achieve this. A range of hospice at home services exist; some services have been evaluated, but there has been limited evidence synthesis. The main objective was to find out what models of hospice at home services work best, for whom and in what circumstances. Other objectives supported this aim, including an analysis of the health economic costs of hospice at home models. The study was an overarching, non-interventional, realist evaluation comprising three phases. Phase 1 was a survey of hospice at home services. Phase 2 involved 12 case studies, grouped into four models on the basis of size and 24 hours per day, 7 days per week (24/7), operations, from which quantitative and health economics data were gathered. Qualitative interview data from bereaved carers, commissioners and providers were analysed to generate context–mechanism–outcome configurations. Phase 3 comprised stakeholder consensus meetings. Hospice at home services across England. A total of 70 hospice at home managers responded to the survey. A total of 339 patient and family/informal carer dyads were recruited; 85 hospice at home providers and commissioners were interviewed. A total of 88 stakeholders participated in consensus meetings. The quality of dying and death of patients was assessed by bereaved carers (using the Quality of Dying and Death questionnaire). A patient’s use of services was collected using the Ambulatory and Home Care Record. Hospice at home services varied; two-thirds were mainly charitably funded, and not all operated 24/7. Most patients (77%) had cancer. Hospice at home services overall provided care that was likely to deliver ‘a good death’, and 73% of patients died in their preferred place. Six context–mechanism–outcome configurations captured factors relevant to providing optimum hospice at home services: (1) sustainability (of the hospice at home service); (2) volunteers (use of, in the hospice at home service); (3) integration and co-ordination (with the wider health and social care system); (4) marketing and referral (of the hospice at home service); (5) knowledge, skills and ethos (of hospice at home staff); and (6) support directed at the carer at home. Key markers of a good service included staff who had time to care, providing hands-on care; staff whose knowledge and behaviour promoted supportive relationships and confidence through the process of dying; and services attending to the needs of the informal carer. Areas of potential improvement for most hospice at home services were the use of volunteers in hospice at home, and bereavement care. The study had the following limitations – heterogeneity of hospice at home services, variations in numbers and patient clinical statuses at recruitment, a low Quality of Dying and Death questionnaire response rate, and missing data. Only patients with
{"title":"Optimum models of hospice at home services for end-of-life care in England: a realist-informed mixed-methods evaluation","authors":"C. Butler, P. Wilson, V. Abrahamson, Rasa Mikelyte, H. Gage, Peter Williams, Charlotte Brigden, Brooke Swash, M. Rees-Roberts, G. Silsbury, Mary Goodwin, Kay Greene, B. Wee, S. Barclay","doi":"10.3310/msay4464","DOIUrl":"https://doi.org/10.3310/msay4464","url":null,"abstract":"\u0000 \u0000 Many people prefer to die at home when the time comes. Hospice at home services aim to support patients to achieve this. A range of hospice at home services exist; some services have been evaluated, but there has been limited evidence synthesis.\u0000 \u0000 \u0000 \u0000 The main objective was to find out what models of hospice at home services work best, for whom and in what circumstances. Other objectives supported this aim, including an analysis of the health economic costs of hospice at home models.\u0000 \u0000 \u0000 \u0000 The study was an overarching, non-interventional, realist evaluation comprising three phases. Phase 1 was a survey of hospice at home services. Phase 2 involved 12 case studies, grouped into four models on the basis of size and 24 hours per day, 7 days per week (24/7), operations, from which quantitative and health economics data were gathered. Qualitative interview data from bereaved carers, commissioners and providers were analysed to generate context–mechanism–outcome configurations. Phase 3 comprised stakeholder consensus meetings.\u0000 \u0000 \u0000 \u0000 Hospice at home services across England.\u0000 \u0000 \u0000 \u0000 A total of 70 hospice at home managers responded to the survey. A total of 339 patient and family/informal carer dyads were recruited; 85 hospice at home providers and commissioners were interviewed. A total of 88 stakeholders participated in consensus meetings.\u0000 \u0000 \u0000 \u0000 The quality of dying and death of patients was assessed by bereaved carers (using the Quality of Dying and Death questionnaire). A patient’s use of services was collected using the Ambulatory and Home Care Record.\u0000 \u0000 \u0000 \u0000 Hospice at home services varied; two-thirds were mainly charitably funded, and not all operated 24/7. Most patients (77%) had cancer. Hospice at home services overall provided care that was likely to deliver ‘a good death’, and 73% of patients died in their preferred place. Six context–mechanism–outcome configurations captured factors relevant to providing optimum hospice at home services: (1) sustainability (of the hospice at home service); (2) volunteers (use of, in the hospice at home service); (3) integration and co-ordination (with the wider health and social care system); (4) marketing and referral (of the hospice at home service); (5) knowledge, skills and ethos (of hospice at home staff); and (6) support directed at the carer at home. Key markers of a good service included staff who had time to care, providing hands-on care; staff whose knowledge and behaviour promoted supportive relationships and confidence through the process of dying; and services attending to the needs of the informal carer. Areas of potential improvement for most hospice at home services were the use of volunteers in hospice at home, and bereavement care.\u0000 \u0000 \u0000 \u0000 The study had the following limitations – heterogeneity of hospice at home services, variations in numbers and patient clinical statuses at recruitment, a low Quality of Dying and Death questionnaire response rate, and missing data. Only patients with","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-08-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49071559","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Aled Jones, J. Maben, Mary Adams, R. Mannion, C. Banks, Joanne Blake, Kathleen Job, D. Kelly
The introduction of ‘Freedom to Speak Up Guardians’ into every NHS trust in England was intended to support workers and trusts to better raise, respond to and learn from speaking-up concerns. However, only broad guidance was provided on how to implement the role. As a result, there is the potential for important local differences to emerge as the role is implemented across England. The overall aim of this study was to better understand the implementation of Guardians in acute trusts and mental health trusts. The Freedom to Speak Up Guardian role was conceptualised as a complex intervention consisting of several interacting and interlocking components spanning the macro level (national organisations), the meso level (individual trusts) and the micro level (employees, teams and wards/units). A mixed-methods study was designed, which consisted of three work packages: (1) a systematic narrative review of the international literature regarding interventions promoting ‘speaking up’ by health-care employees; (2) semistructured telephone interviews with Guardians working in acute hospital trusts and mental health trusts; and (3) qualitative case studies of Freedom to Speak Up Guardian implementation, consisting of observations and interviews undertaken in four acute trusts and two mental health trusts. Interviews were also undertaken with national stakeholders. Acute trusts and mental health NHS trusts in England. Work package 2: Freedom to Speak Up Guardians (n = 87) were interviewed. Work package 3: 116 interviews with key stakeholders involved in pre-implementation and early implementation decision-making, workers who had spoken up to the Guardian, and national stakeholders. Wide variability was identified in how the Guardian role had been implemented, resourced and deployed by NHS trusts. ‘Freedom to Speak Up Guardian’ is best considered an umbrella term, and multiple versions of the role exist simultaneously across England. Any comparisons of Guardians’ effectiveness are likely to be possible or meaningful only when this variability is properly accounted for. Many Freedom to Speak Up Guardians identified how a lack of available resources, especially time scarcity, negatively and significantly affected their ability to effectively respond to concerns; their opportunities to collect, analyse and learn from speaking-up data; and, more generally, the extent to which they developed their role and speak-up culture. It is possible that those whom we interviewed were more receptive of Freedom to Speak Up Guardians or may have been biased by ‘socially desirability’, and their answers may not always have represented respondents’ true perceptions. Optimal implementation of the Guardian role has five components: (1) establishing an early, collaborative and coherent strategy congruent with the values of Freedom to Speak Up fosters the implementation of (2) policies and robust, yet supportive, practices (3) inf
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