J. Baker, Kathryn Berzins, K. Canvin, S. Kendal, Stella Branthonne-Foster, J. Wright, T. McDougall, B. Goldson, I. Kellar, J. Duxbury
Incidents in which children or young people experience severe distress or harm or cause distress or harm to others occur frequently in children and young people’s institutional settings. These incidents are often managed using restrictive practices, such as restraint, seclusion, sedation or constant observation; however, these also present significant risks of physical and psychological harm to children and young people as well as staff. Numerous interventions aim to reduce the use of restrictive techniques, but research is hampered by limited attention to specific intervention components. The behavior change technique taxonomy may improve reporting by providing a common language for specifying the content and mechanisms of behaviour change. This study aimed to identify, standardise and report the effectiveness of components of interventions to reduce restrictive practices in children and young people’s institutional settings. To map interventions aimed at reducing restrictive practices in children and young people’s institutional settings internationally, to conduct behaviour change technique analysis of intervention components, to identify process elements, and to explore effectiveness evidence to identify promising behaviour change techniques and compare the results with those found in adult psychiatric inpatient settings in a companion review. Systematic mapping review with programme content coding using the behavior change technique taxonomy. Eleven relevant English-language health and social care research databases 1989–2019 [including Applied Social Sciences Index (ASSIA), Criminal Justice Abstracts, Educational Resources Information Center (ERIC), MEDLINE and PsycInfo®], grey literature and social media were searched during 2019 (updated January 2020). Data extraction, guided by Workgroup for Intervention Development and Evaluation Research (WIDER), Cochrane Library and theory coding scheme recommendations, included intervention characteristics and study design and reporting. Screening and quality appraisal used the Mixed Methods Appraisal Tool. The behavior change technique taxonomy was applied systematically, and interventions were coded for behaviour change technique components. Outcomes data were then related back to these components. There were 121 records, including 76 evaluations. Eighty-two interventions, mostly multicomponent, were identified. Evaluation approaches commonly used a non-randomised design. There were no randomised controlled trials. Behaviour change techniques from 14 out of a possible 16 clusters were detected. Four clusters (i.e. goals and planning, antecedents, shaping knowledge, and feedback and monitoring) contained the majority of identified behaviour change techniques and were detected in over half of all interventions. Two clusters (i.e. self-belief and covert learning) contained no identified behaviour change techniques. The most common setting in which behaviour change techn
{"title":"Components of interventions to reduce restrictive practices with children and young people in institutional settings: the Contrast systematic mapping review","authors":"J. Baker, Kathryn Berzins, K. Canvin, S. Kendal, Stella Branthonne-Foster, J. Wright, T. McDougall, B. Goldson, I. Kellar, J. Duxbury","doi":"10.3310/yvkt5692","DOIUrl":"https://doi.org/10.3310/yvkt5692","url":null,"abstract":"\u0000 \u0000 Incidents in which children or young people experience severe distress or harm or cause distress or harm to others occur frequently in children and young people’s institutional settings. These incidents are often managed using restrictive practices, such as restraint, seclusion, sedation or constant observation; however, these also present significant risks of physical and psychological harm to children and young people as well as staff. Numerous interventions aim to reduce the use of restrictive techniques, but research is hampered by limited attention to specific intervention components. The behavior change technique taxonomy may improve reporting by providing a common language for specifying the content and mechanisms of behaviour change. This study aimed to identify, standardise and report the effectiveness of components of interventions to reduce restrictive practices in children and young people’s institutional settings.\u0000 \u0000 \u0000 \u0000 To map interventions aimed at reducing restrictive practices in children and young people’s institutional settings internationally, to conduct behaviour change technique analysis of intervention components, to identify process elements, and to explore effectiveness evidence to identify promising behaviour change techniques and compare the results with those found in adult psychiatric inpatient settings in a companion review.\u0000 \u0000 \u0000 \u0000 Systematic mapping review with programme content coding using the behavior change technique taxonomy.\u0000 \u0000 \u0000 \u0000 Eleven relevant English-language health and social care research databases 1989–2019 [including Applied Social Sciences Index (ASSIA), Criminal Justice Abstracts, Educational Resources Information Center (ERIC), MEDLINE and PsycInfo®], grey literature and social media were searched during 2019 (updated January 2020). Data extraction, guided by Workgroup for Intervention Development and Evaluation Research (WIDER), Cochrane Library and theory coding scheme recommendations, included intervention characteristics and study design and reporting. Screening and quality appraisal used the Mixed Methods Appraisal Tool. The behavior change technique taxonomy was applied systematically, and interventions were coded for behaviour change technique components. Outcomes data were then related back to these components.\u0000 \u0000 \u0000 \u0000 There were 121 records, including 76 evaluations. Eighty-two interventions, mostly multicomponent, were identified. Evaluation approaches commonly used a non-randomised design. There were no randomised controlled trials. Behaviour change techniques from 14 out of a possible 16 clusters were detected. Four clusters (i.e. goals and planning, antecedents, shaping knowledge, and feedback and monitoring) contained the majority of identified behaviour change techniques and were detected in over half of all interventions. Two clusters (i.e. self-belief and covert learning) contained no identified behaviour change techniques. The most common setting in which behaviour change techn","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":"1 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"41366837","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}
R. Randell, Natasha Alvarado, Mai Elshehaly, Lynn McVey, R. West, P. Doherty, D. Dowding, A. Farrin, R. Feltbower, C. Gale, J. Greenhalgh, Julia Lake, M. Mamas, R. Walwyn, R. Ruddle
National audits aim to reduce variations in quality by stimulating quality improvement. However, varying provider engagement with audit data means that this is not being realised. The aim of the study was to develop and evaluate a quality dashboard (i.e. QualDash) to support clinical teams’ and managers’ use of national audit data. The study was a realist evaluation and biography of artefacts study. The study involved five NHS acute trusts. In phase 1, we developed a theory of national audits through interviews. Data use was supported by data access, audit staff skilled to produce data visualisations, data timeliness and quality, and the importance of perceived metrics. Data were mainly used by clinical teams. Organisational-level staff questioned the legitimacy of national audits. In phase 2, QualDash was co-designed and the QualDash theory was developed. QualDash provides interactive customisable visualisations to enable the exploration of relationships between variables. Locating QualDash on site servers gave users control of data upload frequency. In phase 3, we developed an adoption strategy through focus groups. ‘Champions’, awareness-raising through e-bulletins and demonstrations, and quick reference tools were agreed. In phase 4, we tested the QualDash theory using a mixed-methods evaluation. Constraints on use were metric configurations that did not match users’ expectations, affecting champions’ willingness to promote QualDash, and limited computing resources. Easy customisability supported use. The greatest use was where data use was previously constrained. In these contexts, report preparation time was reduced and efforts to improve data quality were supported, although the interrupted time series analysis did not show improved data quality. Twenty-three questionnaires were returned, revealing positive perceptions of ease of use and usefulness. In phase 5, the feasibility of conducting a cluster randomised controlled trial of QualDash was assessed. Interviews were undertaken to understand how QualDash could be revised to support a region-wide Gold Command. Requirements included multiple real-time data sources and functionality to help to identify priorities. Audits seeking to widen engagement may find the following strategies beneficial: involving a range of professional groups in choosing metrics; real-time reporting; presenting ‘headline’ metrics important to organisational-level staff; using routinely collected clinical data to populate data fields; and dashboards that help staff to explore and report audit data. Those designing dashboards may find it beneficial to include the following: ‘at a glance’ visualisation of key metrics; visualisations configured in line with existing visualisations that teams use, with clear labelling; functionality that supports the creation of reports and presentations; the ability to explore relationships between variables and drill down to look at subgroups; and
{"title":"Design and evaluation of an interactive quality dashboard for national clinical audit data: a realist evaluation","authors":"R. Randell, Natasha Alvarado, Mai Elshehaly, Lynn McVey, R. West, P. Doherty, D. Dowding, A. Farrin, R. Feltbower, C. Gale, J. Greenhalgh, Julia Lake, M. Mamas, R. Walwyn, R. Ruddle","doi":"10.3310/wbkw4927","DOIUrl":"https://doi.org/10.3310/wbkw4927","url":null,"abstract":"\u0000 \u0000 National audits aim to reduce variations in quality by stimulating quality improvement. However, varying provider engagement with audit data means that this is not being realised.\u0000 \u0000 \u0000 \u0000 The aim of the study was to develop and evaluate a quality dashboard (i.e. QualDash) to support clinical teams’ and managers’ use of national audit data.\u0000 \u0000 \u0000 \u0000 The study was a realist evaluation and biography of artefacts study.\u0000 \u0000 \u0000 \u0000 The study involved five NHS acute trusts.\u0000 \u0000 \u0000 \u0000 In phase 1, we developed a theory of national audits through interviews. Data use was supported by data access, audit staff skilled to produce data visualisations, data timeliness and quality, and the importance of perceived metrics. Data were mainly used by clinical teams. Organisational-level staff questioned the legitimacy of national audits. In phase 2, QualDash was co-designed and the QualDash theory was developed. QualDash provides interactive customisable visualisations to enable the exploration of relationships between variables. Locating QualDash on site servers gave users control of data upload frequency. In phase 3, we developed an adoption strategy through focus groups. ‘Champions’, awareness-raising through e-bulletins and demonstrations, and quick reference tools were agreed. In phase 4, we tested the QualDash theory using a mixed-methods evaluation. Constraints on use were metric configurations that did not match users’ expectations, affecting champions’ willingness to promote QualDash, and limited computing resources. Easy customisability supported use. The greatest use was where data use was previously constrained. In these contexts, report preparation time was reduced and efforts to improve data quality were supported, although the interrupted time series analysis did not show improved data quality. Twenty-three questionnaires were returned, revealing positive perceptions of ease of use and usefulness. In phase 5, the feasibility of conducting a cluster randomised controlled trial of QualDash was assessed. Interviews were undertaken to understand how QualDash could be revised to support a region-wide Gold Command. Requirements included multiple real-time data sources and functionality to help to identify priorities.\u0000 \u0000 \u0000 \u0000 Audits seeking to widen engagement may find the following strategies beneficial: involving a range of professional groups in choosing metrics; real-time reporting; presenting ‘headline’ metrics important to organisational-level staff; using routinely collected clinical data to populate data fields; and dashboards that help staff to explore and report audit data. Those designing dashboards may find it beneficial to include the following: ‘at a glance’ visualisation of key metrics; visualisations configured in line with existing visualisations that teams use, with clear labelling; functionality that supports the creation of reports and presentations; the ability to explore relationships between variables and drill down to look at subgroups; and","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43382127","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. Waring, S. Bishop, Jenelle M. Clarke, M. Exworthy, N. Fulop, J. Hartley, A. Ramsay, G. Black, B. Roe
The implementation of change in health and care services is often complicated by the ‘micropolitics’ of the care system. There is growing recognition that health and care leaders need to develop and use types of ‘political skill’ or ‘political astuteness’ to understand and manage the micropolitics of change. The aim of this study was to produce a new empirical and theoretical understanding of the acquisition, use and contribution of leadership with ‘political astuteness’, especially in the implementation of major system change, from which to inform the co-design of training, development and recruitment resources. The qualitative study comprised four work packages. Work package 1 involved two systematic literature reviews: one ‘review of reviews’ on the concept of political astuteness and another applying the learning from this to the health services research literature. Work package 2 involved biographical narrative interviews with 66 health and care leaders to investigate their experiences of acquiring and using political skills in the implementation of change. Work package 3 involved in-depth qualitative case study research with nine project teams drawn from three regional Sustainability and Transformation Partnerships operating in different English regions. Work package 4 involved a series of co-design workshops to develop learning materials and resources to support service leaders’ acquisition and use of political skills and astuteness. The concepts of political skills and astuteness have had growing influence on health services research, yet these have tended to emphasise a relatively individualised and behavioural view of change leadership. The interview study suggests that, although leaders certainly use individual skills and behaviours when implementing change, change processes are contingent on local contextual factors and the patterns of collective action in the forms of interlocking constellations of political interactions. The in-depth case study research further shows these interactive, contingent and collective processes in the implementation of major system change. The study finds that major system change occurs over several linked stages, each involving particular controversies for which skills, strategies and actions are needed. Informed by these findings, and through a series of co-design workshops, the study has produced a set of resources and materials and a workbook to support individuals and project teams to acquire and develop political skill. The study was complicated by the COVID-19 pandemic and there were difficulties in recruiting in-depth cases for observational research, and also recruiting patient and community groups. Health and care leaders can develop and use a range of skills, strategies and actions to understand and navigate the diverse interests that complicate change. Building on the literature, the study presents a novel empirical framework of these skills, strategies an
{"title":"Healthcare Leadership with Political Astuteness and its role in the implementation of major system change: the HeLPA qualitative study","authors":"J. Waring, S. Bishop, Jenelle M. Clarke, M. Exworthy, N. Fulop, J. Hartley, A. Ramsay, G. Black, B. Roe","doi":"10.3310/ffci3260","DOIUrl":"https://doi.org/10.3310/ffci3260","url":null,"abstract":"\u0000 \u0000 The implementation of change in health and care services is often complicated by the ‘micropolitics’ of the care system. There is growing recognition that health and care leaders need to develop and use types of ‘political skill’ or ‘political astuteness’ to understand and manage the micropolitics of change.\u0000 \u0000 \u0000 \u0000 The aim of this study was to produce a new empirical and theoretical understanding of the acquisition, use and contribution of leadership with ‘political astuteness’, especially in the implementation of major system change, from which to inform the co-design of training, development and recruitment resources.\u0000 \u0000 \u0000 \u0000 The qualitative study comprised four work packages. Work package 1 involved two systematic literature reviews: one ‘review of reviews’ on the concept of political astuteness and another applying the learning from this to the health services research literature. Work package 2 involved biographical narrative interviews with 66 health and care leaders to investigate their experiences of acquiring and using political skills in the implementation of change. Work package 3 involved in-depth qualitative case study research with nine project teams drawn from three regional Sustainability and Transformation Partnerships operating in different English regions. Work package 4 involved a series of co-design workshops to develop learning materials and resources to support service leaders’ acquisition and use of political skills and astuteness.\u0000 \u0000 \u0000 \u0000 The concepts of political skills and astuteness have had growing influence on health services research, yet these have tended to emphasise a relatively individualised and behavioural view of change leadership. The interview study suggests that, although leaders certainly use individual skills and behaviours when implementing change, change processes are contingent on local contextual factors and the patterns of collective action in the forms of interlocking constellations of political interactions. The in-depth case study research further shows these interactive, contingent and collective processes in the implementation of major system change. The study finds that major system change occurs over several linked stages, each involving particular controversies for which skills, strategies and actions are needed. Informed by these findings, and through a series of co-design workshops, the study has produced a set of resources and materials and a workbook to support individuals and project teams to acquire and develop political skill.\u0000 \u0000 \u0000 \u0000 The study was complicated by the COVID-19 pandemic and there were difficulties in recruiting in-depth cases for observational research, and also recruiting patient and community groups.\u0000 \u0000 \u0000 \u0000 Health and care leaders can develop and use a range of skills, strategies and actions to understand and navigate the diverse interests that complicate change. Building on the literature, the study presents a novel empirical framework of these skills, strategies an","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43258119","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}
I. McDermott, S. Spooner, M. Goff, J. Gibson, E. Dalgarno, Igor Francetic, M. Hann, Damian Hodgson, A. Mcbride, K. Checkland, M. Sutton
General practices have had difficulty recruiting and retaining enough general practitioners to keep up with increasing demand for primary health care in recent years. Proposals to increase workforce capacity include a policy-driven strategy to employ additional numbers and a wider range of health professionals. Our objective was to conduct a comprehensive study of the scale, scope and impact of changing patterns of practitioner employment in general practice in England. This included an analysis of employment trends, motivations behind employment decisions, staff and patient experiences, and how skill mix changes are associated with outcome measures and costs. NHS Digital workforce data (2015–19) were used to analyse employment changes and to look at their association with outcomes data, such as the General Practitioner Patient Survey, General Practitioner Worklife Survey, prescribing data, Hospital Episode Statistics, Quality and Outcomes Framework and NHS payments to practices. A practice manager survey (August–December 2019) explored factors motivating general practices’ employment decisions. An in-depth case study of five general practices in England (August–December 2019) examined how a broader range of practitioners is experienced by practice staff and patients. We found a 2.84% increase in reported full-time equivalent per 1000 patients across all practitioners during the study period. The full-time equivalent of general practitioner partners decreased, while the full-time equivalent of salaried general practitioners, advanced nurse practitioners, clinical pharmacists, physiotherapists, physician associates and paramedics increased. General practitioners and practice managers reported different motivating factors regarding skill mix employment. General practitioners saw skill mix employment as a strategy to cope with a general practitioner shortage, whereas managers prioritised potential cost-efficiencies. Case studies demonstrated the importance of matching patients’ problems with practitioners’ competencies and ensuring flexibility for practitioners to obtain advice when perfect matching was not achieved. Senior clinicians provided additional support and had supervisory and other responsibilities, and analysis of the General Practitioner Worklife Survey data suggested that general practitioners’ job satisfaction may not increase with skill mix changes. Patients lacked information about newer practitioners, but felt reassured by the accessibility of expert advice. However, General Practitioner Patient Survey data indicated that higher patient satisfaction was associated with a higher general practitioner full-time equivalent. Quality and Outcomes Framework achievement was higher when more practitioners were employed (i.e. full-time equivalent per 1000 patients). Higher clinical pharmacist full-time equivalents per 1000 patients were associated with higher quality and lower cost prescribing. Associations between sk
{"title":"Scale, scope and impact of skill mix change in primary care in England: a mixed-methods study","authors":"I. McDermott, S. Spooner, M. Goff, J. Gibson, E. Dalgarno, Igor Francetic, M. Hann, Damian Hodgson, A. Mcbride, K. Checkland, M. Sutton","doi":"10.3310/ywtu6690","DOIUrl":"https://doi.org/10.3310/ywtu6690","url":null,"abstract":"\u0000 \u0000 General practices have had difficulty recruiting and retaining enough general practitioners to keep up with increasing demand for primary health care in recent years. Proposals to increase workforce capacity include a policy-driven strategy to employ additional numbers and a wider range of health professionals.\u0000 \u0000 \u0000 \u0000 Our objective was to conduct a comprehensive study of the scale, scope and impact of changing patterns of practitioner employment in general practice in England. This included an analysis of employment trends, motivations behind employment decisions, staff and patient experiences, and how skill mix changes are associated with outcome measures and costs.\u0000 \u0000 \u0000 \u0000 NHS Digital workforce data (2015–19) were used to analyse employment changes and to look at their association with outcomes data, such as the General Practitioner Patient Survey, General Practitioner Worklife Survey, prescribing data, Hospital Episode Statistics, Quality and Outcomes Framework and NHS payments to practices. A practice manager survey (August–December 2019) explored factors motivating general practices’ employment decisions. An in-depth case study of five general practices in England (August–December 2019) examined how a broader range of practitioners is experienced by practice staff and patients.\u0000 \u0000 \u0000 \u0000 We found a 2.84% increase in reported full-time equivalent per 1000 patients across all practitioners during the study period. The full-time equivalent of general practitioner partners decreased, while the full-time equivalent of salaried general practitioners, advanced nurse practitioners, clinical pharmacists, physiotherapists, physician associates and paramedics increased. General practitioners and practice managers reported different motivating factors regarding skill mix employment. General practitioners saw skill mix employment as a strategy to cope with a general practitioner shortage, whereas managers prioritised potential cost-efficiencies. Case studies demonstrated the importance of matching patients’ problems with practitioners’ competencies and ensuring flexibility for practitioners to obtain advice when perfect matching was not achieved. Senior clinicians provided additional support and had supervisory and other responsibilities, and analysis of the General Practitioner Worklife Survey data suggested that general practitioners’ job satisfaction may not increase with skill mix changes. Patients lacked information about newer practitioners, but felt reassured by the accessibility of expert advice. However, General Practitioner Patient Survey data indicated that higher patient satisfaction was associated with a higher general practitioner full-time equivalent. Quality and Outcomes Framework achievement was higher when more practitioners were employed (i.e. full-time equivalent per 1000 patients). Higher clinical pharmacist full-time equivalents per 1000 patients were associated with higher quality and lower cost prescribing. Associations between sk","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-05-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"46823250","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}
Stephen Morris, E. Hudson, Lara Bloom, L. Chitty, N. Fulop, A. Hunter, Jennifer Jones, J. Kai, L. Kerecuk, M. Kokocinska, K. Leeson-Beevers, P. L. Ng, Sharon Parkes, A. Ramsay, Amy Simpson, A. Sutcliffe, Christine Taylor, H. Walton
A condition is defined as rare if it affects fewer than 1 in 2000 people in the general population. Limited evidence suggests that care is poorly co-ordinated for people affected by rare conditions. To investigate if and how care of people with rare conditions is co-ordinated in the UK, and how people affected by rare conditions would like care to be co-ordinated. A mixed-methods study comprising (1) a scoping review to develop a definition of co-ordinated care and identify components of co-ordinated care (n = 154 studies); (2) an exploratory qualitative interview study to understand the impact of a lack of co-ordinated care (n = 15 participants); (3) a national survey among people affected by rare conditions of experiences of care co-ordination (n = 1457 participants); (4) a discrete choice experiment of preferences for co-ordination (n = 996 participants); (5) the development of a taxonomy of co-ordinated care for rare conditions (n = 79 participants); and (6) a review of costs of providing co-ordinated care. Health services for people affected by rare conditions, including gatekeeping to social care provision and third-sector care. Adult patients with rare conditions, parents/carers of children or adults with rare conditions and health-care professionals (e.g. doctors, nurses and allied health professionals) involved in the care of people with rare conditions. No limits were set on the rare conditions included or where people live in the UK. Participants were sampled from patient and provider networks and organisations. A definition of co-ordinated care for rare conditions was developed. Care for people affected by rare diseases was found to be not well co-ordinated. For example, only 12% of 760 adult patients affected by a rare disease reported that they had a formal care co-ordinator, 32% reported that they attended a specialist centre and 10% reported that they had a care plan. Patients, parents/carers and health-care professionals all would like care to be better co-ordinated, with some differences in preferences reported by patients and parents/carers and those reported by health-care professionals. Our taxonomy of care co-ordination for rare conditions outlined six domains: (1) ways of organising care, (2) ways of organising teams, (3) responsibilities, (4) how often care appointments and co-ordination take place, (5) access to records and (6) mode of communication. It was not possible to capture the experiences of people affected by every rare condition. Our sampling strategy in the study may have been biased if study participants were systematically different from the population affected by rare conditions. The cost analysis was limited. There is evidence of a lack of co-ordinated care for people affected by rare diseases. This can have a negative impact on the physical and mental health of patients and families, and their financial well-being. Further research would be benefi
{"title":"Co-ordinated care for people affected by rare diseases: the CONCORD mixed-methods study","authors":"Stephen Morris, E. Hudson, Lara Bloom, L. Chitty, N. Fulop, A. Hunter, Jennifer Jones, J. Kai, L. Kerecuk, M. Kokocinska, K. Leeson-Beevers, P. L. Ng, Sharon Parkes, A. Ramsay, Amy Simpson, A. Sutcliffe, Christine Taylor, H. Walton","doi":"10.3310/lnzz5321","DOIUrl":"https://doi.org/10.3310/lnzz5321","url":null,"abstract":"\u0000 \u0000 A condition is defined as rare if it affects fewer than 1 in 2000 people in the general population. Limited evidence suggests that care is poorly co-ordinated for people affected by rare conditions.\u0000 \u0000 \u0000 \u0000 To investigate if and how care of people with rare conditions is co-ordinated in the UK, and how people affected by rare conditions would like care to be co-ordinated.\u0000 \u0000 \u0000 \u0000 A mixed-methods study comprising (1) a scoping review to develop a definition of co-ordinated care and identify components of co-ordinated care (n = 154 studies); (2) an exploratory qualitative interview study to understand the impact of a lack of co-ordinated care (n = 15 participants); (3) a national survey among people affected by rare conditions of experiences of care co-ordination (n = 1457 participants); (4) a discrete choice experiment of preferences for co-ordination (n = 996 participants); (5) the development of a taxonomy of co-ordinated care for rare conditions (n = 79 participants); and (6) a review of costs of providing co-ordinated care.\u0000 \u0000 \u0000 \u0000 Health services for people affected by rare conditions, including gatekeeping to social care provision and third-sector care.\u0000 \u0000 \u0000 \u0000 Adult patients with rare conditions, parents/carers of children or adults with rare conditions and health-care professionals (e.g. doctors, nurses and allied health professionals) involved in the care of people with rare conditions. No limits were set on the rare conditions included or where people live in the UK. Participants were sampled from patient and provider networks and organisations.\u0000 \u0000 \u0000 \u0000 A definition of co-ordinated care for rare conditions was developed. Care for people affected by rare diseases was found to be not well co-ordinated. For example, only 12% of 760 adult patients affected by a rare disease reported that they had a formal care co-ordinator, 32% reported that they attended a specialist centre and 10% reported that they had a care plan. Patients, parents/carers and health-care professionals all would like care to be better co-ordinated, with some differences in preferences reported by patients and parents/carers and those reported by health-care professionals. Our taxonomy of care co-ordination for rare conditions outlined six domains: (1) ways of organising care, (2) ways of organising teams, (3) responsibilities, (4) how often care appointments and co-ordination take place, (5) access to records and (6) mode of communication.\u0000 \u0000 \u0000 \u0000 It was not possible to capture the experiences of people affected by every rare condition. Our sampling strategy in the study may have been biased if study participants were systematically different from the population affected by rare conditions. The cost analysis was limited.\u0000 \u0000 \u0000 \u0000 There is evidence of a lack of co-ordinated care for people affected by rare diseases. This can have a negative impact on the physical and mental health of patients and families, and their financial well-being.\u0000 \u0000 \u0000 \u0000 Further research would be benefi","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44408714","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}
Ruth Harris, S. Fletcher, S. Sims, F. Ross, S. Brearley, J. Manthorpe
As the organisation of health and social care in England moves rapidly towards greater integration, the resulting systems and teams will require distinctive leadership. However, little is known about how the effective leadership of these teams and systems can be supported and improved. In particular, there is relatively little understanding of how effective leadership across integrated care teams and systems may be enacted, the contexts in which this might take place and the subsequent implications this has on integrated care. This realist review developed and refined programme theories of leadership of integrated health and social care teams and systems, exploring what works, for whom and in what circumstances. The review utilised a realist synthesis approach, informed by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards, to explore existing literature on the leadership of integrated care teams and systems, complemented by ongoing stakeholder consultation. Empirical evidence specifically addressing leadership of integrated teams or services was limited, with only 36 papers included in the review. The evidence collected from these 36 papers was synthesised to identify and build a comprehensive description of the mechanisms of leadership of integrated teams and systems and their associated contexts and outcomes. Consultation with key stakeholders with a range of expertise throughout the process ensured that the review remained grounded in the reality of health and social care delivery and addressed practice and policy challenges. Evidence was identified for seven potentially important components of leadership in integrated care teams and systems. These were ‘inspiring intent to work together’, ‘creating the conditions to work together’, ‘balancing multiple perspectives’, ‘working with power’, ‘taking a wider view’, ‘a commitment to learning and development’ and ‘clarifying complexity’. No empirical evidence was found for an eighth mechanism, ‘fostering resilience’, although stakeholders felt that this was potentially an important, long-term component of leadership. A key message of the review was that empirical research often focused on the importance of who the leader of an integrated team or service was (i.e. their personality traits and characteristics) rather than what they did (i.e. the specific role that they played in integrated working), although stakeholders considered that a focus on leader personality was not sufficient. Other key messages highlighted the way in which power and influence are used by integrated service leaders and identified the hierarchies between health and social care which complicate the leading of integrated teams and systems. Evidence specifically addressing leadership of integrated care teams and systems was limited and lacking in detail, which restricted the degree to which definitive conclusions could be drawn around what works,
{"title":"Developing programme theories of leadership for integrated health and social care teams and systems: a realist synthesis","authors":"Ruth Harris, S. Fletcher, S. Sims, F. Ross, S. Brearley, J. Manthorpe","doi":"10.3310/wpng1013","DOIUrl":"https://doi.org/10.3310/wpng1013","url":null,"abstract":"\u0000 \u0000 As the organisation of health and social care in England moves rapidly towards greater integration, the resulting systems and teams will require distinctive leadership. However, little is known about how the effective leadership of these teams and systems can be supported and improved. In particular, there is relatively little understanding of how effective leadership across integrated care teams and systems may be enacted, the contexts in which this might take place and the subsequent implications this has on integrated care.\u0000 \u0000 \u0000 \u0000 This realist review developed and refined programme theories of leadership of integrated health and social care teams and systems, exploring what works, for whom and in what circumstances.\u0000 \u0000 \u0000 \u0000 The review utilised a realist synthesis approach, informed by the Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) publication standards, to explore existing literature on the leadership of integrated care teams and systems, complemented by ongoing stakeholder consultation. Empirical evidence specifically addressing leadership of integrated teams or services was limited, with only 36 papers included in the review. The evidence collected from these 36 papers was synthesised to identify and build a comprehensive description of the mechanisms of leadership of integrated teams and systems and their associated contexts and outcomes. Consultation with key stakeholders with a range of expertise throughout the process ensured that the review remained grounded in the reality of health and social care delivery and addressed practice and policy challenges.\u0000 \u0000 \u0000 \u0000 Evidence was identified for seven potentially important components of leadership in integrated care teams and systems. These were ‘inspiring intent to work together’, ‘creating the conditions to work together’, ‘balancing multiple perspectives’, ‘working with power’, ‘taking a wider view’, ‘a commitment to learning and development’ and ‘clarifying complexity’. No empirical evidence was found for an eighth mechanism, ‘fostering resilience’, although stakeholders felt that this was potentially an important, long-term component of leadership. A key message of the review was that empirical research often focused on the importance of who the leader of an integrated team or service was (i.e. their personality traits and characteristics) rather than what they did (i.e. the specific role that they played in integrated working), although stakeholders considered that a focus on leader personality was not sufficient. Other key messages highlighted the way in which power and influence are used by integrated service leaders and identified the hierarchies between health and social care which complicate the leading of integrated teams and systems.\u0000 \u0000 \u0000 \u0000 Evidence specifically addressing leadership of integrated care teams and systems was limited and lacking in detail, which restricted the degree to which definitive conclusions could be drawn around what works, ","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"49553101","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}
B. Hannigan, D. Edwards, S. Anstey, M. Coffey, Paul Gill, M. Mann, A. Meudell
People with severe mental illness have significant comorbidities and a reduced life expectancy. This project answered the following question: what evidence is there relating to the organisation, provision and receipt of care for people with severe mental illness who have an additional diagnosis of advanced incurable cancer and/or end-stage lung, heart, renal or liver failure and who are likely to die within the next 12 months? The objectives were to locate, appraise and synthesise relevant research; to locate and synthesise policy, guidance, case reports and other grey and non-research literature; to produce outputs with clear implications for service commissioning, organisation and provision; and to make recommendations for future research. This systematic review and narrative synthesis followed international standards and was informed by an advisory group that included people with experience of mental health and end-of-life services. Database searches were supplemented with searches for grey and non-research literature. Relevance and quality were assessed, and data were extracted prior to narrative synthesis. Confidence in synthesised research findings was assessed using the Grading of Recommendations, Assessment, Development and Evaluation and the Confidence in the Evidence from Reviews of Qualitative Research approaches. One hundred and four publications were included in two syntheses: 34 research publications, 42 case studies and 28 non-research items. No research was excluded because of poor quality. Research, policy and guidance were synthesised using four themes: structure of the system, professional issues, contexts of care and living with severe mental illness. Case studies were synthesised using five themes: diagnostic delay and overshadowing, decisional capacity and dilemmas, medical futility, individuals and their networks, and care provision. A high degree of confidence applied to 10 of the 52 Grading of Recommendations, Assessment, Development and Evaluation and Confidence in the Evidence from Reviews of Qualitative Research summary statements. Drawing on these statements, policy, services and practice implications are as follows: formal and informal partnership opportunities should be taken across the whole system, and ways need to be found to support people to die where they choose; staff caring for people with severe mental illness at the end of life need education, support and supervision; services for people with severe mental illness at the end of life necessitate a team approach, including advocacy; and the timely provision of palliative care requires proactive physical health care for people with severe mental illness. Research recommendations are as follows: patient- and family-facing studies are needed to establish the factors helping and hindering care in the UK context; and studies are needed that co-produce and evaluate new ways of providing and organising end-of-life care for people wit
{"title":"End-of-life care for people with severe mental illness: the MENLOC evidence synthesis","authors":"B. Hannigan, D. Edwards, S. Anstey, M. Coffey, Paul Gill, M. Mann, A. Meudell","doi":"10.3310/ulti9178","DOIUrl":"https://doi.org/10.3310/ulti9178","url":null,"abstract":"\u0000 \u0000 People with severe mental illness have significant comorbidities and a reduced life expectancy. This project answered the following question: what evidence is there relating to the organisation, provision and receipt of care for people with severe mental illness who have an additional diagnosis of advanced incurable cancer and/or end-stage lung, heart, renal or liver failure and who are likely to die within the next 12 months?\u0000 \u0000 \u0000 \u0000 The objectives were to locate, appraise and synthesise relevant research; to locate and synthesise policy, guidance, case reports and other grey and non-research literature; to produce outputs with clear implications for service commissioning, organisation and provision; and to make recommendations for future research.\u0000 \u0000 \u0000 \u0000 This systematic review and narrative synthesis followed international standards and was informed by an advisory group that included people with experience of mental health and end-of-life services. Database searches were supplemented with searches for grey and non-research literature. Relevance and quality were assessed, and data were extracted prior to narrative synthesis. Confidence in synthesised research findings was assessed using the Grading of Recommendations, Assessment, Development and Evaluation and the Confidence in the Evidence from Reviews of Qualitative Research approaches.\u0000 \u0000 \u0000 \u0000 One hundred and four publications were included in two syntheses: 34 research publications, 42 case studies and 28 non-research items. No research was excluded because of poor quality. Research, policy and guidance were synthesised using four themes: structure of the system, professional issues, contexts of care and living with severe mental illness. Case studies were synthesised using five themes: diagnostic delay and overshadowing, decisional capacity and dilemmas, medical futility, individuals and their networks, and care provision.\u0000 \u0000 \u0000 \u0000 A high degree of confidence applied to 10 of the 52 Grading of Recommendations, Assessment, Development and Evaluation and Confidence in the Evidence from Reviews of Qualitative Research summary statements. Drawing on these statements, policy, services and practice implications are as follows: formal and informal partnership opportunities should be taken across the whole system, and ways need to be found to support people to die where they choose; staff caring for people with severe mental illness at the end of life need education, support and supervision; services for people with severe mental illness at the end of life necessitate a team approach, including advocacy; and the timely provision of palliative care requires proactive physical health care for people with severe mental illness. Research recommendations are as follows: patient- and family-facing studies are needed to establish the factors helping and hindering care in the UK context; and studies are needed that co-produce and evaluate new ways of providing and organising end-of-life care for people wit","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":"40 1","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-03-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"69498611","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. Marshall, Huw Davies, Vicky Ward, J. Waring, N. Fulop, Liz Mear, Breid O’Brien, Richard Parnell, Katherine Kirk, Benet Reid, T. Tooman
The limitations of ‘knowledge transfer’ are increasingly recognised, with growing interest in ‘knowledge co-production in context’. One way of achieving the latter is by ‘embedding’ researchers in health service settings, yet how to deliver such schemes successfully is poorly understood. The objectives were to examine the nature of ‘embedded knowledge co-production’ and explore how embedded research initiatives can be designed more effectively. The study used four linked workstreams. Workstream 1 involved two parallel literature reviews to examine how ‘knowledge co-production’ and ‘embedded research’ are conceptualised, operationalised and discussed. In workstream 2, a scoping review of exisiting or recent ‘embedded researcher’ schemes in UK health settings was carried out. Workstream 3 involved developing four in-depth case studies on such schemes to understand their mechanisms, effectiveness and challenges. In workstream 4, insights from the other workstreams were used to provide recommendations, guidance and templates for the different ways embedded co-production may be framed and specified. The overall goal was to help those interested in developing and using such approaches to understand and address the design choices they face. Embedded research initiatives in UK health settings. Data were sourced from the following: analysis of the published and grey literature (87 source articles on knowledge co-production, and 47 published reports on extant embedded research initiatives), documentation and interviews with key actors across 45 established embedded research initiatives, in-depth interviews and site observations with 31 participants over 12 months in four intensive case studies, and informal and creative engagement in workshops (n = 2) and with participants in embedded research initiatives who joined various managed discussion forums. The participants were stakeholders and participants in embedded research initiatives. The literature reviews from workstream 1 produced practical frameworks for understanding knowledge co-production and embedded research initiatives, which, with the scoping review (workstream 2), informed the identification and articulation of 10 design concerns under three overarching categories: intent (covering outcomes and power dynamics), structures (scale, involvement, proximity and belonging) and processes (the functional activities, skills and expertise required, nature of the relational roles, and the learning mechanisms employed). Current instances of embedded research were diverse across many of these domains. The four case studies (workstream 3) added insights into scheme dynamics and life cycles, deepening understanding of the overarching categories and showing the contingencies experienced in co-producing knowledge. A key finding is that there was often a greater emphasis on embeddedness per se than on co-production, which can be hard to discern. Finally, the engaging
{"title":"Optimising the impact of health services research on the organisation and delivery of health services: a mixed-methods study","authors":"M. Marshall, Huw Davies, Vicky Ward, J. Waring, N. Fulop, Liz Mear, Breid O’Brien, Richard Parnell, Katherine Kirk, Benet Reid, T. Tooman","doi":"10.3310/hfuu3193","DOIUrl":"https://doi.org/10.3310/hfuu3193","url":null,"abstract":"\u0000 \u0000 The limitations of ‘knowledge transfer’ are increasingly recognised, with growing interest in ‘knowledge co-production in context’. One way of achieving the latter is by ‘embedding’ researchers in health service settings, yet how to deliver such schemes successfully is poorly understood.\u0000 \u0000 \u0000 \u0000 The objectives were to examine the nature of ‘embedded knowledge co-production’ and explore how embedded research initiatives can be designed more effectively.\u0000 \u0000 \u0000 \u0000 The study used four linked workstreams. Workstream 1 involved two parallel literature reviews to examine how ‘knowledge co-production’ and ‘embedded research’ are conceptualised, operationalised and discussed. In workstream 2, a scoping review of exisiting or recent ‘embedded researcher’ schemes in UK health settings was carried out. Workstream 3 involved developing four in-depth case studies on such schemes to understand their mechanisms, effectiveness and challenges. In workstream 4, insights from the other workstreams were used to provide recommendations, guidance and templates for the different ways embedded co-production may be framed and specified. The overall goal was to help those interested in developing and using such approaches to understand and address the design choices they face.\u0000 \u0000 \u0000 \u0000 Embedded research initiatives in UK health settings.\u0000 \u0000 \u0000 \u0000 Data were sourced from the following: analysis of the published and grey literature (87 source articles on knowledge co-production, and 47 published reports on extant embedded research initiatives), documentation and interviews with key actors across 45 established embedded research initiatives, in-depth interviews and site observations with 31 participants over 12 months in four intensive case studies, and informal and creative engagement in workshops (n = 2) and with participants in embedded research initiatives who joined various managed discussion forums.\u0000 \u0000 \u0000 \u0000 The participants were stakeholders and participants in embedded research initiatives.\u0000 \u0000 \u0000 \u0000 The literature reviews from workstream 1 produced practical frameworks for understanding knowledge co-production and embedded research initiatives, which, with the scoping review (workstream 2), informed the identification and articulation of 10 design concerns under three overarching categories: intent (covering outcomes and power dynamics), structures (scale, involvement, proximity and belonging) and processes (the functional activities, skills and expertise required, nature of the relational roles, and the learning mechanisms employed). Current instances of embedded research were diverse across many of these domains. The four case studies (workstream 3) added insights into scheme dynamics and life cycles, deepening understanding of the overarching categories and showing the contingencies experienced in co-producing knowledge. A key finding is that there was often a greater emphasis on embeddedness per se than on co-production, which can be hard to discern. Finally, the engaging","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-02-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"44333157","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}
S. Shepperd, Andrea Cradduck-Bamford, Christopher C. Butler, G. Ellis, M. Godfrey, A. Gray, A. Hemsley, P. Khanna, P. Langhorne, Petra Mäkelä, S. Mort, Scott Ramsay, R. Schiff, Surya Singh, Susan Smith, D. Stott, A. Tsiachristas, A. Wilkinson, Ly-Mee Yu, J. Young
Evidence is required to guide the redesign of health care for older people who require hospital admission. We assessed the clinical effectiveness and cost-effectiveness of geriatrician-led admission avoidance hospital at home with comprehensive geriatric assessment, the experiences of older people and their caregivers, and how the services differed. A multisite, randomised, open trial of comprehensive geriatric assessment hospital at home, compared with admission to hospital, using a 2 : 1 (hospital at home to hospital) ratio, and a parallel economic and process evaluation. Participants were randomised using a secure online system. Participants were recruited from primary care or acute hospital assessment units from nine sites across the UK. Older people who required hospital admission because of an acute change in health. Geriatrician-led admission avoidance hospital at home with comprehensive geriatric assessment. The main outcome, ‘living at home’ (the inverse of death or living in a residential care setting), was measured at 6-month follow-up. Secondary outcomes at 6 months were the incidence of delirium, mortality, new long-term residential care, cognitive impairment, ability to perform activities of daily living, quality-adjusted survival, length of stay and transfer to hospital. Secondary outcomes at 12 months were living at home, new long-term residential care and mortality. Participants were allocated to hospital at home (n = 700) or to hospital (n = 355). All reported relative risks (RRs) were adjusted and are reported for hospital at home compared with hospital. There were no significant differences between the groups in the proportions of patients ‘living at home’ at 6 months [528/672 (78.6%) vs. 247/328 (75.3%), RR 1.05, 95% confidence interval (CI) 0.95 to 1.15; p = 0.36] or at 12 months [443/670 (66.1%) vs. 219/325 (67.4%), RR 0.99, 95% CI 0.89 to 1.10; p = 0.80]; mortality at 6 months [114/673 (16.9%) vs. 58/328 (17.7%), RR 0.98, 95% CI 0.65 to 1.47; p = 0.92] or at 12 months [188/670 (28.1%) vs. 82/325 (25.2%), RR 1.14, 95% CI 0.80 to 1.62]; the proportion of patients with cognitive impairment [273/407 (67.1%) vs. 115/183 (62.8%), RR 1.06, 95% CI 0.93 to 1.21; p = 0.36]; or in ability to perform the activities of daily living as measured by the Barthel Index (mean difference 0.24, 95% CI –0.33 to 0.80; p = 0.411; hospital at home, n = 521 patients contributed data; hospital, n = 256 patients contributed data) or Comorbidity Index (adjusted mean difference 0.0002, 95% CI –0.15 to 0.15; p = 0.10; hospital at home, n = 474 patients contributed data; hospital, n = 227 patients contributed data) at 6 months. The varying denominator reflects the number of participants who contributed data to the different outcomes. There was a significant reduction in the RR of living in residential care at 6 months [37/646 (5.7%) vs. 27/311 (8.7%), RR 0.58, 95% CI 0.45 to 0.76; p < 0.001] and 12 mon
需要证据来指导重新设计需要住院的老年人的保健服务。我们通过全面的老年病学评估、老年人及其护理人员的经验，以及服务的不同，评估了老年医生主导的家庭住院避免医院的临床效果和成本效益。一项多地点、随机、开放的综合老年评估在家医院与入院进行比较的试验，采用2:1(在家医院与医院)的比例，并进行平行经济和过程评估。参与者是通过一个安全的在线系统随机抽取的。参与者是从英国九个地点的初级保健或急性医院评估单位招募的。因健康状况发生严重变化而需要住院的老年人。以老年病医生为主导的住院避免在家进行全面的老年评估。主要结果“在家生活”(与死亡或住在养老院相反)是在6个月的随访中测量的。6个月时的次要结局是谵妄的发生率、死亡率、新的长期住院护理、认知障碍、进行日常生活活动的能力、质量调整生存率、住院时间和转院时间。12个月时的次要结果是住在家里、新的长期住宿护理和死亡率。参与者被分配到家庭医院(n = 700)或医院(n = 355)。对所有报告的相对风险(rr)进行了调整，并将家庭医院与医院的报告进行了比较。6个月时，两组患者“住在家里”的比例无显著差异[528/672(78.6%)比247/328 (75.3%)，RR 1.05, 95%可信区间(CI) 0.95 ~ 1.15;p = 0.36]或12个月时[443/670(66.1%)比219/325 (67.4%)，RR 0.99, 95% CI 0.89 ~ 1.10;p = 0.80];6个月死亡率[114/673(16.9%)比58/328 (17.7%)，RR 0.98, 95% CI 0.65 ~ 1.47;p = 0.92]或12个月时[188/670(28.1%)比82/325 (25.2%)，RR 1.14, 95% CI 0.80 ~ 1.62];认知障碍患者比例[273/407(67.1%)比115/183 (62.8%)，RR 1.06, 95% CI 0.93 ~ 1.21;p = 0.36];或以Barthel指数衡量的日常生活活动能力(平均差0.24,95% CI -0.33至0.80;p = 0.411;家庭医院，n = 521例患者提供数据;医院，n = 256例患者提供数据)或合并症指数(调整后平均差0.0002,95% CI -0.15 ~ 0.15;p = 0.10;家庭医院，n = 474名患者提供数据;医院，n = 227例患者提供资料)6个月时。变化的分母反映了为不同结果提供数据的参与者的数量。6个月时住在养老院的相对危险度显著降低[37/646(5.7%)比27/311(8.7%)，相对危险度0.58,95% CI 0.45 ~ 0.76;p < 0.001]和12个月[39/646(6.0%)比27/311 (8.7%)，RR 0.61, 95% CI 0.46 ~ 0.82;p < 0.001]， 1个月时谵妄的风险显著降低[10/602(1.7%)比13/295 (4.4%)，RR 0.38, 95% CI 0.19 ~ 0.76;p = 0.006]和1个月转院风险增加[173/672(25.7%)比64/330 (19.4%)，RR 1.32, 95% CI 1.06 ~ 1.64;p = 0.012]，但6个月时无差异[343/631(54.40%)比171/302 (56.6%)，RR 0.95, 95% CI 0.86 ~ 1.06;p = 0.40]。病人的满意度有利于家庭医院。一个可能与研究相关的意外不良事件被报告给研究伦理委员会。6个月时，NHS、个人社会护理和非正式护理费用的平均差异(平均差异为3017英镑，95% CI为5765英镑至269英镑)，质量调整生存率无差异。老年人和护理人员在支持提供保健服务方面发挥了至关重要的作用。在家庭医院，这包括监测病人的健康状况和管理过渡性护理安排。研究结果最适用于从急性医院评估单位转介的患者。家庭综合老年评估医院可以为选定的老年人提供一种具有成本效益的替代住院治疗的方法。进一步的研究，包括更强的护理人员支持因素，可能会产生改善健康结果的证据。该试验注册号为ISRCTN60477865。该项目由国家卫生研究所(NIHR)卫生和社会保健提供研究方案资助，将全文发表在《卫生和社会保健提供研究》上;第10卷第2期请参阅NIHR期刊图书馆网站了解更多项目信息。
{"title":"Hospital at Home admission avoidance with comprehensive geriatric assessment to maintain living at home for people aged 65 years and over: a RCT","authors":"S. Shepperd, Andrea Cradduck-Bamford, Christopher C. Butler, G. Ellis, M. Godfrey, A. Gray, A. Hemsley, P. Khanna, P. Langhorne, Petra Mäkelä, S. Mort, Scott Ramsay, R. Schiff, Surya Singh, Susan Smith, D. Stott, A. Tsiachristas, A. Wilkinson, Ly-Mee Yu, J. Young","doi":"10.3310/htaf1569","DOIUrl":"https://doi.org/10.3310/htaf1569","url":null,"abstract":"\u0000 \u0000 Evidence is required to guide the redesign of health care for older people who require hospital admission.\u0000 \u0000 \u0000 \u0000 We assessed the clinical effectiveness and cost-effectiveness of geriatrician-led admission avoidance hospital at home with comprehensive geriatric assessment, the experiences of older people and their caregivers, and how the services differed.\u0000 \u0000 \u0000 \u0000 A multisite, randomised, open trial of comprehensive geriatric assessment hospital at home, compared with admission to hospital, using a 2 : 1 (hospital at home to hospital) ratio, and a parallel economic and process evaluation. Participants were randomised using a secure online system.\u0000 \u0000 \u0000 \u0000 Participants were recruited from primary care or acute hospital assessment units from nine sites across the UK.\u0000 \u0000 \u0000 \u0000 Older people who required hospital admission because of an acute change in health.\u0000 \u0000 \u0000 \u0000 Geriatrician-led admission avoidance hospital at home with comprehensive geriatric assessment.\u0000 \u0000 \u0000 \u0000 The main outcome, ‘living at home’ (the inverse of death or living in a residential care setting), was measured at 6-month follow-up. Secondary outcomes at 6 months were the incidence of delirium, mortality, new long-term residential care, cognitive impairment, ability to perform activities of daily living, quality-adjusted survival, length of stay and transfer to hospital. Secondary outcomes at 12 months were living at home, new long-term residential care and mortality.\u0000 \u0000 \u0000 \u0000 Participants were allocated to hospital at home (n = 700) or to hospital (n = 355). All reported relative risks (RRs) were adjusted and are reported for hospital at home compared with hospital. There were no significant differences between the groups in the proportions of patients ‘living at home’ at 6 months [528/672 (78.6%) vs. 247/328 (75.3%), RR 1.05, 95% confidence interval (CI) 0.95 to 1.15; p = 0.36] or at 12 months [443/670 (66.1%) vs. 219/325 (67.4%), RR 0.99, 95% CI 0.89 to 1.10; p = 0.80]; mortality at 6 months [114/673 (16.9%) vs. 58/328 (17.7%), RR 0.98, 95% CI 0.65 to 1.47; p = 0.92] or at 12 months [188/670 (28.1%) vs. 82/325 (25.2%), RR 1.14, 95% CI 0.80 to 1.62]; the proportion of patients with cognitive impairment [273/407 (67.1%) vs. 115/183 (62.8%), RR 1.06, 95% CI 0.93 to 1.21; p = 0.36]; or in ability to perform the activities of daily living as measured by the Barthel Index (mean difference 0.24, 95% CI –0.33 to 0.80; p = 0.411; hospital at home, n = 521 patients contributed data; hospital, n = 256 patients contributed data) or Comorbidity Index (adjusted mean difference 0.0002, 95% CI –0.15 to 0.15; p = 0.10; hospital at home, n = 474 patients contributed data; hospital, n = 227 patients contributed data) at 6 months. The varying denominator reflects the number of participants who contributed data to the different outcomes. There was a significant reduction in the RR of living in residential care at 6 months [37/646 (5.7%) vs. 27/311 (8.7%), RR 0.58, 95% CI 0.45 to 0.76; p < 0.001] and 12 mon","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48224899","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}
D. Allen, Amy Lloyd, Dawn Edwards, A. Grant, K. Hood, Chao Huang, J. Hughes, Nina Jacob, David Lacy, Yvonne Moriarty, A. Oliver, J. Preston, G. Sefton, R. Skone, H. Strange, Khadijeh Taiyari, E. Thomas-Jones, R. Trubey, L. Tume, C. Powell, D. Roland
The Paediatric early warning system Utilisation and Morbidity Avoidance (PUMA) study was commissioned to develop, implement and evaluate a paediatric track-and-trigger tool for widespread adoption. Following findings from three systematic reviews, revised aims focused on implementation of a whole-systems improvement programme. (1) Identify, through systematic review, the following: evidence for core components of effective paediatric track-and-trigger tools and paediatric early warning systems, and contextual factors consequential for paediatric track-and-trigger tool and early warning system effectiveness. (2) Develop and implement an evidence-based paediatric early warning system improvement programme (i.e. the PUMA programme). (3) Evaluate the effectiveness of the PUMA programme by examining clinical practice and core outcomes trends. (4) Identify ingredients of successful implementation of the PUMA programme. The quantitative reviews addressed the following two questions: how well validated are existing paediatric track-and-trigger tools and their component parts for predicting inpatient deterioration? How effective are paediatric early warning systems (with or without a tool) at reducing mortality and critical events? The qualitative review addressed the following question: what sociomaterial and contextual factors are associated with successful or unsuccessful paediatric early warning systems (with or without tools)? Interrupted time series and ethnographic case studies were used to evaluate the PUMA programme. Qualitative methods were deployed in a process evaluation. The study was set in two district general and two tertiary children’s hospitals. The PUMA programme is a paediatric early warning system improvement programme designed to harness local expertise to implement contextually appropriate interventions. The primary outcome was a composite metric, representing children who experienced one of the following in 1 month: mortality, cardiac arrest, respiratory arrest, unplanned admission to a paediatric intensive care unit or unplanned admission to a high-dependency unit. Paediatric early warning system changes were assessed through ethnographic ward case studies. The reviews showed limited effectiveness of paediatric track-and-trigger tools in isolation, and multiple failure points in paediatric early warning systems. All sites made paediatric early warning system changes; some of the clearer quantitative findings appeared to relate to qualitative observations. Systems changed in response to wider contextual factors. Low event rates made quantitative outcome measures challenging. Implementation was not a one-shot event, creating challenges for the interrupted time series in conceptualising ‘implementation’ and ‘post-intervention’ periods. Detecting and acting on deterioration in the acute hospital setting requires a whole-systems approach. The PUMA programme offers a framewo
{"title":"Development, implementation and evaluation of an early warning system improvement programme for children in hospital: the PUMA mixed-methods study","authors":"D. Allen, Amy Lloyd, Dawn Edwards, A. Grant, K. Hood, Chao Huang, J. Hughes, Nina Jacob, David Lacy, Yvonne Moriarty, A. Oliver, J. Preston, G. Sefton, R. Skone, H. Strange, Khadijeh Taiyari, E. Thomas-Jones, R. Trubey, L. Tume, C. Powell, D. Roland","doi":"10.3310/chck4556","DOIUrl":"https://doi.org/10.3310/chck4556","url":null,"abstract":"The Paediatric early warning system Utilisation and Morbidity Avoidance (PUMA) study was commissioned to develop, implement and evaluate a paediatric track-and-trigger tool for widespread adoption. Following findings from three systematic reviews, revised aims focused on implementation of a whole-systems improvement programme.\u0000 \u0000 \u0000 \u0000 (1) Identify, through systematic review, the following: evidence for core components of effective paediatric track-and-trigger tools and paediatric early warning systems, and contextual factors consequential for paediatric track-and-trigger tool and early warning system effectiveness. (2) Develop and implement an evidence-based paediatric early warning system improvement programme (i.e. the PUMA programme). (3) Evaluate the effectiveness of the PUMA programme by examining clinical practice and core outcomes trends. (4) Identify ingredients of successful implementation of the PUMA programme.\u0000 \u0000 \u0000 \u0000 The quantitative reviews addressed the following two questions: how well validated are existing paediatric track-and-trigger tools and their component parts for predicting inpatient deterioration? How effective are paediatric early warning systems (with or without a tool) at reducing mortality and critical events? The qualitative review addressed the following question: what sociomaterial and contextual factors are associated with successful or unsuccessful paediatric early warning systems (with or without tools)?\u0000 \u0000 \u0000 \u0000 Interrupted time series and ethnographic case studies were used to evaluate the PUMA programme. Qualitative methods were deployed in a process evaluation.\u0000 \u0000 \u0000 \u0000 The study was set in two district general and two tertiary children’s hospitals.\u0000 \u0000 \u0000 \u0000 The PUMA programme is a paediatric early warning system improvement programme designed to harness local expertise to implement contextually appropriate interventions.\u0000 \u0000 \u0000 \u0000 The primary outcome was a composite metric, representing children who experienced one of the following in 1 month: mortality, cardiac arrest, respiratory arrest, unplanned admission to a paediatric intensive care unit or unplanned admission to a high-dependency unit. Paediatric early warning system changes were assessed through ethnographic ward case studies.\u0000 \u0000 \u0000 \u0000 The reviews showed limited effectiveness of paediatric track-and-trigger tools in isolation, and multiple failure points in paediatric early warning systems. All sites made paediatric early warning system changes; some of the clearer quantitative findings appeared to relate to qualitative observations. Systems changed in response to wider contextual factors.\u0000 \u0000 \u0000 \u0000 Low event rates made quantitative outcome measures challenging. Implementation was not a one-shot event, creating challenges for the interrupted time series in conceptualising ‘implementation’ and ‘post-intervention’ periods.\u0000 \u0000 \u0000 \u0000 Detecting and acting on deterioration in the acute hospital setting requires a whole-systems approach. The PUMA programme offers a framewo","PeriodicalId":73204,"journal":{"name":"Health and social care delivery research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2022-01-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48544468","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}
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