440 research outputs found
The role of nursing in multimorbidity care
Background
Multimorbidity (the co-occurrence of two or more chronic conditions in the same person) affects around one in three persons, and it is strongly associated with a range of negative outcomes including worsening physical function, increased health care use, and premature death. Due to the way healthcare is provided to people with multimorbidity, treatment can become burdensome, fragmented and inefficient. In people with palliative conditions, multimorbidity is increasingly common. Better models of care are needed.
Methods
A mixed-methods programme of research designed to inform the development of a nurse-led intervention for people with multimorbidity and palliative conditions. A mixed-methods systematic review explored nurse-led interventions for multimorbidity and their effects on outcomes. A cross-sectional study of 63,328 emergency department attenders explored the association between multimorbidity, complex multimorbidity (≥3 conditions affecting ≥3 body systems), and disease-burden on healthcare use and inpatient mortality. A focussed ethnographic study of people with multimorbidity and life-limiting conditions and their carers (n=12) explored the concept of treatment burden.
Findings
Nurse-led interventions for people with multimorbidity generally focus on care coordination (i.e., case management or transitional care); patients view them positively, but they do not reliably reduce health care use or costs. Multimorbidity and complex multimorbidity were significantly associated with admission from the emergency department and reattendance within 30 and 90 days. The association was greater in those with more conditions. There was no association with inpatient mortality. People with multimorbidity and palliative conditions experienced treatment burden in a manner consistent with existing theoretical models. This thesis also noted the effect of uncertainty on the balance between capacity and workload and proposes a model of how these concepts relate to one another.
Discussion
This thesis addresses a gap in what is known about the role of nurses in providing care to the growing number of people with multimorbidity. A theory-based nurse-led intervention is proposed which prioritises managing treatment burden and uncertainty.
Conclusions
Nursing in an age of multimorbidity necessitates a perspective shift which conceptualises chronic conditions as multiple overlapping phenomena situated within an individual. The role of the nurse should be to help patients navigate the complexity of living with multiple chronic conditions
Anwendungen maschinellen Lernens für datengetriebene Prävention auf Populationsebene
Healthcare costs are systematically rising, and current therapy-focused healthcare systems are not sustainable in the long run. While disease prevention is a viable instrument for reducing costs and suffering, it requires risk modeling to stratify populations, identify high- risk individuals and enable personalized interventions. In current clinical practice, however, systematic risk stratification is limited: on the one hand, for the vast majority of endpoints, no risk models exist. On the other hand, available models focus on predicting a single disease at a time, rendering predictor collection burdensome. At the same time, the den- sity of individual patient data is constantly increasing. Especially complex data modalities, such as -omics measurements or images, may contain systemic information on future health trajectories relevant for multiple endpoints simultaneously. However, to date, this data is inaccessible for risk modeling as no dedicated methods exist to extract clinically relevant information. This study built on recent advances in machine learning to investigate the ap- plicability of four distinct data modalities not yet leveraged for risk modeling in primary prevention. For each data modality, a neural network-based survival model was developed to extract predictive information, scrutinize performance gains over commonly collected covariates, and pinpoint potential clinical utility. Notably, the developed methodology was able to integrate polygenic risk scores for cardiovascular prevention, outperforming existing approaches and identifying benefiting subpopulations. Investigating NMR metabolomics, the developed methodology allowed the prediction of future disease onset for many common diseases at once, indicating potential applicability as a drop-in replacement for commonly collected covariates. Extending the methodology to phenome-wide risk modeling, elec- tronic health records were found to be a general source of predictive information with high systemic relevance for thousands of endpoints. Assessing retinal fundus photographs, the developed methodology identified diseases where retinal information most impacted health trajectories. In summary, the results demonstrate the capability of neural survival models to integrate complex data modalities for multi-disease risk modeling in primary prevention and illustrate the tremendous potential of machine learning models to disrupt medical practice toward data-driven prevention at population scale.Die Kosten im Gesundheitswesen steigen systematisch und derzeitige therapieorientierte Gesundheitssysteme sind nicht nachhaltig. Angesichts vieler verhinderbarer Krankheiten stellt die Prävention ein veritables Instrument zur Verringerung von Kosten und Leiden dar. Risikostratifizierung ist die grundlegende Voraussetzung für ein präventionszentri- ertes Gesundheitswesen um Personen mit hohem Risiko zu identifizieren und Maßnah- men einzuleiten. Heute ist eine systematische Risikostratifizierung jedoch nur begrenzt möglich, da für die meisten Krankheiten keine Risikomodelle existieren und sich verfüg- bare Modelle auf einzelne Krankheiten beschränken. Weil für deren Berechnung jeweils spezielle Sets an Prädiktoren zu erheben sind werden in Praxis oft nur wenige Modelle angewandt. Gleichzeitig versprechen komplexe Datenmodalitäten, wie Bilder oder -omics- Messungen, systemische Informationen über zukünftige Gesundheitsverläufe, mit poten- tieller Relevanz für viele Endpunkte gleichzeitig. Da es an dedizierten Methoden zur Ex- traktion klinisch relevanter Informationen fehlt, sind diese Daten jedoch für die Risikomod- ellierung unzugänglich, und ihr Potenzial blieb bislang unbewertet. Diese Studie nutzt ma- chinelles Lernen, um die Anwendbarkeit von vier Datenmodalitäten in der Primärpräven- tion zu untersuchen: polygene Risikoscores für die kardiovaskuläre Prävention, NMR Meta- bolomicsdaten, elektronische Gesundheitsakten und Netzhautfundusfotos. Pro Datenmodal- ität wurde ein neuronales Risikomodell entwickelt, um relevante Informationen zu extra- hieren, additive Information gegenüber üblicherweise erfassten Kovariaten zu quantifizieren und den potenziellen klinischen Nutzen der Datenmodalität zu ermitteln. Die entwickelte Me-thodik konnte polygene Risikoscores für die kardiovaskuläre Prävention integrieren. Im Falle der NMR-Metabolomik erschloss die entwickelte Methodik wertvolle Informa- tionen über den zukünftigen Ausbruch von Krankheiten. Unter Einsatz einer phänomen- weiten Risikomodellierung erwiesen sich elektronische Gesundheitsakten als Quelle prädik- tiver Information mit hoher systemischer Relevanz. Bei der Analyse von Fundusfotografien der Netzhaut wurden Krankheiten identifiziert für deren Vorhersage Netzhautinformationen genutzt werden könnten. Zusammengefasst zeigten die Ergebnisse das Potential neuronaler Risikomodelle die medizinische Praxis in Richtung einer datengesteuerten, präventionsori- entierten Medizin zu verändern
Automatic Generation of Personalized Recommendations in eCoaching
Denne avhandlingen omhandler eCoaching for personlig livsstilsstøtte i sanntid ved bruk av informasjons- og kommunikasjonsteknologi. Utfordringen er å designe, utvikle og teknisk evaluere en prototyp av en intelligent eCoach som automatisk genererer personlige og evidensbaserte anbefalinger til en bedre livsstil. Den utviklede løsningen er fokusert på forbedring av fysisk aktivitet. Prototypen bruker bærbare medisinske aktivitetssensorer. De innsamlede data blir semantisk representert og kunstig intelligente algoritmer genererer automatisk meningsfulle, personlige og kontekstbaserte anbefalinger for mindre stillesittende tid. Oppgaven bruker den veletablerte designvitenskapelige forskningsmetodikken for å utvikle teoretiske grunnlag og praktiske implementeringer. Samlet sett fokuserer denne forskningen på teknologisk verifisering snarere enn klinisk evaluering.publishedVersio
Predicting and preventing relapse of depression in primary care: a mixed methods study
BackgroundMost people with depression are managed in primary care. Relapse (reemergence of depression symptoms after improvement) is common and contributes to the burden and morbidity associated with depression. There is a lack of evidence-based approaches for risk-stratifying people according to risk of relapse and for preventing relapse in primary care.MethodsIn this mixed methods study, I initially reviewed studies looking to predict relapse of depression across all settings. I then attempted to derive and validate a prognostic model to predict relapse within 6-8 months in a primary care setting, using multilevel logistic regression analysis on individual participant data from seven studies (n=1244). Concurrently, a qualitative workstream, using thematic analysis, explored the perspectives of general practitioners (GPs) and people with lived experience of depression around relapse risk and prevention in practice.ResultsThe systematic review identified eleven models; none could currently be implemented in a primary care setting. The prognostic model developed in this study had inadequate predictive performance on internal validation (Cstatistic 0.60; calibration slope 0.81). I carried out twenty-two semi-structured interviews with GPs and twenty-three with people with lived experience of depression. People with lived experience of depression and GPs reflected that a discussion around relapse would be useful but was not routinely offered. Both participant groups felt there would be benefits to relapse prevention for depression being embedded within primary care.ConclusionsWe are currently unable to accurately predict an individual’s risk ofdepression relapse. The longer-term care of people with depression ingeneral practice could be improved by enabling continuity of care, increased consistency and clarity around follow-up arrangements, and focussed discussions around relapse risk and prevention. Scalable, brief relapse prevention interventions are needed, which would require policy change and additional resource. We need to better understand existing interventions and barriers to implementation in practice
Resource use and costs at the end of life: essays on common ways to collect data on resource use and derive costs at the end of life in a UK setting
BACKGROUND: Within the given environment of scarce health care resources and increasing demands on the health care system, it is imperative to organise health care in the most efficient manner. Sustainability of the overall system, equity issues concerning access to care and a move to patient-centred care - informing the decision making process by patient needs, are current hot topics when considering care, from curative through to the end of life.
The decision making process within UK’s health care sector is relying on a standardised approach including the benefits and the costs of interventions and "guarantees" that resources are used in a way, which provide best value. This approach falls short when looking at interventions at the end of life, jeopardising appropriate focus and attention for end of life and palliative care.
AIM: The aim of the thesis is threefold:
1. Understanding the current landscape of ’resource use data collection’ and deriving costs at the end of life in an UK setting.
2. Reflect on the challenges, benefits and limitations of using administrative data versus trial data in an end of life care setting.
3. Present potential solutions to challenges arising in collecting and analysing cost of end of life care and recommendations for further research.
METHODS: This work starts by highlighting why end of life care is an outlier when considering the measurement and allocation of health care resources. An update of a systematic review is then presented to identify current methodology used to capture resource use and cost assignment at the end of life. The benefits and limitations of using administrative data or clinical trial data to capture these components is then explored via a series of case studies. The administrative data studies are retrospective whole population secondary care administrative data linkage studies, capturing resources used in the last year prior to death.
The first clinical trial is a two-arm parallel group cluster randomised (1:1) trial on pain assessment, the second, a feasibility trial of an Exercise and Nutrition-based Rehabilitation program at the end of life.
RESULTS: Most of the results from the included studies are in line with the results of the systematic review. There is a wide variety of perspectives, approaches to resource use collection, costing sources and derivation of costs making a comparison between studies challenging.
As the administrative data studies included whole population data, they provided novel insight into the main drivers of secondary care resource use in patients last year of life namely the cause of death being, despite age being a confounding factor, of greater importance than age itself. Further, some equity issues, related to rurality were proven, which was shown to be of bigger influence than deprivation. Different illnesses require various levels of care intensity and are therefore connected to specific care pathways, with cancer care showing an exceptionally high need for secondary care involvement. Both of the studies showed a massive increase in secondary care use with proximity to death, especially within the last three month.
The two clinical trials included, showcase different approaches of increasing patients quality of life whilst keeping the impact on resource use low. Both of the trials confirmed secondary care use as the main driver of costs. The second, despite being a small scale feasibility trial, showing a considerable share of resource use falling outside secondary care, hence demonstrate the need to include multiple data sources when aiming to understand the “true cost” of end of life care.
Data collection and costing within administrative data studies and clinical trials comes with specific benefits and limitations, some of which could potentially be addressed when combining data generated through trials with administrative data.
CONCLUSION: Fair evidence based decision-making requires comprehensive knowledge of the current state of the system, being conscious of the costs and the benefits of interventions and having a system in place which enables comparing different interventions, which in itself requires a standardised way to capture costs and benefits.
This thesis presents various examples of different approaches to resource use collection and applying costs. In order to be able to recommend at least a Scotland wide costing strategy for costing administrative datasets, more research is needed to understand the impact of different costing methods applied to the same dataset.
Within clinical trials, collection of resource use data should be kept to a minimum in order to keep patient burden low. The development of a standardized questionnaire is recommended, highlighting the need for adaptability to different trials.
Linkage between data collected from individual trials and administrative data is an appealing concept, offering extensive data whilst keeping the patient burden at a minimum. Looking at the current landscape of data protection regulations, there are yet some hurdles to overcome
Impact of Childhood Trauma on Levels of Depressive Symptoms, Pain, Functionality, and Cognitive Conflicts in Fibromyalgia
[eng] In recent years, much scientific evidence has shown the role of child maltreatment in human development, which impacts all aspects of growth, physical, behavioral, emotional, and cognitive. Depending on the extent of the maltreatment, it may lead to childhood trauma and generate a vulnerability to mental and physical health. The extent of the maltreatment encompasses its frequency and duration, the age in which it occurred, and the type of maltreatment, whether one isolated type or several types of maltreatment. When more than one type of maltreatment is present, it produces a cumulative effect that can be potentially more damaging than a single type of maltreatment. Although little is known to date, many studies focus on uncovering the role and influence of childhood trauma in chronic pain. Moreover, even less is known about the role of specific types of maltreatment experienced in childhood or the cumulative effect of multiple maltreatment types on the treatment outcome of patients with chronic pain. This research investigated the impact of single types of childhood trauma and the cumulative effect of more than one type of maltreatment on reported levels of depressive symptoms, pain, functionality, and indexes of cognitive conflict before and after psychological treatment for participants with Fibromyalgia (FM) and depressive symptoms. The research was divided into two studies, Study 1 was a cross-sectional analysis, and Study 2 included pre and posttreatment data analysis. For these two studies, 104 women with FM and depressive symptoms responded to the childhood trauma questionnaire at baseline assessment. In Study 1, our sample was assessed for single and cumulative types of maltreatment using a cutoff indicative of traumatic levels and compared with similar samples from other studies. In addition, childhood trauma scores were compared with scores of depressive symptoms, pain, functionality, and cognitive conflicts at pretreatment (baseline). Results revealed that our sample had considerably higher percentages of participants with childhood trauma in at least four maltreatment dimensions than community samples of other studies. Regarding the hypotheses predicting possible correlations between depressive symptoms, pain, functionality, and cognitive conflicts with rates of childhood trauma, for both single and cumulative maltreatment types, there was only one small-sized correlation indicating a tendency of those women with FM to display low levels of functionality in the presence of a history of childhood emotional abuse. In Study 2, participants were treated with either cognitive-behavioral therapy (CBT) or personal construct therapy (PCT). There was minimal difference between the treatment outcomes of those two therapies, and for this reason, this investigation considered the two groups as one sample. The change index of depressive symptoms, pain levels, functionality, and cognitive conflicts at posttreatment scores was calculated and compared to childhood trauma scores at baseline. In addition, childhood trauma scores and dropouts were analyzed to identify a potential correlation between these two variables. Results of Study 2 showed that participants with a history of sexual or emotional abuse had an improvement in pain levels at discharge, based on a small size correlation between the change index of pain levels and sexual abuse, and a medium size correlation between the same change index and emotional abuse, suggesting that such a history of CT may impact pain levels in FM. One medium and one small size correlation showed less change in the discrepancy of selfconstructions related, respectively, to the items “self” and “ideal self” when participants had a history of emotional abuse and “ideal self” and “others” when they had a history of emotional neglect. These negative correlations may indicate a tendency that a history of emotional abuse and neglect might be a handicap to accessing positive therapy outcomes in terms of a positive view of oneself and perceived similarity to others. There was one significant positive correlation between the change index of the number of IDs and physical neglect, and one medium size correlation between that same index and emotional neglect. These results might indicate that the impact of childhood neglect lost its strength following therapy, perhaps because of an acceptance of new possibilities for understanding conflicts. Lastly, the change index of the discrepancy between the “ideal self” and “others” showed a significant negative correlation with five and three types of cumulative maltreatment, suggesting that a cumulative history of CT may affect access to positive therapy outcomes regarding a critical view of others. In addition, one type and absence of maltreatment also showed a medium size negative correlation for this same change index. No other correlations were found for the indexes of change. Furthermore, there was no correlation between single or cumulative childhood trauma and dropouts. By exploring the possible impact of childhood trauma on depressive symptoms, pain, functionality, and cognitive conflicts in FM with depressive symptoms, this study intended to generate knowledge to inform psychological treatments and strategies to enhance treatment outcomes.[cat] En los últimos años, mucha evidencia científica ha demostrado el papel del maltrato infantil en el desarrollo humano, que afecta todos los aspectos del crecimiento, físico, conductual, emocional y cognitivo. Dependiendo de la extensión del maltrato, puede conducir a un trauma infantil y generar una vulnerabilidad a la salud mental y física. El alcance del maltrato abarca su frecuencia y duración, la edad en que ocurrió y el tipo de maltrato, ya sea un tipo aislado o varios tipos de maltrato. Cuando está presente más de un tipo de maltrato, produce un efecto acumulativo que puede ser potencialmente más dañino que un solo tipo de maltrato. Aunque hasta la fecha se sabe poco, muchos estudios se centran en descubrir el papel y la influencia del trauma infantil en el dolor crónico. Además, se sabe aún menos sobre el papel de tipos específicos de maltrato experimentados en la infancia o el efecto acumulativo de múltiples tipos de maltrato en el resultado del tratamiento de pacientes con dolor crónico. Esta investigación examinó el impacto de tipos únicos de trauma infantil y el efecto acumulativo de más de un tipo de maltrato en los niveles informados de síntomas depresivos, dolor, funcionalidad e índices de conflicto cognitivo antes y después del tratamiento psicológico para participantes con Fibromialgia (FM). y síntomas depresivos. La investigación se dividió en dos estudios, el Estudio 1 fue un análisis transversal y el Estudio 2 incluyó análisis de datos previos y posteriores al tratamiento. Para estos dos estudios, 104 mujeres con FM y síntomas depresivos respondieron al cuestionario de trauma infantil en la evaluación inicial. En el Estudio 1, nuestra muestra se evaluó en cuanto a tipos de maltrato único y acumulativo utilizando un punto de corte indicativo de niveles traumáticos y se comparó con muestras similares de otros estudios. Además, las puntuaciones de trauma infantil se compararon con puntuaciones de síntomas depresivos, dolor, funcionalidad y conflictos cognitivos antes del tratamiento (línea de base). Los resultados revelaron que nuestra muestra tenía porcentajes considerablemente más altos de participantes con trauma infantil en al menos cuatro dimensiones de maltrato que las muestras comunitarias de otros estudios. En cuanto a las hipótesis sobre las posibles correlaciones entre los síntomas depresivos, el dolor, la funcionalidad y los conflictos cognitivos con las tasas de trauma infantil, tanto para el tipo de maltrato único como acumulativo, solo hubo una correlación de tamaño pequeño que indica una tendencia de aquellas mujeres con FM a mostrar niveles bajos. de funcionalidad en presencia de antecedentes de abuso emocional infantil. En el Estudio 2, los participantes fueron tratados con terapia cognitivo-conductual (CBT) o terapia de construcción personal (PCT). Hubo una diferencia mínima entre los resultados del tratamiento de esas dos terapias y, por este motivo, esta investigación consideró a los dos grupos como una sola muestra. Se calculó el índice de cambio de los síntomas depresivos, los niveles de dolor, la funcionalidad y los conflictos cognitivos en las puntuaciones posteriores al tratamiento y se comparó con las puntuaciones de trauma infantil al inicio del estudio. Además, se analizaron las puntuaciones de trauma infantil y los abandonos para identificar una posible correlación entre estas dos variables. Los resultados del Estudio 2 mostraron que los participantes con antecedentes de abuso sexual o emocional tuvieron una mejora en los niveles de dolor al momento del alta, según una correlación de tamaño pequeño entre el índice de cambio de los niveles de dolor y el abuso sexual, y una correlación de tamaño medio entre el mismo cambio índice y abuso emocional, lo que sugiere que tal historial de trauma infantil puede afectar los niveles de dolor en la FM. Otras correlaciones de mediano y pequeño tamaño que muestran menos cambio en la discrepancia de las autoconstrucciones se relacionaron, respectivamente, con los ítems “yo” y “yo ideal” cuando los participantes tenían antecedentes de abuso emocional y “yo ideal” y “otros” cuando tenía un historial de negligencia emocional. Estas correlaciones negativas pueden indicar una tendencia a que un historial de abuso y negligencia emocional pueda ser una desventaja para acceder a resultados positivos de la terapia en términos de una visión positiva de uno mismo y la similitud percibida con los demás. Hubo una correlación significativa positiva entre el índice de cambio del número de dilemas implicativos y la negligencia física, y una correlación de tamaño medio entre ese mismo índice y el negligencia emocional. Estos resultados podrían indicar que el impacto del trauma infantil perdió fuerza después de la terapia, quizás debido a la aceptación de nuevas posibilidades para comprender los conflictos. Por último, el índice de cambio de la discrepancia del “yo ideal” y los “otros” mostró una correlación negativa significativa con cinco y tres tipos de maltrato acumulativo, lo que sugiere que un historial acumulativo de trauma infantil puede afectar el acceso a resultados de terapia positivos con respecto a una visión crítica de los demás. Además, un tipo y la ausencia de maltrato también mostraron una correlación negativa de tamaño medio para este mismo índice de cambio. Al explorar el posible impacto del trauma infantil en los síntomas depresivos, el dolor, la funcionalidad y los conflictos cognitivos en FM con síntomas depresivos, este estudio pretendía generar conocimiento para informar los tratamientos psicológicos y las estrategias para mejorar los resultados del tratamiento
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