Mixed-method exploratory study of general practitioner and nurse perceptions of a new community based nurse-led heart failure service

Introduction: The treatment of patients with chronic heart failure (CHF) remains sub-optimal. Specialist CHF nurses are proven to improve care and reduce admission but developing such services, especially in remote areas, can be difficult. This study aimed: first, to assess the perceived acceptability and effectiveness of a new community based nurse-led heart failure service by general practitioners (GPs) in an area with a dispersed population; second, to assess the knowledge and learning needs of GPs; and third, to assess perceptions of the use of national guidelines and telehealth on heart failure management. Methods: The study was conducted in the Scottish Highlands, a large geographical area in the north of the UK which includes both rural and urban populations. The area has a total population of 240 000, approximately 60% of whom are within 1 hour travel time of the largest urban centre. A postal survey of all GPs (n = 260) and structured email survey of all CHF specialist nurses (n = 3) was performed. All responses were entered into a Microsoft Excel spreadsheet, summarised and subjected to thematic analysis. Differences between GPs in ‘rural’, ‘urban’ or both ‘urban & rural’ was investigated using an F-test for continuous variables and a three-sample test for equality of proportions for nominal data. Results: Questionnaires were returned from 83 GPs (32%) and all three CHF specialist nurses. In this sample there were only a few differences between GPs from ‘rural’, ‘urban’ and ‘urban & rural’. There also appeared to be little difference in responses between those who had the experience of the CHF nurse service and those who had not. Overall, 32 GPs (39%) wished better, local access to echocardiography, while 63 (76%) wished access to testing for brain natriuretic peptide (BNP). Only 27 GPs (33%) referred all patients with CHF to hospital. A number of GPs stated that this was dependant on individual circumstances and the patient’s ability to travel. The GPs were confident to initiate standard heart failure drugs although only 54 (65%) were confident in the initiation of beta-blockers. Most GPs (69%) had had experience of the CHF specialist nurse service and the responses were mixed. The GPs who had experienced the service appeared less confident that it would lead to reduced admission of patients to hospital (51% vs 77%, p = 0.046). Three main themes emerged from the nurse responses: service planning, communication and attitudinal changes after service embedment. Conclusions: This study demonstrates that a community based heart failure nurse service was not universally valued. Differences between urban and rural localities (communication) suggest that models of care derived from evidence based practice in urban areas may not be directly transferable to remote areas. Clearly, good communication among staff groups at all stages of implementation is important; however, despite best efforts and clinical trial evidence, specialist nurse services will not be welcomed by all doctors. Service providers and commissioners should be cognisant of the different roles of urban and rural GPs when designing such services. Among GPs there was a high degree of confidence with initiation and titration of drugs for heart failure with the exception of beta-blockers so clearly this is an area of ongoing educational need and support. Education and support should focus on ensuring that all doctors who care for patients with CHF have the skills and confidence to use medical therapies and specialist services as appropriate

Longitudinal study of the relationship between patients' medication adherence and quality of life outcomes and illness perceptions and beliefs about cardiac rehabilitation

Background Adherence to medication regimens is essential for preventing and reducing adverse outcomes among patients with coronary artery disease (CAD). Greater understanding of the relation between negative illness perceptions, beliefs about cardiac rehabilitation (CR) and medication adherence may help inform future approaches to improving medication adherence and quality of life (QoL) outcomes. The aims of the study are: 1) to compare changes in illness perceptions, beliefs about CR, medication adherence and QoL on entry to a CR programme and 6 months later; 2) to examine associations between patients’ illness perceptions and beliefs about CR at baseline and medication adherence and QoL at 6 months. Methods A longitudinal study of 40 patients with CAD recruited from one CR service in Scotland. Patients completed the Medication Adherence Report Scale, Brief Illness Perception Questionnaire, Beliefs about CR questionnaire and the Short-Form 12 Health Survey. Data were analysed using the Wilcoxon Signed Ranks test, Pearson Product Moment correlation and Bayesian multiple logistic regression. Results Most patients were men (70%), aged 62.3 mean (SD 7.84) years. Small improvements in ‘perceived suitability’ of CR at baseline increased the odds of being fully adherent to medication by approximately 60% at 6 months. Being fully adherent at baseline increased the odds of staying so at 6 months by 13.5 times. ‘Perceived necessity, concerns for exercise and practical barriers’ were negatively associated with reductions in the probability of full medication adherence of 50, 10, and 50%. Small increases in concerns about exercise decreased the odds of better physical health at 6 months by about 50%; and increases in practical barriers decreased the odds of better physical health by about 60%. Patients perceived fewer consequences of their cardiac disease at 6 months. Conclusions Patients’ beliefs on entry to a CR programme are especially important to medication adherence at 6 months. Negative beliefs about CR should be identified early in CR to counteract any negative effects on QoL. Interventions to improve medication adherence and QoL outcomes should focus on improving patients’ negative beliefs about CR and increasing understanding of the role of medication adherence in preventing a future cardiac event

Longitudinal evaluation of the effects of illness perceptions and beliefs about cardiac rehabilitation on quality of life of patients with coronary artery disease and their caregivers

Background Patients’ negative illness perceptions and beliefs about cardiac rehabilitation (CR) can influence uptake and adherence to CR. Little is known about the interpartner influence of these antecedent variables on quality of life of patients with coronary artery disease (CAD) and their family caregivers. The aims of the study were: 1) to assess differences in illness perceptions, beliefs about CR and quality of life between patients with CAD and their family caregivers upon entry to a CR programme and at 6 months follow-up; and 2) to examine whether patients’ and caregivers’ perceptions of the patient’s illness and beliefs about CR at baseline predict their own and their partner’s quality of life at 6 months. Methods In this longitudinal study of 40 patient-caregiver dyads from one CR service, patients completed the Brief Illness Perception Questionnaire and Beliefs about Cardiac Rehabilitation Questionnaire at baseline and 6 months; and caregivers completed these questionnaires based on their views about the patient’s illness and CR. The Short-Form 12 Health Survey was used to assess patients’ and caregivers’ perceived health status. Dyadic data were analysed using the Actor–Partner Interdependence Model. Results Most patients (70%) were men, mean age 62.45 years; and most caregivers (70%) were women, mean age 59.55 years. Caregivers were more concerned about the patient’s illness than the patients themselves; although they had similar scores for beliefs about CR. Patients had poorer physical health than caregivers, but their level of mental health was similar. Caregivers’ poorer mental health at 6 months was predicted by the patient’s perceptions of timeline and illness concern (i.e. partner effects). Patient’s and caregiver’s illness perceptions and beliefs about CR were associated with their own physical and mental health at 6 months (i.e. actor effects). Conclusions Overall, the patients and caregivers had similar scores for illness perceptions and beliefs about CR. The actor and partner effect results indicate a need to focus on specific illness perceptions and beliefs about CR, targeting both the individual and the dyad, early in the rehabilitation process to help improve patients and caregivers physical and mental health (outcomes)

Dryland Performance Tests Are Not Good Predictors of World Aquatics Points in Elite Male and Female Swimmers

Swim performance can be reliant on strength and power. Standardisation of swim performance in different events, distances, and sexes can be completed using World Aquatics points, allowing for ranking of swimmers. The aim of this retrospective cross-sectional study was to assess whether relationships between World Aquatics points and dryland markers of performance existed in male and female elite swimmers separately and combined. Methods: Dryland tests included Optojump® photoelectric cell countermovement jump, countermovement jump reach with a Vertec® system, standing broad jump using a tape measure, repetition maximum testing in the barbell back squat, barbell deadlift, and barbell bench press. Swim performance data and dryland test data onelite male (n = 38) and female (n = 20) Scottish swimmers from 2009–2017 were collected. Swim performance data were converted to World Aquatics federation points, and Bayesian linear regression analyses examined relationships between World Aquatics points and dryland performance tests:countermovement jump height (cm) using an Optojump® photoelectric cells system, countermove ment jump height (cm) using a Vertec® device, standing broad jump distance (cm), relative strength(load lifted (kg) per kg of body mass) in the barbell bench press (kg/kg), barbell back squat (kg/kg), barbell deadlift (kg/kg). Results: The Bayesian estimates of change of World Aquatics points for a unit change in jump-based measures were: Optojump®—men = 0.6, women = 0.6, combined = 0.4; Vertec®—men = 4.3, women = −1.6, combined = 2.4; standing broad jump—men = 0, women = −0, combined = 0.4. Strength-based measures were: barbell back squat—men = 2.3, women = 22, combined = −2.5; barbell deadlift—men = −5; barbell bench press—men = 41.8. Conclusions: Dryland performance tests are not good predictors of World Aquatics points and should rather be used for assessing training quality and monitoring injury risks

Perception of soundscapes : an interdisciplinary approach

This paper takes an overall view of findings from the Positive Soundscape Project, a large inter-disciplinary soundscapes study. Qualitative fieldwork (soundwalks and focus groups) have found that soundscape perception is influenced by cognitive effects such as the meaning of a soundscape and its components, and how information is conveyed by a soundscape, for example on the behaviour of people within the soundscape. Three significant clusters were found in the language people use to describe soundscapes: sound sources, sound descriptors and soundscape descriptors. Results from listening tests and soundwalks have been integrated to show that the two principal dimensions of soundscape emotional response seem to be calmness and vibrancy. Further, vibrancy seems to have two aspects: organisation of sounds and changes over time. The possible application of the results to soundscape assessment and design are briefly discussed

Haemorrhoidal artery ligation versus rubber band ligation for the management of symptomatic second-degree and third-degree haemorrhoids (HubBLe): a multicentre, open-label, randomised controlled trial.

BACKGROUND: Optimum surgical intervention for low-grade haemorrhoids is unknown. Haemorrhoidal artery ligation (HAL) has been proposed as an efficacious, safe therapy while rubber band ligation (RBL) is a commonly used outpatient treatment. We compared recurrence after HAL versus RBL in patients with grade II-III haemorrhoids. METHODS: This multicentre, open-label, parallel group, randomised controlled trial included patients from 17 acute UK NHS trusts. We screened patients aged 18 years or older presenting with grade II-III haemorrhoids. We excluded patients who had previously received any haemorrhoid surgery, more than one injection treatment for haemorrhoids, or more than one RBL procedure within 3 years before recruitment. Eligible patients were randomly assigned (in a 1:1 ratio) to either RBL or HAL with Doppler. Randomisation was computer-generated and stratified by centre with blocks of random sizes. Allocation concealment was achieved using a web-based system. The study was open-label with no masking of participants, clinicians, or research staff. The primary outcome was recurrence at 1 year, derived from the patient's self-reported assessment in combination with resource use from their general practitioner and hospital records. Recurrence was analysed in patients who had undergone one of the interventions and been followed up for at least 1 year. This study is registered with the ISRCTN registry, ISRCTN41394716. FINDINGS: From Sept 9, 2012, to May 6, 2014, of 969 patients screened, 185 were randomly assigned to the HAL group and 187 to the RBL group. Of these participants, 337 had primary outcome data (176 in the RBL group and 161 in the HAL group). At 1 year post-procedure, 87 (49%) of 176 patients in the RBL group and 48 (30%) of 161 patients in the HAL group had haemorrhoid recurrence (adjusted odds ratio [aOR] 2·23, 95% CI 1·42-3·51; p=0·0005). The main reason for this difference was the number of extra procedures required to achieve improvement (57 [32%] participants in the RBL group and 23 [14%] participants in the HAL group had a subsequent procedure for haemorrhoids). The mean pain 1 day after procedure was 3·4 (SD 2·8) in the RBL group and 4·6 (2·8) in the HAL group (difference -1·2, 95% CI -1·8 to -0·5; p=0·0002); at day 7 the scores were 1·6 (2·3) in the RBL group and 3·1 (2·4) in the HAL group (difference -1·5, -2·0 to -1·0; p<0·0001). Pain scores did not differ between groups at 21 days and 6 weeks. 15 individuals reported serious adverse events requiring hospital admission. One patient in the RBL group had a pre-existing rectal tumour. Of the remaining 14 serious adverse events, 12 (7%) were among participants treated with HAL and two (1%) were in those treated with RBL. Six patients had pain (one treated with RBL, five treated with HAL), three had bleeding not requiring transfusion (one treated with RBL, two treated with HAL), two in the HAL group had urinary retention, two in the HAL group had vasovagal upset, and one in the HAL group had possible sepsis (treated with antibiotics). INTERPRETATION: Although recurrence after HAL was lower than a single RBL, HAL was more painful than RBL. The difference in recurrence was due to the need for repeat bandings in the RBL group. Patients (and health commissioners) might prefer such a course of RBL to the more invasive HAL. FUNDING: NIHR Health Technology Assessment programme

Validation of a UPDRS-/MDS-UPDRS-based definition of functional dependency for Parkinson's disease

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