NHS Health Check programme: a rapid review update

OBJECTIVE: To update a rapid review published in 2017, which evaluated the NHS Health Check programme. METHODS: An enlarged body of evidence was used to readdress six research objectives from a rapid review published in 2017, relating to the uptake, patient experiences and effectiveness of the NHS Health Check programme. Data sources included MEDLINE, PubMed, Embase, Health Management Information Consortium (HMIC), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Global Health, PsycINFO, the Cochrane Library, NHS Evidence, Google Scholar, Google, ClinicalTrials.gov and the ISRCTN registry, Web of Science, Science Citation Index, The Cochrane Library, NHS Evidence, OpenGrey and hand searching article reference lists. These searches identified records from between January 1996 and December 2019. Screening, data extraction and quality appraisal using the Critical Appraisals Skills Programme checklists were performed in duplicate. Grading of Recommendations Assessment, Development and Evaluations was implemented. Data were synthesised narratively. RESULTS: 697 studies were identified, and 29 new studies included in the review update. The number of published studies on the uptake, patient experiences and effectiveness of the NHS Health Check programme has increased by 43% since the rapid review published in 2017. However, findings from the original review remain largely unchanged. NHS Health Checks led to an overall increase in the detection of raised risk factors and morbidities including diabetes mellitus, hypertension, raised blood pressure, cholesterol and chronic kidney disease. Individuals most likely to attend the NHS Health Check programme included women, persons aged ≥60 years and those from more socioeconomically advantaged backgrounds. Opportunistic invitations increased uptake among men, younger persons and those with a higher deprivation level. CONCLUSIONS: Although results are inconsistent between studies, the NHS Health Check programme is associated with increased detection of heightened cardiovascular disease risk factors and diagnoses. Uptake varied between population subgroups. Opportunistic invitations may increase uptake

Electric current circuits in astrophysics

Cosmic magnetic structures have in common that they are anchored in a dynamo, that an external driver converts kinetic energy into internal magnetic energy, that this magnetic energy is transported as Poynting fl ux across the magnetically dominated structure, and that the magnetic energy is released in the form of particle acceleration, heating, bulk motion, MHD waves, and radiation. The investigation of the electric current system is particularly illuminating as to the course of events and the physics involved. We demonstrate this for the radio pulsar wind, the solar flare, and terrestrial magnetic storms

Timing of urinary catheter removal after surgery: Identification of factors of importance to patients using a qualitative approach

Background: Catheter-associated urinary tract infection (CAUTI) is a key focus of patient safety initiatives [1]. Duration of catheterisation is a major risk factor for CAUTI with bacteriuria increasing by 5% daily, but early catheter removal is hampered by clinician and patient factors [2]. Identification of these barriers may help reduce CAUTI risk. Aim: To explore patients’ beliefs and perceptions regarding short term catheterisation. Methods: Semi-structured recorded interviews were carried out in November 2010 with three men and seven women, aged 25 – 75 years, catheterised following elective neurosurgery. Interviews were transcribed and thematically analysed using grounded theory approach. Results: The main themes were: • Uncertainty: Lack of information; ‘I spent the night worried sick thinking that I had to go back to theatre to get my catheter removed’ • Consent: Not being told of the need for catheterisation; ‘It should definitely be written and on the consent form because it’s your personal parts. I was very upset waking up with one • Dignity: ‘I suppose what I usually don’t like to talk about is seeing the urine. I think that’s quite undignified. Not having a catheter may also be detrimental; ‘I wasn’t so embarrassed about the catheter because I’d rather have that than keep weeing the bed your dignity is taken away from you • Environment: Participants preferred to have the catheter left in rather than having to ask the staff to take them to the toilet. Discussions: Participant’s fears predominantly arose from lack of knowledge. This should be modified by provision of an information leaflet and pre-operative discussion. Embarrassment related to lack of concealment of drainage bags and shared toilet facilities which could be addressed by appropriate equipment and individual en-suite patient rooms. Recommended reading: Department of Health (2009) High Impact Actions for Nursing and Midwifery l-Weise, BS. Van den Broek, PJ. (2005). Urinary catheter policies for short-term bladder drainage in adults. Cochrane Database of Systematic Reviews Issue 3. Art. No.: CD004203. Funding: UK – Research Council 10,001 – 50,00

NHS Health Check Programme Rapid Review Update

Summary Introduction: This report is an update of a rapid review of evidence published on the NHS Health Checks programme in 2017. This update includes evidence from the original review (studies published between 2009 and 2016) alongside evidence indexed up until the end of December 2019. The update uses this enlarged body of evidence to re-address the following six research objectives: 1. Who is and who is not having an NHS Health Check? 2. What are the factors that increase take-up among the population at large and sub-groups? 3. Why do people not take-up an offer of an NHS Health Check? 4. How is primary care managing people identified as being at risk of cardiovascular disease or with abnormal risk factor results? 5. What are patients’ experiences of having an NHS Health Check? 6. What is the effect of the NHS Health Check on disease detection, changing behaviours, referrals to local risk management services, reductions in individual risk factor prevalence, reducing cardiovascular disease risk and on statin and anti-hypertensive prescribing? Methods A rapid review of qualitative and quantitative data published between January 2016 and December 2019 identified using a systematic search strategy within Medline, PubMed, Embase, Health Management Information Consortium (HMIC), Cumulative Index of Nursing and Allied Health Literature (CINAHL), Global Health, PsycInfo, Web of Science, Science Citation Index, the Cochrane Library, NHS Evidence, Google Scholar, Google, OpenGrey, Clinical Trials.gov, the ISRCTN registry, and through hand searching article reference lists. Studies identified were initially screened by two researchers for relevance to the NHS Health Checks and then against a set of pre-specified inclusion and exclusion criteria. Data were extracted on to pre-specified, piloted data pro-forma by two researchers. A 10% sample of the data reported in the original review were checked for consistency with reporting in the primary studies from which data were extracted. As consistency was 100% previously extracted and reported data were not re-extracted without indication. The quality of the newly included studies were assessed by a single researcher using the Page 8 of 168 relevant Critical Appraisal Skills Programme tools. Quality assessments were verified by a second reviewer. Synthesis of quantitative data was completed as an extension to the synthesis presented in the original review. With a structured, narrative synthesis using, tables and data visualisation undertaken as appropriate. Meta-analysis was not methodologically appropriate even where feasible due to the high heterogeneity and low number of high quality studies reporting on each domain in a consistent manner. Synthesis of qualitative data was completed as an extension to that undertaken in the original review. A three-stage thematic synthesis approach was completed with the newly identified studies in order that we could add to and revise findings identified in the original review. Completing a thematic synthesis incorporating just the new data alone to compare to the original thematic synthesis, or re-completing the whole thematic synthesis were inappropriate due to the lack of new qualitative studies identified. GRADE, GRADE-CERQual and GRADE-Mixed methods were used to assess the certainty and confidence in the research evidence contributing to each objective or sub-objective as appropriate. Findings There were 97 studies (29 newly identified) addressing Objectives one to six. The 29 newly identified studies contributed data to the synthesis addressing Objectives one (n=6/29), two (n=9/31), four (n=3/21), five (n=2/22) and six (n=13/33). Of the 97 studies identified, 33 included data collected from 2014 onwards. Who is and who is not having an NHS Health Check? In total, 29 studies (six newly identified) contributed data to Objective one. Seven of the 29 studies reported on data from 2014 onwards. The overall uptake of NHS Health Checks has increased by a small amount since the end of 2016, however, we are still a long way off having 75% of the eligible population attending. Attendance patterns for 2017-2018 vary by region with uptake between 41.3 and 49.2%. There is limited new data identified on coverage, most new evidence is on the unadjusted characteristics of NHS Health Check attendees vs. non-attendees. This increasing body of evidence shows that those most likely to attend an NHS Health Check are female, white British and aged 60 or more. Further analyses are needed to understand why differences exist in the Page 9 of 168 effects of ethnicity on attendance. New evidence indicates that smokers and those from high levels of deprivation are less likely to attend. A single study using opportunistic invite within a community setting observed an increased attendance from younger individuals. There is low certainty in this body of evidence (29 studies) due to the study designs used, high heterogeneity and inconsistency found. What factors increase take-up among the population and sub-groups? In total, 31 studies (nine newly identified) contributed data to Objective two. Twelve of these 31 studies reported on data from 2014 onwards. These studies contribute evidence on the impact to uptake of the following: Sociodemographic factors Twelve quantitative studies (one newly identified) contained data on the demographics of those attending vs. not attending an NHS Health Check after invitation. Findings of a newly included study, a high quality RCT, almost mirror those from studies of unadjusted characteristics of NHS Health Check attendees vs. non-attendees. The RCT showed females, those >60 years old and those with lower levels of deprivation were more likely to attend. Converse to the findings of unadjusted studies on characteristics of NHS Health Check attendees vs. non-attendees, it showed that white British were less likely to attend than those from an African/Caribbean, Asian or mixed background. Across the whole body of evidence there is a lack of consistency in findings on the impact of ethnic background on uptake. Further analysis are needed to understand these effects. The certainty in the body of evidence informing these findings was rated as low as only one of the included studies was an RCT. However, no other criteria affected the quality of this evidence. Invitation method Thirteen quantitative studies (six newly identified) investigated the effects of variations in invitation method on take up of an NHS Health Check. Evidence shows that opportunistic invites in a general practice or community setting increase uptake in particular amongst those at high risk of CVD and from ethnic minority groups. Personalised invitational letters, an SMS pre- and post-invitational letter and invite via telephone have also been shown to increase uptake. The strength of effect being greatest for Page 10 of 168 telephone invite. The certainty in the body of evidence informing these findings was rated as ‘very low’ as most contributing evidence was observational and studies were identified as being at a high risk of bias. Six qualitative studies (one newly identified) contained data on the effect of invitation method on take up of an NHS Health Check. In the original review, telephone invitations were identified as preferred by patients due to their informative immediacy and the perceived value of this. The single newly identified study yielded no first or second order constructs leading to further analytical themes. However, its findings added richness and depth to the following themes ‘Benefit of community ambassadors for ethnic minority groups’ and ‘Differing opinions on opportunistic invitation dependent on setting’. Review findings for invitation method are supported with moderate to high confidence. However, data from the primary publications that informed these findings lacks adequacy. In particular, the whole body of evidence has limited richness and sufficiency to allow themes and findings to emerge or to allow for dimensional comparisons. Setting Two newly identified quantitative studies assessed whether the setting of the NHS Health Checks (community or pharmacy or general practice) influenced uptake. Uptake did not differ dependent on whether invite was to a general practice or community pharmacy, however, when NHS Health Checks were completed opportunistically there was higher uptake at community outreach services. A greater number of those at high risk of CVD and from hard-to-reach groups were more likely to take-up an NHS Health Check if it was opportunistic, in both community and general practice settings. However, opportunistic methods can only target people attending the settings within which they are conducted. Qualitative data shows the need to allow those taking up an opportunistic invite time to digest the invite information and to allow for informed decision making on their attendance. The certainty in this evidence was rated as very low as both contributing studies are observational, and showed imbalances in baseline characteristics between groups as well as being deemed at risk of bias due to plausible confounding. Why do people not take up an offer of an NHS Health Check? Page 11 of 168 There were no new studies informing why people do not take up an offer of an NHS Health Check. Ten studies in the original review found reasons for non-attendance were as follows: a lack of knowledge on the purpose of the NHS Health Check, time constraints and an aversion to preventative medicine. These analytical themes have been identified within the qualitative data on individual’s experiences of NHS Health Checks, indicating their applicability and transferability. How is primary care managing those at Risk of CVD? No further studies were identified reporting on delivery, recall systems, lifestyle advice provided or service availability. It is likely the large regional variation in NHS Health Check delivery and post-delivery management (lifestyle advice, referral to services or interventions and follow up) identified in the original review remain. Long-term impact of NHS Health Checks One (newly identified) large, high quality quantitative study found NHS Health Checks were associated with a decrease in CVD risk, BMI, smoking prevalence, blood pressure and total cholesterol. Reductions could be due to improved patient management as lifestyle advice, smoking cessation, prescriptions for statins and for anti-hypertensives all increased amongst those who had an NHS Health Check. However, onward referral to lifestyle services varied geographically. There was also an increase in the detection of new morbidities, however, the effect varied by gender and deprivation level. Although this data is from a single study, the study recruited nationally across England and could therefore be representative of the wider population. Healthcare professionals views towards NHS Health Checks and Delivery Eighteen (three newly identified) studies provided qualitative data on how NHS Health Checks affect risk management and health-care workers views of this. These data contribute to the synthesis of healthcare workers views on the implementation and delivery of the NHS Health Checks programme. No new first or second order constructs leading to further analytical themes were identified. Extracted findings aligned with the analytical theme of ‘Doubts about long term cost-effectiveness’ and ‘Inadequate training’. Studies identified add adequacy, richness and thickness to the body of evidence included within the previously conducted thematic synthesis. Confidence in the evidence supporting concepts and outcomes on how CVD risk is managed in primary care were judged as being moderate mainly due to a sparsity of quantitative Page 12 of 168 evidence, plausibility of responder bias and potential lack of objectivity in studies identified. What are patients’ experiences of having an NHS Health Check? Nine quantitative studies and 17 (two newly identified) qualitative studies provided data on patients experiences of NHS Health Checks. There were no newly identified quantitative studies reporting patients’ experiences. Previously high levels of satisfaction with the programme were reported. However, satisfaction is likely linked with temporal factors and new patient survey findings could plausibly differ. Two newly identified qualitative studies report patients’ experiences of having an NHS Health\ud Check. No new first or second order constructs that lead to new analytical themes were identified within these studies. Extracted findings aligned with the analytical themes on ‘Understanding of the risk score’, ‘Quality of information (format detail and personalisation)’ and being ‘A potential trigger for behaviour change’. The following barriers to change were identified: ‘Pressure to change rather than facilitation from practitioners’, ‘Perceived genetic determinism (including of longevity)’, ‘Practical issues in joining change interventions’, ‘Environmental factors’, ‘Resources such as access to services’, ‘Cost and time to the individual’ which are not always controllable. Evidence contributing quantitative or qualitative data to the concept of patients’ experiences of the NHS Health Checks were rated as low to moderate, with inferences made reflected across both data types. What is the effect of the NHS Health Check on: Disease detection There were 17 studies (five newly identified) reporting data on disease detection. NHS Health Checks led to an overall increase in the detection of raised risk factors and morbidities (raised hyperglycemia, pre-diabetes, diabetes mellitus, cholesterol, hypertension, chronic kidney disease), however, the effect varied between diagnoses and in relation to gender and deprivation level. The certainty in the body of evidence on disease detection was judged to be very low due to large variations in effect (likely due to ecological effects) and indirectness. Changing behaviours There were six studies (one newly identified) which assessed the impact of attendance at an Page 13 of 168 NHS Health Check on health behaviour change. The only intended behaviour change assessed is smoking. Findings from the newly identified study indicate net reductions in smoking prevalence for NHS Health Check and control participants over a six-year period following the intervention. However, comparative reduction in smoking was greater for participants in the control group. Three studies in the earlier review reported NHS Health Check participants were more likely to stop smoking compared to baseline and, or, non-attendees. However another study reported no significant change over time in smoking prevalence amongst NHS Health Check attendees following the intervention. The certainty in the evidence is very low due to the observational study types identified, opportunistically collated self-report outcome data with high risk of bias, inconsistency and imprecision. Referrals to local risk management services Ten studies (four newly identified) report the effect of NHS Health Checks on referrals to local risk management. There was consistent evidence across the studies that amongst those attendees of an NHS Health Check compared to non-attendees stop smoking advice and weight management advice were more commonly given. As well as evidence of increases in referrals to smoking cessation, dietician support, a physical activity service or an alcohol service. The certainty in the evidence was rated as very low due to the observational nature of the studies included, confounding, risk of bias, inconsistency in outcome measurement, poor internal validity and large heterogeneity of effects. Reductions in risk at the individual level Five studies (one newly identified) included data on the effect of the NHS Health Check on risk factor prevalence and cardiovascular disease risk. Across the studies, after an NHS Health Check the following risk factors decreased: BMI, diastolic blood pressure, total cholesterol and cardiovascular risk. Results for other risk factors were inconsistent across studies although none saw an increase. The certainty in the body of evidence was rated as ‘very low’ as study designs were mainly observational and the largest study had high risk of bias related to the outcome which could lead to poor internal validity. Page 14 of 168 Reducing prescribing of statins/anti-hypertensive medication Sixteen studies (four newly identified) report prescribing after an NHS Health Check. All report an increase in statin prescribing amongst those who attend an NHS Health Check. Four of five studies report an increase in anti-hypertensive prescribing; a single cohort study reports a decrease in anti-hypertensive prescribing. The certainty in the evidence on prescribing was rated as low because the majority of data came from observational studies and heterogeneity of effects was present. Modelling In the earlier review, three microsimulation studies were identified which assessed the costeffectiveness of the NHS Health Checks programme based on different implementation approaches. A further three economic modelling studies were identified. Two of these studies were allied with one another assessing implementation and re-design scenarios using demographic data from Liverpool’s population, risk factor exposures and CVD epidemiology to assess health benefits, equity and cost effectiveness. The third assessed whether the impact of the NHS Health Checks on BMI were sufficient to justify its costs. The findings from the newly-identified studies indicated that equitability and cost-effectiveness of the NHS Health Check Programme would be increased through the addition of policies targeting dietary consumption; through combining current provision, with targeting of the intervention towards deprived areas; and that modest changes in BMI from the NHS Health Check programme are associated with significant cost-saving benefits making the programme cost-effective

Confidence of UK Ophthalmology Registrars in Managing Posterior Capsular Rupture: Results from a National Trainee Survey

IntroductionTo establish the level of confidence amongst UK ophthalmology specialist registrars (residents) in managing posterior capsule rupture (PCR) during cataract surgery. Methods: An online nine-item questionnaire was distributed to all registrars, recruited nationwide via regional representatives. Data collected included stage of training, number of completed cataract operations, cumulative PCR rate, number of PCRs independently managed, understanding of vitrectomy settings and fluidic parameters and access to simulation. Respondents self-evaluated their confidence in managing PCR with vitreous loss. ResultsComplete responses were obtained from 248 registrars (35% response rate). Mean number of phacoemulsification procedures performed was 386. For senior registrars (OST 6–7), 35 out of 70 (50%) felt confident to manage PCR independently and 55 out of 70 (78.6%) were either quite confident or very confident at deciding when to implant an intraocular lens during PCR management. Lower confidence levels were noted for junior trainees (OST 1–2). Over 65% of survey respondents had access to relevant simulation. ConclusionsOur results represent the largest UK survey analysing the confidence of PCR management amongst registrars. Confidence improves with duration of training and increased exposure to management of PCR. However, 50% of senior registrars still lacked confidence to independently manage PCR and vitreous loss. A specific competency-based framework, potentially using a simulator or simulating a PCR event, incorporated into the curriculum may be desirable.</div