Harnessing the electronic health care record to optimise patient safety in primary care: a framework for evaluating “electronic safety netting” tools

The management of diagnostic uncertainty is part of every primary care physician’s role. e–Safety-netting tools help health care professionals to manage diagnostic uncertainty. Using software in addition to verbal or paper based safety-netting methods could make diagnostic delays and errors less likely. There are an increasing number of software products that have been identified as e–safety-netting tools, particularly since the start of the COVID-19 pandemic. e–Safety-netting tools can have a variety of functions, such as sending clinician alerts, facilitating administrative tasking, providing decision support, and sending reminder text messages to patients. However, these tools have not been evaluated by using robust research designs for patient safety interventions. We present an emergent framework of criteria for effective e–safety-netting tools that can be used to support the development of software. The framework is based on validated frameworks for electronic health record development and patient safety. There are currently no tools available that meet all of the criteria in the framework. We hope that the framework will stimulate clinical and public conversations about e–safety-netting tools. In the future, a validated framework would drive audits and improvements. We outline key areas for future research both in primary care and within integrated care systems

Socioeconomic differences in help seeking for colorectal cancer symptoms during COVID-19: a UK-wide qualitative interview study of patient experiences in primary care

BACKGROUND: COVID-19 has led to rapid changes in healthcare delivery, raising concern that these changes may exacerbate existing inequalities in patient outcomes. AIM: To understand how patients' help-seeking experiences in primary care for colorectal cancer symptoms during COVID-19 were affected by their socioeconomic status (SES). DESIGN AND SETTING: Qualitative semi-structured interviews with males and females across the UK, recruited using purposive sampling by SES. METHOD: Interviews were carried out with 39 participants (20 higher SES; 19 lower SES) who contacted primary care about possible symptoms of colorectal cancer during COVID-19. Data were analysed using framework analysis followed by comparative thematic analysis to explore differences between groups. RESULTS: Three themes were identified with differences between SES groups: 1) how people decided to seek medical help through appraisal of symptoms; 2) how people navigated services; and 3) impact of COVID-19 on how patients interacted with healthcare professionals. The lower SES group expressed uncertainty appraising symptoms and navigating services (in terms of new processes resulting from COVID-19 and worries about infection). There was also potential for increased disparity in diagnosis and management, with other methods of getting in touch (for example, email or 111) taken up more readily by higher SES patients. CONCLUSION: The findings suggest that COVID-19 exacerbated disparities between higher and lower SES participants. This study raises awareness around challenges in help seeking in the context of the pandemic, which are likely to persist (post-COVID-19) as healthcare systems settle on new models of care (for example, digital). Recommendations are provided to reduce inequalities of care

Healthcare Professional and Patient Perceptions of Changes in Colorectal Cancer Care Delivery During the COVID-19 Pandemic and Impact on Health Inequalities

BACKGROUND: The COVID-19 pandemic changed the way in which people were diagnosed and treated for cancer. We explored healthcare professional and patient perceptions of the main changes to colorectal cancer delivery during the COVID-19 pandemic and how they impacted on socioeconomic inequalities in care. METHODS: In 2020, using a qualitative approach, we interviewed patients (n = 15) who accessed primary care with colorectal cancer symptoms and were referred for further investigations. In 2021, we interviewed a wide range of healthcare professionals (n = 30) across the cancer care pathway and gathered national and local documents/guidelines regarding changes in colorectal cancer care. RESULTS: Changes with the potential to exacerbate inequalities in care, included: the move to remote consultations; changes in symptomatic triage, new COVID testing procedures/ways to access healthcare, changes in visitor policies and treatment (e.g., shorter course radiotherapy). Changes that improved patient access/convenience or the diagnostic process have the potential to reduce inequalities in care. DISCUSSION: Changes in healthcare delivery during the COVID-19 pandemic have the ongoing potential to exacerbate existing health inequalities due to changes in how patients are triaged, changes to diagnostic and disease management processes, reduced social support available to patients and potential over-reliance on digital first approaches. We provide several recommendations to help mitigate these harms, whilst harnessing the gains

Factors influencing feeding practices of extreme poor infants and young children in families of working mothers in Dhaka slums: A qualitative study

BackgroundNutritional status differs between infants and young children living in slum and non-slum conditions—infants and young children living in City Corporation slums are likely to have worse nutritional status compared to those from non-slums. Furthermore, families in slums tend to engage female labor in cash-earning activities as a survival strategy; hence, a higher percentage of mothers stay at work. However, little is known about feeding practices for infants and young children in families with working mothers in slums. This study aims to understand the factors that determine feeding practices for infants and young children living in families with working mothers in Dhaka slums.MethodsThis study adopted a qualitative approach. Sixteen In-depth Interviews, five Key Informant Interviews, and Focused Group Discussions were conducted with family members, community leaders, and program staff. Method triangulation and thematic analyses were conducted.ResultsFeeding practices for infants and young children in families with working mothers are broadly determined by mothers’ occupation, basis civic facilities, and limited family buying capacity. Although mothers have good nutritional knowledge, they negotiate between work and feeding their infants and young children. Household composition, access to cooking facilities, and poverty level were also found to be significant determining factors.ConclusionThe results suggest a trade-off between mothers’ work and childcare. The absence of alternative care support in homes and/or work places along with societal factors outweighs full benefits of project interventions. Improving alternative childcare support could reduce the burden of feeding practice experienced by working mothers and may improve nutritional outcomes

Centralisation of specialist cancer surgery services in two areas of England: the RESPECT-21 mixed-methods evaluation

Background: Centralising specialist cancer surgical services is an example of major system change. High-volume centres are recommended to improve specialist cancer surgery care and outcomes. Objective: Our aim was to use a mixed-methods approach to evaluate the centralisation of specialist surgery for prostate, bladder, renal and oesophago-gastric cancers in two areas of England [i.e. London Cancer (London, UK), which covers north-central London, north-east London and west Essex, and Greater Manchester Cancer (Manchester, UK), which covers Greater Manchester]. Design: Stakeholder preferences for centralising specialist cancer surgery were analysed using a discrete choice experiment, surveying cancer patients (n = 206), health-care professionals (n = 111) and the general public (n = 127). Quantitative analysis of impact on care, outcomes and cost-effectiveness used a controlled before-and-after design. Qualitative analysis of implementation and outcomes of change used a multisite case study design, analysing documents (n = 873), interviews (n = 212) and non-participant observations (n = 182). To understand how lessons apply in other contexts, we conducted an online workshop with stakeholders from a range of settings. A theory-based framework was used to synthesise these approaches. Results: Stakeholder preferences – patients, health-care professionals and the public had similar preferences, prioritising reduced risk of complications and death, and better access to specialist teams. Travel time was considered least important. Quantitative analysis (impact of change) – only London Cancer’s centralisations happened soon enough for analysis. These changes were associated with fewer surgeons doing more operations and reduced length of stay [prostate –0.44 (95% confidence interval –0.55 to –0.34) days; bladder –0.563 (95% confidence interval –4.30 to –0.83) days; renal –1.20 (95% confidence interval –1.57 to –0.82) days]. The centralisation meant that renal patients had an increased probability of receiving non-invasive surgery (0.05, 95% confidence interval 0.02 to 0.08). We found no evidence of impact on mortality or re-admissions, possibly because risk was already low pre-centralisation. London Cancer’s prostate, oesophago-gastric and bladder centralisations had medium probabilities (79%, 62% and 49%, respectively) of being cost-effective, and centralising renal services was not cost-effective (12% probability), at the £30,000/quality-adjusted life-year threshold. Qualitative analysis, implementation and outcomes – London Cancer’s provider-led network overcame local resistance by distributing leadership throughout the system. Important facilitators included consistent clinical leadership and transparent governance processes. Greater Manchester Cancer’s change leaders learned from history to deliver the oesophago-gastric centralisation. Greater Manchester Cancer’s urology centralisations were not implemented because of local concerns about the service model and local clinician disengagement. London Cancer’s network continued to develop post implementation. Consistent clinical leadership helped to build shared priorities and collaboration. Information technology difficulties had implications for interorganisational communication and how reliably data follow the patient. London Cancer’s bidding processes and hierarchical service model meant that staff reported feelings of loss and a perceived ‘us and them’ culture. Workshop – our findings resonated with workshop attendees, highlighting issues about change leadership, stakeholder collaboration and implications for future change and evaluation. Limitations: The discrete choice experiment used a convenience sample, limiting generalisability. Greater Manchester Cancer implementation delays meant that we could study the impact of only London Cancer changes. We could not analyse patient experience, quality of life or functional outcomes that were important to patients (e.g. continence). Future research: Future research may focus on impact of change on care options offered, patient experience, functional outcomes and long-term sustainability. Studying other approaches to achieving high-volume services would be valuable. Study registration: ational Institute for Health and Care Research (NIHR) Clinical Research Network Portfolio reference 19761

Harnessing the Electronic Health Care Record to Optimize Patient Safety in Primary Care:Framework for Evaluating e-Safety-Netting Tools

The management of diagnostic uncertainty is part of every primary care physician's role. e-Safety-netting tools help health care professionals to manage diagnostic uncertainty. Using software in addition to verbal or paper based safety-netting methods could make diagnostic delays and errors less likely. There are an increasing number of software products that have been identified as e-safety-netting tools, particularly since the start of the COVID-19 pandemic. e-Safety-netting tools can have a variety of functions, such as sending clinician alerts, facilitating administrative tasking, providing decision support, and sending reminder text messages to patients. However, these tools have not been evaluated by using robust research designs for patient safety interventions. We present an emergent framework of criteria for effective e-safety-netting tools that can be used to support the development of software. The framework is based on validated frameworks for electronic health record development and patient safety. There are currently no tools available that meet all of the criteria in the framework. We hope that the framework will stimulate clinical and public conversations about e-safety-netting tools. In the future, a validated framework would drive audits and improvements. We outline key areas for future research both in primary care and within integrated care systems

Socioeconomic differences in help-seeking experiences in primary care for symptoms related to colorectal cancer during COVID-19: A UK-wide qualitative interview study

Background COVID-19 has led to rapid changes in healthcare delivery, raising concern that these changes may exacerbate existing inequalities in patient outcomes.Aim To understand how patients’ help-seeking experiences in primary care for colorectal cancer symptoms during COVID-19 were affected by their socioeconomic status (SES).Design and setting Qualitative semi-structured interviews with males and females across the UK, recruited using purposive sampling by SES.Method Interviews were carried out with 39 participants (20 higher SES; 19 lower SES) who contacted primary care about possible symptoms of colorectal cancer during COVID-19. Data were analysed using framework analysis followed by comparative thematic analysis to explore differences between groups.Results Three themes were identified with differences between SES groups: 1) how people decided to seek medical help through appraisal of symptoms; 2) how people navigated services; and 3) impact of COVID-19 on how patients interacted with healthcare professionals. The lower SES group expressed uncertainty appraising symptoms and navigating services (in terms of new processes resulting from COVID-19 and worries about infection). There was also potential for increased disparity in diagnosis and management, with other methods of getting in touch (for example, email or 111) taken up more readily by higher SES patients.Conclusion The findings suggest that COVID-19 exacerbated disparities between higher and lower SES participants. This study raises awareness around challenges in help seeking in the context of the pandemic, which are likely to persist (post-COVID-19) as healthcare systems settle on new models of care (for example, digital). Recommendations are provided to reduce inequalities of care