A primary care research agenda for multiple long-term conditions:A Delphi study

BackgroundMultiple long-term conditions (MLTC, multimorbidity) has been identified as a priority research topic, globally. Research priorities from the perspectives of patients and research funders have been described. Although most care for MLTC is delivered in primary care, the priorities of academic primary care have not been identified. AimTo identify and prioritise the academic primary care research agenda for MLTC.Design and SettingThree-phase study with primary care MLTC researchers from the UK and other high-income countries.Method(i) Open-ended survey question; (ii) face-to-face workshop to elaborate questions with researchers from the UK and Ireland; (iii) and a two-round Delphi consensus survey with international multimorbidity researchers.ResultsTwenty-five primary care researchers responded to the initial open-ended survey and generated 84 potential research questions. In the subsequent workshop discussion (18 participants), this list was reduced to 31 questions. The long list of 31 research questions was included in round one of the Delphi; 27 of the 50 (54%) round one and 24 of the 27 to round two (89%) invitees took part in the Delphi. Ten questions reached final consensus. These focused broadly on addressing complexity of the patient group with (a) development of new models of care for multimorbidity, (b) methods and data development.ConclusionThese high priority research questions offer funders and researchers a basis upon which to build future grant calls and research plans. Addressing complexity in our research is needed to inform improvements in our systems of care and for prevention.<br/

Factors affecting the offer of pulmonary rehabilitation to patients with chronic obstructive pulmonary disease by primary care professionals : a qualitative study

Aim: To explore health professionals&rsquo; experiences of barriers and facilitators to referring patients for pulmonary rehabilitation in a primary care setting. Background: Pulmonary rehabilitation involves a multidisciplinary teamwork approach to improvingthe quality of life for people with chronic obstructive pulmonary disease. This study aimed to find out about health care professionals&rsquo; experiences when referring patients. Reports suggest that a health care professional&rsquo;s attitude towards a treatment affects the willingness of patients to accept advice. Methods: Five focus group interviews were undertaken with 21 health professionals from North Midlands, UK. Data were analysed using a thematic analysis drawing on the techniques of grounded theory.Findings: Chronic disease management has been delegated to Practice Nurses in many cases leaving some nurses feeling unsupported and some General Practitioners feeling deskilled. Problems with communication, a lack of adequate and timely local service provision, a difficult referral process, time pressures and lack of information were barriers to health care professionals making an offer of pulmonary rehabilitation. An explanatory model is proposed to describe how addressing barriers to referral may improve health care professionals views about pulmonary rehabilitation and therefore may mean that they present it in a more positive manner.<br /

Challenges in the management of people with heart failure with preserved ejection fraction (HFpEF) in primary care : A qualitative study of general practitioner perspectives

Objectives To explore the perspectives of general practitioners (GPs) on the identification and management of people, including those from ethnic minority groups, with Heart Failure with Preserved Ejection Fraction (HFpEF). Methods Qualitative study. Semi-structured, face-to-face or telephone interviews and focus groups were conducted with 35 GPs in England, which were audio-recorded and transcribed verbatim. Framework analysis was used to manage and interpret data. Results Themes presented reflect four inter-related challenges: GPs’ 1) lack of understanding HFpEF, impacting on 2) difficulties in communicating the diagnosis, leading to 3) uncertainty in managing people with HFpEF, further hindered by (4) discontinuity across the primary/secondary interface. All were considered more challenging by GPs when managing people from different cultures and languages. Discussion HFpEF is not well understood by GPs, leading to diagnostic difficulty, management uncertainty and potential inequity in care offered. People with HFpEF are seen as complex, with multiple long-term conditions and requiring personalised care. Challenges in their management occur across the healthcare system. This study has identified learning needs for GPs around identification and on-going support for people with HFpEF in primary care. It will contribute to the development of more flexible and patient-centred pathways across the primary/secondary care interface

Identification and management of frail patients in English primary care: an analysis of the General Medical Services 2018/2019 contract dataset

Objectives - The aim of this study was to explore the extent of implementation of the General Medical Services 2018/2019 ‘frailty identification and management’ contract in general practitioner (GP) practices in England, and link implementation outcomes to a range of practice and Clinical Commissioning Group (CCG) factors. Design - A cross-sectional study design using publicly available datasets relating to the year 2018 for all GP practices in England. Settings - English general practices. Data - The analysis was conducted across 6632 practices in 193 CCGs with 9 995 558 patients aged 65 years or older. Outcomes - Frailty assessment rates, frailty coding rates and frailty prevalence rates, plus rates of medication reviews, falls assessments and enriched Summary Care Records (SCRs). Analysis - Summary statistics were calculated and multilevel negative binomial regression analysis was used to investigate relationships of the six outcomes with explanatory factors. Results - 14.3% of people aged 65 years or older were assessed for frailty, with 35.4% of these—totalling 5% of the eligible population—coded moderately or severely frail. 59.2% received a medications review, but rates of falls assessments (3.7%) and enriched SCRs (21%) were low. However, percentages varied widely across practices and CCGs. Practice differences in contract implementation were most strongly accounted for by their grouping within CCGs, with weaker but still important associations with some practice and CCG factors, particularly healthcare demand-related factors of chronic caseload and (negatively) % of patients aged 65 years or older. Conclusion - CCG appears the strongest determinant of practice engagement with the frailty contract, and fuller implementation may depend on greater engagement of CCGs themselves, particularly in commissioning suitable interventions. Practices understandably targeted frailty assessments at patients more likely to be found severely frail, resulting in probable underidentification of moderately frail individuals who might benefit most from early interventions. Frailty prevalence estimates based on the contract data may not reflect actual rates

What are the risks and benefits of temporarily discontinuing medications to prevent acute kidney injury? A systematic review and meta-analysis.

OBJECTIVES: To summarise evidence on temporary discontinuation of medications to prevent acute kidney injury (AKI). DESIGN: Systematic review and meta-analysis of randomised and non-randomised studies. PARTICIPANTS: Adults taking diuretics, ACE inhibitors (ACEI), angiotensin receptor blockers (ARB), direct renin inhibitors, non-steroidal anti-inflammatories, metformin or sulfonylureas, experiencing intercurrent illnesses, radiological or surgical procedures. INTERVENTIONS: Temporary discontinuation of any of the medications of interest. PRIMARY AND SECONDARY OUTCOME MEASURES: Risk of AKI. Secondary outcome measures were estimated glomerular filtration rate and creatinine post-AKI, urea, systolic and diastolic blood pressure, death, clinical outcomes and biomarkers. RESULTS: 6 studies were included (1663 participants), 3 randomised controlled trials (RCTs) and 3 prospective cohort studies. The mean age ranged from 65 to 73 years, and the proportion of women ranged from 31% to 52%. All studies were in hospital settings; 5 evaluated discontinuation of medication prior to coronary angiography and 1 prior to cardiac surgery. 5 studies evaluated discontinuation of ACEI and ARBs and 1 small cohort study looked at discontinuation of non-steroidal anti-inflammatory drugs. No studies evaluated discontinuation of medication in the community following an acute intercurrent illness. There was an increased risk of AKI of around 15% in those in whom medication was continued compared with those in whom it was discontinued (relative risk (RR) 1.17, 95% CI 0.99 to 1.38; 5 studies). When only results from RCTs were pooled, the increase in risk was almost 50% (RR 1.48, 95% CI 0.84 to 2.60; 3 RCTs), but the CI was wider. There was no difference between groups for any secondary outcomes. CONCLUSIONS: There is low-quality evidence that withdrawal of ACEI/ARBs prior to coronary angiography and cardiac surgery may reduce the incidence of AKI. There is no evidence of the impact of drug cessation interventions on AKI incidence during intercurrent illness in primary or secondary care. TRIAL REGISTRATION NUMBER: PROSPERO CRD42015023210

Understanding the implementation of interventions to improve the management of frailty in primary care: a rapid realist review

OBJECTIVE: Identifying and managing the needs of frail people in the community is an increasing priority for policy makers. We sought to identify factors that enable or constrain the implementation of interventions for frail older persons in primary care. DESIGN: A rapid realist review. DATA SOURCES: Cochrane Library, SCOPUS and EMBASE, and grey literature. The search was conducted in September 2019 and rerun on 8 January 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We considered all types of empirical studies describing interventions targeting frailty in primary care. ANALYSIS: We followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication criteria for our synthesis to systematically analyse and synthesise the existing literature and to identify (intervention-context-mechanism-outcome) configurations. We used normalisation processes theory to illuminate mechanisms surrounding implementation. RESULTS: Our primary research returned 1755 articles, narrowed down to 29 relevant frailty intervention studies conducted in primary care. Our review identified two families of interventions. They comprised: (1) interventions aimed at the comprehensive assessment and management of frailty needs; and (2) interventions targeting specific frailty needs. Key factors that facilitate or inhibit the translation of frailty interventions into practice related to the distribution of resources; patient engagement and professional skill sets to address identified need. CONCLUSION: There remain challenges to achieving successful implementation of frailty interventions in primary care. There were a key learning points under each family. First, targeted allocation of resources to address specific needs allows a greater alignment of skill sets and reduces overassessment of frail individuals. Second, earlier patient involvement may also improve intervention implementation and adherence

Beyond the control of the care home: A meta‐ethnography of qualitative studies of Infection Prevention and Control in residential and nursing homes for older people

OBJECTIVE: This study aimed to develop interpretive insights concerning Infection Prevention and Control (IPC) in care homes for older people. DESIGN: This study had a meta‐ethnography design. DATA SOURCES: Six bibliographic databases were searched from inception to May 2020 to identify the relevant literature. REVIEW METHODS: A meta‐ethnography was performed. RESULTS: Searches yielded 652 records; 15 were included. Findings were categorized into groups: The difficulties of enacting IPC measures in the care home environment; workload as an impediment to IPC practice; the tension between IPC and quality of life for care home residents; and problems dealing with medical services located outside the facility including diagnostics, general practice and pharmacy. Infection was revealed as something seen to lie ‘outside’ the control of the care home, whether according to origins or control measures. This could help explain the reported variability in IPC practice. Facilitators to IPC uptake involved repetitive training and professional development, although such opportunities can be constrained by the ways in which services are organized and delivered. CONCLUSIONS: Significant challenges were revealed in implementing IPC in care homes including staffing skills, education, workloads and work routines. These challenges cannot be properly addressed without resolving the tension between the objectives of maintaining resident quality of life while enacting IPC practice. Repetitive staff training and professional development with parallel organisational improvements have prospects to enhance IPC uptake in residential and nursing homes. PATIENT OR PUBLIC CONTRIBUTION: A carer of an older person joined study team meetings and was involved in writing a lay summary of the study findings

Is telephone health coaching a useful population health strategy for supporting older people with multimorbidity? : An evaluation of reach, effectiveness and cost-effectiveness using a 'trial within a cohort'

BACKGROUND: Innovative ways of delivering care are needed to improve outcomes for older people with multimorbidity. Health coaching involves 'a regular series of phone calls between patient and health professional to provide support and encouragement to promote healthy behaviours'. This intervention is promising, but evidence is insufficient to support a wider role in multimorbidity care. We evaluated health coaching in older people with multimorbidity. METHODS: We used the innovative 'Trials within Cohorts' design. A cohort was recruited, and a trial was conducted using a 'patient-centred' consent model. A randomly selected group within the cohort were offered the intervention and were analysed as the intervention group whether they accepted the offer or not. The intervention sought to improve the skills of patients with multimorbidity to deal with a range of long-term conditions, through health coaching, social prescribing and low-intensity support for low mood. RESULTS: We recruited 4377 older people, and 1306 met the eligibility criteria (two or more long-term conditions and moderate 'patient activation'). We selected 504 for health coaching, and 41% consented. More than 80% of consenters received the defined 'dose' of 4+ sessions. In an intention-to-treat analysis, those selected for health coaching did not improve on any outcome (patient activation, quality of life, depression or self-care) compared to usual care. We examined health care utilisation using hospital administrative and self-report data. Patients selected for health coaching demonstrated lower levels of emergency care use, but an increase in the use of planned services and higher overall costs, as well as a quality-adjusted life year (QALY) gain. The incremental cost per QALY was £8049, with a 70-79% probability of being cost-effective at conventional levels of willingness to pay. CONCLUSIONS: Health coaching did not lead to significant benefits on the primary measures of patient-reported outcome. This is likely related to relatively low levels of uptake amongst those selected for the intervention. Demonstrating effectiveness in this design is challenging, as it estimates the effect of being selected for treatment, regardless of whether treatment is adopted. We argue that the treatment effect estimated is appropriate for health coaching, a proactive model relevant to many patients in the community, not just those seeking care. TRIAL REGISTRATION: International Standard Randomised Controlled Trial Number ( ISRCTN12286422 )

The problem of success and failure in public-private innovation partnerships

Public-Private Innovation Partnerships (PPIPs) are increasingly used as a tool for addressing ‘wicked’ public sector challenges. ‘Innovation’ is, however, frequently treated as a ‘magic’ concept: used unreflexively, taken to be axiomatically ‘good’, and left undefined within policy programmes. Using McConnell’s framework of policy success and failure and a case study of a multi-level PPIP in the English health service (NHS Test Beds), this paper critically explores the implications of the mobilisation of innovation in PPIP policy and practice. We highlight how the interplay between levels (macro/micro and policy maker/recipient) can shape both emerging policies and their prospects for success or failure. The paper contributes to an understanding of PPIP success and failure by extending McConnell’s framework to explore inter-level effects between policy and innovation project, and demonstrating how the success of PPIP policy cannot be understood without recognising the particular political effects of ‘innovation’ on formulation and implementation