Patients' unvoiced agendas in general practice consultations.

Objective: To investigate patients' agendas before consultation and to assess which aspects of agendas are voiced in the consultation and the effects of unvoiced agendas on outcomes. Design: Qualitative study. Setting: 20 general practices in south east England and the West Midlands. Participants: 35 patients consulting 20 general practitioners in appointment and emergency surgeries. Results: Patients' agendas are complex and multifarious. Only four of 35 patients voiced all their agendas in consultation. Agenda items most commonly voiced were symptoms and requests for diagnoses and prescriptions. The most common unvoiced agenda items were: worries about possible diagnosis and what the future holds; patients' ideas about what is wrong; side effects; not wanting a prescription; and information relating to social context. Agenda items that were not raised in the consultation often led to specific problem outcomes (for example, major misunderstandings), unwanted prescriptions, non-use of prescriptions, and non-adherence to treatment. In all of the 14 consultations with problem outcomes at least one of the problems was related to an unvoiced agenda item. Conclusion: Patients have many needs and when these are not voiced they can not be addressed. Some of the poor outcomes in the case studies were related to unvoiced agenda items. This suggests that when patients and their needs are more fully articulated in the consultation better health care may be effected. Steps should be taken in both daily clinical practice and research to encourage the voicing of patients' agenda

Misunderstandings in general practice prescribing decisions: a qualitative study

Objectives: To identify and describe misunderstandings between patients and doctors associated with prescribing decisions in general practice. Design: Qualitative study. Setting: 20 general practices in the West Midlands and south east England. Participants: 20 general practitioners and 35 consulting patients. Main outcome measures: Misunderstandings between patients and doctors that have potential or actual adverse consequences for taking medicine. Results: 14 categories of misunderstanding were identified relating to patient information unknown to the doctor, doctor information unknown to the patient, conflicting information, disagreement about attribution of side effects, failure of communication about doctor's decision, and relationship factors. All the misunderstandings were associated with lack of patients' participation in the consultation in terms of the voicing of expectations and preferences or the voicing of responses to doctors' decisions and actions. They were all associated with potential or actual adverse outcomes such as non-adherence to treatment. Many were based on inaccurate guesses and assumptions. In particular doctors seemed unaware of the relevance of patients' ideas about medicines for successful prescribing. Conclusions: Patients' participation in the consultation and the adverse consequences of lack of participation are important. The authors are developing an educational intervention that builds on these findings

“How can anybody be representative for those kind of people?” Forms of patient representation in health research, and why it is always contestable

This is the author accepted manuscript. The final version is available from Elsevier via the DOI in this record.Different discourses that co-exist within the world of patient and public involvement in health and social care mirror a tangle of historical, social, political and theoretical roots. These range from the radical activism, born of civil rights movements, to a more passive model in which patients are the recipients of information. This paper explores the concept of ‘representation’ and the ways the concept is used by people serving as ‘patient’ or ‘lay’ representatives in a range of roles within research projects, funding bodies and academic institutions. We address the issue of why the representativeness of those involved is contestable. Drawing on qualitative research and engaged practice as well as on literature from social and political sciences we question how people conceptualise their own and their fellows' acts of representation. In doing this we identify nine different conceptualisations of what it is to represent and use these to explore how judgements are made about what can count as legitimate forms of representation.The PhD study “Public and Patient Involvement in Theory and in Practice” was funded by the National Institute for Health Research Collaboration for Leadership in Applied Health Research and Care for the South West Peninsula. The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health. We would also like to acknowledge the generous contributions of time and thought made by study participants and the Peninsula Public involvement Group (PenPIG)

Collaborative research and the co-production of knowledge for practice: an illustrative case study.

This is the final version of the article. Available from BioMed Central via the DOI in this record.BACKGROUND: In 2008, the National Institute for Health Research (NIHR) began funding a major 5-year pilot research programme of translational research in England, establishing nine 'Collaborations for Leadership in Applied Health Research and Care' (CLAHRCs). A number of evaluations were carried out to examine whether or not the various collaborations worked as intended and why. In this paper, we examine what the theory of co-production adds to understanding of processes of knowledge creation and translation we observed in one of the CLAHRCs. METHODS: A case study of a successful knowledge translation project was identified from our wider realist evaluation of the mechanisms of closer collaboration at play in the CLAHRC. In the project, a computer simulation model of an emergency pathway for acute ischaemic stroke was built to explore if and how the time between the onset and treatment of the condition could be minimised by redesigning the pathway. The aim of the case study was to improve our understanding of the nature and workings of the mechanisms of closer collaboration that were associated with the more successful projects by examining the relevance of the theory of co-production. Qualitative methods of analysis were used to explore the fit between the mechanisms of closer collaboration we observed in the realist evaluation and the principles of co-production we identified from the literature. RESULTS: We found a close fit between the nine mechanisms of closer collaboration at work in the project and the principles of co-production (active agents; equality of partners; reciprocity and mutuality; transformative; and facilitated). The successful style of collaborative working exemplified by the project was consistent with a strong form of co-production. CONCLUSIONS: In our view, the theory of co-production provides useful insights into what it is about the qualities of collaborative working that inspire the requisite mechanisms for generating knowledge that is translated into practice. The theory provides a potentially useful basis for future knowledge translation programmes and projects in applied health research in a range of contexts.We would like to thank the participants for taking part in this research and giving their time so generously and the reviewers for their helpful comments on an earlier version of the paper. This research was supported by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South-West Peninsula. The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health

The contribution of digital technology in supporting older people manage their medicines

This is the author accepted manuscript. The final version is available from the publisher via the DOI in this recordBackground: With an ageing population, the concurrent use of multiple medicines, or polypharmacy, is increasing. Multiple medicines and conditions can have a considerable impact on an individual, and between one‐half and one half of all medication prescribed for long‐term conditions is not taken as recommended.1 Supporting community‐dwelling older people to manage their multiple medicines is therefore imperative. Aims: This review identifies and assesses which tools or resources are available for older people to manage multiple medicines or complex treatment regimens. Methods: A scoping review2 was conducted. Electronic databases (MEDLINE and CINAHL), grey literature, select paper citations, conference presentations, Cochrane Database of Systematic Reviews, and key author publications were iteratively searched. English‐language studies that included medicines self‐management tools were eligible. Data extracted from included articles were categorised on the basis of their utility, and the similarities and differences between tools were mapped. Results: One hundred nineteen articles met our inclusion criteria and are included in the review. Findings suggest that, firstly, most tools are developed to ensure adherence—not medicine optimisation. Secondly, there has been a considerable growth in the development of digital technology for medicines management in the last decade. Lastly, it is unclear whether such tools are supporting medicines optimisation or mere adherence. Conclusions: This review outlines the tools or resources, which may be useful for older people to self‐manage multiple medicines, the evidence for the use of different tools, and gaps in knowledge for further research. It also questions the contribution of digital technology in supporting older people to manage their medicines. Evidence about such tools is warranted so that older people can maximise the use of their medicines, and consequently reduce the societal costs of the inappropriate use of medicines

Multiple repair sequences in everyday conversations involving people with Parkinson's disease

Background Features of dysarthria associated with Parkinson's disease (PD), such as low volume, variable rate of speech and increased pauses, impact speaker intelligibility. Those affected report restricted interactional participation, although this area is under explored. Aims To examine naturally occurring instances of problems with intelligibility that resulted in multiple attempts at repair in order to consider repair initiation strategies that might restrict or enhance participation. Methods & Procedures Thirteen people with PD (PwPD) video-recorded over 10 h of informal conversation data in their home setting involving familiar conversation partners (CPs). Using a conversation analytic (CA) approach, and drawing on an existing typology of repair initiators (RIs) for everyday talk-in-interaction and their relative power to locate a turn's repairable element, the design and ordering of RIs used by CPs was addressed, alongside their local consequences. Outcomes & Results CPs tended to increase the specificity of their RIs in line with the existing typology, progressing from open class forms (e.g. ‘mm?’) to more specific forms (e.g. questions/partial repeats). Repeated open class repair initiators (OCRIs) were used where PD speakers’ self-repair attempts provided limited information. Sometimes, however, specificity was increased too soon, before enough syntactic knowledge was gleaned, which resulted in an extended repair sequence. Where one OCRI followed another, the second always took a different form: lexically or in terms of prosodic/non-verbal features. RI forms not described in the existing typology were also identified, such as ‘prompts to modify speech’ (e.g. ‘Speak louder’) and repeating/rephrasing the original first pair part (e.g. question), and their effectiveness examined. Conclusions & Implications First steps are presented towards the design of a communication intervention promoting the efficient resolution of repair to moderate social withdrawal and increase participation for this client group. Future research will need to explore the feasibility and acceptability of such a resource

The potential and pitfalls of narrative elicitation in person‐centred care.

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Speed and Accuracy of Static Image Discrimination by Rats

When discriminating dynamic noisy sensory signals, human and primate subjects achieve higher accuracy when they take more time to decide, an effect attributed to accumulation of evidence over time to overcome neural noise. We measured the speed and accuracy of twelve freely behaving rats discriminating static, high contrast photographs of real-world objects for water reward in a self-paced task. Response latency was longer in correct trials compared to error trials. Discrimination accuracy increased with response latency over the range of 500-1200ms. We used morphs between previously learned images to vary the image similarity parametrically, and thereby modulate task difficulty from ceiling to chance. Over this range we find that rats take more time before responding in trials with more similar stimuli. We conclude that rats' perceptual decisions improve with time even in the absence of temporal information in the stimulus, and that rats modulate speed in response to discrimination difficulty to balance speed and accuracy

N of 1 trials and the optimal individualisation of drug treatments: a systematic review protocol

This is the final version of the article. Available from BioMed Central via the DOI in this record.BACKGROUND: Guidelines and evidence-based drug treatment recommendations are usually based on the results of clinical trials, which have limited generalisability in routine clinical settings due to their restrictive eligibility criteria. These trials are also conducted in ideal and rigorously controlled settings. N of 1 trials, which are single patient multiple crossover studies, offer a means of increasing the evidence base and individualising care for individuals in clinical practice. This systematic review of the N of 1 drug treatment trial aims to investigate its usefulness for achieving optimal individualised patient care. METHODS: The following databases will be searched for relevant articles: MEDLINE, EMBASE, PsycINFO (all via Ovid), AMED, CINAHAL (via EBSCO), The Cochrane Library (including CENTRAL, NHS EED, and DARE), and Web of Science (Thomson Reuters). Supplementary searches will include ongoing trial databases and organisational websites. All N of 1 trials in which patients have been treated with a drug will be considered. Outcomes will include information on the clinical usefulness of N of 1 trials-i.e. achievement of optimal individualised care, health-care utilisation of patients, frequently used practices, experiences of clinical care or participation in N of 1 trials, adherence to treatment plan, and unwanted effects of the treatment. Screening of included papers will be undertaken independently by two reviewers, while data extraction and the quality of reporting will be conducted by one reviewer and checked by another. Both quantitative and qualitative summaries will be reported using appropriate methods. DISCUSSION: This review will provide new insights into the clinical utility of N of 1 drug trials in helping participants find the most acceptable treatment as defined by patients and clinicians based on the selected outcome measures and the perspectives of participants involved in such trials. Findings from this review will inform the development of a stakeholder workshop and guidance to help physicians find the optimum therapy for their patients and will help guide future research on N of 1 trials. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42016032452.This research was funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care South West Peninsula

Adapting QOF to focus on wellbeing and health

This is the final version of the article. Available from BMJ Publishing Group via the DOI in this record