Variations in GP-patient communication by ethnicity, age, and gender: evidence from a national primary care patient survey.

BACKGROUND: Doctor-patient communication is a key driver of overall satisfaction with primary care. Patients from minority ethnic backgrounds consistently report more negative experiences of doctor-patient communication. However, it is currently unknown whether these ethnic differences are concentrated in one gender or in particular age groups. AIM: To determine how reported GP-patient communication varies between patients from different ethnic groups, stratified by age and gender. DESIGN AND SETTING: Analysis of data from the English GP Patient Survey from 2012-2013 and 2013-2014, including 1,599,801 responders. METHOD: A composite score was created for doctor-patient communication from five survey items concerned with interpersonal aspects of care. Mixed-effect linear regression models were used to estimate age- and gender-specific differences between white British patients and patients of the same age and gender from each other ethnic group. RESULTS: There was strong evidence (P<0.001 for age by gender by ethnicity three-way interaction term) that the effect of ethnicity on reported GP-patient communication varied by both age and gender. The difference in scores between white British and other responders on doctor-patient communication items was largest for older, female Pakistani and Bangladeshi responders, and for younger responders who described their ethnicity as 'Any other white'. CONCLUSION: The identification of groups with particularly marked differences in experience of GP-patient communication--older, female, Asian patients and younger 'Any other white' patients--underlines the need for a renewed focus on quality of care for these groups.This work was funded by the National Institute for Health Research Programme Grants for Applied Research (NIHR PGfAR) Programme (RP-PG-0608-10050).This is the final version of the article. It first appeared from the Royal College of General Practitioners via http://dx.doi.org/10.3399/bjgp15X68763

Does the availability of a South Asian language in practices improve reports of doctor-patient communication from South Asian patients? Cross sectional analysis of a national patient survey in English general practices.

BACKGROUND: Ethnic minorities report poorer evaluations of primary health care compared to White British patients. Emerging evidence suggests that when a doctor and patient share ethnicity and/or language this is associated with more positive reports of patient experience. Whether this is true for adults in English general practices remains to be explored. METHODS: We analysed data from the 2010/2011 English General Practice Patient Survey, which were linked to data from the NHS Choices website to identify languages which were available at the practice. Our analysis was restricted to single-handed practices and included 190,582 patients across 1,068 practices. Including only single-handed practices enabled us to attribute, more accurately, reported patient experience to the languages that were listed as being available. We also carried out sensitivity analyses in multi-doctor practices. We created a composite score on a 0-100 scale from seven survey items assessing doctor-patient communication. Mixed-effect linear regression models were used to examine how differences in reported experience of doctor communication between patients of different self-reported ethnicities varied according to whether a South Asian language concordant with their ethnicity was available in their practice. Models were adjusted for patient characteristics and a random effect for practice. RESULTS: Availability of a concordant language had the largest effect on communication ratings for Bangladeshis and the least for Indian respondents (p < 0.01). Bangladeshi, Pakistani and Indian respondents on average reported poorer communication than White British respondents [-2.9 (95%CI -4.2, -1.6), -1.9 (95%CI -2.6, -1.2) and -1.9 (95%CI -2.5, -1.4), respectively]. However, in practices where a concordant language was offered, the experience reported by Pakistani patients was not substantially worse than that reported by White British patients (-0.2, 95%CI -1.5,+1.0), and in the case of Bangladeshi patients was potentially much better (+4.5, 95%CI -1.0,+10.1). This contrasts with a worse experience reported among Bangladeshi (-3.3, 95%CI -4.6, -2.0) and Pakistani (-2.7, 95%CI -3.6, -1.9) respondents when a concordant language was not offered. CONCLUSIONS: Substantial differences in reported patient experience exist between ethnic groups. Our results suggest that patient experience among Bangladeshis and Pakistanis is improved where the practice offers a language that is concordant with the patient's ethnicity

IMproving the practice of intrapartum electronic fetal heart rate MOnitoring with cardiotocography for safer childbirth (the IMMO programme): protocol for a qualitative study.

INTRODUCTION: Suboptimal electronic fetal heart rate monitoring (EFM) in labour using cardiotocography (CTG) has been identified as one of the most common causes of avoidable harm in maternity care. Training staff is a frequently proposed solution to reduce harm. However, current approaches to training are heterogeneous in content and format, making it difficult to assess effectiveness. Technological solutions, such as digital decision support, have not yet demonstrated improved outcomes. Effective improvement strategies require in-depth understanding of the technical and social mechanisms underpinning the EFM process. The aim of this study is to advance current knowledge of the types of errors, hazards and failure modes in the process of classifying, interpreting and responding to CTG traces. This study is part of a broader research programme aimed at developing and testing an intervention to improve intrapartum EFM. METHODS AND ANALYSIS: The study is organised into two workstreams. First, we will conduct observations and interviews in three UK maternity units to gain an in-depth understanding of how intrapartum EFM is performed in routine clinical practice. Data analysis will combine the insights of an ethnographic approach (focused on the social norms and interactions, values and meanings that appear to be linked with the process of EFM) with a systems thinking approach (focused on modelling processes, actors and their interactions). Second, we will use risk analysis techniques to develop a framework of the errors, hazards and failure modes that affect intrapartum EFM. ETHICS AND DISSEMINATION: This study has been approved by the West Midlands-South Birmingham Research Ethics Committee, reference number: 18/WM/0292. Dissemination will take the form of academic articles in peer-reviewed journals and conferences, along with tailored communication with various stakeholders in maternity care

Influences on patient safety in intrapartum electronic fetal heart rate monitoring with cardiotocography (iSafe): protocol for a systematic scoping review

Intrapartum electronic fetal monitoring (EFM) using cardiotocography (CTG) is the recommended method for monitoring the fetal heart rate during labour for high-risk births in England. An abnormal CTG indicates the need for further review and management including potential urgent intervention (e.g. expediting birth) to minimise risk of serious long-term harm to the baby or stillbirth. In the UK, as other European countries, sub-optimal intrapartum EFM management is implicated in a large share of cerebral palsy, birth asphyxia, peripartum hypoxic brain injuries and obstetric malpractice claims. In addition to the psychosocial and social impact of stillbirth or life-long disability on parents and babies, obstetric brain injury is costly, potentially resulting in settlements for millions of pounds to support families over a lifetime of care. Every baby born in the NHS in England now incurs indemnity costs of £1,100. Of the total Clinical Negligence Scheme for Trusts provision of £78bn, 70% relates to maternity. Though maternity claims made up just 10% of the number of clinical negligence claims received by NHS Resolution in 2018-19, they accounted for 50% of the total value of claims. The need for action to improve safety of intrapartum EFM is now urgent, but questions remain about how it can best be achieved. We propose that reducing avoidable harm linked to intrapartum EFM requires sound understanding of the influences on sub-optimal practice. A perhaps more fruitful approach than one that focuses solely on CTG interpretation, more technology and/or solely on training, is to look more broadly at influences on safety. Such an approach would be consistent with the literature in patient safety that has advocated a systems approach to understanding and addressing the effects and interactions of real-world contexts such as teamwork, tasks, equipment, workspace, culture and organisation on clinical performance. It is also consistent with a well-established definition of safety as an attribute of health systems. This systematic scoping review aims to identify what is known in the published literature about such influences on patient safety in intrapartum electronic fetal heart rate monitoring with cardiotocography.This work is part of THIS Institute’s research programme and is funded by the Health Foundation’s grant for THIS Institute to the University of Cambridge. The Health Foundation is an independent charity committed to bringing about better health and health care for people in the UK. The Health Foundation have had no involvement in the development of this protocol

Understanding negative feedback from South Asian patients: an experimental vignette study.

OBJECTIVES: In many countries, minority ethnic groups report poorer care in patient surveys. This could be because they get worse care or because they respond differently to such surveys. We conducted an experiment to determine whether South Asian people in England rate simulated GP consultations the same or differently from White British people. If these groups rate consultations similarly when viewing identical simulated consultations, it would be more likely that the lower scores reported by minority ethnic groups in real surveys reflect real differences in quality of care. DESIGN: Experimental vignette study. Trained fieldworkers completed computer-assisted personal interviews during which participants rated 3 video recordings of simulated GP-patient consultations, using 5 communication items from the English GP Patient Survey. Consultations were shown in a random order, selected from a pool of 16. SETTING: Geographically confined areas of ∼130 households (output areas) in England, selected using proportional systematic sampling. PARTICIPANTS: 564 White British and 564 Pakistani adults recruited using an in-home face-to-face approach. MAIN OUTCOME MEASURE: Mean differences in communication score (on a scale of 0-100) between White British and Pakistani participants, estimated from linear regression. RESULTS: Pakistani participants, on average, scored consultations 9.8 points higher than White British participants (95% CI 8.0 to 11.7, p55) and where communication was scripted to be poor. CONCLUSIONS: Substantial differences in ratings were found between groups, with Pakistani respondents giving higher scores than White British respondents to videos showing the same care. Our findings suggest that the lower scores reported by Pakistani patients in national surveys represent genuinely worse experiences of communication compared to the White British majority.This work was funded by the National Institute for Health Research Programme Grants for Applied Research (NIHR PGfAR) Programme (RP-PG-0608-10050).

Modulation of the Proteostasis Network Promotes Tumor Resistance to Oncogenic KRAS Inhibitors

Despite substantial advances in targeting mutant KRAS, tumor resistance to KRAS inhibitors (KRASi) remains a major barrier to progress. Here, we report proteostasis reprogramming as a key convergence point of multiple KRASi-resistance mechanisms. Inactivation of oncogenic KRAS down-regulated both the heat shock response and the inositol-requiring enzyme 1α (IRE1α) branch of the unfolded protein response, causing severe proteostasis disturbances. However, IRE1α was selectively reactivated in an ER stress-independent manner in acquired KRASi-resistant tumors, restoring proteostasis. Oncogenic KRAS promoted IRE1α protein stability through extracellular signal-regulated kinase (ERK)-dependent phosphorylation of IRE1α, leading to IRE1α disassociation from 3-hydroxy-3-methylglutaryl reductase degradation (HRD1) E3-ligase. In KRASi-resistant tumors, both reactivated ERK and hyperactivated AKT restored IRE1α phosphorylation and stability. Suppression of IRE1α overcame resistance to KRASi. This study reveals a druggable mechanism that leads to proteostasis reprogramming and facilitates KRASi resistance

Frequency and Risk Indicators of Tooth Decay among Pregnant Women in France: A Cross-Sectional Analysis

INTRODUCTION: Little is known on the prevalence of tooth decay among pregnant women. Better knowledge of tooth decay risk indicators during pregnancy could help to develop follow-up protocols for women at risk, along with better prevention strategies. The aim of this study was to assess the frequency of tooth decay and the number of decayed teeth per woman in a large sample of pregnant women in France, and to study associated risk indicators. METHODS: A secondary cross-sectional analysis of data from a French multicentre case-control study was performed. The sample was composed of 1094 at-term women of six maternity units. A dental examination was carried out within 2 to 4 days post-partum. Socio-demographic and behavioural characteristics were obtained through a standardised interview with the women. Medical characteristics were obtained from the women's medical records. Risk indicators associated with tooth decay were identified using a negative binomial hurdle model. RESULTS: 51.6% of the women had tooth decay. The mean number of decayed teeth among women having at least one was 3.1 (s.d. = 2.8). Having tooth decay was statistically associated with lower age (aOR = 1.58, 95%CI [1.03,2.45]), lower educational level (aOR = 1.53, 95%CI [1.06,2.23]) and dental plaque (aOR = 1.75, 95%CI [1.27,2.41]). The number of decayed teeth was associated with the same risk indicators and with non-French nationality and inadequate prenatal care. DISCUSSION: The frequency of tooth decay and the number of decayed teeth among pregnant women were high. Oral health promotion programmes must continue to inform women and care providers about the importance of dental care before, during and after pregnancy. Future research should also assess the effectiveness of public policies related to oral health in target populations of pregnant women facing challenging social or economic situations

The Use of a Mobile Laboratory Unit in Support of Patient Management and Epidemiological Surveillance during the 2005 Marburg Outbreak in Angola

A mobile laboratory unit (MLU) was deployed to Uige, Angola as part of the World Health Organization response to an outbreak of viral hemorrhagic fever caused by Marburg virus (MARV). Utilizing mainly quantitative real-time PCR assays, this laboratory provided specific MARV diagnostics in the field. The MLU operated for 88 consecutive days allowing MARV-specific diagnostic response in <4 hours from sample receiving. Most cases were found among females in the child-bearing age and in children less than five years of age including a high number of paediatric cases implicating breastfeeding as potential transmission route. Oral swabs were identified as a useful alternative specimen source to the standard whole blood/serum specimens for patients refusing blood draw. There was a high concordance in test results between the MLU and the reference laboratory in Luanda operated by the US Centers for Disease Control and Prevention. The MLU was an important outbreak response asset providing valuable support in patient management and epidemiological surveillance. Field laboratory capacity should be expanded and made an essential part of any future outbreak investigation

Seven features of safety in maternity units: a framework based on multisite ethnography and stakeholder consultation

Background: Reducing avoidable harm in maternity services is a priority globally. As well as learning from mistakes, it is important to produce rigorous descriptions of ‘what good looks like’. Objective: We aimed to characterise features of safety in maternity units and to generate a plain language framework that could be used to guide learning and improvement. Methods: We conducted a multisite ethnography involving 401 hours of non-participant observations 33 semistructured interviews with staff across six maternity units, and a stakeholder consultation involving 65 semistructured telephone interviews and one focus group. Results: We identified seven features of safety in maternity units and summarised them into a framework, named For Us (For Unit Safety). The features include: (1) commitment to safety and improvement at all levels, with everyone involved; (2) technical competence, supported by formal training and informal learning; (3) teamwork, cooperation and positive working relationships; (4) constant reinforcing of safe, ethical and respectful behaviours; (5) multiple problem-sensing systems, used as basis of action; (6) systems and processes designed for safety, and regularly reviewed and optimised; (7) effective coordination and ability to mobilise quickly. These features appear to have a synergistic character, such that each feature is necessary but not sufficient on its own: the features operate in concert through multiple forms of feedback and amplification. Conclusions: This large qualitative study has enabled the generation of a new plain language framework—For Us—that identifies the behaviours and practices that appear to be features of safe care in hospital-based maternity units