Family Coverage: Covering Parents Along With Their Children

Explores the high uninsured rate among parents compared to children, due to the lack of both employer-sponsored and public insurance options. Argues for expanding state Medicaid coverage to parents. Offers strategies for addressing costs and other issues

A computer template to enhance patient-centredness in multimorbidity reviews:a qualitative evaluation in primary care

BackgroundComputer templates for review of single long-term conditions are commonly used to record care processes, but they may inhibit communication and prevent patients from discussing their wider concerns.AimTo evaluate the effect on patient-centredness of a novel computer template used in multimorbidity reviews.Design and settingA qualitative process evaluation of a randomised controlled trial in 33 GP practices in England and Scotland examining the implementation of a patient-centred complex intervention intended to improve management of multimorbidity. A purpose-designed computer template combining long-term condition reviews was used to support the patient-centred intervention.MethodTwenty-eight reviews using the intervention computer template and nine usual-care reviews were observed and recorded. Sixteen patient interviews, four patient focus groups, and 23 clinician interviews were also conducted in eight of the 12 intervention practices. Transcripts were thematically analysed based on predefined core components of patient-centredness and template use.ResultsDisrupted communication was more evident in intervention reviews because the template was unfamiliar, but the first template question about patients’ important health issues successfully elicited wide-ranging health concerns. Patients welcomed the more holistic, comprehensive reviews, and some unmet healthcare needs were identified. Most clinicians valued identifying patients’ agendas, but some felt it diverted attention from care of long-term conditions. Goal-setting was GP-led rather than collaborative.ConclusionIncluding patient-centred questions in long-term condition review templates appears to improve patients’ perceptions about the patient-centredness of reviews, despite template demands on a clinician’s attention. Adding an initial question in standardised reviews about the patient’s main concerns should be considered.</jats:sec

Reporting and appraising the context, process and impact of PPI on contributors, researchers and the trial during a randomised controlled trial - the 3D study

Background Patient and public involvement (PPI) is believed to enhance health care delivery research, and is widely required in research proposals. Detailed, standardised reporting of PPI is needed so that strategies to implement more than token PPI that achieves impact can be identified, properly evaluated and reproduced. Impact includes effects on the research, PPI contributors and researchers. Using contributor and researcher perspectives and drawing on published guidelines for reporting PPI, we aimed to reflect on our experience and contribute evidence relevant to two important questions: ‘What difference does PPI make?’ and ‘What’s the best way to do it?’ Methods Fourteen people living with multiple long-term conditions (multimorbidity) were PPI contributors to a randomised controlled trial to improve care for people with multimorbidity. Meetings took place approximately four times a year throughout the trial, beginning at grant application stage. Meeting notes were recorded and a log of PPI involvement was kept. At the end of the trial, seven PPI contributors and four researchers completed free-text questionnaires about their experience of PPI involvement and their perception of PPI impact. The responses were analysed thematically by two PPI contributors and one researcher. The PPI group proposed writing this report, which was co-authored by three PPI contributors and two researchers. Results Meeting attendance averaged nine PPI contributors and three to four researchers. The involvement log and meeting notes recorded a wide range of activities and impact including changes to participant documentation, advice on qualitative data collection, contribution to data analysis and dissemination advice. Three themes were identified from the questionnaires: impact on the study, including keeping the research grounded in patient experience; impact on individuals, including learning from group diversity and feeling valued; and an environment that facilitated participation. The size of the group influenced impact. Researchers and PPI contributors described a rewarding interaction that benefitted them and the research. Conclusions PPI was wide-ranging and had impact on the trial, contributors and researchers. The group environment facilitated involvement. Feedback and group interactions benefitted individuals. The insights gained from this study will positively influence the researchers’ and contributors’ future involvement with PPI

Implementing State-Level Policy and Operational Processes That Enhance Access to Medicaid Family Planning Program Services

Medicaid provides a critical source of health care coverage for low-income individuals in the United States, including 13 million women of reproductive age. Medicaid is also the primary source of family planning coverage, accounting for 75% of public expenditures for family planning services in the United States. State Medicaid programs have a long-standing requirement to provide family planning services in the benefits package that is provided to people enrolled in full-scope coverage. In order to expand the number of people who can access family planning services, states have also taken the option to establish Medicaid family planning programs that cover a suite of family planning services for individuals not otherwise eligible for full-scope Medicaid.States have considerable flexibility in designing their Medicaid family planning programs. As a result, access to and utilization of Medicaid family planning programs are largely impacted by the policies and operational processes a state Medicaid program chooses to implement. The decisions a state makes related to its application process, consumer outreach, confidentiality policies, scope of covered benefits and provider network are all critical programmatic features that determine how easy or difficult it is for an individual to enroll in and receive services through Medicaid family planning programs.To promote access and utilization, this issue brief provides an array of best practice strategies in place across the nation to serve as an actionable road map for states that might be considering adopting such a program as well as states with existing programs looking to bolster participation and utilization rates. The strategies are derived from a review of national literature and policies and practices across the country and informed by an analysis of participation rates and utilization of services in 22 of the 30 states with programs in place

Can implementation failure or intervention failure explain the result of the 3D multimorbidity trial in general practice:mixed-methods process evaluation

Objectives During a cluster randomised trial, (the 3D study) of an intervention enacting recommended care for people with multimorbidity, including continuity of care and comprehensive biennial reviews, we examined implementation fidelity to interpret the trial outcome and inform future implementation decisions. Design Mixed-methods process evaluation using cross-trial data and a sample of practices, clinicians, administrators and patients. Interviews, focus groups and review observations were analysed thematically and integrated with quantitative data about implementation. Analysis was blind to trial outcomes and examined context, intervention adoption, reach and maintenance, and delivery of reviews to patients. Setting Thirty-three UK general practices in three areas. Participants The trial included 1546 people with multimorbidity. 11 general practitioners, 14 nurses, 7 administrators and 38 patients from 9 of 16 intervention practices were sampled for an interview. Results Staff loss, practice size and different administrative strategies influenced implementation fidelity. Practices with whole administrative team involvement and good alignment between the intervention and usual care generally implemented better. Fewer reviews than intended were delivered (49% of patients receiving both intended reviews, 30% partially reviewed). In completed reviews >90% of intended components were delivered, but review observations and interviews with patients and clinicians found variation in style of component delivery, from ‘tick-box’ to patient-centred approaches. Implementation barriers included inadequate skills training to implement patient-centred care planning, but patients reported increased patient-centredness due to comprehensive reviews, extra time and being asked about their health concerns. Conclusions Implementation failure contributed to lack of impact of the 3D intervention on the trial primary outcome (quality of life), but so did intervention failure since modifiable elements of intervention design were partially responsible. When a decisive distinction between implementation failure and intervention failure cannot be made, identifying potentially modifiable reasons for suboptimal implementation is important to enhance potential for impact and effectiveness of a redesigned intervention. Trial registration number ISRCTN0618095

Involving patients and families in a social robot study

Innovative research in care practice for older people can benefit from the active involvement of patient and family partners. Involvement may begin with identifying priorities, then move to formulate research questions and to plan the research methods, to data collection, and finally to analysis and knowledge dissemination. However, in the field of dementia care, actively engaging patients and families in co-research is a novel practice that needs exploration. This paper describes the experiences and perspectives of two patient researchers and three family researchers, along with four clinicians (two physicians, a nurse, and an occupational therapist) within a social robot project in dementia care. Meeting notes, team reflection focus groups, follow–up interviews, and a research journal were used to document the research process. The results are presented in three themes: (a) identify challenges and lessons learned, (b) co-inquire enriched learning, (c) co-produce knowledge for care improvement. All team members agreed that an inclusive environment was important to facilitate meaningful partnerships for undertaking research together. Trust and respect were seen as vital for a rewarding and productive experience in the co-inquiry journey. Some of the challenges to sustaining participant engagement were competing priorities and a risk of tokenism. This article provides a rich description as well as practical details of the research experiences among team members. We offer examples of lessons learned and practical tips to help others increase the engagement of patients and families in research. Experience Framework This article is associated with the Innovation & Technology lens of The Beryl Institute Experience Framework. (http://bit.ly/ExperienceFramework) Access other PXJ articles related to this lens. Access other resources related to this len

Management of multimorbidity using a patient-centred care model:a pragmatic cluster-randomised trial of the 3D approach

Background: The management of people with multiple chronic conditions challenges health-care systems designed around single conditions. There is international consensus that care for multimorbidity should be patient-centred, focus on quality of life, and promote self-management towards agreed goals. However, there is little evidence about the effectiveness of this approach. Our hypothesis was that the patient-centred, so-called 3D approach (based on dimensions of health, depression, and drugs) for patients with multimorbidity would improve their health-related quality of life, which is the ultimate aim of the 3D intervention. Methods: We did this pragmatic cluster-randomised trial in general practices in England and Scotland. Practices were randomly allocated to continue usual care (17 practices) or to provide 6-monthly comprehensive 3D reviews, incorporating patient-centred strategies that reflected international consensus on best care (16 practices). Randomisation was computer-generated, stratified by area, and minimised by practice deprivation and list size. Adults with three or more chronic conditions were recruited. The primary outcome was quality of life (assessed with EQ-5D-5L) after 15 months' follow-up. Participants were not masked to group assignment, but analysis of outcomes was blinded. We analysed the primary outcome in the intention-to-treat population, with missing data being multiply imputed. This trial is registered as an International Standard Randomised Controlled Trial, number ISRCTN06180958. Findings: Between May 20, 2015, and Dec 31, 2015, we recruited 1546 patients from 33 practices and randomly assigned them to receive the intervention (n=797) or usual care (n=749). In our intention-to-treat analysis, there was no difference between trial groups in the primary outcome of quality of life (adjusted difference in mean EQ-5D-5L 0·00, 95% CI −0·02 to 0·02; p=0·93). 78 patients died, and the deaths were not considered as related to the intervention. Interpretation: To our knowledge, this trial is the largest investigation of the international consensus about optimal management of multimorbidity. The 3D intervention did not improve patients' quality of life. Funding: National Institute for Health Research

The Benefits of and Barriers to Using Social Robot PARO in Care Settings: A Scoping Review

Background Given the complexity of providing dementia care in hospitals, integrating technology into practice is a high challenge and an important opportunity. Although there are a growing demand and interest in using social robots in a variety of care settings to support dementia care, little is known about the impacts of the robotics and their application in care settings, i.e., what worked, in which situations, and how. &nbsp; Methods Scientific databases and Google Scholar were searched to identify publications published since 2000. The inclusion criteria consisted of older people with dementia, care setting, and social robot PARO. &nbsp; Results A total of 29 papers were included in the review. Content analysis identified 3 key benefits of and 3 barriers to the use of PARO. Main benefits include: reducing negative emotion and behavioral symptoms, improving social engagement, and promoting positive mood and quality of care experience. Key barriers are: cost and workload, infection concerns, and stigma and ethical issues. This review reveals 3 research gaps: (a) the users’ needs and experiences remain unexplored, (b) few studies investigate the process of how to use the robot effectively to meet clinical needs, and (c) theory should be used to guide implementation. &nbsp; Conclusions Most interventions conducted have been primarily researcher-focused. Future research should pay more attention to the clinical needs of the patient population and develop strategies to overcome barriers to the adoption of PARO in order to maximize patient benefits

Is glycoprotein IIb/IIIa antagonism as effective in women as in men following percutaneous coronary intervention? Lessons from the ESPRIT study

AbstractObjectivesThe study was done to determine whether eptifibatide, a platelet glycoprotein (GP) IIb/IIIa antagonist, prevents ischemic complications following percutaneous coronary interventions (PCIs) in women as well as in men.BackgroundEptifibatide reduces ischemic complications after nonurgent coronary stent interventions.MethodsWe compared outcomes in women (n = 562) and men (n = 1,502) enrolled in the Enhanced Suppression of the Platelet GP IIb/IIIa Receptor with Integrilin Therapy (ESPRIT) trial of double-bolus eptifibatide during PCI.ResultsWomen in the ESPRIT trial were older, and more frequently had hypertension, diabetes mellitus, or acute coronary syndromes, but were less likely to have prior PCI or coronary artery bypass graft surgery. The primary end point, a composite at 48 h of death, myocardial infarction (MI), urgent target vessel revascularization (TVR), and unplanned GP IIb/IIIa use, occurred in 10.5% of women and 7.9% of men (p = 0.082). The composite of death, MI, or TVR after one year occurred in 24.5% of women compared with 18% of men (p = 0.0008). At 48 h, eptifibatide reduced the composite of death, MI, and TVR from 14.5% to 6.0% in women versus 9.0% to 6.8% in men. At one year, these differences persisted: 28.9% versus 20.0% for women and 19.5% versus 16.6% for men. No statistical interaction existed between treatment and gender at either 48 h (p = 0.063) or one year (p = 0.2). Bleeding occurred more commonly in women (5.5% vs. 2.6%, p = 0.002), and was more common in eptifibatide-treated women. After adjustment for age, weight, and hypertension, no interaction between treatment and gender was present.ConclusionsEptifibatide is effective to prevent ischemic complications of PCI in women and may eliminate gender-related differences in PCI outcomes