Medical student confidence to care for a dying patient and their family: a systematic review

Background: The General Medical Council expects medical graduates to care for dying patients with skill, clinical judgement and compassion. UK surveys continually demonstrate low confidence and increasing distress amongst junior doctors when providing care to the dying. Aim: This systematic review aims to determine what has been evidenced within worldwide literature regarding medical undergraduate confidence to care for dying patients. Design: A systematic electronic search was undertaken. Data extraction included measurements of baseline confidence, associated assessment tools, and details of applied educational interventions. Pre/post-intervention confidence comparisons were made. Factors influencing confidence levels were explored. The review was prospectively registered via PROSPERO (CRD42019119057). Data sources: MEDLINE, CINAHL, EMBASE, ISI Web of Science, ERIC, PsychINFO, British Education Index and Cochrane Review databases were accessed, with no restrictions on publication year. Eligible studies included the terms ‘medical student’, ‘confidence’, and ‘dying’, alongside appropriate MeSH headings. Study quality was assessed using the Mixed Methods Appraisal Tool. Results: Fifteen eligible studies were included, demonstrating a diversity of assessment tools. Student confidence was low in provision of symptom management, family support, and psycho-spiritual support to dying patients. Eight interventional studies demonstrated increased post-interventional confidence. Lack of undergraduate exposure to dying patients and lack of structure within undergraduate palliative care curricula were cited as factors responsible for low confidence. Conclusion: This review clarifies the objective documentation of medical undergraduate confidence to care for the dying. Identifying where teaching fails to prepare graduates for realities in clinical practice will help inform future undergraduate palliative care curriculum planning

Co-designing health services for people living with HIV who have multimorbidity:a feasibility study

This study explored the feasibility of using an experience-based co-design service improvement methodology to develop a new approach to managing multimorbidity in people living with HIV. Patients with HIV and multimorbidity and staff were recruited from five hospital departments and general practice. Staff and patient experiences were gathered through semi-structured interviews, filmed patient interviews, non-participant observation and patient diaries. A composite film developed from interviews illustrated the touchpoints in the patient journey, and priorities for service improvement were identified by staff and patients in focus groups. Twenty-two people living with HIV and 14 staff took part. Four patients completed a diary and 10 a filmed interview. Analysis identified eight touchpoints, and group work pinpointed three improvement priorities: medical records and information sharing; appointment management; and care co-ordination and streamlining. This study demonstrates that experience-based co-design is feasible in the context of HIV and can inform healthcare improvement for people with multimorbidity.</p

HIV testing in patients presenting with indicator conditions in outpatient settings: offer and uptake rates, and educational and active interventions

Approximately 13% of people living with HIV in the UK are undiagnosed which has significant implications in terms of onward transmission and late diagnosis. HIV testing guidelines recommend routine screening in anyone presenting to healthcare with an HIV indicator condition (IC); however, this does not occur routinely. This study aimed to assess the feasibility and effectiveness of using case note prompts highlighting the presence of an IC to increase HIV testing. Clinicians in three outpatient departments received case note prompts either before or after a period of clinician-led identification. Test offer and uptake rates were assessed. A parallel anonymous seroprevalence study estimated the prevalence of undiagnosed HIV. A total of 4191 patients had an appointment during the study period; 608 (14.5%) had an IC. HIV test offer was significantly higher when a prompt was inserted into notes (34.3% versus 3.2%, p < 0.001). The prevalence of diagnosed HIV in the cohort was 4.1%. No cases of undiagnosed HIV infection were identified. Despite guidelines, offer of HIV testing is low. Strategies to increase routine screening of patients presenting with an IC are needed. Individual case note prompts significantly increase HIV test offer; however, the effect is lost if the strategy is withdrawn

Barriers and facilitators to HIV testing in people age 50 and above: a systematic review

Background: Effective therapy means HIV-positive individuals can now experience near normal life expectancy. Despite these advances in treatment, about one in six people living with HIV in the UK are unaware of their infection. Although overall number of new HIV diagnoses have decreased, the number of people diagnosed aged 50 and over is increasing. It may be that there are unique factors associated with the decision to test in this group. This systematic review aims to identify patient and clinician related barriers and facilitators to HIV testing in people aged 50 and above. Methods: A systematic electronic search of MEDLINE, Embase, PsychINFO and CINAHL was conducted on 07/04/2016. Search terms included combinations of words describing HIV, old age, and testing. Papers were assessed for eligibility (published since 01/01/1997, describing barriers/facilitators to testing, research in people ≥50 years, written in English). Data from eligible studies were extracted (including study design, sample size and characteristics, analysis and reported barriers/facilitators to testing). Reported barriers/facilitators were grouped into themes and number of times each was reported was noted. Findings: Electronic searches identified 1752 articles, of which 14 primary studies met the inclusion criteria. A further 3 eligible papers were identified from reference and citation searching. Seventeen papers were included in the review. Most of the studies (n=14) were from the US. The main patient-barriers to non-test were low perceived risk and not being offered/encouraged to test by a healthcare professional (HCP) (reported 5 and 3 times respectively). The main clinician-barrier was preconceptions about older people and discomfort discussing sexuality and risk, reported 5 times. Main facilitators of test were being offered/encouraged to test by a HCP, previous interactions with healthcare services and high perceived risk (all reported >5 times). Interpretation: Clinicians’ beliefs that people ≥50 years are not at risk, or will feel uncomfortable discussing risk and sexuality, were among the most commonly cited barriers to test offer. However, being offered or encouraged to test by a healthcare professional was the most commonly cited facilitator to testing. This shows a divide between clinicians’ preconceptions and patient’s expectations, which may impact on testing rates

Understanding HIV-positive patients' preferences for healthcare services: a protocol for a discrete choice experiment

Introduction: While the care of HIV-positive patients, including the detection and management of comorbidities, has historically been provided in HIV specialist outpatient clinics, recent years have seen a greater involvement of non-HIV specialists and general practitioners (GPs). The aim of this study is to determine whether patients would prefer to see their GP or HIV physician given general symptoms, and to understand what aspects of care influence their preferences. Methods/analysis: We have developed and piloted a discrete choice experiment (DCE) to better understand patients’ preferences for care of non-HIV-related acute symptoms. The design of the DCE was informed by our exploratory research, including the findings of a systematic literature review and a qualitative study. Additional questionnaire items have been included to measure demographics, service use and experience of non HIV illnesses and quality of life (EQ5D). We plan to recruit 1000 patients from 14 HIV clinics across South East England. Data will be analysed using random-effects logistic regression and latent class analysis. ORs and 95% CIs will be used to estimate the relative importance of each of the attribute levels. Latent class analysis will identify whether particular groups of people value the service attribute levels differently. Ethics/dissemination: Ethical approval for this study was obtained from the Newcastle and North Tyneside Research Ethics Committee (reference number 14/NE/1193. The results will be disseminated at national and international conferences and peer-reviewed publications. A study report, written in plain English, will be made available to all participants. The Patient Advisory Group will develop a strategy for wider dissemination of the findings to patients and the public

Factors associated with offering HIV testing to people aged ≥50 years: a qualitative study

Background Individuals aged ≥ 50 years continue to be disproportionately affected by late HIV diagnosis, which is associated with poorer health outcomes and onward transmission. Despite HIV testing guidelines and high acceptability of HIV testing among all patients, clinicians are less likely to offer a test to an older individual. The aim of this study was to identify clinician-related factors associated with offering HIV testing to patients aged ≥ 50 years. Methods Twenty clinicians who had been involved in the care of an older patient diagnosed late with HIV were interviewed. Results Thematic analysis identified seven factors associated with offering HIV testing to older people: knowledge, stigma, stereotyping and perception of risk, symptom attribution, discussing HIV with patients, consent procedures and practical issues. Conclusions Although some factors are not unique to older patients, some are unique to this group. Many clinicians lack up-to-date HIV-related knowledge, feel anxious discussing HIV with older patients and perceive asexuality in older age. In order to increase the offer of HIV testing to this group, we identified clinician-related barriers to test offer that need to be addressed

Patients’ perspectives on the development of HIV services to accommodate ageing with HIV: a qualitative study

Objectives: To identify aspects of healthcare that are most valued by people with HIV; and to describe their concerns and preferences for the future delivery of services for non-HIV related illness amongst people living with HIV (PLWHIV). Methods: Twelve focus groups of people receiving HIV care were conducted in community settings in South-East England. Groups were quota sampled based on age, sex, sexual orientation, and ethnicity. Data were analysed using Framework Analysis. Results: Among the 74 respondents (61% male) a preference for maintaining all care within specialist HIV clinics was commonplace, but was highest among participants with more extensive histories of HIV and comorbidities. Participants valued care-coordination, inter-service communication, and timely updates to medical notes. There were high levels of concern around HIV skills in general practices and the capacity of general practitioners (GP) to manage patient confidentiality or deal appropriately with the emotional and social changes of living with HIV. Implications: Participants valued, and had an overall preference for, the specialist knowledge and skills of HIV services, suggesting that non-HIV-specialist services will need to build their appeal if they are to have a greater future role in the care of people with HIV. Particular concerns that should be addressed include: patient confidence in the HIV knowledge and skills of non-specialist service providers; clear processes for prescribing and referrals; improved levels of care-coordination and communication between services; increased patient confidence in the capacity of primary care to maintain confidentiality and to appreciate the stigma associated with HIV

An audit of HIV testing practice in people aged 50 years and over presenting with a known clinical indicator condition in secondary care

Objectives: To evaluate HIV testing of patients aged ≥50 years presenting to secondary care with clinical indicator conditions (CICs) for HIV. Methods: Retrospective audit of electronic records for patients aged ≥50 years discharged from hospital between January 1st and July 31st 2019 who had at least one documented CIC. Patient demographics and HIV testing data were collected from clinical systems (excluding sexual health databases). Results: 2478 patients with a CIC were identified. 222 (9.0%) received an HIV test within 31 days of discharge. Patients receiving a test were significantly younger (mean 68.6 versus 75.3 years; P < 0.001) and significantly more men underwent testing than women (60.4% versus 39.6%; P = 0.001). 32 CICs were identified across nine disease systems. By system, those with a haematological CIC were significantly more likely to undergo testing compared with all other CICs combined (P < 0.001). Of individual CICs, patients with Kaposi's sarcoma, hepatitis C, neutropenia, lymphadenopathy, pyrexia of unknown origin and thrombocytopenia (P < 0.001), and seborrhoeic dermatitis, hepatitis B, other unexplained blood dyscrasia, and non-Hodgkin's lymphoma (P < 0.05) were more likely to undergo testing than those presenting with other CICs. Patients with dementia and lung cancer were less likely to undergo testing (P < 0.001). Patients presenting with a greater number of CICs were significantly more likely to undergo testing (P = 0.002). Conclusions: HIV testing among patients aged ≥50 years presenting to secondary care with a CIC is low. Work is needed to improve HIV testing practice in this patient group

The effect of statins on falls and physical activity in people aged 65 and older: a systematic review

PURPOSE: Statins are commonly prescribed medications with recognised side effects including muscle weakness. Despite this, little is known about their effect on the physical activity and falls risk in the older population. This paper aims to explore the relationship between statin use and the physical activity and falls risk in adults aged 65 and older. METHODS: MEDLINE, Embase, CINAHL and PsycINFO were searched on 21/11/2022 to obtain relevant articles. Data considered appropriate included that relating to muscle strength, grip strength, gait speed, balance and falls incidence. Reference and citation searches were performed to identify further relevant papers, and all eligible articles were subject to a Critical Appraisal Skills Programme (CASP) to assess potential bias. With the data being highly heterogeneous, no attempt to measure effect size was made and a narrative synthesis approach was used. The review proposal was registered with PROSPERO: CRD42022366159. RESULTS: Twenty articles were included. Data were inconsistent throughout, with the overall trend suggesting no significant negative effects of statins on the parameters of physical activity, or on falls risk. This was especially true in matched and adjusted cohorts, where potential confounders had been accounted for. CONCLUSION: This review did not identify a relationship between statin use and physical activity and falls risk in people aged 65 years and older. Ultimately, the risks and benefits of every medication should be considered in the context of each individual.</p