Weight loss interventions for overweight and obese patients in primary care: A literature review.

Primary care is the ideal place to tackle the obesity crisis. This literature review looks at which interventions are suitable for use in general practice. Objective: To identify which weight loss interventions are best delivered through primary care to achieve beneficial outcomes for patients and practitioners. Methods: A literature search was conducted using online databases: Academic Search Complete, CINAHL complete, Internurse, Medline Complete, PubMed, Trip, Psych-Info and Web of Science. The search was limited to peer reviewed, English-language articles published between 2007–2017. Findings: Three core themes emerged from the literature: recruitment of participants, attrition rates and the effects of intervention. The intervention that used a commercial provider yielded the highest percentage (60%) of patients who lost a clinically significant 5% body weight. Mean attrition rates between studies were below 30% average at 23.87%, and men were underrepresented in recruitment. Conclusion: Commercial providers can assist primary care with the burden related to obesity. In addition, training is required to support and encourage primary care practitioners to manage weight-related interactions with their patients. Male under-representation could be decreased by forming male-specific services and further research into mechanisms behind attrition, such as motivation, is recommended

Combining Microdialysis and Near-Infrared Spectroscopy for Studying Effects of Low-Load Repetitive Work on the Intramuscular Chemistry in Trapezius Myalgia

Epidemiological research provides strong evidence for a link between repetitive work (RW) and the development of chronic trapezius myalgia (TM). The aims were to further elucidate if an accumulation of sensitising substances or impaired oxygenation is evident in painful muscles during RW. Females with TM (n = 14) were studied during rest, 30 minutes RW and 60 minutes recovery. Microdialysate samples were obtained to determine changes in intramuscular microdialysate (IMMD) [glutamate], [PGE2], [lactate], and [pyruvate] (i.e., [concentration]) relative to work. Muscle oxygenation (%StO2) was assessed using near-infrared spectroscopy. During work, all investigated substances, except PGE2, increased significantly: [glutamate] (54%, P < .0001), [lactate] (26%, P < .005), [pyruvate] (19%, P < .0001), while the %StO2 decreased (P < .05). During recovery [PGE2] decreased (P < .005), [lactate] remained increased (P < .001), [pyruvate] increased progressively (P < .0001), and %StO2 had returned to baseline. Changes in substance concentrations and oxygenation in response to work indicate normal increase in metabolism but no ongoing inflammation in subjects with TM

The SUMAMOS EXCELENCIA Project

Aim: The gap between research and clinical practice leads to inconsistent decision‐making and clinical audits are an effective way of improving the implementation of best practice. Our aim is to assess the effectiveness of a model that implements evidence‐based recommendations for patient outcomes and healthcare quality. Design: National quasi‐experimental, multicentre, before and after study. Methods: This study focuses on patients attending primary care and hospital care units and associated socio‐healthcare services. It uses the Joanna Brigg's Institute Getting Research into Practice model, which improves processes by referring to prior baseline clinical audits. The variables are process and outcome criteria for pain, urinary incontinence, and fall prevention, with data collection at baseline and key points over 12 months drawn from clinical histories and records. Project funding was received from the Spanish Strategic Health Action in November 2014. Discussion: The project results will provide knowledge on the effectiveness of the Getting Research into Practice model, to apply evidence‐based recommendations for the detection and management of pain, urinary incontinence, and fall prevention. It will also establish whether using research results, based on clinical audits and situation analysis, is effective for implementing evidence‐based recommendations and improving patients’ health. Impact: This nationwide Spanish project aims to detect and prevent high‐prevalence healthcare problems, namely pain in patients at any age and falls and urinary incontinence in people aged 65 and over. Tailoring clinical practice to evidence‐based recommendations will reduce unjustified clinical variations in providing healthcare services. Clinical Trial ID: NCT03725774.This project is funded by the Ministry of Economic Affairs and Competitiveness/Strategic Health Action 2014 (PI14CIII/00044)

Reducing avoidable deaths from failure to rescue: a discussion paper.

AIM: This article proposes a radical new approach to the monitoring and governance of services, and the education and training of nurses to meet 'failure to rescue' requirements. BACKGROUND: Healthcare policy in the UK that seeks to ensure safe and effective services for the acutely ill has largely failed, resulting in adult patients dying unnecessarily. Despite grand rhetoric, UK governments have distanced themselves from implementation, resulting in patchy localised developments and creating inconsistent service responses. DESIGN AND DATA SOURCES: This article draws on a review of research and UK policy literature and best international practice to propose a new national framework approach that combines competency development, governance and performance monitoring to address 'failure to rescue' shortcomings. IMPLICATIONS FOR NURSING: Paramount is a nationally agreed and fit-for-purpose competency tool using simulation to assess staff in order to improve recognition of the deteriorating patient. Service improvements should include increased investment in telemedicine; service performance should be communicated through publicly available ratings and overseen by patient panels; and governance will require strengthening through enhanced Care Quality Commission/Monitor input, which should be linked to the maintenance of foundation trust status. CONCLUSION: Health professional bodies, regulators, providers and the Government must work together to strengthen the safety and effectiveness of acute services. This will require investment in staff competency and enhancement of the governance to ensure services consistently meet public expectations and reduce unnecessary deaths

What works and why in the identification and referral of adults with comorbid obesity in primary care: a realist review

Primary care practitioners (PCPs) are well placed to identify individuals with obesity and weight‐related comorbidities and to refer them to weight management services (WMS), but this does not often happen in practice. In this realist review, we searched six databases for intervention studies targeted at PCPs to improve the identification and referral of adults with comorbid obesity. Realist analysis was used to identify context‐mechanism‐outcome (CMO) configurations across 30 included papers (reporting on 27 studies). Most studies used multiple intervention strategies, categorised into: (a) training, (b) tools to improve identification, (c) tools to improve ease of referral, (d) audit/feedback, (e) working in networks/quality circles, and (f) other. The realist synthesis identified 12 mechanisms through which interventions work to improve identification and referral, including increasing knowledge about obesity and awareness of and confidence in WMS among practitioners, improved communication and trust between practitioners and WMS, and higher priority given to weight management among primary care teams. The theory of “candidacy” (a person's eligibility for medical attention and intervention) provided a robust explanatory framework but required refinement: (a) to take account of the different services (primary care and weight management) that patients must navigate to access support; and (b) to acknowledge the importance of wider contextual factors

Unintended Consequences of Incentive Provision for Behaviour Change and Maintenance around Childbirth

Financial (positive or negative) and non-financial incentives or rewards are increasingly used in attempts to influence health behaviours. While unintended consequences of incentive provision are discussed in the literature, evidence syntheses did not identify any primary research with the aim of investigating unintended consequences of incentive interventions for lifestyle behaviour change. Our objective was to investigate perceived positive and negative unintended consequences of incentive provision for a shortlist of seven promising incentive strategies for smoking cessation in pregnancy and breastfeeding. A multi-disciplinary, mixed-methods approach included involving two service-user mother and baby groups from disadvantaged areas with experience of the target behaviours as study co-investigators. Systematic reviews informed the shortlist of incentive strategies. Qualitative semi-structured interviews and a web-based survey of health professionals asked open questions on positive and negative consequences of incentives. The participants from three UK regions were a diverse sample with and without direct experience of incentive interventions: 88 pregnant women/recent mothers/partners/family members; 53 service providers; 24 experts/decision makers and interactive discussions with 63 conference attendees. Maternity and early years health professionals (n = 497) including doctors, midwives, health visitors, public health and related staff participated in the survey. Qualitative analysis identified ethical, political, cultural, social and psychological implications of incentive delivery at population and individual levels. Four key themes emerged: how incentives can address or create inequalities; enhance or diminish intrinsic motivation and wellbeing; have a positive or negative effect on relationships with others within personal networks or health providers; and can impact on health systems and resources by raising awareness and directing service delivery, but may be detrimental to other health care areas. Financial incentives are controversial and generated emotive and oppositional responses. The planning, design and delivery of future incentive interventions should evaluate unexpected consequences to inform the evidence for effectiveness, cost-effectiveness and future implementation

SERIES: eHealth in primary care. Part 1: Concepts, conditions and challenges.

Primary care is challenged to provide high quality, accessible and affordable care for an increasingly ageing, complex, and multimorbid population. To counter these challenges, primary care professionals need to take up new and innovative practices, including eHealth. eHealth applications hold the promise to overcome some difficulties encountered in the care of people with complex medical and social needs in primary care. However, many unanswered questions regarding (cost) effectiveness, integration with healthcare, and acceptability to patients, caregivers, and professionals remain to be elucidated. What conditions need to be met? What challenges need to be overcome? What downsides must be dealt with? This first paper in a series on eHealth in primary care introduces basic concepts and examines opportunities for the uptake of eHealth in primary care. We illustrate that although the potential of eHealth in primary care is high, several conditions need to be met to ensure that safe and high-quality eHealth is developed for and implemented in primary care. eHealth research needs to be optimized; ensuring evidence-based eHealth is available. Blended care, i.e. combining face-to-face care with remote options, personalized to the individual patient should be considered. Stakeholders need to be involved in the development and implementation of eHealth via co-creation processes, and design should be mindful of vulnerable groups and eHealth illiteracy. Furthermore, a global perspective on eHealth should be adopted, and eHealth ethics, patients' safety and privacy considered.Published versio