Eliciting the Impact of Digital Consulting for Young People Living With Long-term Conditions (Lync Study): Cognitive Interviews to Assess the Face and Content Validity of Two Patient-Reported Outcome Measures

BACKGROUND: Digital consulting, using email, text, and Skype, is increasingly offered to young people accessing specialist care for long-term conditions. No patient-reported outcome measures (PROMs) have been evaluated for assessing outcomes of digital consulting. Systematic and scoping reviews, alongside patient involvement, revealed 2 candidate PROMs for this purpose: the patient activation measure (PAM) and the physician’s humanistic behaviors questionnaire (PHBQ). PAM measures knowledge, beliefs, and skills that enable people to manage their long-term conditions. PHBQ assesses the presence of behaviors that are important to patients in their physician-patient interactions. OBJECTIVE: This study aimed to assess the face and content validity of PAM and PHBQ to explore whether they elicit important outcomes of digital consulting and whether the PROMs can isolate the digital consultation component of care. METHODS: Participants were drawn from 5 clinics providing specialist National Health Service care to 16- to 24-year-olds with long-term health conditions participating in the wider LYNC (Long-Term Conditions, Young People, Networked Communications) study. Overall, 14 people undertook a cognitive interview in this substudy. Of these, 7 participants were young people with either inflammatory bowel disease, cystic fibrosis, or cancer. The remaining 7 participants were clinicians who were convenience sampled. These included a clinical psychologist, 2 nurses, 3 consultant physicians, and a community youth worker practicing in cancer, diabetes, cystic fibrosis, and liver disease. Cognitive interviews were transcribed and analyzed, and a spreadsheet recorded the participants’ PROM item appraisals. Illustrative quotes were extracted verbatim from the interviews for all participants. RESULTS: Young people found 11 of the PAM 13 items and 7 of the additional 8 PAM 22 items to be relevant to digital consulting. They were only able to provide spontaneous examples of digital consulting for 50% (11/22) of the items. Of the 7 clinicians, 4 appraised all PAM 13 items and 20 of the PAM 22 items to be relevant to evaluating digital consulting and articulated operationalization of the items with reference to their own digital consulting practice with greater ease than the young people. Appraising the PHBQ, in 14 of the 25 items, two-thirds of the young people’s appraisals offered digital consulting examples with ease, suggesting that young people can detect and discern humanistic clinician behaviors via digital as well as face-to-face communication channels. Moreover, 17 of the 25 items were appraised as relevant by the young people. This finding was mirrored in the clinician appraisals. Both young people and the clinicians found the research task complex. Young participants required considerably more researcher prompting to elicit examples related to digital consulting rather than their face-to-face care. CONCLUSIONS: PAM and PHBQ have satisfactory face and content validity for evaluating digital consulting to warrant proceeding to psychometric evaluation. Completion instructions require revision to differentiate between digital and face-to-face consultations

Timely digital patient-clinician communication in specialist clinical services for young people : a mixed-methods study (the LYNC study)

BACKGROUND: Young people (aged 16-24 years) with long-term health conditions can disengage from health services, resulting in poor health outcomes, but clinicians in the UK National Health Service (NHS) are using digital communication to try to improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, and ethical and safety issues. OBJECTIVE: Our objective was to understand how the use of digital communication between young people with long-term conditions and their NHS specialist clinicians changes engagement of the young people with their health care; and to identify costs and necessary safeguards. METHODS: We conducted mixed-methods case studies of 20 NHS specialist clinical teams from across England and Wales and their practice providing care for 13 different long-term physical or mental health conditions. We observed 79 clinical team members and interviewed 165 young people aged 16-24 years with a long-term health condition recruited via case study clinical teams, 173 clinical team members, and 16 information governance specialists from study NHS Trusts. We conducted a thematic analysis of how digital communication works, and analyzed ethics, safety and governance, and annual direct costs. RESULTS: Young people and their clinical teams variously used mobile phone calls, text messages, email, and voice over Internet protocol. Length of clinician use of digital communication varied from 1 to 13 years in 17 case studies, and was being considered in 3. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged, particularly at times of change for young people. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver, but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information, and communication failures, which are mostly mitigated by young people and clinicians using common-sense approaches. CONCLUSIONS: As NHS policy prompts more widespread use of digital communication to improve the health care experience, our findings suggest that benefit is most likely, and harms are mitigated, when digital communication is used with patients who already have a relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments, or lived context. Clinical teams need a proactive approach to ethics, governance, and patient safety

Extracting the domestic from indigenous Sicily

This paper assesses the advantages of the virtual reconstruction of archaeological structures, taking advantage of new, easily employed and readily available software. The paper reports the analysis of a Chalcolithic structure from upland Sicily. Architectural details were assembled from the study of the drystone ground-plan and analysis of daub impressions, followed by comparative study of broadly contemporary structures. It is emphasised that software can now be employed to analyse relatively simple archaeological evidence, much enhancing our knowledge of the reconstruction process. In a CD or web-based format, a wide range of alternative reconstructions can be presented for assessment by the reader.<br/

Enculturating environments: rock art and the archaeology of interior south-central California

The disarticulation of rock art from the archaeological record and its changing environment remains a primary obstacle facing many rock art researchers across the globe, but particularly in the American Far West, and California specifically (Robinson &amp; Sturt 2009). A schism, so to speak, exists between the archaeological record and rock art as well as 'dirt' archaeologists and rock art specialists. This is because, in California, and particularly in the rock art rich area of south-central California, rock art research has not focused on investigating archaeological deposits associated with rock art, but delved into ethnographic accounts gathered in colonial and post-colonial times and/or focused upon the images themselves. Equally most 'dirt' archaeology in the region has concentrated either on coastal plain or lacustrine areas, where rock art is scarce. The Enculturating Environments Project broadens the investigation of the rock art of the American Far West by undertaking a combined landscape and geoarchaeological approach to rock art with its associated archaeological and environmental record. Additionally, this project works within interior regions where scant archaeological research has occurred. In so doing, we are applying a suite of approaches to situate rock art within long term landscape change. Entering its fourth year, this is a sustained investigation of the prehistoric and historic enculturation of the environment of hunter-gatherers seen in rock art, land-use, material culture and social interaction

Doubts about how the Middle Horizon Collapsed on the South Coast of Peru (c. AD 1000), and other insights from the looted cemeteries of the Lower Ica Valley

This paper presents new information from funerary contexts in the lower Ica Valley, south coast of Peru, spanning two millennia from the end of the Early Horizon to the Late Intermediate Period. Although severely looted, these sites can still yield valuable information. We discuss their architecture and material culture in the context of radiocarbon dates. Among other findings, these cast new light on the poorly understood transition from the Middle Horizon to the Late Intermediate Period, for which a paucity of archaeological data from c.A.D. 1000 to 1250 has long been taken as evidence of an environmentally or socially-induced demographic collapse. Yet the data we present here suggests that the basins of the lower Ica Valley were likely occupied continuously over this period, and that the echoes of Wari influence here may have lasted longer than previously thought

Benefits and costs of digital consulting in clinics serving young people with long-term conditions: Mixed-methods approach

Background: Since the introduction of digital health technologies in National Health Service (NHS), health professionals are starting to use email, text, and other digital methods to consult with their patients in a timely manner. There is lack of evidence regarding the economic impact of digital consulting in the United Kingdom (UK) NHS. Objective: This study aimed to estimate the direct costs associated with digital consulting as an adjunct to routine care at 18 clinics serving young people aged 16-24 years with long-term conditions. Methods: This study uses both quantitative and qualitative approaches. Semistructured interviews were conducted with 173 clinical team members on the impacts of digital consulting. A structured questionnaire was developed and used for 115 health professionals across 12 health conditions at 18 sites in the United Kingdom to collect data on time and other resources used for digital consulting. A follow-up semistructured interview was conducted with a single senior clinician at each site to clarify the mechanisms through which digital consulting use might lead to outcomes relevant to economic evaluation. We used the two-part model to see the association between the time spent on digital consulting and the job role of staff, type of clinic, and the average length of the working hours using digital consulting. Results: When estimated using the two-part model, consultants spent less time on digital consulting compared with nurses (95.48 minutes; P&lt;.001), physiotherapists (55.3 minutes; P&lt;.001), and psychologists (31.67 minutes; P&lt;.001). Part-time staff spent less time using digital consulting than full-time staff despite insignificant result (P=.15). Time spent on digital consulting differed across sites, and no clear pattern in using digital consulting was found. Health professionals qualitatively identified the following 4 potential economic impacts for the NHS: decreasing adverse events, improving patient well-being, decreasing wait lists, and staff workload. We did not find evidence to suggest that the clinical condition was associated with digital consulting use. Conclusions: Nurses and physiotherapists were the greatest users of digital consulting. Teams appear to use an efficient triage system with the most expensive members digitally consulting less than lower-paid team members. Staff report showed concerns regarding time spent digitally consulting, which implies that direct costs increase. There remain considerable gaps in evidence related to cost-effectiveness of digital consulting, but this study has highlighted important cost-related outcomes for assessment in future cost-effectiveness trials of digital consulting

Timely Digital Patient-Clinician Communication in Specialist Clinical Services for Young People:A Mixed-Methods Study (The LYNC Study)

Background Young people (age 16-24 years) with long-term health conditions can disengage from health services resulting in poor health outcomes, but clinicians in the UK NHS are using digital communication to try and improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, ethical and safety issues. Objectives To understand how the use of digital communication between young people with long-term conditions and their UK NHS specialist clinicians changes engagement of the young people with their health care; to identify costs and necessary safeguards. Methods Mixed method case studies of 20 NHS specialist clinical teams from across England and Wales and their current practice providing care for 13 different long-term physical or mental health conditions. Observation of 79 clinical team members; interviews with 165 young people aged 16-24 years living with a long-term health condition recruited via case study clinical teams, 173 clinical team members, 16 Information Governance Specialists from study NHS Trusts. Analysis: thematic analysis of how digital communication works; ethics, safety and governance; annual direct costs. Results Young people and their clinical teams variously used: mobile phone calls, text messages, email, Voice over Internet Protocol. Length of clinician use of digital communication varied from one to 13 years in 17 case studies, and was being considered in three. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, which are mostly mitigated by young people and clinicians using common sense approaches. Conclusions Timely digital access to clinical teams is providing a flexible, personalised service for young people with long-term conditions. It engages young people with their health care including those who are otherwise hard to reach. As NHS policy prompts more widespread use of digital communication to improve health care experience, our findings suggest benefit is most likely, and harms mitigated, when used with patients where there is already an existing relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments or lived context. Clinical teams need a proactive approach to ethics, governance and patient safety

Local knowledge is required: a rhythmanalytical approach to the late Mesolithic and early Neolithic of the East Anglian Fenland, UK

This is a paper about blurring the boundaries between people, land and water in the past and of appreciating the importance of the wider environment in our accounts of prehistory. Maritime approaches to time/space are shown to offer new ways of looking at how people engage with the world around them. Informed by these approaches, and building on Lefebvre’s concepts of lived space and rhythm, current tensions within archaeology between cartesian and phenomenological approaches to the past will be shown to be unconstructive. These issues are all addressed in relation the late Mesolithic and early Neolithic of the East Anglian Fenland. Here a rhythmical, maritime approach will be shown to offer us a subtly different view of life during this period

The role of digital communication in patient-clinician communication for NHS providers of specialist clinical services for young people [the Long-term conditions Young people Networked Communication (LYNC) study]: a mixed-methods study

Background Young people (age 16-25 years) with long term health conditions tend to disengage from health services resulting in poor health outcomes. They are prolific users of digital communications. Innovative UK National Health Service (NHS) clinicians use digital communication with these young people. The NHS plans to use digital communication with patients more widely. Objectives To explore how health care engagement can be improved using digital clinical communication; understand effects, impacts, costs and necessary safeguards; provide critical analysis of its use, monitoring and evaluation. Design Observational mixed methods case studies; systematic scoping literature reviews; assessment of patient reported outcome measures; public and patient involvement (PPI); consensus development through focus groups. Setting Twenty NHS specialist clinical teams from across England and Wales, providing care for 13 different long term physical or mental health conditions. Participants 165 young people aged 16-25 years living with a long term health condition; 13 parents; 173 clinical team members; 16 Information Governance Specialists. Interventions Clinical teams and young people variously used: mobile phone calls, text messages, email, Voice over Internet Protocol. Main outcome measures Empirical work: thematic and ethical analysis of qualitative data; annual direct costs; Did Not Attend, Accident and Emergency Attendance and Hospital Admissions rates plus clinic specific clinical outcomes. Scoping reviews: patient, health professional and service delivery outcomes and technical problems. Patient reported outcome measures: scale validity, relevance and credibility. Data sources Observation, interview, structured survey, routinely collected data, focus groups, peer reviewed publications. Results Digital communication enables access for young people to the right clinician when it makes a difference for managing their health condition. This is valued as additional to traditional clinic appointments. This access challenges the nature and boundaries of therapeutic relationships but can improve them, increase patient empowerment and enhance activation. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, but clinicians and young people mitigate these risks. Workload increases, and staff time is the main cost. Clinical teams had not evaluated impact of their intervention, and analysis of routinely collected data did not identify any impact. There are no currently used generic outcome measures but the Patient Activation Measure and the Physician Humanistic Behaviour Questionnaire are promising. Scoping reviews suggest digital clinical communication is acceptable to young people but with no clear evidence of benefit except for mental health. Limitations Qualitative data was mostly from clinician enthusiasts. No interviews were achieved with young people who do not attend clinics. Clinicians struggled to estimate workload. Only eight full sets of routine data were available. Conclusions Timely digital clinical communication is perceived as making a difference to health care and health outcome for young people with long term conditions but this is not supported by evidence that measures health outcome. Such communication is challenging and costly to provide but valued by young people. Future work Future development should distinguish digital communication replacing traditional clinic appointments and additional timely communication. Evaluation is needed that uses relevant generic outcomes

The role of digital communication in patient-clinician communication for NHS providers of specialist clinical services for young people [the Long-term conditions Young people Networked Communication (LYNC) study]: a mixed-methods study

Background Young people (age 16-25 years) with long term health conditions tend to disengage from health services resulting in poor health outcomes. They are prolific users of digital communications. Innovative UK National Health Service (NHS) clinicians use digital communication with these young people. The NHS plans to use digital communication with patients more widely. Objectives To explore how health care engagement can be improved using digital clinical communication; understand effects, impacts, costs and necessary safeguards; provide critical analysis of its use, monitoring and evaluation. Design Observational mixed methods case studies; systematic scoping literature reviews; assessment of patient reported outcome measures; public and patient involvement (PPI); consensus development through focus groups. Setting Twenty NHS specialist clinical teams from across England and Wales, providing care for 13 different long term physical or mental health conditions. Participants 165 young people aged 16-25 years living with a long term health condition; 13 parents; 173 clinical team members; 16 Information Governance Specialists. Interventions Clinical teams and young people variously used: mobile phone calls, text messages, email, Voice over Internet Protocol. Main outcome measures Empirical work: thematic and ethical analysis of qualitative data; annual direct costs; Did Not Attend, Accident and Emergency Attendance and Hospital Admissions rates plus clinic specific clinical outcomes. Scoping reviews: patient, health professional and service delivery outcomes and technical problems. Patient reported outcome measures: scale validity, relevance and credibility. Data sources Observation, interview, structured survey, routinely collected data, focus groups, peer reviewed publications. Results Digital communication enables access for young people to the right clinician when it makes a difference for managing their health condition. This is valued as additional to traditional clinic appointments. This access challenges the nature and boundaries of therapeutic relationships but can improve them, increase patient empowerment and enhance activation. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, but clinicians and young people mitigate these risks. Workload increases, and staff time is the main cost. Clinical teams had not evaluated impact of their intervention, and analysis of routinely collected data did not identify any impact. There are no currently used generic outcome measures but the Patient Activation Measure and the Physician Humanistic Behaviour Questionnaire are promising. Scoping reviews suggest digital clinical communication is acceptable to young people but with no clear evidence of benefit except for mental health. Limitations Qualitative data was mostly from clinician enthusiasts. No interviews were achieved with young people who do not attend clinics. Clinicians struggled to estimate workload. Only eight full sets of routine data were available. Conclusions Timely digital clinical communication is perceived as making a difference to health care and health outcome for young people with long term conditions but this is not supported by evidence that measures health outcome. Such communication is challenging and costly to provide but valued by young people. Future work Future development should distinguish digital communication replacing traditional clinic appointments and additional timely communication. Evaluation is needed that uses relevant generic outcomes