Epilepsy service provision and re-design with a focus on primary care

This thesis reports four studies which have been designed to promote the greater involvement of primary care in the treatment of epilepsy. The primary aim is to study whether programs of high capacity, low interventional care for people with epilepsy are feasible and effective in primary care, within specific programs. The secondary aims explore the uptake and utility of such programs with preliminary examination on national trends in mortality and hospitalisation for people with epilepsy during the time of the study. 1.) The first study called the Primary Care Clinical Effectiveness program 2 [PRICCE-2] determined the extent to which primary care in East Kent was able to be produce an epilepsy register, ascertain the number of people who were seizure free and identify people at risk from retinal damage from vigabatrin. Also GPs were required to ensure that women were prescribed appropriate contraception and that pregnant women were offered folic acid. The program also studied trends in unplanned visits to hospital which occurred during the program. The PRICCE-2 project demonstrated GPs are willing to participate [89% of eligible practices in 2001] and could identify people who were seizure free [71.25% by the end of the program.] The identification of people on Vigabatrin was also successful identifying 21 people, [20 were expected,] but the ability to support women with epilepsy was less successful. The number of emergency admissions to the local three hospitals for epilepsy was seen to rise steadily, however diagnostic indexing was fairly poor at this stage. 2.) The second study called the Quality and Outcome Framework, determined the extent to which primary care was able to produce an epilepsy register, record seizure frequency, perform a basic epilepsy medication review and 4 determine people who were seizure free. Later on in the study, GPs were required to ensure that women were prescribed appropriate contraceptive medication and offered prenatal advice. The program also studied trends in mortality from epilepsy and trends in unplanned visits to hospital for epilepsy. The study revealed GPs were able to identify people with epilepsy [initially 86.8% rising to 99.8% by 2011], review their medication [95.3% in 2011] and identify people who were seizure free [73.9% in 2011] however they have found it harder to support women with epilepsy with high exception reporting used for this group [36.7% in 2011/12]. The unplanned hospital admissions steadily rose during this time, whilst the mortality for epilepsy began to decline [ R 2 = 0.6118] however whether this was a casual or causal link could not be determined. 3.) The third study determined if primary care could proactively identify social consequences of active epilepsy including the recording of driving status and social factors affected by epilepsy. It also identified and offered women with epilepsy folic acid, pre conception advice and ensured they were prescribed appropriate contraceptive. In addition it required GPs to identify people with epilepsy under hospital care. The study revealed that GPs were able to identify social consequences of epilepsy and identify people under hospital care but once again they found it difficult to support women with epilepsy related issues. The restructuring of PCTs at this time resulted in a loss of data. 4.) The final study determined the extent to which pharmacists can be trained to proactively support people with epilepsy in a Medicines Use Review [MUR] format. Pharmacists grasp of epilepsy before and after training and customer’s knowledge and readiness to approach their pharmacist for support were assessed before and after the consultation. In addition pharmacists were 5 taught how to recognise red flag symptoms and directly refer at risk patients to specialist epilepsy services. The pharmacists readily absorbed the epilepsy training and their customers reported benefit in improved knowledge about epilepsy and also indicated that in future they would seek support for epilepsy from their pharmacist. The direct referral process for epilepsy was not successful however and would need refining in the future. The overall aim to study whether high capacity, low interventional care for epilepsy is both feasible and effective has I believe, been demonstrated in these studies to be possible. Pro-active care for epilepsy is possible in general practice, with GPs being able to provide high capacity epilepsy care. The influence on admission rates and mortality for epilepsy is less clear and requires further study

Masculinity, racism, social support, and colorectal cancer screening uptake among African American men: A systematic review

Colorectal cancer (CRC) is highly preventable when CRC screening is utilized, yet CRC screening completion among African American men is relatively low and their mortality rates remain 50% higher juxtaposed to their White counterparts. Since a growing body of literature indicates masculinity, racism, and social support each have strong influences on CRC screening uptake, this systematic review examined the connections between these three sociocultural factors and CRC screening uptake among African American men. Potential studies were retrieved from MEDLINE, CINAHL, EMBASE, and PsycINFO. Cited reference searching for the final sample was employed to identify and assess additional studies for inclusion using Scopus. The methodological quality of the reviewed evidence was also evaluated. Nineteen studies met inclusion/exclusion criteria. Thirteen studies employed nonexperimental research designs; a quasi-experimental design was present in four, and two utilized experimental designs. Studies were published between 2000 and 2014; the majority between 2009 and 2013. Social support was most frequently addressed (84%) while masculinity and racism were equally studied with paucity (11%) for their influence on CRC screening. After evaluating conceptual and methodological characteristics of the studies, 42% fell below average in quality and rigor. The need for increased attention to the sociocultural correlates of CRC screening for African American men are highlighted in this systematic review, and important recommendations for research and practice are provided. Alongside a call for more rigorous research, further research examining the influence of masculinity and racism on CRC screening completion among African American men is warrante

Blurring the boundaries between synthesis and evaluation. A customized realist evaluative synthesis into adolescent risk behavior prevention

Realist methodologies have been increasingly advocated for the investigation of complex social issues. Public health programs, such as those designed to prevent adolescent risk behavior, are typically considered complex. In conducting a realist review of the empirical literature relating to such programs, we encountered several challenges, including (a) an overabundance of empirical evidence, (b) a problematic level of heterogeneity within and between methodological approaches, (c) discrepancies between theoretical underpinnings and program operationalization, (d) homogeneity of program outcomes, with very little variation in program effectiveness, and (d) a paucity of description relating to content and process. To overcome these challenges, we developed a customized approach to realist evidence synthesis, drawing on the VICTORE (Volition, Implementation, Contexts, Time, Outcomes, Rivalry, and Emergence) complexity checklist and incorporating stakeholder engagement as primary data to achieve greater depth of understanding relating to contextual and mechanistic factors, and the complex interactions between them. Here we discuss the benefits of this adapted methodology alongside an overview of the research through which the methodology was developed. A key finding from this research was that combining the complexity checklist with primary data from stakeholder engagement enabled us to systematically interrogate the data across data sources, uncovering and evidencing mechanisms which may otherwise have remained hidden, giving greater ontological depth to our research findings. This paper builds on key methodological developments in realist research, demonstrating how realist methodologies can be customized to overcome challenges in developing and refining program theory from the literature, and contributes to the broader literature of innovative approaches to realist research

Global data for ecology and epidemiology: a novel algorithm for temporal Fourier processing MODIS data

Background. Remotely-sensed environmental data from earth-orbiting satellites are increasingly used to model the distribution and abundance of both plant and animal species, especially those of economic or conservation importance. Time series of data from the MODerate-resolution Imaging Spectroradiometer (MODIS) sensors on-board NASA's Terra and Aqua satellites offer the potential to capture environmental thermal and vegetation seasonality, through temporal Fourier analysis, more accurately than was previously possible using the NOAA Advanced Very High Resolution Radiometer (AVHRR) sensor data. MODIS data are composited over 8- or 16-day time intervals that pose unique problems for temporal Fourier analysis. Applying standard techniques to MODIS data can introduce errors of up to 30% in the estimation of the amplitudes and phases of the Fourier harmonics. Methodology/Principal Findings. We present a novel spline-based algorithm that overcomes the processing problems of composited MODIS data. The algorithm is tested on artificial data generated using randomly selected values of both amplitudes and phases, and provides an accurate estimate of the input variables under all conditions. The algorithm was then applied to produce layers that capture the seasonality in MODIS data for the period from 2001 to 2005. Conclusions/Significance. Global temporal Fourier processed images of 1 km MODIS data for Middle Infrared Reflectance, day- and night-time Land Surface Temperature (LST), Normalised Difference Vegetation Index (NDVI), and Enhanced Vegetation Index (EVI) are presented for ecological and epidemiological applications. The finer spatial and temporal resolution, combined with the greater geolocational and spectral accuracy of the MODIS instruments, compared with previous multi-temporal data sets, mean that these data may be used with greater confidence in species' distribution modelling

Challenges in applying human factors approaches to health service design

A participatory systems approach is a fundamental characteristic of the human factors and ergonomics discipline. However, the appropriate application of relevant methods is challenging in healthcare, since there is very limited time for staff to participate and their knowledge on design methods is usually very limited. An action research was carried out in a health service design project commissioned by a local health service commissioner. The aim of this paper is to examine and discuss challenges in applying the participatory systems approach

Apropriate Ultrasonic System Components for NDE of Thick Polymer-Composites

In certain marine applications, thick polymer-composite materials may have to endure different operating environments than those experienced in traditional aerospace applications. In particular, structures made of such materials may experience very large compressive and bending forces. To prevent in-service failure, appropriate NDE methods and instrumentation are needed to characterize the state of the material. Specifically, in addition to detecting high-contrast anomalies (cracks and delaminations) it may be of interest to determine the pore content, measure the fiber volume, assess the severity of fiber waviness, and the like [1]

Are lower levels of red blood cell transfusion more cost-effective than liberal levels after cardiac surgery? Findings from the TITRe2 randomised controlled trial.

OBJECTIVE: To assess the incremental cost and cost-effectiveness of a restrictive versus a liberal red blood cell transfusion threshold after cardiac surgery. DESIGN: A within-trial cost-effectiveness analysis with a 3-month time horizon, based on a multicentre superiority randomised controlled trial from the perspective of the National Health Service (NHS) and personal social services in the UK. SETTING: 17 specialist cardiac surgery centres in UK NHS hospitals. PARTICIPANTS: 2003 patients aged >16 years undergoing non-emergency cardiac surgery with a postoperative haemoglobin of <9 g/dL. INTERVENTIONS: Restrictive (transfuse if haemoglobin <7.5 g/dL) or liberal (transfuse if haemoglobin <9 g/dL) threshold during hospitalisation after surgery. MAIN OUTCOME MEASURES: Health-related quality of life measured using the EQ-5D-3L to calculate quality-adjusted life years (QALYs). RESULTS: The total costs from surgery up to 3 months were £17 945 and £18 127 in the restrictive and liberal groups (mean difference is -£182, 95% CI -£1108 to £744). The cost difference was largely attributable to the difference in the cost of red blood cells. Mean QALYs to 3 months were 0.18 in both groups (restrictive minus liberal difference is 0.0004, 95% CI -0.0037 to 0.0045). The point estimate for the base-case cost-effectiveness analysis suggested that the restrictive group was slightly more effective and slightly less costly than the liberal group and, therefore, cost-effective. However, there is great uncertainty around these results partly due to the negligible differences in QALYs gained. CONCLUSIONS: We conclude that there is no clear difference in the cost-effectiveness of restrictive and liberal thresholds for red blood cell transfusion after cardiac surgery. TRIAL REGISTRATION NUMBER: ISRCTN70923932; Results

Masculinity, racism, social support, and colorectal cancer screening uptake among African American men: A systematic review

Colorectal cancer (CRC) is highly preventable when CRC screening is utilized, yet CRC screening completion among African American men is relatively low and their mortality rates remain 50% higher juxtaposed to their White counterparts. Since a growing body of literature indicates masculinity, racism, and social support each have strong influences on CRC screening uptake, this systematic review examined the connections between these three sociocultural factors and CRC screening uptake among African American men. Potential studies were retrieved from MEDLINE, CINAHL, EMBASE, and PsycINFO. Cited reference searching for the final sample was employed to identify and assess additional studies for inclusion using Scopus. The methodological quality of the reviewed evidence was also evaluated. Nineteen studies met inclusion/exclusion criteria. Thirteen studies employed nonexperimental research designs; a quasi-experimental design was present in four, and two utilized experimental designs. Studies were published between 2000 and 2014; the majority between 2009 and 2013. Social support was most frequently addressed (84%) while masculinity and racism were equally studied with paucity (11%) for their influence on CRC screening. After evaluating conceptual and methodological characteristics of the studies, 42% fell below average in quality and rigor. The need for increased attention to the sociocultural correlates of CRC screening for African American men are highlighted in this systematic review, and important recommendations for research and practice are provided. Alongside a call for more rigorous research, further research examining the influence of masculinity and racism on CRC screening completion among African American men is warrante

Factors Impacting Clinicians’ Adoption of a Clinical Photo Documentation App and its Implications for Clinical Workflows and Quality of Care: Qualitative Case Study

Background: Mobile health (mHealth) tools have shown promise in clinical photo and wound documentation for their potential to improve workflows, expand access to care, and improve the quality of patient care. However, some barriers to adoption persist. Objective: This study aims to understand the social, organizational, and technical factors affecting clinicians’ adoption of a clinical photo documentation mHealth app and its implications for clinical workflows and quality of care. Methods: A qualitative case study of a clinical photo and wound documentation app called imitoCam was conducted. The data were collected through 20 in-depth interviews with mHealth providers, clinicians, and medical informatics experts from 8 clinics and hospitals in Switzerland and Germany. Results: According to the study participants, the use of mHealth in clinical photo and wound documentation provides numerous benefits such as time-saving and efficacy, better patient safety and quality of care, enhanced data security and validation, and better accessibility. The clinical workflow may also improve when the app is a good fit, resulting in better collaboration and transparency, streamlined daily work, clinician empowerment, and improved quality of care. The findings included important factors that may contribute to or hinder adoption. Factors may be related to the material nature of the tool, such as the perceived usefulness, ease of use, interoperability, cost, or security of the app, or social aspects such as personal experience, attitudes, awareness, or culture. Organizational and policy barriers include the available clinical practice infrastructure, workload and resources, the complexity of decision making, training, and ambiguity or lack of regulations. User engagement in the development and implementation process is a vital contributor to the successful adoption of mHealth apps. Conclusions: The promising potential of mHealth in clinical photo and wound documentation is clear and may enhance clinical workflow and quality of care; however, the factors affecting adoption go beyond the technical features of the tool itself to embrace significant social and organizational elements. Technology providers, clinicians, and decision makers should work together to carefully address any barriers to improve adoption and harness the potential of these tools

PROTOCOL: What is the effect of intergenerational activities on the wellbeing and mental health of older people?

This is the protocol for a Campbell systematic review. The objectives are as follows: This systematic review will examine the impact of intergenerational interventions on the mental health and wellbeing of older people and will identify areas for future research as well as key messages for service commissioners