PACE: Program of All-inclusive Care for the Elderly

Educational Objectives 1. Describe the Program of Allinclusive Care for the Elderly model of care for frail seniors with chronic health care needs. 2. Demonstrate how PACE benefits providers in the delivery of services. 3. Explain how the PACE concept complements Virginia’s Long Term Care Reform, as well as initiatives to develop further the PACE program in Virginia

Prison(er) auto/biography, 'true crime', and teaching, learning, and research in criminology

The main aim of this essay is to explore prisoner life writing within the specific, richly and multiply dependent context of teaching and learning undergraduate criminology at an English university, from the authorial viewpoint of a teacher and her students as budding criminologists and co-authors. This article seeks to redress a continuing resistance to life history approaches in the teaching of criminology, despite the discipline being formally devoted to the understanding of the meaning and experience of imprisonment in all its forms and consequences. What follows is a trucated narrative of what students had to say on the fascinating subjects of prisoner auto/biography and its place in popular and expert discourses on crime, criminality, and punishment, contextualised within the academic discipline of criminology

What happens after an NHS Health Check? A survey and realist review

Background: The National Health Service Health Check in England aims to provide adults aged 40 to 74 with an assessment of their risk of developing cardiovascular disease and to offer advice to help manage and reduce this risk. The programme is commissioned by local authorities and delivered by a range of providers in different settings, although primarily in general practices. This project focused on variation in the advice, onward referrals and prescriptions offered to attendees following their health check. Objectives: (1) Map recent programme delivery across England via a survey of local authorities; (2) conduct a realist review to enable understanding of how the National Health Service Health Check programme works in different settings, for different groups; (3) provide recommendations to improve delivery. Design: Survey of local authorities and realist review of the literature. Review methods: Realist review is a theory-driven, interpretive approach to evidence synthesis that seeks to explain why, when and for whom outcomes occur. We gathered published research and grey literature (including local evaluation documents and conference materials) via searching and supplementary methods. Extracted data were synthesised using a realist logic of analysis to develop an understanding of important contexts that affect the delivery of National Health Service Health Checks, and underlying mechanisms that produce outcomes related to our project focus. Results: Our findings highlight the variation in National Health Service Health Check delivery models across England. Commissioners, providers and attendees understand the programme’s purpose in different ways. When understood primarily as an opportunity to screen for disease, responsibility for delivery and outcomes rests with primary care, and there is an emphasis on volume of checks delivered, gathering essential data and communicating risk. When understood as an opportunity to prompt and support behaviour change, more emphasis is placed on delivery of advice and referrals to ‘lifestyle services’. Practical constraints limit what can be delivered within the programme’s remit. Public health funding restricts delivery options and links with onward services, while providers may struggle to deliver effective checks when faced with competing priorities. Attendees’ responses to the programme are affected by features of delivery models and the constraints they face within their own lives. Limitations: Survey response rate lower than anticipated; review findings limited by the availability and quality of the literature. Conclusions and implications: The purpose and remit of the National Health Service Health Check programme should be clarified, considering prevailing attitudes about its value (especially among providers) and what can be delivered within existing resources. Some variation in delivery is likely to be appropriate to meet local population needs, but lack of clarity for the programme contributes to a ‘postcode lottery’ effect in the support offered to attendees after a check. Our findings raise important questions about whether the programme itself and services that it may feed into are adequately resourced to achieve positive outcomes for attendees, and whether current delivery models may produce inequitable outcomes. Future work: Policy-makers and commissioners should consider the implications of the findings of this project; future research should address the relative scarcity of studies focused on the end of the National Health Service Health Check pathway. Study registration: PROSPERO registration CRD42020163822. Funding: This project was funded by the National Institute for Health and Care Research (NIHR) Health Services and Delivery Research programme (NIHR129209)

Analysis of English general practice level data linking medication levels, service activity and demography to levels of glycaemic control being achieved in type 2 diabetes to improve clinical practice and patient outcomes.

OBJECTIVE: Evaluate relative clinical effectiveness of treatment options for type 2 diabetes mellitus (T2DM) using a statistical model of real-world evidence within UK general practitioner practices (GPP), to quantify the opportunities for diabetes care performance improvement. METHOD: From the National Diabetes Audit in 2015-2016 and 2016-2017, GPP target glycaemic control (TGC-%HbA1c ≤58 mmol/mol) and higher glycaemic risk (HGR -%HbA1c results >86 mmol/mol) outcomes were linked using multivariate linear regression to prescribing, demographics and practice service indicators. This was carried out both cross-sectionally (XS) (within year) and longitudinally (Lo) (across years) on 35 indicators. Standardised β coefficients were used to show relative level of impact of each factor. Improvement opportunity was calculated as impact on TGC & HGR numbers. RESULTS: Values from 6525 GPP with 2.7 million T2DM individuals were included. The cross-sectional model accounted for up to 28% TGC variance and 35% HGR variance, and the longitudinal model accounted for up to 9% TGC and 17% HGR variance. Practice service indicators including % achieving routine checks/blood pressure/cholesterol control targets were positively correlated, while demographic indicators including % younger age/social deprivation/white ethnicity were negatively correlated. The β values for selected molecules are shown as (increased TGC; decreased HGR), canagliflozin (XS 0.07;0.145/Lo 0.04;0.07), metformin (XS 0.12;0.04/Lo -;-), sitagliptin (XS 0.06;0.02/Lo 0.10;0.06), empagliflozin (XS-;0.07/Lo 0.09;0.07), dapagliflozin (XS -;0.04/Lo -;0.4), sulphonylurea (XS -0.18;-0.12/Lo-;-) and insulin (XS-0.14;0.02/ Lo-0.09;-). Moving all GPP prescribing and interventions to the equivalent of the top performing decile of GPP could result in total patients in TGC increasing from 1.90 million to 2.14 million, and total HGR falling from 191 000 to 123 000. CONCLUSIONS: GPP using more legacy therapies such as sulphonylurea/insulin demonstrate poorer outcomes, while those applying holistic patient management/use of newer molecules demonstrate improved glycaemic outcomes. If all GPP moved service levels/prescribing to those of the top decile, both TGC/HGR could be substantially improved

Clinical management of nausea and vomiting in pregnancy and hyperemesis gravidarum across primary and secondary care: a population based study

Objectives: To assess how nausea and vomiting in pregnancy (NVP) and hyperemesis gravidarum (HG) are managed and treated across primary and secondary care.Design: Population-based pregnancy cohortSetting: Medical records (CPRD-GOLD) from EnglandPopulation: 417,028 pregnancies, during 1998-2014 Methods: Proportions of pregnancies with recorded NVP/HG diagnoses, primary care treatment and hospital admissions were calculated. Multinomial logistic regression was employed to estimate adjusted relative risk ratios (aRRRs) with 99% confidence intervals (CIs) for the association between NVP/HG management paths and maternal characteristics.Main Outcome Measures: NVP/HG diagnoses, treatments and hospital admissions. Results: Overall prevalence of clinically recorded NVP/HG was 9.1%: 2.1% had hospital admissions, 3.4% were treated with antiemetics in primary care only, and 3.6% had only recorded diagnoses. Hospital admissions and antiemetic prescribing increased continuously during 1998-2013 (trend p less than 0.001). Younger age, deprivation, Black/Asian/Mixed ethnicity, multiple-pregnancy were associated with NVP/HG generally across all levels, but associations were strongest for hospital admissions. Most comorbidities had patterns of association with NVP/HG levels. Among women with NVP/HG who had no hospital admissions, 49% were prescribed antiemetics, mainly from first line treatment (21% prochlorperazine, 15% promethazine, 13% cyclizine) and metoclopramide (10%). Of those admitted, 38% had prior antiemetic prescriptions (34% first-line, 9% second-line, 1% third-line treatment).Conclusion: Previous focus on hospital admissions has greatly underestimated the NVP/HG burden. Although primary care prescribing has increased, most women admitted to hospital have no antiemetics prescribed before this. An urgent call is made to assess whether admissions could be prevented with better primary care recognition and timely treatment

A critical systems evaluation of the introduction of a ‘discharge to assess’ service in Kent

Discharge to Assess (D2A) models of care have been developed to expedite the process of discharging hospital patients as soon as they are medically fit to leave, thereby improving the efficiency and effectiveness of the healthcare system. This article focuses on the implementation of a D2A model in Kent, England, which formed a case study for a European research programme of improvements in integrated care for older people. It uses the Critical Systems Heuristics framework to examine the implementation process and focuses in particular on why this improvement project proved to be so difficult to implement and why the anticipated outcomes were so elusive. The analysis highlights the value in using critical systems thinking to better evaluate integrated care initiatives, in particular by identifying more explicitly different stakeholder perspectives and power relationships within the system and its decision environment

Discordance between physical symptoms versus perception of severity by women with nausea and vomiting in pregnancy (NVP)

BACKGROUND: Nausea and vomiting in pregnancy (NVP) is a multifaceted condition that affects more than half of pregnant women and can range in severity from mild nausea to severe dehydration. Presently physicians evaluate mostly physical symptoms of NVP in trying to assess the severity of the condition. The objective of this study was to investigate how factors, other than the physical morbidity of nausea and vomiting, influence self-perception of NVP by affected women. METHODS: Five hundred women with NVP calling a 1–800 NVP Healthline were asked to rate their NVP severity and report their nausea duration and number of vomiting/retching episodes. RESULTS: Nausea and vomiting/retching correlated significantly but very poorly with self-assessment of NVP severity. There was also a correlation between nausea duration and vomiting/retching frequency however the correlations were weak and overall physical symptoms could only explain 14% of the variability of women's feelings and perceptions through multivariate analysis. CONCLUSIONS: Physical symptoms weakly correlate with self-assessment of NVP severity. Other aspects of this condition, most probably psychosocial, influence women's perception of NVP severity

Religious Vehicle Stickers in Nigeria: a discourse of identity, faith and social vision

This study focuses on analysing the ways in which vehicle stickers construct individual and group identities, people’s religious faith and social vision in the context of religious assumptions and practices in Nigeria. Data comprise 73 vehicle stickers collected in Lagos and Ota, between 2006 and 2007 and are analysed within the framework of the post-structuralist model of discourse analysis which views discourse as a product of a complex system of social and institutional practices that sustain its continuous existence (Derrida, 1982; Fairclough, 1989, 1992, 1995; Foucault, 1972, 1981). Results show that through stickers people define their individual and group identities within religious institutional practices. And as a means of group identification, they guarantee social security and privileges. In constructing social vision the stickers help mould the individual aspiration about a future which transcends the present. Significantly, stickers in the data also reveal the tension between Islam and Christianity and the struggle to propagate one above the other. KEY WORDS: assumption, discourse, discursive, practices, religion, stickers

Comparison of engagement and emotional responses of older and younger adults interacting with 3D cultural heritage artefacts on personal devices

The availability of advanced software and less expensive hardware allows museums to preserve and share artefacts digitally. As a result, museums are frequently making their collections accessible online as interactive, 3D models. This could lead to the unique situation of viewing the digital artefact before the physical artefact. Experiencing artefacts digitally outside of the museum on personal devices may affect the user's ability to emotionally connect to the artefacts. This study examines how two target populations of young adults (18–21 years) and the elderly (65 years and older) responded to seeing cultural heritage artefacts in three different modalities: augmented reality on a tablet, 3D models on a laptop, and then physical artefacts. Specifically, the time spent, enjoyment, and emotional responses were analysed. Results revealed that regardless of age, the digital modalities were enjoyable and encouraged emotional responses. Seeing the physical artefacts after the digital ones did not lessen their enjoyment or emotions felt. These findings aim to provide an insight into the effectiveness of 3D artefacts viewed on personal devices and artefacts shown outside of the museum for encouraging emotional responses from older and younger people

Real-world practice level data analysis confirms link between variability within Blood Glucose Monitoring Strip (BGMS) and glycosylated haemoglobin (HbA1c) in Type 1 Diabetes.

AIMS/HYPOTHESIS: Our aim was to quantify the impact of Blood Glucose Monitoring Strips variability (BGMSV) at GP practice level on the variability of reported glycated haemoglobin (HbA1cV) levels. METHODS: Overall GP Practice BGMSV and HbA1cV were calculated from the quantity of main types of BGMS being prescribed combined with the published accuracy, as % results within ±% bands from reference value for the selected strip type. The regression coefficient between the BGMSV and HbA1cV was calculated. To allow for the aggregation of estimated three tests/day over 13 weeks (ie, 300 samples) of actual Blood Glucose (BG) values up to the HbA1c, we multiplied HbA1cV coefficient by √300 to estimate an empirical value for impact of BGMSV on BGV. RESULTS: Four thousand five hundred and twenty-four practice years with 159 700 T1DM patient years where accuracy data were available for more than 80% of strips prescribed were included, with overall BGMSV 6.5% and HbA1c mean of 66.9 mmol/mol (8.3%) with variability of 13 mmol/mol equal to 19% of the mean. At a GP practice level, BGMSV and HbA1cV as % of mean HbA1c (in other words, the spread of HbA1c) were closely related with a regression coefficient of 0.176, P ±4.5 mmol/L from target, compared with the best performing BGMS with BG >±2.2 mmol/L from reference on 1/20 occasions. CONCLUSION: Use of more variable/less accurate BGMS is associated both theoretically and in practice with a larger variability in measured BG and HbA1c, with implications for patient confidence in their day-to-day monitoring experience