A vitamin K prophylaxis survey among breastfeeding mothers

A survey was distributed among new breastfeeding mothers in northern England to gain insight into their experiences with different forms of neonatal vitamin K prophylaxis. Two-thirds of mothers were knowledgeable about the reasons for giving vitamin K and a quarter felt that they had not received adequate information on the subject. The importance of neonatal vitamin K prophylaxis must be fully explained by healthcare workers to all expectant parents

Peripheral arterial disease: diagnostic challenges and how photoplethysmography may help

Peripheral arterial disease (PAD) affects approximately 20% of patients aged ≥60 years.1 A GP with an average list size of 1800 patients can expect to have 50–60 patients with PAD. Ankle-brachial pressure index (ABPI), which is the ratio of the ankle to brachial systolic pressure measured by sphygmomanometer and hand-held Doppler ultrasound probe, is used to assess PAD in general practice. ABPI has been shown to have a sensitivity of 95% and specificity of 99% compared to angiographic imaging,2 however it is relatively time-consuming and requires adequately trained staff. There are limitations with ABPI in patients with diabetes, renal disease, and older people where an underestimation of disease can occur with a falsely high ratio due to the presence of incompressible calcified blood vessels

Negotiating commissioning pathways for the successful implementation of innovative health technology in primary care

Background: Commissioning innovative health technologies is typically complex and multi-faceted. Drawing on the negotiated order perspective, we explore the process by which commissioning organisations make their decisions to commission innovative health technologies. The empirical backdrop to this discussion is provided by a case study exploring the commissioning considerations for a new photoplethysmography-based diagnostic technology for peripheral arterial disease in primary care in the UK. Methods: The research involved an empirical case study of four Clinical Commissioning Groups (CCGs) involved in the commissioning of services in primary and secondary care. Semi-structured in-depth interviews (16 in total) and two focus groups (a total of eight people participated, four in each group) were conducted with key individuals involved in commissioning services in the NHS including (i) senior NHS clinical leaders and directors (ii) commissioners and health care managers across CCGs and (iii) local general practitioners. Results: Commissioning of a new diagnostic technology for peripheral arterial disease in primary care involves high levels of protracted negotiations over funding between providers and commissioners, alliance building, conflict resolution and compromise of objectives where the outcomes of change are highly contingent upon interventions made across different care settings. Our evidence illustrates how reconfigurations of inter-organisational relations, and of clinical and related work practices required for the successful implementation of a new technology could become the major challenge in commissioning negotiations. Conclusions: Innovative health technologies such as the diagnostic technology for peripheral arterial disease are commissioned in care pathways where the value of such technology is realised by those delivering care to patients. The detail of how care pathways are commissioned is complex and involves high degrees of uncertainty concerning such issues as prioritisation decisions, patient benefits, clinical buy-in, value for money and unintended consequences. Recent developments in the new care models and integrated care systems (ICSs) in the UK offer a unique opportunity for the successful commissioning arrangements of innovative health technologies in primary care such as the new diagnostic technology for peripheral arterial disease. Keywords: Commissioning, Decision-making, Diagnostics, Innovative health technologies, Primary care, Peripheral arterial disease, United Kingdo

Rapid Evaluation for health and social care innovations: Challenges for “quick wins” using interrupted time series.

Background: Rapid evaluation was at the heart of National Health Service England’s evaluation strategy of the new models of care vanguard programme. This was to facilitate the scale and spread of successful models of care throughout the health & social care system. The aim of this paper is to compare the findings of the two evaluations of the Enhanced health in Care Homes (EHCH) vanguard in Gateshead, one using a smaller data set for rapidity and one using a larger longitudinal data set and to investigate the implications of the use of rapid evaluations using interrupted time series (ITS) methods. Methods: A quasi-experimental design study in the form of an ITS was used to evaluate the impact of the vanguard on secondary care use. Two different models are presented differing by timeframes only. The short-term model consisted of data for 11 months data pre and 20 months post vanguard. The long-term model consisted of data for 23 months pre and 34 months post vanguard. Results: The cost consequences, including the cost of running the EHCH vanguard, were estimated using both a single tariff non-elective admissions methodology and a tariff per bed day methodology. The short-term model estimated a monthly cost increase of £73,408 using a single tariff methodology. When using a tariff per bed day, there was an estimated monthly cost increase of £14,315. The long-term model had, using a single tariff for non-elective admissions, an overall cost increase of £7576 per month. However, when using a tariff per bed-days, there was an estimated monthly cost reduction of £57,168. Conclusions: Although it is acknowledged that there is often a need for rapid evaluations in order to identify “quick wins” and to expedite learning within health and social care systems, we conclude that this may not be appropriate for quasi-experimental designs estimating effect using ITS for complex interventions. Our analyses suggests that care must be taken when conducting and interpreting the results of short-term evaluations using ITS methods, as they may produce misleading results and may lead to a misallocation of resources

Prospective assessment of the diagnostic accuracy of multi-site photoplethysmography pulse measurements for diagnosis of peripheral artery disease in primary care

Peripheral arterial disease (PAD) is associated with cerebral and coronary artery disease. Symptomatic PAD affects about 5% of people over 55 years; many more have asymptomatic PAD. Early detection enables modification of arterial disease risk factors. Diagnostically, assessment of symptoms or signs can be unreliable; ankle brachial pressure index (ABPI) testing is time-consuming and few healthcare professionals are properly trained. This study assessed the diagnostic accuracy of multi-site photoplethysmography (MPPG), an alternative non-invasive test for PAD, in primary care. PAD patients identified from general practice registers were age- and sex-matched with controls. Participants were assessed using MPPG, ABPI and duplex ultrasound (DUS). Outcome measures were sensitivity and specificity of MPPG and ABPI (relative to DUS) and concordance. MPPG test results were available in 249 of 298 eligible participants from 16 practices between May 2015 and November 2016. DUS detected PAD in 101/249 (40.6%). MPPG sensitivity was 79.8% (95% confidence interval [CI] 69.9-87.6%), with specificity 71.9% (95% CI 63.7-79.2%). ABPI sensitivity was 80.2% (95% CI 70.8-87.6%), with specificity 88.6% (95% CI 82-93.5%). With comparable sensitivity to ABPI, MPPG is quick, automated and simpler to do than ABPI; it offers the potential for rapid and accessible PAD assessments in primary care

Intervention to reduce excessive alcohol consumption and improve comorbidity outcomes in hypertensive or depressed primary care patients: two parallel cluster randomized feasibility trials

Wilson, G. B. Wray, C. McGovern, R. Newbury-Birch, D. McColl, E. Crosland, A. Background Many primary care patients with raised blood pressure or depression drink potentially hazardous levels of alcohol. Brief interventions (BI) to reduce alcohol consumption may improve comorbid conditions and reduce the risk of future alcohol problems. However,research has not established their effectiveness in this patient population. This study aimed to establish the feasibility of definitive trials of BI to reduce excessive drinking in primary care patients with hypertension or mild to moderate depression. Methods Thirteen general practices in North East England were randomized to the intervention or control arm of one of two parallel pilot trials. Adult patients drinking excessively and diagnosed with hypertension or mild-to-moderate depression received the Alcohol Use Disorders Identification Test (AUDIT) by postal survey. Consenting respondents scoring more than 7 on AUDIT (score range 0 to 40) received brief alcohol consumption advice plus an information leaflet (intervention) or an information leaflet alone(control) with follow-up at six months. Measurements included the numbers of patients eligible, recruited, and retained, and the AUDIT score and systolic/diastolic blood pressure of each patient or the nine-item Patient Health Questionnaire (PHQ-9) score. Acceptability was assessed via practitioner feedback and patient willingness to be screened, recruited, and retained at follow-up. Results In the hypertension trial, 1709 of 33,813 adult patients(5.1%) were eligible and were surveyed. Among the eligible patients, 468 (27.4%) returned questionnaires; 166 (9.6% of those surveyed) screened positively on AUDIT and 83 (4.8% of those surveyed) were recruited (50.0% of positive screens). Sixty-seven cases (80.7% of recruited patients)completed follow-up at six months. In the depression trial, 1,044 of 73,146 adult patients(1.4%)were eligible and surveyed. Among these eligible patients, 215(20.6%)responded;104(10.0% of those surveyed)screened positively on AUDIT and 29 (2.8% of those surveyed) were recruited (27.9% of positive screens). Nineteen cases(65.5% of recruited patients)completed follow-up at six months. Conclusions Recruitment and retention rates were higher in the hypertension trial than in the depression trial. A full brief intervention trial appears feasible for primary care patients with hypertension who drink excessively. High AUDIT scores in the depression trial suggest the importance of alcohol intervention in this group. However, future work may require alternative screening and measurement procedures

Using care and support planning to implement routine falls prevention and management for people living with frailty: A qualitative evaluation

Background Frailty is a key issue in current healthcare delivery and falls is an important component. Care and support planning (CSP) is an established approach to managing long term conditions (LTCs) and has potential to provide more person-centred care for those at risk of falling. This qualitative evaluation aimed to understand the barriers and success criteria involved in incorporating falls assessment and management into the CSP process. Methods CSP for falls prevention was implemented in eight general practices in the North of England. Six of the eight practices participated in the qualitative evaluation. Seven group interviews were undertaken with staff (n = 31) that included practice nurses, health care assistants, nurses, and administrative staff (n = 2–8 per group). Observations of the falls and CSP training provided additional data. Interviews covered experiences and potential impacts of training, and processes of implementation of the programme, and were informed by normalisation process theory. Thematic analysis was undertaken using a team-based approach. Results Although successfully implemented across the practices, how established CSP was and therefore ‘organisational readiness’ was an overarching theme that illustrated differences in how easily sites were able to implement the additional elements for frailty. The challenges, successes and impacts of implementation are demonstrated through this theme and four further themes: training resources and learning; positive impacts of the programme (including enabling easier conversations around ‘frailty’); integrating work processes/work with patients; and dealing with uncertainty and complexity. Conclusions Care and Support Planning services designed to target frailty and falls is feasible and can successfully be delivered in the primary care setting, if key enablers are promoted and challenges to implementation addressed from planning through to integration in practice

Breastfeeding peer support: are there additional benefits?

Anecdotal discussion among breastfeeding peer supporters and the infant-feeding co-ordinator suggested that breastfeeding peer support provided by breastfeeding peer supporters may offer benefits to breastfeeding women and their families other than increasing breastfeeding initiation and sustainability. The aim of this research was to determine whether there was evidence to support this. The research team used focus groups to obtain information from 16 local women who had received breastfeeding peer support from breastfeeding peer supporters. The key themes that emerged were--improved mental health, increased self-esteem or confidence, parenting skills, improved family diet, breastfeeding sustainability and poor hospital experience.The findings suggest that breastfeeding peer supporters supporting mothers to breastfeed, with the intention of increasing both breastfeeding rates and sustainability, may have additional benefits in several aspects of families' lives. Breastfeeding peer support may play an important role in helping to attain targets such as reducing obesity and postnatal depression