Primary care doctor and nurse consultations among people who live in slums: a retrospective, cross-sectional survey in four countries

Objectives To survey on the availability and use of primary care services in slum populations. Design Retrospective, cross-sectional, household, individual and healthcare provider surveys. Setting Seven slum sites in four countries (Nigeria, Kenya, Pakistan and Bangladesh). Participants Residents of slums and informal settlements. Primary and secondary outcome measures Primary care consultation rates by type of provider and facility. Results We completed 7692 household, 7451 individual adult and 2633 individual child surveys across seven sites. The majority of consultations were to doctors/nurses (in clinics or hospitals) and pharmacies rather than single-handed providers or traditional healers. Consultation rates with a doctor or nurse varied from 0.2 to 1.5 visits per person-year, which was higher than visit rates to any other type of provider in all sites except Bangladesh, where pharmacies predominated. Approximately half the doctor/nurse visits were in hospital outpatient departments and most of the remainder were to clinics. Over 90% of visits across all sites were for acute symptoms rather than chronic disease. Median travel times were between 15 and 45 min and the median cost per visit was between 2% and 10% of a household’s monthly total expenditure. Medicines comprised most of the cost. More respondents reported proximity (54%–78%) and service quality (31%–95%) being a reason for choosing a provider than fees (23%–43%). Demand was relatively inelastic with respect to both price of consultation and travel time. Conclusions People in slums tend to live sufficiently close to formal doctor/nurse facilities for their health-seeking behaviour to be influenced by preference for provider type over distance and cost. However, costs, especially for medicines are high in relation to income and use rates remain significantly below those of high-income countries

Acute kidney injury: an acceptable risk of treatment with renin-angiotensin system blockade in primary care?

Background: Use of renin-angiotensin system (RAS) blockade has become increasingly widespread driven by evidence-based guidance. There is concern about the role of these agents in the genesis of avoidable acute kidney injury (AKI). Objectives: To investigate the association between AKI and use of RAS blockade. Design: Multilevel hierarchical analysis of a large cohort of patients registered with UK general practitioners. Setting: Primary care practices in East and West Kent, United Kingdom. Patients: 244,715 patients from 27 practices. Measurements: Demographic, clinical, biochemical and prescription data. Methods: Analyses of data acquired between 02/3/2004 and 17/04/2012 using multilevel logistic regression to determine the relationship between AKI and use of RAS blockade; further analysed by indication for treatment with RAS blockade. Results: Sufficient serum creatinine data were available to define AKI in 63,735 patients with 208,275 blood test instances. In 95,569 instances the patient was prescribed a RAS antagonist of which 5.4% fulfilled criteria for AKI. The unadjusted odds ratio (OR) for AKI in those prescribed RAS blockade was 1.93 (1.81-2.06, 95%CI) falling to 1.11 (1.02-1.20, 95%CI) when adjusted for age, gender, co-morbidity, GFR category, proteinuria, systolic blood pressure and diuretic therapy. In patients with an evidence-based indication there was no difference in absolute risk of AKI. However, prescription of RAS blockade in the absence of indication appeared to be associated with greater risk of AKI. When analysis was repeated with AKIN2/AKIN3 as the outcome, although risk of AKI remained significant when unadjusted (OR 1.73, 95%CI 1.42-2.11, p<0.001), after full adjustment there was no increased risk (OR 0.83, 95%CI 0.63-1.09) in those taking RAS antagonists. However, when analysed by indication AKIN2/AKIN3 was significantly more likely in those prescribed RAS antagonists without indication (OR 2.04, 95%CI 1.41-2.94, p<0.001). Limitations: Observational database study. No information concerning hospitalisation. Prescribing assumptions and potential inaccurate coding. Potential survival bias; patients surviving longer will contribute more data. Conclusions: Use of RAS antagonists increased the risk of AKI, independent of common confounding variables. After correction for confounders the risk fell away and became non-significant for moderate and severe AKI. However, where there was no evidence-based indication for RAS antagonists the risk of AKI, whether mild, moderate or severe, remained greater

Integrated Care to Address the Physical Health Needs of People with Severe Mental Illness : A Mapping Review of the Recent Evidence on Barriers, Facilitators and Evaluations

People with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. Evidence suggests this is due to a combination of clinical risk factors, socioeconomic factors, and health system factors, notably a lack of integration when care is required across service settings. Several recent reports have looked at ways to better integrate physical and mental health care for people with severe mental illness (SMI). We built on these by conducting a mapping review that looked for the most recent evidence and service models in this area. This involved searching the published literature and speaking to people involved in providing or using current services. Few of the identified service models were described adequately and fewer still were evaluated, raising questions about the replicability and generalisability of much of the existing evidence. However, some common themes did emerge. Efforts to improve the physical health care of people with SMI should empower staff and service users and help remove everyday barriers to delivering and accessing integrated care. In particular, there is a need for improved communication among professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and greater awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered

Applying a healthcare model to Huntington's disease: the key worker approach

This paper follows on from an overview of the literature and current policy for Huntington’s disease (HD) published by the BJNN (Wilson et al. 2014). The previous paper highlighted a paucity of knowledge in terms of best practice available for those commissioning services to draw upon when planning care of those with HD. This discussion paper draws on this literature base and findings from a recent longitudinal research study from Wilson’s (2013) unpublished PhD thesis (available online at http://etheses.nottingham.ac.uk/3487/) to suggest a model of care, which may provide some guidance

Improving health literacy for older adults: expert panel report 2009

"To address concerns about the barriers for older adults to understand and use health information, the Centers for Disease Control and Prevention (CDC) convened an Expert Panel on Improving Health Literacy for Older Adults on December 67, 2007, in Atlanta, Georgia. The panel's deliberations and conclusions are a critical component of efforts by CDC's Division of Health Communication and Marketing, which is part of the National Center for Health Marketing (NCHM), to develop an agenda to improve health literacy for all U.S. population groups. The meeting was designed to assess health literacy issues among older adults and to identify opportunities for health professionals at CDC and other organizations to better meet the health communication needs of older adults." - p. 2Introduction -- Background -- CDC Convenes Expert Panel -- Panel Presentations -- Presentation 1. - Overview: Low Health Literacy Among Older Adults - Presentation 2. Aging, E-Health Tools, and Health Literacy - Presentation 3. Older Adults and the Practice of Obtaining Health Information - Presentation 4. Health Literacy in Aging: Processing Health Information - Presentation 5. Improving Health Literacy for Older Adults: A Provider Perspective - Presentation 6. Functional Understanding of Medical Information Among Older Adults - Presentation 7. Health Literacy: Ingredient for Better Health - Presentation 8. The Aging, Health Literacy, and Decision-Making Research Milieu - Presentation 9: Health Literacy and Health Decision Making in Practice -- Discussion -- Summary of Panel Presentations -- Summary of Discussion -- References -- Appendix A: Participant Profiles -- Appendix B: Expert Panel Agenda.Title from title caption (viewed on February 16, 2010)."CS204220"System requirements: Adobe Acrobat Reader.Includes bibliographical references (p. 33-34).Text in PDF format (1.97 MB, 56 p.)

Organisational change readiness assessment during healthcare digitalisation (eHealth) projects

One of the pillars for Malta’s National Health Systems Strategy (2023 - 2030) focuses on ‘‘Incorporating digital health into Innovation, Technology, and Research for Better Health’’. Investments in digital transformation in healthcare settings are a crucial opportunity to increase health system resilience. Organisational change readiness assessment (OCRA) is essential in the process for implementation of digitalisation, as it identifies stakeholder motivation in relation to change management, supports the organisational digitalisation process and measures the capabilities within the organisation.peer-reviewe

Integrated care to address the physical health needs of people with severe mental illness : a rapid review

Background People with mental health conditions have a lower life expectancy and poorer physical health outcomes than the general population. Evidence suggests that this discrepancy is driven by a combination of clinical risk factors, socioeconomic factors and health system factors. Objective(s) To explore current service provision and map the recent evidence on models of integrated care addressing the physical health needs of people with severe mental illness (SMI) primarily within the mental health service setting. The research was designed as a rapid review of published evidence from 2013–15, including an update of a comprehensive 2013 review, together with further grey literature and insights from an expert advisory group. Synthesis We conducted a narrative synthesis, using a guiding framework based on nine previously identified factors considered to be facilitators of good integrated care for people with mental health problems, supplemented by additional issues emerging from the evidence. Descriptive data were used to identify existing models, perceived facilitators and barriers to their implementation, and any areas for further research. Findings and discussion The synthesis incorporated 45 publications describing 36 separate approaches to integrated care, along with further information from the advisory group. Most service models were multicomponent programmes incorporating two or more of the nine factors: (1) information sharing systems; (2) shared protocols; (3) joint funding/commissioning; (4) colocated services; (5) multidisciplinary teams; (6) liaison services; (7) navigators; (8) research; and (9) reduction of stigma. Few of the identified examples were described in detail and fewer still were evaluated, raising questions about the replicability and generalisability of much of the existing evidence. However, some common themes did emerge from the evidence. Efforts to improve the physical health care of people with SMI should empower people (staff and service users) and help remove everyday barriers to delivering and accessing integrated care. In particular, there is a need for improved communication between professionals and better information technology to support them, greater clarity about who is responsible and accountable for physical health care, and awareness of the effects of stigmatisation on the wider culture and environment in which services are delivered. Limitations and future work The literature identified in the rapid review was limited in volume and often lacked the depth of description necessary to acquire new insights. All members of our advisory group were based in England, so this report has limited information on the NHS contexts specific to Scotland, Wales and Northern Ireland. A conventional systematic review of this topic would not appear to be appropriate in the immediate future, although a more interpretivist approach to exploring this literature might be feasible. Wherever possible, future evaluations should involve service users and be clear about which outcomes, facilitators and barriers are likely to be context-specific and which might be generalisable

Strategies for assessing renal function prior to outpatient contrast-enhanced CT: a UK survey

YesThe purpose of this paper is to identify current UK screening practices prior to contrast-enhanced CT. To determine the patient management strategies to minimize the risk of contrast-induced acute kidney injury (CI-AKI) risk in outpatients. An invitation to complete an electronic survey was distributed to the CT managers of 174 UK adult National Health Service hospital trusts. The survey included questions related to local protocols and national guidance on which these are based. Details of the assessment of renal function prior to imaging and thresholds for contrast contraindication and patient management were also sought. A response rate of 47.1% was received. Almost all sites had a policy in place for contrast administration (n = 80/82; 97.6%). The majority of sites require a blood test on outpatients undergoing a contrast-enhanced CT scan (n = 75/82; 91.5%); however, some (15/75; 20.0%) sites only check the result in patients at high risk and a small number (7/82; 8.5%) of sites indicated that it was a referrer responsibility. The estimated glomerular filtration rate (eGFR) or serum creatinine (SCr) result threshold at which i.v. contrast was contraindicated varied and 19 different threshold levels of eGFR or SCr were identified, each leading to different prophylactic strategies. Inconsistency was noted in the provision of follow-up blood tests after contrast administration. The wide variation in practice reflects inconsistencies in published guidance. Evidence-based consensuses of which patients to test and subsequent risk thresholds will aid clinicians identify those patients in which the risk of CI-AKI is clinically significant but manageable. There is also a need to determine the value of the various prophylactic strategies, follow-up regimen and efficient service delivery pathways. This survey has identified that further work is required to define which patients are high risk, confirm those which require renal function testing prior to contrast administration and how best to manage patients at risk of CI-AKI. The role of new technologies within this service delivery pathway requires further investigation

Factors associated with initiation and completion of the quadrivalent human papillomavirus vaccine series in an ontario cohort of grade 8 girls

Abstract Background Although over a hundred million dollars have been invested in offering free quadrivalent human papillomavirus (HPV) vaccination to young girls in Ontario, there continues to be very little information about its usage. In order to successfully guide future HPV vaccine programming, it is important to monitor HPV vaccine use and determine factors associated with use in this population. Methods Linking administrative health and immunization databases, we conducted a population-based, retrospective cohort study of girls eligible for Ontario's Grade 8 HPV vaccination program in Kingston, Frontenac, Lennox, and Addington. We determined the proportion of girls who initiated (at least one dose) and completed (all three doses) the vaccination series overall and according to socio-demographics, vaccination history, health services utilization, medical history, and program year. Multivariable logistic regression was used to estimate the strength of association between individual factors and initiation and completion, adjusted for all other factors. Results We identified a cohort of 2519 girls, 56.6% of whom received at least one dose of the HPV vaccine. Among vaccinated girls, 85.3% received all three doses. Vaccination history was the strongest predictor of initiation in that girls who received the measles-mumps-rubella, meningococcal C, and hepatitis B vaccines were considerably more likely to also receive the HPV vaccine (odds ratio 4.89; 95% confidence interval 4.04-5.92). Nevertheless, HPV vaccine uptake was more than 20% lower than that of these other vaccines. In addition, while series initiation was not influenced by income, series completion was. In particular, girls of low income were the least likely to receive all three indicated doses of the HPV vaccine (odds ratio 0.45; 95% confidence interval 0.28-0.72). Conclusions The current low level of HPV vaccine acceptance in Kingston, Frontenac, Lennox, and Addington will likely have important implications in terms of the health benefits and cost-effectiveness of its publicly funded program. We identified important factors associated with series initiation and completion that should be considered in efforts to improve HPV vaccine use in this population