Using mixed methods for evaluating the effect of a quality improvement collaborative for management of sleep problems presenting to primary care

Context This improvement project was set in Lincolnshire, a large rural county in the East Midlands with high prescribing rates of hypnotic drugs compared with the rest of England. Eight general practices volunteered to participate in a Quality Improvement Collaborative (QIC) designed to improve management of sleep problems in patients presenting to primary care. Problem Sleep problems are common affecting around 40% of adults in the UK. Insomnia has considerable resource implications in terms of disability, impaired quality of life and health service utilisation. Up to half of individuals with Insomnia seek help from primary care and hypnotic drugs are often inappropriately prescribed for long term use. Non-pharmacological treatment measures are rarely implemented in practice despite guidance supporting their use. A lack of training as well as limited availability of resources for effective sleep assessment and treatment in primary care are possible explanations for this. It is clear that there is considerable scope for improving management of sleep problems in general practice Assessment of problem and analysis of its causes We used a Quality Improvement Collaborative to introduce practitioners to sleep assessment tools including the Insomnia Severity Index (ISI), Pittsburgh Sleep Quality Index (PSQI) and Sleep Diaries and non-pharmacological interventions such as Cognitive Behavioural Therapy for Insomnia (CBTi). Practitioners from participating practices were asked to begin using these where appropriate within their day to day practice. Strategy for change The project team met bi-monthly with practice teams to share learning. We used adult learning techniques to promote rapid experimentation (Plan, Do, Study, Act) cycles, process redesign and monthly feedback of prescribing rates and costs of hypnotic drugs using statistical control charts. Data were collected from the collaborative meetings to understand the facilitators, barriers and changes that practices were making as a result of the Quality Improvement Collaborative (QIC). Measure of improvement Qualitative data were collected via audio recordings of practice and collaborative meetings with practitioners and practice staff. This data was then transcribed verbatim. Thematic analysis was carried out supported by computer software MaxQDA using a framework method. Nine themes emerged which were then reviewed by five members of the evaluation steering group to assess inter-rater reliability of the themes. We used statistical process control charts and an interrupted time series design to analyse prescribing data for the two year period preceding the establishment of the collaborative and for the six months of its operation. Effects of changes There was a significant reduction in hypnotic prescribing of benzodiazepines and Z drugs in the practices over the six months of the project and this improvement has been sustained since the initiative. Nine themes emerged from the qualitative data: - Engagement of staff: Most practitioners showed enthusiasm to incorporate changes in their practice and encouraged other members of the practice to become involved by demonstrating use of the tools and reminders during meetings “It’s brought up at every practice meeting and so it’s always fresh in people minds. It’s not something that’s then forgotten.” Practitioner views of the tools: Practitioners tried the tools and techniques and overall seemed to favour the Sleep diary and Insomnia Severity Index (ISI) over the Pittsburgh Sleep Quality Index (PSQI) “Generally we found that the ISI was easy to complete, score and interpret and can be used in general practice” Practitioner preconceptions: Practitioners came with preconceptions about the feasibility of sleep tools and techniques. Patients’ age and intellect were factors that practitioners thought might affect whether tools were completed correctly or at all. Needs & educational needs of patients & staff: Before this project hypnotics had been seen as the solution to most sleep problems by both patients and practitioners. “When people come in it was so easy to give them a prescription” "As GPs we’re overly limited and actually to have a slightly more sophisticated response would actually be better for us but also for the patient”. Barriers to implementing tools & techniques: This related to systems (of care) practitioners and patients Systems: “Once the psychiatrist says you should have this, it is really hard as a GP to go against it because you know they say the psychiatrist has asked me to take this.” Practitioner: “We come down to the cognitive behaviour therapy approach; it’s a bit thin on my part, we’ve not got great skills in that”. Patient: “I think the key is also definitely how to communicate it…the minute you start even trying to approach the subject that the tablets are not really very good and what about thinking about alternative ways, they will kind of glare very rudely and be like I have been there before doc[tor]. So you have got to kind of approach it in a kind of a fresh way to make them thing they are trying something new. You have got to be a salesman’. Changes initiated by practices: Some practices had taken other measures to try and reduce hypnotic prescribing including implementing withdrawal programmes and limiting repeat prescriptions which let to improvement is patient and practitioner experience GP-Patient treatment & expectations: Practitioners revealed what they thought patients expected and made suggestions of how consultations could be improved to meet patients’ needs and increase successful outcomes from a sleep consultation. Importance of tailored approach: Each patient with Insomnia would need to have their treatment tailored to their individual requirements therefore every consultation could potentially have very different solutions Lack of feedback from patients: Receiving feedback from patients was difficult for some practitioners when patients didn’t return for their follow-up consultation or didn’t complete and return their sleep assessment tools. This lead practitioners to feel unsure as to whether patients had read and absorbed the information provided to them Lessons learnt Qualitative methods for collecting and analysing data were invaluable in understanding the factors which helped bring about change, how change happened and the effect of the change on process of care and patient and practitioner experience Message for others Quality improvement collaboratives benefit from careful analysis using qualitative as well as quantitative methods. Further information www.restproject.org.uk Project manager: [email protected] Project lead: [email protected]

Drivers for change in primary care of diabetes following a protected learning time educational event: interview study of practitioners

Background: A number of protected learning time schemes have been set up in primary care across the United Kingdom but there has been little published evidence of their impact on processes of care. We undertook a qualitative study to investigate the perceptions of practitioners involved in a specific educational intervention in diabetes as part of a protected learning time scheme for primary health care teams, relating to changing processes of diabetes care in general practice. Methods: We undertook semistructured interviews of key informants from a sample of practices stratified according to the extent they had changed behaviour in prescribing of ramipril and diabetes care more generally, following a specific educational intervention in Lincolnshire, United Kingdom. Interviews sought information on facilitators and barriers to change in organisational behaviour for the care of diabetes. Results: An interprofessional protected learning time scheme event was perceived by some but not all participants as bringing about changes in processes for diabetes care. Participants cited examples of change introduced partly as a result of the educational session. This included using ACE inhibitors as first line for patients with diabetes who developed hypertension, increased use of aspirin, switching patients to glitazones, and conversion to insulin either directly or by referral to secondary care. Other reported factors for change, unrelated to the educational intervention, included financially driven performance targets, research evidence and national guidance. Facilitators for change linked to the educational session were peer support and teamworking supported by audit and comparative feedback. Conclusion: This study has shown how a protected learning time scheme, using interprofessional learning, local opinion leaders and early implementers as change agents may have influenced changes in systems of diabetes care in selected practices but also how other confounding factors played an important part in changes that occurred in practice

Life course dietary patterns and bone health in later life in a British birth cohort study

Evidence for the contribution of individual foods and nutrients to bone health is weak. Few studies have considered hypothesis-based dietary patterns and bone health. We investigated whether a protein, calcium and potassium-rich (PrCaK-rich) dietary pattern over the adult life course, was positively associated with bone outcomes at 60-64 years of age. Diet diaries were collected at ages 36, 46, 53 and 60-64 years in 1263 participants (661 women) from the MRC National Survey of Health and Development. DXA and pQCT measurements were obtained at 60-64y, including size-adjusted bone mineral content (SA-BMC) and volumetric bone mineral density (vBMD). A food-based dietary pattern best explaining dietary calcium, potassium and protein intakes (g/1000?kcal) was identified using reduced rank regression. Dietary pattern z-scores were calculated for each individual, at each time point. Individual trajectories in dietary pattern z-scores were modelled to summarise changes in z-scores over the study period. Regression models examined associations between these trajectories and bone outcomes at 60-64y, adjusting for baseline dietary pattern z-score and other confounders. A consistent PrCaK-rich dietary pattern was identified within the population, over time. Mean [SD] dietary pattern z-scores at age 36 and 60-64 years were -0.32[0.97], 2.2[1.5] (women) and -0.35[0.98], 1.7[1.6] (men). Mean trajectory in dietary pattern z-scores [SD] was 0.07[0.02]SD units/year. Among women, a 0.02 SD unit/year higher trajectory in dietary pattern z-score over time was associated with higher SA-BMC (spine 1.40% [95% CI: 0.30,2.51]; hip 1.35% [95% CI: 0.48,2.23]) and vBMD (radius 1.81% [95% CI: 0.13,3.50]) at 60-64 y. No statistically significant associations were found in men. During adulthood, an increasing score for a dietary pattern rich in protein, calcium and potassium was associated with greater SA-BMC at fracture-prone sites in women. This study emphasises the importance of these nutrients, within the context of the whole diet, to bone healt

Experimental and Natural Warming Elevates Mercury Concentrations in Estuarine Fish

Marine food webs are the most important link between the global contaminant, methylmercury (MeHg), and human exposure through consumption of seafood. Warming temperatures may increase human exposure to MeHg, a potent neurotoxin, by increasing MeHg production as well as bioaccumulation and trophic transfer through marine food webs. Studies of the effects of temperature on MeHg bioaccumulation are rare and no study has specifically related temperature to MeHg fate by linking laboratory experiments with natural field manipulations in coastal ecosystems. We performed laboratory and field experiments on MeHg accumulation under varying temperature regimes using the killifish, Fundulus heteroclitus. Temperature treatments were established in salt pools on a coastal salt marsh using a natural temperature gradient where killifish fed on natural food sources. Temperatures were manipulated across a wider range in laboratory experiments with killifish exposed to MeHg enriched food. In both laboratory microcosms and field mesocosms, MeHg concentrations in killifish significantly increased at elevated temperatures. Moreover, in field experiments, other ancillary variables (salinity, MeHg in sediment, etc.) did not relate to MeHg bioaccumulation. Modeling of laboratory experimental results suggested increases in metabolic rate as a driving factor. The elevated temperatures we tested are consistent with predicted trends in climate warming, and indicate that in the absence of confounding factors, warmer sea surface temperatures could result in greater in bioaccumulation of MeHg in fish, and consequently, increased human exposure

Food insecurity, diet quality and body composition:data from the Healthy Life Trajectories Initiative (HeLTI) pilot survey in urban Soweto, South Africa

Objective: To determine whether food security, diet diversity and diet quality are associated with anthropometric measurements and body composition among women of reproductive age. The association between food security and anaemia prevalence was also tested. Design: Secondary analysis of cross-sectional data from the Healthy Life Trajectories Initiative (HeLTI) study. Food security and dietary data were collected by an interviewer-administered questionnaire. Hb levels were measured using a HemoCue, and anaemia was classified as an altitude-adjusted haemoglobin level &lt; 12·5 g/dl. Body size and composition were assessed using anthropometry and dual-energy x-ray absorptiometry. Setting: The urban township of Soweto, Johannesburg, South Africa. Participants: Non-pregnant women aged 18-25 years (n 1534). Results: Almost half of the women were overweight or obese (44 %), and 9 % were underweight. Almost a third of women were anaemic (30 %). The prevalence rates of anaemia and food insecurity were similar across BMI categories. Food insecure women had the least diverse diets, and food security was negatively associated with diet quality (food security category v. diet quality score: B = -0·35, 95 % CI -0·70, -0·01, P = 0·049). Significant univariate associations were observed between food security and total lean mass. However, there were no associations between food security and body size or composition variables in multivariate models. Conclusions: Our data indicate that food security is an important determinant of diet quality in this urban-poor, highly transitioned setting. Interventions to improve maternal and child nutrition should recognise both food security and the food environment as critical elements within their developmental phases.</p

Life course longitudinal growth and risk of knee osteoarthritis at age 53 years: evidence from the 1946 British birth cohort study

ObjectiveTo examine the relationship between height gain across childhood and adolescence with knee osteoarthritis in the MRC National Survey of Health and Development (NSHD).Materials and methodsData are from 3035 male and female participants of the NSHD. Height was measured at ages 2, 4, 6, 7, 11 and 15 years, and self-reported at ages 20 years. Associations between (i) height at each age (ii) height gain during specific life periods (iii) Super-Imposition by Translation And Rotation (SITAR) growth curve variables of height size, tempo and velocity, and knee osteoarthritis at 53 years were tested.ResultsIn sex-adjusted models, estimated associations between taller height and decreased odds of knee osteoarthritis at age 53 years were small at all ages - the largest associations were an OR of knee osteoarthritis of 0.9 per 5cm increase in height at age 4, (95% CI 0.7-1.1) and an OR of 0.9 per 5cm increase in height, (95% CI 0.8-1.0) at age 6. No associations were found between height gain during specific life periods or the SITAR growth curve variables and odds of knee osteoarthritis.ConclusionsThere was limited evidence to suggest that taller height in childhood is associated with decreased odds of knee osteoarthritis at age 53 years in this cohort. This work enhances our understanding of osteoarthritis predisposition and the contribution of life course height to this

COVID-19 impacts equine welfare : Policy implications for laminitis and obesity

Funding: This study was funded by Mars Petcare and is part of a PhD studentship funded by the Scottish Funding Council Research Excellence Grant (REG). Authors WR and MN receive salary support from the Rural and Environment Science and Analytical Services Division (RESAS). With the exception of PH (employed by the funding organization), the funding organization did not have any additional role in the conceptualization, methodology, investigation, data curation, formal analysis, decision to publish, or preparation of the manuscript. PH was involved in study design, data interpretation, and manuscript preparation. Acknowledgments We wish to extend our gratitude to the local horse owners, veterinarians, farriers and welfare centre managers who volunteered their time to take part in this research. Our thanks also to Dr Charlotte Maltin for supporting recruitment for the study and to World Horse Welfare for their continued interest in the key welfare issues addressed in the present study.Peer reviewedPublisher PD

The IMpact of Vertical HIV infection on child and Adolescent Skeletal development in Harare, Zimbabwe (IMVASK Study):a protocol for a prospective cohort study

INTRODUCTION: The scale-up of antiretroviral therapy (ART) across sub-Saharan Africa (SSA) has reduced mortality so that increasing numbers of children with HIV (CWH) are surviving to adolescence. However, they experience a range of morbidities due to chronic HIV infection and its treatment. Impaired linear growth (stunting) is a common manifestation, affecting up to 50% of children. However, the effect of HIV on bone and muscle development during adolescent growth is not well characterised. Given the close link between pubertal timing and musculoskeletal development, any impairments in adolescence are likely to impact on future adult musculoskeletal health. We hypothesise that bone and muscle mass accrual in CWH is reduced, putting them at risk of reduced bone mineral density (BMD) and muscle function and increasing fracture risk. This study aims to determine the impact of HIV on BMD and muscle function in peripubertal children on ART in Zimbabwe. METHODS AND ANALYSIS: Children with (n=300) and without HIV (n=300), aged 8-16 years, established on ART, will be recruited into a frequency-matched prospective cohort study and compared. Musculoskeletal assessments including dual-energy X-ray absorptiometry, peripheral quantitative computed tomography, grip strength and standing long jump will be conducted at baseline and after 1 year. Linear regression will be used to estimate mean size-adjusted bone density and Z-scores by HIV status (ie, total-body less-head bone mineral content for lean mass adjusted for height and lumbar spine bone mineral apparent density. The prevalence of low size-adjusted BMD (ie, Z-scores <-2) will also be determined. ETHICS AND DISSEMINATION: Ethical approval for this study has been granted by the Medical Research Council of Zimbabwe and the London School of Hygiene and Tropical Medicine Ethics Committee. Baseline and longitudinal analyses will be published in peer-reviewed journals and disseminated to research communities