Case finding for depression in patients with long-term physical conditions in primary care

The aim of this thesis was to describe the impact and consequences of case finding for depression in patients with long-term physical conditions in primary care from the perspective of primary healthcare professionals. Study one (chapter two) evaluated the effects of incentivised case finding using an interrupted time series analysis of routinely collected data. It found that incentivised case finding increased new depression-related diagnoses and rates of antidepressant prescribing. Increased prescribing is of concern as it may include treatment of people unlikely to respond to medication. Study two (chapter three) identified and classified what has been written about primary healthcare professionals beliefs on implementing case finding using a systematic review and the ‘best fit’ framework synthesis approach. A range of contradictory beliefs and three new themes were identified; mistrust, trade-offs and dilemmas. These findings demonstrate conflict and tensions which could undermine implementation of case finding. Study three (chapter four) characterised the range of positions held by primary healthcare professionals on the role, implementation and value of case finding using an online Q method study involving primary healthcare professionals. Three recognisable positions were produced; objections to the principle of case finding for depression, case finding for depression is worthwhile and objections to implementation of case finding for depression. These positions may influence how clinicians deliver and respond to case finding. Implementation is challenging if there is a spread of perspectives. These findings, considered alongside the absence of evidence that case finding improves clinical outcomes, indicate that case finding for depression in long-term physical conditions should not be recommended or incentivised until more robust evidence of improved patient outcomes resulting from the changes case finding is likely to drive, especially in prescribing, and acceptability to professionals becomes available

Understanding the organisational influences on the quality of and access to primary care in English prisons: a qualitative interview study

Background Primary care for routine healthcare conditions is delivered to thousands of people in the English prison estate every day but the prison environment presents unique challenges to the provision of high-quality health care. Little research has focused on the organisational factors that affect quality of and access to prison health care. Aim To understand key influences on the quality of primary care in prisons. Design and setting This was a qualitative interview study across the North of England from 2019 to 2021. Method Interviews were undertaken with 43 participants: 21 prison leavers and 22 prison healthcare professionals. Reflexive thematic analysis was undertaken. Results The overarching organisational issue influencing quality and access was that of chronic understaffing coupled with a workforce in flux and dependence on locum staff. This applied across different prisons, roles, and grades of staff, and was vocally discussed by both patient and staff participants. Intricately related to understaffing (and fuelled by it) was the propensity for a reactive and sometimes crisis-led service to develop that was characterised by continual firefighting. A persistent problem exacerbated by the above issues was unreliable communication about healthcare matters within some prisons, creating frustration. Positive commentary focused on the characteristics and actions of individual healthcare professionals. Conclusion This study highlights understaffing and its consequences as the most significant threat to the quality of and access to prison primary care. Strategies to address health care affecting prison populations urgently need to consider staffing. This issue should receive high-profile and mainstream attention to address health inequalities

The Quality of Prison Primary Care: Cross-Sectional Analyses of Prison Healthcare Data in England

Background: Prisoners have significant health needs, are relatively high users of healthcare and often die prematurely. Strong primary care systems are associated with better population health outcomes. We investigated the quality of primary care delivered to prisoners.Methods: We assessed achievement against 30 quality indicators spanning different domains of care in 13 prisons in the North of England. We conducted repeated cross-sectional analyses of routinely recorded data from electronic health records over 2017-20. Multi-level mixed effects logistic regression models explored associations between indicator achievement and prison and prisoner characteristics.Findings: We found marked variations in achievement between indicators and between prisons. Achievement ranged from 0·2% of people with epilepsy coded as seizure-free to 93·8% of people with diabetes having blood pressure checks over the preceding year. Achievement improved over three years for 11 indicators and worsened for six, including declining antipsychotic monitoring and rising opioid prescribing. Achievement varied between prisons, e.g. 1·93-fold for gabapentinoid prescribing without coded neuropathic pain (odds ratio [OR] range 0·67 to 1·29) and 169-fold for dried blood spot testing (OR range 0·05 to 8·45). Shorter lengths of stay were frequently associated with lower achievement. Ethnicity was associated with some indicators achievement, although the associations differed with indicators.Interpretation: We found substantial scope for improvement and marked variations in quality, which were largely unaltered after adjustment for prison and prisoner characteristics

The quality of prison primary care: cross-sectional cluster-level analyses of prison healthcare data in the North of England

Background Prisoners have significant health needs, are relatively high users of healthcare, and often die prematurely. Strong primary care systems are associated with better population health outcomes. We investigated the quality of primary care delivered to prisoners. Methods We assessed achievement against 30 quality indicators spanning different domains of care in 13 prisons in the North of England. We conducted repeated cross-sectional analyses of routinely recorded data from electronic health records over 2017–20. Multi-level mixed effects logistic regression models explored associations between indicator achievement and prison and prisoner characteristics. Findings Achievement varied markedly between indicators, prisons and over time. Achieved processes of care ranged from 1% for annual epilepsy reviews to 94% for blood pressure checks in diabetes. Intermediate outcomes of care ranged from only 0.2% of people with epilepsy being seizure-free in the preceding year to 34% with diabetes having sufficient blood pressure control. Achievement improved over three years for 11 indicators and worsened for six, including declining antipsychotic monitoring and rising opioid prescribing. Achievement varied between prisons, e.g., 1.93-fold for gabapentinoid prescribing without coded neuropathic pain (odds ratio [OR] range 0.67–1.29) and 169-fold for dried blood spot testing (OR range 0.05–8.45). Shorter lengths of stay were frequently associated with lower achievement. Ethnicity was associated with some indicators achievement, although the associations differed (both positive and negative) with indicators. Interpretation We found substantial scope for improvement and marked variations in quality, which were largely unaltered after adjustment for prison and prisoner characteristics. Funding National Institute for Health and Care Research Health and Social Care and Delivery Research Programme: 17/05/26

How patients understand depression associated with chronic physical disease - A systematic review

Background: Clinicians are encouraged to screen people with chronic physical illness for depression. Screening alone may not improve outcomes, especially if the process is incompatible with patient beliefs. The aim of this research is to understand peoples beliefs about depression, particularly in the presence of chronic physical disease. Methods: A mixed method systematic review involving a thematic analysis of qualitative studies and quantitative studies of beliefs held by people with current depressive symptoms. MEDLINE, EMBASE, PSYCHINFO, CINAHL, BIOSIS, Web of Science, The Cochrane Library, UKCRN portfolio, National Research Register Archive, Clinicaltrials.gov and OpenSIGLE were searched from database inception to 31st December 2010. A narrative synthesis of qualitative and quantitative data, based initially upon illness representations and extended to include other themes not compatible with that framework. Results: A range of clinically relevant beliefs was identified from 65 studies including the difficulty in labeling depression, complex causal factors instead of the biological model, the roles of different treatments and negative views about the consequences of depression. We found other important themes less related to ideas about illness: the existence of a self-sustaining depression spiral; depression as an existential state; the ambiguous status of suicidal thinking; and the role of stigma and blame in depression. Conclusions: Approaches to detection of depression in physical illness need to be receptive to the range of beliefs held by patients. Patient beliefs have implications for engagement with depression screening

Rehabilitation versus surgical reconstruction for non-acute anterior cruciate ligament injury (ACL SNNAP): a pragmatic randomised controlled trial

BackgroundAnterior cruciate ligament (ACL) rupture is a common debilitating injury that can cause instability of the knee. We aimed to investigate the best management strategy between reconstructive surgery and non-surgical treatment for patients with a non-acute ACL injury and persistent symptoms of instability.MethodsWe did a pragmatic, multicentre, superiority, randomised controlled trial in 29 secondary care National Health Service orthopaedic units in the UK. Patients with symptomatic knee problems (instability) consistent with an ACL injury were eligible. We excluded patients with meniscal pathology with characteristics that indicate immediate surgery. Patients were randomly assigned (1:1) by computer to either surgery (reconstruction) or rehabilitation (physiotherapy but with subsequent reconstruction permitted if instability persisted after treatment), stratified by site and baseline Knee Injury and Osteoarthritis Outcome Score—4 domain version (KOOS4). This management design represented normal practice. The primary outcome was KOOS4 at 18 months after randomisation. The principal analyses were intention-to-treat based, with KOOS4 results analysed using linear regression. This trial is registered with ISRCTN, ISRCTN10110685, and ClinicalTrials.gov, NCT02980367.FindingsBetween Feb 1, 2017, and April 12, 2020, we recruited 316 patients. 156 (49%) participants were randomly assigned to the surgical reconstruction group and 160 (51%) to the rehabilitation group. Mean KOOS4 at 18 months was 73·0 (SD 18·3) in the surgical group and 64·6 (21·6) in the rehabilitation group. The adjusted mean difference was 7·9 (95% CI 2·5–13·2; p=0·0053) in favour of surgical management. 65 (41%) of 160 patients allocated to rehabilitation underwent subsequent surgery according to protocol within 18 months. 43 (28%) of 156 patients allocated to surgery did not receive their allocated treatment. We found no differences between groups in the proportion of intervention-related complications.InterpretationSurgical reconstruction as a management strategy for patients with non-acute ACL injury with persistent symptoms of instability was clinically superior and more cost-effective in comparison with rehabilitation management

Fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin with gemtuzumab ozogamicin improves event-free survival in younger patients with newly diagnosed aml and overall survival in patients with npm1 and flt3 mutations

Purpose To determine the optimal induction chemotherapy regimen for younger adults with newly diagnosed AML without known adverse risk cytogenetics. Patients and Methods One thousand thirty-three patients were randomly assigned to intensified (fludarabine, cytarabine, granulocyte colony-stimulating factor, and idarubicin [FLAG-Ida]) or standard (daunorubicin and Ara-C [DA]) induction chemotherapy, with one or two doses of gemtuzumab ozogamicin (GO). The primary end point was overall survival (OS). Results There was no difference in remission rate after two courses between FLAG-Ida + GO and DA + GO (complete remission [CR] + CR with incomplete hematologic recovery 93% v 91%) or in day 60 mortality (4.3% v 4.6%). There was no difference in OS (66% v 63%; P = .41); however, the risk of relapse was lower with FLAG-Ida + GO (24% v 41%; P < .001) and 3-year event-free survival was higher (57% v 45%; P < .001). In patients with an NPM1 mutation (30%), 3-year OS was significantly higher with FLAG-Ida + GO (82% v 64%; P = .005). NPM1 measurable residual disease (MRD) clearance was also greater, with 88% versus 77% becoming MRD-negative in peripheral blood after cycle 2 (P = .02). Three-year OS was also higher in patients with a FLT3 mutation (64% v 54%; P = .047). Fewer transplants were performed in patients receiving FLAG-Ida + GO (238 v 278; P = .02). There was no difference in outcome according to the number of GO doses, although NPM1 MRD clearance was higher with two doses in the DA arm. Patients with core binding factor AML treated with DA and one dose of GO had a 3-year OS of 96% with no survival benefit from FLAG-Ida + GO. Conclusion Overall, FLAG-Ida + GO significantly reduced relapse without improving OS. However, exploratory analyses show that patients with NPM1 and FLT3 mutations had substantial improvements in OS. By contrast, in patients with core binding factor AML, outcomes were excellent with DA + GO with no FLAG-Ida benefit

Understanding the organisational influences on the quality of and access to primary care in English prisons: a qualitative interview study.

Primary care for routine healthcare conditions is delivered to thousands of people in the English prison estate every day but the prison environment presents unique challenges to the provision of high-quality health care. Little research has focused on the organisational factors that affect quality of and access to prison health care. To understand key influences on the quality of primary care in prisons. This was a qualitative interview study across the North of England from 2019 to 2021. Interviews were undertaken with 43 participants: 21 prison leavers and 22 prison healthcare professionals. Reflexive thematic analysis was undertaken. The overarching organisational issue influencing quality and access was that of chronic understaffing coupled with a workforce in flux and dependence on locum staff. This applied across different prisons, roles, and grades of staff, and was vocally discussed by both patient and staff participants. Intricately related to understaffing (and fuelled by it) was the propensity for a reactive and sometimes crisis-led service to develop that was characterised by continual firefighting. A persistent problem exacerbated by the above issues was unreliable communication about healthcare matters within some prisons, creating frustration. Positive commentary focused on the characteristics and actions of individual healthcare professionals. This study highlights understaffing and its consequences as the most significant threat to the quality of and access to prison primary care. Strategies to address health care affecting prison populations urgently need to consider staffing. This issue should receive high-profile and mainstream attention to address health inequalities. [Abstract copyright: © The Authors.

Quality indicators and performance measures for prison healthcare: a scoping review

Background Internationally, people in prison should receive a standard of healthcare provision equivalent to people living in the community. Yet efforts to assess the quality of healthcare through the use of quality indicators or performance measures have been much more widely reported in the community than in the prison setting. This review aims to provide an overview of research undertaken to develop quality indicators suitable for prison healthcare. Methods An international scoping review of articles published in English was conducted between 2004 and 2021. Searches of six electronic databases (MEDLINE, CINAHL, Scopus, Embase, PsycInfo and Criminal Justice Abstracts) were supplemented with journal searches, author searches and forwards and backwards citation tracking. Results Twelve articles were included in the review, all of which were from the United States. Quality indicator selection processes varied in rigour, and there was no evidence of patient involvement in consultation activities. Selected indicators predominantly measured healthcare processes rather than health outcomes or healthcare structure. Difficulties identified in developing performance measures for the prison setting included resource constraints, data system functionality, and the comparability of the prison population to the non-incarcerated population. Conclusions Selecting performance measures for healthcare that are evidence-based, relevant to the population and feasible requires rigorous and transparent processes. Balanced sets of indicators for prison healthcare need to reflect prison population trends, be operable within data systems and be aligned with equivalence principles. More effort needs to be made to meaningfully engage people with lived experience in stakeholder consultations on prison healthcare quality. Monitoring healthcare structure, processes and outcomes in prison settings will provide evidence to improve care quality with the aim of reducing health inequalities experienced by people living in prison

The quality of prison primary care: cross-sectional analyses of prison healthcare data in Northern England

Background: Prisoners have considerable health needs, are relatively high users of health care and often die prematurely. Prison healthcare research has typically focused on specific problems such as substance misuse, but ‘routine’ primary care has received less attention. Strong primary care systems are associated with better population outcomes. Identifying inappropriate variations in care will inform strategies to close gaps in health care and reduce preventable deaths. Aim: To explore variations in the quality of primary care for prisoners. Method: We assessed achievement against 30 quality indicators examining different aspects of care in 13 prisons. We conducted repeated cross-sectional analyses of routinely recorded data from electronic health records across 2017–2020. Multi-level logistic regression models explored associations between indicator achievement and prison and prisoner characteristics. Results: We found marked variations in achievement between different indicators and different prisons. Achievement ranged from 0·2% of people with epilepsy coded as seizure-free, to 93·8% of people with diabetes having blood pressure checks, in the preceding year. Achievement improved over three years for 11 indicators and worsened for six, including declining antipsychotic monitoring and rising opioid prescribing. Achievement varied between prisons, from 1·93-fold for prescribing of gabapentinoids with no coded diagnosis of neuropathic pain (Odds Ratio (OR) range 0·67 to 1·29) to 21,610-fold for medicine reconciliation (OR range 0·45 to 9724·5). Shorter lengths of stay were frequently associated with lower achievement. Some associations between ethnicity and achievement were identified. Conclusion: We found substantial scope for improvement and marked variations in quality which were largely unaltered after adjustment for prison and prisoner characteristics