Advance care planning in older hospitalised patients following an emergency admission: A mixed methods study.

INTRODUCTION: Although advance care planning may be beneficial for older adults in the last year of life, its relevance following an emergency hospitalisation requires further investigation. This study quantifies the one-year mortality outcomes of all emergency admissions for patients aged 70+ years and explores patient views on the value of advance care planning following acute hospitalisation. METHOD: This mixed methods study used a two-stage approach: firstly, a quantitative longitudinal cohort study exploring the one-year mortality of patients aged 70+ admitted as an emergency to a large multi-centre hospital cohort; secondly, a qualitative semi-structured interview study gathering information on patient views of advance care planning. RESULTS: There were 14,260 emergency admissions for 70+-year olds over a 12-month period. One-year mortality for admissions across all conditions was 22.6%. The majority of these deaths (59.3%) were within 3 months of admission. Binary logistic regression analysis indicated higher one-year mortality with increasing age and male sex. Interviews with 20 patients resulted in one superordinate theme, "Planning for health and wellbeing in the spectrum of illness". Sub-themes entitled (1) Advance care planning benefitting healthcare for physical and psycho-social health, (2) Contemplation of physical deterioration death and dying and 3) Collaborating with healthcare professionals to undertake advance care planning, suggest that views of advance care planning are shaped by experiences of acute hospitalisation. CONCLUSION: Since approximately 1 in 5 patients aged 70+ admitted to hospital as an emergency are in the last year of life, acute hospitalisation can act as a trigger for tailored ACP. Older hospitalised patients believe that advance care planning can benefit physical and psychosocial health and that discussions should consider a spectrum of possibilities, from future health to the potential of chronic illness, disability and death. In this context, patients may look for expertise from healthcare professionals for planning their future care

Knowledge brokering: Exploring the process of transferring knowledge into action

There are many theories about knowledge transfer but there are few clear descriptions of knowledge transfer interventions or the processes they involve. This failure to characterise structure and process in proposed KT interventions is a major barrier to the design and implementation of evaluations of particular KT strategies. This study is designed to provide a detailed description of the processes involved in a knowledge transfer intervention and to develop and refine a useful model of the knowledge transfer process

Interpreting outcome following foot surgery in people with rheumatoid arthritis

BACKGROUND: Foot surgery is common in RA but the current lack of understanding of how patients interpret outcomes inhibits evaluation of procedures in clinical and research settings. This study aimed to explore which factors are important to people with RA when they evaluate the outcome of foot and ankle surgery. METHODS AND RESULTS: Semi structured interviews with 11 RA participants who had mixed experiences of foot surgery were conducted and analysed using thematic analysis. Responses showed that while participants interpreted surgical outcome in respect to a multitude of factors, five major themes emerged: functional ability, participation, appearance of feet and footwear, surgeons' opinion, and pain. Participants interpreted levels of physical function in light of other aspects of their disease, reflecting on relative change from their preoperative state more than absolute levels of ability. Appearance was important to almost all participants: physical appearance, foot shape, and footwear were closely interlinked, yet participants saw these as distinct concepts and frequently entered into a defensive repertoire, feeling the need to justify that their perception of outcome was not about cosmesis. Surgeons' post-operative evaluation of the procedure was highly influential and made a lasting impression, irrespective of how the outcome compared to the participants' initial goals. Whilst pain was important to almost all participants, it had the greatest impact upon them when it interfered with their ability to undertake valued activities. CONCLUSIONS: People with RA interpret the outcome of foot surgery using multiple interrelated factors, particularly functional ability, appearance and surgeons' appraisal of the procedure. While pain was often noted, this appeared less important than anticipated. These factors can help clinicians in discussing surgical options in patients

“They made me feel comfortable”: a comparison of methods to measure patient experience in a sexual health clinic

Background High quality sexual health services are needed to improve both individual and public health outcomes. This study set out to explore what is important to patients who visit a sexual health clinic, and examine their understanding of standard survey questions, in order to inform the collection and interpretation of patient experience data that are used to improve services. Methods We conducted a cross-sectional, qualitative study. In the first part of the interview, we used “discovery interviews” to explore patients’ experiences of attending a central London walk-in sexual health clinic. In the second part, we asked patients how they would respond to eight standard patient experience survey questions and to provide an explanation for each of their responses. We conducted a thematic analysis of the interview data. Results We interviewed seventeen participants (nine women, eight men) of different ethnicities and backgrounds. All interviewees were positive about their experience. They described how staff had made them feel “comfortable”, and talked about how staff spent time, listened and did not rush them, despite being a very busy clinic. In response to the survey questions, fourteen patients rated their as care excellent or very good overall. However, survey questions were interpreted in different ways and were not always easily understood. Conclusions The open-ended “discovery interviews” provided new insights into aspects of care that were most valued or could improve. Standard patient experience questions provide a rating but little elucidation of the experiences that lie behind patients’ responses. They do not always measure aspects of care valued by patients or identify areas for improvement. They are not uniformly understood and necessarily collapse a wide range of experiences and views into categories that may seem inappropriate. Qualitative methods have a key role in measuring patient experience and involving patients in service improvement

Duodenal-Jejunal bypass liner for the management of Type 2 Diabetes mellitus and obesity - a multicenter randomized controlled trial

Objective: The aim of this study was to examine the clinical efficacy and safety of the duodenal-jejunal bypass liner (DJBL) while in situ for 12 months and for 12 months after explantation. Summary Background Data: This is the largest randomized controlled trial (RCT) of the DJBL, a medical device used for the treatment of people with type 2 diabetes mellitus (T2DM) and obesity. Endoscopic interventions have been developed as potential alternatives to those not eligible or fearful of the risks of metabolic surgery. Methods: In this multicenter open-label RCT, 170 adults with inadequately controlled T2DM and obesity were randomized to intensive medical care with or without the DJBL. Primary outcome was the percentage of participants achieving a glycated hemoglobin reduction of ≥20% at 12 months. Secondary outcomes included weight loss and cardiometabolic risk factors at 12 and 24 months. Results: There were no significant differences in the percentage of patients achieving the primary outcome between both groups at 12 months [DJBL 54.6% (n = 30) vs control 55.2% (n = 32); odds ratio (OR) 0.93, 95% confidence interval (CI): 0.44–2.0; P = 0.85]. Twenty-four percent (n = 16) patients achieved ≥15% weight loss in the DJBL group compared to 4% (n = 2) in the controls at 12 months (OR 8.3, 95% CI: 1.8–39; P = .007). The DJBL group experienced superior reductions in systolic blood pressure, serum cholesterol, and alanine transaminase at 12 months. There were more adverse events in the DJBL group. Conclusions: The addition of the DJBL to intensive medical care was associated with superior weight loss, improvements in cardiometabolic risk factors, and fatty liver disease markers, but not glycemia, only while the device was in situ. The benefits of the devices need to be balanced against the higher rate of adverse events when making clinical decisions

Untangling approaches to management and leadership across systems of medical education

Aims: How future doctors might be educated and trained in order to meet the population and system needs of countries is currently being debated. Incorporation of a broad range of capabilities, encompassed within categories of management and, increasingly, leadership, form part of this discussion. The purpose of this paper is to outline a framework by which countries’ progress in this area might be assessed and compared. Methods: Key databases and journals related to this area were reviewed. From relevant articles potential factors impacting on the incorporation of aspects of management and leadership within medical education and training were identified. These factors were tested via an online survey during 2013 with six members of a European Association of doctors who promote medical involvement in hospital management, including members from countries less represented in the health management literature. Results: A framework for analysing how management and leadership education is being approached within different systems of healthcare is developed and presented. Conclusions: More systematic work across a wider range of countries is needed if we are to have a better understanding of how countries within and beyond Europe are approaching and progressing the education of doctors in management and leadership. Keywords: Medical education, Management, Leadership, Competency framework

Foot health education for people with rheumatoid arthritis —some patient perspectives

Background: Patient education is an important component of foot health management for people with rheumatoid arthritis (RA). The content and strategies for delivery require investigation in relation to the patients’needs. This study explores patients’ experiences of foot health education, to inform how the patients’ needs could be identified in clinical practice and inform effective education delivery. Method: A focus group was used to collect data. The dialogue was recorded digitally, transcribed verbatim and analysed using a structured thematic approach. Member checking and peer review added to credibility of the data. Six themes emerged; (i) content and purpose of patient education – what it should be, (ii) content of patient education – what it should not be, (iii) timing of information on foot health, (iv) method of delivery, (v) ability to engage with foot health education and (vi) the patient/practitioner relationship. Conclusions: This study identified aspects of patient education considered important by this group of patients in relation to content, timing and delivery, forming the basis for further research on clinical and patient focussed outcomes of patient education. Identifying health education needs and provision of supportive verbal and written information can foster an effective therapeutic relationship, supporting effective foot health education for people with RA