Timely digital patient-clinician communication in specialist clinical services for young people : a mixed-methods study (the LYNC study)

BACKGROUND: Young people (aged 16-24 years) with long-term health conditions can disengage from health services, resulting in poor health outcomes, but clinicians in the UK National Health Service (NHS) are using digital communication to try to improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, and ethical and safety issues. OBJECTIVE: Our objective was to understand how the use of digital communication between young people with long-term conditions and their NHS specialist clinicians changes engagement of the young people with their health care; and to identify costs and necessary safeguards. METHODS: We conducted mixed-methods case studies of 20 NHS specialist clinical teams from across England and Wales and their practice providing care for 13 different long-term physical or mental health conditions. We observed 79 clinical team members and interviewed 165 young people aged 16-24 years with a long-term health condition recruited via case study clinical teams, 173 clinical team members, and 16 information governance specialists from study NHS Trusts. We conducted a thematic analysis of how digital communication works, and analyzed ethics, safety and governance, and annual direct costs. RESULTS: Young people and their clinical teams variously used mobile phone calls, text messages, email, and voice over Internet protocol. Length of clinician use of digital communication varied from 1 to 13 years in 17 case studies, and was being considered in 3. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged, particularly at times of change for young people. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver, but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information, and communication failures, which are mostly mitigated by young people and clinicians using common-sense approaches. CONCLUSIONS: As NHS policy prompts more widespread use of digital communication to improve the health care experience, our findings suggest that benefit is most likely, and harms are mitigated, when digital communication is used with patients who already have a relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments, or lived context. Clinical teams need a proactive approach to ethics, governance, and patient safety

In the (After) Life: Tracing Black Queer Spatialities under Regimes of Displacement, 1963-1989

"In the (After) Life: Tracing Black Queer Spatialities under Regimes of Displacement, 1963- 1989" is a dissertation that explores emotional geographies found within the artistic works of Black Queer cultural producers who witnessed and produced art in a context of Black mass displacement. Informed by the burgeoning field of Black Geographies, "In the (After) Life" comprises chapters that use archival research and narrative inquiry to analyze how madness and abjection constitute the Black Queer urban subject's everyday spatial practice. This dissertation will explore the notes and warnings of Black Queer cultural producers who speak intimately to the process of urban renewal as producing a structured otherness in real space-time. This dissertation will analyze these experiences of abjection from James Baldwin’s Take This Hammer (1963), Pat Parker's Jonestown and Other Madness (1984), and Marlon Riggs' Tongues Untied (1989). Primarily drawing from approaches in Queer of Color Critique, Critical Human Geographies, and Black Studies, "In the (After) Life" explores the term "Archive of Black Queer Spatialities" as a reference for Black Queer subjects creating a spatial response to displacement across multiple waves of urban restructuring in San Francisco. This dissertation closely reads the long history of urban renewal and the various forms that have taken place across the 20th century that has produced emotional geographies of abjection. These affective geographies have material consequences that this dissertation explores: neighborhood isolation, premature death, and mass criminalization. Ultimately, "In the (After) Life" provides a socio-spatial approach to reading anti-Blackness in the built environment of San Francisco

Cost-utility of real-time continuous glucose monitoring versus self-monitoring of blood glucose in people with insulin-treated Type II diabetes in France

Aim: Clinical trials and real-world data for Type II diabetes both show that glycated hemoglobin (HbA1c) levels and hypoglycemia occurrence can be reduced by real-time continuous glucose monitoring (rt-CGM) versus self-monitoring of blood glucose (SMBG). The present cost-utility study investigated the long-term health economic outcomes associated with using rt-CGM versus SMBG in people with insulin-treated Type II diabetes in France. Materials & methods: Effectiveness data were obtained from a real-world study, which showed rt-CGM reduced HbA1c by 0.56% (6.1 mmol/mol) versus sustained SMBG. Analyses were conducted using the IQVIA Core Diabetes Model. A French payer perspective was adopted over a lifetime horizon for a cohort aged 64.5 years with baseline HbA1c of 8.3% (67 mmol/mol). A willingness-to-pay threshold of €147,093 was used, and future costs and outcomes were discounted at 4% annually. Results: The analysis projected quality-adjusted life expectancy was 8.50 quality-adjusted life years (QALYs) for rt-CGM versus 8.03 QALYs for SMBG (difference: 0.47 QALYs), while total mean lifetime costs were €93,978 for rt-CGM versus €82,834 for SMBG (difference: €11,144). This yielded an incremental cost-utility ratio (ICUR) of €23,772 per QALY gained for rt-CGM versus SMBG. Results were particularly sensitive to changes in the treatment effect (i.e., change in HbA1c), annual price and quality of life benefit associated with rt-CGM, SMBG frequency, baseline patient age and complication costs. Conclusion: The use of rt-CGM is likely to be cost-effective versus SMBG for people with insulin-treated Type II diabetes in France

Timely Digital Patient-Clinician Communication in Specialist Clinical Services for Young People:A Mixed-Methods Study (The LYNC Study)

Background Young people (age 16-24 years) with long-term health conditions can disengage from health services resulting in poor health outcomes, but clinicians in the UK NHS are using digital communication to try and improve engagement. Evidence of effectiveness of this digital communication is equivocal. There are gaps in evidence as to how it might work, its cost, ethical and safety issues. Objectives To understand how the use of digital communication between young people with long-term conditions and their UK NHS specialist clinicians changes engagement of the young people with their health care; to identify costs and necessary safeguards. Methods Mixed method case studies of 20 NHS specialist clinical teams from across England and Wales and their current practice providing care for 13 different long-term physical or mental health conditions. Observation of 79 clinical team members; interviews with 165 young people aged 16-24 years living with a long-term health condition recruited via case study clinical teams, 173 clinical team members, 16 Information Governance Specialists from study NHS Trusts. Analysis: thematic analysis of how digital communication works; ethics, safety and governance; annual direct costs. Results Young people and their clinical teams variously used: mobile phone calls, text messages, email, Voice over Internet Protocol. Length of clinician use of digital communication varied from one to 13 years in 17 case studies, and was being considered in three. Digital communication enables timely access for young people to the right clinician at the time when it can make a difference to how they manage their health condition. This is valued as an addition to traditional clinic appointments and can engage those otherwise disengaged. It can enhance patient autonomy, empowerment and activation. It challenges the nature and boundaries of therapeutic relationships but can improve trust. The clinical teams studied had not themselves formally evaluated the impact of their intervention. Staff time is the main cost driver but offsetting savings are likely elsewhere in the health service. Risks include increased dependence on clinicians, inadvertent disclosure of confidential information and communication failures, which are mostly mitigated by young people and clinicians using common sense approaches. Conclusions Timely digital access to clinical teams is providing a flexible, personalised service for young people with long-term conditions. It engages young people with their health care including those who are otherwise hard to reach. As NHS policy prompts more widespread use of digital communication to improve health care experience, our findings suggest benefit is most likely, and harms mitigated, when used with patients where there is already an existing relationship of trust with the clinical team, and where there is identifiable need for patients to have flexible access, such as when transitioning between services, treatments or lived context. Clinical teams need a proactive approach to ethics, governance and patient safety