Using information to deliver safer care: a mixed-methods study exploring general practitioners’ information needs in North West London primary care

The National Health Service in England has given increasing priority to improving inter-professional communication, enabling better management of patients with chronic conditions and reducing medical errors through effective use of information. Despite considerable efforts to reduce patient harm through better information usage, medical errors continue to occur, posing a serious threat to patient safety.This study explores the range, quality and sophistication of existing information systems in primary care with the aim to capture what information practitioners need to provide a safe service and identify barriers to its effective use in care pathways.Data were collected through semi-structured interviews with general practitioners from surgeries in North West London and a survey evaluating their experience with information systems in care pathways.Important information is still missing, specifically discharge summaries detailing medication changes and changes in the diagnosis and management of patients, blood results ordered by hospital specialists and findings from clinical investigations. Participants identified numerous barriers, including the communication gap between primary and secondary care, the variable quality and consistency of clinical correspondence and the inadequate technological integration.Despite attempts to improve integration and information flow in care pathways, existing systems provide practitioners with only partial access to information, hindering their ability to take informed decisions. This study offers a framework for understanding what tools should be in place to enable effective use of information in primary care

Development of the CHARIOT Research Register for the Prevention of Alzheimer’s Dementia and Other Late Onset Neurodegenerative Diseases

Identifying cognitively healthy people at high risk of developing dementia is an ever-increasing focus. These individuals are essential for inclusion in observational studies into the natural history of the prodromal and early disease stages and for interventional studies aimed at prevention or disease modification. The success of this research is dependent on having access to a well characterised, representative and sufficiently large population of individuals. Access to such a population remains challenging as clinical research has, historically, focussed on patients with dementia referred to secondary and tertiary services. The primary care system in the United Kingdom allows access to a true prodromal population prior to symptoms emerging and specialist referral. We report the development and recruitment rates of the CHARIOT register, a primary care-based recruitment register for research into the prevention of dementia. The CHARIOT register was designed specifically to support recruitment into observational natural history studies of pre-symptomatic or prodromal dementia stages, and primary or secondary prevention pharmaceutical trials or other prevention strategies for dementia and other cognitive problems associated with ageing.Participants were recruited through searches of general practice lists across the west and central London regions. Invitations were posted to individuals aged between 60 and 85 years, without a diagnosis of dementia. Upon consent, a minimum data set of demographic and contact details was extracted from the patient's electronic health record.To date, 123 surgeries participated in the register, recruiting a total of 24,509 participants-a response rate of 22.3%. The age, gender and ethnicity profiles of participants closely match that of the overall eligible population. Higher response rates tended to be associated with larger practices (r = 0.34), practices with a larger older population (r = 0.27), less socioeconomically disadvantaged practices (r = 0.68), and practices with a higher proportion of White patients (r = 0.82).Response rates are comparable to other registers reported in the literature, and indicate good interest and support for a research register and for participation in research for the prevention of age-related neurodegenerative diseases and dementia. We consider that the simplicity of the approach means that this system is easily scalable and replicable across the UK and internationally

Adherence of popular smoking cessation mobile applications to evidence-based guidelines

Background Smoking remains one of the major preventable causes of chronic diseases. Considering the promising evidence on the effectiveness of mobile technology for health behaviour change, along with the increasing adoption of smartphones, this review aims to systematically assess the adherence of popular mobile apps for smoking cessation to evidence-based guidelines. Methods The United Kingdom Android and iOS markets were searched in February 2018 to identify smoking cessation apps. After screening, 125 Android and 15 iOS apps were tested independently by two reviewers for adherence to the National Institute of Care and Excellence (NICE) Smoking Cessation Guidelines for Self-Help Materials and the Five A Guidelines for Smoking Cessation. Pearson chi square tests were run to examine differences between the two operating systems. Results A majority of apps across both operating systems had low adherence (fulfils 1–2 out of 5 guidelines) to the Five A Guidelines (65.7%) and low adherence (fulfils 1–3 out of 9 guidelines) to the NICE Smoking Cessation Guidelines for Self-Help Materials (63.6%). Only 15% of mobile apps provided information about the benefits of nicotine replacement therapy (NRT), and even fewer provided information regarding types of NRT products (7.1%) or how to use them (2.1%). In addition, only a minority of apps arrange follow-up appointments or provide additional support to help smokers quit. Conclusion Similar to previous mobile app reviews dating back to 2014, our findings show that most mobile apps do not follow existing smoking cessation treatment guidelines, indicating little change regarding the availability of evidence-based mobile apps for smoking cessation in the UK market. Smokers seeking to quit, tobacco control policy makers and software developers need to work together to develop apps that are in line with the latest clinical guidelines and strategies to maximise effectiveness

Engagement with gamification elements in a smoking cessation app and short-term smoking abstinence: a quantitative assessment

Background: Gamification in smoking cessation apps has been found to improve cognitive outcomes associated with higher odds of quitting. Although some research has shown that gamification can also positively impact behavioral outcomes such as smoking cessation, studies have largely focused on physical activity and mental health. Only a few studies have explored the effects of gamification on smoking cessation outcomes, of which the majority have adopted qualitative methodologies and/or assessed engagement with apps using self-report. Objective: This study aimed to explore levels of user engagement with gamification features in a smoking cessation app via in-app metrics. Specifically, the objective of this paper was to investigate whether higher engagement with gamification features is associated with the likelihood of quitting in the short term. Methods: Data from a larger online study that recruited smokers seeking to quit were analyzed to address the objectives presented in this paper. The study took place between June 2019 and July 2020, and participants were primarily recruited via social media posts. Participants who met the eligibility criteria used 1 of 2 mobile apps for smoking cessation. In-app metrics shared by the developer of one of the smoking cessation apps, called Kwit, were used to assess engagement with gamification features. Out of 58 participants who used the Kwit app, 14 were excluded due to missing data or low engagement with the app (ie, not opening the app once a week). For the remaining 44 participants, mean (SD) values were calculated for engagement with the app using in-app metrics. A logistic regression model was used to investigate the association between engagement with gamification and 7-day smoking abstinence. Results: In total, data from 44 participants who used the Kwit app were analyzed. The majority of participants were male, married, and employed. Almost 30% (n=13) of participants self-reported successful 7-day abstinence at the end of the study. On average, the Kwit app was opened almost 31 (SD 39) times during the 4-week study period, with the diary feature used the most often (mean 22.8, SD 49.3). Moreover, it was found that each additional level unlocked was associated with approximately 22% higher odds of achieving 7-day abstinence after controlling for other factors such as age and gender (odds ratio 1.22, 95% CI 1.01-1.47). Conclusions: This study highlights the likely positive effects of certain gamification elements such as levels and achievements on short-term smoking abstinence. Although more robust research with a larger sample size is needed, this research highlights the important role that gamification features integrated into mobile apps can play in facilitating and supporting health behavior change

Regulatory standards and guidance for the use of health applications for self-management in Africa: scoping review protocol

Introduction: Despite health applications becoming ubiquitous and with enormous potential to facilitate self-management, regulatory challenges such as poor application quality, breach of data privacy and limited interoperability have impeded their full adoption. While many countries now have digital health-related policies/strategies, there is also a need for regulatory standards and guidance that address key regulatory challenges associated with the use of health applications. Currently, it is unclear the status of countries in Africa regarding regulatory standards and guidance that address the use of health applications. This protocol describes the process of conducting a scoping review which aims to investigate the extent to which regulatory standards and guidance address the use of health applications for self-management within the WHO African Region countries. Methods: The review will follow the methodological framework for conducting a scoping study by Arksey and O’Malley (2005), and the updated methodological guidance for conducting a Joanna Briggs Institute (JBI) scoping review. Given that regulatory standards and guidance are unlikely to be available in scientific databases, we will search Scopus, Google, OpenGrey, WHO Regional Office for Africa Library (AFROLIB), African Index Medicus (AIM), websites of WHO, ITU and Ministries of Health, repositories for digital health policies. We will also search the reference lists of included documents, and contact key stakeholders in the region. Results will be reported using descriptive qualitative content analysis based on the review objectives. The policy analysis framework by Walt and Gilson (1994) will be used to organise findings. A summary of the key findings will be presented using tables, charts and maps. Ethics and dissemination: The collection of primary data is not anticipated in this study and hence ethical approval will not be required. The review will be published in a peer-reviewed journal while key findings will be shared with relevant organisations and/or presented at conferences

Estimating blood pressure trends and the nocturnal dip from photoplethysmography

Objective: Evaluate a method for the estimation of the nocturnal systolic blood pressure dip from 24-hour blood pressure trends using a wrist-worn Photoplethysmography (PPG) sensor and a deep neural network in free-living individuals, comparing the deep neural network to traditional machine learning and non-machine learning baselines. Approach: A wrist-worn PPG sensor was worn by 106 healthy individuals for 226 days during which 5111 reference values for blood pressure were obtained with a 24-hour ambulatory blood pressure monitor as ground truth and matched with the PPG sensor data. Features based on heart rate variability and pulse morphology were extracted from the PPG waveforms. Machine learning models (linear regression, random forests, dense neural networks and long- and short-term memory neural networks) were then trained and evaluated in their capability of tracking trends in systolic and diastolic blood pressure, as well as the estimation of the nocturnal systolic blood pressure dip. Main results Best performance was obtained with a deep long- and shortterm memory neural network with a Root Mean Squared Error (RMSE) of 3.12±2.20 ∆mmHg and a correlation of 0.69 (p = 3 ∗ 10−5) with the ground truth Systolic Blood Pressure (SBP) dip. This dip was derived from trend estimates of blood pressure which had an RMSE of 8.22±1.49 mmHg for systolic and 6.55±1.39 mmHg for diastolic blood pressure. The random forest model showed slightly lower average error magnitude for SBP trends (7.86±1.57 mmHg), however Bland-Altmann analysis revealed systematic problems in its predictions that were less present in the long- and short-term memory model. Significance The work provides first evidence for the unobtrusive estimation of the nocturnal blood pressure dip, a highly prognostic clinical parameter. It is also the first to evaluate unobtrusive blood pressure measurement in a large data set of unconstrained 24-hour measurements in free-living individuals and provides evidence for the utility of long- and short-term models in this domain

The Importance of form field validation: lessons learnt from a feasibility study of an mHealth application in Malawi, Africa

Measuring adherence to clinical guidelines using mobile health (mHealth) technologies when form field validation is enforced or turned on could potentially be viewed as skewing the dataset, leading to 100% adherence to the clinical rule base. In theory, healthcare providers should fully abide by clinical guidelines, whether in paper or digital format, to ensure that the patient receives appropriate care. However, what happens when mHealth form field validation is turned off? As part of a feasibility study in Malawi, Africa, we explored this phenomenon. Switching off validation on the mHealth artefact served its purpose within the context of a feasibility study where a parallel paper-based clinical assessment process remained in place. The design of this technical artefact with the turnkey validation feature afforded us the opportunity to turn validation on and off seamlessly. Ultimately, from an ethical, clinical and technical perspective the optimum approach is to ensure that form field validation is switched on. With form field validation on adherence to the clinical guidelines is enforced which minimises incomplete assessment and the potential for suboptimal clinical decisions that could adversely affect patient care

Training community healthcare workers on the use of information and communication technologies: a randomised controlled trial of traditional versus blended learning in Malawi, Africa

Background: Despite the increasing uptake of information and communication technologies (ICT) within healthcare services across developing countries, community healthcare workers (CHWs) have limited knowledge to fully utilise computerised clinical systems and mobile apps. The ‘Introduction to Information and Communication Technology and eHealth’ course was developed with the aim to provide CHWs in Malawi, Africa, with basic knowledge and computer skills to use digital solutions in healthcare delivery. The course was delivered using a traditional and a blended learning approach. Methods: Two questionnaires were developed and tested for face validity and reliability in a pilot course with 20 CHWs. Those were designed to measure CHWs’ knowledge of and attitudes towards the use of ICT, before and after each course, as well as their satisfaction with each learning approach. Following validation, a randomised controlled trial was conducted to assess the effectiveness of the two learning approaches. A total of 40 CHWs were recruited, stratified by position, gender and computer experience, and allocated to the traditional or blended learning group using block randomisation. Participants completed the baseline and follow-up questionnaires before and after each course to assess the impact of each learning approach on their knowledge, attitudes, and satisfaction. Per-item, pre-post and between-group, mean differences for each approach were calculated using paired and unpaired t-tests, respectively. Per-item, between-group, satisfaction scores were compared using unpaired t-tests. Results: Scores across all scales improved after attending the traditional and blended learning courses. Self-rated ICT knowledge was significantly improved in both groups with significant differences between groups in seven domains. However, actual ICT knowledge scores were similar across groups. There were no significant differences between groups in attitudinal gains. Satisfaction with the course was generally high in both groups. However, participants in the blended learning group found it more difficult to follow the content of the course. Conclusions: This study shows that there is no difference between blended and traditional learning in the acquisition of actual ICT knowledge among community healthcare workers in developing countries. Given the human resource constraints in remote resource-poor areas, the blended learning approach may present an advantageous alternative to traditional learning

Integrated care pilot in north-west London: a mixed methods evaluation

Introduction: This paper provides the results of a year-long evaluation of a large-scale integrated care pilot in north-west London. The pilot aimed to integrate care across primary, acute, community, mental health and social care for people with diabetes and/or those aged 75+ through care planning, multidisciplinary case reviews, information sharing and project management support. Methods: The evaluation team conducted qualitative studies of change at organisational, clinician and patient levels (using interviews, focus groups and a survey); and quantitative analysis of change in service use and patient-level clinical outcomes (using patient-level datasets and a matched control study). Results: The pilot had successfully engaged provider organisations, created a shared strategic vision and established governance structures. However, the engagement of clinicians was variable and there was no evidence to date of significant reductions in emergency admissions. There was some evidence of changes in care processes. Conclusion: Although the pilot has demonstrated the beginnings of large-scale change, it remains in the early stages and faces significant challenges as it seeks to become sustainable for the longer term. It is critical that National Health Service managers and clinicians have realistic expectations of what can be achieved in a relatively short period of time

Codesigning a Measure of Person-Centred Coordinated Care to Capture the Experience of the Patient: The Development of the P3CEQ

Background: Person-centred coordinated care (P3C) is a priority for stakeholders (ie, patients, carers, professionals, policy makers). As a part of the development of an evaluation framework for P3C, we set out to identify patient-reported experience measures (PREMs) suitable for routine measurement and feedback during the development of services. Methods: A rapid review of the literature was undertaken to identity existing PREMs suitable for the probing person-centred and/or coordinated care. Of 74 measures identified, 7 met our inclusion criteria. We critically examined these against core domains and subdomains of P3C. Measures were then presented to stakeholders in codesign workshops to explore acceptability, utility, and their strengths/weaknesses. Results: The Long-Term Condition 6 questionnaire was preferred for its short length, utility, and tone. However, it lacked key questions in each core domain, and in response to requests from our codesign group, new questions were added to cover consideration as a whole person, coordination, care plans, carer involvement, and a single coordinator. Cognitive interviews, on-going codesign, and mapping to core P3C domains resulted in the refinement of the questionnaire to 11 items with 1 trigger question. The 11-item modified version was renamed the P3C Experiences Questionnaire. Conclusions: Due to a dearth of brief measures available to capture people’s experience of P3C for routine practice, an existing measure was modified using an iterative process of adaption and validation through codesign workshops. Next steps include psychometric validation and modification for people with dementia and learning difficulties.</p