Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

Background Current NHS policy favours the expansion of diagnostic testing services in community and primary care settings. Objectives Our objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community. Review methods We performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion. Results We identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed. Conclusions In the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control. Limitations We have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers. Future work There is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area. Funding The National Institute for Health Research Health Services and Delivery Research programme

European Society of Cardiology: Cardiovascular Disease Statistics 2019

Aims The 2019 report from the European Society of Cardiology (ESC) Atlas provides a contemporary analysis of cardiovascular disease (CVD) statistics across 56 member countries, with particular emphasis on international inequalities in disease burden and healthcare delivery together with estimates of progress towards meeting 2025 World Health Organization (WHO) non-communicable disease targets. Methods and results In this report, contemporary CVD statistics are presented for member countries of the ESC. The statistics are drawn from the ESC Atlas which is a repository of CVD data from a variety of sources including the WHO, the Institute for Health Metrics and Evaluation, and the World Bank. The Atlas also includes novel ESC sponsored data on human and capital infrastructure and cardiovascular healthcare delivery obtained by annual survey of the national societies of ESC member countries. Across ESC member countries, the prevalence of obesity (body mass index ≥30 kg/m2) and diabetes has increased two- to three-fold during the last 30 years making the WHO 2025 target to halt rises in these risk factors unlikely to be achieved. More encouraging have been variable declines in hypertension, smoking, and alcohol consumption but on current trends only the reduction in smoking from 28% to 21% during the last 20 years appears sufficient for the WHO target to be achieved. The median age-standardized prevalence of major risk factors was higher in middle-income compared with high-income ESC member countries for hypertension {23.8% [interquartile range (IQR) 22.5–23.1%] vs. 15.7% (IQR 14.5–21.1%)}, diabetes [7.7% (IQR 7.1–10.1%) vs. 5.6% (IQR 4.8–7.0%)], and among males smoking [43.8% (IQR 37.4–48.0%) vs. 26.0% (IQR 20.9–31.7%)] although among females smoking was less common in middle-income countries [8.7% (IQR 3.0–10.8) vs. 16.7% (IQR 13.9–19.7%)]. There were associated inequalities in disease burden with disability-adjusted life years per 100 000 people due to CVD over three times as high in middle-income [7160 (IQR 5655–8115)] compared with high-income [2235 (IQR 1896–3602)] countries. Cardiovascular disease mortality was also higher in middle-income countries where it accounted for a greater proportion of potential years of life lost compared with high-income countries in both females (43% vs. 28%) and males (39% vs. 28%). Despite the inequalities in disease burden across ESC member countries, survey data from the National Cardiac Societies of the ESC showed that middle-income member countries remain severely under-resourced compared with high-income countries in terms of cardiological person-power and technological infrastructure. Under-resourcing in middle-income countries is associated with a severe procedural deficit compared with high-income countries in terms of coronary intervention, device implantation and cardiac surgical procedures. Conclusion A seemingly inexorable rise in the prevalence of obesity and diabetes currently provides the greatest challenge to achieving further reductions in CVD burden across ESC member countries. Additional challenges are provided by inequalities in disease burden that now require intensification of policy initiatives in order to reduce population risk and prioritize cardiovascular healthcare delivery, particularly in the middle-income countries of the ESC where need is greatest

Pocket-size ultrasound, a new diagnostic tool in clinical practice

PhD i medisinsk teknologiPhD in Medical Technolog

KNOWING PATIENTS AS PERSONS: A theory-driven, qualitative study of the relevance of person-related knowledge in primary health care

Norsk sammenfatning: Kunnskap om pasienter som personer. En teori-drevet kvalitative studie av relevansen personrelatert kunnskap kan ha i primærhelsetjenesten. Det er økende dokumentasjon for at belastende livserfaring og alvorlige hendelser i livet kan være utslagsgivende for helsa, noe vi i dag har fått innsikt i bl.a. ved hjelp av moderne kunnskap om stressfysiologi. Den nye fagkunnskapen tilsier at biografisk og personrelatert kunnskap om pasienter er medisinsk relevant, men slik kunnskap har tradisjonelt blitt lite vektlagt innenfor biomedisinen; den dominerende forståelsesrammen for dagens medisinske praksis. Det overordnede formålet med dette prosjektet har vært å utforske og å identifisere hva allmennlegers personrelaterte kunnskap om egne pasienter består av, og om allmennleger vurderer slik kunnskap som medisinsk relevant. Videre å undersøke i hvilken grad pasienter som er innlagt til et kortvarig rehabiliteringsopphold validerer informasjonen fra sin fastlege med hensyn til personrelatert kunnskap, samt å utforske om denne kunnskapen ble gjort relevant under oppholdet. Prosjektet har blitt gjennomført innenfor rammen av to typer studier; fokusgruppeintervju av allmennleger og en intervensjonsstudie på en rehabiliteringsavdeling på et sykehjem. I første del ble to grupper av allmennleger (seniorer med mye erfaring og juniorer med mindre erfaring) bedt om å diskutere i hvilken grad de har slik kunnskap om pasienter og om denne kunnskapen kan være medisinsk relevant (artikkel I). I intervensjonsstudien ble fastleger telefonintervjuet om deres pasienter som nylig hadde blitt innlagt på en rehabiliteringsavdeling på et sykehjem. Informasjonen fra telefonintervjuene ble sammenholdt med hva pasientene kunne fortelle om seg selv og sin livshistorie i påfølgende individuelle dybdeintervjuer. På den måten kunne vi utforske i hvilken grad allmennlegene faktisk hadde personrelatert kunnskap om sine pasienter. Både fastlegene - og pasientene selv- ble også spurt om hva de mente var vesentlig å legge vekt på under rehabiliteringsoppholdet (artikkel II). I artikkel III har vi sammenlignet og diskutert tre ulike perspektiver på pasientenes behov når de ble innlagt i rehabiliteringsavdelingen; 1) fastlegens anbefaling på vegne av sin pasient 2) hva pasienten selv vurderte som mest sentralt og 3) hvordan institusjonen responderte på disse individuelle behovene. Både erfarne og mindre erfarne allmennleger som deltok i fokusgruppene vektla personrelatert kunnskap om pasienter som viktig, og identifiserte flere hindre som gjør det vanskelig å dokumentere og overføre slik kunnskap til annet helsepersonell. De erfarne allmennlegene vektla personrelatert kunnskap om pasienter som medisinsk relevant i større grad enn de mindre erfarne legene. De fleste av fastlegene som deltok i intervensjonsstudien var i stand til å gi en adekvat beskrivelse av pasientenes personlighet, og de hadde mye kunnskap om pasientenes yrkesliv og nære relasjoner (partner, barn). Fastlegene hadde mindre kunnskap om pasientenes interesser (hobbyer, fritidsaktiviteter), sosialt nettverk og relasjoner til foreldre og søsken. Fastlegene hadde lite eller ingen kunnskap om pasientenes barndom, oppvekst vilkår og betydningsfulle livshendelser. Noen av fastlegene ble overrasket over hvor lite de egentlig visste om pasienter som de hadde kjent i mange år (gjennomsnitt varighet av lege-pasient forhold var 15 år). De fastlegene som hadde et mer personlig lege-pasient forhold til sine pasienter var i større grad i stand til å formulere anbefalinger som stemte overens med pasientens uttrykte ønsker og behov. Pasientens ønsker og behov varierte mye, men var ofte nært knyttet til deres livsverden. Tiltross for institusjonens intensjon om å lage individuell behandlingsplaner for pasientene, var tilnærmingen i stor grad standardisert og tok i liten grad hensyn til allmennlegenes anbefalinger og pasientenes individuelle ønsker, selv der disse lå innenfor hva som hadde vært mulig å få til på institusjonen. I avhandlingens innledning gis en historisk fremstilling av en utvikling der pasienten som person ser ut til å ha blitt borte i medisinen. Avhandlingens tre artikler diskuterer behovet for en mer fleksibel og person-senteret tilnæring til pasienter slik at helsevesenet i større grad kan gjenvinne sin ”humanitet” og bli i stand til å gi genuint skreddersy behandling som i større grad tar hensyn til pasientens spesifikke og uttrykte behov. I avhandlingens diskusjonsdel beskrives ulike tilnærminger til hvordan personen kan gjeninnføres i medisinen, herunder en humanistisk og en teknologisk variant av persontilpasset medisin, foruten narrativt basert medisin

KNOWING PATIENTS AS PERSONS: A theory-driven, qualitative study of the relevance of person-related knowledge in primary health care

Norsk sammenfatning: Kunnskap om pasienter som personer. En teori-drevet kvalitative studie av relevansen personrelatert kunnskap kan ha i primærhelsetjenesten. Det er økende dokumentasjon for at belastende livserfaring og alvorlige hendelser i livet kan være utslagsgivende for helsa, noe vi i dag har fått innsikt i bl.a. ved hjelp av moderne kunnskap om stressfysiologi. Den nye fagkunnskapen tilsier at biografisk og personrelatert kunnskap om pasienter er medisinsk relevant, men slik kunnskap har tradisjonelt blitt lite vektlagt innenfor biomedisinen; den dominerende forståelsesrammen for dagens medisinske praksis. Det overordnede formålet med dette prosjektet har vært å utforske og å identifisere hva allmennlegers personrelaterte kunnskap om egne pasienter består av, og om allmennleger vurderer slik kunnskap som medisinsk relevant. Videre å undersøke i hvilken grad pasienter som er innlagt til et kortvarig rehabiliteringsopphold validerer informasjonen fra sin fastlege med hensyn til personrelatert kunnskap, samt å utforske om denne kunnskapen ble gjort relevant under oppholdet. Prosjektet har blitt gjennomført innenfor rammen av to typer studier; fokusgruppeintervju av allmennleger og en intervensjonsstudie på en rehabiliteringsavdeling på et sykehjem. I første del ble to grupper av allmennleger (seniorer med mye erfaring og juniorer med mindre erfaring) bedt om å diskutere i hvilken grad de har slik kunnskap om pasienter og om denne kunnskapen kan være medisinsk relevant (artikkel I). I intervensjonsstudien ble fastleger telefonintervjuet om deres pasienter som nylig hadde blitt innlagt på en rehabiliteringsavdeling på et sykehjem. Informasjonen fra telefonintervjuene ble sammenholdt med hva pasientene kunne fortelle om seg selv og sin livshistorie i påfølgende individuelle dybdeintervjuer. På den måten kunne vi utforske i hvilken grad allmennlegene faktisk hadde personrelatert kunnskap om sine pasienter. Både fastlegene - og pasientene selv- ble også spurt om hva de mente var vesentlig å legge vekt på under rehabiliteringsoppholdet (artikkel II). I artikkel III har vi sammenlignet og diskutert tre ulike perspektiver på pasientenes behov når de ble innlagt i rehabiliteringsavdelingen; 1) fastlegens anbefaling på vegne av sin pasient 2) hva pasienten selv vurderte som mest sentralt og 3) hvordan institusjonen responderte på disse individuelle behovene. Både erfarne og mindre erfarne allmennleger som deltok i fokusgruppene vektla personrelatert kunnskap om pasienter som viktig, og identifiserte flere hindre som gjør det vanskelig å dokumentere og overføre slik kunnskap til annet helsepersonell. De erfarne allmennlegene vektla personrelatert kunnskap om pasienter som medisinsk relevant i større grad enn de mindre erfarne legene. De fleste av fastlegene som deltok i intervensjonsstudien var i stand til å gi en adekvat beskrivelse av pasientenes personlighet, og de hadde mye kunnskap om pasientenes yrkesliv og nære relasjoner (partner, barn). Fastlegene hadde mindre kunnskap om pasientenes interesser (hobbyer, fritidsaktiviteter), sosialt nettverk og relasjoner til foreldre og søsken. Fastlegene hadde lite eller ingen kunnskap om pasientenes barndom, oppvekst vilkår og betydningsfulle livshendelser. Noen av fastlegene ble overrasket over hvor lite de egentlig visste om pasienter som de hadde kjent i mange år (gjennomsnitt varighet av lege-pasient forhold var 15 år). De fastlegene som hadde et mer personlig lege-pasient forhold til sine pasienter var i større grad i stand til å formulere anbefalinger som stemte overens med pasientens uttrykte ønsker og behov. Pasientens ønsker og behov varierte mye, men var ofte nært knyttet til deres livsverden. Tiltross for institusjonens intensjon om å lage individuell behandlingsplaner for pasientene, var tilnærmingen i stor grad standardisert og tok i liten grad hensyn til allmennlegenes anbefalinger og pasientenes individuelle ønsker, selv der disse lå innenfor hva som hadde vært mulig å få til på institusjonen. I avhandlingens innledning gis en historisk fremstilling av en utvikling der pasienten som person ser ut til å ha blitt borte i medisinen. Avhandlingens tre artikler diskuterer behovet for en mer fleksibel og person-senteret tilnæring til pasienter slik at helsevesenet i større grad kan gjenvinne sin ”humanitet” og bli i stand til å gi genuint skreddersy behandling som i større grad tar hensyn til pasientens spesifikke og uttrykte behov. I avhandlingens diskusjonsdel beskrives ulike tilnærminger til hvordan personen kan gjeninnføres i medisinen, herunder en humanistisk og en teknologisk variant av persontilpasset medisin, foruten narrativt basert medisin.Abstract: A growing body of research documents, that adverse life experiences can have a decisive impact on people’s health. However, traditional biomedicine, the dominant perspective through which today’s medical practice is conceptualized, has placed little emphasis on expert findings, such as those within modern stress physiology, indicating that biographical and person-related knowledge have medical relevance. The primary aim of this project was to explore the person-related knowledge general practitioners (GPs) had about their patients and the degree to which they ascribed medical relevance to it. We also sought to assess the importance given to person-related knowledge by patients undergoing rehabilitation, and to explore the interactions between GPs and health care personnel at a nursing home rehabilitation unit regarding the transfer of such knowledge. The project consisted of three phases. In practice, these were carried out within the framework of two consecutive studies: first, focus group interviews with GPs and, later, a two-part intervention study at a nursing home rehabilitation unit. In the first phase, (focus group interview study), two sets of GPs (seniors with more experience, and juniors with less) were asked to discuss the extent to which knowledge about patients as persons might be medically relevant. The next two phases were carried out within the context of the intervention study. GPs were interviewed by telephone regarding the person-related knowledge they had about patients who had recently been referred to a nursing home rehabilitation unit. Information from those interviews was then compared to what the patients themselves related during indepth interviews. In this way, we could determine the extent and accuracy of the personrelated knowledge GPs actually had acquired. In the final phase of the project, we discussed the patients’ needs upon admission from three perspectives: 1) the GPs’ recommendations on the patients’ behalf; 2) the needs the patients themselves considered most important to have addressed; 3) how the institution responded to the patients’ individual needs. Both groups of focus study GPs considered person-related knowledge about patients to be important, those with more experience attributing greater relevance to it than those with less experience. Members of both groups identified various factors complicating both the documentation of such information and its transfer to other health care personnel. Most of the GPs participating in the intervention study could describe the personality of their patients adequately and, to some extent, their working life and close relationships (partner,children). They had less knowledge about their patients’ interests (hobbies, activities), social networks and relationships to parents and siblings. They had little or no knowledge, however, about their patients’ childhood as regards either facts or conditions, or significant events or experiences. Some of the GPs expressed surprise at how little they actually knew, even about people whom they had been treating for many years (15 years was the average duration of the doctor-patient relationships). While all the GPs were able to formulate treatment/rehabilitation recommendations for their patients, the suggestions of the physicians with more personal knowledge of their patients came closer to reflecting the needs and wishes expressed by the patients themselves. These varied greatly, often connected to the patients’ living conditions and life-world. The institution’s expressed intention was to create individualized patient treatment plans. Nonetheless, those composed by the rehabilitation personnel consisted primarily of standardized elements. Even though many of the GPs’ recommendations and the patients’ wishes fell well within what the institution was equipped to offer, these were barely addressed by or integrated into the treatment actually provided. All three articles upon which this dissertation is based discuss the need for a more flexible and person-oriented approach to patients. This would enable public health services to provide more genuinely tailored treatment which, to a greater extent, takes the individual patient’s specific life-world into consideration

Finding their place – general practitioners' experiences with palliative care—a Norwegian qualitative study

Abstract Background Modern palliative care focuses on enabling patients to spend their remaining time at home, and dying comfortably at home, for those patients who want it. Compared to many European countries, few die at home in Norway. General practitioners’ (GPs’) involvement in palliative care may increase patients’ time at home and achievements of home death. Norwegian GPs are perceived as missing in this work. The aim of this study is to explore GPs’ experiences in palliative care regarding their involvement in this work, how they define their role, and what they think they realistically can contribute towards palliative patients. Methods We performed focus group interviews with GPs, following a semi-structured interview guide. We included four focus groups with a total of 25 GPs. Interviews were recorded and transcribed verbatim. We performed qualitative analysis on these interviews, inspired by interpretative phenomenological analysis. Results Strengths of the GP in the provision of palliative care consisted of characteristics of general practice and skills they relied on, such as general medical knowledge, being coordinator of care, and having a personal and longitudinal knowledge of the patient and a family perspective. They generally had positive attitudes but differing views about their formal role, which was described along three positions towards palliative care: the highly involved, the weakly involved, and the uninvolved GP. Conclusion GPs have evident strengths that could be important in the provision of palliative care. They rely on general medical knowledge and need specialist support. They had no consensus about their role in palliative care. Multiple factors interact in complex ways to determine how the GPs perceive their role and how involved they are in palliative care. GPs may possess skills and knowledge complementary to the specialized skills of palliative care team physicians. Specialized teams with extensive outreach activities should be aware of the potential they have for both enabling and deskilling GPs

Perceptions of the medical relevance of patients` stories of painful and adverse life experiences: a focus group study among Norwegian General Practitioners

Purpose Adverse life experiences increase the risk of health problems. Little is known about General Practitioners’ (GPs') thoughts, clinical concepts, and work patterns related to eliciting, including, or excluding their patients’ stories of painful and adverse life experiences. We wanted to explore GPs’ perceptions of the medical relevance of stories of painful and adverse life experiences, and to focus on what hinders or facilitates working with such stories. Method Eighteen Norwegian GPs participated in three focus group interviews. The interviews were analysed using reflexive thematic analysis. Results The participating GPs’ views on the clinical relevance of patients’ painful and adverse experiences varied considerably. Our analysis revealed two distinct stances: a confident-accepting stance, and an ambivalent-conditional stance. GPs encountered barriers to exploring such stories: scepticism on behalf of the medical discipline; scepticism on behalf of the patients; and, uncertainty regarding how to address stories of painful and adverse experiences in consultations. Work with painful stories was best facilitated when GPs manifested personal openness and prepared availability, within the context of a doctor-patient relationship based on trust. Conclusions Clearer processes for handling biographical information and life experiences that affect patients’ health are needed to facilitate the work of primary care physicians