560 research outputs found
Evaluating the implementation and delivery of a social prescribing intervention: a research protocol
Background: In response to the increasing numbers of people with (multiple) chronic conditions, the need for integrated care is increasing too. Social prescribing is a new approach that aims to integrate the social and healthcare sector to improve the quality of care and user experience. Understanding main stakeholders’ perceptions and experiences is key to the implementation of social prescription and for informing future initiatives.
Objectives: This paper presents the protocol of a qualitative research study to explore factors that (i) facilitate and hinder the implementation of a social prescribing pilot in the East of England, and (ii) affect the uptake, adherence, and completion rates by service users.
Methods: A qualitative study including semi-structured interviews with managers, health professionals, service providers, navigators, and service users. Iterative thematic analysis will be used to analyse the data.
Conclusion: This study will produce evidence on factors that hinder and facilitate the implementation of a social prescribing programme, as well as factors affecting the engagement, and non-engagement, of service users. Findings can contribute to the development of an evidence base for social prescription programmes in the UK, and inform practice, policy, and future research in the field
Sensitivity of first trimester ultrasound in the detection of congenital anomalies in twin pregnancies: population study and systematic review.
INTRODUCTION: The first aim of this study was to ascertain the diagnostic performance of first trimester ultrasound in detecting congenital anomalies in twins. The secondary aim was to explore the strength of association between different pregnancy characteristics and early detection of structural anomalies in a large unselected population of twin pregnancies. A systematic review of the published literature was also carried out MATERIAL AND METHODS: Retrospective analysis of prospectively collected data from consecutive twin pregnancies booked for antenatal care from 1996 till 2014. Predictive accuracy of those covariates independently associated with the occurrence of fetal anomalies were assessed with logistic regression analysis and ROC curves RESULTS: 1064 twin pregnancies (820 dichorionic and 264 monochorionic) were included in the analysis. 42 pregnancies had one or more fetuses with structural abnormalities. Detection of structural abnormalities using ultrasound was possible in the first trimester in 27.3% (95% CI: 15.0-42.8) of twin pregnancies. Mono-chorionicity (OR 2.3, 95% CI: 1.1-4.7) and discordance in crown-rump length and nuchal translucency were associated with an increased risk of fetal anomalies. However, their predictive accuracy was only moderate (AUC: 0.67, 95% CI: 0.6-0.8 and 0.68, 95% CI: 0.6 - 0.8, for crown-rump length and nuchal translucency discrepancy respectively CONCLUSIONS: First trimester detection of structural abnormalities in twin pregnancies is possible in 27.3% (95% CI: 15.0-42.8) of cases. The likelihood for first trimester detection of structural anomalies in twins was maximum for cranial vault, midline brain and abdominal wall defects. Monochorionicity and increasing discrepancy in crown-rump length and nuchal translucency were associated with fetal structural abnormalities, although their predictive performance was only moderately good. This article is protected by copyright. All rights reserved
Mobility and Maternal Position during Childbirth in Tanzania: An Exploratory Study at Four Government Hospitals.
Emerging research evidence suggests a potential benefit in being upright in the first stage of labour and a systematic review of trials suggests both benefits and harmful effects associated with being upright in the second stage of labour. Implementing evidence-based obstetric care in African countries with scarce resources is particularly challenging, and requires an understanding of the cumulative nature of science and commitment to applying the most up to date evidence to clinical decisions. In this study, we documented current practice rates, explored the barriers and opportunities to implementing these procedures from the provider perspective, and documented women's preferences and satisfaction with care. This was an exploratory study using quantitative and qualitative methods. Practice rates were determined by exit interviews with a consecutive sample of postnatal women. Provider views were explored using semi-structured interviews (with doctors and traditional birth attendants) and focus group discussions (with midwives). The study was conducted at four government hospitals, two in Dar es Salaam and two in the neighbouring Coast region, Tanzania. MAIN OUTCOME MEASURES: Practice rates for mobility during labour and delivery position; women's experiences, preferences and views about the care provided; and provider views of current practice and barriers and opportunities to evidence-based obstetric practice. Across all study sites more women were mobile at home (15.0%) than in the labour ward (2.9%), but movement was quite restricted at home before women were admitted to labour ward (51.6% chose to rest with little movement). Supine position for delivery was used routinely at all four hospitals; this was consistent with women's preferred choice of position, although very few women are aware of other positions. Qualitative findings suggest obstetricians and midwives favoured confining to bed during the first stage of labour, and supine position for delivery. The barriers to change appear to be complicated and require providers to want to change, and women to be informed of alternative positions during the first stage of labour and delivery. We believe that highlighting the gap between actual practice and current evidence provides a platform for dialogue with providers to evaluate the threats and opportunities for changing practice
Reducing avoidable inequalities in health: a new criterion for setting health care capitation payments
Traditionally, most health care systems which pretend to any sort of rationality and cost control have sought to allocate their limited funds in order to secure equal opportunity of access for equal need. The UK government is implementing a fundamental change of resource allocation philosophy towards contributing to the reduction of avoidable health inequalities. The purpose of this essay is to explore some of the economic issues that arise when seeking to allocate health care resources according to the new criterion. It indicates that health inequalities might arise because of variations in the quality of health services, variations in access to those services, or variations in the way people produce health, and that the resource allocation consequences differ depending on which source is being addressed. The paper shows that an objective of reducing health inequalities is not necessarily compatible with an objective of equity of access, nor with the objective of maximising health gain. The results have profound consequences for approaches towards economic evaluation, the role of clinical guidelines and performance management, as well as for resource allocation methods
Small fetal thymus and adverse obstetrical outcome: a systematic review and a meta-analysis.
INTRODUCTION: To explore the association between small fetal thymus on ultrasound and adverse obstetrical outcome. MATERIAL AND METHODS: Medline, Embase, Cochrane and Web of Science databases were searched. Primary outcome was the risk of preterm birth before 37 and 34 weeks in fetuses with compared to those without a small thymus on ultrasound. SECONDARY OUTCOMES: occurrence of chorioamnionitis, intra-uterine growth restriction, neonatal sepsis, gestational age at birth, birthweight, neonatal morbidity and pre-eclampsia. RESULTS: Twelve studies including 1744 fetuses who had ultrasound assessment of thymus during pregnancy were included. Women with preterm premature rupture of the membranes (PPROM) or with preterm labour with a small fetal thymus were at higher risk of preterm birth <37 (p= 0.01), <34 (12.5 (p<0.001) weeks in fetuses with compared to those without small thymus, and the risk of chorioamnionitis was higher when the thymus was small (p<0.001). Fetuses with small thymus were not at higher risk of intra-uterine growth restriction (p= 0.3). A small thymus increased the risk of neonatal sepsis (p= 0.007) and morbidity (p= 0.003), but not the risk of pre-eclampsia (p= 0.9). CONCLUSIONS: A small fetal thymus is associated with a higher risk of preterm birth, chorioamnionitis, neonatal sepsis and morbidity, but not with intra-uterine growth restriction and pre-eclampsia. This article is protected by copyright. All rights reserved
The failure of suicide prevention in primary care: family and GP perspectives - a qualitative study
Background Although Primary care is crucial for suicide prevention, clinicians tend to report completed suicides in their care as non-preventable. We aimed to examine systemic inadequacies in suicide prevention from the perspectives of bereaved family members and GPs.Methods Qualitative study of 72 relatives or close friends bereaved by suicide and 19 General Practitioners who have experienced the suicide of patients.Results Relatives highlight failures in detecting symptoms and behavioral changes and the inability of GPs to understand the needs of patients and their social contexts. A perceived overreliance on anti-depressant treatment is a major source of criticism by family members. GPs tend to lack confidence in the recognition and management of suicidal patients, and report structural inadequacies in service provision.Conclusions Mental health and primary care services must find innovative and ethical ways to involve families in the decision-making process for patients at risk of suicide
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Improving outcomes for people in mental health crisis: a rapid synthesis of the evidence for available models of care
BACKGROUND: Crisis Concordat was established to improve outcomes for people experiencing a mental health crisis. The Crisis Concordat sets out four stages of the crisis care pathway: (1) access to support before crisis point; (2) urgent and emergency access to crisis care; (3) quality treatment and care in crisis; and (4) promoting recovery.
OBJECTIVES: To evaluate the clinical effectiveness and cost-effectiveness of the models of care for improving outcomes at each stage of the care pathway.
DATA SOURCES: Electronic databases were searched for guidelines, reviews and, where necessary, primary studies. The searches were performed on 25 and 26 June 2014 for NHS Evidence, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, NHS Economic Evaluation Database, and the Health Technology Assessment (HTA) and PROSPERO databases, and on 11 November 2014 for MEDLINE, PsycINFO and the Criminal Justice Abstracts databases. Relevant reports and reference lists of retrieved articles were scanned to identify additional studies.
STUDY SELECTION: When guidelines covered a topic comprehensively, further literature was not assessed; however, where there were gaps, systematic reviews and then primary studies were assessed in order of priority.
STUDY APPRAISAL AND SYNTHESIS METHODS: Systematic reviews were critically appraised using the Risk Of Bias In Systematic reviews assessment tool, trials were assessed using the Cochrane risk-of-bias tool, studies without a control group were assessed using the National Institute for Health and Care Excellence (NICE) prognostic studies tool and qualitative studies were assessed using the Critical Appraisal Skills Programme quality assessment tool. A narrative synthesis was conducted for each stage of the care pathway structured according to the type of care model assessed. The type and range of evidence identified precluded the use of meta-analysis.
RESULTS AND LIMITATIONS: One review of reviews, six systematic reviews, nine guidelines and 15 primary studies were included. There was very limited evidence for access to support before crisis point. There was evidence of benefits for liaison psychiatry teams in improving service-related outcomes in emergency departments, but this was often limited by potential confounding in most studies. There was limited evidence regarding models to improve urgent and emergency access to crisis care to guide police officers in their Mental Health Act responsibilities. There was positive evidence on clinical effectiveness and cost-effectiveness of crisis resolution teams but variability in implementation. Current work from the Crisis resolution team Optimisation and RElapse prevention study aims to improve fidelity in delivering these models. Crisis houses and acute day hospital care are also currently recommended by NICE. There was a large evidence base on promoting recovery with a range of interventions recommended by NICE likely to be important in helping people stay well.
CONCLUSIONS AND IMPLICATIONS: Most evidence was rated as low or very low quality, but this partly reflects the difficulty of conducting research into complex interventions for people in a mental health crisis and does not imply that all research was poorly conducted. However, there are currently important gaps in research for a number of stages of the crisis care pathway. Particular gaps in research on access to support before crisis point and urgent and emergency access to crisis care were found. In addition, more high-quality research is needed on the clinical effectiveness and cost-effectiveness of mental health crisis care, including effective components of inpatient care, post-discharge transitional care and Community Mental Health Teams/intensive case management teams.
STUDY REGISTRATION: This study is registered as PROSPERO CRD42014013279. FUNDING: The National Institute for Health Research HTA programme
Implementing iron management clinical practice guidelines in patients with chronic kidney disease having dialysis
The document attached has been archived with permission from the editor of the Medical Journal of Australia. An external link to the publisher’s copy is included.Objective: To evaluate the outcomes of and barriers to implementing standard guidelines (Caring for Australasians with renal impairment [CARI]), using iron management in patients having dialysis as an example. Design and setting: On-site review of iron management processes at six Australian dialysis units varying in size and locality. Patients’ iron indices and haemoglobin levels were obtained from the Australian and New Zealand Dialysis and Transplant Registry. Participants: Patients with chronic kidney disease who were dependent on dialysis. Main outcome measures: Processes for assessing indices of iron stores and iron supplementation; comparison with target indices in the CARI guidelines. Results: There was considerable variability among the units in achievement of haemoglobin and iron targets, with 25%–32% of patients achieving haemoglobin targets of 110–120 g/L, 30%–68% achieving ferritin targets of 300–800 μg/L, and 65%–73% achieving transferrin saturation targets of 20%–50%. Implementation barriers included lack of knowledge, lack of awareness of or trust in the CARI guideline, inability to implement the guideline, and inability to agree on a uniform unit protocol. Factors associated with achieving the CARI guideline targets included nurse-driven iron management protocols, use of an iron management decision aid, fewer nephrologists per dialysis unit, and a “proactive” (actively keeping iron levels within target range) rather than “reactive” (only reacting if iron levels are out of the range) protocol. Conclusions: Variability in achievement of iron targets, despite the availability of a clinical practice guideline, may be explained by variability in processes of care for achieving and maintaining adequate iron parameters.Michelle J Irving, Jonathan C Craig, Martin Gallagher, Stephen McDonald, Kevan R Polkinghorne, Rowan G Walker and Simon D Roge
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