The ideal blood pressure: assessment of fixed and variant targets over time in clinical trial and routine clinical practice

Recent evaluation of the research evidence on blood pressure thresholds for intervention by the Scottish Intercollegiate Guidelines Network (SIGN) and the American Heart Association (AHA) led to different updated hypertension guidelines. The question remains what the ideal blood pressure is in hypertensive patients. In clinical trials, blood pressure targets are fixed and blood pressure is treated accordingly during the intervention time, however this is done in a selective group of patients for a relatively short follow-up of less than five years. In routine clinical practice, patients are observed during most of their lifetime and sequential treatment decisions are made in treating blood pressure according to the latest guideline. These data qualities make the assessment of blood pressure targets complex. In this study, various Cox’s proportional hazards regression models were fitted to assess the time-variant effect of blood pressure targets on survival and chronic kidney disease outcomes (main adverse effect of antihypertensive treatment) using US Systolic Blood Pressure Intervention Trial (SPRINT) data and UK The Health Improvement Network (THIN) primary care data. The studied systolic blood pressure targets were <140 mmHg (standard treatment in routine clinical practice in the UK and previously also in the US) and <120 mmHg (intensive treatment). This work was supported by the Institute and Faculty of Actuaries (IFoA) and by the Business and Local Government Data Research Centre [grant ES/L011859/1]

Cholesteatoma and family history: An international survey

Objective To explore the relative frequency of a family history of cholesteatoma in patients with known cholesteatoma, and whether bilateral disease or earlier diagnosis is more likely in those with a family history. Associations between cleft lip or palate and bilateral disease and age of diagnosis were also explored. Design An online survey of patients with diagnosed cholesteatoma was conducted between October 2017 and April 2019. Participants The sample consisted of patients recruited from two UK clinics and self‐selected respondents recruited internationally via social media. Main outcome measures Side of cholesteatoma, whether respondents had any family history of cholesteatoma, age of diagnosis and personal or family history of cleft lip or palate were recorded. Results Of 857 respondents, 89 (10.4%) reported a positive family history of cholesteatoma. Respondents with a family history of cholesteatoma were more likely to have bilateral cholesteatoma (P = .001, odds ratio (OR) 2.15, 95% confidence interval (CI) 1.35‐3.43), but there was no difference in the age of diagnosis (P = .23). Those with a history of cleft lip or palate were not more likely to have bilateral disease (P = .051, OR 2.71, CI 1.00‐7.38), and there was no difference in age of diagnosis (P = .11). Conclusion The relatively high proportion of respondents that reported a family history of cholesteatoma offers supporting evidence of heritability in cholesteatoma. The use of social media to recruit respondents to this survey means that the results cannot be generalised to other populations with cholesteatoma. Further population‐based research is suggested to determine the heritability of cholesteatoma

The paradox of coaching in a non-native language

Purpose. Language plays a complex role in coaching, facilitating communication, comprehension and meaning construction. Yet, the implications of coaching in a non-native language are uncertain and under-researched. This study explores the role of non-native language (NNL) in dyadic workplace coaching practice. Specifically, it explores how working in a NNL influences the coaching experience from the coach’s perspective. Design/methodology/approach. A qualitative approach was chosen to explore the way coaches view coaching in a NNL. Twenty-three semi-structured interviews were conducted with coaches experienced in coaching in NNL. Reflexive thematic analysis (RTA) was applied for data analysis. Findings. NNL coaching presents a paradoxical mix of negative and positive tensions for the coach and coachee in communication, relationship and insight. NNL coaching is nuanced and may be accommodated using coaching competencies to mitigate the potential for misunderstanding and relationship rupture. It offers alternative perspectives to existing worldviews, eliciting deeper insights. Coaches’ confidence in coaching in a NNL varies from a challenging struggle that perceptually hinders performance, through ambivalence, to a sense of greater resourcefulness. Originality/value. The study contributes to the stream of literature on language in international business, sociolinguistic research and how meaning is constructed in a coaching process. First, the work develops a distinction between coaching in a native language (NL) and a NNL. Second, study results indicate that the context of NNL creates challenges as well as opportunities in a dyadic coaching process, particularly regarding aspects of the coach–coachee relationship and insight elicitation via alternative perspectives. Moreover, several practical implications of the study for the coaching practice are discussed

The paradox of coaching in a non-native language

Language plays a complex role in coaching, facilitating communication, comprehension, and meaning construction. Yet, the implications of coaching in a non-native language are uncertain and under-researched. This study explores the role of non-native language (NNL) in dyadic workplace coaching practice. Specifically, it explores how working in a NNL influences the coaching experience from the coach’s perspective. A qualitative approach was chosen to explore the way coaches view coaching in a NNL. Twenty-three semi-structured interviews were conducted with coaches experienced in coaching in NNL. Reflexive Thematic Analysis (RTA) was applied for data analysis. NNL coaching presents a paradoxical mix of negative and positive tensions for the coach and coachee in communication, relationship, and insight. NNL coaching is nuanced and may be accommodated using coaching competencies to mitigate the potential for misunderstanding and relationship rupture. It offers alternative perspectives to existing worldviews, eliciting deeper insights. Coaches’ confidence in coaching in a NNL varies from a challenging struggle that perceptually hinders performance, through ambivalence, to a sense of greater resourcefulness. The study contributes to the stream of literature on language in international business, sociolinguistic research, and how meaning is constructed in a coaching process. First, the work develops a distinction between coaching in a native language (NL) and a NNL. Second, study results indicate that the context of NNL creates challenges as well as opportunities in a dyadic coaching process, particularly regarding aspects of the coach–coachee relationship and insight elicitation via alternative perspectives. Moreover, several practical implications of the study for the coaching practice are discussed

Massive open online courses for continuing professional development of GPs

Continuing professional development (CPD) is essential for the maintenance and improvement of the knowledge and skills of healthcare professionals. GP registrars are required to evidence CPD in their ePortfolio and likewise, GPs are mandated to accrue and evidence a minimum of 50 hours CPD for their annual appraisal. CPD can be delivered in many ways, with an increasing movement towards online learning. Technology-enhanced learning (TEL) encompasses online learning and is ever changing. This article will discuss a type of TEL known as massive open online courses (MOOCs) and the role of MOOCs in delivering CPD

Self-reported quality of care for older adults from 2004 to 2011: a cohort study

Background: little is known about changes in the quality of medical care for older adults over time. Objective: to assess changes in technical quality of care over 6 years, and associations with participants' characteristics. Design: a national cohort survey covering RAND Corporation-derived quality indicators (QIs) in face-to-face structured interviews in participants' households. Participants: a total of 5,114 people aged 50 or more in four waves of the English Longitudinal Study of Ageing. Methods: the percentage achievement of 24 QIs in 10 general medical and geriatric clinical conditions was calculated for each time point, and associations with participants' characteristics were estimated using logistic regression. Results: participants were eligible for 21,220 QIs. QI achievement for geriatric conditions (cataract, falls, osteoarthritis and osteoporosis) was 41% [95% confidence interval (CI): 38–44] in 2004–05 and 38% (36–39) in 2010–11. Achievement for general medical conditions (depression, diabetes mellitus, hypertension, ischaemic heart disease, pain and cerebrovascular disease) improved from 75% (73–77) in 2004–05 to 80% (79–82) in 2010–11. Achievement ranged from 89% for cerebrovascular disease to 34% for osteoarthritis. Overall achievement was lower for participants who were men, wealthier, infrequent alcohol drinkers, not obese and living alone. Conclusion: substantial system-level shortfalls in quality of care for geriatric conditions persisted over 6 years, with relatively small and inconsistent variations in quality by participants' characteristics. The relative lack of variation by participants' characteristics suggests that quality improvement interventions may be more effective when directed at healthcare delivery systems rather than individuals

Improving primary care Access in Context and Theory (I-ACT trial): a theory-informed randomised cluster feasibility trial using a realist perspective

Background Primary care access can be challenging for older, rural, socio-economically disadvantaged populations. Here we report the I-ACT cluster feasibility trial which aims to assess the feasibility of trial design and context-sensitive intervention to improve primary care access for this group and so expand existing theory. Methods Four general practices were recruited; three randomised to intervention and one to usual care. Intervention practices received £1500, a support manual and four meetings to develop local, innovative solutions to improve the booking system and transport. Patients aged over 64 years old and without household car access were recruited to complete questionnaires when booking an appointment or attending the surgery. Outcome measures at 6 months included: self-reported ease of booking an appointment and transport; health care use; patient activation; capability; and quality of life. A process evaluation involved observations and interviews with staff and participants. Results Thirty-four patients were recruited (26 female, eight male, mean age 81.6 years for the intervention group and 79.4 for usual care) of 1143 invited (3% response rate). Most were ineligible because of car access. Twenty-nine participants belonged to intervention practices and five to usual care. Practice-level data was available for all participants, but participant self-reported data was unavailable for three. Fifty-six appointment questionnaires were received based on 150 appointments (37.3%). Practices successfully designed and implemented the following context-sensitive interventions: Practice A: a stacked telephone system and promoting community transport; Practice B: signposting to community transport, appointment flexibility, mobility scooter charging point and promoting the role of receptionists; and Practice C: local taxi firm partnership and training receptionists. Practices found the process acceptable because it gave freedom, time and resource to be innovative or provided an opportunity to implement existing ideas. Data collection methods were acceptable to participants, but some found it difficult remembering to complete booking and appointment questionnaires. Expanded theory highlighted important mechanisms, such as reassurance, confidence, trust and flexibility. Conclusions Recruiting older participants without access to a car proved challenging. Retention of participants and practices was good but only about a third of appointment questionnaires were returned. This study design may facilitate a shift from one-size-fits-all interventions to more context-sensitive interventions

Primary care evidence in clinical guidelines: a mixed methods study of practitioners' views

BACKGROUND: Clinical practice guidelines are widely used in primary care, yet are not always based on applicable research. AIM: To explore primary care practitioners’ views on the applicability to primary care patients of evidence underpinning National Institute for Health and Care Excellence (NICE) guideline recommendations. DESIGN AND SETTING: Delphi survey and focus groups in primary care, England, UK. METHOD: Delphi survey of the perceived applicability of 14 guideline recommendations rated before and after a description of their evidence base, followed by two focus groups. RESULTS: GPs significantly reduced scores for their perceived likelihood of pursuing recommendations after finding these were based on studies with low applicability to primary care, but maintained their scores for recommendations based on highly applicable research. GPs reported they were more likely to use guidelines where evidence was applicable to primary care, and less likely if the evidence base came from a secondary care population. Practitioners in the focus groups accepted that guideline developers would use the most relevant evidence available, but wanted clearer signposting of those recommendations particularly relevant for primary care patients. Their main need was for brief, clear, and accessible guidelines. CONCLUSION: Guidelines should specify the extent to which the research evidence underpinning each recommendation is applicable to primary care. The relevance of guideline recommendations to primary care populations could be more explicitly considered at all three stages of guideline development: scoping and evidence synthesis, recommendation development, and publication. The relevant evidence base needs to be presented clearly and concisely, and in an easy to identify way

“I have travelled along on my own”—Experiences of seeking help for serious non-COVID health problems during the COVID-19 pandemic: A qualitative study

Objectives: During COVID-19 the UK general population has been given strong messages to stay at home. Concurrently unprecedented changes occurred in healthcare access with moves to remote/triage systems. Data have shown that the number of people accessing healthcare services decreased and there are significant concerns that the pandemic has negatively affected help-seeking for serious conditions, with potentially increased morbidity and mortality. An understanding of help-seeking is urgently needed to inform public campaigns. We aimed to develop an in-depth, theory-based understanding of how, when and why people sought help for potentially serious symptoms (for example, related to major cardiovascular events or cancer diagnoses) during the pandemic, and what influenced their decisions. Design: Qualitative semi-structured interviews Methods: We interviewed 25 adults recruited through a targeted social media campaign. Interviews were conducted via telephone or online platform. Our topic guide was informed by the Model of Pathways to Treatment and the Capability-Opportunity-Motivation-Behaviour model. Results: Analysis identified four main themes: Delay in recognition, Holding on to concerns, Weighing it up and Long-term impacts. Multiple societal and environmental factors influenced participants’ help-seeking and motivation, capability and opportunity to seek help, with long-term impacts on well-being and future help-seeking. Conclusions: There is a need for clear guidance about pathways to raise concerns about symptoms and gain advice while usual healthcare contacts are paused or stopped. Recommendations for future interventions to support help-seeking during pandemics include clearer messaging, co-produced with end users, on when, where and how to seek help