Administration Launches Next Chapter of Education Reform

Background: Although the recovery of patients suffering from low back pain is highly context dependent, patient preferences about treatment options are seldom incorporated into the therapeutic plan. Shared decision-making (SDM) offers a tool to overcome this deficiency. The reinforcement by the general practitioner (GP) of a 'shared' chosen therapy might increase patients' expectations of favourable outcomes and thus contribute to recovery. Methods: In the Netherlands, a clustered randomised controlled trial was performed to assess the effectiveness of shared decision-making followed by positive reinforcement of the chosen therapy (SDM&PR) on patient-related clinical outcomes. Overall, 68 GPs included 226 patients visiting their GP for a new episode of non-chronic low back pain. GPs in the intervention group were trained in implementing SDM&PR using a structured training programme with a focus on patient preferences in reaching treatment decisions. GPs in the control group provided care as usual. The primary outcome was the change in physical disability measured with the Roland-Morris disability questionnaire (RMD) during the six-month follow-up after the first consultation. Physical disability (RMD), pain, adequate relief, absenteeism and healthcare consumption at 2, 6, 12 and 26 weeks were secondary outcomes. A multivariate analysis with a mixed model was used to estimate the differences in outcomes. Results: Of the patients in the intervention and the control groups, 66 and 62%, respectively, completed the follow-up. Most patients (77%) recovered to no functional restrictions due to back pain within 26 weeks. No significant differences in the mean scores for any outcome were observed between intervention patients and controls during the follow-up, and in multivariate analysis, there was no significant difference in the main outcome during the six-month follow-up. Patients in the intervention group reported more involvement in decision-making. Conclusion: This study did not detect any improvement in clinical outcome or in health care consumption of patients with non-chronic low back pain after the training of GPs in SDM&PR. The implementation of SDM merely introduces task-oriented communication. The training of the GPs may have been more effective if it had focused more on patient-oriented communication techniques and on stressing the expectation of favourable outcomes. Trial registration: The Netherlands National Trial Register (NTR) number: NTR1960. The trial was registered in the NTR on August 20, 2009

Unravelling effectiveness of a nurse-led behaviour change intervention to enhance physical activity in patients at risk for cardiovascular disease in primary care: study protocol for a cluster randomised controlled trial

BACKGROUND: Self-management interventions are considered effective in patients with chronic disease, but trials have shown inconsistent results, and it is unknown which patients benefit most. Adequate self-management requires behaviour change in both patients and health care providers. Therefore, the Activate intervention was developed with a focus on behaviour change in both patients and nurses. The intervention aims for change in a single self-management behaviour, namely physical activity, in primary care patients at risk for cardiovascular disease. The aim of this study is to evaluate the effectiveness of the Activate intervention. METHODS/DESIGN: A two-arm cluster randomised controlled trial will be conducted to compare the Activate intervention with care as usual at 31 general practices in the Netherlands. Approximately 279 patients at risk for cardiovascular disease will participate. The Activate intervention is developed using the Behaviour Change Wheel and consists of 4 nurse-led consultations in a 3-month period, integrating 17 behaviour change techniques. The Behaviour Change Wheel was also applied to analyse what behaviour change is needed in nurses to deliver the intervention adequately. This resulted in 1-day training and coaching sessions (including 21 behaviour change techniques). The primary outcome is physical activity, measured as the number of minutes of moderate to vigorous physical activity using an accelerometer. Potential effect modifiers are age, body mass index, level of education, social support, depression, patient-provider relationship and baseline number of minutes of physical activity. Data will be collected at baseline and at 3 months and 6 months of follow-up. A process evaluation will be conducted to evaluate the training of nurses, treatment fidelity, and to identify barriers to and facilitators of implementation as well as to assess participants' satisfaction. DISCUSSION: To increase physical activity in patients and to support nurses in delivering the intervention, behaviour change techniques are applied to change behaviours of the patients and nurses. Evaluation of the effectiveness of the intervention, exploration of which patients benefit most, and evaluation of our theory-based training for primary care nurses will enhance understanding of what works and for whom, which is essential for further implementation of self-management in clinical practice. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT02725203 . Registered on 25 March 2016

Do presenting symptoms, use of pre-diagnostic endoscopy and risk of emergency cancer diagnosis vary by comorbidity burden and type in patients with colorectal cancer?

BACKGROUND: Cancer patients often have pre-existing comorbidities, which can influence timeliness of cancer diagnosis. We examined symptoms, investigations and emergency presentation (EP) risk among colorectal cancer (CRC) patients by comorbidity status. METHODS: Using linked cancer registration, primary care and hospital records of 4836 CRC patients (2011-2015), and multivariate quantile and logistic regression, we examined variations in specialist investigations, diagnostic intervals and EP risk. RESULTS: Among colon cancer patients, 46% had at least one pre-existing hospital-recorded comorbidity, most frequently cardiovascular disease (CVD, 18%). Comorbid versus non-comorbid cancer patients more frequently had records of anaemia (43% vs 38%), less frequently rectal bleeding/change in bowel habit (20% vs 27%), and longer intervals from symptom-to-first relevant test (median 136 vs 74 days). Comorbid patients were less likely investigated with colonoscopy/sigmoidoscopy, independently of symptoms (adjusted OR = 0.7[0.6, 0.9] for Charlson comorbidity score 1-2 and OR = 0.5 [0.4-0.7] for score 3+ versus 0. EP risk increased with comorbidity score 0, 1, 2, 3+: 23%, 35%, 33%, 47%; adjusted OR = 1.8 [1.4, 2.2]; 1.7 [1.3, 2.3]; 3.0 [2.3, 4.0]) and for patients with CVD (adjusted OR = 2.0 [1.5, 2.5]). CONCLUSIONS: Comorbid individuals with as-yet-undiagnosed CRC often present with general rather than localising symptoms and are less likely promptly investigated with colonoscopy/sigmoidoscopy. Comorbidity is a risk factor for diagnostic delay and has potential, additionally to symptoms, as risk-stratifier for prioritising patients needing prompt assessment to reduce EP

The degree of integration of non-dispensing pharmacists in primary care practice and the impact on health outcomes: A systematic review

Background: A non-dispensing pharmacist conducts clinical pharmacy services aimed at optimizing patients individual pharmacotherapy. Embedding a non-dispensing pharmacist in primary care practice enables collaboration, probably enhancing patient care. The degree of integration of non-dispensing pharmacists into multidisciplinary health care teams varies strongly between settings. The degree of integration may be a determinant for its success. Objectives: This study investigates how the degree of integration of a non-dispensing pharmacist impacts medication related health outcomes in primary care. Methods: In this literature review we searched two electronic databases and the reference list of published literature reviews for studies about clinical pharmacy services performed by non-dispensing pharmacists physically co-located in primary care practice. We assessed the degree of integration via key dimensions of integration based on the conceptual framework of Walshe and Smith. We included English language studies of any design that had a control group or baseline comparison published from 1966 to June 2016. Descriptive statistics were used to correlate the degree of integration to health outcomes. The analysis was stratified for disease-specific and patient-centered clinical pharmacy services. Results: Eighty-nine health outcomes in 60 comparative studies contributed to the analysis. The accumulated evidence from these studies shows no impact of the degree of integration of non-dispensing pharmacists on health outcomes. For disease specific clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 75%, 63% and 59%. For patient-centered clinical pharmacy services the percentage of improved health outcomes for none, partial and fully integrated NDPs is respectively 55%, 57% and 70%. Conclusions: Full integration adds value to patient-centered clinical pharmacy services, but not to disease-specific clinical pharmacy services. To obtain maximum benefits of clinical pharmacy services for patients with multiple medications and comorbidities, full integration of non-dispensing pharmacists should be promoted

Measurement properties of oral health assessments for non-dental healthcare professionals in older people:a systematic review

Background: Regular inspection of the oral cavity is required for prevention, early diagnosis and risk reduction of oral-and general health-related problems. Assessments to inspect the oral cavity have been designed for non-dental healthcare professionals, like nurses. The purpose of this systematic review was to evaluate the content and the measurement properties of oral health assessments for use by non-dental healthcare professionals in assessing older peoples' oral health, in order to provide recommendations for practice, policy, and research. Methods: A systematic search in PubMed, EMBASE.com, and Cinahl (via Ebsco) has been performed. Search terms referring to 'oral health assessments', 'non-dental healthcare professionals' and 'older people (60+)' were used. Two reviewers individually performed title/abstract, and full-text screening for eligibility. The included studies have investigated at least one measurement property (validity/reliability) and were evaluated on their methodological quality using "The Consensus-based Standards for the selection of health Measurement Instruments"(COSMIN) checklist. The measurement properties were then scored using quality criteria (positive/negative/indeterminate). Results: Out of 879 hits, 18 studies were included in this review. Five studies showed good methodological quality on at least one measurement property and 14 studies showed poor methodological quality on some of their measurement properties. None of the studies assessed all measurement properties of the COSMIN. In total eight oral health assessments were found: the Revised Oral Assessment Guide (ROAG); the Minimum Data Set (MDS), with oral health component; the Oral Health Assessment Tool (OHAT); The Holistic Reliable Oral Assessment Tool (THROAT); Dental Hygiene Registration (DHR); Mucosal Plaque Score (MPS); The Brief Oral Health Screening Examination (BOHSE) and the Oral Assessment Sheet (OAS). Most frequently assessed items were: lips, mucosa membrane, tongue, gums, teeth, denture, saliva, and oral hygiene. Conclusion: Taken into account the scarce evidence of the proposed assessments, the OHAT and ROAG are most complete in their included oral health items and are of best methodological quality in combination with positive quality criteria on their measurement properties. Non-dental healthcare professionals, policymakers and researchers should be aware of the methodological limitations of the available oral health assessments and realize that the quality of the measurement properties remains uncertain

Artificial Intelligence Techniques That May Be Applied to Primary Care Data to Facilitate Earlier Diagnosis of Cancer : Systematic Review

Acknowledgments This research was funded by the National Institute for Health Research (NIHR) Policy Research Programme, conducted through the Policy Research Unit in Cancer Awareness, Screening, and Early Diagnosis, PR-PRU-1217-21601. The views expressed are those of the authors and not necessarily those of the NIHR or the Department of Health and Social Care. This work was also supported by the CanTest Collaborative (funded by Cancer Research UK C8640/A23385), of which FW and WH are directors and JE, HS, and NdW are associate directors. HS is additionally supported by the Houston Veterans Administration Health Services Research and Development Center for Innovations in Quality, Effectiveness, and Safety (CIN13-413) and the Agency for Healthcare Research and Quality (R01HS27363). The funding sources had no role in the study design, data collection, data analysis, data interpretation, writing of the report, or the decision to submit for publication. The authors would like to thank Isla Kuhn, Reader Services Librarian, University of Cambridge Medical Library, for her help in developing the search strategy.Peer reviewedPublisher PD

The CombiConsultation for patients with diabetes, COPD and cardiovascular diseases: Evaluation of interventions and personal health-related goals

Background: The CombiConsultation is a consultation with the community pharmacist for patients with diabetes, COPD and/or cardiovascular disease (CVD), aligned with the annual or quarterly consultation with the practice nurse (PN) or general practitioner (GP). The consultation is focused on the personal health-related goals of the patient. Objectives: To assess the number and types of personal health-related goals, drug-related problems (DRPs) and interventions identified by pharmacists during a CombiConsultation and to investigate which patients can benefit most from such consultation. Method: Twenty-one Dutch community pharmacies and associated GP practices were included in the CombiConsultation study. CombiConsultations were performed, involving patients with diabetes, COPD and/or (at risk of) CVD. The pharmacists set health-related goals together with the patients and identified DRPs. The number and types of personal health-related goals, DRPs and interventions were analysed. Associations between patient characteristics and the identification of at least one DRP were analysed by multivariate regression analysis. Results: In 834 patients (49% men, mean age: 70 years), 939 DRPs were identified, mostly (potential) side effects (33%), undertreatment (18%) and overtreatment (14%). In 71% of the patients, one or more DRPs were found, with a median of one DRP per patient. Pharmacists proposed 935 recommendations, of which 72% were implemented. DRPs were found more often in patients using a higher number of drugs for chronic conditions. A total of 425 personal health-related goals were set, of which 53% were (partially) attained. Conclusion: The CombiConsultation can be used as a compact health service contributing to safe and effective use of medication for patients with diabetes, COPD and/or (at risk of) CVD, also in patients under 65 or with less than 5 medications in use. The output of the CombiConsultation reflects its characteristics

Artificial Intelligence Techniques That May Be Applied to Primary Care Data to Facilitate Earlier Diagnosis of Cancer: Systematic Review.

BACKGROUND: More than 17 million people worldwide, including 360,000 people in the United Kingdom, were diagnosed with cancer in 2018. Cancer prognosis and disease burden are highly dependent on the disease stage at diagnosis. Most people diagnosed with cancer first present in primary care settings, where improved assessment of the (often vague) presenting symptoms of cancer could lead to earlier detection and improved outcomes for patients. There is accumulating evidence that artificial intelligence (AI) can assist clinicians in making better clinical decisions in some areas of health care. OBJECTIVE: This study aimed to systematically review AI techniques that may facilitate earlier diagnosis of cancer and could be applied to primary care electronic health record (EHR) data. The quality of the evidence, the phase of development the AI techniques have reached, the gaps that exist in the evidence, and the potential for use in primary care were evaluated. METHODS: We searched MEDLINE, Embase, SCOPUS, and Web of Science databases from January 01, 2000, to June 11, 2019, and included all studies providing evidence for the accuracy or effectiveness of applying AI techniques for the early detection of cancer, which may be applicable to primary care EHRs. We included all study designs in all settings and languages. These searches were extended through a scoping review of AI-based commercial technologies. The main outcomes assessed were measures of diagnostic accuracy for cancer. RESULTS: We identified 10,456 studies; 16 studies met the inclusion criteria, representing the data of 3,862,910 patients. A total of 13 studies described the initial development and testing of AI algorithms, and 3 studies described the validation of an AI algorithm in independent data sets. One study was based on prospectively collected data; only 3 studies were based on primary care data. We found no data on implementation barriers or cost-effectiveness. Risk of bias assessment highlighted a wide range of study quality. The additional scoping review of commercial AI technologies identified 21 technologies, only 1 meeting our inclusion criteria. Meta-analysis was not undertaken because of the heterogeneity of AI modalities, data set characteristics, and outcome measures. CONCLUSIONS: AI techniques have been applied to EHR-type data to facilitate early diagnosis of cancer, but their use in primary care settings is still at an early stage of maturity. Further evidence is needed on their performance using primary care data, implementation barriers, and cost-effectiveness before widespread adoption into routine primary care clinical practice can be recommended.CRU

Barriers and facilitators for the implementation of the CombiConsultation by general practitioners, pharmacists and practice nurses: a qualitative interview study

BACKGROUND: The CombiConsultation is a consultation with the pharmacist for patients with a chronic condition, aligned with the periodic consultation with the practice nurse or general practitioner. Implementation requires adjustments in the working methods of these healthcare providers and therefore behavioural changes. AIM: The aim of this study was to identify the barriers and facilitators that determine the behavioural changes by pharmacists, general practitioners and practice nurses required for the implementation of the CombiConsultation. METHOD: Ten community pharmacists, 5 practice nurses and 5 general practitioners were sampled from practices enrolled in the CombiConsultation study. Their views regarding the implementation of this clinical pharmacy service were explored using interviews based on the 14 domains of the Theoretical Domains Framework (TDF), which are linked to the Capability-Opportunity-Motivation-Behaviour-model. Barriers and facilitators in the domains were assessed by content analysis. RESULTS: Twelve barriers and 23 facilitators were found within 13 TDF domains with high agreement between the healthcare providers. Important facilitators for implementation were the pharmacists' expertise in pharmacotherapy (capability), access to medical data and physical proximity between professional practices (opportunity). Barriers were pharmacists' insufficient consultation- and clinical-reasoning skills (capability), insufficient staff (opportunity) and reimbursement and lack of coordination among all involved healthcare providers (motivation). CONCLUSION: All healthcare providers are motivated to implement the CombiConsultation. An existing collaborative practice, with a clear and accepted professional role of the pharmacist is essential. Training of pharmacists in consultation and clinical-reasoning skills can be beneficial, as well as arrangements on the consultation logistics, and reimbursement

The CombiConsultation: a new concept of sequential consultation with the pharmacist and practice nurse/general practitioner for patients with a chronic condition

The primary health care system is generally well organized for dealing with chronic diseases, but comprehensive medication management is still a challenge. Studies suggest that pharmacists can contribute to effective and safe drug therapy by providing services like a clinical medication review (CMR). However, several factors limit the potential impact of a CMR. Therefore, we propose a new pharmaceutical care service for patients with a chronic condition: the CombiConsultation. The CombiConsultation is a medication evaluation service conducted by the (community) pharmacist and either the practice nurse or general practitioner. It consists of 3 steps: medication check, implementation and follow-up. The pharmacist primarily focusses on setting treatment goals for 1 or 2 drug-related problems in relation to a specific chronic condition. In this manuscript we describe the process and characteristics of the CombiConsultation. We compare the CombiConsultation with the CMR and explain the choices made and the implications for implementation