Mixed methods study of a new model of care for chronic disease: co-design and sustainable implementation of group consultations into clinical practice

Objectives: Group consultations are used for chronic conditions, such as inflammatory arthritis, but evidence of efficacy for treatment to target or achieving tight control is lacking. Our aim was to establish whether group consultation is a sustainable, co-designed routine care option and to explore factors supporting spread. Methods: The study used mixed methods, observational process/outcome data, plus qualitative exploration of enabling themes. It was set in two community hospitals, in 2008-19, with a third hospital from 2016, and was triangulated with primary care qualitative data. There was a total of 3363 arthritis patient attendances at 183 clinics during 2008-19. The early arthritis cohort comprised 46 patients, followed monthly until the treatment target was achieved, during 2016-19. Focus groups included 15 arthritis and 11 osteoporosis group attendees. Intervention was a 2 h group consultation, attended monthly for early/active disease and annually for stable disease. Measurements included attendance, DAS, satisfaction and enabling themes. Results: There was a mean number of 18.4 patients per clinic ( n  = 16, 2010-15; n  = 18, 2016; n  = 20, 2017; n  = 23, 2018-19). Forty per cent (1161/2874) of patients with DAS data reached low disease activity (DAS < 3.2) or remission (DAS < 2.6). Forty-six early arthritis patients followed monthly until they achieved remission responded even better: 50% remission; and 89% low disease activity/remission by 6 months. Qualitative analysis derived five main enabling themes (efficiency, empathy, education, engagement and empowerment) and five promotors to translate these themes into practice (prioritization, personalization, participation, personality and pedagogy). Limitations included the prospectively collected observational data and pragmatic design susceptible to bias. Conclusion: Co-designed group consultations can be sustainable, clinically effective and efficient for monthly review of early active disease and annual review of stable disease. Promoting factors may support effective training for chronic disease group consultations

HBV continuum of care using community- and hospital-based screening interventions in Senegal: Results from the PROLIFICA programme

BACKGROUND & AIMS: Strategies to implement HBV screening and treatment are critical to achieve HBV elimination but have been inadequately evaluated in sub-Saharan Africa (sSA). METHODS: We assessed the feasibility of screen-and-treat interventions in 3 real-world settings (community, workplace, and hospital) in Senegal. Adult participants were screened using a rapid HBsAg point-of-care test. The proportion linked to care, the proportion who had complete clinical staging (alanine transaminase [ALT], viral load, and FibroScan®), and the proportion eligible for treatment were compared among the 3 intervention groups. RESULTS: In 2013-2016, a total of 3,665 individuals were screened for HBsAg in the community (n = 2,153) and in workplaces (n = 1,512); 199/2,153 (9.2%) and 167/1,512 (11%) were HBsAg-positive in the community and workplaces, respectively. In the hospital setting (outpatient clinics), 638 HBsAg-positive participants were enrolled in the study. All infected participants were treatment naïve. Linkage to care was similar among community-based (69.9%), workplace-based (69.5%), and hospital-based interventions (72.6%, p = 0.617). Of HBV-infected participants successfully linked to care, full clinical staging was obtained in 47.5% (66/139), 59.5% (69/116), and 71.1% (329/463) from the community, workplaces, and hospitals, respectively (p <0.001). The proportion eligible for treatment (EASL criteria) differed among community- (9.1%), workplace- (30.4%), and hospital-based settings (17.6%, p = 0.007). Acceptability of antiviral therapy, adherence, and safety at 1 year were very good. CONCLUSIONS: HBV screen-and-treat interventions are feasible in non-hospital and hospital settings in Senegal. However, the continuum of care is suboptimal owing to limited access to full clinical staging. Improvement in access to diagnostic services is urgently needed in sSA. LAY SUMMARY: Hepatitis B infection is highly endemic in Senegal. Screening for infection can be done outside hospitals, in communities or workplaces. However, the hepatitis B continuum of care is suboptimal in Senegal and needs to be simplified to scale-up diagnosis and treatment coverage

Hydrate occurrence in Europe: a review of available evidence

Large national programs in the United States and several Asian countries have defined and characterised their marine methane hydrate occurrences in some detail, but European hydrate occurrence has received less attention. The European Union-funded project “Marine gas hydrate – an indigenous resource of natural gas for Europe” (MIGRATE) aimed to determine the European potential inventory of exploitable gas hydrate, to assess current technologies for their production, and to evaluate the associated risks. We present a synthesis of results from a MIGRATE working group that focused on the definition and assessment of hydrate in Europe. Our review includes the western and eastern margins of Greenland, the Barents Sea and onshore and offshore Svalbard, the Atlantic margin of Europe, extending south to the northwestern margin of Morocco, the Mediterranean Sea, the Sea of Marmara, and the western and southern margins of the Black Sea. We have not attempted to cover the high Arctic, the Russian, Ukrainian and Georgian sectors of the Black Sea, or overseas territories of European nations. Following a formalised process, we defined a range of indicators of hydrate presence based on geophysical, geochemical and geological data. Our study was framed by the constraint of the hydrate stability field in European seas. Direct hydrate indicators included sampling of hydrate; the presence of bottom simulating reflectors in seismic reflection profiles; gas seepage into the ocean; and chlorinity anomalies in sediment cores. Indirect indicators included geophysical survey evidence for seismic velocity and/or resistivity anomalies, seismic reflectivity anomalies or subsurface gas escape structures; various seabed features associated with gas escape, and the presence of an underlying conventional petroleum system. We used these indicators to develop a database of hydrate occurrence across Europe. We identified a series of regions where there is substantial evidence for hydrate occurrence (some areas offshore Greenland, offshore west Svalbard, the Barents Sea, the midNorwegian margin, the Gulf of Cadiz, parts of the eastern Mediterranean, the Sea of Marmara and the Black Sea) and regions where the evidence is more tenuous (other areas offshore Greenland and of the eastern Mediterranean, onshore Svalbard, offshore Ireland and offshore northwest Iberia). We provide an overview of the evidence for hydrate occurrence in each of these regions. We conclude that around Europe, areas with strong evidence for the presence of hydrate commonly coincide with conventional thermogenic hydrocarbon provinces