Informing NHS policy in 'digital-first primary care': a rapid evidence synthesis

Background In ‘digital-first primary care’ models of health-care delivery, a patient’s first point of contact with a general practitioner or other health professional is through a digital channel, rather than a face-to-face consultation. Patients are able to access advice and treatment remotely from their home or workplace via a number of different technologies. Objectives This rapid responsive evidence synthesis was undertaken to inform NHS England policy in ‘digital-first primary care’. It was conducted in two stages: (1) scoping the published evidence and (2) addressing a refined set of questions produced by NHS England from the evidence retrieved during the scoping stage. Data sources Searches were conducted of five electronic databases (MEDLINE, Cochrane Database of Systematic Reviews, Database of Abstracts of Reviews of Effects, the Health Technology Assessment database and PROSPERO were searched in July 2018) and relevant research/policy and government websites, as well as the National Institute for Health Research Health Service and Delivery Research programme database of ongoing and completed projects. No date or geographical limitations were applied. Review methods After examining the initial scoping material, NHS England provided a list of questions relating to the potential effects of digital modes and models of engagement, and the contracting and integration of these models into primary care. Systematic reviews and evidence syntheses, including evidence on the use of digital (online) modes and models of engagement between patients and primary care, were examined more closely, as was ongoing research and any incidentally identified primary studies focused on the use of digital (online) modes and models of engagement. All records were screened by two reviewers, with disagreements resolved by consensus or consulting a third reviewer. Results Evidence suggests that uptake of existing digital modes of engagement is currently low. Patients who use digital alternatives to face-to-face consultations are likely to be younger, female and have higher income and education levels. There is some evidence that online triage tools can divert demand away from primary care, but results vary between interventions and outcome measures. A number of potential barriers exist to using digital alternatives to face-to-face consultations, including inadequate NHS technology and staff concerns about workload and confidentiality. There are currently insufficient empirical data to either substantiate or allay such concerns. Very little evidence exists on outcomes related to quality of care, service delivery, benefits or harms for patients, or on financial costs/cost-effectiveness. No studies examining how to contract and commission alternatives to face-to-face consultations were identified. Limitations The quality of the included reviews was variable. Poor reporting of methodology and a lack of adequate study details were common issues. Much of the evidence focused on exploring stakeholder views rather than on objective measurement of potential impacts. The current evidence synthesis is based on a rapid scoping exercise and cannot provide the breadth or depth of insight that might have been achieved with a full systematic review. Conclusions Rapid scoping of the literature suggests that there is little high-quality evidence relating to ‘digital-first primary care’ as defined by NHS England. The broader evidence on alternatives to face-to-face consultation addresses certain policy-maker concerns, such as the possible impact of new technologies on workload and workforce, inequalities, local implementation and integration with existing services. However, although this evidence gives an insight into the views and experiences of health professionals in relation to such concerns, quantitative empirical data are lacking

Release and Establishment of Megamelus scutellaris (Hemiptera: Delphacidae) on Waterhyacinth in Florida

More than 73,000 Megamelus scutellaris (Hemiptera: Delphacidae) were released in Florida over a 2 to 3 yr period at 10 sites in an attempt to establish sustainable populations on waterhyacinth, Eichhornia crassipes Mart. Solms (Commelinales: Pontederiaceae). Insect populations persisted at most sites including those furthest north and consecutive overwintering was confirmed in as many as three times at some sites. Establishment appeared to be promoted at sites with some cover or shading compared to open areas. Insects readily dispersed over short distances which made detection and monitoring difficultFil: Tipping, Philip W.. Invasive Plant Research Laboratory; Estados UnidosFil: Sosa, Alejandro Joaquín. Consejo Nacional de Investigaciones Científicas y Técnicas; Argentina. Fundación para el Estudio de Especies Invasivas; ArgentinaFil: Pokorny, Eileen N.. Invasive Plant Research Laboratory; Estados UnidosFil: Foley, Jeremiah. Invasive Plant Research Laboratory; Estados UnidosFil: Schmitz, Don C.. Florida Fish and Wildlife Conservation Commission; Estados UnidosFil: Lane, Jon S.. U.S. Army Corps of Engineers; Estados UnidosFil: Rodgers, Leroy. South Florida Water Management District; Estados UnidosFil: Mccloud, Lori. St. Johns River Water Management District; Estados UnidosFil: Livingston-Way, Pam. St. Johns River Water Management District; Estados UnidosFil: Cole, Matthew S.. St. Johns River Water Management District; Estados UnidosFil: Nichols, Gary. St. Johns River Water Management District; Estados Unido

(±)-9-exo-Amino-5,6,7,8-tetrahydro-5,8-methano-9H-benzocyclohepten-8-ol Hydrochloride

This is the published version, also available here: http://www.dx.doi.org/10.1107/S0567740878004458

Regulating and inspecting integrated health and social care in the UK : scoping the literature

Background: The integration of care, particularly across the health and social care sectors, has been a long-standing policy objective in the UK. We sought to scope the evidence related to the regulation and inspection of integrated care. Objective(s): To identify and classify published material that could potentially address four key questions: 1. What models of regulation and inspection of integrated care have been proposed? (Including approaches taken in other countries) 2. What evidence is available on the effectiveness of such models? 3. What are the barriers and enablers of effective regulation and inspection of integrated care? 4. Can barriers to effective regulation and inspection be overcome without legislative change? Design: Rapid scoping review. Publication type and focus: Both empirical and non-empirical publications related to the regulation and inspection of integrated care were included. Setting: Publications focused on the integration of health and social care services, or provision delivered across other settings/sectors by different professional groups working together. Outcomes: Empirical studies reporting on any outcome relevant to the regulation and/or inspection of integrated care. Non-empirical publications focusing on any relevant issue including proposed models of regulation or outcome frameworks. Data sources: A targeted search of five databases was undertaken. Additionally, we conducted supplementary searches of the websites of key organisations and searched for other grey literature using the advanced search function of Google. Key contacts were also approached, and a request made for relevant documents. Review methods: The title and abstracts of 5380 records were screened and a total of 166 publications were included. Documents were coded based on key characteristics, and a descriptive summary of the literature produced. No attempt was made to assess the quality or synthesise the findings of the retrieved evidence. Results Out of the 166 included publications, 71 were identified from database searches and 95 were included from supplementary website searches. While there were records that could be classified as relevant to one or more of the research questions identified through the stakeholder consultation, there was a notable absence of evidence relating to (a) effectiveness of regulatory/inspection strategies and (b) professional regulation. Conclusions and future work The evidence base relating to the regulation or inspection of integrated care is relatively small. There may be an opportunity to synthesise some of the existing views and experience data on system regulation and inspection identified in a more formal systematic review. However, before a useful evidence base can be developed, policy makers and researchers need to agree what constitutes ‘effective’ regulation, how this can be measured, and which study designs are most appropriate for evaluation. Related questions about what constitutes ‘successful’ integration of care should also be taken into account when planning such research. While potentially useful reforms have been proposed, empirical evidence in relation to professional regulation appears particularly scarce. Organisations responsible for regulating professionals might therefore consider incorporating some form of evaluation into any planned strategic reforms. Limitations The degree of focus on integration or regulation was a difficult criterion to apply with strict consistency

Trajectory mapping: A tool for validation of trace gas observations

We investigate the effectiveness of trajectory mapping(TM) as a data validation tool. TM combines a dynamical model of the atmosphere with trace gas observations to provide more statistically robust estimates of instrument performance over much broader geographic areas than traditional techniques are able to provide. We present four detailed case studies selected so that the traditional techniques are expected to work well. In each case the TM results are equivalent to or improve upon the measurement comparisons performed with traditional approaches. The TM results are statistically more robust than those achieved using traditional approaches since the TM comparisons occur over a much larger range of geophysical variability. In the first case study we compare ozone data from the Halogen Occultation Experiment (HALOE) with Microwave Limb Sounder(MLS). TM comparisons appear to introduce little to no error as compared to the traditional approach. In the second case study we compare ozone data from HALOE with that from the Stratospheric Aerosol and Gas Experiment TT(SAGE TT). TM results in differences of less than 5% as compared to the traditional approach at altitudes between 18 and 25 km and less than 10% at altitudes between 25 and 40 km.In the third case study we show that ozone profiles generated from HALOE data using TM compare well with profiles from five European ozonesondes. In the fourth case study we evaluate the precision of MLS H20 using TM and find typical precision uncertainties of 3-7% at most latitudes and altitudes. The TM results agree well with previous estimates but are the result of a global analysis of the data rather than an analysis in the limited latitude bands in which traditional approaches work. Finally, sensitivity studies using the MLS H20 data show the following: (1) a combination of forward and backward trajectory calculations minimize uncertainties in isentropic TM; (2) although the uncertainty of the technique increases with trajectory duration,TM calculations of up to 14 days can provide reliable information for use in data validation studies; (3) a correlation coincidence criterion of 400 km produces the best TM results under most circumstances; (4) TM performs well compared to (and sometimes better than) traditional approaches at all latitudes and in most seasons and; (5) TM introduces no statistically significant biases at altitudes between 22 and 40 km

The stroke ‘Act FAST’ campaign: Remembered but not understood?

Background: The stroke awareness raising campaign ‘Act FAST' (Face, Arms, Speech: Time to call Emergency Medical Services) has been rolled out in multiple waves in England, but impact on stroke recognition and response remains unclear. Purpose: The purpose of this study was to test whether providing knowledge of the FAST acronym through a standard Act FAST campaign leaflet increases accurate recognition and response in stroke-based scenario measures. Methods: This is a population-based, cross-sectional survey of adults in Newcastle upon Tyne, UK, sampled using the electoral register, with individuals randomized to receive a questionnaire and Act FAST leaflet (n = 2500) or a questionnaire only (n = 2500) in 2012. Campaign message retention, stroke recognition, and response measured through 16 scenario-based vignettes were assessed. Data were analyzed in 2013. Results: Questionnaire return rate was 32·3% (n = 1615). No differences were found between the leaflet and no-leaflet groups in return rate or demographics. Participants who received a leaflet showed better campaign recall (75·7% vs. 68·2%, P = 0·003) and recalled more FAST mnemonic elements (66·1% vs. 45·3% elements named correctly, P < 0·001). However, there were no between-group differences for stroke recognition and response to stroke-based scenarios (P > 0·05). Conclusions: Despite greater levels of recall of specific ‘Act FAST' elements among those receiving the Act FAST leaflet, there was no impact on stroke recognition and response measures

Cost-Effectiveness of Treating Upper Limb Spasticity Due to Stroke with Botulinum Toxin Type A: Results from the Botulinum Toxin for the Upper Limb after Stroke (BoTULS) Trial

Stroke imposes significant burdens on health services and society, and as such there is a growing need to assess the cost-effectiveness of stroke treatment to ensure maximum benefit is derived from limited resources. This study compared the cost-effectiveness of treating post-stroke upper limb spasticity with botulinum toxin type A plus an upper limb therapy programme against the therapy programme alone. Data on resource use and health outcomes were prospectively collected for 333 patients with post-stroke upper limb spasticity taking part in a randomized trial and combined to estimate the incremental cost per quality adjusted life year (QALY) gained of botulinum toxin type A plus therapy relative to therapy alone. The base case incremental cost-effectiveness ratio (ICER) of botulinum toxin type A plus therapy was £93,500 per QALY gained. The probability of botulinum toxin type A plus therapy being cost-effective at the England and Wales cost-effectiveness threshold value of £20,000 per QALY was 0.36. The point estimates of the ICER remained above £20,000 per QALY for a range of sensitivity analyses, and the probability of botulinum toxin type A plus therapy being cost-effective at the threshold value did not exceed 0.39, regardless of the assumptions made

Factors that influence clinicians’ decisions to offer intravenous alteplase in acute ischemic stroke patients with uncertain treatment indication:Results of a discrete choice experiment

Background: Treatment with intravenous alteplase for eligible patients with acute ischemic stroke is underused, with variation in treatment rates across the UK. This study sought to elucidate factors influencing variation in clinicians’ decision-making about this thrombolytic treatment. Methods: A discrete choice experiment using hypothetical patient vignettes framed around areas of clinical uncertainty was conducted with UK-based clinicians. Mixed logit regression analyses were conducted on the data. Results: A total of 138 clinicians completed the discrete choice experiment. Seven patient factors were individually predictive of increased likelihood of immediately offering IV alteplase (compared to reference levels in brackets): stroke onset time 2 h 30 min [50 min]; pre-stroke dependency mRS 3 [mRS 4]; systolic blood pressure 185 mm/Hg [140 mm/Hg]; stroke severity scores of NIHSS 5 without aphasia, NIHSS 14 and NIHSS 23 [NIHSS 2 without aphasia]; age 85 [68]; Afro-Caribbean [white]. Factors predictive of withholding treatment with IV alteplase were: age 95 [68]; stroke onset time of 4 h 15 min [50 min]; severe dementia [no memory problems]; SBP 200 mm/Hg [140 mm/Hg]. Three clinician-related factors were predictive of an increased likelihood of offering IV alteplase (perceived robustness of the evidence for IV alteplase; thrombolyzing more patients in the past 12 months; and high discomfort with uncertainty) and one with a decreased likelihood (high clinician comfort with treating patients outside the licensing criteria). Conclusions: Both patient- and clinician-related factors have a major influence on the use of alteplase to treat patients with acute ischemic stroke. Clinicians’ views of the evidence, comfort with uncertainty and treating patients outside the license criteria are important factors to address in programs that seek to reduce variation in care quality regarding treatment with IV alteplase. Further research is needed to further understand the differences in clinical decision-making about treating patients with acute ischemic stroke with IV alteplase

Witness Response at Acute Onset of Stroke: A Qualitative Theory-Guided Study

Background: Delay in calling emergency medical services following stroke limits access to early treatment that can reduce disability. Emergency medical services contact is mostly initiated by stroke witnesses (often relatives), rather than stroke patients. This study explored appraisal and behavioural factors that are potentially important in influencing witness behaviour in response to stroke. Methods and Findings: Semi-structured interviews with 26 stroke witnesses were transcribed and theory-guided content analysed was undertaken based on the Common Sense Self-Regulation Model (appraisal processes) and Theory Domains Framework (behavioural determinants). Response behaviours were often influenced by heuristics-guided appraisal (i.e. mental rules of thumb). Some witnesses described their responses to the situation as ‘automatic' and ‘instinctive', rather than products of deliberation. Potential behavioural influences included: environmental context and resources (e.g. time of day), social influence (e.g. prompts from patients) and beliefs about consequences (e.g. 999 accesses rapid help). Findings are based on retrospective accounts and need further verification in prospective studies. Conclusions: Witnesses play a key role in patient access to emergency medical services. Factors that potentially influence witnesses' responses to stroke were identified and could inform behavioural interventions and future research. Interventions might benefit from linking automatic/instinctive threat perceptions with deliberate appraisal of stroke symptoms, prompting action to call emergency medical services