GP access for inclusion health groups: perspectives and recommendations.

BACKGROUND: General practice has seen the widespread adoption of remote consulting and triage systems. There is a lack of evidence exploring how inclusion health populations have been impacted by this transformation. AIM: This study aimed to explore the post-pandemic GP access for inclusion health populations, through the lens of those with lived experience, and identify practical recommendations for improving access for this population. DESIGN & SETTING: A mixed methods study exploring the direct experience of people from inclusion health groups trying to access GP care in 13 practices in east London. METHOD: A mystery shopper exercise involving 39 in-person practice visits and 13 phone-calls were undertaken. The findings were reflected upon by a multidisciplinary stakeholder group which identified recommendations for improvements. RESULTS: Only 31% of the mystery shopper visits (n=8) resulted in registration and the offer of an appointment to see a GP for an urgent problem. None of the mystery shoppers was able to book an appointment over the phone but 10/13 felt that they would be able to register and make an appointment if they followed the receptionist's instructions. Most mystery shoppers felt respected, listened to and understood the information provided to them. Just under half of the practices (46%, n=6) received positive comments on how accessible and supportive their spaces felt.Practice and system-level recommendations were identified by the stakeholder group. CONCLUSION: Ongoing GP access issues persist for inclusion health populations. We identified practice and system level recommendations for improving access for this vulnerable population

Inclusion health patient perspectives on remote access to general practice: a qualitative study.

BACKGROUND: The COVID-19 pandemic has led to rapid and widespread adoption of remote consultations and triage-first pathways in general practice. However, there is a lack of evidence on how these changes have been perceived by patients from inclusion health groups. AIM: To explore the perspectives of individuals from inclusion health groups on the provision and accessibility of remote general practice services. DESIGN & SETTING: A qualitative study with individuals from Gypsy, Roma and Traveller communities, sex workers, vulnerable migrants, and those experiencing homelessness, recruited by Healthwatch in east London. METHOD: The study materials were co-produced with people with lived experience of social exclusion. Semi-structured interviews with 21 participants were audiorecorded, transcribed, and analysed using the framework method. RESULTS: Analysis identified barriers to access owing to lack of translation availability, digital exclusion, and a complex healthcare system, which is difficult to navigate. The role of triage and general practice in emergencies often seemed unclear to participants. Other themes identified included the importance of trust, face-to-face consultation options for ensuring safety, and the benefits of remote access, particularly in terms of convenience and saving time. Themes on reducing barriers included improving staff capacity and communication, offering tailored options and continuity of care, and simplifying care processes. CONCLUSION: The study highlighted the importance of a tailored approach for addressing the multiple barriers to care for inclusion health groups and the need for clearer and inclusive communication on the available triage and care pathways

Policies on doctors’ declaration of interests in medical organisations : a thematic analysis

ObjectivesThere has been growing concern about doctors? conflicts of interests (COIs) but it is unclear what processes and tools exist to enable the consistent declaration and management of such interests. This study mapped existing policies across a variety of organisations and settings to better understand the degree of variation and identify opportunities for improvement.DesignThematic analysis.Setting and ParticipantsWe studied the COI policies of 31 UK and international organisations which set or influence professional standards or engage doctors in healthcare commissioning and provision settings.Main outcome measures:Organisational policy similarities and differences.ResultsMost policies (29/31) referred to the need for individuals to apply judgement when deciding whether an interest is a conflict, with just over half (18/31) advocating a low threshold. Policies differed on the perception of frequency of COI, the timings of declarations, the type of interests that needed to be declared, and how COI and policy breaches should be managed. Just 14/31 policies stated a duty to report concerns in relation to COI. Only 18/31 policies advised COI would be published, while three stated that any disclosures would remain confidential.ConclusionsThe analysis of organisational policies revealed wide variation in what interests should be declared, when and how. This variation suggests that the current system may not be adequate to maintain a high level of professional integrity in all settings and that there is a need for better standardisation that reduces the risk of errors while addressing the needs of doctors, organisations and the public.Publisher PDFPeer reviewe

Feasibility and acceptability of exercise interventions for adults with tendinopathy: a mixed methods review.

This is a protocol for a review that aims to explore the feasibility and acceptability of any exercise intervention for the treatment of any tendinopathy. The first specific review question is: What is the current knowledge about the feasibility of delivering exercise interventions for tendinopathy from the perspective of those delivering and receiving interventions? Specifically: a) How feasible is the delivery of exercise therapy for tendinopathy in terms of rates (e.g. of adherence, attendance, fidelity); and b) What are patients' and healthcare professionals' perceptions of the feasibility of exercise therapy for tendinopathy? The second specific review question is: What is the current knowledge about acceptability of receiving exercise therapy for tendinopathy from the perspective of people with tendinopathy? Specifically: a) How acceptable is exercise therapy in terms of tolerability; and b) What are patients' and healthcare professionals' perceptions of the acceptability of exercise therapy for tendinopathy

The effectiveness of exercise interventions for tendinopathy.

This is a protocol for a study that aimed to determine: 1) which exercise interventions are most effective across all tendinopathies; 2) does the type/location of the tendinopathy, or other specific covariates, affect which are the most effective exercise therapies. The protocol was intended to guide a scoping review, and was then meant to be updated for the effectiveness review

Applications of Future NASA Decadal Missions for Observing Earths Land and Water Processes

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Are patients satisfied? A systematic review and meta-analysis of patient ratings in exercise therapy for the management of tendinopathy.

Outcomes measuring patient rating of overall condition, including patient satisfaction, are associated with improved general health and higher quality of life. However, this outcome domain is under-explored in the management of tendinopathy. The purpose of this systematic review and meta-analysis was to synthesise intervention data investigating patient satisfaction and perceived improvement or deterioration following engagement in exercise therapy for the management of tendinopathy. A search of randomised controlled trials investigating exercise therapy interventions across all tendinopathies was conducted, extracting data assessing patient rating of overall condition. Outcomes were split into those measuring satisfaction (binary) and those measuring global rating of change (GROC). Bayesian hierarchical models were used to meta-analyse proportions and mean effect size (percentage of maximum) for the two outcome categories. From a total of 124 exercise therapy studies, 34 (Achilles: 41%, rotator cuff: 32%, patellar: 15%, elbow: 9% and gluteal: 3%) provided sufficient information to be meta-analysed. The data were obtained across 48 treatment arms and 1246 participants. The pooled estimate for proportion of satisfaction was 0.63 [95% CrI: 0.53 to 0.73], and the pooled estimate for percentage of maximum GROC was 53 [95% CrI: 38 to 69%]. Evidence was also obtained that the proportion of patients reporting positive satisfaction and perception of change increased with longer durations relative to treatment onset. The study concluded that patient satisfaction is not commonly reported in tendinopathy research and, in those studies where it is reported, satisfaction and GROC appear similar and are ranked moderately high, demonstrating that patients generally perceive exercise therapy for tendinopathy management positively. Further research including greater consistency in measurement tools is required to explore, and where possible identify patient and exercise moderating factors that can be used to improve person-centred care

Effect of resistance exercise dose components for tendinopathy management: a systematic review with meta-analysis.

The objective of this study was to investigate potential moderating effects of resistance exercise dose components - including intensity, volume and frequency - for the management of common tendinopathies. The study was conducted through a systematic review with meta-analysis and meta-regressions, using sources that included (but were not limited to) MEDLINE, CINAHL, SPORTDiscus, ClinicalTrials.gov and the ISRCTN Registry. Selection criteria were based on randomised and non-randomised controlled trials investigating resistance exercise as the dominant treatment class, reporting sufficient information regarding two or more components of exercise dose. A total of 110 studies were included in meta-analyses (148 treatment arms (TAs), 3953 participants), reporting on five tendinopathy locations (rotator cuff: 48 TAs; Achilles: 43 TAs; lateral elbow: 29 TAs; patellar: 24 TAs; gluteal: 4 TAs). Meta-regressions provided consistent evidence of greater pooled mean effect sizes for higher intensity therapies comprising additional external resistance compared to body mass only (large effect size domains: βBodyMass:External = 0.50 [95% CrI: 0.15 to 0.84; p = 0.998]; small effect size domains βBodyMass:External = 0.04 [95% CrI: -0.21 to 0.31; p = 0.619]) when combined across tendinopathy locations or analysed separately. Greater pooled mean effect sizes were also identified for the lowest frequency (less than daily) compared with mid (daily) and high frequencies (more than once per day) for both effect size domains, when combined or analysed separately (p ≥ 0.976). Evidence for associations between training volume and pooled mean effect sizes was minimal and inconsistent. The study found that resistance exercise dose is poorly reported within tendinopathy management literature. However, this large meta-analysis identified some consistent patterns indicating greater efficacy on average with therapies prescribing higher intensities (through inclusion of additional loads) and lower frequencies, potentially creating stronger stimuli and facilitating adequate recovery

Which treatment classes and combinations are more effective for the management of common tendinopathies? A systematic review and network meta-analysis.

The aim of this research was to quantify the comparative effectiveness of treatment classes used for the management of the most common tendinopathies. The project studied network meta-analyses comparing combinations of exercise, non-exercise, and non-active treatments across a range of tendinopathy locations and outcome domains. The review covered randomised and quasi-randomised controlled trials including an exercise arm and persons with a tendinopathy diagnosis at any location, and of any severity or duration. Outcome measures included outcomes assessing disability, function, pain, shoulder range of motion, physical function capacity, or quality of life. Through network meta-analyses, broad (exercise/non-exercise/combined/non-active) and more specific (exercise/biomechanics/injection/electrotherapy/manual-therapy/non-active/surgery) treatment class models were fitted with hierarchical Bayesian models. Results were interpreted using pooled standardised mean difference effect sizes and ranking through Surface Under the Cumulative Ranking curves (SUCRA). Treatment hierarchies were assessed using the GRADE minimally contextualised framework. Two-hundred studies comprising 458 treatments arms were identified. Many comparisons were within the same class reducing data available to assess comparative effectiveness. Data from 85 studies generating 140 pairwise comparisons consistently identified the superiority of combining exercise and non-exercise treatment classes (SUCRA: 0.70 to 0.88). Central estimates indicated that combining exercise and non-exercise treatments increased effect sizes by ~0.1 to 0.3 compared with exercise alone. Analysis of more specific treatment classes identified with low/very low certainty the superiority of combining exercise with either biomechanical (e.g. taping, bracing or splinting; SUCRA: 0.73) or injection therapies (SUCRA: 0.72). The study concluded that clinicians should consider combining exercise and non-exercise therapies as a starting point for tendinopathy management. The most effective treatment combinations include exercise with the use of biomechanical or injection therapies

What are small, medium and large effect sizes for exercise treatments of tendinopathy? A systematic review and meta-analysis.

The objective of this study was to quantify and describe effect size distributions from exercise therapies across a range of tendinopathies and outcome domains, to inform future research and clinical practice through conducting a systematic review with meta-analysis. The review and meta-analysis explored moderating effects and context specific small, medium, and large thresholds. The study looked specifically at randomised and quasi-randomised controlled trials involving any persons with a diagnosis of rotator cuff, lateral elbow, patellar, Achilles or gluteal tendinopathy of any severity or duration. The study was conducted using common databases, six trial registries and six grey literature databases, which were searched on 18/01/21 (PROSPERO: CRD42020168187). Standardised mean difference (SMDpre) effect sizes were used with Bayesian hierarchical meta-analysis models to calculate the 0.25- (small), 0.5- (medium) and 0.75-quantiles (large), and to compare pooled means across potential moderators. Risk of bias was assessed with Cochrane's Risk of Bias tool. Data were obtained from 114 studies comprising 171 treatments and 4104 participants. SMDpre effect sizes were similar across tendinopathies but varied across outcome domains. Greater threshold values were obtained for self-reported measures of pain (small = 0.5; medium = 0.9; large = 1.4), disability (small = 0.6; medium = 1.0; large = 1.5) and function (small = 0.6; medium = 1.1; large = 1.8); and lower threshold values obtained for quality of life (small = -0.2; medium = 0.3; large = 0.7), and objective measures of physical function (small = 0.2; medium = 0.4; large = 0.7). Potential moderating effects of assessment duration, exercise supervision and symptom duration were also identified, with greater pooled mean effect sizes estimated for longer assessment durations, supervised therapies and studies comprising patients with shorter symptom durations. The study found that the effect size of exercise on tendinopathy is dependent on the type of outcome measure assessed. Threshold values presented here can be used to guide interpretation and assist with further research better establishing minimal important change