Assessing collaborative efforts of making care fit for each patient: A systematic review

IntroductionFor too many people, their care plans are designed without fully accounting for who they are, the lives they live, what matters to them or what they aspire to achieve. We aimed to summarize instruments capable of measuring dimensions of patient–clinician collaboration to make care fit.MethodsWe systematically searched several databases (Medline, Embase, Cochrane, Scopus and Web of Science) from inception to September 2021 for studies using quantitative measures to assess, evaluate or rate the work of making care fit by any participant in real-life clinical encounters. Eligibility was assessed in duplicate. After extracting all items from relevant instruments, we coded them deductively on dimensions relevant to making care fit (as presented in a recent Making Care Fit Manifesto), and inductively on the main action described.ResultsWe included 189 papers, mostly from North America (N = 83, 44%) and in the context of primary care (N = 54, 29%). Half of the papers (N = 88, 47%) were published in the last 5 years. We found 1243 relevant items to assess efforts of making care fit, included within 151 instruments. Most items related to the dimensions ‘Patient-clinician collaboration: content’ (N = 396, 32%) and ‘Patient-clinician collaboration: manner’ (N = 382, 31%) and the least related to ‘Ongoing and iterative process’ (N = 22, 2%) and in ‘Minimally disruptive of patient lives’ (N = 29, 2%). The items referred to 27 specific actions. Most items referred to ‘Informing’ (N = 308, 25%) and ‘Exploring’ (N = 93, 8%), the fewest items referred to ‘Following up’, ‘Comforting’ and ‘Praising’ (each N = 3, 0.2%).DiscussionMeasures of the work that patients and clinicians do together to make care fit focus heavily on the content of their collaborations, particularly on exchanging information. Other dimensions and actions previously identified as crucial to making care fit are assessed infrequently or not at all. The breadth of extant measures of making care fit and the lack of appropriate measures of this key construct limit both the assessment and the successful implementation of efforts to improve patient care.Patient ContributionPatients and caregivers from the ‘Making care fit Collaborative’ were involved in drafting the dimensions relevant to patient–clinician collaboration

Understanding the Primary Care Osteoarthritis Consultation using Video-Stimulated Recall

Background: Osteoarthritis (OA) is the commonest long term condition in primary care. Current guidance suggests that much can be done to improve outcomes but existing research suggests doctors and patients are pessimistic about OA treatment. An important question concerns the role of the primary care consultation in this incongruity. This study used a combination of video recorded consultations and post consultation interviews using video-stimulated recall (VSR), to uncover what happens when patients discuss OA with their general practitioners (GPs). Methods: With ethical approval, GP consultations with 190 consenting patients aged ≥ 45 were recorded. Twenty consultations contained reference to OA, and 17 of these patients and their GPs (n=13) participated in post consultation interviews. Analysis involved thematic analysis of videotapes and comparisons of patient and GP interviews with the consultation findings. Results: Osteoarthritis arises in the consultation in complex contexts of multi-morbidity, multiple and varied patient agendas which are often not explicit, and against a background of clinician agendas including time pressures, multiple guidelines and service requirements. Dissonance between doctors and patients was observed and was often underpinned by patient perception of lack of empathy and symptom validation. Doctors and patients often adopt a ‘lay’ construct of OA where joint pain is seen as a normal part of life; this influences doctor and patient behaviour and acts as a significant barrier to formal recognition and hence treatment of the condition. Conclusions: The design of interventions to improve outcomes of patients with OA must take account of the complexity and heterogeneity of presentations in primary care. Osteoarthritis appears to be experiencing an identity crisis, with doctors and patients uncertain of what constitutes OA and when to use the term ‘osteoarthritis’. Further work is needed to identify effective ways of translating best evidence about OA management into effective primary care strategies

Comparison of patient experiences of the osteoarthritis consultation with GP attitudes and beliefs to OA: a narrative review

Osteoarthritis (OA) is a common cause of disability and consultation with a GP. However, little is known about what currently happens when patients with OA consult their GP. This review aims to compare existing literature reporting patient experiences of consultations in which OA is discussed with GP attitudes and beliefs regarding OA, in order to identify any consultation events that may be targeted for intervention

Design, validation and dissemination of an undergraduate assessment tool using SimMan® in simulated medical emergencies

Background: Increasingly, medical students are being taught acute medicine using whole-body simulator manikins. Aim: We aimed to design, validate and make widely available two simple assessment tools to be used with Laerdal SimMan (R) for final year students. Methods: We designed two scenarios with criterion-based checklists focused on assessment and management of two medical emergencies. Members of faculty critiqued the assessments for face validity and checklists revised. We assessed three groups of different experience levels: Foundation Year 2 doctors, third and final year medical students. Differences between groups were analysed, and internal consistency and interrater reliability calculated. A generalisability analysis was conducted using scenario and rater as facets in design. Results: A maximum of two items were removed from either checklist following the initial survey. Significantly different scores for three groups of experience for both scenarios were reported (p0.90). Internal consistency was poor (alpha<50.5). Generalizability study results suggest that four cases would provide reliable discrimination between final year students. Conclusions: These assessments proved easy to administer and we have gone some way to demonstrating construct validity and reliability. We have made the material available on a simulator website to enable others to reproduce these assessments

Getting back to the dissecting room: an evaluation of an innovative course in musculoskeletal anatomy for UK-based rheumatology training

BackgroundThe rheumatologist relies heavily on clinical skills to diagnose diverse conditions, something that is correlated with one's knowledge of clinical anatomy. More recently, rheumatology has offered further career flexibility with opportunities to develop skills such as joint injection and musculoskeletal (MSK) ultrasound, both of which require a sound understanding of anatomy. Currently, there are no formal strategies to support competency-based anatomy learning in rheumatology in the UK. This study aimed to evaluate an innovative applied anatomy course utilizing cadaveric material, targeted at clinicians practising in rheumatology and MSK medicine.MethodsA new course was developed for rheumatologists, rheumatology trainees and allied health professionals practising rheumatology and MSK medicine, with the principal focus being on applied MSK anatomy. A questionnaire was given to course attendees and a mixed methods approach of evaluation used. Descriptive statistical data analysis was performed.ResultsThe course received overall positive feedback and statistically significant improvements in levels of confidence in anatomy (mean 52.35–83.53, p < 0.0001), injections (mean 57.65–81.18, p < 0.0001), examination of the upper limb (mean 60.59–76.47, p < 0.0001) and examination of the lower limb (mean 58.24–77.65, p < 0.0001). Course attendees also favoured a peer-assisted and multidisciplinary learning approach.ConclusionsThis study lends support for the use of cadaveric material in the teaching of postgraduate anatomy to rheumatologists. It has demonstrated a continual need for hands-on and interactive anatomy training in an ever-advancing digital world. To be successful, cadaveric learning should not be viewed in a purely ‘pre-clinical’ setting, but instead integrated with postgraduate learning

Acceptability of nurse-led reviews for inflammatory rheumatological conditions: A qualitative study.

Background: People with inflammatory rheumatological conditions (IRCs), are at increased risk of comorbidities such as cardiovascular disease, osteoporosis, anxiety and depression. The INCLUDE pilot trial evaluated a nurse-delivered review of people with IRCs which sought to identify and initiate management of comorbid conditions. Aim: A nested qualitative study was undertaken to examine the acceptability of the INCLUDE review. Methods: A qualitative interview-based design in UK primary care settings. A purposive sample of 20 patients who attended an INCLUDE review, were interviewed. Inductive thematic analysis was undertaken. Themes were agreed through multidisciplinary team discussion and mapped onto constructs of the Theoretical Framework of Acceptability (TFA). Results: Six themes mapped onto six of the seven TFA constructs. Patients reported the review to be effective by identifying and initiating management of previously unrecognised comorbid conditions. Some participants reported barriers to following recommendations, such as lifestyle modifications or taking more medication. Conclusion: A nurse-delivered review to identify comorbidities is acceptable to patients with IRCs. The TFA provided a novel analytical lens

Bone health assessment in adults with fragility fracture risk factors between 2002-2014: a retrospective cohort study.

Background Lifetime risk of fragility fractures is 50% in post-menopausal women and 20% in men aged over 50 years. Identifying people at high risk facilitates early intervention and reduction of biopsychosocial morbidity associated with these fractures.Aim To explore if bone health assessment (BHA) rates differ between women and men aged 50 years and over with fragility fracture risk factors.Design & setting A primary care-based cohort studyMethod Patients were identified from the Consultations in Primary Care Archive (CiPCA) database between 2002 and 2014 with one or more fragility fracture risk factors (previous fractures, falls and prolonged steroid use). Evaluation of BHA within twelve months of presentation of the first risk factor was carried out by searching for codes for fracture risk assessment tools (FRAX/QFracture), bone density measurement, specialist service referral or if bone-protection medication was started.Results 15,581 patients with risk factors were identified; men represented 40% of the cohort. 1,172 (7.5%) had BHA performed within one year of presentation. 8.9% of females and 5.5% of males had BHAs, which was found with strong statistical evidence (X2=59.88, P=1 × 10-14). This relationship prevailed after adjusting for other covariates such as co-morbidity and number of consultations with an odds ratio of 1.25 (95% Confidence Interval 1.08–1.43).Conclusion This study shows that rates of BHA were generally low and even lower in men. Primary care clinicians should be alert to fragility fracture risk factors in both men and women to enable early assessment and intervention

Using Twitter (X) to mobilise knowledge for First Contact Physiotherapists: A qualitative study (Preprint)

Background:Twitter (now X) is a virtual social network commonly used by healthcare professionals. Little is known about whether it helps healthcare professionals to share, mobilise and co-create knowledge, or reduce the time between research knowledge being created and used in clinical practice (the evidence-to-practice gap). Musculoskeletal First Contact Physiotherapists (FCPs) are primary care specialists who diagnose and treat people with musculoskeletal conditions without needing to see their General Practitioner (family physician) first. They often work as a sole FCP in practice, hence are an ideal healthcare professional group with whom to explore knowledge mobilisation using Twitter.Objective:To explore if, how and why Twitter can be used to mobilise knowledge, including research findings, to inform FCP clinical practice.Methods:Semi-structured interviews of FCPs with experience of working in English primary care. FCPs were purposively sampled based on employment arrangements and Twitter use. Recruitment was via known FCP networks and Twitter, supplemented by snowball sampling. Online interviews used a topic guide exploring FCP's perceptions and experiences of accessing knowledge, via Twitter, for clinical practice. Data were analysed thematically and informed by the knowledge mobilisation mindlines model. Public contributors were involved throughout.Results:Nineteen FCPs consented to interview (Twitter users n=14, female n=9). Three themes were identified: 1) How Twitter meets the needs of FCPs, 2) Twitter and a journey of knowledge to support clinical practice and 3) Factors impeding knowledge sharing on Twitter. FCPs described needs relating to isolated working practice, time demands and role uncertainty. Twitter provided rapid access to succinct knowledge, opportunity to network and peer reassurance regarding clinical cases, evidence and policy. FCPs took a journey of knowledge exchange on Twitter, including scrolling for knowledge, filtering for credibility and adapting knowledge for in-service training and clinical practice. Participants engaged best with images and infographics. FCPs described misinformation, bias, echo chambers, unprofessionalism, hostility, privacy concerns and blurred personal boundaries as factors impeding knowledge sharing on Twitter. Consequently, many did not feel confident to actively participate with Twitter.Conclusions:This study explores if, how and why Twitter can be used to mobilise knowledge to inform FCP clinical practice. Twitter can meet knowledge needs of FCPs through rapid access to succinct knowledge, networking opportunities and professional reassurance. The journey of knowledge exchange from Twitter to clinical practice can be explained by considering the mindlines model, which describes how FCPs exchange knowledge in online and offline contexts. Findings demonstrate that Twitter can be a useful adjunct to FCP practice although several factors impeded knowledge sharing on the platform. We recommend social media training and enhanced governance guidance from professional bodies to support the use of Twitter for knowledge mobilisation

Vertebral fractures and daily pain are associated with lower physical activity in postmenopausal women with back pain

Around 12% of women have vertebral fractures (VFs), and many of these individuals also have back pain which limits physical activity (PA). PA is important for health, but little is known about how VFs affect PA, and if so how this compares with individuals with back pain due to other causes. Therefore, we recruited 37 postmenopausal women from primary care with back pain, in whom the presence or absence of VFs was ascertained by spine radiographs. To provide an objective PA measure, vertical accelerations were recorded at 100 Hz for 7 days using a hip-worn GT3X+ accelerometer (Actigraph, USA). The number of low (0.5g-2g) was recorded. Participants also recorded their average back pain each day using a 10-point Likert scale. Linear mixed-effects models were used to assess group differences (fracture/nofracture cases) in low, medium and high-impact PA, and associations between daily pain and different PA impact levels. Daily PA and pain data had non-normal distributions and were log transformed. 12 women were found to have previously sustained VFs. These participants had lower levels of lowimpact PA (regression coefficient -0.64, 95%CI -1.03 to -0.25, P=0.002) but not medium or highimpact PA (both P>0.2). Across all participants, higher daily pain was associated with lower highimpact PA levels (-0.08, 95%CI -0.14 to -0.02, P=0.014) and weakly with medium–impact PA (-0.1, 95%CI -0.22 to 0.02, P=0.081) but not low-impact PA (P=0.25). These results suggest that VFs and daily pain are associated with lower levels of low and high-impact PA respectively, shown previously to differentially affect components of health. Low levels of low impact PA in women with VFs may impair weight control in these women. In contrast, reduced PA, in particular high-impact PA, in women with higher daily pain levels may increase the risk of sarcopenia and osteoporosis

Comparing medication adherence in patients receiving bisphosphonates for preventing fragility fractures: a comprehensive systematic review and network meta-analysis

Background: Bisphosphonates are effective in preventing fragility fractures; however, high rates of adherence are needed to preserve clinical benefits. Objective: To investigate persistence and compliance to oral and intravenous bisphosphonates (alendronate, ibandronate, risedronate, and zoledronate). Methods: Searches of 12 databases, unpublished sources, and trial registries were conducted, covering the period from 2000 to April 2021. Screening, data extraction, and risk of bias assessment (Cochrane Collaboration risk-of-bias tool 1.0 & ROBINS-I) were independently undertaken by two study authors. Randomised controlled trials (RCTs) and observational studies that used prescription claim databases or hospital medical records to examine patients’ adherence were included. Network meta-analyses (NMA) embedded within a Bayesian framework were conducted, investigating users’ likelihood in discontinuing bisphosphonate treatment. Where meta-analysis was not possible, data were synthesised using the vote-counting synthesis method. Results: Fifty-nine RCTs and 43 observational studies were identified, resulting in a total population of 2,656,659 participants. Data from 59 RCTs and 24 observational studies were used to populate NMAs. Zoledronate users were the least likely to discontinue their treatment HR = 0.73 (95%CrI: 0.61, 0.88). Higher rates of compliance were observed in those receiving intravenous treatments. The paucity of data and the heterogeneity in the reported medication possession ratio thresholds precluded a NMA of compliance data. Conclusions: Users of intravenously administered bisphosphonates were found to be the most adherent to treatment among bisphosphonates’ users. Patterns of adherence will permit the more precise estimation of clinical and cost-effectiveness of bisphosphonates. Trial registration: PROSPERO 2020 CRD42020177166