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 effect of shared decision-making on recovery from non-chronic aspecific low back pain in primary care; a post-hoc analysis from the patient, physician and observer perspectives

BACKGROUND: Although shared decision-making (SDM) is increasingly accepted in healthcare and has demonstrated merits for several psychological outcomes, the effect on recovery from somatic conditions is still subject to debate. The objective of this study is to measure the effect of SDM on recovery from non-chronic aspecific low back pain (LBP). METHODS: This study is a post-hoc analysis of data from a cluster-randomised trial that evaluated the effectiveness of SDM on recovery in patients with non-chronic aspecific LBP. In this analysis, we re-evaluate the impact of SDM from three perspectives: that of external observers, participating GPs and participating patients. Recovery was measured with the Visual Analogue Scale (VAS) for pain and with the Roland Morris Disability questionnaire (RMD) and defined as a VAS < 30 and an RMD < 4. Logistic regression was used to analyse the effect of SDM on recovery at 6 and 26 weeks. RESULTS: At 26 weeks, 105 (74%) of all 176 included patients had recovered. No significant effect of SDM on recovery at 6 or 26 weeks after the consultation was found when considering SDM from an observer perspective or a patient perspective. From a GP perspective SDM had a significant effect on recovery, but at 26 weeks only, and with the lowest probability of recovery observed at a medium level of GP-perceived SDM. CONCLUSIONS: We found no evidence that SDM as perceived by the patient or by external observation improves recovery from non-chronic aspecific low back pain. The long-term recovery may be better for patients in whom the GP perceives SDM during their consultations. Further research should highlight the hierarchy and the relation between the perspectives, which is needed to come to an integral effect evaluation of SDM. TRIAL REGISTRATION: The Netherlands National Trial Register (NTR) number: NTR1960

Impact of organizational context on patient outcomes in a proactive primary care program:a longitudinal observational study

BACKGROUND: The effectiveness of health care interventions is co-determined by contextual factors. Unknown is the extent of this impact on patient outcomes. Therefore, the aim of this study is to explore which characteristics of general practices are associated with patient outcomes in a proactive primary care program, the U-PROFIT 2.0. METHODS: A longitudinal observational study was conducted from January 2016 till October 2017. Two questionnaires were send out, one to collect characteristics of general practices such as practice neighbourhood socio-economic status, general practice versus healthcare centre (involving multiple primary care professionals), and professional- frail older patient ratio per practice of general practitioners and practice nurses. Regarding delivering the program, the practice or district nurse who delivered the program, number of years since the start of the implementation, and choice of age threshold for frailty screening were collected. Patient outcomes collected by the second questionnaire and send to frail patients were daily functioning, hospital admissions, emergency department visits, and general practice out-of-hours consultations. Linear and generalized linear mixed models were used. RESULTS: A total of 827 frail older people were included at baseline. Delivery of the program by a district nurse compared to a practice nurse was significantly associated with a decrease in daily functioning on patient-level (β = 2.19; P = < 0.001). Duration since implementation of 3 years compared to 9 years was significantly associated with less out-of-hours consultations to a general practice (OR 0.11; P = 0.001). Applying frailty screening from the age of 75 compared to those targeted from the age of 60 showed a significant increase in emergency visits (OR 5.26; P = 0.03). CONCLUSION: Three associations regarding the organizational context 1) the nurse who delivered the program, 2) the number of years the program was implemented and 3) the age threshold for defining a frail patient are significant and clinically relevant for frail patients that receive a proactive primary care program. In general, contextual factors need more attention when implementing complex primary care programs which can result in better balanced choices to enhance effective proactive care for older people living in the community

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

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

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