Community nursing needs more silver surfers: a questionnaire survey of primary care nurses' use of information technology

BACKGROUND: In the UK the health service is investing more than ever before in information technology (IT) and primary care nurses will have to work with computers. Information about patients will be almost exclusively held in electronic patient records; and much of the information about best practice is most readily accessible via computer terminals. OBJECTIVE: To examine the influence of age and nursing profession on the level of computer use. METHODS: A questionnaire was developed to examine: access, training received, confidence and use of IT. The survey was carried out in a Sussex Primary Care Trust, in the UK. RESULTS: The questionnaire was sent to 109 nurses with a 64% response rate. Most primary care nurses (89%) use their computer regularly at work: 100% of practice nurses daily, compared with 60% of district nurses and 59% of health visitors (p < 0.01). Access to IT was not significantly different between different age groups; but 91% of practice nurses had their own computer while many district nurses and health visitors had to share (p < 0.01). Nurses over 50 had received more training that their younger colleagues (p < 0.01); yet despite this, they lacked confidence and used computers less (p < 0.001). 96% of practice nurses were confident at in using computerised medical records, compared with 53% of district nurses and 44% of health visitors (p < 0.01.) One-to-one training and workshops were the preferred formats for training, with Internet based learning and printed manuals the least popular (p < 0.001). CONCLUSIONS: Using computers in the surgery has become the norm for primary care nurses. However, nurses over 50, working out in the community, lack the confidence and skill of their younger and practice based colleagues

Triumph of hope over experience: learning from interventions to reduce avoidable hospital admissions identified through an Academic Health and Social Care Network.

BACKGROUND: Internationally health services are facing increasing demands due to new and more expensive health technologies and treatments, coupled with the needs of an ageing population. Reducing avoidable use of expensive secondary care services, especially high cost admissions where no procedure is carried out, has become a focus for the commissioners of healthcare. METHOD: We set out to identify, evaluate and share learning about interventions to reduce avoidable hospital admission across a regional Academic Health and Social Care Network (AHSN). We conducted a service evaluation identifying initiatives that had taken place across the AHSN. This comprised a literature review, case studies, and two workshops. RESULTS: We identified three types of intervention: pre-hospital; within the emergency department (ED); and post-admission evaluation of appropriateness. Pre-hospital interventions included the use of predictive modelling tools (PARR - Patients at risk of readmission and ACG - Adjusted Clinical Groups) sometimes supported by community matrons or virtual wards. GP-advisers and outreach nurses were employed within the ED. The principal post-hoc interventions were the audit of records in primary care or the application of the Appropriateness Evaluation Protocol (AEP) within the admission ward. Overall there was a shortage of independent evaluation and limited evidence that each intervention had an impact on rates of admission. CONCLUSIONS: Despite the frequency and cost of emergency admission there has been little independent evaluation of interventions to reduce avoidable admission. Commissioners of healthcare should consider interventions at all stages of the admission pathway, including regular audit, to ensure admission thresholds don't change

The QICKD study protocol: a cluster randomised trial to compare quality improvement interventions to lower systolic BP in chronic kidney disease (CKD) in primary care

BACKGROUND: Chronic kidney disease (CKD) is a relatively newly recognised but common long-term condition affecting 5 to 10% of the population. Effective management of CKD, with emphasis on strict blood pressure (BP) control, reduces cardiovascular risk and slows the progression of CKD. There is currently an unprecedented rise in referral to specialist renal services, which are often located in tertiary centres, inconvenient for patients, and wasteful of resources. National and international CKD guidelines include quality targets for primary care. However, there have been no rigorous evaluations of strategies to implement these guidelines. This study aims to test whether quality improvement interventions improve primary care management of elevated BP in CKD, reduce cardiovascular risk, and slow renal disease progression DESIGN: Cluster randomised controlled trial (CRT) METHODS: This three-armed CRT compares two well-established quality improvement interventions with usual practice. The two interventions comprise: provision of clinical practice guidelines with prompts and audit-based education. The study population will be all individuals with CKD from general practices in eight localities across England. Randomisation will take place at the level of the general practices. The intended sample (three arms of 25 practices) powers the study to detect a 3 mmHg difference in systolic BP between the different quality improvement interventions. An additional 10 practices per arm will receive a questionnaire to measure any change in confidence in managing CKD. Follow up will take place over two years. Outcomes will be measured using anonymised routinely collected data extracted from practice computer systems. Our primary outcome measure will be reduction of systolic BP in people with CKD and hypertension at two years. Secondary outcomes will include biomedical outcomes and markers of quality, including practitioner confidence in managing CKD. A small group of practices (n = 4) will take part in an in-depth process evaluation. We will use time series data to examine the natural history of CKD in the community. Finally, we will conduct an economic evaluation based on a comparison of the cost effectiveness of each intervention. CLINICAL TRIALS REGISTRATION: ISRCTN56023731. ClinicalTrials.gov identifier

Evaluating tools to support a new practical classification of diabetes: excellent control may represent misdiagnosis and omission from disease registers is associated with worse control.

To conduct a service evaluation of usability and utility on-line clinical audit tools developed as part of a UK Classification of Diabetes project to improve the categorisation and ultimately management of diabetes

Predicting the prevalence of chronic kidney disease in the English population: a cross-sectional study.

BACKGROUND: There is concern that not all cases of chronic kidney disease (CKD) are known to general practitioners, leading to an underestimate of its true prevalence. We carried out this study to develop a model to predict the prevalence of CKD using a large English primary care dataset which includes previously undiagnosed cases of CKD. METHODS: Cross-sectional analysis of data from the Quality Improvement in CKD trial, a representative sample of 743 935 adults in England aged 18 and over. We created multivariable logistic regression models to identify important predictive factors. RESULTS: A prevalence of 6.76% was recorded in our sample, compared to a national prevalence of 4.3%. Increasing age, female gender and cardiovascular disease were associated with a significantly increased prevalence of CKD (p < 0.001 for all). Age had a complex association with CKD. Cardiovascular disease was a stronger predictive factor in younger than in older patients. For example, hypertension has an odds ratio of 2.02 amongst patients above average and an odds ratio of 3.91 amongst patients below average age. CONCLUSION: In England many cases of CKD remain undiagnosed. It is possible to use the results of this study to identify areas with high levels of undiagnosed CKD and groups at particular risk of having CKD

Caring for the patient, caring for the record: an ethnographic study of 'back office' work in upholding quality of care in general practice

© 2015 Swinglehurst and Greenhalgh; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Additional file 1: Box 1. Field notes on summarising (Clover Surgery). Box 2. Extract of document prepared for GPs by summarisers at Clover Surgery. Box 3. Fieldnotes on coding incoming post, Clover (original notes edited for brevity).This work was funded by a research grant from the UK Medical Research Council (Healthcare Electronic Records in Organisations 07/133) and a National Institute of Health Research doctoral fellowship award for DS (RDA/03/07/076). The funders were not involved in the selection or analysis of data nor did they make any contribution to the content of the final manuscript

Detecting referral and selection bias by the anonymous linkage of practice, hospital and clinic data using Secure and Private Record Linkage (SAPREL): case study from the evaluation of the Improved Access to Psychological Therapy (IAPT) service

Background: The evaluation of demonstration sites set up to provide improved access to psychological therapies (IAPT) comprised the study of all people identified as having common mental health problems (CMHP), those referred to the IAPT service, and a sample of attenders studied in-depth. Information technology makes it feasible to link practice, hospital and IAPT clinic data to evaluate the representativeness of these samples. However, researchers do not have permission to browse and link these data without the patients’ consent. Objective: To demonstrate the use of a mixed deterministic-probabilistic method of secure and private record linkage (SAPREL) - to describe selection bias in subjects chosen for in-depth evaluation. Method: We extracted, pseudonymised and used fuzzy logic to link multiple health records without the researcher knowing the patient’s identity. The method can be characterised as a three party protocol mainly using deterministic algorithms with dynamic linking strategies; though incorporating some elements of probabilistic linkage. Within the data providers’ safe haven we extracted: Demographic data, hospital utilisation and IAPT clinic data; converted post code to index of multiple deprivation (IMD); and identified people with CMHP. We contrasted the age, gender, ethnicity and IMD for the in-depth evaluation sample with people referred to IAPT, use hospital services, and the population as a whole. Results: The in IAPT-in-depth group had a mean age of 43.1 years; CI: 41.0 - 45.2 (n = 166); the IAPT-referred 40.2 years; CI: 39.4 - 40.9 (n = 1118); and those with CMHP 43.6 years SEM 0.15. (n = 12210). Whilst around 67% of those with a CMHP were women, compared to 70% of those referred to IAPT, and 75% of those subject to indepth evaluation (Chi square p< 0.001). The mean IMD score for the in-depth evaluation group was 36.6; CI: 34.2 - 38.9; (n = 166); of those referred to IAPT 38.7; CI: 37.9 - 39.6; (n = 1117); and of people with CMHP 37.6; CI 37.3- 37.9; (n = 12143). Conclusions: The sample studied in-depth were older, more likely female, and less deprived than people with CMHP, and fewer had recorded ethnic minority status. Anonymous linkage using SAPREL provides insight into the representativeness of a study population and possible adjustment for selection bias

Granular jamming based controllable organ design for abdominal palpation

Medical manikins play an essential role in the training process of physicians. Currently, most available simulators for abdominal palpation training do not contain controllable organs for dynamic simulations. In this paper, we present a soft robotics controllable liver that can simulate various liver diseases and symptoms for effective and realistic palpation training. The tumors in the liver model are designed based on granular jamming with positive pressure, which converts the fluid-like impalpable particles to a solid-like tumor state by applying low positive pressure on the membrane. Through inflation, the tumor size, liver stiffness, and liver size can be controlled from normal liver state to various abnormalities including enlarged liver, cirrhotic liver, and multiple cancerous and malignant tumors. Mechanical tests have been conducted in the study to evaluate the liver design and the role of positive pressure granular jamming in tumor simulations

The computerized medical record as a tool for clinical governance in australian primary care

Background: Computerized medical records (CMR) are used in most Australian general practices. Although CMRs have the capacity to amalgamate and provide data to the clinician about their standard of care, there is little research on the way in which they may be used to support clinical governance: the process of ensuring quality and accountability that incorporates the obligation that patients are treated according to best evidence. Objective: The objective of this study was to explore the capability, capacity, and acceptability of CMRs to support clinical governance. Methods: We conducted a realist review of the role of seven CMR systems in implementing clinical governance, developing a four-level maturity model for the CMR. We took Australian primary care as the context, CMR to be the mechanism, and looked at outcomes for individual patients, localities, and for the population in terms of known evidence-based surrogates or true outcome measures. Results: The lack of standardization of CMRs makes national and international benchmarking challenging. The use of the CMR was largely at level two of our maturity model, indicating a relatively simple system in which most of the process takes place outside of the CMR, and which has little capacity to support benchmarking, practice comparisons, and population-level activities. Although national standards for coding and projects for record access are proposed, they are not operationalized. Conclusions: The current CMR systems can support clinical governance activities; however, unless the standardization and data quality issues are addressed, it will not be possible for current systems to work at higher levels