Identifying Factors Leading to Harm in English General Practices

This is the author accepted manuscript. The final version is available from Lippincott, Williams & Wilkins via the DOI in this record.Objective The aim of the study was to identify the main factors leading to harm in primary care based on the experiences reported by patients. Methods We conducted a mixed-methods, cross-sectional study in 45 primary care centers in England. A random sample of 6736 patients was invited to complete the Patient-Reported Experiences and Outcomes of Safety in Primary Care questionnaire. We fitted structural equation modeling on the quantitative data (n = 1244 respondents) to identify contributory factors and primary incidents leading to harm. We conducted content analyses of responses to seven open-ended questions (n = 386) to obtain deeper insight into patient perceptions of the causes of harm experienced. Results from quantitative and qualitative analyses were triangulated. Results Patients reported harm related to physical health (13%), pain (11%), and mental health (19%) and harm that increased limitations in social activities (14%). Physical harm was associated with incidents affecting diagnosis (β = 0.43; delayed and wrong), and treatment (0.12; delayed, wrong treatment, or dose), which were in turn associated with incidents with patient-provider communication, coordination between providers, appointments, and laboratory tests. Pain was associated with laboratory tests (0.21; caused when collecting blood or tissue samples) and with problems booking an appointment when needed (0.13; delaying treatment for pain). Harm to mental health was associated with incidents related to the following: diagnosis (0.28), patient-provider communication (0.18), appointments (0.17), coordination between different providers (0.14), and laboratory tests (0.12). Harm increasing limitations in social activities was associated with incidents related to diagnosis (0.42) and diagnostic and monitoring procedures (0.20). Conclusions Our findings suggest the need for patient-centered strategies to reduce harm in primary care focusing on the improvement of the quality of diagnosis and patient-provider communication

Quality of care assessment for people with multimorbidity.

Multimorbidity, the simultaneous presence of multiple health conditions in an individual, is an increasingly common phenomenon globally. The systematic assessment of the quality of care delivered to people with multimorbidity will be key to informing the organization of services for meeting their complex needs. Yet, current assessments tend to focus on single conditions and do not capture the complex processes that are required for providing care for people with multimorbidity. We conducted a scoping review on quality of care and multimorbidity in selected databases in June 2018 and identified 87 documents as eligible for review, predominantly original research and reviews from North America, Europe and Australasia and mostly frequently related to primary care settings. We synthesized data qualitatively in terms of perceived challenges, evidence and proposed metrics. Findings reveal that the association between quality of care and multimorbidity is complex and depends on the conditions involved (quality appears to be higher for those with concordant conditions, and lower in the presence of discordant conditions) and the approach used for measuring quality (quality appears to be higher in people with multimorbidity when measured using condition/drug-specific process or intermediate outcome indicators, and worse when using patient-centred reports of experiences of care). People with discordant multimorbidity may be disadvantaged by current approaches to quality assessment, particularly when they are linked to financial incentives. A better understanding of models of care that best meet the needs of this group is needed for developing appropriate quality assessment frameworks. Capturing patient preferences and values and incorporate patients' voices in the form of patient-reported experiences and outcomes of care will be critical towards the achievement of high-performing health systems that are responsive to the needs of people with multimorbidity

STOPP/START interventions to improve medicines management for people aged 65 years and over: a realist synthesis

Background Drug-related problems and potentially inappropriate prescribing impose a huge burden on patients and the health-care system. The most widely used tools for appropriate prescription in older adults in England and in other European countries are the Screening Tool of Older People’s Prescriptions (STOPP)/Screening Tool to Alert to the Right Treatment (START) tools. STOPP/START tools support medicines optimisation for older adults. Objectives To identify, test and refine the programme theories underlying how interventions based on the STOPP/START tools are intended to work, for whom, in what circumstances and why, as well as the resource use and cost requirements or impacts. Design A realist synthesis. Setting Primary care, hospital care and nursing homes. Patients Patients aged ≥ 65 years. Interventions Any intervention based on the use of the STOPP/START tools. Review methods Database and web-searching was carried out to retrieve relevant evidence to identify and test programme theories about how interventions based on the use of the STOPP/START tools work. A project reference group made up of health-care professionals, NHS decision-makers, older people, carers and members of the public was set up. In phase 1 we identified programme theories about STOPP/START interventions on how, for whom, in what contexts and why they are intended to work. We searched the peer-reviewed and grey literature to identify documents relevant to the research questions. We interviewed experts in the field in our reference group to gain input on our list of candidate context–mechanism–outcome configurations, to identify additional context–mechanism–outcome configurations and to identify additional literature and/or relevant concepts. In phase 2 we reviewed and synthesised relevant published and unpublished empirical evidence and tested the programme theories using evidence from a larger set of empirical studies. Results We developed a single logic model structured around three key mechanisms: (1) personalisation, (2) systematisation and (3) evidence implementation. Personalisation: STOPP/START-based interventions are based on shared decision-making, taking into account patient preferences, experiences and expectations (mechanisms), leading to increased patient awareness, adherence, satisfaction, empowerment and quality of life (outcomes). Systematisation: STOPP/START tools provide a standardised/systematic approach for medication reviews (mechanisms), leading to changes in professional and organisational culture and burden/costs (outcomes). Evidence implementation: delivery of STOPP/START-based interventions is based on the implementation of best evidence (mechanisms), reducing adverse outcomes through appropriate prescribing/deprescribing (outcomes). For theory testing, we identified 40 studies of the impact of STOPP/START-based interventions in hospital settings, nursing homes, primary care and community pharmacies. Most of the interventions used multiple mechanisms. We found support for the impact of the personalisation and evidence implementation mechanisms on selected outcome variables, but similar impact was achieved by interventions not relying on these mechanisms. We also observed that the impact of interventions was linked to the proximity of the selected outcomes to the intervention in the logic model, resulting in a clearer benefit for appropriateness of prescribing, adverse drug events and prescription costs. Limitations None of the available studies had been explicitly designed for evaluating underlying causal mechanisms, and qualitative information was sparse. Conclusions No particular configuration of the interventions is associated with a greater likelihood of improved outcomes in given settings. Study registration This study is registered as PROSPERO CRD42018110795. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 23. See the NIHR Journals Library website for further project information

Routine provision of feedback from patient-reported outcome measurements to healthcare providers and patients in clinical practice

Background Patient‐reported outcomes measures (PROMs) assess a patient’s subjective appraisal of health outcomes from their own perspective. Despite hypothesised benefits that feedback on PROMs can support decision‐making in clinical practice and improve outcomes, there is uncertainty surrounding the effectiveness of PROMs feedback. Objectives To assess the effects of PROMs feedback to patients, or healthcare workers, or both on patient‐reported health outcomes and processes of care. Search methods We searched MEDLINE, Embase, CENTRAL, two other databases and two clinical trial registries on 5 October 2020. We searched grey literature and consulted experts in the field. Selection criteria Two review authors independently screened and selected studies for inclusion. We included randomised trials directly comparing the effects on outcomes and processes of care of PROMs feedback to healthcare professionals and patients, or both with the impact of not providing such information. Data collection and analysis Two groups of two authors independently extracted data from the included studies and evaluated study quality. We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. We conducted meta‐analyses of the results where possible. Main results We identified 116 randomised trials which assessed the effectiveness of PROMs feedback in improving processes or outcomes of care, or both in a broad range of disciplines including psychiatry, primary care, and oncology. Studies were conducted across diverse ambulatory primary and secondary care settings in North America, Europe and Australasia. A total of 49,785 patients were included across all the studies. The certainty of the evidence varied between very low and moderate. Many of the studies included in the review were at risk of performance and detection bias. The evidence suggests moderate certainty that PROMs feedback probably improves quality of life (standardised mean difference (SMD) 0.15, 95% confidence interval (CI) 0.05 to 0.26; 11 studies; 2687 participants), and leads to an increase in patient‐physician communication (SMD 0.36, 95% CI 0.21 to 0.52; 5 studies; 658 participants), diagnosis and notation (risk ratio (RR) 1.73, 95% CI 1.44 to 2.08; 21 studies; 7223 participants), and disease control (RR 1.25, 95% CI 1.10 to 1.41; 14 studies; 2806 participants). The intervention probably makes little or no difference for general health perceptions (SMD 0.04, 95% CI ‐0.17 to 0.24; 2 studies, 552 participants; low‐certainty evidence), social functioning (SMD 0.02, 95% CI ‐0.06 to 0.09; 15 studies; 2632 participants; moderate‐certainty evidence), and pain (SMD 0.00, 95% CI ‐0.09 to 0.08; 9 studies; 2386 participants; moderate‐certainty evidence). We are uncertain about the effect of PROMs feedback on physical functioning (14 studies; 2788 participants) and mental functioning (34 studies; 7782 participants), as well as fatigue (4 studies; 741 participants), as the certainty of the evidence was very low. We did not find studies reporting on adverse effects defined as distress following or related to PROM completion. Authors' conclusions PROM feedback probably produces moderate improvements in communication between healthcare professionals and patients as well as in diagnosis and notation, and disease control, and small improvements to quality of life. Our confidence in the effects is limited by the risk of bias, heterogeneity and small number of trials conducted to assess outcomes of interest. It is unclear whether many of these improvements are clinically meaningful or sustainable in the long term. There is a need for more high‐quality studies in this area, particularly studies which employ cluster designs and utilise techniques to maintain allocation concealment

Suomen videopeliteollisuuden käyttäjäinnovaatioiden juridiset haasteet ja mahdollisuudet

Opinnäytetyössä selvitettiin minkälaisia juridisia ongelmia käyttäjäinnovaatioiden hyödyntäminen aiheuttaa videopelialan suomalaisille yrityksille. Työssä selvitettiin käyttäjäinnovaatioilla saavutettuja hyötyjä sekä avattiin käyttäjäinnovaatioista aiheutuvia juridisia ongelmia. Kaiken kaikkiaan aiheesta on hyvin vähän juridista tutkimusta, varsinkaan kansallisella tasolla ja tästä syystä aihe on hyvin ajankohtainen Toimeksiantajani opinnäytetyössä oli lakipalveluita tarjoava yritys Fondia Oy ja idea opinnäytetyönaiheeksi on myös lähtöisin heiltä. Aiheen käsittely aloitetiin erilaisien videopelityyppien ja käyttäjäinnovaatiomallien teoriaan tutustumalla. Videopelialan käyttäjäinnovaatioille tyypillisiä juridisia ongelmia puolestaan selvitettiin käyttämällä pääasiassa teemahaastatteluja. Teoriapohjaan tutustumisen jälkeen, havaittuja ongelmia on tulkittu olemassa olevan lainsäädännön pohjalta. Opinnäytetyön tuloksena havaittiin, että lainsäädännön vanhentuneisuus ja hajanaisuus ovat suurimmat juridiset ongelmat videopeliteollisuuden osalta. Käytännön toimintamallien ja juridisen tietotaidon puute aiheuttaa ongelmia pelien immateriaalioikeuksien suojaamisessa sekä kansallisesti että kansainvälisesti. Opinnäytetyössä huomattiin myös, että kansainvälisen lainsäädännön tasolla tehdyillä tulevaisuuden ratkaisuilla tulee olemaan merkittävä rooli käyttäjäinnovaatiotoiminnan turvaamiseksi. EU-lainsäädännölle on syntynyt korostunut rooli tekijänoikeuksien yhdenmukaistamiseksi. Myöskään USA:n lainsäädäntöä immateriaalioikeuksien osalta ei voida unohtaa videopelien kansainvälisen luonteen vuoksi. Tuloksena tästä opinnäytetyöstä voidaan todeta kansainväliselle sopimukselle olevan videopeliteollisuuden näkökulmasta todellinen tarve.This thesis studies what kinds of legal problems the utilization of user innovation causes Finnish companies in the video game industry. It also looks at the benefits of user innovations as well as legal problems that arise from them. All in all, there is very little legal research about the topic, especially in Finland, and for this reason this is a very timely study. The thesis was suggested and commissioned by Fondia Ltd, a legal services provider. To begin, it was necessary to become familiar with various theories on video games and user innovation models. Typical legal problems regarding user innovations in the video game industry were also studied in theme interviews. The observed problems in theory are interpreted on the basis of existing legislation. Findings in this study showed that the outdated and fragmented natures of legislation are the main legal problems in the video game industry. The lack of practical models and legal know-how cause problems for the security of intellectual property rights of video games, both domestically and internationally. It was also noted that the level of international law in future solutions will play a significant role in safeguarding user innovation. EU legislation has become a prominent factor in the harmonization of intellectual property rights. Furthermore, in respect to these rights, US legislation cannot be forgotten because of the international context of video games. The results of this thesis underscore the real need for international agreements for the video game industry

Quality of care assessment for people with multimorbidity.

Multimorbidity, the simultaneous presence of multiple health conditions in an individual, is an increasingly common phenomenon globally. The systematic assessment of the quality of care delivered to people with multimorbidity will be key to informing the organization of services for meeting their complex needs. Yet, current assessments tend to focus on single conditions and do not capture the complex processes that are required for providing care for people with multimorbidity. We conducted a scoping review on quality of care and multimorbidity in selected databases in June 2018 and identified 87 documents as eligible for review, predominantly original research and reviews from North America, Europe and Australasia and mostly frequently related to primary care settings. We synthesized data qualitatively in terms of perceived challenges, evidence and proposed metrics. Findings reveal that the association between quality of care and multimorbidity is complex and depends on the conditions involved (quality appears to be higher for those with concordant conditions, and lower in the presence of discordant conditions) and the approach used for measuring quality (quality appears to be higher in people with multimorbidity when measured using condition/drug-specific process or intermediate outcome indicators, and worse when using patient-centred reports of experiences of care). People with discordant multimorbidity may be disadvantaged by current approaches to quality assessment, particularly when they are linked to financial incentives. A better understanding of models of care that best meet the needs of this group is needed for developing appropriate quality assessment frameworks. Capturing patient preferences and values and incorporate patients' voices in the form of patient-reported experiences and outcomes of care will be critical towards the achievement of high-performing health systems that are responsive to the needs of people with multimorbidity

Clinical rating systems in elbow research-a systematic review exploring trends and distributions of use.

Clinical rating systems are used as outcome measures in clinical trials and attempt to gauge the patient's view of his or her own health. The choice of clinical rating system should be supported by its performance against established quality standards

Proceedings of patient reported outcome measure’s (PROMs) conference Sheffield 2016: Advances in patient reported outcomes research

Table of contents S1 Using computerized adaptive testing Tim Croudace S2 Well-being: what is it, how does it compare to health and what are the implications of using it to inform health policy John Brazier O1 “Am I going to get better?”—Using PROMs to inform patients about the likely benefit of surgery Nils Gutacker, Andrew Street O2 Identifying Patient Reported Outcome Measures for an electronic Personal Health Record Dan Robotham, Samantha Waterman, Diana Rose, Safarina Satkunanathan, Til Wykes O3 Examining the change process over time qualitatively: transformative learning and response shift Nasrin Nasr, Pamela Enderby O4 Developing a PROM to evaluate self-management in diabetes (HASMID): giving patients a voice Jill Carlton, Donna Rowen, Jackie Elliott, John Brazier, Katherine Stevens, Hasan Basarir, Alex Labeit O5 Development of the Primary Care Outcomes Questionnaire (PCOQ) Mairead Murphy, Sandra Hollinghurst, Chris Salisbury O6 Developing the PKEX score- a multimodal assessment tool for patients with shoulder problems Dominic Marley, James Wilson, Amy Barrat, Bibhas Roy O7 Applying multiple imputation to multi-item patient reported outcome measures: advantages and disadvantages of imputing at the item, sub-scale or score level Ines Rombach, Órlaith Burke, Crispin Jenkinson, Alastair Gray, Oliver Rivero-Arias O8 Integrating Patient Reported Outcome Measures (PROMs) into routine primary care for patients with multimorbidity: a feasibility study Ian Porter, Jaheeda Gangannagaripalli, Charlotte Bramwell, Jose M. Valderas O9 eRAPID: electronic self-report and management of adverse-events for pelvic radiotherapy (RT) patients Patricia Holch, Susan Davidson, Jacki Routledge, Ann Henry, Kevin Franks, Alex Gilbert, Kate Absolom & Galina Velikova O10 Patient reported outcomes (PROMs) based recommendation in clinical guidance for the management of chronic conditions in the United Kingdom Ian Porter, Jose M.Valderas O11 Cross-sectional and longitudinal parameter shifts in epidemiological data: measurement invariance and response shifts in cohort and survey data describing the UK’s Quality of Life Jan R. Boehnke O12 Patient-reported outcomes within health technology decision making: current status and implications for future policy Andrew Trigg, Ruth Howells O13 Can social care needs and well-being be explained by the EQ-5D? Analysis of Health Survey for England dataset Jeshika Singh, Subhash Pokhrel, Louise Longworth O14 Where patients and policy meet: exploring individual-level use of the Long-Term Conditions Questionnaire (LTCQ) Caroline Potter, Cheryl Hunter, Laura Kelly, Elizabeth Gibbons, Julian Forder, Angela Coulter, Ray Fitzpatrick, Michele Peter