Drivers for change in primary care of diabetes following a protected learning time educational event: interview study of practitioners

Background: A number of protected learning time schemes have been set up in primary care across the United Kingdom but there has been little published evidence of their impact on processes of care. We undertook a qualitative study to investigate the perceptions of practitioners involved in a specific educational intervention in diabetes as part of a protected learning time scheme for primary health care teams, relating to changing processes of diabetes care in general practice. Methods: We undertook semistructured interviews of key informants from a sample of practices stratified according to the extent they had changed behaviour in prescribing of ramipril and diabetes care more generally, following a specific educational intervention in Lincolnshire, United Kingdom. Interviews sought information on facilitators and barriers to change in organisational behaviour for the care of diabetes. Results: An interprofessional protected learning time scheme event was perceived by some but not all participants as bringing about changes in processes for diabetes care. Participants cited examples of change introduced partly as a result of the educational session. This included using ACE inhibitors as first line for patients with diabetes who developed hypertension, increased use of aspirin, switching patients to glitazones, and conversion to insulin either directly or by referral to secondary care. Other reported factors for change, unrelated to the educational intervention, included financially driven performance targets, research evidence and national guidance. Facilitators for change linked to the educational session were peer support and teamworking supported by audit and comparative feedback. Conclusion: This study has shown how a protected learning time scheme, using interprofessional learning, local opinion leaders and early implementers as change agents may have influenced changes in systems of diabetes care in selected practices but also how other confounding factors played an important part in changes that occurred in practice

Perceptions on use of home telemonitoring in patients with long term conditions – concordance with the Health Information Technology Acceptance Model: a qualitative collective case study

Background Health information technology (HIT) may be used to improve care for increasing numbers of older people with long term conditions (LTCs) who make high demands on health and social care services. Despite its potential benefits for reducing disease exacerbations and hospitalisations, HIT home monitoring is not always accepted by patients. Using the Health Information Technology Acceptance Model (HITAM) this qualitative study examined the usefulness of the model for understanding acceptance of HIT in older people (≥60 years) participating in a RCT for older people with Chronic Obstructive Pulmonary Disease (COPD) and associated heart diseases (CHROMED). Methods An instrumental, collective case study design was used with qualitative interviews of patients in the intervention arm of CHROMED. These were conducted at two time points, one shortly after installation of equipment and again at the end of (or withdrawal from) the study. We used Framework Analysis to examine how well the HITAM accounted for the data. Results Participants included 21 patients aged between 60–99 years and their partners or relatives where applicable. Additional concepts for the HITAM for older people included: concerns regarding health professional access and attachment; heightened illness anxiety and desire to avoid continuation of the ‘sick-role’. In the technology zone, HIT self-efficacy was associated with good organisational processes and informal support; while ease of use was connected to equipment design being suitable for older people. HIT perceived usefulness was related to establishing trends in health status, detecting early signs of infection and potential to self-manage. Due to limited feedback to users opportunities to self-manage were reduced. Conclusions HITAM helped understand the likelihood that older people with LTCs would use HIT, but did not explain how this might result in improved self-management. In order to increase HIT acceptance among older people, equipment design and organisational factors need to be considered. Trial registration ClinicalTrials.gov Identifier: NCT01960907 October 9 2013 (retrospectively registered) Clinical tRials fOr elderly patients with MultiplE Disease (CHROMED). Start date October 2012, end date March 2016. Date of enrolment of the first participant was February 2013

Integrating online communities and social networks with computerised treatment for insomnia: a qualitative study of service user and primary health care professional perspectives

The problem: Insomnia is the most commonly reported psychological complaint in Britain. Although hypnotic drugs are widely used for treatment of insomnia, they are only licensed short term and adverse effects are common. Cognitive Behavioural Therapy for insomnia (CBT-I), which is effective and safe long term, is recommended first line but is not widely used nor available, in part because of the lack of trained providers. In response to this, Computerised Cognitive Behavioural Therapy (CCBT) has been advocated. Existing CCBT programmes can suffer from poor rates of uptake, adherence and completion. We aimed to investigate patients and practitioners’ views on how CCBT for insomnia (CCBT-I) could be improved by incorporating features of modern technology including social networking functions. The approach: We used a qualitative design and the theory of planned behaviour to underpin the study. Interviews and focus groups were held with adult service users and health professionals using a topic guide designed to elicit participants’ beliefs, intentions and controlling factors that might facilitate or create barriers to the uptake and adherence to CCBT-I. We explored the data using thematic analysis supported by Nvivo. Findings: We interviewed 23 health professionals and 28 patients. We identified multi-faceted issues focused on meta-themes of trust and functionality which were perceived to increase likelihood of successful uptake and adherence. Trust and confidence would be increased if CCBT-I was perceived to be evidence-based and accredited; when referral was from a trusted professional within a supervised package of care; and when online support and follow-up were provided. Interaction with other users, by integrating CCBT-I with social networking, was perceived to provide mutual support but concerns from people with sleep problems included apprehension about online ‘strangers’ and concerns from practitioners included information security. Asynchronous communication such as posting a note, commenting on a forum or adding to a thread was considered safer than engaging in real-time on-line communication. To improve functionality patients wanted mobile applications; access in short periods; self-assessment of insomnia and its causes; more personalised information on sleep; an interactive approach; and contact with other users to be moderated or overseen. Consequences: Although previous qualitative studies have looked at CCBT uptake and adherence, none have looked at insomnia exclusively or explored the feasibility, advantages and drawbacks of online communication between participants. Improving uptake and adherence to online programmes for insomnia requires attention to design features which are focused on trust and functionality. Although computerised therapies for insomnia would allow more people to access treatment, some would not be suitable for online therapies because of lack of online access or poor computer literacy. The results of the study are being used the development of a novel platform for CCBT for insomnia and other health conditions

Integrating online communities and social networks with computerised treatment for insomnia: a qualitative study of service user and multiprofessional primary health care perspectives

Purpose: We explored patient and multiprofessional health perspectives to inform the development of a computerised cognitive behavioural therapy programme for insomnia (CCBT-I) that includes social networking. Theory: We used a qualitative design and theory of planned behaviour to underpin the analysis. Methods: Interviews and focus groups were held with service users and health professionals to elicit beliefs and intentions that might facilitate or create barriers to the uptake and adherence to CCBT-I. Findings: We interviewed 23 health professionals and 28 patients. Features designed to increase confidence in CCBT-I; engender trust in professional relationships; provide online support and improve programme functionality were perceived to increase the successful uptake and adherence. Interaction with other users via integrated social networking would provide mutual support but concerns included apprehension about online ‘strangers’ and information security. Patients wanted mobile applications; access in short periods; self-assessment; more interactive, personalised information on sleep and moderated contact with other users. Discussion: Improving uptake and adherence to online programmes for insomnia requires design features which are focused on trust and functionality. Computerised therapies for insomnia would allow access treatment for more people across geographical and heath system borders

How effective are Z-drug hypnotics for treatment of adult insomnia? Meta-analysis of data submitted to the Food and Drug Administration

The Problem: Z-drugs are the most commonly prescribed hypnotics worldwide. They are widely prescribed because general practitioners and patients believe that they are effective and superior to older hypnotics. Previous meta-analyses of Z-drugs suffer from publication or reporting bias and did not adequately examine study heterogeneity. We wanted to investigate the effectiveness of Z-drugs in adults using a data source that was less likely to be affected by publication bias. The approach: We examined clinical trials of currently approved Z-drugs submitted to the Food and Drug Administration (FDA) since pharmaceutical companies are required to provide information on all sponsored trials, whether published or not, when applying for new drug approvals. We included randomized double blind placebo controlled trials and excluded studies with a crossover design, those including healthy patients with normal sleep or single night studies with induced insomnia. We analysed drug efficacy as change score from baseline to posttest for drug and placebo groups, and the difference of both change scores for available outcomes. Weighted raw and standardized mean differences with their confidence intervals (CIs) under random-effects assumptions were calculated for polysomnographic (PSG) and subjective outcomes: wake after sleep onset, sleep latency, number of awakenings, total sleep time, sleep efficiency, subjective sleep quality, and morning sleepiness score. We performed weighted regression moderator analysis to explain heterogeneity of drug effects. Findings: We included 16 studies comprising 4973 subjects from different countries, varying drug dosages, treatment lengths and study years. Z-drugs showed significant but small improvements (reductions) only in PSG (d+ = -0.36, 95% CI = -0.57 to -0.16) and subjective sleep latency (d+ = -0.33, 95% CI = -0.62 to -0.041) compared with placebo. Analyses of weighted mean raw differences indicated that drugs decreased sleep latency by only 22 minutes (95% CI = -33 TO -11) with no evidence of change in other measures. Moderator analyses indicated that sleep latency was more likely to be reduced with larger drug doses, studies published earlier, including higher proportions of younger or women patients, and of longer treatment duration. Consequences: This study of FDA data shows that, despite being commonly prescribed, Z-drugs have limited benefit with small reductions in subjective and PSG sleep latency especially with larger dosages, but no improvement in other sleep measures compared to placebo. Placebo effects were moderate for sleep latency. Doctors and patients need to be aware of the relative benefits as well as harms of hypnotic drugs when deciding to use them in preference to psychological treatments

Applicability of the Health Information Technology Acceptance Model in assessing readiness of older patients with multiple chronic diseases to adopt telecare qualitative study

The problem Health information technology (HIT) has potential benefits for patient care, patient safety and reduced healthcare costs. For example, telecare (including remote monitoring and a clinical response to changes in measures) is associated with lower mortality, emergency admission rates and primary care contacts in patients with stable chronic obstructive pulmonary disease (COPD). There are many reasons for poor uptake of HIT, including those which relate to service users, e.g., patients' concerns about loss of the ‘human touch' in care. We aimed to explore factors that might explain use of telecare in older people with multimorbidities. The approach We undertook a qualitative study of patients using telecare in a European randomised controlled trial of telecare for older people with multimorbidity (CHROMED), applying a behavioural model to the data. Interview data from 13 patients were analysed using NVivo, Applying the Health Information Technology Acceptance Model (HITAM) as a conceptual framework. This model encompasses eight elements that directly or indirectly influence someone's attitude towards HIT and its acceptance. The HITAM model, constructed on previous behavioural models (e.g. Health Belief Model) has not been previously tested in this setting. Findings Most participants (patients) had a positive attitude to using the monitoring devices, their ease of use and the possibilities it generated for their future care. The support from and attitudes of healthcare providers provided extra motivation for patients to use the equipment. Although patients mentioned several facilitators with regard to the usefulness of the equipment (e.g. continuity of information, prevention or early detection, and feeling monitored), some did not perceive an immediate personal benefit. Barriers to the acceptance of HIT included some patients' heightened focus on their illness when undertaking daily clinical testing, which occasionally increased anxiety. Some patients were also fearful that the technology would replace facetoface, personal contact with healthcare providers. In addition some patients disliked the lack of interactivity with the equipment or the design of the devices (e.g. finding them too intrusive and bulky). Where patients' clinical data were visible to them before being transferred electronically, these were often manually recorded onto paper format by patients for their personal records. Decisions about contacting the doctor or changing physical activity levels were reported to be unaffected as a result of collecting these data. Consequences This study showed that elements of the HITAM were valid, but it did not entirely explain the impact of telecare. Based on our findings, we present some suggestions for additional factors to HITAM that help understand the acceptance of HIT in older adults with chronic conditions. A modified HITAM is presented based on our findings which showed that psychosocial threats were as important as threats of deterioration of patients' chronic conditions

Psychoeducational interventions for informal caregivers of people with dementia: a systematic review

A summary of key features from a systematic review protocol registered in PROSPERO International prospective register of systematic reviews

Education-based interventions for informal carers of people with dementia: a meta-analysis. PROSPERO 2014 CRD42014014606

A summary of key features from an updated meta-analysis protocol registered with PROSPERO International prospective register of systematic reviews

Introducing genetic testing for cardiovascular disease in primary care: a qualitative study

Background: While primary care systematically offers conventional cardiovascular risk assessment, genetic tests for coronary heart disease (CHD) are increasingly commercially available to patients. It is unclear how individuals may respond to these new sources of risk information. Aim: To explore how patients who have had a recent conventional cardiovascular risk assessment, perceive additional information from genetic testing for CHD. Design and setting: Qualitative interview study in 12 practices in Nottinghamshire from both urban and rural settings. Method: Interviews were conducted with 29 adults, who consented to genetic testing after having had a conventional cardiovascular risk assessment. Results: Individuals’ principal motivation for genetic testing was their family history of CHD and a desire to convey the results to their children. After testing, however, there was limited recall of genetic test results and scepticism about the value of informing their children. Participants dealt with conflicting findings from the genetic test, family history, and conventional assessment by either focusing on genetic risk or environmental lifestyle factors. In some participants, genetic test results appeared to reinforce healthy behaviour but others were falsely reassured, despite having an ‘above-average’ conventional cardiovascular risk score. Conclusion: Although genetic testing was acceptable, participants were unclear how to interpret genetic risk results. To facilitate healthy behaviour, health professionals should explore patients’ understanding of genetic test results in light of their family history and conventional risk assessment

Caregivers’ interactions with health care services: mediator of stress or added strain? Experiences and perceptions of informal caregivers of people with dementia: a qualitative study

Background: There are an estimated 46.8 million people worldwide living with dementia in 2015, being cared for usually by family members or friends (informal caregivers). The challenges faced by informal caregivers often lead to increased levels of stress, burden and risk of care-recipient institutionalisation. Aim: The overarching aim of this study was to explore the experiences and perceptions of informal caregivers of people with dementia when interacting with the health care system, and whether the support received acted as a mediator of caregiver stress. The secondary aim was to investigate healthcare professionals’ views and current practice regarding people with dementia and their interactions with informal caregivers. Method: We employed a qualitative research design, using focus groups and one face-to-face interview with a purposive sample of informal caregivers and healthcare professionals (HCPs) in Lincolnshire, UK. Data were collected between March and July 2015. We used the stress-process model of stress in caregivers as a theoretical framework. Results: We interviewed 18 caregivers and 17 HCPs. Five themes, mapped to the stress-process in caregivers’ model, captured the main challenges faced by caregivers and the type of support they wanted from health care services. Primary stressors included the challenge of diagnosing dementia; caregivers’ needs and expectations of an in-depth knowledge and understanding of dementia from HCPs; and need for carer education. Secondary role strain included lack of support and mismatch of communication and expectations. Caregiver involvement in monitoring care and disease was a potential mediator tool. Conclusions: Fragmentation of dementia care services, lack of training for HCPs and the dearth of information for caregivers means health care services are only partially fulfilling a support role. In turn, lack of support may be intensifying caregiver stress leading to worsening in their health and well-being; thus, potentially increasing the risk of institutionalisation of their care-recipient