Delirium is a common complication for older people in hospital. Evidence suggests that delirium incidence in hospital may be reduced by about a third through a multi-component intervention targeted at known modifiable risk factors. We describe the research design and conceptual framework underpinning it that informed the development of a novel delirium prevention system of care for acute hospital wards. Particular focus of the study was on developing an implementation process aimed at embedding practice change within routine care delivery.
We adopted a participatory action research approach involving staff, volunteers, and patient and carer representatives in three northern NHS Trusts in England. We employed Normalization Process Theory to explore knowledge and ward practices on delirium and delirium prevention. We established a Development Team in each Trust comprising senior and frontline staff from selected wards, and others with a potential role or interest in delirium prevention. Data collection included facilitated workshops, relevant documents/records, qualitative one-to-one interviews and focus groups with multiple stakeholders and observation of ward practices. We used grounded theory strategies in analysing and synthesising data.
Awareness of delirium was variable among staff with no attention on delirium prevention at any level; delirium prevention was typically neither understood nor perceived as meaningful. The busy, chaotic and challenging ward life rhythm focused primarily on diagnostics, clinical observations and treatment. Ward practices pertinent to delirium prevention were undertaken inconsistently. Staff welcomed the possibility of volunteers being engaged in delirium prevention work, but existing systems for volunteer support were viewed as a barrier.
Our evolving conception of an integrated model of delirium prevention presented major implementation challenges flowing from minimal understanding of delirium prevention and securing engagement of volunteers alongside practice change. The resulting Prevention of Delirium (POD) Programme combines a multi-component delirium prevention and implementation process, incorporating systems and mechanisms to introduce and embed delirium prevention into routine ward practices.
Although our substantive interest was in delirium prevention, the conceptual and methodological strategies pursued have implications for implementing and sustaining practice and service improvements more broadly.
Delirium; Prevention; Acute hospital care; Complex intervention; Implementation; Normalization process theory
Good quality spatial data on Family Physicians or General Practitioners (GPs) are key to accurately measuring geographic access to primary health care. The validity of computed associations between health outcomes and measures of GP access such as GP density is contingent on geographical data quality. This is especially true in rural and remote areas, where GPs are often small in number and geographically dispersed. However, there has been limited effort in assessing the quality of nationally comprehensive, geographically explicit, GP datasets in Australia or elsewhere.
Our objective is to assess the extent of association or agreement between different spatially explicit nationwide GP workforce datasets in Australia. This is important since disagreement would imply differential relationships with primary healthcare relevant outcomes with different datasets. We also seek to enumerate these associations across categories of rurality or remoteness.
We compute correlations of GP headcounts and workload contributions between four different datasets at two different geographical scales, across varying levels of rurality and remoteness.
The datasets are in general agreement with each other at two different scales. Small numbers of absolute headcounts, with relatively larger fractions of locum GPs in rural areas cause unstable statistical estimates and divergences between datasets.
In the Australian context, many of the available geographic GP workforce datasets may be used for evaluating valid associations with health outcomes. However, caution must be exercised in interpreting associations between GP headcounts or workloads and outcomes in rural and remote areas. The methods used in these analyses may be replicated in other locales with multiple GP or physician datasets.
Primary health care; Geographical information systems (GIS); Spatial; Mailing lists; General practitioner (GP); Family physician; Data quality
The performance of comorbidity measures for predicting mortality in chronic disease populations and using ICD-9 diagnosis codes in administrative health data has been investigated in several studies, but less is known about predictive performance with ICD-10 data and for other health outcomes. This study investigated predictive performance of five comorbidity measures for population-based diabetes cohorts in administrative data. The objectives were to evaluate performance for: (a) disease-specific and general health outcomes, (b) data based on the ICD-9 and ICD-10 diagnoses, and (c) different age groups.
Performance was investigated for heart attack, stroke, amputation, renal disease, hospitalization, and death in all-age and age-specific cohorts. Hospital records, physician billing claims, and prescription drug records from one Canadian province were used to identify diabetes cohorts and measure comorbidity. The data were analysed using multiple logistic regression models and summarized using measures of discrimination, accuracy, and fit.
In Cohort 1 (n = 29,058), for which only ICD-9 diagnoses were recorded in administrative data, the Elixhauser index showed good or excellent prediction for amputation, renal disease, and death and performed better than the Charlson index. Number of diagnoses was a good predictor of hospitalization. Similar results were obtained for Cohort 2 (n = 41,925), in which both ICD-9 and ICD-10 diagnoses were recorded in administrative data, although predictive performance was sometimes higher. For age-specific models of mortality, the Elixhauser index resulted in the largest improvement in predictive performance in all but the youngest age group.
Cohort age and the health outcome under investigation, but not the diagnosis coding system, may influence the predictive performance of comorbidity measure for studies about diabetes populations using administrative health data.
Administrative health data; Comorbid conditions; Diabetes; Risk adjustment; Statistical models
Few studies have investigated the relationships between HIV-related knowledge, fear of contagion in dental environments and Oral Impacts on Daily Performance (OIDP) among dental patients. Our objectives were to investigate the associations between HIV-related knowledge and fear of contagion in dental environments and OIDP among dental patients, and to evaluate whether those associations were modified by the frequency of dental service attendance.
A total of 1262 patients (mean age 30.7 years, 56.5% females) were recruited from the Khartoum Dental Teaching Hospital and the University of Science and Technology during March–July 2008. The participants underwent a full-mouth oral clinical examination and completed an interview in a face-to-face setting.
Of the study participants, 41.4% had visited a dentist at least twice during the last 2 years, 96.2% had caries experience (DT > 0) and 79.1% reported oral impacts (OIDP > 0). The most frequently reported oral impacts were problems eating, sleeping and cleaning teeth. In total, 26.3% of the participants had HIV transmission knowledge, 75.6% knew people with HIV/AIDS and 58.7% perceived a high risk of cross-infection in dental environments. After adjusting for sociodemographic characteristics, frequency of dental service attendance and caries experience, patients who had high HIV-related information exposure, a positive attitude toward people with HIV/AIDS and a high perceived risk of cross-infection were more likely to report oral impacts, whereas patients who knew people with HIV/AIDS were less likely to report oral impacts. The association between OIDP and HIV transmission knowledge was modified by frequency of dental service attendance.
Dental patients who were informed about HIV and had a high HIV/AIDS risk perception were more likely to report impaired oral health-related quality of life than their less informed counterparts and those who perceived a low risk of contagion. The effect of HIV transmission knowledge on oral impacts was influenced by frequency of dental service attendance.
HIV; AIDS; Attitudes; Oral impacts on daily performance; Dental; Sudan
Primary health care is recognised as an integral part of a country’s health care system. Measuring hospitalisations, that could potentially be avoided with high quality and accessible primary care, is one indicator of how well primary care services are performing. This review was interested in the association between chronic disease related hospitalisations and primary health care resourcing.
Studies were included if peer reviewed, written in English, published between 2002 and 2012, modelled hospitalisation as a function of PHC resourcing and identified hospitalisations for type 2 diabetes as a study outcome measure. Access and use of PHC services were used as a proxy for PHC resourcing. Studies in populations with a predominant user pay system were excluded to eliminate patient financial barriers to PHC access and utilisation. Articles were systematically excluded based on the inclusion criteria, to arrive at the final set of studies for review.
The search strategy identified 1778 potential articles using EconLit, Medline and Google Scholar databases. Ten articles met the inclusion criteria and were subject to review. PHC resources were quantified by workforce (either medical or nursing) numbers, number of primary care episodes, service availability (e.g. operating hours), primary care practice size (e.g. single or group practitioner practice—a larger practice has more care disciplines onsite), or financial incentive to improve quality of diabetes care. The association between medical workforce numbers and ACSC hospitalisations was mixed. Four of six studies found that less patients per doctor was significantly associated with a decrease in ambulatory care sensitive hospitalisations, one study found the opposite and one study did not find a significant association between the two. When results were categorised by PHC access (e.g. GPs/capita, range of services) and use (e.g. n out-patient visits), better access to quality PHC resulted in fewer ACSC hospitalisations. This finding remained when only studies that adjusted for health status were categorised. Financial incentives to improve the quality of diabetes care were associated with less ACSC hospitalisations, reported in one study.
Seven of 12 measures of the relationship between PHC resourcing and ACSC hospitalisations had a significant inverse association. As a collective body of evidence the studies provide inconclusive support that more PHC resourcing is associated with reduced hospitalisation for ACSC. Characteristics of improved or increased PHC access showed inverse significant associations with fewer ACSC hospitalisations after adjustment for health status. The varied measures of hospitalisation, PHC resourcing, and health status may contribute to inconsistent findings among studies and make it difficult to interpret findings.
Type 2 diabetes; Chronic disease; Primary health care resourcing; Ambulatory care sensitive conditions; Hospitalisation
A Swedish version of the USA Agency for Healthcare Research and Quality
“Hospital Survey on Patient Safety Culture” (S-HSOPSC) was
developed to be used in both hospitals and primary care. Two new dimensions
with two and four questions each were added as well as one outcome measure.
This paper describes this Swedish version and an assessment of its
psychometric properties which were tested on a large sample of responses
from personnel in both hospital and primary care.
The questionnaire was mainly administered in web form and 84215 forms were
returned (response rate 60%) between 2009 and 2011. Eleven per cent of the
responses came from primary care workers and 46% from hospital care workers.
The psychometric properties were analyzed using both the total sample and
the hospital and primary care subsamples by assessment of construct validity
and internal consistency. Construct validity was assessed by confirmatory
(CFA) and exploratory factor (EFA) analyses and internal consistency was
established by Cronbachs’s α.
CFA of the total, hospital and primary care samples generally showed a good
fit while the EFA pointed towards a 9-factor model in all samples instead of
the 14-dimension S-HSOPSC instrument. Internal consistency was acceptable
with Cronbach’s α values above 0.7 in a major part of the
The S-HSOPSC, consisting of 14 dimensions, 48 items and 3 single-item outcome
measures, is used both in hospitals and in primary care settings in Sweden
for different purposes. This version of the original American instrument has
acceptable construct validity and internal consistency when tested on large
datasets of first-time responders from both hospitals and primary care
centres. One common instrument for measurements of patient safety culture in
both hospitals and primary care settings is an advantage since it enables
comparisons between sectors and assessments of national patient safety
improvement programs. Future research into this version of the instrument
includes comparing results from patient safety culture measurements with
other outcomes in relation to safety improvement strategies.
Patient safety culture; Hospital Survey on Patient Safety Culture; S-Hospital Survey on Patient Safety Culture; Primary care; Psychometric properties; Construct validity; Internal consistency
Assistive Technologies, defined as “electrical or mechanical devices designed to help people recover movement” have demonstrated clinical benefits in upper-limb stroke rehabilitation. Stroke services are becoming community-based and more reliant on self-management approaches. Assistive technologies could become important tools within self-management, however, in practice, few people currently use assistive technologies. This study investigated patients’, family caregivers and health professionals’ experiences and perceptions of stroke upper-limb rehabilitation and assistive technology use and identified the barriers and facilitators to their use in supporting stroke self-management.
A three-day exhibition of assistive technologies was attended by 204 patients, family caregivers/friends and health professionals. Four focus groups were conducted with people purposively sampled from exhibition attendees. They included i) people with stroke who had used assistive technologies (n = 5), ii) people with stroke who had not used assistive technologies (n = 6), iii) family caregivers (n = 5) and iv) health professionals (n = 6). The audio-taped focus groups were facilitated by a moderator and observer. All participants were asked to discuss experiences, strengths, weaknesses, barriers and facilitators to using assistive technologies. Following transcription, data were analysed using thematic analysis.
All respondents thought assistive technologies had the potential to support self-management but that this opportunity was currently unrealised. All respondents considered assistive technologies could provide a home-based solution to the need for high intensity upper-limb rehabilitation. All stakeholders also reported significant barriers to assistive technology use, related to i) device design ii) access to assistive technology information and iii) access to assistive technology provision. The lack of and need for a coordinated system for assistive technology provision was apparent. A circular limitation of lack of evidence in clinical settings, lack of funded provision, lack of health professional knowledge about assistive technologies and confidence in prescribing them leading to lack of assistive technology service provision meant that often patients either received no assistive technologies or they and/or their family caregivers liaised directly with manufacturers without any independent expert advice.
Considerable systemic barriers to realising the potential of assistive technologies in upper-limb stroke rehabilitation were reported. Attention needs to be paid to increasing evidence of assistive technology effectiveness and develop clinical service provision. Device manufacturers, researchers, health professionals, service funders and people with stroke and family caregivers need to work creatively and collaboratively to develop new funding models, improve device design and increase knowledge and training in assistive technology use.
Stroke; Upper limb; Assistive technology; Self-management; Patient; Family caregivers; Health care professional; Rehabilitation; Qualitative research
Community-based health care planning and regulation necessitates grouping facilities and areal units into regions of similar health care use. Limited research has explored the methodologies used in creating these regions. We offer a new methodology that clusters facilities based on similarities in patient utilization patterns and geographic location. Our case study focused on Hospital Groups in Michigan, the allocation units used for predicting future inpatient hospital bed demand in the state’s Bed Need Methodology. The scientific, practical, and political concerns that were considered throughout the formulation and development of the methodology are detailed.
The clustering methodology employs a 2-step K-means + Ward’s clustering algorithm to group hospitals. The final number of clusters is selected using a heuristic that integrates both a statistical-based measure of cluster fit and characteristics of the resulting Hospital Groups.
Using recent hospital utilization data, the clustering methodology identified 33 Hospital Groups in Michigan.
Despite being developed within the politically charged climate of Certificate of Need regulation, we have provided an objective, replicable, and sustainable methodology to create Hospital Groups. Because the methodology is built upon theoretically sound principles of clustering analysis and health care service utilization, it is highly transferable across applications and suitable for grouping facilities or areal units.
Health care utilization; Hospital planning; Certificate of need; Clustering; K-means; Ward’s
Discharge Against Medical Advice (DAMA) from hospital is associated with adverse outcomes and is considered an indicator of the responsiveness of hospitals to the needs of Aboriginal and Torres Strait Islander Australians, the indigenous people of Australia. We investigated demographic and clinical factors that predict DAMA in patients experiencing their first-ever inpatient admission for ischaemic heart disease (IHD). The study focuses particularly on the differences in the risk of DAMA in Aboriginal and non-Aboriginal patients while also investigating other factors in their own right.
A cross-sectional analytical study was undertaken using linked hospital and mortality data with complete coverage of Western Australia. Participants included all first-ever IHD inpatients (aged 25–79 years) admitted between 2005 and 2009, selected after a 15-year clearance period and who were discharged alive. The main outcome measure was DAMA as reflected in the hospital record.
Multiple logistic regression was used to determine disparities in DAMA between Aboriginal and non-Aboriginal patients, adjusting for a range of demographic and clinical factors, including comorbidity based on 5-year hospitalization history. A series of additional models were run on subgroups of the cohort to refine the analysis. Ethics approval was granted by the WA Human Research and the WA Aboriginal Health Ethics Committees.
Aboriginal patients comprised 4.3% of the cohort of 37,304 IHD patients and 23% of the 224 DAMAs. Emergency admission (OR=5.9, 95% CI 2.9-12.2), alcohol admission history (alcohol-related OR=2.9, 95% CI 2.0-4.2) and Aboriginality (OR 2.3, 95% CI 1.5-3.5) were the strongest predictors of DAMA in the multivariate model. Patients living in rural areas while attending non-metropolitan hospitals had a 50% higher risk of DAMA than those living and hospitalised in metropolitan areas. There was consistency in the ORs for Aboriginality in the different multivariate models using restricted sub-cohorts and different Aboriginal identifiers. Sex, IHD diagnosis type and co-morbidity scores imparted different risks in Aboriginal versus non-Aboriginal patients.
Understanding the risks and reasons for DAMA is important for health system policy and proactive management of those at risk of DAMA. Improving care to prevent DAMA should target unplanned admissions, rural hospitals and young men, Aboriginal people and those with alcohol and mental health comorbidities.
Discharge against medical advice; Aboriginal health; Ischaemic Heart Disease; Linked data; Australia
The pharmaceutical industry invests heavily in promotion, and it uses a variety of promotional strategies to influence physicians’ prescribing decisions. Within this context, medical representatives (MRs) are the key personnel employed in promoting their products. One significant consequence of the interactions between physicians and medical representatives is a conflict of interests which may contribute to the over prescribing of medications and thus negative effects on patients’ health and economics. There is limited detailed information published on the reasons why physicians interact with pharmaceutical representatives. This study aims to qualitatively explore physicians’ attitudes about interactions with medical representatives and their reasons for accepting the medical representatives’ visits.
In-depth interviews were used to gain a better understanding of physicians’ perceptions of medical representative visits. A total of 32 physicians from both private and public hospitals were interviewed. The recordings of the interviews were transcribed verbatim and subject to thematic analysis using a framework analysis approach.
The present qualitative study found that the majority of the physicians had positive interactions with medical representatives. The physicians’ main reasons stated for allowing medical representatives’ visits are the social contacts and mutual benefits they will gain from these representatives. They also emphasized that the meeting with representatives provides educational and scientific benefits. A few physicians stated that the main reasons behind refusing the meeting with medical representatives were lack of conviction about the product and obligation to prescribe medicine from the representative company. Most of the physicians believed that they were under marketing pressure to prescribe certain medicines.
Although physicians are aware that the medical representatives could influence their prescribing decision, they welcome representatives to visit them and consider receiving free samples, gifts and various kinds of support as a normal practice. The findings provided insight into possible target areas for educational interventions concerning pharmaceutical marketing. Such a finding will provide the basis for policymakers in the public and private health sector in Yemen to develop a suitable policy and regulations in terms of drug promotion.
Medical representatives; Information; Yemen; Qualitative study
Stakeholder roles in the application of evidence are influenced by context, the nature of the evidence, the policy development process, and stakeholder interactions. Past research has highlighted the role of stakeholders in knowledge translation (KT) without paying adequate attention to the peculiarities of low-income countries. Here we identify the roles, relations, and interactions among the key stakeholders involved in KT in Uganda and the challenges that they face.
This study employed qualitative approaches to examine the roles of and links among various stakeholders in KT. In-depth interviews were conducted with 21 key informants and focused on the key actors in KT, their perceived roles, and challenges.
Major stakeholders included civil society organizations with perceived roles of advocacy, community mobilization, and implementation. These stakeholders may ignore unconvincing evidence. The community’s role was perceived as advocacy and participation in setting research priorities. The key role of the media was perceived as knowledge dissemination, but respondents noted that the media may misrepresent evidence if it is received in a poorly packaged form. The perceived roles of policy makers were evidence uptake, establishing platforms for KT and stewardship; negative roles included ignoring or even misrepresenting evidence that is not in their favor. The roles of parliamentarians were perceived as advocacy and community mobilization, but they were noted to pursue objectives that may not be supported by the evidence. The researchers’ main role was defined as evidence generation, but focusing disproportionately on academic interests was cited as a concern. The donors’ main role was defined as funding research and KT, but respondents were concerned about the local relevance of donor-supported research. Respondents reported that links among stakeholders were weak due to the absence of institutionalized, inclusive platforms. Challenges facing the stakeholders in the process of KT were identified.
Our investigation revealed the need to consider the roles that various stakeholders are best placed to play. Links and necessary platforms must be put in place to achieve synergy in KT. Relevant capacities need to be built to overcome the challenges faced by the various stakeholders.
Research; Uptake; Policy; Practice; Roles; Stakeholders; Uganda; Low-income countries
Translating evidence into practice is an important final step in the process of evidence-based practice. Medical record audits can be used to examine how well practice compares with published evidence, and identify evidence-practice gaps. After providing audit feedback to professionals, local barriers to practice change can be identified and targetted with focussed behaviour change interventions. This study aimed to identify barriers and enablers to implementing multiple stroke guideline recommendations at one Australian stroke unit.
A qualitative methodology was used. A sample of 28 allied health, nursing and medical professionals participated in a group or individual interview. These interviews occurred after staff had received audit feedback and identified areas for practice change. Questions focused on barriers and enablers to implementing guideline recommendations about management of: upper limb sensory impairments, mobility including sitting balance; vision; anxiety and depression; neglect; swallowing; communication; education for stroke survivors and carers; advice about return to work and driving. Qualitative data were analysed for themes using theoretical domains described by Michie and colleagues (2005).
Six group and two individual interviews were conducted, involving six disciplines. Barriers were different across disciplines. The six key barriers identified were: (1) Beliefs about capabilities of individual professionals and their discipline, and about patient capabilities (2) Beliefs about the consequences, positive and negative, of implementing the recommendations (3) Memory of, and attention to, best practices (4) Knowledge and skills required to implement best practice; (5) Intention and motivation to implement best practice, and (6) Resources. Some barriers were also enablers to change. For example, occupational therapists required new knowledge and skills (a barrier), to better manage sensation and neglect impairments while physiotherapists generally knew how to implement best-practice mobility rehabilitation (an enabler).
Findings add to current knowledge about barriers to change and implementation of multiple guideline recommendations. Major challenges included sexuality education and depression screening. Limited knowledge and skills was a common barrier. Knowledge about specific interventions was needed before implementation could commence, and to maintain treatment fidelity. The provision of detailed online intervention protocols and manuals may help clinicians to overcome the knowledge barrier.
Translational research; Implementation; Quality improvement
In most Western countries, the referral letter forms the basis for establishing the priority of patients for specialised health care and for the coordination of care between the services. To be able to define the quality of referral letters, the potential impact of the quality on the organisation of care, and to improve the quality of the letters, we need a multidimensional definition of the ideal content. The study’s aim was to explore what information is seen as most important and should be included in referral letters from primary care to specialised mental health care to facilitate prioritisation and planning of treatment and follow-up of the patients.
Based on purposive sampling, four mixed discussion groups, which included general practitioners, mental health nurses from primary health care, psychiatrists and psychologists from specialised mental health care, managers and patient representatives, were formed; they were asked to identify the information they considered important in a mental health referral letter. In line with the Delphi technique, the importance of the themes was later individually rated by the participants. The study was conducted within The Western Norway Regional Health Authority.
The four groups identified 174 information themes. After excluding themes that were assessed as duplicates, replaceable or less important, 40 themes were suggested, organised in seven units. A set of check-off points of essential information is recommended as an introduction in the referral letter.
Compared with general guidelines and guidelines for somatic care, the results of this study suggest that the referral letter to specialised mental health care should have a larger emphasis on the overall treatment plan, on the specific role of specialised health care in the continuum of care, and on patient involvement. Further research should evaluate the validity of these findings for other patient groups in need of integrated care and investigate how the quality of referral letters affects patient-related and organisational outcomes.
Trial Registration number: NCT01374035
Referral and consultation; Mental health; Health services; General practice; Group interview
Patient safety can be increased by improving the organization of care. A tool that evaluates the actual organization of care, as perceived by multidisciplinary teams, is the Care Process Self-Evaluation Tool (CPSET). CPSET was developed in 2007 and includes 29 items in five subscales: (a) patient-focused organization, (b) coordination of the care process, (c) collaboration with primary care, (d) communication with patients and family, and (e) follow-up of the care process. The goal of the present study was to further evaluate the psychometric properties of the CPSET at the team and hospital levels and to compile a cutoff score table.
The psychometric properties of the CPSET were assessed in a multicenter study in Belgium and the Netherlands. In total, 3139 team members from 114 hospitals participated. Psychometric properties were evaluated by using confirmatory factor analysis (CFA), Cronbach’s alpha, interclass correlation coefficients (ICCs), Kruskall-Wallis test, and Mann–Whitney test. For the cutoff score table, percentiles were used. Demographic variables were also evaluated.
CFA showed a good model fit: a normed fit index of 0.93, a comparative fit index of 0.94, an adjusted goodness-of-fit index of 0.87, and a root mean square error of approximation of 0.06. Cronbach’s alpha values were between 0.869 and 0.950. The team-level ICCs varied between 0.127 and 0.232 and were higher than those at the hospital level (0.071-0.151). Male team members scored significantly higher than females on 2 of the 5 subscales and on the overall CPSET. There were also significant differences among age groups. Medical doctors scored significantly higher on 4 of the 5 subscales and on the overall CPSET. Coordinators of care processes scored significantly lower on 2 of the 5 subscales and on the overall CPSET. Cutoff scores for all subscales and the overall CPSET were calculated.
The CPSET is a valid and reliable instrument for health care teams to measure the extent care processes are organized. The cutoff table permits teams to compare how they perceive the organization of their care process relative to other teams.
Psychometric properties; Care process; Organization of care; Validity; Reliability; Health care teams; CPSET; Multidisciplinary teams; Multicenter study
Person-centeredness is increasingly advocated in the literature as a gold-standard, best practice concept in health services for older people. This concept describes care that incorporates individual and multidimensional needs, personal biography, subjectivity and interpersonal relationships. However, acute in-patient hospital services have a long-standing biomedical tradition that may contrast with person-centred care. Since few tools exist that enable measurements of the extent to which acute in-patient hospital services are perceived as being person-centred, this study aimed to translate the English version of the Person-centred care of older people with cognitive impairment in acute care scale (POPAC) to Swedish, and evaluate its psychometric properties in a sample of acute hospital staff.
The 15-item POPAC was translated, back-translated and culturally adjusted, and distributed to a cross-sectional sample of Swedish acute care staff (n = 293). Item performance was evaluated through assessment of item means, internal consistency by Cronbach’s alpha on total and on subscale levels; temporal stability was assessed through Pearson’s product correlation and intra-class correlation between test and retest scores. Confirmatory factor analysis was used to explore model fit.
The results indicate that the Swedish version POPAC provides a tentatively construct-valid and reliable contribution to measuring the extent to which acute in-patient hospital services have processes and procedures that can facilitate person-centred care of older patients with cognitive impairment. However, some questions remain regarding the dimensionality of POPAC.
POPAC provides a valuable contribution to the quest of improving acute care for older patients with cognitive impairment by enabling measures and subsequent accumulation of internationally comparable data for research and practice development purposes. POPAC can be used to highlight strengths and areas for improvements in care practice for older patients, and to illuminate aspects that risk being overlooked in busy acute hospital settings.
Person-centred care; Nursing; Older people; Cognitive impairment; Scale; Measurement; Intervention
Despite a high prevalence of disability, Aboriginal Australians access disability services in Australia less than non-Aboriginal Australians with a disability. The needs of Aboriginal children with disability are particularly poorly understood. They can endure long delays in treatment which can impact adversely on development. This study sought to ascertain the factors involved in accessing services and support for Aboriginal children with a disability.
Using the focus group method, two community forums, one for health and service providers and one for carers of Aboriginal children with a disability, were held at an Aboriginal Community Controlled Health Service (ACCHS) in the Sydney, metropolitan area of New South Wales, Australia. Framework analysis was applied to qualitative data to elucidate key issues relevant to the dimensions of access framework. Independent coding consistency checks were performed and consensus of analysis verified by the entire research team, several of whom represented the local Aboriginal community.
Seventeen health and social service providers representing local area government and non-government-funded health and social service organisations and five carers participated in two separate forums between September and October 2011. Lack of awareness of services and inadequate availability were prominent concerns in both groups despite geographic proximity to a major metropolitan area with significant health infrastructure. Carers noted racism, insufficient or non-existent services, and the need for an enhanced role of ACCHSs and AHWs in disability support services. Providers highlighted logistical barriers and cultural and historical issues that impacted on the effectiveness of mainstream services for Aboriginal people.
Despite dedicated disability services in an urban community, geographic proximity does not mitigate lack of awareness and availability of support. This paper has enumerated a number of considerations to address provision of disability services in an urban Australian Aboriginal community including building expertise and specialist capacity within Aboriginal Health Worker positions and services.
Increasing awareness of services, facilitating linkages and referrals, eliminating complexities to accessing support, and working with families and Aboriginal community organisations within a framework of resilience and empowerment to ensure a relevant and acceptable model are necessary steps to improving support and care for Aboriginal children with a disability.
Childhood disability; Aboriginal and Torres Strait Islander peoples; Early intervention; Focus groups
In Canada, demand for multidisciplinary bariatric (obesity) care far outstrips capacity. Consequently, prolonged wait times exist and contribute to substantial health impairments.
A supportive, educational intervention (with in-person and web-based versions) designed to enhance the self-management skills of patients wait-listed for multidisciplinary bariatric medical and surgical care has been variably implemented across Alberta, Canada. However, its effectiveness has not been evaluated. Our objectives were: 1. To determine if this program improves clinical and humanistic outcomes and is cost-effective compared to a control intervention; and 2. To compare the effectiveness and cost-effectiveness of in-person group-based versus web-based care. We hypothesize that both the web-based and in-person programs will reduce body weight and improve outcomes compared to the control group. Furthermore, we hypothesize that the in-person version will be more effective but more costly than the web-based version.
This pragmatic, prospective controlled trial will enrol 660 wait-listed subjects (220 per study arm) from regional bariatric programs in Alberta and randomly assign them to: 1. an in-person, group-based intervention (9 modules delivered over 10 sessions); 2. a web-based intervention (13 modules); and 3. controls who will receive mailed literature. Subjects will have three months to review the content assigned to them (the intervention period) after which they will immediately enter the weight management clinic. Data will be collected at baseline and every 3 months for 9 months (study end), including: 1. Clinical [5% weight loss responders (primary outcome), absolute and % weight losses, changes in obesity-related comorbidities]; 2. Humanistic (health related quality of life, patient satisfaction, depression, and self-efficacy); and 3. Economic (incremental costs and utilities and cost per change in BMI assessed from the third party health care payor perspective) outcomes. Covariate-adjusted baseline-to-nine-month change-scores will be compared between groups for each outcome using linear regression for continuous outcomes and logistic regression for dichotomous ones.
Our findings will determine whether this intervention is effective and cost-effective compared to controls and if online or in-person care delivery is preferred. This information will be useful for clinicians, health-service providers and policy makers and should be generalizable to similar publically-funded bariatric care programs.
Trial Identifier: NCT01860131
Bariatric care; Wait list; Severe obesity; Randomized controlled trial; Self management
Children with respiratory tract infections are the single most frequent patient group to make use of primary care health care resources. The use of antibiotics remains highly prevalent in young children, but can lead to antimicrobial resistance as well as reinforcing the idea that parents should re-consult for similar symptoms. One of the main drivers of indiscriminate antimicrobial use is the lack of evidence for, and therefore uncertainty regarding, which children are at risk of poor outcome. This paper describes the protocol for the TARGET cohort study, which aims to derive and validate a clinical prediction rule to identify children presenting to primary care with respiratory tract infections who are at risk of hospitalisation.
The TARGET cohort study is a large, multicentre prospective observational study aiming to recruit 8,300 children aged ≥3 months and <16 years presenting to primary care with a cough and respiratory tract infection symptoms from 4 study centres (Bristol, London, Oxford and Southampton). Following informed consent, symptoms, signs and demographics will be measured. In around a quarter of children from the Bristol centre, a single sweep, dual bacterial-viral throat swab will be taken and parents asked to complete a symptom diary until the child is completely well or for 28 days, whichever is sooner. A review of medical notes including clinical history, re-consultation and hospitalisations will be undertaken. Multivariable logistic regression will be used to identify the independent clinical predictors of hospitalisation as well as the prognostic significance of upper respiratory tract microbes. The clinical prediction rule will be internally validated using various methods including bootstrapping.
The clinical prediction rule for hospitalisation has the potential to help identify a small group of children for hospitalisation and a much larger group where hospitalisation is very unlikely and antibiotic prescribing would be less warranted. This study will also be the largest natural history study to date of children presenting to primary care with acute cough and respiratory tract infections, and will provide important information on symptom duration, re-consultations and the microbiology of the upper respiratory tract.
Cohort study; Children; Respiratory tract infections (RTIs); Primary care; Protocol; Throat swab
Low literacy is a significant problem across the developed world. A considerable body of research has reported associations between low literacy and less appropriate access to healthcare services, lower likelihood of self-managing health conditions well, and poorer health outcomes. There is a need to explore the previously neglected perspectives of people with low literacy to help explain how low literacy can lead to poor health, and to consider how to improve the ability of health services to meet their needs.
Two stage qualitative study. In-depth individual interviews followed by focus groups to confirm analysis and develop suggestions for service improvements. A purposive sample of 29 adults with English as their first language who had sought help with literacy was recruited from an Adult Learning Centre in the UK.
Over and above the well-documented difficulties that people with low literacy can have with the written information and complex explanations and instructions they encounter as they use health services, the stigma of low literacy had significant negative implications for participants’ spoken interactions with healthcare professionals.
Participants described various difficulties in consultations, some of which had impacted negatively on their broader healthcare experiences and abilities to self-manage health conditions. Some communication difficulties were apparently perpetuated or exacerbated because participants limited their conversational engagement and used a variety of strategies to cover up their low literacy that could send misleading signals to health professionals.
Participants’ biographical narratives revealed that the ways in which they managed their low literacy in healthcare settings, as in other social contexts, stemmed from highly negative experiences with literacy-related stigma, usually from their schooldays onwards. They also suggest that literacy-related stigma can significantly undermine mental wellbeing by prompting self-exclusion from social participation and generating a persistent anxiety about revealing literacy difficulties.
Low-literacy-related stigma can seriously impair people’s spoken interactions with health professionals and their potential to benefit from health services. As policies increasingly emphasise the need for patients’ participation, services need to simplify the literacy requirements of service use and health professionals need to offer non-judgemental (universal) literacy-sensitive support to promote positive healthcare experiences and outcomes.
Low literacy; Patient-provider communication; Patient-provider relationships; Person-centred care; Qualitative
Healthcare provider spontaneous reporting of suspected adverse events following immunisation (AEFI) is central to monitoring post-licensure vaccine safety, but little is known about how healthcare professionals recognise and report to surveillance systems. The aim of this study was explore the knowledge, experience and attitudes of medical and nursing professionals towards detecting and reporting AEFI.
We conducted a qualitative study, using semi-structured, face to face interviews with 13 Paediatric Emergency Department consultants from a tertiary paediatric hospital, 10 General Practitioners, 2 local council immunisation and 4 General Practice nurses, recruited using purposive sampling in Adelaide, South Australia, between December 2010 and September 2011. We identified emergent themes related to previous experience of an AEFI in practice, awareness and experience of AEFI reporting, factors that would facilitate or impede reporting and previous training in vaccine safety. Thematic analysis was used to analyse the data.
AEFI reporting was infrequent across all groups, despite most participants having reviewed an AEFI. We found confusion about how to report an AEFI and variability, according to the provider group, as to the type of events that would constitute a reportable AEFI. Participants’ interpretation of a “serious” or “unexpected” AEFI varied across the three groups. Common barriers to reporting included time constraints and unsatisfactory reporting processes. Nurses were more likely to have received formal training in vaccine safety and reporting than medical practitioners.
This study provides an overview of experience and beliefs of three healthcare professional groups in relation to identifying and reporting AEFI. The qualitative assessment reveals differences in experience and awareness of AEFI reporting across the three professional groups. Most participants appreciated the importance of their role in AEFI surveillance and monitoring the ongoing safety of vaccines. Future initiatives to improve education, such as increased training to health care providers, particularly, medical professionals, are required and should be included in both undergraduate curricula and ongoing, professional development.
Adverse event following immunisation (AEFI), Surveillance; Healthcare provider; Reporting; Qualitative
Stroke is a time-dependent medical emergency in which early presentation to specialist care reduces death and dependency. Up to 70% of all stroke patients obtain first medical contact from the Emergency Medical Services (EMS). Identifying ‘true stroke’ from an EMS call is challenging, with over 50% of strokes being misclassified. The aim of this study was to evaluate the impact of the training package on the recognition of stroke by Emergency Medical Dispatchers (EMDs).
This study took place in an ambulance service and a hospital in England using an interrupted time-series design. Suspected stroke patients were identified in one week blocks, every three weeks over an 18 month period, during which time the training was implemented. Patients were included if they had a diagnosis of stroke (EMS or hospital). The effect of the intervention on the accuracy of dispatch diagnosis was investigated using binomial (grouped) logistic regression.
In the Pre-implementation period EMDs correctly identified 63% of stroke patients; this increased to 80% Post-implementation. This change was significant (p=0.003), reflecting an improvement in identifying stroke patients relative to the Pre-implementation period both the During-implementation (OR=4.10 [95% CI 1.58 to 10.66]) and Post-implementation (OR=2.30 [95% CI 1.07 to 4.92]) periods. For patients with a final diagnosis of stroke who had been dispatched as stroke there was a marginally non-significant 2.8 minutes (95% CI −0.2 to 5.9 minutes, p=0.068) reduction between Pre- and Post-implementation periods from call to arrival of the ambulance at scene.
This is the first study to develop, implement and evaluate the impact of a training package for EMDs with the aim of improving the recognition of stroke. Training led to a significant increase in the proportion of stroke patients dispatched as such by EMDs; a small reduction in time from call to arrival at scene by the ambulance also appeared likely. The training package has been endorsed by the UK Stroke Forum Education and Training, and is free to access on-line.
Emergency medical services; Emergency medical dispatchers; Stroke; Recognition training
In recent years, there has been growing interest in measuring the efficiency of hospitals in Iran and several studies have been conducted on the topic. The main objective of this paper was to review studies in the field of hospital efficiency and examine the estimated technical efficiency (TE) of Iranian hospitals.
Persian and English databases were searched for studies related to measuring hospital efficiency in Iran. Ordinary least squares (OLS) regression models were applied for statistical analysis. The PRISMA guidelines were followed in the search process.
A total of 43 efficiency scores from 29 studies were retrieved and used to approach the research question. Data envelopment analysis was the principal frontier efficiency method in the estimation of efficiency scores. The pooled estimate of mean TE was 0.846 (±0.134). There was a considerable variation in the efficiency scores between the different studies performed in Iran. There were no differences in efficiency scores between data envelopment analysis (DEA) and stochastic frontier analysis (SFA) techniques. The reviewed studies are generally similar and suffer from similar methodological deficiencies, such as no adjustment for case mix and quality of care differences. The results of OLS regression revealed that studies that included more variables and more heterogeneous hospitals generally reported higher TE. Larger sample size was associated with reporting lower TE.
The features of frontier-based techniques had a profound impact on the efficiency scores among Iranian hospital studies. These studies suffer from major methodological deficiencies and were of sub-optimal quality, limiting their validity and reliability. It is suggested that improving data collection and processing in Iranian hospital databases may have a substantial impact on promoting the quality of research in this field.
Technical efficiency; Meta-regression; Data envelopment analysis; Stochastic frontier analysis; Iran
To formulate sustainable long-term care policies, it is critical first to understand the relationship between informal care and formal care expenditure. The aim of this paper is to examine to what extent informal care reduces public expenditure on elderly care.
Data from a geriatric rehabilitation program conducted in Finland (Age Study, n = 732) were used to estimate the annual public care expenditure on elderly care. We first constructed hierarchical multilevel regression models to determine the factors associated with elderly care expenditure. Second, we calculated the adjusted mean costs of care in four care patterns: 1) informal care only for elderly living alone; 2) informal care only from a co-resident family member; 3) a combination of formal and informal care; and 4) formal care only. We included functional independence and health-related quality of life (15D score) measures into our models. This method standardizes the care needs of a heterogeneous subject group and enabled us to compare expenditure among various care categories even when differences were observed in the subjects’ physical health.
Elder care that consisted of formal care only had the highest expenditure at 25,300 Euros annually. The combination of formal and informal care had an annual expenditure of 22,300 Euros. If a person received mainly informal care from a co-resident family member, then the annual expenditure was only 4,900 Euros and just 6,000 Euros for a person living alone and receiving informal care.
Our analysis of a frail elderly Finnish population shows that the availability of informal care considerably reduces public care expenditure. Therefore, informal care should be taken into account when formulating policies for long-term care. The process whereby families choose to provide care for their elderly relatives has a significant impact on long-term care expenditure.
Formal care; Informal care; Costs; Public expenditure; Elderly; Long-term care; Health and social services
The purpose of this study is to identify which variables –among those commonly available and used in the primary care setting– best predict mortality in a cohort of elderly dependent patients living at home (EDPLH) that were included in a home care program provided by Primary Care Teams (PCT). Additionally, we explored the risk of death among a sub-group of these patients that were admitted to hospital the year before they entered the home care program.
A one-year longitudinal cohort study of a sample of EDPLH patients included in a home care programme provided by 72 PCTs. Variables collected from each individual patient included health and social status, carer’s characteristics, carer’s burden of care, health and social services received.
1,001 patients completed the study (91.5%), 226 were admitted to hospital the year before inclusion. 290 (28.9%) died during the one-year follow-up period. In the logistic regression analysis women show a lower risk of death [OR= 0.67 (0.50-0.91)]. The risk of death increases with comorbidity [Charlson index OR= 1.14 (1,06-1.23)], the number of previous hospital admissions [OR= 1,16 (1.03-1.33)], and with the degree of pressure ulcers [ulcers degree 1–2 OR = 2.94 (1.92-4.52); ulcers degree 3–4 OR = 4.45 (1.90-10.92)]. The logistic predictive model of mortality for patients previously admitted to hospital identified male sex, comorbidity, degree of pressure ulcers, and having received home care rehabilitation as independent variables that predict death.
Comorbidity, hospital admissions and pressure ulcers predict mortality in the following year in EDPLH patients. The subgroup of patients that entered home care programs with a previous record of hospital admission and a high score in our predictive model might be considered as candidates for palliative care.
Primary care; Home care; Elderly patients; Dependency; Mortality
Patients diagnosed with cancer by the emergency route often have more advanced diseases and poorer outcomes. Rates of cancer diagnosed through unplanned admissions vary within and between countries, suggesting potential inconsistencies in the quality of care. To reduce diagnoses by this route and improve patient outcomes, high risk patient groups must be identified. This cross-sectional observational study determined the incidence of first-ever diagnoses of cancer by emergency (unplanned) admission and identified patient-level risk factors for these diagnoses in England.
Data for 74,763 randomly selected patients at 457 general practices between 1999 and 2008 were obtained from the General Practice Research Database (GPRD), including integrated Hospital Episode Statistics (HES) data and Office for National Statistics (ONS) mortality data. The proportion of first-ever diagnoses by emergency admission out of all recorded first cancer diagnoses by any route was analysed by patient characteristics.
Diagnosis by emergency admission was recorded in 13.9% of patients diagnosed with cancer for the first time (n = 817/5870). The incidence of first cases by the emergency route was 2.51 patients per 10,000 person years. In adjusted regression analyses, patients of older age (p < 0.0001), living in the most deprived areas (RR 1.93, 95% CI 1.51 to 2.47; p < 0.0001) or who had a total Charlson score of 1 compared to 0 (RR 1.34, 95% CI 1.06 to 1.69; p = 0.014) were most at risk of diagnosis by emergency admission. Patients with more prior (all-cause) emergency admissions were less at risk of subsequent diagnosis by the emergency route (RR 0.31 per prior emergency admission, 95% CI 0.20 to 0.46; p < 0.0001).
A much lower incidence of first-ever cancer diagnoses by emergency admission was found compared with previous studies. Identified high risk groups may benefit from interventions to reduce delayed diagnosis. Further studies should include screening and cancer staging data to improve understanding of delayed or untimely diagnosis and patient care pathways.
Cancer; Primary care; Emergency admissions; Diagnosis; Risk factors; Patient records