Chronic multisite pain in major depression and bipolar disorder: cross-sectional study of 149,611 participants in UK Biobank

BACKGROUND

Chronic pain has a strong association with major depressive disorder (MDD), but there is a relative paucity of studies on the association between chronic multisite pain and bipolar disorder (BD). Such studies are required to help elucidate the complex biological and psychological overlap between pain and mood disorders. The aim of this study is to investigate the relationship between chronic multisite pain and mood disorder across the unipolar-bipolar spectrum.

METHODS

We conducted a cross-sectional study of 149,611 UK Biobank participants. Self-reported depressive and bipolar features were used to categorise participants into MDD and BD groups and a non-mood disordered comparison group. Multinomial logistic regression was used to establish whether there was an association between extent of chronic pain (independent variable) and mood disorder category (dependent variable), using no pain as the referent category, and adjusting for a wide range of potential sociodemographic, lifestyle and comorbidity confounders.

RESULTS

Multisite pain was significantly more prevalent in participants with BD and MDD, for example, 4-7 pain sites: BD 5.8%, MDD 4.5%, and comparison group 1.8% (p < 0.001). A relationship was observed between extent of chronic pain and risk of BD and persisted after adjusting for confounders (relative to individuals with no chronic pain): 2-3 sites RRR of BD 1.84 (95% CI 1.61, 2.11); 4-7 sites RRR of BD 2.39 (95% CI 1.88, 3.03) and widespread pain RRR of BD 2.37 (95% CI 1.73, 3.23). A similar relationship was observed between chronic pain and MDD: 2-3 sites RRR of MDD 1.59 (95% CI 1.54, 1.65); 4-7 sites RRR of MDD 2.13 (95% CI 1.98, 2.30); widespread pain RRR of MDD 1.86 (95% CI 1.66, 2.08).

CONCLUSIONS

Individuals who report chronic pain and multiple sites of pain are more likely to have MDD and are at higher risk of BD. These findings highlight an important aspect of comorbidity in MDD and BD and may have implications for understanding the shared neurobiology of chronic pain and mood disorders.

Implementation of an integrated preoperative care pathway and regional electronic clinical portal for preoperative assessment

BACKGROUND

Effective surgical pre-assessment will depend upon the collection of relevant medical information, good data management and communication between the members of the preoperative multi-disciplinary team. NHS Greater Glasgow and Clyde has implemented an electronic preoperative integrated care pathway (eForm) allowing all hospitals to access a comprehensive patient medical history via a clinical portal on the health-board intranet.

METHODS

We conducted six face-to-face semi-structured interviews and participated in one focus group and two workshops with key stakeholders involved in the Planned Care Improvement (PCIP) and Electronic Patient Record programmes. We used qualitative methods and Normalisation Process Theory in order to identify the key factors which led to the successful deployment of the preoperative eForm in the health-board.

RESULTS

In January 2013, more than 90,000 patient preoperative assessments had been completed via the electronic portal. Two complementary strategic efforts were instrumental in the successful deployment of the preoperative eForm. At the local health-board level: the PCIP led to the rationalisation of surgical pre-assessment clinics and the standardisation of preoperative processes. At the national level: the eHealth programme selected portal technology as an iterative strategic technology solution towards a virtual electronic patient record. Our study has highlighted clear synergies between these two standardisation efforts.

CONCLUSION

The adoption of the eForm into routine preoperative work practices can be attributed to: (i) a policy context - including performance targets - promoting the rationalisation of surgical pre-assessment pathways, (ii) financial and organisational resources to support service redesign and the use of information technology for operationalising the standardisation of preoperative processes, (iii) a sustained engagement with stakeholders throughout the iterative phases of the preoperative clinics redesign, guidelines standardisation and the eForm development, (iv) the use of a pragmatic and domain-agnostic technology solution and finally: (v) a consensual and contextualised implementation.

Revisiting the J shaped curve, exploring the association between cardiovascular risk factors and concurrent depressive symptoms in patients with cardiometabolic disease: Findings from a large cross-sectional study

Background

Depression is common in patients with cardiometabolic diseases but little is known about the relationship, if any, between cardiovascular risk factor values and depressive symptoms in patients with these conditions. The objective of this paper is to study the association between cardiovascular risk factors and concurrent depressive symptoms in patients with three common cardiometabolic conditions: coronary heart disease (CHD), stroke and diabetes.

Methods

We retrospectively reviewed primary care data for N = 35537 with 1 of the above 3 conditions who underwent depression screening using the depressive subscale of hospital anxiety and depression score (HADS-D). We reviewed 4 cardiometabolic risk factors (Systolic Blood Pressure [SBP], Diastolic Blood Pressure [DBP], BMI and total cholesterol) recorded concurrently in all patients and HbA1c in patients with diabetes (n = 18453). We analysed the association between individual risk factor value and a positive HADS-D screening result (>7) using logistic regression.

Results

SBP and BMI were noted to have a non-linear “J-shaped” relationship with the probability of having a positive HADS-D and observed nadirs (levels with the lowest probability) of 148 mm Hg and 30.70 kg/m2, respectively. Total cholesterol and DBP found to have a weaker curvilinear association with concurrent depression symptoms and nadirs of 3.60 mmol/l and 74 mmHg. Among patients with Diabetes, HbA1c was also found to have a “J-shaped” relationship with probability of having a positive HADS-D with an observed nadir of 7.06% DCCT. The above relationships remain significant after adjusting for age, sex, socio-economic status and number of co-morbid conditions.

Conclusion

In patients with cardiometabolic disease, cardiovascular risk factor values at both extremes were associated with higher positive depression screening after adjusting for confounders. These findings have potentially important implications for clinical practice in relation to both risk stratification for depression and approaches to secondary prevention in individuals with cardiometabolic disease and merit further investigation to determine the nature and direction of the observed association.

Please see related article: http://www.biomedcentral.com/1741-7015/12/199.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2261-14-139) contains supplementary material, which is available to authorized users.

Stroke, multimorbidity and polypharmacy in a nationally representative sample of 1,424,378 patients in Scotland: implications for treatment burden

BACKGROUND

The prevalence of multimorbidity (the presence of two or more long-term conditions) is rising internationally. Multimorbidity affects patients by increasing their burden of symptoms, but is also likely to increase the self-care demands, or treatment burden, that they experience. Treatment burden refers to the effort expended in operationalising treatments, navigating healthcare systems and managing relations with healthcare providers. This is an important problem for people with chronic illness such as stroke. Polypharmacy is an important marker of both multimorbidity and burden of treatment. In this study, we examined the prevalence of multimorbidity and polypharmacy in a large, nationally representative population of primary care patients with and without stroke, adjusting for age, sex and deprivation.

METHODS

A cross-sectional study of 1,424,378 participants aged 18 years and over, from 314 primary care practices in Scotland that were known to be demographically representative of the Scottish adult population. Data included information on the presence of stroke and another 39 long-term conditions, plus prescriptions for regular medications.

RESULTS

In total, 35,690 people (2.5%) had a diagnosis of stroke. Of the 39 comorbidities examined, 35 were significantly more common in people with stroke. Of the people with a stroke, the proportion that had one or more additional morbidities present (94.2%) was almost twice that in the control group (48%) (odds ratio (OR) adjusted for age, sex and socioeconomic deprivation 5.18; 95% confidence interval (CI) 4.95 to 5.43). In the stroke group, 12.6% had a record of 11 or more repeat prescriptions compared with only 1.5% of the control group (OR adjusted for age, sex, deprivation and morbidity count 15.84; 95% CI 14.86 to 16.88). Limitations include the use of data collected for clinical rather than research purposes, a lack of consensus in the literature on the definition of certain long-term conditions, and the absence of statistical weighting in the measurement of multimorbidity, although the latter was deemed suitable for descriptive analyses.

CONCLUSIONS

Multimorbidity and polypharmacy were strikingly more common in those with a diagnosis of stroke compared with those without. This has important implications for clinical guidelines and the design of health services.

Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials

IMPORTANCE

Reducing early (<30 days) hospital readmissions is a policy priority aimed at improving health care quality. The cumulative complexity model conceptualizes patient context. It predicts that highly supportive discharge interventions will enhance patient capacity to enact burdensome self-care and avoid readmissions.

OBJECTIVE

To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features--including their impact on treatment burden and on patients' capacity to enact postdischarge self-care--that might explain their varying effects.

DATA SOURCES

We searched PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013), contacted experts, and reviewed bibliographies.

STUDY SELECTION

Randomized trials that assessed the effect of interventions on all-cause or unplanned readmissions within 30 days of discharge in adult patients hospitalized for a medical or surgical cause for more than 24 hours and discharged to home.

DATA EXTRACTION AND SYNTHESIS

Reviewer pairs extracted trial characteristics and used an activity-based coding strategy to characterize the interventions; fidelity was confirmed with authors. Blinded to trial outcomes, reviewers noted the extent to which interventions placed additional work on patients after discharge or supported their capacity for self-care in accordance with the cumulative complexity model.

MAIN OUTCOMES AND MEASURES

Relative risk of all-cause or unplanned readmission with or without out-of-hospital deaths at 30 days postdischarge.

RESULTS

In 42 trials, the tested interventions prevented early readmissions (pooled random-effects relative risk, 0.82 [95% CI, 0.73-0.91]; P < .001; I² = 31%), a finding that was consistent across patient subgroups. Trials published before 2002 reported interventions that were 1.6 times more effective than those tested later (interaction P = .01). In exploratory subgroup analyses, interventions with many components (interaction P = .001), involving more individuals in care delivery (interaction P = .05), and supporting patient capacity for self-care (interaction P = .04) were 1.4, 1.3, and 1.3 times more effective than other interventions, respectively. A post hoc regression model showed incremental value in providing comprehensive, postdischarge support to patients and caregivers.

CONCLUSIONS AND RELEVANCE

Tested interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care. Interventions tested more recently are less effective.

Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness

BACKGROUND

In this article we outline Burden of Treatment Theory, a new model of the relationship between sick people, their social networks, and healthcare services. Health services face the challenge of growing populations with long-term and life-limiting conditions, they have responded to this by delegating to sick people and their networks routine work aimed at managing symptoms, and at retarding - and sometimes preventing - disease progression. This is the new proactive work of patient-hood for which patients are increasingly accountable: founded on ideas about self-care, self-empowerment, and self-actualization, and on new technologies and treatment modalities which can be shifted from the clinic into the community. These place new demands on sick people, which they may experience as burdens of treatment.

DISCUSSION

As the burdens accumulate some patients are overwhelmed, and the consequences are likely to be poor healthcare outcomes for individual patients, increasing strain on caregivers, and rising demand and costs of healthcare services. In the face of these challenges we need to better understand the resources that patients draw upon as they respond to the demands of both burdens of illness and burdens of treatment, and the ways that resources interact with healthcare utilization.

SUMMARY

Burden of Treatment Theory is oriented to understanding how capacity for action interacts with the work that stems from healthcare. Burden of Treatment Theory is a structural model that focuses on the work that patients and their networks do. It thus helps us understand variations in healthcare utilization and adherence in different healthcare settings and clinical contexts.

A Randomized trial of an Asthma Internet Self-management Intervention (RAISIN): study protocol for a randomized controlled trial

Background

The financial costs associated with asthma care continue to increase while care remains suboptimal. Promoting optimal self-management, including the use of asthma action plans, along with regular health professional review has been shown to be an effective strategy and is recommended in asthma guidelines internationally. Despite evidence of benefit, guided self-management remains underused, however the potential for online resources to promote self-management behaviors is gaining increasing recognition. The aim of this paper is to describe the protocol for a pilot evaluation of a website ‘Living well with asthma’ which has been developed with the aim of promoting self-management behaviors shown to improve outcomes.

Methods/Design

The study is a parallel randomized controlled trial, where adults with asthma are randomly assigned to either access to the website for 12 weeks, or usual asthma care for 12 weeks (followed by access to the website if desired). Individuals are included if they are over 16-years-old, have a diagnosis of asthma with an Asthma Control Questionnaire (ACQ) score of greater than, or equal to 1, and have access to the internet. Primary outcomes for this evaluation include recruitment and retention rates, changes at 12 weeks from baseline for both ACQ and Asthma Quality of Life Questionnaire (AQLQ) scores, and quantitative data describing website usage (number of times logged on, length of time logged on, number of times individual pages looked at, and for how long). Secondary outcomes include clinical outcomes (medication use, health services use, lung function) and patient reported outcomes (including adherence, patient activation measures, and health status).

Discussion

Piloting of complex interventions is considered best practice and will maximise the potential of any future large-scale randomized controlled trial to successfully recruit and be able to report on necessary outcomes. Here we will provide results across a range of outcomes which will provide estimates of efficacy to inform the design of a future full-scale randomized controlled trial of the ‘Living well with asthma’ website.

Trial registration

This trial is registered with Current Controlled Trials ISRCTN78556552 on 18/06/13.

A qualitative evaluation of general practitioners' views on protocol-driven eReferral in Scotland

Background

The ever increasing volume of referrals from primary care to specialist services is putting considerable pressure on resource-constrained health services while effective communication across fragmented services remains a substantial challenge. Previous studies have suggested that electronic referrals (eReferral) can bear important benefits for cross-organisational processes and patient care management.

Methods

We conducted 25 semi-structured interviews and 1 focus group with primary care providers to elucidate General Practitioners’ (GPs) perspectives on information management processes in the patient pathway in NHSScotland, 1 focus group with members of the Scottish Electronic Patient Record programme and one interview with a senior architect of the Scottish Care Information national eReferral System (SCI Gateway). Using Normalisation Process Theory, we performed a qualitative analysis to elucidate GPs’ perspectives on eReferral to identify the factors which they felt either facilitated or hindered referral processes.

Results

The majority of GPs interviewed felt that eReferral substantially streamlined communication processes, with the immediate transfer of referral documents and the availability of an electronic audit trail perceived as two substantial improvements over paper-based referrals. Most GPs felt that the SCI Gateway system was reasonably straightforward to use. Referral protocols and templates could be perceived as useful by some GPs while others considered them to be cumbersome at times.

Conclusion

Our study suggests that the deployment and adoption of eReferral across the NHS in Scotland has been achieved by a combination of factors: (i) a policy context – including national mandatory targets for eReferral – which all NHS health-boards were bound to operationalise through their Local Delivery Plans and also (ii) the fact that primary care doctors considered that the overall benefits brought by the deployment of eReferral throughout the patient pathway significantly outweigh any potential disbenefits.

Patient, carer and professional perspectives on barriers and facilitators to quality care in advanced heart failure

BACKGROUND

Those with advanced heart failure (HF) experience high levels of morbidity and mortality, similar to common cancers. However, there remains evidence of inequity of access to palliative care services compared to people with cancer. This study examines patient, carer, and professional perspectives on current management of advanced HF and barriers and facilitators to improved care.

METHODS

Qualitative study involving semi-structured interviews and focus groups with advanced HF patients (n = 30), carers (n = 20), and professionals (n = 65). Data analysed using Normalisation Process Theory (NPT) as the underpinning conceptual framework.

FINDINGS

Uncertainty is ubiquitous in accounts from advanced HF patients and their caregivers. This uncertainty relates to understanding of the implications of their diagnosis, appropriate treatments, and when and how to seek effective help. Health professionals agree this is a major problem but feel they lack knowledge, opportunities, or adequate support to improve the situation. Fragmented care with lack of coordination and poor communication makes life difficult. Poor understanding of the condition extends to the wider circle of carers and means that requests for help may not be perceived as legitimate, and those with advanced HF are not prioritised for social and financial supports. Patient and caregiver accounts of emergency care are uniformly poor. Managing polypharmacy and enduring concomitant side effects is a major burden, and the potential for rationalisation exists. This study has potential limitations because it was undertaken within a single geographical location within the United Kingdom.

CONCLUSIONS

Little progress is being made to improve care experiences for those with advanced HF. Even in the terminal stages, patients and caregivers are heavily and unnecessarily burdened by health care services that are poorly coordinated and offer fragmented care. There is evidence that these poor experiences could be improved to a large extent by simple organisational rather than complex clinical mechanisms.

A study of clinical and information management processes in the surgical pre-assessment clinic

Background

Establishing day-case surgery as the preferred hospital admission route for all eligible patients requires adequate preoperative assessment of patients in order to quickly distinguish those who will require minimum assessment and are suitable for day-case admission from those who will require more extensive management and will need to be admitted as inpatients.

Methods

As part of a study to elucidate clinical and information management processes within the patient surgical pathway in NHS Scotland, we conducted a total of 10 in-depth semi-structured interviews during 4 visits to the Dumfries & Galloway Royal Infirmary surgical pre-assessment clinic. We modelled clinical processes using process-mapping techniques and analysed interview data using qualitative methods. We used Normalisation Process Theory as a conceptual framework to interpret the factors which were identified as facilitating or hindering information elucidation tasks and communication within the multi-disciplinary team.

Results

The pre-assessment clinic of Dumfries & Galloway Royal Infirmary was opened in 2008 in response to clinical and workflow issues which had been identified with former patient management practices in the surgical pathway. The preoperative clinic now operates under well established processes and protocols. The use of a computerised system for managing preoperative documentation substantially transformed clinical practices and facilitates communication and information-sharing among the multi-disciplinary team.

Conclusion

Successful deployment and normalisation of innovative clinical and information management processes was possible because both local and national strategic priorities were synergistic and the system was developed collaboratively by the POA staff and the health-board IT team, resulting in a highly contextualised operationalisation of clinical and information management processes. Further concerted efforts from a range of stakeholders are required to fully integrate preoperative assessment within the health-board surgical care pathway. A substantial – yet unfulfilled – potential benefit in embedding information technology in routine use within the preoperative clinic would be to improve the reporting of surgical outcomes.

Digital asthma self-management interventions: a systematic review

BACKGROUND

Many people with asthma tolerate symptoms and lifestyle limitations unnecessarily by not utilizing proven therapies. Better support for self-management is known to improve asthma control, and increasingly the Internet and other digital media are being used to deliver that support.

OBJECTIVE

Our goal was to summarize current knowledge, evidenced through existing systematic reviews, of the effectiveness and implementation of digital self-management support for adults and children with asthma and to examine what features help or hinder the use of these programs.

METHODS

A comprehensive search strategy combined 3 facets of search terms: (1) online technology, (2) asthma, and (3) self-management/behavior change/patient experience. We undertook searches of 14 databases, and reference and citation searching. We included qualitative and quantitative systematic reviews about online or computerized interventions facilitating self-management. Title, abstract, full paper screening, and quality appraisal were performed by two researchers independently. Data extraction was undertaken using standardized forms.

RESULTS

A total of 3810 unique papers were identified. Twenty-nine systematic reviews met inclusion criteria: the majority were from the United States (n=12), the rest from United Kingdom (n=6), Canada (n=3), Portugal (n=2), and Australia, France, Spain, Norway, Taiwan, and Greece (1 each). Only 10 systematic reviews fulfilled pre-determined quality standards, describing 19 clinical trials. Interventions were heterogeneous: duration of interventions ranging from single use, to 24-hour access for 12 months, and incorporating varying degrees of health professional involvement. Dropout rates ranged from 5-23%. Four RCTs were aimed at adults (overall range 3-65 years). Participants were inadequately described: socioeconomic status 0/19, ethnicity 6/19, and gender 15/19. No qualitative systematic reviews were included. Meta-analysis was not attempted due to heterogeneity and inadequate information provision within reviews. There was no evidence of harm from digital interventions. All RCTs that examined knowledge (n=2) and activity limitation (n=2) showed improvement in the intervention group. Digital interventions improved markers of self care (5/6), quality of life (4/7), and medication use (2/3). Effects on symptoms (6/12) and school absences (2/4) were equivocal, with no evidence of overall benefits on lung function (2/6), or health service use (2/15). No specific data on economic analyses were provided. Intervention descriptions were generally brief making it impossible to identify which specific "ingredients" of interventions contribute most to improving outcomes.

CONCLUSIONS

Digital self-management interventions show promise, with evidence of beneficial effects on some outcomes. There is no evidence about utility in those over 65 years and no information about socioeconomic status of participants, making understanding the "reach" of such interventions difficult. Digital interventions are poorly described within reviews, with insufficient information about barriers and facilitators to their uptake and utilization. To address these gaps, a detailed quantitative systematic review of digital asthma interventions and an examination of the primary qualitative literature are warranted, as well as greater emphasis on economic analysis within trials.

A qualitative systematic review of studies using the normalization process theory to research implementation processes

BACKGROUND

There is a well-recognized need for greater use of theory to address research translational gaps. Normalization Process Theory (NPT) provides a set of sociological tools to understand and explain the social processes through which new or modified practices of thinking, enacting, and organizing work are implemented, embedded, and integrated in healthcare and other organizational settings. This review of NPT offers readers the opportunity to observe how, and in what areas, a particular theoretical approach to implementation is being used. In this article we review the literature on NPT in order to understand what interventions NPT is being used to analyze, how NPT is being operationalized, and the reported benefits, if any, of using NPT.

METHODS

Using a framework analysis approach, we conducted a qualitative systematic review of peer-reviewed literature using NPT. We searched 12 electronic databases and all citations linked to six key NPT development papers. Grey literature/unpublished studies were not sought. Limitations of English language, healthcare setting and year of publication 2006 to June 2012 were set.

RESULTS

Twenty-nine articles met the inclusion criteria; in the main, NPT is being applied to qualitatively analyze a diverse range of complex interventions, many beyond its original field of e-health and telehealth. The NPT constructs have high stability across settings and, notwithstanding challenges in applying NPT in terms of managing overlaps between constructs, there is evidence that it is a beneficial heuristic device to explain and guide implementation processes.

CONCLUSIONS

NPT offers a generalizable framework that can be applied across contexts with opportunities for incremental knowledge gain over time and an explicit framework for analysis, which can explain and potentially shape implementation processes. This is the first review of NPT in use and it generates an impetus for further and extended use of NPT. We recommend that in future NPT research, authors should explicate their rationale for choosing NPT as their theoretical framework and, where possible, involve multiple stakeholders including service users to enable analysis of implementation from a range of perspectives.

Challenges and implications of routine depression screening for depression in chronic disease and multimorbidity: a cross sectional study

Background

Depression screening in chronic disease is advocated but its impact on routine practice is uncertain. We examine the effects of a programme of incentivised depression screening in chronic disease within a UK primary care setting.

Methods and Findings

Cross sectional analysis of anonymised, routinely collected data (2008-9) from family practices in Scotland serving a population of circa 1.8 million. Primary care registered patients with at least one of three chronic diseases, coronary heart disease, diabetes and stroke, underwent incentivised depression screening using the Hospital Anxiety and Depression Score (HADS).

125143 patients were identified with at least one chronic disease. 10670 (8.5%) were under treatment for depression and exempt from screening. Of remaining, HADS were recorded for 35537 (31.1%) patients. 7080 (19.9% of screened) had raised HADS (≥8); majority had indications of mild depression with HADS between 8 and 10. Over 6 months, 572 (8%) of those with raised HADS (≥8) were initiated on antidepressants, while 696 (2.4%) patients with normal HADS (<8) were also initiated on antidepressants (relative risk of antidepressant initiation with raised HADS 3.3 (CI 2.97-3.67), p value <0.0001). Of those with multimorbidity who were screened, 24.3% had raised HADS (≥8). A raised HADS was more likely in females, socioeconomically deprived, multimorbid or younger (18-44) individuals. Females and 45-64 years old were more likely to receive antidepressants.

Limitations

retrospective study of routinely collected data.

Conclusions

Despite incentivisation, only a minority of patients underwent depression screening, suggesting that systematic depression screening in chronic disease can be difficult to achieve in routine practice. Targeting those at greatest risk such as the multimorbid or using simpler screening methods may be more effective. Raised HADS was associated with higher number of new antidepressant prescriptions which has significant resource implications. The clinical benefits of such screening remain uncertain and merits investigation.

A study of general practitioners' perspectives on electronic medical records systems in NHSScotland

BACKGROUND

Primary care doctors in NHSScotland have been using electronic medical records within their practices routinely for many years. The Scottish Health Executive eHealth strategy (2008-2011) has recently brought radical changes to the primary care computing landscape in Scotland: an information system (GPASS) which was provided free-of-charge by NHSScotland to a majority of GP practices has now been replaced by systems provided by two approved commercial providers. The transition to new electronic medical records had to be completed nationally across all health-boards by March 2012.

METHODS

We carried out 25 in-depth semi-structured interviews with primary care doctors to elucidate GPs' perspectives on their practice information systems and collect more general information on management processes in the patient surgical pathway in NHSScotland. We undertook a thematic analysis of interviewees' responses, using Normalisation Process Theory as the underpinning conceptual framework.

RESULTS

The majority of GPs' interviewed considered that electronic medical records are an integral and essential element of their work during the consultation, playing a key role in facilitating integrated and continuity of care for patients and making clinical information more accessible. However, GPs expressed a number of reservations about various system functionalities - for example: in relation to usability, system navigation and information visualisation.

CONCLUSION

Our study highlights that while electronic information systems are perceived as having important benefits, there remains substantial scope to improve GPs' interaction and overall satisfaction with these systems. Iterative user-centred improvements combined with additional training in the use of technology would promote an increased understanding, familiarity and command of the range of functionalities of electronic medical records among primary care doctors.

Examining health promotion interventions for patients with chronic conditions using a novel patient-centered complexity model: protocol for a systematic review and meta-analysis

BACKGROUND

Successful chronic care self-management requires adherence to healthy lifestyle behaviors, but many healthcare-based health promotion interventions have resulted in small and unsustainable changes in patient behavior. Patients with chronic conditions may already be overwhelmed by burdensome illnesses and treatments, and not have the capacity to respond well to the additional work required of behavior modifications. To explore this phenomenon, we will apply the cumulative complexity model (CCM), a patient-centered model of patient complexity, to a systematic review and meta-analysis of healthcare-based health behavior interventions.

METHODS/DESIGN

This systematic review will include randomized trials published between 2002 and 2012 that compared healthcare-based interventions aimed at improving healthy diet and physical activity in community dwelling adult patients with chronic conditions. After extracting study and risk of bias features from each trial, we will classify the interventions according to the conceptual model. We will then use meta-analysis and subgroup analysis to test hypotheses based on the conceptual model.

DISCUSSION

Healthcare providers need evidence of successful health promoting interventions for patients with chronic conditions who display common behavioral risk factors. To better understand how patients respond to interventions, we will apply the CCM, which accounts for both the capacity of patients with chronic conditions and their treatment-related workload, and posits that a balance between capacity and workload predicts successful enactment of self-care. Analysis will also include whether patients with multiple chronic conditions respond differently to interventions compared to those with single chronic conditions. The results of this review will provide insights as to how patients with chronic conditions respond to health-promoting interventions.

REVIEW REGISTRATION

PROSPERO registration number: CRD42012003428.

Improving the normalization of complex interventions: measure development based on normalization process theory (NoMAD): study protocol

BACKGROUND

Understanding implementation processes is key to ensuring that complex interventions in healthcare are taken up in practice and thus maximize intended benefits for service provision and (ultimately) care to patients. Normalization Process Theory (NPT) provides a framework for understanding how a new intervention becomes part of normal practice. This study aims to develop and validate simple generic tools derived from NPT, to be used to improve the implementation of complex healthcare interventions.

OBJECTIVES

The objectives of this study are to: develop a set of NPT-based measures and formatively evaluate their use for identifying implementation problems and monitoring progress; conduct preliminary evaluation of these measures across a range of interventions and contexts, and identify factors that affect this process; explore the utility of these measures for predicting outcomes; and develop an online users' manual for the measures.

METHODS

A combination of qualitative (workshops, item development, user feedback, cognitive interviews) and quantitative (survey) methods will be used to develop NPT measures, and test the utility of the measures in six healthcare intervention settings.

DISCUSSION

The measures developed in the study will be available for use by those involved in planning, implementing, and evaluating complex interventions in healthcare and have the potential to enhance the chances of their implementation, leading to sustained changes in working practices.

Qualitative systematic reviews of treatment burden in stroke, heart failure and diabetes - methodological challenges and solutions

BACKGROUND

Treatment burden can be defined as the self-care practices that patients with chronic illness must perform to respond to the requirements of their healthcare providers, as well as the impact that these practices have on patient functioning and well being. Increasing levels of treatment burden may lead to suboptimal adherence and negative outcomes. Systematic review of the qualitative literature is a useful method for exploring the patient experience of care, in this case the experience of treatment burden. There is no consensus on methods for qualitative systematic review. This paper describes the methodology used for qualitative systematic reviews of the treatment burdens identified in three different common chronic conditions, using stroke as our exemplar.

METHODS

Qualitative studies in peer reviewed journals seeking to understand the patient experience of stroke management were sought. Limitations of English language and year of publication 2000 onwards were set. An exhaustive search strategy was employed, consisting of a scoping search, database searches (Scopus, CINAHL, Embase, Medline & PsycINFO) and reference, footnote and citation searching. Papers were screened, data extracted, quality appraised and analysed by two individuals, with a third party for disagreements. Data analysis was carried out using a coding framework underpinned by Normalization Process Theory (NPT).

RESULTS

A total of 4364 papers were identified, 54 were included in the review. Of these, 51 (94%) were retrieved from our database search. Methodological issues included: creating an appropriate search strategy; investigating a topic not previously conceptualised; sorting through irrelevant data within papers; the quality appraisal of qualitative research; and the use of NPT as a novel method of data analysis, shown to be a useful method for the purposes of this review.

CONCLUSION

The creation of our search strategy may be of particular interest to other researchers carrying out synthesis of qualitative studies. Importantly, the successful use of NPT to inform a coding frame for data analysis involving qualitative data that describes processes relating to self management highlights the potential of a new method for analyses of qualitative data within systematic reviews.

A study of information management in the patient surgical pathway in NHSScotland

We conducted a study of information management processes across the patient surgical pathway in NHSScotland. While the majority of general practitioners (GPs) consider electronic medical records systems as an essential and integral part of their work during the patient consultation, many were not fully satisfied with the functionalities of these systems. A majority of GPs considered that the national eReferral system streamlined referral processes. Almost all GPs reported marked variability in the quality of discharge information. Preoperative processes vary significantly across Scotland, with most services using paper-based systems. Insufficient use is made of information provided through the patient electronic referral leading to a considerable duplication of tasks already performed in primary care. Three health-boards have implemented electronic preoperative information systems. These have transformed clinical practices and facilitated communication and information-sharing among the multi-disciplinary team and within the health-boards. Substantial progress has been made towards improving information transfer and sharing within the surgical pathway in recent years. However, there remains scope for further improvements at the interface between services.

Uncovering treatment burden as a key concept for stroke care: a systematic review of qualitative research

BACKGROUND

Patients with chronic disease may experience complicated management plans requiring significant personal investment. This has been termed 'treatment burden' and has been associated with unfavourable outcomes. The aim of this systematic review is to examine the qualitative literature on treatment burden in stroke from the patient perspective.

METHODS AND FINDINGS

The search strategy centred on: stroke, treatment burden, patient experience, and qualitative methods. We searched: Scopus, CINAHL, Embase, Medline, and PsycINFO. We tracked references, footnotes, and citations. Restrictions included: English language, date of publication January 2000 until February 2013. Two reviewers independently carried out the following: paper screening, data extraction, and data analysis. Data were analysed using framework synthesis, as informed by Normalization Process Theory. Sixty-nine papers were included. Treatment burden includes: (1) making sense of stroke management and planning care, (2) interacting with others, (3) enacting management strategies, and (4) reflecting on management. Health care is fragmented, with poor communication between patient and health care providers. Patients report inadequate information provision. Inpatient care is unsatisfactory, with a perceived lack of empathy from professionals and a shortage of stimulating activities on the ward. Discharge services are poorly coordinated, and accessing health and social care in the community is difficult. The study has potential limitations because it was restricted to studies published in English only and data from low-income countries were scarce.

CONCLUSIONS

Stroke management is extremely demanding for patients, and treatment burden is influenced by micro and macro organisation of health services. Knowledge deficits mean patients are ill equipped to organise their care and develop coping strategies, making adherence less likely. There is a need to transform the approach to care provision so that services are configured to prioritise patient needs rather than those of health care systems.

Factors that promote or inhibit the implementation of e-health systems: an explanatory systematic review

OBJECTIVE

To systematically review the literature on the implementation of e-health to identify: (i) barriers and facilitators to e-health implementation, and (ii) outstanding gaps in research on the subject.

METHODS

MEDLINE, EMBASE, CINAHL, PSYCINFO and the Cochrane Library were searched for reviews published between 1 January 1995 and 17 March 2009. Studies had to be systematic reviews, narrative reviews, qualitative metasyntheses or meta-ethnographies of e-health implementation. Abstracts and papers were double screened and data were extracted on country of origin; e-health domain; publication date; aims and methods; databases searched; inclusion and exclusion criteria and number of papers included. Data were analysed qualitatively using normalization process theory as an explanatory coding framework.

FINDINGS

Inclusion criteria were met by 37 papers; 20 had been published between 1995 and 2007 and 17 between 2008 and 2009. Methodological quality was poor: 19 papers did not specify the inclusion and exclusion criteria and 13 did not indicate the precise number of articles screened. The use of normalization process theory as a conceptual framework revealed that relatively little attention was paid to: (i) work directed at making sense of e-health systems, specifying their purposes and benefits, establishing their value to users and planning their implementation; (ii) factors promoting or inhibiting engagement and participation; (iii) effects on roles and responsibilities; (iv) risk management, and (v) ways in which implementation processes might be reconfigured by user-produced knowledge.

CONCLUSION

The published literature focused on organizational issues, neglecting the wider social framework that must be considered when introducing new technologies.

Cumulative complexity: a functional, patient-centered model of patient complexity can improve research and practice

OBJECTIVE

To design a functional, patient-centered model of patient complexity with practical applicability to analytic design and clinical practice. Existing literature on patient complexity has mainly identified its components descriptively and in isolation, lacking clarity as to their combined functions in disrupting care or to how complexity changes over time.

STUDY DESIGN AND SETTING

The authors developed a cumulative complexity model, which integrates existing literature and emphasizes how clinical and social factors accumulate and interact to complicate patient care. A narrative literature review is used to explicate the model.

RESULTS

The model emphasizes a core, patient-level mechanism whereby complicating factors impact care and outcomes: the balance between patient workload of demands and patient capacity to address demands. Workload encompasses the demands on the patient's time and energy, including demands of treatment, self-care, and life in general. Capacity concerns ability to handle work (e.g., functional morbidity, financial/social resources, literacy). Workload-capacity imbalances comprise the mechanism driving patient complexity. Treatment and illness burdens serve as feedback loops, linking negative outcomes to further imbalances, such that complexity may accumulate over time.

CONCLUSION

With its components largely supported by existing literature, the model has implications for analytic design, clinical epidemiology, and clinical practice.