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Worthington J, Frost J, Sanderson E, Cochrane M, Wheeler J, Cotterill N, MacNeill SJ, Noble S, Avery M, Clarke S, Fader M, Hashim H, McGeagh L, Macaulay M, Rees J, Robles L, Taylor G, Taylor J, Thompson J, Lane JA, Ridd MJ, Drake MJ. Lower urinary tract symptoms in men: the TRIUMPH cluster RCT. Health Technol Assess 2024; 28:1-162. [PMID: 38512051 PMCID: PMC11017146 DOI: 10.3310/gvbc3182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Abstract
Background Conservative therapies are recommended as initial treatment for male lower urinary tract symptoms. However, there is a lack of evidence on effectiveness and uncertainty regarding approaches to delivery. Objective The objective was to determine whether or not a standardised and manualised care intervention delivered in primary care achieves superior symptomatic outcome for lower urinary tract symptoms to usual care. Design This was a two-arm cluster randomised controlled trial. Setting The trial was set in 30 NHS general practice sites in England. Participants Participants were adult men (aged ≥ 18 years) with bothersome lower urinary tract symptoms. Interventions Sites were randomised 1 : 1 to deliver the TReatIng Urinary symptoms in Men in Primary Health care using non-pharmacological and non-surgical interventions trial intervention or usual care to all participants. The TReatIng Urinary symptoms in Men in Primary Health care using non-pharmacological and non-surgical interventions intervention comprised a standardised advice booklet developed for the trial from the British Association of Urological Surgeons' patient information sheets, with patient and expert input. Patients were directed to relevant sections by general practice or research nurses/healthcare assistants following urinary symptom assessment, providing the manualised element. The healthcare professional provided follow-up contacts over 12 weeks to support adherence to the intervention. Main outcome measures The primary outcome was the validated patient-reported International Prostate Symptom Score 12 months post consent. Rather than the minimal clinically important difference of 3.0 points for overall International Prostate Symptom Score, the sample size aimed to detect a difference of 2.0 points, owing to the recognised clinical impact of individual symptoms. Results A total of 1077 men consented to the study: 524 in sites randomised to the intervention arm (n = 17) and 553 in sites randomised to the control arm (n = 13). A difference in mean International Prostate Symptom Score at 12 months was found (adjusted mean difference of -1.81 points, 95% confidence interval -2.66 to -0.95 points), with a lower score in the intervention arm, indicating less severe symptoms. Secondary outcomes of patient-reported urinary symptoms, quality of life specific to lower urinary tract symptoms and perception of lower urinary tract symptoms all showed evidence of a difference between the arms favouring the intervention. No difference was seen between the arms in the proportion of urology referrals or adverse events. In qualitative interviews, participants welcomed the intervention, describing positive effects on their symptoms, as well as on their understanding of conservative care and their attitude towards the experience of lower urinary tract symptoms. The interviews highlighted that structured, in-depth self-management is insufficiently embedded within general practitioner consultations. From an NHS perspective, mean costs and quality-adjusted life-years were similar between trial arms. The intervention arm had slightly lower mean costs (adjusted mean difference of -£29.99, 95% confidence interval -£109.84 to £22.63) than the usual-care arm, and a small gain in quality-adjusted life-years (adjusted mean difference of 0.001, 95% confidence interval -0.011 to 0.014). Conclusions The intervention showed a small, sustained benefit for men's lower urinary tract symptoms and quality of life across a range of outcome measures in a UK primary care setting. Qualitative data showed that men highly valued the intervention. Intervention costs were marginally lower than usual-care costs. Limitations of the study included that trial participants were unmasked, with limited diversity in ethnicity and deprivation level. Additional research is needed to assess the applicability of the intervention for a more ethnically diverse population.. Trial registration This trial is registered as ISRCTN11669964. Funding This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/90/03) and is published in full in Health Technology Assessment; Vol. 28, No. 13. See the NIHR Funding and Awards website for further award information.
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Affiliation(s)
- Jo Worthington
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jessica Frost
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Emily Sanderson
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Madeleine Cochrane
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jessica Wheeler
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nikki Cotterill
- School of Health and Social Wellbeing, College of Health, Science and Society, University of the West of England, Bristol, UK
| | - Stephanie J MacNeill
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Miriam Avery
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Samantha Clarke
- Clinical Research Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Mandy Fader
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Hashim Hashim
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Lucy McGeagh
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | - Margaret Macaulay
- School of Health Sciences, University of Southampton, Southampton, UK
| | | | - Luke Robles
- National Institute for Health and Care Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust, University of Bristol, Bristol, UK
| | | | - Jodi Taylor
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Joanne Thompson
- Clinical Research Centre, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - J Athene Lane
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew J Ridd
- Centre of Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Marcus J Drake
- Bristol Urological Institute, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
- Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Drake MJ, Worthington J, Frost J, Sanderson E, Cochrane M, Cotterill N, Fader M, McGeagh L, Hashim H, Macaulay M, Rees J, Robles LA, Taylor G, Taylor J, Ridd MJ, MacNeill SJ, Noble S, Lane JA. Treatment of lower urinary tract symptoms in men in primary care using a conservative intervention: cluster randomised controlled trial. BMJ 2023; 383:e075219. [PMID: 37967894 PMCID: PMC10646682 DOI: 10.1136/bmj-2023-075219] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/02/2023] [Indexed: 11/17/2023]
Abstract
OBJECTIVE To determine whether a standardised and manualised care intervention in men in primary care could achieve superior improvement of lower urinary tract symptoms (LUTS) compared with usual care. DESIGN Cluster randomised controlled trial. SETTING 30 National Health Service general practice sites in England. PARTICIPANTS Sites were randomised 1:1 to the intervention and control arms. 1077 men (≥18 years) with bothersome LUTS recruited between June 2018 and August 2019: 524 were assigned to the intervention arm (n=17 sites) and 553 were assigned to the usual care arm (n=13 sites). INTERVENTION Standardised information booklet developed with patient and expert input, providing guidance on conservative and lifestyle interventions for LUTS in men. After assessment of urinary symptoms (manualised element), general practice nurses and healthcare assistants or research nurses directed participants to relevant sections of the manual and provided contact over 12 weeks to assist with adherence. MAIN OUTCOME MEASURES The primary outcome was patient reported International Prostate Symptom Score (IPSS) measured 12 months after participants had consented to take part in the study. The target reduction of 2.0 points on which the study was powered reflects the minimal clinically important difference where baseline IPSS is <20. Secondary outcomes were patient reported quality of life, urinary symptoms and perception of LUTS, hospital referrals, and adverse events. The primary intention-to-treat analysis included 887 participants (82% of those recruited) and used a mixed effects multilevel linear regression model adjusted for site level variables used in the randomisation and baseline scores. RESULTS Participants in the intervention arm had a lower mean IPSS at 12 months (adjusted mean difference -1.81 points, 95% confidence interval -2.66 to -0.95) indicating less severe urinary symptoms than those in the usual care arm. LUTS specific quality of life, incontinence, and perception of LUTS also improved more in the intervention arm than usual care arm at 12 months. The proportion of urology referrals (intervention 7.3%, usual care 7.9%) and adverse events (intervention seven events, usual care eight events) were comparable between the arms. CONCLUSIONS A standardised and manualised intervention in primary care showed a sustained reduction in LUTS in men at 12 months. The mean difference of -1.81 points (95% confidence interval -0.95 to -2.66) on the IPSS was less than the predefined target reduction of 2.0 points. TRIAL REGISTRATION ISRCTN Registry ISRCTN11669964.
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Affiliation(s)
- Marcus J Drake
- Department of Surgery and Cancer, Faculty of Medicine, Imperial College, Hammersmith Hospital, London, UK
| | - Jo Worthington
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Jessica Frost
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Emily Sanderson
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Madeleine Cochrane
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Nikki Cotterill
- Department of Nursing and Midwifery, Faculty of Health and Applied Sciences, University of the West of England, Bristol, UK
| | - Mandy Fader
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Lucy McGeagh
- Oxford Institute Nursing, Midwifery and Allied Health Research, Oxford Brookes University, Oxford, UK
| | - Hashim Hashim
- Bristol Urological Institute, North Bristol NHS Trust, Southmead Hospital, Bristol, UK
| | - Margaret Macaulay
- School of Health Sciences, University of Southampton, Southampton, UK
| | - Jonathan Rees
- Tyntesfield Medical Group, Brockway Medical Centre, Nailsea, Bristol, UK
| | - Luke A Robles
- NIHR Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and the University of Bristol, University Hospitals Bristol Education Centre, Bristol, UK
| | | | - Jodi Taylor
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Matthew J Ridd
- Centre of Academic Primary Care, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Stephanie J MacNeill
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Sian Noble
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - J Athene Lane
- Bristol Trials Centre, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
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Howel D, Moffatt S, Haighton C, Bryant A, Becker F, Steer M, Lawson S, Aspray T, Milne EMG, Vale L, McColl E, White M. Does domiciliary welfare rights advice improve health-related quality of life in independent-living, socio-economically disadvantaged people aged ≥60 years? Randomised controlled trial, economic and process evaluations in the North East of England. PLoS One 2019; 14:e0209560. [PMID: 30629609 PMCID: PMC6328099 DOI: 10.1371/journal.pone.0209560] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 12/09/2018] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND There are major socio-economic gradients in health that could be influenced by increasing personal resources. Welfare rights advice can enhance resources but has not been rigorously evaluated for health-related impacts. METHODS Randomised, wait-list controlled trial with individual allocation, stratified by general practice, of welfare rights advice and assistance with benefit entitlements, delivered in participants' homes by trained advisors. Control was usual care. Participants were volunteers sampled from among all those aged ≥60 years registered with general practices in socio-economically deprived areas of north east England. Outcomes at 24 months were: CASP-19 score (primary), a measure of health-related quality of life; changes in income, social and physical function, and cost-effectiveness (secondary). Intention to treat analysis compared outcomes using multiple regression, with adjustment for stratification and key covariates. Qualitative interviews with purposive samples from both trial arms were thematically analysed. FINDINGS Of 3912 individuals approached, 755 consented and were randomised (381 Intervention, 374 Control). Results refer to outcomes at 24 months, with data available on 562 (74.4%) participants. Intervention was received as intended by 335 (88%), with 84 (22%) awarded additional benefit entitlements; 46 did not receive any welfare rights advice, and none of these were awarded additional benefits. Mean CASP-19 scores were 42.9 (Intervention) and 42.4 (Control) (adjusted mean difference 0.3 [95%CI -0.8, 1.5]). There were no significant differences in secondary outcomes except Intervention participants reported receiving more care at home at 24m (53.7 (Intervention) vs 42.0 (Control) hours/week (adjusted mean difference 26.3 [95%CIs 0.8, 56.1]). Exploratory analyses did not support an intervention effect and economic evaluation suggested the intervention was unlikely to be cost-effective. Qualitative data from 50 interviews suggested there were improvements in quality of life among those receiving additional benefits. CONCLUSIONS We found no effects on health outcomes; fewer participants than anticipated received additional benefit entitlements, and participants were more affluent than expected. Our findings do not support delivery of domiciliary welfare rights advice to achieve the health outcomes assessed in this population. However, better intervention targeting may reveal worthwhile health impacts.
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Affiliation(s)
- Denise Howel
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Suzanne Moffatt
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Haighton
- Department of Social Work, Education & Community Wellbeing, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Frauke Becker
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
- Health Economics Research Centre, University of Oxford, Oxford, United Kingdom
| | - Melanie Steer
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Sarah Lawson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Terry Aspray
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Eugene M. G. Milne
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
- Newcastle City Council, Newcastle upon Tyne, United Kingdom
| | - Luke Vale
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Elaine McColl
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Martin White
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, United Kingdom
- MRC Epidemiology Unit, University of Cambridge, Cambridge, United Kingdom
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Haighton C, Moffatt S, Howel D, Steer M, Becker F, Bryant A, Lawson S, McColl E, Vale L, Milne E, Aspray T, White M. Randomised controlled trial with economic and process evaluations of domiciliary welfare rights advice for socioeconomically disadvantaged older people recruited via primary health care (the Do-Well study). PUBLIC HEALTH RESEARCH 2019. [DOI: 10.3310/phr07030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundWelfare rights advice services are effective at maximising previously unclaimed welfare benefits, but their impact on health has not been evaluated.ObjectiveTo establish the acceptability, cost-effectiveness and effect on health of a domiciliary welfare rights advice service targeting older people, compared with usual practice.DesignA pragmatic, individually randomised, parallel-group, single-blinded, wait-list controlled trial, with economic and process evaluations. Data were collected by interview at baseline and 24 months, and by self-completion questionnaire at 12 months. Qualitative interviews were undertaken with purposive samples of 50 trial participants and 17 professionals to explore the intervention’s acceptability and its perceived impacts.SettingParticipants’ homes in North East England, UK.ParticipantsA total of 755 volunteers aged ≥ 60 years, living in their own homes, fluent in English and not terminally ill, recruited from the registers of 17 general practices with an Index of Multiple Deprivation within the most deprived two-fifths of the distribution for England, and with no previous access to welfare rights advice services.InterventionsWelfare rights advice, comprising face-to-face consultations, active assistance with benefit claims and follow-up as required until no longer needed, delivered in participants’ own homes by a qualified welfare rights advisor. Control group participants received usual care until the 24-month follow-up, after which they received the intervention.Main outcome measuresThe primary outcome was health-related quality of life (HRQoL), assessed using the CASP-19 (Control, Autonomy, Self-realisation and Pleasure) score. The secondary outcomes included general health status, health behaviours, independence and hours per week of care, mortality and changes in financial status.ResultsA total of 755 out of 3912 (19%) general practice patients agreed to participate and were randomised (intervention,n = 381; control,n = 374). In the intervention group, 335 participants (88%) received the intervention. A total of 605 (80%) participants completed the 12-month follow-up and 562 (75%) completed the 24-month follow-up. Only 84 (22%) intervention group participants were awarded additional benefits. There was no significant difference in CASP-19 score between the intervention and control groups at 24 months [adjusted mean difference 0.3, 95% confidence interval (CI) –0.8 to 1.5], but a significant increase in hours of home care per week in the intervention group (adjusted difference 26.3 hours/week, 95% CI 0.8 to 56.1 hours/week). Exploratory analyses found a weak positive correlation between CASP-19 score and the amount of time since receipt of the benefit (0.39, 95% CI 0.16 to 0.58). The qualitative data suggest that the intervention was acceptable and that receipt of additional benefits was perceived by participants and professionals as having had a positive impact on health and quality of life. The mean cost was £44 per participant, the incremental mean health gain was 0.009 quality-adjusted life-years (QALYs) (95% CI –0.038 to 0.055 QALYs) and the incremental cost-effectiveness ratio was £1914 per QALY gained.ConclusionsThe trial did not provide sufficient evidence to support domiciliary welfare rights advice as a means of promoting health among older people, but it yielded qualitative findings that suggest important impacts on HRQoL. The intervention needs to be better targeted to those most likely to benefit.Future workFurther follow-up of the trial could identify whether or not outcomes diverge among intervention and control groups over time. Research is needed to better understand how to target welfare rights advice to those most in need.Trial registrationCurrent Controlled Trials ISRCTN37380518.FundingThis project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full inPublic Health Research; Vol. 7, No. 3. See the NIHR Journals Library website for further project information. The authors also received a grant of £28,000 from the North East Strategic Health Authority in 2012 to cover the costs of intervention delivery and training as well as other non-research costs of the study.
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Affiliation(s)
- Catherine Haighton
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Suzanne Moffatt
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Mel Steer
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Frauke Becker
- Health Economics Group, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Bryant
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Sarah Lawson
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Health Economics Group, Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Eugene Milne
- Public Health Directorate, Newcastle City Council, Newcastle upon Tyne, UK
- School of Medicine, Pharmacy and Health, Durham University, Durham, UK
- Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Terry Aspray
- Institute for Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Martin White
- Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
- Medical Research Council (MRC) Epidemiology Unit, University of Cambridge, Cambridge, UK
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Tarrant C, Angell E, Baker R, Boulton M, Freeman G, Wilkie P, Jackson P, Wobi F, Ketley D. Responsiveness of primary care services: development of a patient-report measure – qualitative study and initial quantitative pilot testing. HEALTH SERVICES AND DELIVERY RESEARCH 2014. [DOI: 10.3310/hsdr02460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundPrimary care service providers do not always respond to the needs of diverse groups of patients, and so certain patients groups are disadvantaged. General practitioner (GP) practices are increasingly encouraged to be more responsive to patients’ needs in order to address inequalities.Objectives(1) Explore the meaning of responsiveness in primary care. (2) Develop a patient-report questionnaire for use as a measure of patient experience of responsiveness by a range of primary care organisations (PCOs). (3) Investigate methods of population mapping available to GP practices.Design settingPCOs, including GP practices, walk-in centres and community pharmacies.ParticipantsPatients and staff from 12 PCOs in the East Midlands in the development stage, and 15 PCOs across three different regions of England in stage 3.InterventionsTo investigate what responsiveness means, we conducted a literature review and interviews with patients and staff in 12 PCOs. We developed, tested and piloted the use of a questionnaire. We explored approaches for GP practices to understand the diversity of their populations.Main outcome measures(1) Definition of primary care responsiveness. (2) Three patient-report questionnaires to provide an assessment of patient experience of GP, pharmacy and walk-in centre responsiveness. (3) Insight into challenges in collecting diversity data in primary care.ResultsThe literature covers three overlapping themes of service quality, inequalities and patient involvement. We suggest that responsiveness is achieved through alignment between service delivery and patient needs, involving strategies to improve responsive service delivery, and efforts to manage patient expectations. We identified three components of responsive service delivery: proactive population orientation, reactive population orientation and individual patient orientation. PCOs tend to utilise reactive strategies rather than proactive approaches. Questionnaire development involved efforts to include patients who are ‘seldom heard’. The questionnaire was checked for validity and consistency and is available in three versions (GP, pharmacy, and walk-in centre), and in Easy Read format. We found the questionnaires to be acceptable to patients, and to have content validity. We produced some preliminary evidence of reliability and construct validity. Measuring and improving responsiveness requires PCOs to understand the characteristics of their patient population, but we identified significant barriers and challenges to this.ConclusionsResponsiveness is a complex concept. It involves alignment between service delivery and the needs of diverse patient groups. Reactive and proactive strategies at individual and population level are required, but PCOs mainly rely on reactive approaches. Being responsive means giving good care equally to all, and some groups may require extra support. What this extra support is will differ in different patient populations, and so knowledge of the practice population is essential. Practices need to be motivated to collect and use diversity data. Future work needed includes further evaluation of the patient-report questionnaires, including Easy Read versions, to provide further evidence of their quality and acceptability; research into how to facilitative the use of patient experience data in primary care; and implementation of strategies to improve responsiveness, and evaluation of effectiveness.FundingThe National Institute for Health Research Service Delivery and Organisation programme.
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Affiliation(s)
- Carolyn Tarrant
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Emma Angell
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Richard Baker
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Mary Boulton
- Department of Clinical Health Care, Oxford Brookes University, Oxford, UK
| | - George Freeman
- School of Public Health, Imperial College London, London, UK
| | - Patricia Wilkie
- National Association for Patient Participation, Walton-on-Thames, UK
| | - Peter Jackson
- School of Management, University of Leicester, Leicester, UK
| | - Fatimah Wobi
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Diane Ketley
- Department of Health Sciences, University of Leicester, Leicester, UK
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Haighton C, Moffatt S, Howel D, McColl E, Milne E, Deverill M, Rubin G, Aspray T, White M. The Do-Well study: protocol for a randomised controlled trial, economic and qualitative process evaluations of domiciliary welfare rights advice for socio-economically disadvantaged older people recruited via primary health care. BMC Public Health 2012; 12:382. [PMID: 22639988 PMCID: PMC3408348 DOI: 10.1186/1471-2458-12-382] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2012] [Accepted: 05/28/2012] [Indexed: 11/23/2022] Open
Abstract
Background Older people in poor health are more likely to need extra money, aids and adaptations to allow them to remain independent and cope with ill health, yet in the UK many do not claim the welfare benefits to which they are entitled. Welfare rights advice interventions lead to greater welfare income, but have not been rigorously evaluated for health benefits. This study will evaluate the effects on health and well-being of a domiciliary welfare rights advice service provided by local government or voluntary organisations in North East England for independent living, socio-economically disadvantaged older people (aged ≥60 yrs), recruited from general (primary care) practices. Methods/Design The study is a pragmatic, individually randomised, single blinded, wait-list controlled trial of welfare rights advice versus usual care, with embedded economic and qualitative process evaluations. The qualitative study will examine whether the intervention is delivered as intended; explore responses to the intervention and examine reasons for the trial findings; and explore the potential for translation of the intervention into routine policy and practice. The primary outcome is the effect on health-related quality of life, measured using the CASP 19 questionnaire. Volunteer men and women aged ≥60 years (1/household) will be identified from general practice patient registers. Patients in nursing homes or hospitals at the time of recruitment will be excluded. General practice populations will be recruited from disadvantaged areas of North East England, including urban, rural and semi-rural areas, with no previous access to targeted welfare rights advice services delivered to primary care patients. A minimum of 750 participants will be randomised to intervention and control arms in a 1:1 ratio. Discussion Achieving a trial design that is both ethical and acceptable to potential participants, required methodological compromises. The choice of follow-up length required a trade-off between sufficient time to demonstrate health impact and the need to allow the control group access to the intervention as early as possible. The study will have implications for fundamental understanding of social inequalities and how to tackle them, and provides a model for similar evaluations of health-orientated social interventions. If the health benefits of this intervention are proven, targeted welfare rights advice services should be extended to ensure widespread provision for older people and other vulnerable groups. Current Controlled Trials ISRCTN Number ISRCTN37380518
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Affiliation(s)
- Catherine Haighton
- Institute of Health and Society, Newcastle University, Baddiley Clark Building, Richardson Road, Newcastle, NE2 4AX, UK.
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Purdy S, Griffin T, Salisbury C, Sharp D. Emergency respiratory admissions: influence of practice, population and hospital factors. J Health Serv Res Policy 2011; 16:133-40. [PMID: 21719477 DOI: 10.1258/jhsrp.2010.010013] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
OBJECTIVE To determine the influence of population, hospital and general practice characteristics on practice admission rates for asthma and chronic obstructive pulmonary disease (COPD) in England. METHODS Cross sectional study using Hospital Episode Statistics (HES), routine population data and primary care data. Admissions for all general practices in England during 2005-06, adjusted for age and sex composition of practice population. Univariable analysis of population, practice and hospital care provision variables, including prevalence and quality data. Significant factors included in multiple regression Poisson model. RESULTS Admissions from 8169 practices were included. Risk of admission for each condition increased with deprivation, prevalence and smoking. Admission rates were higher in urban than rural practices. Hospital bed availability and distance to the nearest emergency department were also significantly associated with risk of admission. The associations with practice factors including practice size and quality markers varied across conditions. CONCLUSIONS Practice population, geographic and hospital supply factors are consistently associated with asthma and COPD admissions. Higher smoking rates among such patients in a practice are associated with higher admission rates. There is little evidence from this study that other modifiable general practice factors are important in influencing admission rates.
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Affiliation(s)
- Sarah Purdy
- Academic Unit of Primary Health Care, University of Bristol, Bristol, UK.
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Bossuyt N, Van den Block L, Cohen J, Meeussen K, Bilsen J, Echteld M, Deliens L, Van Casteren V. Is individual educational level related to end-of-life care use? Results from a nationwide retrospective cohort study in Belgium. J Palliat Med 2011; 14:1135-41. [PMID: 21815816 DOI: 10.1089/jpm.2011.0045] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Educational level has repeatedly been identified as an important determinant of access to health care, but little is known about its influence on end-of-life care use. OBJECTIVES To examine the relationship between individual educational attainment and end-of-life care use and to assess the importance of individual educational attainment in explaining differential end-of-life care use. RESEARCH DESIGN A retrospective cohort study via a nationwide sentinel network of general practitioners (GPs; SENTI-MELC Study) provided data on end-of-life care utilization. Multilevel analysis was used to model the association between educational level and health care use, adjusting for individual and contextual confounders based upon Andersen's behavioral model of health services use. SUBJECTS A Belgian nationwide representative sample of people who died not suddenly in 2005-2007. RESULTS In comparison to their less educated counterparts, higher educated people equally often had a palliative treatment goal but more often used multidisciplinary palliative care services (odds ratios [OR] for lower secondary education 1.28 [1.04-1.59] and for higher [secondary] education: 1.31 [1.02-1.68]), moved between care settings more frequently (OR: 1.68 [1.13-2.48] for lower secondary education and 1.51 [0.93-2.48] for higher [secondary] education) and had more contacts with the GP in the final 3 months of life. CONCLUSIONS Less well-educated people appear to be disadvantaged in terms of access to specialist palliative care services, and GP contacts at the end of life, suggesting a need for empowerment of less well-educated terminally ill people regarding specialist palliative and general end-of-life care use.
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Affiliation(s)
- Nathalie Bossuyt
- Scientific Institute of Public Health, Operational Directorate Public Health & Surveillance, Brussels, Belgium.
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Purdy S, Griffin T, Salisbury C, Sharp D. Emergency admissions for coronary heart disease: A cross-sectional study of general practice, population and hospital factors in England. Public Health 2011; 125:46-54. [DOI: 10.1016/j.puhe.2010.07.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Revised: 06/16/2010] [Accepted: 07/13/2010] [Indexed: 12/21/2022]
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