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Chadborn NH, Devi R, Williams C, Sartain K, Goodman C, Gordon AL. GPs’ involvement to improve care quality in care homes in the UK: a realist review. HEALTH SERVICES AND DELIVERY RESEARCH 2021. [DOI: 10.3310/hsdr09200] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Background
Organising health-care services for residents living in care homes is an important area of development in the UK and elsewhere. Medical care is provided by general practitioners in the UK, and the unique arrangement of the NHS means that general practitioners are also gatekeepers to other health services. Despite recent focus on improving health care for residents, there is a lack of knowledge about the role of general practitioners.
Objectives
First, to review reports of research and quality improvement (or similar change management) in care homes to explore how general practitioners have been involved. Second, to develop programme theories explaining the role of general practitioners in improvement initiatives and outcomes.
Design
A realist review was selected to address the complexity of integration of general practice and care homes.
Setting
Care homes for older people in the UK, including residential and nursing homes.
Participants
The focus of the literature review was the general practitioner, along with care home staff and other members of multidisciplinary teams. Alongside the literature, we interviewed general practitioners and held consultations with a Context Expert Group, including a care home representative.
Interventions
The primary search did not specify interventions, but captured the range of interventions reported. Secondary searches focused on medication review and end-of-life care because these interventions have described general practitioner involvement.
Outcomes
We sought to capture processes or indicators of good-quality care.
Data sources
Sources were academic databases [including MEDLINE, EMBASE™ (Elsevier, Amsterdam, the Netherlands), Cumulative Index to Nursing and Allied Health Literature, PsycInfo® (American Psychological Association, Washington, DC, USA), Web of Science™ (Clarivate Analytics, Philadelphia, PA, USA) and Cochrane Collaboration] and grey literature using Google Scholar (Google Inc., Mountain View, CA, USA).
Methods
Realist And Meta-narrative Evidence Syntheses: Evolving Standards (RAMESES) guidelines were followed, comprising literature scoping, interviews with general practitioners, iterative searches of academic databases and grey literature, and synthesis and development of overarching programme theories.
Results
Scoping indicated the distinctiveness of the health and care system in UK and, because quality improvement is context dependent, we decided to focus on UK studies because of potential problems in synthesising across diverse systems. Searches identified 73 articles, of which 43 were excluded. To summarise analysis, programme theory 1 was ‘negotiated working with general practitioners’ where other members of the multidisciplinary team led initiatives and general practitioners provided support with the parts of improvement where their skills as primary care doctors were specifically required. Negotiation enabled matching of the diverse ways of working of general practitioners with diverse care home organisations. We found evidence that this could result in improvements in prescribing and end-of-life care for residents. Programme theory 2 included national or regional programmes that included clearly specified roles for general practitioners. This provided clarity of expectation, but the role that general practitioners actually played in delivery was not clear.
Limitations
One reviewer screened all search results, but two reviewers conducted selection and data extraction steps.
Conclusions
If local quality improvement initiatives were flexible, then they could be used to negotiate to build a trusting relationship with general practitioners, with evidence from specific examples, and this could improve prescribing and end-of-life care for residents. Larger improvement programmes aimed to define working patterns and build suitable capacity in care homes, but there was little evidence about the extent of local general practitioner involvement.
Future work
Future work should describe the specific role, capacity and expertise of general practitioners, as well as the diversity of relationships between general practitioners and care homes.
Study registration
This study is registered as PROSPERO CRD42019137090.
Funding
This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 20. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Neil H Chadborn
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
- NIHR Applied Research Collaboration – East Midlands (ARC-EM), Nottingham, UK
| | - Reena Devi
- School of Healthcare, Faculty of Medicine and Health, University of Leeds, Leeds, UK
| | | | - Kathleen Sartain
- Dementia and Frail Older Persons Patient and Public Involvement Group, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, UK
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
- NIHR Applied Research Collaboration – East of England (ARC-EoE), Cambridge, UK
| | - Adam L Gordon
- Division of Medical Sciences and Graduate Entry Medicine, University of Nottingham, Nottingham, UK
- NIHR Applied Research Collaboration – East Midlands (ARC-EM), Nottingham, UK
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Barker RO, Hanratty B, Kingston A, Ramsay SE, Matthews FE. Changes in health and functioning of care home residents over two decades: what can we learn from population-based studies? Age Ageing 2021; 50:921-927. [PMID: 33951152 PMCID: PMC8099147 DOI: 10.1093/ageing/afaa227] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Indexed: 11/16/2022] Open
Abstract
Background Care home residents have complex care and support needs. There is a perception that the needs of residents have increased, but the evidence is limited. We investigated changes in health and functioning of care home residents over two decades in England and Wales. Methods We conducted a repeated cross-sectional analysis over a 24 year period (1992–2016), using data from three longitudinal studies, the Cognitive Function and Ageing Studies (CFAS) I and II and the English Longitudinal Study of Ageing (ELSA). To adjust for ageing of respondents over time results are presented for the 75–84 age group. Results Analysis of 2,280 observations from 1,745 care home residents demonstrated increases in severe disability (difficulty in at least two from washing, dressing and toileting). The prevalence of severe disability increased from 63% in 1992 to 87% in 2014 (subsequent fall in 2016 although wide confidence intervals). The prevalence of complex multimorbidity (problems in at least three out of six body systems) increased within studies over time, from 33% to 54% in CFAS I/II between 1992 and 2012, and 26% to 54% in ELSA between 2006 and 2016. Conclusion Over two decades, there has been an increase in disability and the complexity of health problems amongst care home residents in England and Wales. A rise in support needs for residents places increasing demands on care home staff and health professionals, and should be an important consideration for policymakers and service commissioners.
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Affiliation(s)
- Robert O Barker
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Andrew Kingston
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Sheena E Ramsay
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
| | - Fiona E Matthews
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE4 5PL, UK
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Gordon AL, Devi R, Williams C, Goodman C, Sartain K, Chadborn NH. Protocol for a realist review of General Practitioners' Role in Advancing Practice in Care Homes (GRAPE study). BMJ Open 2020; 10:e036221. [PMID: 32546492 PMCID: PMC7299033 DOI: 10.1136/bmjopen-2019-036221] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
INTRODUCTION Older people who live in care homes have a high level of need with complex health conditions. In addition to providing medical care to residents, general practitioners (GPs) play a role as gatekeeper for access to services, as well as leadership within healthcare provision. This review will describe how GPs were involved in initiatives to change arrangements of healthcare services in order to improve quality and experience of care. METHODS AND ANALYSIS Following RAMESES quality and publication guidelines standards, we will proceed with realist review to develop theories of how GPs work with care home staff to bring about improvements. We identify when improvement in outcomes does not occur and why this may be the case. The first stage will include interviews with GPs to ask their views on improvement in care homes. These interviews will enable development of initial theories and give direction for the literature searches. In the second stage, we will use iterative literature searches to add depth and context to the early theories; databases will include Medline, Embase, CINAHL, PsycINFO and ASSIA. In stage 3, evidence that is judged as rigorous and relevant will be used to test the initial theories, and through the process, refine the theory statements. In the final stage, we will synthesise findings and provide recommendations for practice and policy-making.During the review, we will invite a context expert group to reflect on our findings. This group will have expertise in current trends in primary care and the care home sector both in UK and internationally. ETHICS AND DISSEMINATION The study was approved by University of Nottingham Faculty of Medicine and Health Sciences Research Ethics Committee: 354-1907. Findings will be shared through stakeholder networks, published in National Institute for Health Research journal and submitted for peer-reviewed journal publication.
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Affiliation(s)
- Adam L Gordon
- School of Medicine, Division of Medical Science and Graduate Entry Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK
- NIHR Applied Research Collaboration East Midlands, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Reena Devi
- School of Healthcare, University of Leeds, Leeds, UK
| | - Christopher Williams
- Department of Health Sciences, University of Leicester, Leicester, Leicestershire, UK
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, Hertfordshire, UK
- NIHR Applied Research Collaboration East of England, University of Hertfordshire, Hatfield, Hertfordshire, UK
| | - Kathleen Sartain
- Dementia and Frail Older Persons PPI Group, Division of Rehabilitation and Ageing, University of Nottingham, Nottingham, Nottinghamshire, UK
| | - Neil H Chadborn
- School of Medicine, Division of Medical Science and Graduate Entry Medicine, University of Nottingham, Nottingham, Nottinghamshire, UK
- NIHR Applied Research Collaboration East Midlands, University of Nottingham, Nottingham, Nottinghamshire, UK
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Abstract
Aim: To identify discrete approaches to specialist healthcare support for older care home residents in the UK and to estimate their prevalence. Background: Internationally, a range of new initiatives are emerging to meet the multiple and complex healthcare needs of care home residents. However, little is known about their relative effectiveness and, given their heterogeneity, a classification scheme is required to enable research staff to explore this. Method: A UK survey collected information on the funding, age, coverage, aims, staffing and activities of 64 specialist care home support services. Latent class analysis (LCA) was used to allocate the sample into subgroups with similar characteristics. Findings: Three classes were identified. Class 1 (55% of sample) contained services with a high probability of providing scheduled input (regular preplanned visits) and support for all residents and a moderate probability of undertaking medication management, but a low probability of training care home staff (‘predominantly direct care’). Class 2 (23% of sample) had a moderate/high probability of providing scheduled input, support for all residents, medication management and training (‘direct and indirect care’). Class 3 (22% of sample) had a low probability of providing scheduled input, support for all residents and medication management, but a high probability of providing training for care home staff (‘predominantly indirect care’). Consultants were more likely to be members of services in Class 1 than Class 2, and Class 2 than Class 3. Conclusions: LCA offers a promising approach to the creation of a taxonomy of specialist care home support services. The skills and knowledge required by healthcare staff vary between classes, raising important issues for service design. The proposed classification can be used to explore the extent to which different organisational forms are associated with better resident, process and service outcomes.
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Lloyd T, Conti S, Santos F, Steventon A. Effect on secondary care of providing enhanced support to residential and nursing home residents: a subgroup analysis of a retrospective matched cohort study. BMJ Qual Saf 2019; 28:534-546. [PMID: 30956202 PMCID: PMC6593648 DOI: 10.1136/bmjqs-2018-009130] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Revised: 02/05/2019] [Accepted: 03/01/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Thirteen residential care homes and 10 nursing homes specialising in older people in Rushcliffe, England, participated in an improvement programme. The enhanced support provided included regular visits from named general practitioners and additional training for care home staff. We assessed and compared the effect on hospital use for residents in residential and nursing homes, respectively. METHODS Using linked care home and administrative hospital data, we examined people aged 65 years or over who moved to a participating care home between 2014 and 2016 (n=568). We selected matched control residents who had similar characteristics to the residents receiving enhanced support and moved to similar care homes not participating in the enhanced support (n=568). Differences in hospital use were assessed for residents of each type of care home using multivariable regression. RESULTS Residents of participating residential care homes showed lower rates of potentially avoidable emergency admissions (rate ratio 0.50, 95% CI 0.30 to 0.82), emergency admissions (rate ratio 0.60, 95% CI 0.42 to 0.86) and Accident & Emergency attendances (0.57, 95% CI 0.40 to 0.81) than matched controls. Hospital bed days, outpatient attendances and the proportion of deaths that occurred out of hospital were not statistically different. For nursing home residents, there were no significant differences for any outcome. CONCLUSIONS The enhanced support was associated with lower emergency hospital use for older people living in residential care homes but not for people living in nursing homes. This might be because there was more potential to reduce emergency care for people in residential care homes. In nursing homes, improvement programmes may need to be more tailored to residents' needs or the context of providing care in that setting.
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Affiliation(s)
- Therese Lloyd
- Improvement Analytics Unit, The Health Foundation, London, UK
| | - Stefano Conti
- Improvement Analytics Unit and Data, Analysis and Intelligence Services, NHS England, London, UK
| | - Filipe Santos
- Improvement Analytics Unit and Data, Analysis and Intelligence Services, NHS England, London, UK
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Remote Health Care Provision in Care Homes in England: An Exploratory Mixed Methods Study of Yorkshire and the Humber. TECHNOLOGIES 2019. [DOI: 10.3390/technologies7010024] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
An increasing demand for care homes in the UK, has necessitated the evaluation of innovative methods for delivering more effective health care. Videoconferencing may be one way to meet this demand. However, there is a lack of literature on the provision of videoconferencing in England. This mixed-methods study aimed to map current attitudes, knowledge and provision of videoconferencing in the Yorkshire and Humber region of England. Qualitative interviews with care home managers, a scoping review and field notes from a Special Interest Group (SIG) informed the development of a descriptive convenience survey which was sent out to care home managers in the Yorkshire and Humber region of England. The survey had a 14% (n = 124) response rate. Of those who responded, 10% (n = 12) reported using videoconferencing for health care; with over 78% (n = 97) of respondents’ care homes being based in urban areas. Approximately 62% (n = 77) of the 124 respondents had heard of videoconferencing for health care provision. Of those who reported not using videoconferencing (n = 112), 39% (n = 48) said they would consider it but would need to know more. The top ranked reason for not introducing videoconferencing was the belief that residents would not be comfortable using videoconferencing to consult with a healthcare professional. The main reason for implementation was the need for speedier access to services. Those already using videoconferencing rated videoconferencing overall as being very good (50%) (n = 6) or good (42%) (n = 5). Those who were not using it in practice appeared sceptical before implementing videoconferencing. The main driver of uptake was the home’s current access to and satisfaction with traditionally delivered health care services.
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Tucker S, Buck D, Roe B, Hughes J, Challis D. Hospital admissions and place of death of residents of care homes receiving specialist healthcare services: Protocol for a systematic review. J Adv Nurs 2018; 75:443-451. [PMID: 30289570 DOI: 10.1111/jan.13866] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2018] [Accepted: 09/07/2018] [Indexed: 11/29/2022]
Abstract
AIM To synthesize the evidence relating to the ability of specialist care home support services to prevent the hospital admission of older care home residents, including hospital admission at the end-of-life. DESIGN Systematic review and narrative synthesis. METHODS Ten electronic databases will be searched from 2010 - 31 December 2018 using predetermined search terms. All studies of specialist healthcare services to meet care home residents' physical healthcare needs which provide outcome data on hospital admission or place of death compared with usual care will be included. Two reviewers will independently assess studies' eligibility and methodological quality using the Effective Public Health Practice Project Quality Assessment Tool. Data will be extracted by one reviewer and checked by a second according to predetermined categories. Data will be synthesized in evidence tables and narrative. Funder: National Institute for Health Research School for Social Care Research, November 2016. DISCUSSION Care of older people in care home settings is a key aspect of nursing nationally and internationally. This review will increase understanding of the extent to which different models of specialist healthcare support for care homes are associated with key resident outcomes. IMPACT Standard healthcare support for care home residents is often inadequate, resulting in avoidable hospital admissions and lack of resident choice as to place of death. Although a range of specialist healthcare services are emerging, little is known about their relative effectiveness. This paper marshalls evidence of relevance to commissioners investing in healthcare provision to care homes to meet NHS targets.
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Affiliation(s)
- Sue Tucker
- Personal Social Services Research Unit (PSSRU), University of Manchester, Manchester, UK
| | - Deborah Buck
- Personal Social Services Research Unit (PSSRU), University of Manchester, Manchester, UK
| | - Brenda Roe
- Personal Social Services Research Unit (PSSRU), University of Manchester, Manchester, UK.,Evidence-based Practice Research Centre, Faculty of Health & Social Care, Edge Hill University, Ormskirk, UK
| | - Jane Hughes
- Personal Social Services Research Unit (PSSRU), University of Manchester, Manchester, UK
| | - David Challis
- Personal Social Services Research Unit (PSSRU), University of Manchester, Manchester, UK
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Goodman C, Davies SL, Gordon AL, Dening T, Gage H, Meyer J, Schneider J, Bell B, Jordan J, Martin F, Iliffe S, Bowman C, Gladman JRF, Victor C, Mayrhofer A, Handley M, Zubair M. Optimal NHS service delivery to care homes: a realist evaluation of the features and mechanisms that support effective working for the continuing care of older people in residential settings. HEALTH SERVICES AND DELIVERY RESEARCH 2017. [DOI: 10.3310/hsdr05290] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BackgroundCare homes are the institutional providers of long-term care for older people. The OPTIMAL study argued that it is probable that there are key activities within different models of health-care provision that are important for residents’ health care.ObjectivesTo understand ‘what works, for whom, why and in what circumstances?’. Study questions focused on how different mechanisms within the various models of service delivery act as the ‘active ingredients’ associated with positive health-related outcomes for care home residents.MethodsUsing realist methods we focused on five outcomes: (1) medication use and review; (2) use of out-of-hours services; (3) hospital admissions, including emergency department attendances and length of hospital stay; (4) resource use; and (5) user satisfaction. Phase 1: interviewed stakeholders and reviewed the evidence to develop an explanatory theory of what supported good health-care provision for further testing in phase 2. Phase 2 developed a minimum data set of resident characteristics and tracked their care for 12 months. We also interviewed residents, family and staff receiving and providing health care to residents. The 12 study care homes were located on the south coast, the Midlands and the east of England. Health-care provision to care homes was distinctive in each site.FindingsPhase 1 found that health-care provision to care homes is reactive and inequitable. The realist review argued that incentives or sanctions, agreed protocols, clinical expertise and structured approaches to assessment and care planning could support improved health-related outcomes; however, to achieve change NHS professionals and care home staff needed to work together from the outset to identify, co-design and implement agreed approaches to health care. Phase 2 tested this further and found that, although there were few differences between the sites in residents’ use of resources, the differences in service integration between the NHS and care homes did reflect how these institutions approached activities that supported relational working. Key to this was how much time NHS staff and care home staff had had to learn how to work together and if the work was seen as legitimate, requiring ongoing investment by commissioners and engagement from practitioners. Residents appreciated the general practitioner (GP) input and, when supported by other care home-specific NHS services, GPs reported that it was sustainable and valued work. Access to dementia expertise, ongoing training and support was essential to ensure that both NHS and care home staff were equipped to provide appropriate care.LimitationsFindings were constrained by the numbers of residents recruited and retained in phase 2 for the 12 months of data collection.ConclusionsNHS services work well with care homes when payments and role specification endorse the importance of this work at an institutional level as well as with individual residents. GP involvement is important but needs additional support from other services to be sustainable. A focus on strategies that promote co-design-based approaches between the NHS and care homes has the potential to improve residents’ access to and experience of health care.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Claire Goodman
- Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
| | - Sue L Davies
- Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
| | - Adam L Gordon
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Tom Dening
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Heather Gage
- School of Economics, University of Surrey, Guildford, UK
| | - Julienne Meyer
- School of Health Sciences, City, University of London, London, UK
| | - Justine Schneider
- School of Sociology and Social Policy, University of Nottingham, Nottingham, UK
| | - Brian Bell
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Jake Jordan
- School of Economics, University of Surrey, Guildford, UK
| | | | - Steve Iliffe
- Research Department of Primary Care and Population Health (PCPH), University College London, London, UK
| | - Clive Bowman
- School of Health Sciences, City, University of London, London, UK
| | - John RF Gladman
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
| | - Christina Victor
- Institute of Environment, Health and Societies, Brunel University London, London, UK
| | - Andrea Mayrhofer
- Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
| | - Melanie Handley
- Centre for Research in Primary and Community Care (CRIPACC), University of Hertfordshire, Hatfield, UK
| | - Maria Zubair
- Faculty of Medicine and Health Sciences, University of Nottingham, Nottingham, UK
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Care Home Assessment and Review Service: coordinated, proactive care home primary care delivery. Br J Gen Pract 2017; 67:136-137. [PMID: 28232361 DOI: 10.3399/bjgp17x689821] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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Harrison JK, McKay IK, Grant P, Hannah J, Quinn TJ. Appropriateness of unscheduled hospital admissions from care homes. Clin Med (Lond) 2016; 16:103-8. [PMID: 27037376 PMCID: PMC4952960 DOI: 10.7861/clinmedicine.16-2-103] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Unscheduled hospital admissions from care homes are common and potentially avoidable but little guidance is available as to what constitutes an appropriate hospital admission. We surveyed healthcare professionals' opinions on a range of common scenarios affecting care-home residents. We developed seven clinical vignettes and an accompanying questionnaire. We used purposive sampling to obtain opinions from relevant primary care and secondary care teams. We asked assessors to comment on whether they would favour hospital admission and to justify their response using pre-selected options and/or free text. Admission to hospital was judged inappropriate in 54.6% of responses. Opinion on admission varied according to the case, with fewer than half of respondents agreeing for three of the seven cases. Recurring themes were uncertainty around services available to care homes and anticipatory care planning. The lack of consensus suggests that concepts surrounding inappropriate care-home admission are not shared by staff who provide care for this patient group.
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Affiliation(s)
- Jennifer K Harrison
- Centre for Cognitive Ageing and Cognitive Epidemiology and the Alzheimer Scotland Dementia Research Centre, University of Edinburgh, Edinburgh, UK
| | | | - Patrick Grant
- Emergency Department, Western Infirmary, Glasgow, UK
| | | | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Gilmartin JFM, Jani Y, Smith F. Exploring the past, present and future of care home medicine management systems: pharmacists' perceptions of multicompartment compliance aids. JOURNAL OF PHARMACEUTICAL HEALTH SERVICES RESEARCH 2015. [DOI: 10.1111/jphs.12105] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
Abstract
Objectives
Medicines maintain and improve care home (CH) residents' health and therefore, it is imperative that CH medicine management systems are regularly evaluated to ensure they continually provide a high standard of care. Multicompartment compliance aid (MCA) medicine management systems are often used to assist United Kingdom CH staff with managing the large volume of medicines used by residents. This study aimed to identify the factors that led to the widespread adoption of MCAs into United Kingdom CHs, limitations associated with their current use and their relevance in the future.
Method
In June and July 2014 semi-structured interviews were conducted with eight pharmacists who were purposively selected for their expertise in CH medicine management systems in the United Kingdom. A qualitative thematic approach was employed in the analysis of data.
Key findings
Findings indicated that MCAs were introduced into CHs to address unsafe medicine administration practices and because of pharmacy commercial interest. Identified limitations included reduced staff alertness during medicine administration, restricted ability to identify medicines, and medicine wastage. Participants predicted continued use of MCAs in the future due to their perceived benefits of improved safety and efficiency, although some pharmacists recommended that they be removed and CH staff trained to administer medicines from original packaging.
Conclusion
These findings can contribute towards information used by health care providers when deciding on the relevance of MCAs in their current medicine management systems. Additionally, they can contribute towards information used by policy makers when revising United Kingdom CH medicine management guidelines.
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Affiliation(s)
- Julia Fiona-Maree Gilmartin
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
- Centre for Medicine Use and Safety, Faculty of Pharmacy and Pharmaceutical Sciences, Monash University, Victoria, Australia
| | - Yogini Jani
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
- Pharmacy Department, University College London Hospitals NHS Foundation Trust, London, UK
| | - Felicity Smith
- Research Department of Practice and Policy, University College London School of Pharmacy, London, UK
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Provision of NHS generalist and specialist services to care homes in England: review of surveys. Prim Health Care Res Dev 2015; 17:122-37. [DOI: 10.1017/s1463423615000250] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
BackgroundThe number of beds in care homes (with and without nurses) in the United Kingdom is three times greater than the number of beds in National Health Service (NHS) hospitals. Care homes are predominantly owned by a range of commercial, not-for-profit or charitable providers and their residents have high levels of disability, frailty and co-morbidity. NHS support for care home residents is very variable, and it is unclear what models of clinical support work and are cost-effective.ObjectivesTo critically evaluate how the NHS works with care homes.MethodsA review of surveys of NHS services provided to care homes that had been completed since 2008. It included published national surveys, local surveys commissioned by Primary Care organisations, studies from charities and academic centres, grey literature identified across the nine government regions, and information from care home, primary care and other research networks. Data extraction captured forms of NHS service provision for care homes in England in terms of frequency, location, focus and purpose.ResultsFive surveys focused primarily on general practitioner services, and 10 on specialist services to care home. Working relationships between the NHS and care homes lack structure and purpose and have generally evolved locally. There are wide variations in provision of both generalist and specialist healthcare services to care homes. Larger care home chains may take a systematic approach to both organising access to NHS generalist and specialist services, and to supplementing gaps with in-house provision. Access to dental care for care home residents appears to be particularly deficient.ConclusionsHistorical differences in innovation and provision of NHS services, the complexities of collaborating across different sectors (private and public, health and social care, general and mental health), and variable levels of organisation of care homes, all lead to persistent and embedded inequity in the distribution of NHS resources to this population. Clinical commissioners seeking to improve the quality of care of care home residents need to consider how best to provide fair access to health care for older people living in a care home, and to establish a specification for service delivery to this vulnerable population.
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Time to change care home resident management: reflections on a GP-led service. Br J Gen Pract 2014; 64:591-2. [PMID: 25348989 DOI: 10.3399/bjgp14x682501] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022] Open
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The optimal study: describing the key components of optimal health care delivery to UK care home residents: a research protocol. J Am Med Dir Assoc 2014; 15:681-6. [PMID: 25086691 DOI: 10.1016/j.jamda.2014.06.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2014] [Revised: 06/12/2014] [Accepted: 06/13/2014] [Indexed: 11/23/2022]
Abstract
Long-term institutional care in the United Kingdom is provided by care homes. Residents have prevalent cognitive impairment and disability, have multiple diagnoses, and are subject to polypharmacy. Prevailing models of health care provision (ad hoc, reactive, and coordinated by general practitioners) result in unacceptable variability of care. A number of innovative responses to improve health care for care homes have been commissioned. The organization of health and social care in the United Kingdom is such that it is unlikely that a single solution to the problem of providing quality health care for care homes will be identified that can be used nationwide. Realist evaluation is a methodology that uses both qualitative and quantitative data to establish an in-depth understanding of what works, for whom, and in what settings. In this article we describe a protocol for using realist evaluation to understand the context, mechanisms, and outcomes that shape effective health care delivery to care home residents in the United Kingdom. By describing this novel approach, we hope to inform international discourse about research methodologies in long-term care settings internationally.
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Goodman C, Gordon AL, Martin F, Davies SL, Iliffe S, Bowman C, Schneider J, Meyer J, Victor C, Gage H, Gladman JRF, Dening T. Effective health care for older people resident in care homes: the optimal study protocol for realist review. Syst Rev 2014; 3:49. [PMID: 24887325 PMCID: PMC4037277 DOI: 10.1186/2046-4053-3-49] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2014] [Accepted: 05/14/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Care homes in the UK rely on general practice for access to specialist medical and nursing care as well as referral to therapists and secondary care. Service delivery to care homes is highly variable in both quantity and quality. This variability is also evident in the commissioning and organisation of care home-specific services that range from the payment of incentives to general practitioners (GPs) to visit care homes, to the creation of care home specialist teams and outreach services run by geriatricians. No primary studies or systematic reviews have robustly evaluated the impact of these different approaches on organisation and resident-level outcomes. Our aim is to identify factors which may explain the perceived or demonstrated effectiveness of programmes to improve health-related outcomes in older people living in care homes. METHODS/DESIGN A realist review approach will be used to develop a theoretical understanding of what works when, why and in what circumstances. Elements of service models of interest include those that focus on assessment and management of residents' health, those that use strategies to encourage closer working between visiting health care providers and care home staff, and those that address system-wide issues about access to assessment and treatment. These will include studies on continence, dignity, and speech and language assessment as well as interventions to promote person centred dementia care, improve strength and mobility, and nutrition. The impact of these interventions and their different mechanisms will be considered in relation to five key outcomes: residents' medication use, use of out of hours' services, hospital admissions (including use of Accident and Emergency) and length of hospital stay, costs and user satisfaction. An iterative three-stage approach will be undertaken that is stakeholder-driven and optimises the knowledge and networks of the research team. DISCUSSION This realist review will explore why and for whom different approaches to providing health care to residents in care homes improves access to health care in the five areas of interest. It will inform commissioning decisions and be the basis for further research. This systematic review protocol is registered on the PROSPERO database reference number: CRD42014009112.
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Affiliation(s)
- Claire Goodman
- College Lane, University of Hertfordshire, Hatfield, Herts AL10 9AB, UK
| | - Adam L Gordon
- Kings Meadow Campus, University of Nottingham, Lenton Lane, Nottingham NG7 2NR, UK
| | | | - Sue L Davies
- College Lane, University of Hertfordshire, Hatfield, Herts AL10 9AB, UK
| | - Steve Iliffe
- University College London, Gower St, London WC1E 6BT, UK
| | - Clive Bowman
- City University, Northampton Square, London EC1V 0HB, UK
| | - Justine Schneider
- Kings Meadow Campus, University of Nottingham, Lenton Lane, Nottingham NG7 2NR, UK
| | - Julienne Meyer
- City University, Northampton Square, London EC1V 0HB, UK
| | - Christina Victor
- Uxbridge Campus, Kingston Lane, Brunel University, Uxbridge, Middlesex UB8 3PH, UK
| | - Heather Gage
- University of Surrey, Guildford, Surrey GU2 7X, UK
| | - John RF Gladman
- Kings Meadow Campus, University of Nottingham, Lenton Lane, Nottingham NG7 2NR, UK
| | - Tom Dening
- Kings Meadow Campus, University of Nottingham, Lenton Lane, Nottingham NG7 2NR, UK
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Abstract
Care home medicine has been an under-researched area, but over the last decade there has been a substantial growth in publications. Most of these have focused on the 'geriatric giants' of falls, incontinence and mental health issues (especially dementia, behavioural disturbance and depression) as well as other key topics such as medication use and issues related to death and dying. Other areas of recent interest are around access to health services for care home residents, how such services may most effectively be developed and how the quality of life for residents can be enhanced. While many of the reported studies are small and not always well designed, evidence in several areas is emerging which begins to guide service developments. A common theme is that multi-disciplinary interventions are the most effective models of delivery. The role of care home staff as members of these teams is key to their effectiveness. Recent consensus guidelines around falls prevention in care homes synthesise the evidence and recommend multi-disciplinary interventions, and clarify the role of vitamin D and of exercise in certain populations in the care home. The benefits of pharmacist led medication reviews are beginning to emerge; although studies reviewed to date have not yet led to the 'holy grail' of hospital admission avoidance they point to benefits in reduction of drug burden. Effectiveness may be enhanced when working with GPs and care home nurses. Welcome evidence is emerging that in the UK the rate of prescription of anti-psychotics has fallen. This is clear evidence that changes in practice around care homes can be effected. The poor access to non-pharmacological therapies for care home residents with behavioural disturbance remains a significant gap in service. End-of-life care planning and delivery is an important part of care in care homes, and there is evidence that integrated pathways can improve care; however, the use of palliative care medications was limited unless specialist care staff were involved. Integrated models of care that focus on resident-centred goals and which value the role of care home staff as members of the team working to deliver these goals are most likely to result in improvements in the quality of care experienced by care home residents.
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Affiliation(s)
- Eileen Burns
- Department Medicine for the Elderly, St James's Hospital, Beckett St, Leeds LS9 7TF, UK
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Gordon AL, Franklin M, Bradshaw L, Logan P, Elliott R, Gladman JRF. Health status of UK care home residents: a cohort study. Age Ageing 2014; 43:97-103. [PMID: 23864424 PMCID: PMC3861334 DOI: 10.1093/ageing/aft077] [Citation(s) in RCA: 233] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background: UK care home residents are often poorly served by existing healthcare arrangements. Published descriptions of residents’ health status have been limited by lack of detail and use of data derived from surveys drawn from social, rather than health, care records. Aim: to describe in detail the health status and healthcare resource use of UK care home residents Design and setting: a 180-day longitudinal cohort study of 227 residents across 11 UK care homes, 5 nursing and 6 residential, selected to be representative for nursing/residential status and dementia registration. Method: Barthel index (BI), Mini-mental state examination (MMSE), Neuropsychiatric index (NPI), Mini-nutritional index (MNA), EuroQoL-5D (EQ-5D), 12-item General Health Questionnaire (GHQ-12), diagnoses and medications were recorded at baseline and BI, NPI, GHQ-12 and EQ-5D at follow-up after 180 days. National Health Service (NHS) resource use data were collected from databases of local healthcare providers. Results: out of a total of 323, 227 residents were recruited. The median BI was 9 (IQR: 2.5–15.5), MMSE 13 (4–22) and number of medications 8 (5.5–10.5). The mean number of diagnoses per resident was 6.2 (SD: 4). Thirty per cent were malnourished, 66% had evidence of behavioural disturbance. Residents had contact with the NHS on average once per month. Conclusion: residents from both residential and nursing settings are dependent, cognitively impaired, have mild frequent behavioural symptoms, multimorbidity, polypharmacy and frequently use NHS resources. Effective care for such a cohort requires broad expertise from multiple disciplines delivered in a co-ordinated and managed way.
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Affiliation(s)
- Adam Lee Gordon
- Division of Rehabilitation and Ageing, University of Nottingham, Medical School, Queens Medical Centre, Room B98, Nottingham NG7 2UH, UK
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Evans G, Evans JG, Lasserson DS. Questionnaire study of the association between patient numbers and regular visiting by general practitioners in care homes. Age Ageing 2012; 41:269-72. [PMID: 22258115 DOI: 10.1093/ageing/afr183] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND regular visiting in care homes enables proactive care. Surveys of managers found variation in medical care yet little is known about factors influencing general practitioners (GPs) visiting patterns. We examined whether practice factors including numbers of registered patients are associated with regular visiting. DESIGN AND SETTING postal questionnaires sent to 73 care homes of European Care Group and separate questionnaires to visiting practices. METHODS information on regularity of visiting was requested from homes and practices. Practices were asked for numbers of doctors and training status. As data were not normally distributed, non-parametric tests were used to compare practices regularly visiting with those visiting only on request in terms of numbers of registered care home patients. RESULTS forty-seven (64%) of homes responded, with care provided for 1,867 patients by 162 practices. Practices visiting regularly had significantly more patients than practices that did not [median (IQR) 32 (28) versus 3 (5), P < 0.001]. Ninety-five (31%) of practices responded showing a similar association of registrations with regular visiting [median (IQR) 20 (37) versus 4 (4), P < 0.001]. There was no association between numbers of doctors or training status on regular visiting. CONCLUSION the number of registered patients is strongly associated with regular care home visiting. Aligning practices with care homes thereby increasing registered patients per practice could encourage proactive care.
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Affiliation(s)
- Gillie Evans
- Green Templeton College, University of Oxford, 4, Gracious Street, Whittlesey, Peterborough PE7 1AP, UK.
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Clarkson P, Hughes J, Abendstern M, Sutcliffe C, Tucker S, Philp I, Challis D. Involving specialist clinicians in policies for integrated care. JOURNAL OF INTEGRATED CARE 2011. [DOI: 10.1108/14769011111191421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Quinn T. Emergency Hospital Admissions from Care-Homes: Who, Why and What Happens? A Cross-Sectional Study. Gerontology 2011; 57:115-20. [DOI: 10.1159/000314962] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2009] [Accepted: 03/03/2010] [Indexed: 11/19/2022] Open
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Shah SM, Carey IM, Harris T, DeWilde S, Hubbard R, Lewis S, Cook DG. Identifying the clinical characteristics of older people living in care homes using a novel approach in a primary care database. Age Ageing 2010; 39:617-23. [PMID: 20639514 DOI: 10.1093/ageing/afq086] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES to enhance identification of older nursing and residential home residents in a national sample and describe their chronic disease prevalence. DESIGN cross-sectional analysis of an established primary care database (The Health Improvement Network). SETTING 326 English and Welsh general practices. SUBJECTS 435,568 patients aged > or = 65. Care home residents were identified by either a Read code for care home residence or multiple care home residence markers (postcode linkage, household size identifier and location of consultation). COMPARISONS: nursing and residential home residents were compared with a community control group with no markers of care home residence using age and sex standardised chronic disease prevalence ratios. MAIN OUTCOME MEASURES chronic disease prevalence using definitions from the national primary care contract. RESULTS 11,547 (2.7%) older people were identified as care home residents, of whom only 4,403 (38.1%) were directly identified by their primary care record. Mean age for nursing and residential homes was 84.9 and 86.1 years compared to 74.7 for controls. Prevalence ratios for dementia were 14.8 (95% CI 13.4-16.4) for nursing and 13.5 (12.4-14.8) for residential homes compared to controls. Stroke and severe mental illness were commoner in nursing and residential homes but hypertension, respiratory and cancer diagnoses were slightly less common. Recorded disease prevalences in nursing and residential homes were similar. CONCLUSIONS recording of care home residence is limited in primary care and this is a barrier to routine monitoring of this group. Higher dementia and stroke prevalence in care home residents confirms high clinical need, but the small differences in disease prevalence between nursing and residential homes have implications for delivering medical and nursing care to residential homes. Lower prevalence of some chronic diseases suggests incomplete recording or case finding. Routine flagging of care home residents in health care systems is a potential tool for improving monitoring and outcomes.
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Affiliation(s)
- Sunil M Shah
- Division of Community Health Sciences, St George's University of London, London, UK
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Du Moulin MFMT, van Haastregt JCM, Hamers JPH. Monitoring quality of care in nursing homes and making information available for the general public: state of the art. PATIENT EDUCATION AND COUNSELING 2010; 78:288-296. [PMID: 20171037 DOI: 10.1016/j.pec.2010.01.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Revised: 01/15/2010] [Accepted: 01/17/2010] [Indexed: 05/28/2023]
Abstract
OBJECTIVE To improve quality of care, nursing homes need to assess and monitor their performance. This study aims to gain insight in the availability and contents of publicly accessible quality systems in northwestern Europe and the USA. METHODS This study employed a systematic search consisting of searching bibliographic sources from 2005 to September 2009, personal communication with experts, a conventional internet search, and hand-searching of references. RESULTS Ten out of the 14 included countries use a quality systems. There is a large variety in type and number of indicators assessed. In general more attention is paid to the assessment of structure and process indicators, compared to outcome indicators. The countries differ in the way the results are made available to the general public. CONCLUSION It can be concluded that monitoring and publicizing data on quality of care in nursing homes is becoming increasingly widespread. However, the systems still need further development and refinement. PRACTICE IMPLICATIONS The systems need to be further developed regarding validity and reliability. Furthermore, the uniformity of the systems should be increased, more attention must be paid to the assessment of patient satisfaction, and additional insight must be gained in the user-friendliness of the systems.
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Affiliation(s)
- Monique F M T Du Moulin
- Maastricht University, Faculty of Health, Medicine and Life Sciences, School for Public Health and Primary Care (CAPHRI), Department of Health Care and Nursing Science, 6200 MD Maastricht, The Netherlands.
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South A, Tandy C, Watt R, Corrado OJ. Comment on 'Care home medicine in the UK--in from the cold'. Age Ageing 2009; 38:354. [PMID: 19269951 DOI: 10.1093/ageing/afp031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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