Improving access to high-quality primary care for socioeconomically disadvantaged older people in rural areas: a mixed method study protocol

A realist review protocol of the role and contribution of the advanced nurse practitioner (ANP) in gastroenterology nursing

Background: The role and contribution of advanced nurse practitioners (ANP) has been well researched and found to be of great value for improving quality patient care and enhancing patient outcomes through education and health promotion. However, the role and the contribution of the ANP to gastroenterology nursing have not been evaluated either nationally or internationally. A review to determine the role and contribution of the ANP in gastroenterology nursing will inform on the contribution of the role and whether the role makes a difference to patient outcomes and cost effectiveness of patient care. Objective: This review aims to investigate the nursing role and contribution of the advanced nurse practitioner in gastroenterology. Furthermore, improved understanding of the underlying causal mechanisms explaining how the ANP role in gastroenterology nursing works, will provide a deeper understanding of how, why, for whom and in what contexts the role and contribution of the ANP to gastroenterology nursing are most successful. Methods: A realist review will consolidate evidence on how, when why and where the ANP role in gastroenterology works or fails through identifying programme theories underlying to the role’s introduction. The following steps will be operationalised; locating existing theories, searching the literature, documenting literature selection, engaging in data extraction and synthesis and refining programme theory. As an iterative approach, review cycles will uncover explanatory and contingent theories through context-mechanism-outcome configurations (CMOCc). Due to the variation in context and mechanisms, different outcomes will be likely across different clinical settings although similar patterns may be identified. Conclusions: Due to the theory-oriented approach of realist reviews, the pragmatic consequences of the review, will lend itself to deeper understanding of how the role and contribution of the ANP in gastroenterology nursing works in practice.

A Rapid Realist Review of Quality Care Process Metrics Implementation in Nursing and Midwifery Practice

Quality measurement initiatives promote quality improvement in healthcare but can be challenging to implement effectively. This paper presents a Rapid Realist Review (RRR) of published literature on Quality Care-Process Metrics (QCP-M) implementation in nursing and midwifery practice. An RRR informed by RAMESES II standards was conducted as an efficient means to synthesize evidence using an expert panel. The review involved research question development, quality appraisal, data extraction, and evidence synthesis. Six program theories summarised below identify the key characteristics that promote positive outcomes in QCP-M implementation. Program Theory 1: Focuses on the evidence base and accessibility of the QCP-M and their ease of use by nurses and midwives working in busy and complex care environments. Program Theory 2: Examines the influence of external factors on QCP-M implementation. Program Theory 3: Relates to existing cultures and systems within clinical sites. Program Theory 4: Relates to nurses’ and midwives’ knowledge and beliefs. Program Theory 5: Builds on the staff theme of Programme Theory four, extending the culture of organizational learning, and highlights the meaningful engagement of nurses and midwives in the implementation process as a key characteristic of success. Program Theory 6: Relates to patient needs. The results provide nursing and midwifery policymakers and professionals with evidence-based program theory that can be translated into action-orientated strategies to help guide successful QCP-M implementation.

Availability and Accessibility of Primary Care for the Remote, Rural, and Poor Population of Indonesia

Background: Adopting Universal Health Coverage for implementation of a national health insurance system [Jaminan Kesehatan Nasional (JKN)/Badan Penyelenggara Jaminan Sosial or the Indonesian National Social Health Insurance Scheme (BPJS)] targets the 255 million population of Indonesia. The availability, accessibility, and acceptance of healthcare services are the most important challenges during implementation. Referral behavior and the utilization of primary care structures for underserved (rural/remote regions) populations are key guiding elements. In this study, we provided the first assessment of BPJS implementation and its resulting implications for healthcare delivery based on the entire insurance dataset for the initial period of implementation, specifically focusing on poor and remote populations. Methods: Demographic, economic, and healthcare infrastructure information was obtained from public resources. Data about the JKN membership structure, performance information, and reimbursement were provided by the BPJS national head office. For analysis, an ANOVA was used to compare reimbursement indexes for primary healthcare (PHC) and advanced healthcare (AHC). The usage of primary care resources was analyzed by comparing clustered provinces and utilization indices differentiating poor [Penerima Bantuan Iur (PBI) membership] and non-poor populations (non-PBI). Factorial and canonical discrimination analyses were applied to identify the determinants of PHC structures. Results: Remote regions cover 27.8% of districts/municipalities. The distribution of the poor population and PBI members were highly correlated (r2 > 0.8; p < 0.001). Three clusters of provinces [remote high-poor (N = 13), remote low-poor (N = 15), non-remote (N = 5)] were identified. A discrimination analysis enabled the >82% correct cluster classification of infrastructure and human resources of health (HRH)-related factors. Standardized HRH (nurses and general practitioners [GP]) availability showed significant differences between clusters (p < 0.01), whereas the availability of hospital beds was weakly correlated. The usage of PHC was ~2-fold of AHC, while non-PBI members utilized AHC 4- to 5-fold more frequently than PBI members. Referral indices (r2 = 0.94; p < 0.001) for PBI, non-PBI, and AHC utilization rates (r2 = 0.53; p < 0.001) were highly correlated. Conclusion: Human resources of health availability were intensively related to the extent of the remote population but not the numbers of the poor population. The access points of PHC were mainly used by the poor population and in remote regions, whereas other population groups (non-PBI and non-Remote) preferred direct access to AHC. Guiding referral and the utilization of primary care will be key success factors for the effective and efficient usage of available healthcare infrastructures and the achievement of universal health coverage in Indonesia. The short-term development of JKN was recommended, with a focus on guiding referral behavior, especially in remote regions and for non-PBI members.

Improving access to primary care services for those on low income: voluntary advocacy

Nurses in primary care are often the first point of access for those seeking health care, and it is well known that accessing health services can be difficult for some, especially those on a low income. A charity initiative has been developed in a low-income area in England to help such individuals, wherein volunteers help local residents to access local services and support. This study explores the experiences of service users in order to understand their perceptions and feelings about the service, using an instrumental case study method with semi-structured interviews. Qualitative data were collected from six service users and transcribed by the researcher for subsequent thematic analysis. The participants' experiences were characterised by reduced social isolation, reduced emotional distress, improved mobility and transport options, improved confidence and control over life, and effective management of memory issues. Various aspects of advocacy and empowerment were also observed. Further, the coping strategies used by the participants while facing the challenges of social isolation and ageing were highlighted. The findings provide important insight into the support needs of populations on low income, the ways in which they access healthcare and how the volunteer service can best support them.

Developing interventions to improve health: a systematic mapping review of international practice between 2015 and 2016

BACKGROUND

Researchers publish the processes they use to develop interventions to improve health. Reflecting on this endeavour may help future developers to improve their practice.

METHODS

Our aim was to collate, describe, and analyse the actions developers take when developing complex interventions to improve health. We carried out a systematic mapping review of empirical research studies that report the development of complex interventions to improve health. A search was undertaken of five databases over 2015-2016 using the term 'intervention dev*'. Eighty-seven journal articles reporting the process of intervention development were identified. A purposive subset of 30 articles, using a range of published approaches to developing interventions, was selected for in-depth analysis using principles of realist synthesis to identify the actions of intervention development and rationales underpinning those actions.

RESULTS

The 87 articles were from the USA (39/87), the UK (32/87), continental Europe (6/87), and the rest of the world (10/87). These mainly took a pragmatic self-selected approach (n = 43); a theory- and evidence-based approach, e.g. Intervention Mapping, Behaviour Change Wheel (n = 22); or a partnership approach, e.g. community-based participatory research, co-design (n = 10). Ten actions of intervention development were identified from the subset of 30 articles, including identifying a need for an intervention, selecting the intervention development approach to follow, considering the needs of the target population, reviewing published evidence, involving stakeholders, drawing or generating theory, and designing and refining the intervention. Rationales for these actions were that they would produce more engaging, acceptable, feasible, and effective interventions.

CONCLUSIONS

Developers take a variety of approaches to the international endeavour of complex intervention development. We have identified and described a set of actions taken within this endeavour regardless of whether developers follow a published approach or not. Future developers can use these actions and the rationales that underpin them to help them make decisions about the process of intervention development.

TRIAL REGISTRATION

PROSPERO, CRD42017080545.

Improving primary care Access in Context and Theory (I-ACT trial): a theory-informed randomised cluster feasibility trial using a realist perspective

Background

Primary care access can be challenging for older, rural, socio-economically disadvantaged populations. Here we report the I-ACT cluster feasibility trial which aims to assess the feasibility of trial design and context-sensitive intervention to improve primary care access for this group and so expand existing theory.

Methods

Four general practices were recruited; three randomised to intervention and one to usual care. Intervention practices received £1500, a support manual and four meetings to develop local, innovative solutions to improve the booking system and transport.

Patients aged over 64 years old and without household car access were recruited to complete questionnaires when booking an appointment or attending the surgery. Outcome measures at 6 months included: self-reported ease of booking an appointment and transport; health care use; patient activation; capability; and quality of life. A process evaluation involved observations and interviews with staff and participants.

Results

Thirty-four patients were recruited (26 female, eight male, mean age 81.6 years for the intervention group and 79.4 for usual care) of 1143 invited (3% response rate). Most were ineligible because of car access. Twenty-nine participants belonged to intervention practices and five to usual care. Practice-level data was available for all participants, but participant self-reported data was unavailable for three. Fifty-six appointment questionnaires were received based on 150 appointments (37.3%).

Practices successfully designed and implemented the following context-sensitive interventions: Practice A: a stacked telephone system and promoting community transport; Practice B: signposting to community transport, appointment flexibility, mobility scooter charging point and promoting the role of receptionists; and Practice C: local taxi firm partnership and training receptionists. Practices found the process acceptable because it gave freedom, time and resource to be innovative or provided an opportunity to implement existing ideas. Data collection methods were acceptable to participants, but some found it difficult remembering to complete booking and appointment questionnaires. Expanded theory highlighted important mechanisms, such as reassurance, confidence, trust and flexibility.

Conclusions

Recruiting older participants without access to a car proved challenging. Retention of participants and practices was good but only about a third of appointment questionnaires were returned. This study design may facilitate a shift from one-size-fits-all interventions to more context-sensitive interventions.

Trial registration

ISRCTN18321951, Registered on 6 March 2017.

Electronic supplementary material

The online version of this article (10.1186/s13063-019-3299-2) contains supplementary material, which is available to authorized users.

Access to primary care for socio-economically disadvantaged older people in rural areas: exploring realist theory using structural equation modelling in a linked dataset

Background

Realist approaches seek to answer questions such as ‘how?’, ‘why?’, ‘for whom?’, ‘in what circumstances?’ and ‘to what extent?’ interventions ‘work’ using context-mechanism-outcome (CMO) configurations. Quantitative methods are not well-established in realist approaches, but structural equation modelling (SEM) may be useful to explore CMO configurations. Our aim was to assess the feasibility and appropriateness of SEM to explore CMO configurations and, if appropriate, make recommendations based on our access to primary care research. Our specific objectives were to map variables from two large population datasets to CMO configurations from our realist review looking at access to primary care, generate latent variables where needed, and use SEM to quantitatively test the CMO configurations.

Methods

A linked dataset was created by merging individual patient data from the English Longitudinal Study of Ageing and practice data from the GP Patient Survey. Patients registered in rural practices and who were in the highest deprivation tertile were included. Three latent variables were defined using confirmatory factor analysis. SEM was used to explore the nine full CMOs. All models were estimated using robust maximum likelihoods and accounted for clustering at practice level. Ordinal variables were treated as continuous to ensure convergence.

Results

We successfully explored our CMO configurations, but analysis was limited because of data availability. Two hundred seventy-six participants were included. We found a statistically significant direct (context to outcome) or indirect effect (context to outcome via mechanism) for two of nine CMOs. The strongest association was between ‘ease of getting through to the surgery’ and ‘being able to get an appointment’ with an indirect mediated effect through convenience (proportion of the indirect effect of the total was 21%). Healthcare experience was not directly associated with getting an appointment, but there was a statistically significant indirect effect through convenience (53% mediated effect). Model fit indices showed adequate fit.

Conclusions

SEM allowed quantification of CMO configurations and could complement other qualitative and quantitative techniques in realist evaluations to support inferences about strengths of relationships. Future research exploring CMO configurations with SEM should aim to collect, preferably continuous, primary data.

Electronic supplementary material

The online version of this article (10.1186/s12874-018-0514-x) contains supplementary material, which is available to authorized users.

Access to primary care for socio-economically disadvantaged older people in rural areas: A qualitative study

Objective

We aim to explore the barriers to accessing primary care for socio-economically disadvantaged older people in rural areas.

Methods

Using a community recruitment strategy, fifteen people over 65 years, living in a rural area, and receiving financial support were recruited for semi-structured interviews. Four focus groups were held with rural health professionals. Interviews and focus groups were audio-recorded and transcribed. Thematic analysis was used to identify barriers to primary care access.

Findings

Older people’s experience can be understood within the context of a patient perceived set of unwritten rules or social contract–an individual is careful not to bother the doctor in return for additional goodwill when they become unwell. However, most found it difficult to access primary care due to engaged telephone lines, availability of appointments, interactions with receptionists; breaching their perceived social contract. This left some feeling unwelcome, worthless or marginalised, especially those with high expectations of the social contract or limited resources, skills and/or desire to adapt to service changes.

Health professionals’ described how rising demands and expectations coupled with service constraints had necessitated service development, such as fewer home visits, more telephone consultations, triaging calls and modifying the appointment system.

Conclusion

Multiple barriers to accessing primary care exist for this group. As primary care is re-organised to reduce costs, commissioners and practitioners must not lose sight of the perceived social contract and models of care that form the basis of how many older people interact with the service.

Improving best practise for patients receiving hospital discharge letters: a realist review protocol

INTRODUCTION

Discharge documents are important for transferring information from hospitals to the referring clinician; in the UK and many countries, this is often the patient's general practitioner or family physician. However, patients may or may not receive their discharge letters, and whether patients should routinely receive discharge letters remains unclear.

METHODS AND ANALYSIS

The review will consolidate evidence on patients receiving discharge letters through the theory-driven approach of a realist review.The review will be conducted systematically and seek to explain how, why, for whom and in what contexts does this practice 'work'. The review will specifically explore whether there are benefits of this practice and if so what are the important contexts for triggering the mechanisms associated with these outcome benefits. Negative effects will also be considered.Several steps will occur: devising initial rough programme theory, searching the evidence, selecting relevant documents, extracting data, synthesising and finally programme theory refinement. As the process is viewed as iterative, this cycle of steps may be repeated as many times as is necessary to reach theoretical saturation and may not be linear.The initial programme theory will be tested and refined throughout the review process and by stakeholder involvement of National Health Service (NHS) policy makers, practitioners and service users.

ETHICS AND DISSEMINATION

Formal ethical review is not required. The resulting programme theory is anticipated to explain how the intervention of patients receiving written discharge communication may work in practice, for whom and in what contexts; this will inform best practice of patients receiving discharge communication. The review findings will be disseminated in a peer-reviewed journal and presentations and discussions with relevant organisations and stakeholders. While the review will be from the perspective of the UK NHS, its findings should be relevant to other healthcare systems.

PROSPERO REGISTRATION NUMBER

CRD42017069863.

Assessing Impacts on Unplanned Hospitalisations of Care Quality and Access Using a Structural Equation Method: With a Case Study of Diabetes

Background: Enhanced quality of care and improved access are central to effective primary care management of long term conditions. However, research evidence is inconclusive in establishing a link between quality of primary care, or access, and adverse outcomes, such as unplanned hospitalisation. Methods: This paper proposes a structural equation model for quality and access as latent variables affecting adverse outcomes, such as unplanned hospitalisations. In a case study application, quality of care (QOC) is defined in relation to diabetes, and the aim is to assess impacts of care quality and access on unplanned hospital admissions for diabetes, while allowing also for socio-economic deprivation, diabetes morbidity, and supply effects. The study involves 90 general practitioner (GP) practices in two London Clinical Commissioning Groups, using clinical quality of care indicators, and patient survey data on perceived access. Results: As a single predictor, quality of care has a significant negative impact on emergency admissions, and this significant effect remains when socio-economic deprivation and morbidity are allowed. In a full structural equation model including access, the probability that QOC negatively impacts on unplanned admissions exceeds 0.9. Furthermore, poor access is linked to deprivation, diminished QOC, and larger list sizes. Conclusions: Using a Bayesian inference methodology, the evidence from the analysis is weighted towards negative impacts of higher primary care quality and improved access on unplanned admissions. The methodology of the paper is potentially applicable to other long term conditions, and relevant when care quality and access cannot be measured directly and are better regarded as latent variables.

Access to primary care for socioeconomically disadvantaged older people in rural areas: a realist review

OBJECTIVE

The aim of this review is to identify and understand the contexts that effect access to high-quality primary care for socioeconomically disadvantaged older people in rural areas.

DESIGN

A realist review.

DATA SOURCES

MEDLINE and EMBASE electronic databases and grey literature (from inception to December 2014).

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

Broad inclusion criteria were used to allow articles which were not specific, but might be relevant to the population of interest to be considered. Studies meeting the inclusion criteria were assessed for rigour and relevance and coded for concepts relating to context, mechanism or outcome.

ANALYSIS

An overarching patient pathway was generated and used as the basis to explore contexts, causal mechanisms and outcomes.

RESULTS

162 articles were included. Most were from the USA or the UK, cross-sectional in design and presented subgroup data by age, rurality or deprivation. From these studies, a patient pathway was generated which included 7 steps (problem identified, decision to seek help, actively seek help, obtain appointment, get to appointment, primary care interaction and outcome). Important contexts were stoicism, education status, expectations of ageing, financial resources, understanding the healthcare system, access to suitable transport, capacity within practice, the booking system and experience of healthcare. Prominent causal mechanisms were health literacy, perceived convenience, patient empowerment and responsiveness of the practice.

CONCLUSIONS

Socioeconomically disadvantaged older people in rural areas face personal, community and healthcare barriers that limit their access to primary care. Initiatives should be targeted at local contextual factors to help individuals recognise problems, feel welcome, navigate the healthcare system, book appointments easily, access appropriate transport and have sufficient time with professional staff to improve their experience of healthcare; all of which will require dedicated primary care resources.