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Park S, Owen-Boukra E, Burford B, Cohen T, Duddy C, Dunn H, Fadia V, Goodman C, Henry C, Lamb EI, Ogden M, Rapley T, Rees E, Vance G, Wong G. General practitioner workforce sustainability to maximise effective and equitable patient care: a realist review protocol. BMJ Open 2024; 14:e075189. [PMID: 38772888 PMCID: PMC11110576 DOI: 10.1136/bmjopen-2023-075189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Accepted: 04/29/2024] [Indexed: 05/23/2024] Open
Abstract
INTRODUCTION There are not enough general practitioners (GPs) in the UK National Health Service. This problem is worse in areas of the country where poverty and underinvestment in health and social care mean patients experience poorer health compared with wealthier regions. Encouraging more doctors to choose and continue in a GP career is a government priority. This review will examine which aspects of the healthcare system affect GP workforce sustainability, how, why and for whom. METHODS AND ANALYSIS A realist review is a theory-driven interpretive approach to evidence synthesis, that brings together qualitative, quantitative, mixed-methods research and grey literature. We will use a realist approach to synthesise data from the available published literature to refine an evidence-based programme theory that will identify the important contextual factors and underlying mechanisms that underpin observed outcomes relating to GP workforce sustainability. Our review will follow Pawson's five iterative stages: (1) finding existing theories, (2) searching for evidence, (3) article selection, (4) data extraction and (5) synthesising evidence and drawing conclusions. We will work closely with key stakeholders and embed patient and public involvement throughout the review process to refine the focus of the review and enhance the impact and relevance of our research. ETHICS AND DISSEMINATION This review does not require formal ethical approval as it draws on secondary data from published articles and grey literature. Findings will be disseminated through multiple channels, including publication in peer-reviewed journals, at national and international conferences, and other digital scholarly communication tools such as video summaries, X and blog posts. PROSPERO REGISTRATION NUMBER CRD42023395583.
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Affiliation(s)
- Sophie Park
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Emily Owen-Boukra
- Department of Primary Care and Population Health, University College London, London, UK
| | - Bryan Burford
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Tanya Cohen
- Department of Primary Care and Population Health, University College London, London, UK
| | - Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Harry Dunn
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Vacha Fadia
- Department of Primary Care and Population Health, University College London, London, UK
| | - Claire Goodman
- Centre for Research in Public Health and Community Care, University of Hertfordshire, Hatfield, UK
| | - Cecily Henry
- Department of Primary Care and Population Health, University College London, London, UK
| | - Elizabeth I Lamb
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Margaret Ogden
- Department of Primary Care and Population Health, University College London, London, UK
| | - Tim Rapley
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Eliot Rees
- Department of Primary Care and Population Health, University College London, London, UK
- School of Medicine, Keele University, Keele, UK
| | - Gillian Vance
- School of Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Stott H, Goodenough T, Jagosh J, Gibson A, Harris N, Liddiard C, Proctor A, Schofield B, Walsh N, Booker M, Voss S. Understanding paramedic work in general practice in the UK: a rapid realist synthesis. BMC PRIMARY CARE 2024; 25:32. [PMID: 38262987 PMCID: PMC10804758 DOI: 10.1186/s12875-024-02271-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 01/08/2024] [Indexed: 01/25/2024]
Abstract
BACKGROUND General practice in the UK is under substantial pressure and practices are increasingly including paramedics as part of their workforce. Little is known about how different models of paramedic working may affect successful implementation of the role, as viewed from patient, clinician and system perspectives. This realist synthesis developed theories about 'models of paramedic working in general practice' in different UK contexts to understand their impact. METHODS The rapid realist synthesis comprised data from: (1) empirical and grey literature searches; (2) semi-structured realist interviews with system leaders involved with the implementation of the role; and (3) a stakeholder event with healthcare professionals and the public, to develop initial programme theories that can be tested in future work. Sources were analysed using a realist approach that explored the data for novel or causal insights to generate initial programme theories. RESULTS Empirical sources (n = 32), grey sources (n = 95), transcripts from system leader interviews (n = 7) and audio summaries from the stakeholder event (n = 22 participants) were synthesised into a single narrative document. The findings confirmed the presence of a wide variety of models of paramedic working in UK general practice. The perceived success of models was influenced by the extent to which the paramedic service was mature and embedded in practice, and according to four theory areas: (1) Primary care staff understanding and acceptance of the paramedic role; (2) Paramedic induction process, including access to training, supervision and development opportunities; (3) Patient understanding and acceptance of the role; (4) Variations in paramedic employment models. CONCLUSIONS Variability in how the paramedic role is operating and embedding into general practice across the UK affects the success of the role. These findings provide a theoretical foundation for future research to investigate various 'models of paramedic working' in different contexts.
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Affiliation(s)
- Hannah Stott
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Trudy Goodenough
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Justin Jagosh
- Centre for Advancement in Realist Evaluation and Synthesis (CARES), Vancouver, Canada
| | - Andy Gibson
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Nicky Harris
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Cathy Liddiard
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Alyesha Proctor
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Behnaz Schofield
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Nicola Walsh
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK
| | - Matthew Booker
- Bristol Medical School, University of Bristol, Centre for Academic Primary Care, Bristol, BS8 2PS, UK
| | - Sarah Voss
- University of the West of England, Centre for Health and Clinical Research, Glenside Campus, Blackberry Hill, Bristol, BS16 1DD, UK.
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Kuschick D, Dierks MT, Grittner U, Heintze C, Kümpel L, Riens B, Rost L, Schmidt K, Schulze D, Toutaoui K, Wolf F, Döpfmer S. Patient perspective on task shifting from general practitioners to medical practice assistants - a quantitative survey in Germany. BMC PRIMARY CARE 2023; 24:248. [PMID: 38007435 PMCID: PMC10675968 DOI: 10.1186/s12875-023-02211-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 11/17/2023] [Indexed: 11/27/2023]
Abstract
INTRODUCTION Various developments result in increasing workloads in general practices. New models of care and a restructuring of the division of tasks could provide relief. One approach is to extend the delegation of medical tasks from general practitioners (GPs) to medical practice assistants (MPAs). So far, there has been a lack of information about specific situations in which patients are willing to be treated exclusively by MPAs. METHODS In three German federal states, patients who visited a general practice were surveyed exploratively and cross-sectionally with a self-designed, paper-based questionnaire. The data were analysed descriptively and multivariate. A mixed binary logistic regression model was calculated to account for cluster effects at practice level (random intercept model). The dependent variable was patients' acceptance of task delegation. RESULTS A total of 1861 questionnaires from 61 general practices were included in the analysis. Regarding the current problem/request, a total of 30% of respondents could imagine being treated only by MPAs. Regarding theoretical reasons for consultation, more than half of the patients agreed to be treated by MPAs. According to the regression model, MPAs were preferred when patients were younger (10-year OR = 0.84, 95%-CI [0.75, 0.93]) or had a less complicated issue (OR = 0.44, 95%-CI [0.26, 0.8]). For four current problems/requests ("acute complaints" OR = 0.27, 95%-CI [0.17, 0.45], "routine health check" OR = 0.48, 95%-CI [0.3, 0.79], "new problem" OR = 0.13, 95%-CI [0.06, 0.28], "known problem" OR = 0.16, 95%-CI [0.1, 0.27]) patients prefer to be treated by GPs instead of MPAs. DISCUSSION For the first time, statements could be made on patients' acceptance of task delegation in relation to current and theoretical reasons for treatment in general practices in Germany. The discrepancy in response behaviour on a theoretical and individual level could be explained by different contexts of questions and differences at practice level. Overall, patients seem to be open to increased delegation of medical tasks, depending on the reason for treatment. Selection and response biases should be considered in the interpretation. CONCLUSION The results are not completely opposed to an extension of task delegation. Further interventional studies could provide information on the possible effects of expansion of delegable tasks.
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Affiliation(s)
- Doreen Kuschick
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice and Family Medicine, Charitéplatz 1, Berlin, 10117, Germany.
| | - Marius Tibor Dierks
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice and Family Medicine, Charitéplatz 1, Berlin, 10117, Germany
| | - Ulrike Grittner
- Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Institute of General Practice and Family Medicine, Bachstraße 18, Jena, 07743, Germany
| | - Christoph Heintze
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice and Family Medicine, Charitéplatz 1, Berlin, 10117, Germany
| | - Lisa Kümpel
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice and Family Medicine, Charitéplatz 1, Berlin, 10117, Germany
| | - Burgi Riens
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice and Family Medicine, Charitéplatz 1, Berlin, 10117, Germany
| | - Liliana Rost
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Charitéplatz 1, Berlin, 10117, Germany
| | - Konrad Schmidt
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice and Family Medicine, Charitéplatz 1, Berlin, 10117, Germany
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Charitéplatz 1, Berlin, 10117, Germany
| | - Daniel Schulze
- Universitätsklinikum Jena, Friedrich-Schiller-Universität Jena, Institute of General Practice and Family Medicine, Bachstraße 18, Jena, 07743, Germany
| | - Kahina Toutaoui
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice and Family Medicine, Charitéplatz 1, Berlin, 10117, Germany
| | - Florian Wolf
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of Biometry and Clinical Epidemiology, Charitéplatz 1, Berlin, 10117, Germany
| | - Susanne Döpfmer
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Institute of General Practice and Family Medicine, Charitéplatz 1, Berlin, 10117, Germany
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Sun Y, Iwagami M, Komiyama J, Sugiyama T, Inokuchi R, Sakata N, Ito T, Yoshie S, Matsui H, Kume K, Sanuki M, Kato G, Mori Y, Ueshima H, Tamiya N. The Effect of Home Care Support Clinics on Hospital Readmission in Heart Failure Patients in Japan. J Gen Intern Med 2023; 38:2156-2163. [PMID: 36650335 PMCID: PMC10361922 DOI: 10.1007/s11606-023-08030-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Accepted: 12/30/2022] [Indexed: 01/19/2023]
Abstract
BACKGROUND Heart failure is common and is associated with high rates of hospitalization. Home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in Japan in 2006 and 2012, respectively. OBJECTIVE This study aimed to examine the effect of post-discharge care by conventional or enhanced HCSCs on readmission, compared with general clinics. DESIGN Retrospective cohort study using the Japanese nationwide health insurance claims database. PARTICIPANTS Participants were ≥65 years of age, admitted for heart failure and discharged between July 2014 and August 2015 and received a home visit within a month following the discharge (n=12,393). MAIN MEASURES The exposure was the type of medical facility that provides post-discharge home healthcare: general clinics, conventional HCSCs, and enhanced HCSCs. The primary outcome was all-cause readmission for 6 months after the first visit; the incidence of emergency house calls was a secondary outcome. We used a competing risk regression using the Fine and Gray method, in which death was regarded as a competing event. KEY RESULTS At 6 months, readmissions were lower in conventional (38%) or enhanced HCSCs (38%) than general clinics (43%). The adjusted subdistribution hazard ratio (sHR) of readmission was 0.87 (95% CI: 0.78-0.96) for conventional and 0.86 (0.78-0.96) for enhanced HCSCs. Emergency house calls increased with conventional (sHR: 1.77, 95% CI:1.57-2.00) and enhanced HCSCs (sHR: 1.93, 95% CI: 1.71-2.17). CONCLUSIONS Older Japanese patients with heart failure receiving post-discharge home healthcare by conventional or enhanced HCSCs had lower readmission rates, possibly due to compensation with more emergency house calls. Conventional and enhanced HCSCs may be effective in reducing the risk of rehospitalization. Further studies are necessary to confirm the medical functions performed by HCSCs.
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Affiliation(s)
- Yu Sun
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
| | - Masao Iwagami
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan.
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan.
| | - Jun Komiyama
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Takehiro Sugiyama
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ryota Inokuchi
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Nobuo Sakata
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
- Heisei Medical Welfare Group Research Institute, Tokyo, Japan
| | - Tomoko Ito
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
| | - Satoru Yoshie
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Institute of Gerontology, The University of Tokyo, Tokyo, Japan
- Institute for Future Initiatives, The University of Tokyo, Tokyo, Japan
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Keitaro Kume
- Department of Clinical Medicine, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masaru Sanuki
- Department of Clinical Medicine, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Genta Kato
- Solutions Center for Health Insurance Claims, Kyoto University Hospital, Kyoto, Japan
| | - Yukiko Mori
- Division of Medical Information Technology and Administration Planning, Kyoto University Hospital, Kyoto, Japan
| | - Hiroaki Ueshima
- Center for Innovative Research and Education in Data Science, Institute for Liberal Arts and Sciences, Kyoto University, Kyoto, Japan
| | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
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Sun Y, Iwagami M, Komiyama J, Sugiyama T, Inokuchi R, Sakata N, Ito T, Yoshie S, Matsui H, Kume K, Sanuki M, Kato G, Mori Y, Ueshima H, Tamiya N. Association between types of home healthcare and emergency house calls, hospitalization, and end-of-life care in Japan. J Am Geriatr Soc 2023; 71:1795-1805. [PMID: 36789967 DOI: 10.1111/jgs.18268] [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] [Received: 09/04/2022] [Revised: 01/03/2023] [Accepted: 01/08/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND To meet the increasing demand for home healthcare in Japan, as part of the national healthcare system, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012 respectively. This study aimed to evaluate whether HCSCs has succeeded in providing 24-h home care services through the end of life. METHODS A retrospective cohort study was conducted using the national database in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and September 2015, and used general clinics, conventional HCSCs, or enhanced HCSCs. Each patient was followed up for 6 months after the first visit. The outcome measures were (i) emergency house call(s), (ii) hospitalization(s), and (iii) end-of-life care defined as in-home death. Multivariable logistic regression analyses were performed for statistical analysis. RESULTS The analysis included 160,674 patients, including 13,477, 64,616, and 82,581 patients receiving regular home visits by general clinics, conventional HCSCs, and enhanced HCSCs respectively. Compared to general clinics, the use of conventional and enhanced HCSCs was associated with an increased likelihood of emergency house calls (adjusted odds ratio [aOR] and 95% confidence intervals [CIs] of 1.62 [1.56-1.69] and 1.86 [1.79-1.93], respectively) and a decreased likelihood of hospitalizations (aOR [95% CIs] of 0.86 [0.82-0.90] and 0.88 [0.84-0.92] respectively). Among 39,082 patients who died during the follow-up period, conventional and enhanced HCSCs had more in-home deaths (aOR [95% CIs] of 1.46 [1.33-1.59] and 1.60 [1.46-1.74], respectively) compared to general clinics. CONCLUSIONS HCSCs (especially enhanced HCSCs) provided more emergency house calls, reduced hospitalization, and enabled expected deaths at home, suggesting that further promotion of HCSCs (especially enhanced HSCSs) would be advantageous.
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Affiliation(s)
- Yu Sun
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masao Iwagami
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Jun Komiyama
- Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Takehiro Sugiyama
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
- Diabetes and Metabolism Information Center, Research Institute, National Center for Global Health and Medicine, Tokyo, Japan
- Institute for Global Health Policy Research, Bureau of International Health Cooperation, National Center for Global Health and Medicine, Tokyo, Japan
| | - Ryota Inokuchi
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Nobuo Sakata
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
- Heisei Medical Welfare Group Research Institute, Tokyo, Japan
| | - Tomoko Ito
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
| | - Satoru Yoshie
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Institute of Gerontology, The University of Tokyo, Tokyo, Japan
- Institute for Future Initiatives, The University of Tokyo, Tokyo, Japan
- Department of Health Policy and Management, School of Medicine, Keio University, Tokyo, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Keitaro Kume
- Department of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | - Masaru Sanuki
- Department of Clinical Medicine, University of Tsukuba, Ibaraki, Japan
| | - Genta Kato
- Solutions Center for Health Insurance Claims, Kyoto University Hospital, Kyoto, Japan
| | - Yukiko Mori
- Division of Medical Information Technology and Administration Planning, Kyoto University Hospital, Kyoto, Japan
| | - Hiroaki Ueshima
- Center for Innovative Research and Education in Data Science, Institute for Liberal Arts and Sciences, Kyoto University, Kyoto, Japan
| | - Nanako Tamiya
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
- Department of Health Services Research, Institute of Medicine, University of Tsukuba, Ibaraki, Japan
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Duddy C, Wong G. Grand rounds in methodology: when are realist reviews useful, and what does a 'good' realist review look like? BMJ Qual Saf 2023; 32:173-180. [PMID: 36585019 DOI: 10.1136/bmjqs-2022-015236] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 12/07/2022] [Indexed: 01/01/2023]
Abstract
Research in the quality and safety field often necessitates an approach that supports the development of an in-depth understanding of how a complex phenomenon occurs, or how an intervention works. Realist review is an increasingly popular form of evidence synthesis that provides a theory-driven, interpretive approach to secondary research. Realist reviews offer quality and safety researchers the opportunity to draw on diverse types of evidence to develop explanatory theory about how, when and for whom interventions 'work' or outcomes occur. The approach is flexible, iterative and practical, typically drawing on the experience of policymakers, practitioners and patients throughout the review. With the increasing use of realist reviews, some common misconceptions about the approach have become evident in the literature. This paper introduces what is involved when planning and conducting a realist review, and where the approach can offer most value, as well as outlining common challenges that researchers may face when adopting the approach, and recommended solutions. Our aim is to support researchers who are considering conducting a realist review to understand the key principles and concepts involved, and how they can go about producing high-quality work.
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Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Geoff Wong
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Sun Y, Iwagami M, Sakata N, Ito T, Inokuchi R, Komiyama J, Kuroda N, Tamiya N. Evaluation of enhanced home care support clinics regarding emergency home visits, hospitalization, and end-of-life care: a retrospective cohort study in a city of Japan. BMC Health Serv Res 2023; 23:115. [PMID: 36737771 PMCID: PMC9898920 DOI: 10.1186/s12913-023-09088-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 01/20/2023] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND To meet the increasing demand for home healthcare in Japan as the population ages, home care support clinics/hospitals (HCSCs) and enhanced HCSCs were introduced in 2006 and 2012, respectively. This study aimed to evaluate whether enhanced HCSCs fulfilled the expected role in home healthcare. METHODS We conducted a retrospective cohort study using linked medical and long-term care claims data from a municipality in Japan. Participants were ≥ 65 years of age, had newly started regular home visits between July 2014 and March 2018, and used either conventional or enhanced HCSCs. Patients were followed up for one year after they started regular home visits or until the month following the end of the regular home visits if they ended within one year. The outcome measures were (i) emergency home visits at all hours and on nights and holidays at least once, respectively, (ii) hospitalization at least once, and (iii) end-of-life care, which was evaluated based on the place of death and whether a physician was present at the time of in-home death. Multivariable logistic regression analyses were conducted for the outcomes of emergency home visits and hospitalizations. RESULTS The analysis included 802 patients, including 405 patients in enhanced HCSCs and 397 patients in conventional HCSCs. Enhanced HCSCs had more emergency home visits at all hours than conventional HCSCs (65.7% vs. 49.1%; adjusted odds ratio 1.70, 95% CI [1.26-2.28]), more emergency home visits on nights and holidays (33.6% vs. 16.7%; 2.20 [1.55-3.13]), and fewer hospitalizations (21.5% vs. 32.2%; 0.55 [0.39-0.76]). During the follow-up period, 229 patients (152 patients in enhanced HCSCs and 77 patients in HCSCs) died. Deaths at home were significantly more common in enhanced HCSCs than in conventional HCSCs (80.9% vs. 64.9%; p < .001), and physician-attended deaths among those who died at home were also significantly more common in enhanced HCSCs (99.2% vs. 78.0%; p < .001). CONCLUSIONS This study confirms that enhanced HCSCs are more likely to be able to handle emergency home visits and end-of-life care at home, which are important medical functions in home healthcare. Further promotion of enhanced HCSCs would be advantageous.
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Affiliation(s)
- Yu Sun
- grid.20515.330000 0001 2369 4728Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan ,grid.20515.330000 0001 2369 4728Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
| | - Masao Iwagami
- Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan. .,Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan.
| | - Nobuo Sakata
- grid.20515.330000 0001 2369 4728Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan ,grid.20515.330000 0001 2369 4728Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Tomoko Ito
- grid.20515.330000 0001 2369 4728Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan
| | - Ryota Inokuchi
- grid.20515.330000 0001 2369 4728Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan ,grid.20515.330000 0001 2369 4728Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Jun Komiyama
- grid.20515.330000 0001 2369 4728Graduate School of Comprehensive Human Sciences, University of Tsukuba, Ibaraki, Japan ,grid.20515.330000 0001 2369 4728Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Naoaki Kuroda
- grid.20515.330000 0001 2369 4728Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan ,Health Department, Tsukuba City, Ibaraki, Japan ,grid.416859.70000 0000 9832 2227Department of Community Mental Health & Law, National Institute of Mental Health, National Center of Neurology and Psychiatry, Tokyo, Japan
| | - Nanako Tamiya
- grid.20515.330000 0001 2369 4728Health Services Research and Development Center, University of Tsukuba, Ibaraki, Japan ,grid.20515.330000 0001 2369 4728Department of Health Services Research, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
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Ruaux S, Chadborn N. A qualitative exploratory study of training requirements for general practitioners attending older people resident in care homes. JOURNAL OF INTEGRATED CARE 2022. [DOI: 10.1108/jica-11-2021-0060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PurposeOlder people who reside in care homes have varying access and quality of medical care; in the UK, this is provided by general practitioners (GPs). The authors aimed to explore the experiences of trainee GPs in delivering integrated care and discuss, with senior GPs, opportunities to improve training.Design/methodology/approachTwo trainees and thirteen senior GPs were recruited through professional networks and participated in semi-structured interviews. Transcriptions were analysed using thematic analysis, and the theory of negotiated order was used to interpret findings.FindingsTrainees received no specific training on working with care homes. Exposure to the care home setting was variable, and could be negligible, depending on the GP practice placement. Senior GPs expressed concerns about patient safety, due to practical challenges of the consultation and a sense of lack of control. Considering the theory of negotiated order, where GPs had trusting relationships with care home staff, the input of the staff could mitigate the sense of risk. Care plans could communicate needs and preferences within the team and may be a way of extending the negotiated order, for example giving care homes authority to implement end-of-life care when the GP is not present.Research limitations/implicationsThe authors identified a need for trainees to engage with the organisational aspect of the care home to deliver integrated care. Trusted relationships with staff led to improved consultations, care plans, and better management of risk.Originality/valueThis is the first study of learning needs for GP trainees to provide integrated care for older care home residents.
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Consensus about GP interprofessional competencies: A nominal group study. BJGP Open 2022; 6:BJGPO.2021.0243. [PMID: 35338046 DOI: 10.3399/bjgpo.2021.0243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Revised: 12/22/2021] [Accepted: 02/22/2022] [Indexed: 10/31/2022] Open
Abstract
BACKGROUND Since the requirements for collaboration in primary care increase, effective interprofessional teamwork between general practitioners (GPs) and other primary care professionals is crucial. The need for more training in interprofessional collaborative competencies is widely recognised. However, existing competency frameworks do not sufficiently specify interprofessional collaboration to guide interprofessional competency development. AIM Consensus among GPs and other primary care professionals on interprofessional competencies that GP and GP-trainees should learn. DESIGN & SETTING Qualitative consensus study among Dutch GPs and other primary care professionals, all with expertise in primary care interprofessional collaborative practice. METHOD Three nominal group sessions were held, each resulting in its own group consensus on GP interprofessional collaborative competencies. The researchers conducted a content analysis to merge and thematise the prioritised competencies into one list. Participants prioritised this list of competencies. A pre-set cut-off point was applied to determine the overall consensus on core GP interprofessional competencies. RESULTS Eighteen professionals from nine different disciplines participated. The content analysis resulted in 31 unique competencies of which fourteen competencies were prioritised in the final ranking into three main themes: 1. Professional identity development and role definition by the GP. (three competencies); 2. Developing and executing shared care plans for individual patients (6); 3. Setting up and maintaining interprofessional collaborative partnerships.(5) CONCLUSION: An interprofessional group of experts reached consensus on 14 competencies within 3 themes. This framework provides a steppingstone for GPs to focus on their development regarding interprofessional collaboration.
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Duddy C, Roberts N. Identifying evidence for five realist reviews in primary health care: A comparison of search methods. Res Synth Methods 2021; 13:190-203. [PMID: 34494358 DOI: 10.1002/jrsm.1523] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 06/28/2021] [Accepted: 08/20/2021] [Indexed: 01/14/2023]
Abstract
The approach to identifying evidence for inclusion in realist reviews differs from that used in 'traditional' systematic reviews. Guidance suggests that realist reviews should be inclusive of diverse data from a range of sources, gathered in iterative searching cycles. Saturation is prioritised over exhaustiveness. Supplementary techniques such as citation snowballing are emphasised as potentially important sources of evidence. This paper describes the processes used to identify evidence in a selection of realist reviews focused on primary health care settings and examines the origin and type of evidence selected for inclusion. Data from five realist reviews were extracted from (a) reviewers' reference management libraries and (b) records kept by review teams. Although all reviews focused on primary health care, they used data from a wide range of document types and research designs, drawing on learning from multiple perspectives and settings, and sourced the documents containing this data in a variety of ways. Systematic searching of academic databases played an important role, supplementary search techniques such as snowballing were used to identify a significant proportion of documents included in the reviews. Our analysis demonstrates the diverse data sources used within realist reviews and the need for flexible, responsive efforts to identify relevant documents. Reviewers and information specialists should devise approaches to data gathering that reflect the individual needs of realist review projects and report these transparently.
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Affiliation(s)
- Claire Duddy
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Nia Roberts
- Bodleian Health Care Libraries, University of Oxford, Oxford, UK
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Barker RO, Stocker R, Russell S, Hanratty B. Future-proofing the primary care workforce: A qualitative study of home visits by emergency care practitioners in the UK. Eur J Gen Pract 2021; 27:68-76. [PMID: 33978544 PMCID: PMC8118426 DOI: 10.1080/13814788.2021.1909565] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Background Broadening the skill-mix in general practice is advocated to build resilience into the primary care workforce. However, there is little understanding of how extended-scope practitioners from different disciplines, such as paramedicine and nursing, embed into roles traditionally ascribed to general practitioners (GPs). Objectives This study sought to explore patients' and professionals' experiences of a primary care home visiting service delivered by emergency care practitioners (ECPs), in place of GPs; to determine positive impacts/unintended consequences and establish whether interdisciplinary working was achieved. Methods Three practices in England piloted an ECP (extended-scope practitioners with a paramedic or nursing background) home visiting service (November 2018–March 2019). Following the pilot, focus groups were conducted with each of the three primary healthcare teams (14 participants, including eight GPs), and one with ECPs (five participants) and nine individual patient interviews. Data were analysed using a modified framework approach. Results The impact of ECP home visiting on GP workload and patient care was perceived as positive by patients, GPs and ECPs. Initial preconceptions of GPs and patients about the ECP role and expertise, and reservations about the appropriacy of ECPs for home visiting, were perceived to have been overcome by the expertise and interpersonal skills of ECPs. Fostering a culture of collaboration between ECPs and GPs was instrumental to remodelling professional boundaries at the practice level. Conclusion Broadening the skill-mix to incorporate extended-scope practitioners such as ECPs, to deliver primary care home visiting, presents an opportunity to increase resilience in the general practice workforce.
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Affiliation(s)
- Robert Oliver Barker
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Rachel Stocker
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Siân Russell
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom
| | - Barbara Hanratty
- Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom
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12
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Park SE, Alberti H, Barber JRG. Transforming existing norms for payment and legitimacy of 'teaching work' in medical education. MEDICAL EDUCATION 2021; 55:550-552. [PMID: 33434365 DOI: 10.1111/medu.14452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/01/2021] [Accepted: 01/08/2021] [Indexed: 06/12/2023]
Affiliation(s)
- Sophie E Park
- Department of Primary Care and Population Health, University College London, London, UK
| | - Hugh Alberti
- School of Medical Education, Newcastle University, Newcastle upon Tyne, UK
| | - John R G Barber
- Department of Primary Care and Population Health, University College London, London, UK
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Stenner K, van Even S, Collen A. Paramedic independent prescribing: a qualitative study of early adopters in the UK. Br Paramed J 2021; 6:30-37. [PMID: 34335098 PMCID: PMC8312360 DOI: 10.29045/14784726.2021.6.6.1.30] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Background Paramedics working in advanced practice roles in the UK can now train to prescribe medicine. This is anticipated to benefit patient access to medicines and quality of care where there is a national shortage of doctors, particularly in primary care. Aim To explore the experience of paramedics who are early adopters of independent prescribing in a range of healthcare settings in the UK. Design and setting A qualitative study involving interviews between May and August 2019, with paramedics in the UK who had completed a prescribing programme. Methods Individual interviews with a purposive sample of paramedics recruited via social media and regional paramedic networks. Interviews covered experiences, benefits and challenges of the prescribing role. A framework analysis approach was used to identify key themes. Results Participants were 18 advanced paramedics working in primary care, emergency departments, urgent care centres and rapid response units. All participants reported being adequately prepared to prescribe. Key benefits of prescribing included improving service capacity, efficiency and safety, and facilitating advanced clinical roles. Challenges included technological problems, inability to prescribe controlled drugs and managing expectations about the prescribing role. Concerns were raised about support and role expectations, particularly in general practice. Conclusion Paramedic prescribing is most successful in settings with a high volume of same-day presentations and urgent and emergency care. It facilitated advanced roles within multidisciplinary teams. Concerns indicate that greater consideration for support infrastructure and workforce planning is required within primary care to ensure paramedics meet the entry criteria for a prescribing role.
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Affiliation(s)
| | | | - Andy Collen
- South East Coast Ambulance Service NHS Foundation Trust; College of Paramedics; University of Surrey
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Macdonald G, Vernon G, McNab D, Murdoch JC. Home visits for vulnerable older people: journeys to the 'Far End'. Br J Gen Pract 2020; 70:479-480. [PMID: 33004357 PMCID: PMC7518916 DOI: 10.3399/bjgp20x712685] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Affiliation(s)
| | | | | | - J C Murdoch
- Dunedin School of Medicine, University of Otago, Dunedin, New Zealand; Emeritus Professor of Rural and Remote Medicine, Rural Clinical School of Western Australia, Perth, Australia
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