1
|
Attwood D, Hope SV, Spicer SG, Gordon AL, Boorer J, Ellis W, Earley M, Denovan J, Hart G, Williams M, Burdett N, Lemon M. Does proactive care in care homes improve survival? A quality improvement project. BMJ Open Qual 2024; 13:e002771. [PMID: 38834371 PMCID: PMC11163642 DOI: 10.1136/bmjoq-2024-002771] [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: 01/23/2024] [Accepted: 05/10/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND NHS England's 'Enhanced Health in Care Homes' specification aims to make the healthcare of care home residents more proactive. Primary care networks (PCNs) are contracted to provide this, but approaches vary widely: challenges include frailty identification, multidisciplinary team (MDT) capability/capacity and how the process is structured and delivered. AIM To determine whether a proactive healthcare model could improve healthcare outcomes for care home residents. DESIGN AND SETTING Quality improvement project involving 429 residents in 40 care homes in a non-randomised crossover cohort design. The headline outcome was 2-year survival. METHOD All care home residents had healthcare coordinated by the PCN's Older Peoples' Hub. A daily MDT managed the urgent healthcare needs of residents. Proactive healthcare, comprising information technology-assisted comprehensive geriatric assessment (i-CGA) and advanced care planning (ACP), were completed by residents, with prioritisation based on clinical needs.Time-dependent Cox regression analysis was used with patients divided into two groups:Control group: received routine and urgent (reactive) care only.Intervention group: additional proactive i-CGA and ACP. RESULTS By 2 years, control group survival was 8.6% (n=108), compared with 48.1% in the intervention group (n=321), p<0.001. This represented a 39.6% absolute risk reduction in mortality, 70.2% relative risk reduction and the number needed to treat of 2.5, with little changes when adjusting for confounding variables. CONCLUSION A PCN with an MDT-hub offering additional proactive care (with an i-CGA and ACP) in addition to routine and urgent/reactive care may improve the 2-year survival in older people compared with urgent/reactive care alone.
Collapse
Affiliation(s)
| | - Suzy V Hope
- College of Medicine and Health, University of Exeter, Exeter, UK
- Healthcare for Older People, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Stuart G Spicer
- Community and Primary Care Research Group, Faculty of Health, University of Plymouth, Plymouth, UK
| | - Adam L Gordon
- Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK
- NIHR Applied Research Collaboration East Midlands (ARC-EM), Nottingham, UK
| | | | | | | | | | | | | | | | | |
Collapse
|
2
|
Seeley A, Glogowska M, Hayward G. How do primary care clinicians approach the management of frailty? A qualitative interview study. Age Ageing 2024; 53:afae093. [PMID: 38706395 PMCID: PMC11070720 DOI: 10.1093/ageing/afae093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Indexed: 05/07/2024] Open
Abstract
BACKGROUND Around 15% of adults aged over 65 live with moderate or severe frailty. Contractual requirements for management of frailty are minimal and neither incentivised nor reinforced. Previous research has shown frailty identification in primary care is ad hoc and opportunistic, but there has been little focus on the challenges of frailty management, particularly within the context of recent introduction of primary care networks and an expanding allied health professional workforce. AIM Explore the views of primary care clinicians in England on the management of frailty. DESIGN AND SETTING Semi-structured interviews were conducted with clinicians across England, including general practitioners (GPs), physician associates, nurse practitioners, paramedics and clinical pharmacists. Thematic analysis was facilitated through NVivo (Version 12). RESULTS A total of 31 clinicians participated. Frailty management was viewed as complex and outside of clinical guidelines with medication optimisation highlighted as a key example. Senior clinicians, particularly experienced GPs, were more comfortable with managing risk. Relational care was important in prioritising patient wishes and autonomy, for instance to remain at home despite deteriorations in health. In settings where more formalised multidisciplinary frailty services had been established this was viewed as successful by clinicians involved. CONCLUSION Primary care clinicians perceive frailty as best managed through trusted relationships with patients, and with support from experienced clinicians. New multidisciplinary working in primary care could enhance frailty services, but must keep continuity in mind. There is a lack of evidence or guidance for specific interventions or management approaches.
Collapse
Affiliation(s)
- Anna Seeley
- Nuffield Department of Primary Care and Health Sciences, University of Oxford
| | - Margaret Glogowska
- Nuffield Department of Primary Care and Health Sciences, University of Oxford
| | - Gail Hayward
- Nuffield Department of Primary Care and Health Sciences, University of Oxford
| |
Collapse
|
3
|
Westby M, Ijaz S, Savović J, McLeod H, Dawson S, Welsh T, Le Roux H, Walsh N, Bradley N. Virtual wards for people with frailty: what works, for whom, how and why-a rapid realist review. Age Ageing 2024; 53:afae039. [PMID: 38482985 PMCID: PMC10938537 DOI: 10.1093/ageing/afae039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND Virtual wards (VWs) deliver multidisciplinary care at home to people with frailty who are at high risk of a crisis or in crisis, aiming to mitigate the risk of acute hospital admission. Different VW models exist, and evidence of effectiveness is inconsistent. AIM We conducted a rapid realist review to identify different VW models and to develop explanations for how and why VWs could deliver effective frailty management. METHODS We searched published and grey literature to identify evidence on multidisciplinary VWs. Information on how and why VWs might 'work' was extracted and synthesised into context-mechanism-outcome configurations with input from clinicians and patient/public contributors. RESULTS We included 17 peer-reviewed and 11 grey literature documents. VWs could be short-term and acute (1-21 days), or longer-term and preventative (typically 3-7 months). Effective VW operation requires common standards agreements, information sharing processes, an appropriate multidisciplinary team that plans patient care remotely, and good co-ordination. VWs may enable delivery of frailty interventions through appropriate selection of patients, comprehensive assessment including medication review, integrated case management and proactive care. Important components for patients and caregivers are good communication with the VW, their experience of care at home, and feeling involved, safe and empowered to manage their condition. CONCLUSIONS Insights gained from this review could inform implementation or evaluation of VWs for frailty. A combination of acute and longer-term VWs may be needed within a whole system approach. Proactive care is recommended to avoid frailty-related crises.
Collapse
Affiliation(s)
- Maggie Westby
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Sharea Ijaz
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Jelena Savović
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Hugh McLeod
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Sarah Dawson
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
| | - Tomas Welsh
- Bristol Medical School, University of Bristol, Bristol BS8 2PS, UK
- RICE – The Research Institute for the Care of Older People, Bath, UK
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Hein Le Roux
- Churchdown Surgery, Parton Rd, Churchdown, Gloucester GL3 2JH, UK
- NHS England and NHS Improvement South West, Somerset, UK
- One Gloucestershire Integrated Care System Quality Improvement, Gloucester, UK
| | - Nicola Walsh
- The National Institute for Health and Care Research, Applied Research Collaboration West (NIHR ARC West), University Hospitals Bristol NHS Foundation Trust, Bristol BS1 2NT, UK
- Centre for Health & Clinical Research, University of the West of England, Bristol BS16 1DD, UK
| | - Natasha Bradley
- School of Nursing and Midwifery, Queens University Belfast, Belfast BT7 1NN, UK
| |
Collapse
|
4
|
Ijaz N, Jamil Y, Brown CH, Krishnaswami A, Orkaby A, Stimmel MB, Gerstenblith G, Nanna MG, Damluji AA. Role of Cognitive Frailty in Older Adults With Cardiovascular Disease. J Am Heart Assoc 2024; 13:e033594. [PMID: 38353229 PMCID: PMC11010094 DOI: 10.1161/jaha.123.033594] [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: 11/21/2023] [Accepted: 12/19/2023] [Indexed: 02/21/2024]
Abstract
As the older adult population expands, an increasing number of patients affected by geriatric syndromes are seen by cardiovascular clinicians. One such syndrome that has been associated with poor outcomes is cognitive frailty: the simultaneous presence of cognitive impairment, without evidence of dementia, and physical frailty, which results in decreased cognitive reserve. Driven by common pathophysiologic underpinnings (eg, inflammation and neurohormonal dysregulation), cardiovascular disease, cognitive impairment, and frailty also share the following risk factors: hypertension, diabetes, obesity, sedentary behavior, and tobacco use. Cardiovascular disease has been associated with the onset and progression of cognitive frailty, which may be reversible in early stages, making it essential for clinicians to diagnose the condition in a timely manner and prescribe appropriate interventions. Additional research is required to elucidate the mechanisms underlying the development of cognitive frailty, establish preventive and therapeutic strategies to address the needs of older patients with cardiovascular disease at risk for cognitive frailty, and ultimately facilitate targeted intervention studies.
Collapse
Affiliation(s)
- Naila Ijaz
- Thomas Jefferson University HospitalPhiladelphiaPAUSA
| | - Yasser Jamil
- Yale University School of MedicineNew HavenCTUSA
| | | | | | - Ariela Orkaby
- New England GRECC, VA Boston Healthcare SystemBostonMAUSA
- Division of AgingBrigham & Women’s Hospital, Harvard Medical SchoolBostonMAUSA
| | | | | | | | - Abdulla A. Damluji
- Johns Hopkins University School of MedicineBaltimoreMDUSA
- The Inova Center of Outcomes ResearchInova Heart and Vascular InstituteFalls ChurchVAUSA
| |
Collapse
|
5
|
Polley MJ, Barker RE, Collaco NB, Cam C, Appleton J, Seers HE. Developing a framework of concerns from people living with frailty, for the Measure Yourself Concerns and Wellbeing (MYCaW) person-centred outcome measure. BMJ Open Qual 2024; 13:e002689. [PMID: 38296605 PMCID: PMC10831418 DOI: 10.1136/bmjoq-2023-002689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 01/25/2024] [Indexed: 02/03/2024] Open
Abstract
INTRODUCTION Measure Yourself Concerns and Wellbeing is a validated person-centred outcome measure, piloted as a core monitoring tool to understand what matters to people living with frailty in Gloucestershire. This paper describes the acceptability of MYCaW used in this setting, and the development of a framework for analysing personalised concerns from people living with frailty. METHODS MYCaW was implemented in the Complex Care at Home service and South Cotswold Frailty Service from November 2020 onwards. MYCaW was completed at the person's first meeting with a community matron and then 3 months later. Nineteen staff completed an anonymous survey to provide feedback on the acceptability of the tool. A framework of concerns bespoke to people living with frailty was created via iterative rounds of independent coding of 989 concerns from 526 people. The inter-rater reliability of the framework was determined by using the Cronbach alpha test. RESULTS MYCaW was simple to use and helped health professionals' discussions to be patient focused. A pictorial scale accompanying the Numerical Rating Scale was developed and tested to help people engage with scoring their concerns and well-being more easily. A framework of concerns from people living with frailty was produced with five main supercategories: Mental and Emotional Concerns; Physical Concerns; Healthcare and Service Provision Concerns, Concerns with General Health and Well-being and Practical Concerns. Inter-rater reliability was kappa=0.905. CONCLUSIONS MYCaW was acceptable as a core monitoring tool for people living with frailty and enabled a systematic approach to opening 'What Matters to Me' conversations. The personalised data generated valuable insights into how the frailty services positively impacted the outcomes for people living with frailty. The coding framework demonstrated a wide range of concerns-many linked to inequalities and not identified on existing outcome measures recommended for people living with frailty.
Collapse
Affiliation(s)
- Marie J Polley
- Research and Development, Meaningful Measures Ltd, Bristol, Somerset, UK
| | - Ruth E Barker
- Health Innovation Wessex, Southampton, Hampshire, UK
| | - Niçole B Collaco
- Research and Development, Meaningful Measures Ltd, Bristol, Somerset, UK
| | - Christine Cam
- NHS Gloucestershire, Brockworth, Gloucestershire, UK
| | - Joanne Appleton
- NHS England and NHS Improvement South West, Taunton, Somerset, UK
| | - Helen E Seers
- Research and Development, Meaningful Measures Ltd, Bristol, Somerset, UK
- Q Community, The Health Foundation, London, UK
| |
Collapse
|
6
|
Lyndon H, Latour JM, Marsden J, Kent B. A nurse-led comprehensive geriatric assessment intervention in primary care: A feasibility cluster randomized controlled trial. J Adv Nurs 2023; 79:3473-3486. [PMID: 37002595 DOI: 10.1111/jan.15652] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2022] [Revised: 02/02/2023] [Accepted: 03/08/2023] [Indexed: 04/03/2023]
Abstract
AIM To determine the feasibility of a nurse-led, primary care-based comprehensive geriatric assessment (CGA) intervention. DESIGN A feasibility cluster randomized controlled trial. METHODS The trial was conducted in six general practices in the United Kingdom from May 2018 to April 2020. Participants were moderately/severely frail people aged 65 years and older living at home. Clusters were randomly assigned to the intervention arm control arms. A CGA was delivered to the intervention participants, with control participants receiving usual care. Study outcomes related to feasibility of the intervention and of conducting the trial including recruitment and retention. A range of outcome measures of quality of life, function, loneliness, self-determination, mortality, hospital admission/readmission and number of prescribed medications were evaluated. RESULTS All pre-specified feasibility criteria relating to recruitment and retention were met with 56 participants recruited in total (30 intervention and 26 control). Retention was high with 94.6% of participants completing 13-week follow-up and 87.5% (n = 49) completing 26-week follow-up. All outcome measures instruments met feasibility criteria relating to completeness and responsiveness over time. Quality of life was recommended as the primary outcome for a definitive trial with numbers of prescribed medications as a secondary outcome measure. CONCLUSION It is feasible to implement and conduct a randomized controlled trial of a nurse-led, primary care-based CGA intervention. IMPACT The study provided evidence on the feasibility of a CGA intervention for older people delivered in primary care. It provides information to maximize the success of a definitive trial of the clinical effectiveness of the intervention. PATIENT OR PUBLIC CONTRIBUTION Patient and public representatives were involved in the study design including intervention development and production of participant-facing documentation. Representatives served on the trial management and steering committees and, as part of this role, interpreted feasibility data. ISRCTN Number: 74345449.
Collapse
Affiliation(s)
| | - Jos M Latour
- University of Plymouth, Plymouth, UK
- Curtin University, Perth, Australia
| | | | | |
Collapse
|
7
|
Previdoli G, Cheong VL, Alldred D, Tomlinson J, Tyndale-Briscoe S, Silcock J, Okeowo D, Fylan B. A rapid review of interventions to improve medicine self-management for older people living at home. Health Expect 2023; 26:945-988. [PMID: 36919190 PMCID: PMC10154809 DOI: 10.1111/hex.13729] [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: 07/13/2022] [Revised: 12/15/2022] [Accepted: 02/01/2023] [Indexed: 03/16/2023] Open
Abstract
BACKGROUND As people age, they are more likely to develop multiple long-term conditions that require complicated medicine regimens. Safely self-managing multiple medicines at home is challenging and how older people can be better supported to do so has not been fully explored. AIM This study aimed to identify interventions to improve medicine self-management for older people living at home and the aspects of medicine self-management that they address. DESIGN A rapid review was undertaken of publications up to April 2022. Eight databases were searched. Inclusion criteria were as follows: interventions aimed at people 65 years of age or older and their informal carers, living at home. Interventions needed to include at least one component of medicine self-management. Study protocols, conference papers, literature reviews and articles not in the English language were not included. The results from the review were reported through narrative synthesis, underpinned by the Resilient Healthcare theory. RESULTS Database searches returned 14,353 results. One hundred and sixty-seven articles were individually appraised (full-text screening) and 33 were included in the review. The majority of interventions identified were educational. In most cases, they aimed to improve older people's adherence and increase their knowledge of medicines. Only very few interventions addressed potential issues with medicine supply. Only a minority of interventions specifically targeted older people with either polypharmacy, multimorbidities or frailty. CONCLUSION To date, the emphasis in supporting older people to manage their medicines has been on the ability to adhere to medicine regimens. Most interventions identify and target deficiencies within the patient, rather than preparing patients for problems inherent in the medicine management system. Medicine self-management requires a much wider range of skills than taking medicines as prescribed. Interventions supporting older people to anticipate and respond to problems with their medicines may reduce the risk of harm associated with polypharmacy and may contribute to increased resilience in the system. PATIENT OR PUBLIC CONTRIBUTION A patient with lived experience of medicine self-management in older age contributed towards shaping the research question as well as the inclusion and exclusion criteria for this review. She is also the coauthor of this article. A patient advisory group oversaw the study.
Collapse
Affiliation(s)
- Giorgia Previdoli
- Yorkshire Quality and Safety Group, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, United Kingdom
| | - V-Lin Cheong
- Medicines Management & Pharmacy Services, Leeds Teaching Hospitals NHS Trust, Leeds, United Kingdom
| | - David Alldred
- Faculty of Medicine and Health, School of Healthcare, University of Leeds, Leeds, United Kingdom
| | - Justine Tomlinson
- Faculty of Life Sciences, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom
| | | | - Jonathan Silcock
- Faculty of Life Sciences, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom
| | - Daniel Okeowo
- Faculty of Medicine and Health, School of Healthcare, University of Leeds, Leeds, United Kingdom
| | - Beth Fylan
- Faculty of Life Sciences, School of Pharmacy and Medical Sciences, University of Bradford, Bradford, United Kingdom
| |
Collapse
|
8
|
Khan N, Randhawa G, Hewson D. Integrated Care for Older People with Different Frailty Levels: A Qualitative Study of Local Implementation of a National Policy in Luton, England. Int J Integr Care 2023; 23:15. [PMID: 36967836 PMCID: PMC10038114 DOI: 10.5334/ijic.6537] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Accepted: 03/09/2023] [Indexed: 03/29/2023] Open
Abstract
Introduction The NHS England General Medical Services 2017-18 contract made it mandatory for general practices in England to identify and manage older people proactively. In response to the national policy, the Luton Framework for Frailty (LFF) programme was developed to target older residents of Luton and offer interventions according to their frailty level. The aim of this study was to gain a deeper understanding of the LFF and the factors that affect the implementation of a proactive integrated care service for older people with different frailty levels (OPDFL). Methods We undertook document analyses and conducted semi-structured interviews with stakeholders to create a 'thick description' that provides insights into the LFF. Results Healthy ageing interventions bring beneficial outcomes but to increase the uptake they should be co-produced with older people. A common electronic system within primary care and multidisciplinary team meetings (MDT) aid implementation. However, variation in implementation across Luton, different levels of buy-in for MDT, and different data systems in primary and secondary care make implementation challenging. Conclusion The LFF is a promising initiative and lessons learned are likely to be transferable to other settings as proactive management of frailty takes on greater policy prominence in the UK and worldwide.
Collapse
Affiliation(s)
- Nimra Khan
- Institute for Health Research University of Bedfordshire Department of Psychiatry University of Oxford, UK
| | - Gurch Randhawa
- Institute for Health Research University of Bedfordshire, UK
| | - David Hewson
- Institute for Health Research University of Bedfordshire, UK
| |
Collapse
|
9
|
Siqueri CAS, Pereira GA, Sumida GT, Mafra ACCN, Bonfim D, Almeida LYD, Monteiro CN. What are the implications of problem-solving capacity at Primary Health Care in older adult health? EINSTEIN-SAO PAULO 2022; 20:eGS6791. [PMID: 35766675 PMCID: PMC9239563 DOI: 10.31744/einstein_journal/2022gs6791] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 11/29/2021] [Indexed: 11/19/2022] Open
Abstract
Objective To evaluate Primary Health Care attributes and analyze the association between the fulfilment of these attributes and problem-solving capacity of services for elderly patients. Methods A cross-sectional, observational, quantitative study. The Primary Care Assessment Tool, designed to assess Primary Health Care attributes, was employed to evaluate elderly users of Primary Care Units located in the south region of the city of São Paulo (SP). Results Many attributes assessed at the reference services were considered as unsatisfactory by users. Overall scores were also below the cut-off point. “First contact access – use”, “longitudinality” and “coordination – information system” were the only attributes considered as satisfactory. Also, more than half (62.7%) of respondent patients reported having been referred to specialized services. A combined analysis of these three outcomes revealed users referred to other services had a significantly better perception of Primary Health Care attributes. Conclusion The study provides important insights on satisfaction of elderly individuals and the problem-solving capacity of health care services, especially for the study population. Findings reported emphasize the association between Primary Health Care attributes and the problem-solving capacity of health care services at this level.
Collapse
Affiliation(s)
| | - Gabriel Apolinário Pereira
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Giuliana Tamie Sumida
- Faculdade Israelita de Ciências da Saúde Albert Einstein, Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | - Daiana Bonfim
- Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | | | | |
Collapse
|
10
|
Teh SK, Rawtaer I, Tan HP. Predictive Accuracy of Digital Biomarker Technologies for Detection of Mild Cognitive Impairment and Pre-Frailty Amongst Older Adults: A Systematic Review and Meta-Analysis. IEEE J Biomed Health Inform 2022; 26:3638-3648. [PMID: 35737623 DOI: 10.1109/jbhi.2022.3185798] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Digital biomarker technologies coupled with predictive models are increasingly applied for early detection of age-related potentially reversible conditions including mild cognitive impairment (MCI) and pre-frailty (PF). We aimed to determine the predictive accuracy of digital biomarker technologies to detect MCI and PF with systematic review and meta-analysis. A computer-assisted search on major academic research databases including IEEE-Xplore was conducted. Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines were adopted reporting in this study. Summary receiver operating characteristic curve based on random-effect bivariate model was used to evaluate overall sensitivity and specificity for detection of the respective age-related conditions. A total of 43 studies were selected for final systematic review and meta-analysis. 26 studies reported on detection of MCI with sensitivity and specificity of 0.48-1.00 and 0.55-1.00, respectively. On the other hand, there were 17 studies that reported on the detection of PF with reported sensitivity of 0.53-1.00 and specificity of 0.61-1.00. Meta-analysis further revealed pooled sensitivities of 0.84 (95% CI: 0.79-0.88) and 0.82 (95% CI: 0.74-0.88) for in-home detection of MCI and PF, respectively, while pooled specificities were 0.85 (95% CI: 0.80-0.89) and 0.82 (95% CI: 0.75-0.88), respectively. Besides MCI, and PF, in this work during systematic review, we also found one study which reported a sensitivity of 0.93 and a specificity of 0.57 for detection of cognitive frailty (CF). The meta-analytic result, for the first time, quantifies the predictive efficacy of digital biomarker technologies for detection of MCI and PF. Additionally, we found the number of studies for detection of CF to be notably lower, indicating possible research gaps to explore predictive models on digital biomarker technology for detection of CF.
Collapse
|
11
|
Alharbi K, Blakeman T, van Marwijk H, Reeves D, Tsang JY. Understanding the implementation of interventions to improve the management of frailty in primary care: a rapid realist review. BMJ Open 2022; 12:e054780. [PMID: 35649605 PMCID: PMC9161080 DOI: 10.1136/bmjopen-2021-054780] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 01/24/2022] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVE Identifying and managing the needs of frail people in the community is an increasing priority for policy makers. We sought to identify factors that enable or constrain the implementation of interventions for frail older persons in primary care. DESIGN A rapid realist review. DATA SOURCES Cochrane Library, SCOPUS and EMBASE, and grey literature. The search was conducted in September 2019 and rerun on 8 January 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES We considered all types of empirical studies describing interventions targeting frailty in primary care. ANALYSIS We followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication criteria for our synthesis to systematically analyse and synthesise the existing literature and to identify (intervention-context-mechanism-outcome) configurations. We used normalisation processes theory to illuminate mechanisms surrounding implementation. RESULTS Our primary research returned 1755 articles, narrowed down to 29 relevant frailty intervention studies conducted in primary care. Our review identified two families of interventions. They comprised: (1) interventions aimed at the comprehensive assessment and management of frailty needs; and (2) interventions targeting specific frailty needs. Key factors that facilitate or inhibit the translation of frailty interventions into practice related to the distribution of resources; patient engagement and professional skill sets to address identified need. CONCLUSION There remain challenges to achieving successful implementation of frailty interventions in primary care. There were a key learning points under each family. First, targeted allocation of resources to address specific needs allows a greater alignment of skill sets and reduces overassessment of frail individuals. Second, earlier patient involvement may also improve intervention implementation and adherence. PROSPERO REGISTRATION NUMBER The published protocol for the review is registered with PROSPERO (CRD42019161193).
Collapse
Affiliation(s)
- Khulud Alharbi
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, The University of Manchester, Manchester, UK
| | - Thomas Blakeman
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Harm van Marwijk
- Division of Primary Care and Public Health, University of Brighton, Falmer, UK
- Brighton and Sussex Medical School, Brighton, UK
| | - David Reeves
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| | - Jung Yin Tsang
- Division of Population Health, Health Services Research & Primary Care, School of Health Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
12
|
Alharbi K, Blakeman T, van Marwijk H, Reeves D. Identification and management of frail patients in English primary care: an analysis of the General Medical Services 2018/2019 contract dataset. BMJ Open 2021; 11:e041091. [PMID: 34408025 PMCID: PMC8375730 DOI: 10.1136/bmjopen-2020-041091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES The aim of this study was to explore the extent of implementation of the General Medical Services 2018/2019 'frailty identification and management' contract in general practitioner (GP) practices in England, and link implementation outcomes to a range of practice and Clinical Commissioning Group (CCG) factors. DESIGN A cross-sectional study design using publicly available datasets relating to the year 2018 for all GP practices in England. SETTINGS English general practices. DATA The analysis was conducted across 6632 practices in 193 CCGs with 9 995 558 patients aged 65 years or older. OUTCOMES Frailty assessment rates, frailty coding rates and frailty prevalence rates, plus rates of medication reviews, falls assessments and enriched Summary Care Records (SCRs). ANALYSIS Summary statistics were calculated and multilevel negative binomial regression analysis was used to investigate relationships of the six outcomes with explanatory factors. RESULTS 14.3% of people aged 65 years or older were assessed for frailty, with 35.4% of these-totalling 5% of the eligible population-coded moderately or severely frail. 59.2% received a medications review, but rates of falls assessments (3.7%) and enriched SCRs (21%) were low. However, percentages varied widely across practices and CCGs. Practice differences in contract implementation were most strongly accounted for by their grouping within CCGs, with weaker but still important associations with some practice and CCG factors, particularly healthcare demand-related factors of chronic caseload and (negatively) % of patients aged 65 years or older. CONCLUSION CCG appears the strongest determinant of practice engagement with the frailty contract, and fuller implementation may depend on greater engagement of CCGs themselves, particularly in commissioning suitable interventions. Practices understandably targeted frailty assessments at patients more likely to be found severely frail, resulting in probable underidentification of moderately frail individuals who might benefit most from early interventions. Frailty prevalence estimates based on the contract data may not reflect actual rates.
Collapse
Affiliation(s)
- Khulud Alharbi
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Thomas Blakeman
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, University of Manchester, Manchester, UK
| | - Harm van Marwijk
- Division of Primary Care and Public Health, Brighton and Sussex Medical School, University of Brighton, Brighton, UK
| | - David Reeves
- National Institute for Health Research School for Primary Care Research, School of Health Sciences, University of Manchester, Manchester, UK
- Centre for Biostatistics, School of Health Sciences, University of Manchester, Manchester, UK
| |
Collapse
|
13
|
Ford E, Edelman N, Somers L, Shrewsbury D, Lopez Levy M, van Marwijk H, Curcin V, Porat T. Barriers and facilitators to the adoption of electronic clinical decision support systems: a qualitative interview study with UK general practitioners. BMC Med Inform Decis Mak 2021; 21:193. [PMID: 34154580 PMCID: PMC8215812 DOI: 10.1186/s12911-021-01557-z] [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: 10/16/2020] [Accepted: 05/31/2021] [Indexed: 11/29/2022] Open
Abstract
Background Well-established electronic data capture in UK general practice means that algorithms, developed on patient data, can be used for automated clinical decision support systems (CDSSs). These can predict patient risk, help with prescribing safety, improve diagnosis and prompt clinicians to record extra data. However, there is persistent evidence of low uptake of CDSSs in the clinic. We interviewed UK General Practitioners (GPs) to understand what features of CDSSs, and the contexts of their use, facilitate or present barriers to their use. Methods We interviewed 11 practicing GPs in London and South England using a semi-structured interview schedule and discussed a hypothetical CDSS that could detect early signs of dementia. We applied thematic analysis to the anonymised interview transcripts. Results We identified three overarching themes: trust in individual CDSSs; usability of individual CDSSs; and usability of CDSSs in the broader practice context, to which nine subthemes contributed. Trust was affected by CDSS provenance, perceived threat to autonomy and clear management guidance. Usability was influenced by sensitivity to the patient context, CDSS flexibility, ease of control, and non-intrusiveness. CDSSs were more likely to be used by GPs if they did not contribute to alert proliferation and subsequent fatigue, or if GPs were provided with training in their use. Conclusions Building on these findings we make a number of recommendations for CDSS developers to consider when bringing a new CDSS into GP patient records systems. These include co-producing CDSS with GPs to improve fit within clinic workflow and wider practice systems, ensuring a high level of accuracy and a clear clinical pathway, and providing CDSS training for practice staff. These recommendations may reduce the proliferation of unhelpful alerts that can result in important decision-support being ignored. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-021-01557-z.
Collapse
Affiliation(s)
- Elizabeth Ford
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Village Way, Falmer, Brighton, BN1 9PH, UK.
| | - Natalie Edelman
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Village Way, Falmer, Brighton, BN1 9PH, UK.,School of Sport and Health Sciences, University of Brighton, Brighton, UK
| | - Laura Somers
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Village Way, Falmer, Brighton, BN1 9PH, UK
| | - Duncan Shrewsbury
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Village Way, Falmer, Brighton, BN1 9PH, UK
| | - Marcela Lopez Levy
- Psychosocial Department, Centre for Researching and Embedding Human Rights (CREHR), Birkbeck College, London, UK
| | - Harm van Marwijk
- Department of Primary Care and Public Health, Brighton and Sussex Medical School, Watson Building, Village Way, Falmer, Brighton, BN1 9PH, UK
| | - Vasa Curcin
- School of Population Health and Environmental Sciences, King's College London, London, UK
| | - Talya Porat
- Dyson School of Design Engineering, Imperial College London, London, UK
| |
Collapse
|
14
|
Is proactive frailty identification a good idea? A qualitative interview study. Br J Gen Pract 2021; 71:e604-e613. [PMID: 33657008 PMCID: PMC8252857 DOI: 10.3399/bjgp.2020.0178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Accepted: 02/22/2021] [Indexed: 11/06/2022] Open
Abstract
Background In England, GPs are independent contractors working to a national contract. Since 2017, the contract requires GPs to use electronic tools to proactively identify moderate and severe frailty in people aged ≥65 years, and offer interventions to help those identified to stay well and maintain independent living. Little is currently known about GPs’ views of this contractual requirement. Aim To explore GPs’ views of identifying frailty and offering interventions for those living with moderate or severe frailty. Design and setting A sequential mixed-methods study of GPs in the East Midlands region of England — namely Derbyshire, Leicestershire, Lincolnshire, Nottinghamshire, and Northamptonshire — undertaken between January and May 2019. Method GPs were made aware of the study via professional organisations’ newsletters and bulletins, GP email lists, and social media, and were invited to complete an online questionnaire. Responses were analysed using descriptive statistics and, based on those survey responses, GPs with a range of GP and practice characteristics, as well as views on identifying frailty, were selected to participate in a semi-structured telephone interview. Interview transcripts were analysed using framework analysis. Results In total, 188 out of 3058 (6.1%) GPs responded to the survey and 18 GPs were interviewed. GPs were broadly supportive of identifying frailty, but felt risk-stratification tools lacked sensitivity and specificity, and wanted evidence showing clinical benefit. Frailty identification increased workload and was under-resourced, with limited time for, and access to, necessary interventions. GPs felt they lacked knowledge about frailty and more education was required to better understand it. Conclusion Proactively identifying and responding to frailty in primary care requires GP education, highly sensitive and specific risk-stratification tools, better access to interventions to lessen the impact of frailty, and adequate resourcing to achieve potential clinical impact.
Collapse
|