Primary care physicians' perspectives on the identification and management of postnatal mental health problems

BACKGROUND

Postnatal mental health problems (PMHPs) are prevalent and negatively affect mothers, children, and society. International and local guidelines recommend that Singapore primary care physicians (PCP) screen, assess, and manage mothers with PMHPs. However, little is known about their experiences and views.

METHODS

We conducted semi-structured interviews with 14 PCPs in Singapore. Interview questions elicited perspectives on the identification and management of mothers with PMHPs. The interview guide was developed from a conceptual framework incorporating the knowledge-attitudes-practices, self-efficacy, and socio-ecological models. Interviews were audio-recorded and transcribed. Thematic analysis was used to identify emergent themes.

RESULTS

Singapore PCPs viewed themselves as key providers of first-contact care to mothers with PMHPs. They believed mothers preferred them to alternative providers because of greater accessibility and trust. In detection, they were vigilant in identifying at-risk mothers and favoured clinical intuition over screening tools. PCPs were confident in diagnosing common PMHPs and believed that mothers not meeting diagnostic criteria must be readily recognized and supported. In managing PMHPs, PCPs expressed varying confidence in prescribing antidepressants, which were viewed as second-line to supportive counselling and psychoeducation. Impeding physician factors, constraining practice characteristics and health system limitations were barriers. Looking forward, PCPs aspired to leverage technology and multidisciplinary teams to provide comprehensive, team-based care for the mother-child dyad.

CONCLUSION

Singapore PCPs are key in identifying and managing mothers with PMHPs. To fully harness their potential in providing comprehensive care, PCPs need greater multidisciplinary support and technological solutions that promote remote disclosure and enhanced preparation for their role.

Development and validation of the Dermatology Social Comparison (DSC) Scale

BACKGROUND

Social comparison, the process of evaluating one's characteristics in relation to others, influences individuals' self-perception and behavior. However, instruments are scarce for assessing social comparison in the medical setting.

OBJECTIVES

Our aim was to develop and validate a new scale for assessing social comparison.

MATERIALS AND METHODS

Seven statements were developed, encompassing the perceived normality of having rashes, the tendency to compare their situation with others, and the emotional response when seeing someone better or worse off than themselves. The instrument was piloted in 15 patients for readability and face validity, then prospectively validated using modern psychometric methods in 1,053 adult patients with eczema or psoriasis from three tertiary dermatological centers in Singapore.

RESULTS

Of 1,053 adult patients, 802 (76.2%) had eczema, and 251 (23.8%) had psoriasis. Exploratory factor analysis (using a 70% sample split) showed a single factor model comprising three questions (Eigenvalue: 1.4). Confirmatory factor analysis with the remaining 30% of the sample confirmed an excellent model fit. Cronbach's alpha was 0.7, and inter-item correlations ranged from 0.42 to 0.46. In the Rasch analysis, item fit statistics and item characteristic curves showed appropriate discrimination between response options, although reliability was suboptimal with a person separation reliability of 0.63.

CONCLUSIONS

Comprising 3 questions, the newly derived social comparison scale showed acceptable psychometrics as a measure of social comparison for clinical and research purposes in dermatology. Its brief nature likely results from its brevity and applicability to conditions beyond eczema and psoriasis, which warrants further investigation.

A primary care research agenda for multiple long-term conditions: a Delphi study

BACKGROUND

Multiple long-term conditions (MLTC), also known as multimorbidity, has been identified as a priority research topic globally. Research priorities from the perspectives of patients and research funders have been described. Although most care for MLTC is delivered in primary care, the priorities of academic primary care have not been identified.

AIM

To identify and prioritise the academic primary care research agenda for MLTC.

DESIGN AND SETTING

This was a three-phase study with primary care MLTC researchers from the UK and other high-income countries.

METHOD

The study consisted of: an open-ended survey question, a face-to-face workshop to elaborate questions with researchers from the UK and Ireland, and a two-round Delphi consensus survey with international multimorbidity researchers.

RESULTS

Twenty-five primary care researchers responded to the initial open-ended survey and generated 84 potential research questions. In the subsequent workshop discussion (n = 18 participants), this list was reduced to 31 questions. The longlist of 31 research questions was included in round 1 of the Delphi; 27 of the 50 (54%) round 1 invitees and 24 of the 27 (89%) round 2 invitees took part in the Delphi. Ten questions reached final consensus. These questions focused broadly on addressing the complexity of the patient group with development of new models of care for multimorbidity, and methods and data development.

CONCLUSION

These high-priority research questions offer funders and researchers a basis on which to build future grant calls and research plans. Addressing complexity in this research is needed to inform improvements in systems of care and for disease prevention.

Feedback reports to the general practitioner (GP) on the patients' experiences: are GPs interested, and is this interest associated with GP factors and patient experience scores?

BACKGROUND

Patient experience feedback is key in patient centred health systems, but empirical evidence of general practitioner (GP) interest in it is sparse. We aimed to: (i) quantitatively estimate the level of GP interest for feedback reports on patient experience; (ii) explore determinants of such interest; and (iii) examine potential association between a priori interest and patient experience.

METHODS

The patient experience survey included maximum 300 randomly selected patients for each of 50 randomly selected GPs (response rate 41.4%, n = 5,623). GPs were sent a postal letter offering feedback reports and were grouped according to their replies: (i) interested in the report; (ii) not interested. Associations between interest and GP variables were assessed with Chi-square tests and multivariate logistic regression, while associations between interest and scores for 5 patient experiences scales were assessed with multilevel regression models.

RESULTS

About half (n = 21; 45.7%) of the GPs showed interest in the report by asking to receive the report. The only GP variable associated with a priori interest was being a specialist in general practice (58.6% vs. 23.5% for those without) (P = 0.021). Interest was significantly associated with the practice patient experience scale (4.1 higher score compared with those not interested, P = 0.048). Interest in the report had small and nonsignificant associations with the remaining patient experience scales.

CONCLUSIONS

Almost half of the GPs, and almost 3 in 5 of specialists in general practice, were interested in receiving a GP-specific feedback report on patient experiences. Interest in the report was generally not related to patient experience scores.

Patient perspectives of diabetes care in primary care networks in Singapore: a mixed-methods study

BACKGROUND

Type 2 diabetes (T2D) remains an important chronic condition worldwide requiring integrated patient-centred care as advocated by the Chronic Care Model (CCM). The Primary Care Networks (PCNs) in Singapore organise general practitioners (GPs) with nurses and care coordinators to deliver team-based care for patients with chronic conditions. This study examined the quality of care in the PCNs as defined by the CCM from the patients' perspective.

METHODS

This study followed a cross-sectional convergent mixed-method design with T2D patients across three PCN types (GP-led, Group, and Cluster). The Patient Assessment of Chronic Illness Care (PACIC, range 1-5) was completed by a convenience sample of 343 patients. Multivariate linear regression was performed to estimate the associations between patient and service characteristics and PACIC summary score. Twenty-four participants were purposively recruited for interviews on the experienced care until thematic saturation was reached. Quantitative and qualitative data were collected concurrently and independently. Integration occurred during study design and data analysis using the CCM as guidance. Quantitative and qualitative results were compared side-by-side in a joint comparison table to develop key concepts supported by themes, subthemes, and patients' quotes.

RESULTS

The PACIC mean summary score of 3.21 for 343 patients evidenced that some have received CCM consistent care in the PCNs. Being younger and spending more time with the GP were associated with higher PACIC summary scores. PACIC summary scores did not differ across PCN types. The 24 patients interviewed in the qualitative study reported receiving team-based care, nurse services, good continuity of care, as well as patient-centred care, convenient access, and affordable care. Key concepts showed that integrated care consistent with the CCM was sometimes received by patients in the PCNs. Patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling were sometimes received by patients, while follow-up/coordination was generally not received.

CONCLUSIONS

Patients with T2D from the Singapore Primary Care Networks received integrated care consistent with the Chronic Care Model, particularly in patient activation, delivery system design/decision support, goal setting/tailoring, and problem-solving/contextual counselling. Follow-up/coordination needed improvement to ensure higher quality of diabetes care.

Treatment burden in multiple long-term conditions: a mixed-methods study protocol

BACKGROUND

Treatment burden represents the work patients undertake because of their health care, and the impact of that effort on the patient. Most research has focused on older adults (aged >65 years) with multiple long-term conditions (multimorbidity) (MLTC-M), but there are now more younger adults (aged 18-65 years) living with MLTC-M and they may experience treatment burden differently. Understanding experiences of treatment burden, and identifying those most at risk of high treatment burden, are important for designing primary care services to meet their needs.

AIM

To understand the treatment burden associated with MLTC-M, for people aged 18-65 years, and how primary care services affect this burden.

DESIGN & SETTING

Mixed-methods study in up to 33 primary care practices in two UK regions.

METHOD

The following two approaches will be used: (i) in-depth qualitative interviews with adults living with MLTC-M (approximately 40 participants) to understand their experiences of treatment burden and the impact of primary care, with a think-aloud aspect to explore face validity of a novel short treatment burden questionnaire (STBQ) for routine clinical use in the initial 15 interviews; (ii) cross-sectional patient survey (approximately 1000 participants), with linked routine medical record data to examine the factors associated with treatment burden for people living with MLTC-M, and to test the validity of STBQ.

CONCLUSION

This study will generate in-depth understanding of the treatment burden experienced by people aged 18-65 years living with MLTC-M, and how primary care services affect this burden. This will inform further development and testing of interventions to reduce treatment burden, and potentially influence MLTC-M trajectories and improve health outcomes.

Reconsidering the Use of Population Health Surveys for Monitoring of Mental Health

Monitoring of the mental health status of the population and assessment of its determinants are 2 of the most relevant pillars of public mental health, and data from population health surveys could be instrumental to support them. Although these surveys could be an important and suitable resource for these purposes, due to different limitations and challenges, they are often relegated to the background behind other data sources, such as electronic health records. These limitations and challenges include those related to measurement properties and cross-cultural validity of the tools used for the assessment of mental disorders, their degree of representativeness, and possible difficulties in the linkage with other data sources. Successfully addressing these limitations could significantly increase the potential of health surveys in the monitoring of mental disorders and ultimately maximize the impact of the relevant policies to reduce their burden at the population level. The widespread use of data from population health surveys, ideally linked to electronic health records data, would enhance the quality of the information available for research, public mental health decision-making, and ultimately addressing the growing burden of mental disorders.

Measuring health-related quality of life of older people with frailty receiving acute care: feasibility and psychometric performance of the EuroQol EQ-5D

BACKGROUND

Although outcome goals for acute healthcare among older people living with frailty often include Health-Related Quality of Life (HRQoL) and other patient-reported outcome measures (PROMs), current quality metrics usually focus on waiting times and survival. Lay and patient review have identified the EuroQol EQ-5D as a candidate measure for this setting. This research appraised the EQ-5D for feasibility, psychometric performance, and respondents' outcomes in the acute frailty setting.

METHODS

People aged 65 + with Clinical Frailty Scale (CFS) 5-8 were recruited from eight UK hospitals' emergency care and acute admissions settings. They completed the five-level EQ-5D and the EQ-VAS. Feasibility was assessed with completion times and completeness. For reliability, response distributions and internal consistency were analysed. Finally, EQ-Index values were compared with demographic characteristics and service outcomes for construct validity.

RESULTS

The 232 participants were aged 65-102. 38% responded in emergency departments and 62% in admissions wards. Median completion time was 12 (IQR, 11) minutes. 98% responses were complete. EQ-5D had acceptable response distribution (SD 1.1-1.3) and internal consistency (Cronbach's alpha 0.69). EQ-VAS demonstrated a midpoint response pattern. Median EQ-Index was 0.574 (IQR, 0.410) and was related positively with increasing age (p = 0.010) and negatively with CFS (p < 0.001). Participants with higher CFS had more frequent problems with mobility, self-care, and usual activities.

CONCLUSIONS

Administration of the EQ-5D was feasible in these emergency and acute frailty care settings. EQ-5D had acceptable properties, while EQ-VAS appeared problematic. Participants with more severe frailty had also poorer HRQoL.

Prevalence and variability of depressive symptoms in Europe: update using representative data from the second and third waves of the European Health Interview Survey (EHIS-2 and EHIS-3)

BACKGROUND

Assessing the prevalence of clinically relevant depressive symptoms and their possible variation by country and over time could be a valuable resource to inform the development of public health policies and preventive resources to reduce mental health burden. We aimed to assess cross-national differences in the point prevalence of clinically relevant depressive symptoms in Europe in 2018-20, and to evaluate point prevalence differences between countries and over time between 2013-15 and 2018-20.

METHODS

In this population-based study, data from participants in the second and third waves of the European Health Interview Survey (EHIS-2 from 2013 to 2015 and EHIS-3 from 2018 to 2020) from 30 European countries were used (n=542 580). From the total sample, 283 692 participants belonging to EHIS-3 were included in the study (52·4% women and 47·5% men). The non-response in EHIS-3 ranged by country, from 12% to 78%. Point prevalence of clinically relevant depressive symptoms was evaluated using a cutoff score of 10 or more for the 8-item version of the Patient Health Questionnaire. Crude prevalence ratios and adjusted prevalence ratios (aPRs) were obtained to assess differences in the prevalence between countries and over time within countries.

FINDINGS

The point prevalence of clinically relevant depressive symptoms in Europe in 2018-20 was 6·54% (95% CI 6·34-6·73), ranging across countries from 1·85% (1·53-2·17) in Greece to 10·72% (10·04-11·40) in Sweden. Compared with the other European countries, those with the lowest aPRs were Greece, Serbia, and Cyprus and those with the highest aPRs were Belgium, Slovenia, and Croatia. A small but significant increase in the prevalence between EHIS-2 and EHIS-3 was observed (aPR 1·11 [1·07-1·14]). A wide variability over time in the point prevalence within countries was observed, ranging from an aPR of 0·63 (0·54-0·74) in Hungary to 1·88 (1·53-2·31) in Slovenia.

INTERPRETATION

This study, based on large and representative datasets and a valid and reliable screening tool for the assessment of depression, indicates that the point prevalence of clinically relevant depressive symptoms in Europe from 2013 to 2020 remains relatively stable, with wide variability between countries. These findings could be considered a baseline for monitoring the prevalence of clinically relevant depressive symptoms in Europe, and could inform policy for the development of preventive strategies for depression both at a country and European level.

FUNDING

Center for Biomedical Research in Epidemiology and Public Health Network and AGAUR.

Reliability and cross-country equivalence of the 8-item version of the Patient Health Questionnaire (PHQ-8) for the assessment of depression: results from 27 countries in Europe

Background

The 8-item version of the Patient Health Questionnaire (PHQ-8) is one of the self-reported questionnaires most frequently used worldwide for the screening and severity assessment of depression. However, in some European countries its reliability is unknown, and it is unclear whether its psychometric properties vary between European countries. Therefore, the aim of this study was to assess the internal structure, reliability and cross-country equivalence of the PHQ-8 in Europe.

Methods

All participants from the 27 countries included in the second wave of the European Health Interview Survey (EHIS-2) between 2014 and 2015 with complete information on the PHQ-8 were included (n = 258,888). The internal structure of the PHQ-8 was assessed using confirmatory factor analyses (CFA) for categorical items. Additionally, the reliability of the questionnaire was assessed based on the internal consistency, Item Response Theory information functions, and item-discrimination (using Graded Response Models), and the cross-country equivalence based on multi-group CFA.

Findings

The PHQ-8 shows high internal consistency for all countries. The countries in which the PHQ-8 was more reliable were Romania, Bulgaria and Cyprus and less reliable were Iceland, Norway and Austria. The PHQ-8 item with highest discrimination was item 2 (feeling down, depressed, or hopeless) in 24 of the 27 countries. Measurement invariance between countries in Europe was observed from multigroup CFA at the configural, metric and scalar levels.

Interpretation

The results from our study, likely the largest study to the date assessing the internal structure, reliability and cross-country comparability of a self-reported mental health assessment measure, shows that the PHQ-8 has an adequate reliability and cross-country equivalence across the 27 European countries included. These results highlight the suitability of the comparisons of the PHQ-8 scores in Europe. They could be helpful to improve the screening and severity assessment of depressive symptoms at the European level.

Funding

This work was partially funded by CIBER Epidemiology and Public Health (CIBERESP) as part of the Intramural call of 2021 (ESP21PI05).

Understanding Discordant Perceptions of Disease Severity Between Physicians and Patients With Eczema and Psoriasis Using Structural Equation Modeling

Importance

Patients and physicians often have differing opinions on the patient's disease severity. This phenomenon, termed discordant severity grading (DSG), hinders the patient-physician relationship and is a source of frustration.

Objective

To test and validate a model explaining the cognitive, behavioral, and disease factors associated with DSG.

Design, Setting, and Participants

A qualitative study was first performed to derive a theoretical model. In this subsequent prospective cross-sectional quantitative study, the qualitatively derived theoretical model was validated using structural equation modeling (SEM). Recruitment was conducted between October 2021 and September 2022. This was a multicenter study in 3 Singapore outpatient tertiary dermatological centers. Dermatology patients and their attending physicians were recruited by convenience sampling. Patients were aged 18 to 99 years with psoriasis or eczema of at least 3 months' duration and recruited only once. The data were analyzed between October 2022 to May 2023.

Main Outcomes and Measures

The outcome was the difference between global disease severity (0-10 numerical rating scale with a higher score indicating greater severity) as independently scored by the patient and the dermatologist. Positive discordance was defined as patient-graded severity more than 2 points higher (graded more severely) than physicians, and negative discordance if more than 2 points lower than physicians. Confirmatory factor analysis followed by SEM was used to assess the associations between preidentified patient, physician, and disease factors with the difference in severity grading.

Results

Of the 1053 patients (mean [SD] age, 43.5 [17.5] years), a total of 579 (55.0%) patients were male, 802 (76.2%) had eczema, and 251 (23.8%) had psoriasis. Of 44 physicians recruited, 20 (45.5%) were male, 24 (54.5%) were aged between 31 and 40 years, 20 were senior residents or fellows, and 14 were consultants or attending physicians. The median (IQR) number of patients recruited per physician was 5 (2-18) patients. Of 1053 patient-physician pairs, 487 pairs (46.3%) demonstrated discordance (positive, 447 [42.4%]; negative, 40 [3.8%]). Agreement between patient and physician rating was poor (intraclass correlation, 0.27). The SEM analyses showed that positive discordance was associated with higher symptom expression (standardized coefficient B = 0.12; P = .02) and greater quality-of-life impairment (B = 0.31; P < .001), but not patient or physician demographics. A higher quality-of-life impairment was in turn associated with lower resilience and stability (B = -0.23; P < .001), increased negative social comparisons (B = 0.45; P < .001), lower self-efficacy (B = -0.11; P = .02), increased disease cyclicity (B = 0.47; P < .001), and greater expectation of chronicity (B = 0.18; P < .001). The model was well-fitted (Tucker-Lewis: 0.94; Root Mean Square Error of Approximation: 0.034).

Conclusions and Relevance

This cross-sectional study identified various modifiable contributory factors to DSG, increased understanding of the phenomenon, and set a framework for targeted interventions to bridge this discordance.

Interactive or tailored digital interventions to increase uptake in cervical, breast, and colorectal cancer screening to reduce health inequity: a systematic review

BACKGROUND AND OBJECTIVES

Significant health inequities exist in screening uptake for certain types of cancer. The review question was to identify and describe interactive, tailored digital, computer, and web-based interventions to reduce health inequity in cancer screening and review the effectiveness of such interventions in increasing screening rates versus usual care.

METHODS

We searched four medical literature databases for randomized control trials (RCTs) published until 12 January 2023 that evaluated interventions aimed at increasing the percentage of breast, prostate, cervical, or colorectal cancer screening uptake. Meta-analysis was not conducted due to heterogeneity among studies.

RESULTS

After screening 4200 titles and abstracts, 17 studies were included. Studies focused on colorectal ( n  = 10), breast ( n  = 4), cervical ( n  = 2), and prostate ( n  = 1) cancer screening. All were based in the USA except two. Most studies focused on ethnicity/race, while some included low-income populations. Intervention types were heterogeneous and used computer programs, apps, or web-based methods to provide tailored or interactive information to participants about screening risks and options. Some studies found positive effects for increasing cancer screening uptake in the intervention groups compared to usual care, but results were heterogeneous.

CONCLUSION

Interventions that use individual and cultural tailoring of cancer screening educational material should be further developed and investigated outside of the USA. Designing effective digital intervention strategies, with components that can be adapted to remote delivery may be an important strategy for reducing health inequities in cancer screening during the coronavirus disease 2019 pandemic.

Effectiveness of routine provision of feedback from patient-reported outcome measurements for cancer care improvement: a systematic review and meta-analysis

BACKGROUND

Research shows that feeding back patient-reported outcome information to clinicians and/or patients could be associated with improved care processes and patient outcomes. Quantitative syntheses of intervention effects on oncology patient outcomes are lacking.

OBJECTIVE

To determine the effects of patient-reported outcome measure (PROM) feedback intervention on oncology patient outcomes.

DATA SOURCES

We identified relevant studies from 116 references included in our previous Cochrane review assessing the intervention for the general population. In May 2022, we conducted a systematic search in five bibliography databases using predefined keywords for additional studies published after the Cochrane review.

STUDY SELECTION

We included randomized controlled trials evaluating the effects of PROM feedback intervention on processes and outcomes of care for oncology patients.

DATA EXTRACTION AND SYNTHESIS

We used the meta-analytic approach to synthesize across studies measuring the same outcomes. We estimated pooled effects of the intervention on outcomes using Cohen's d for continuous data and risk ratio (RR) with a 95% confidence interval for dichotomous data. We used a descriptive approach to summarize studies which reported insufficient data for a meta-analysis.

MAIN OUTCOME(S) AND MEASURES(S)

Health-related quality of life (HRQL), symptoms, patient-healthcare provider communication, number of visits and hospitalizations, number of adverse events, and overall survival.

RESULTS

We included 29 studies involving 7071 cancer participants. A small number of studies was available for each metanalysis (median = 3 studies, ranging from 2 to 9 studies) due to heterogeneity in the evaluation of the trials. We found that the intervention improved HRQL (Cohen's d = 0.23, 95% CI 0.11-0.34), mental functioning (Cohen's d = 0.14, 95% CI 0.02-0.26), patient-healthcare provider communication (Cohen's d = 0.41, 95% CI 0.20-0.62), and 1-year overall survival (OR = 0.64, 95% CI 0.48-0.86). The risk of bias across studies was considerable in the domains of allocation concealment, blinding, and intervention contamination.

CONCLUSIONS AND RELEVANCE

Although we found evidence to support the intervention for highly relevant outcomes, our conclusions are tempered by the high risk of bias relating mainly to intervention design. PROM feedback for oncology patients may improve processes and outcomes for cancer patients but more high-quality evidence is required.

The relationship between air pollution and multimorbidity: Can two birds be killed with the same stone?

Air pollution and multimorbidity are two of the most important challenges for Public Health worldwide. Although there is a large body of evidence linking air pollution with the development of different single chronic conditions, the evidence about the relationship between air pollution and multimorbidity (the co-occurrence of multiple long-term conditions) is sparse. To obtain evidence about this relationship could be challenging and different aspects should be considered, such as its multifaceted and complex nature, the specific pollutants and their potential influence on health, their levels of exposure over time, or the data that could be used for its study. This evidence could be instrumental to inform the development of new recommendations and measures to reduce harmful levels of air pollutants, as means to prevent the development of multimorbidity and reduce its burden.

Web-Based Public Ratings of General Practitioners in Norway: Validation Study

BACKGROUND

Understanding the complex relationships among multiple strategies for gathering users' perspectives in the evaluation of the performance of services is crucial for the interpretation of user-reported measures.

OBJECTIVE

The main objectives were to (1) evaluate the psychometric performance of an 11-item web-based questionnaire of ratings of general practitioners (GPs) currently used in Norway (Legelisten.no) and (2) assess the association between web-based and survey-based patient experience indicators.

METHODS

We included all published ratings on GPs and practices on Legelisten.no in the period of May 5, 2012, to December 15, 2021 (N=76,521). The questionnaire consists of 1 mandatory item and 10 voluntary items with 5 response categories (1 to 5 stars), alongside an open-ended review question and background variables. Questionnaire dimensionality and internal consistency were assessed with Cronbach α, exploratory factor, and item response theory analyses, and a priori hypotheses were developed for assessing construct validity (chi-square analysis). We calculated Spearman correlations between web-based ratings and reference patient experience indicators based on survey data using the patient experiences with the GP questionnaire (n=5623 respondents for a random sample of 50 GPs).

RESULTS

Web-based raters were predominantly women (n=32,074, 64.0%), in the age range of 20-50 years (n=35,113, 74.6%), and reporting 5 or fewer consultations with the GP each year (n=28,798, 64.5%). Ratings were missing for 18.9% (n=14,500) to 27.4% (n=20,960) of nonmandatory items. A total of 4 of 11 rating items showed a U-shaped distribution, with >60% reporting 5 stars. Factor analysis and internal consistency testing identified 2 rating scales: "GP" (5 items; α=.98) and "practice" (6 items; α=.85). Some associations were not consistent with a priori hypotheses and allowed only partial confirmation of the construct validity of ratings. Item response theory analysis results were adequate for the "practice" scale but not for the "GP" scale, with items with inflated discrimination (>5) distributed over a narrow interval of the scale. The correlations between the web-based ratings GP scale and GP reference indicators ranged from 0.34 (P=.021) to 0.44 (P=.002), while the correlation between the web-based ratings practice scale and reference indicators ranged from 0.17 (not significant) to 0.49 (P<.001). The strongest correlations between web-based and survey scores were found for items measuring practice-related experiences: phone availability (ρ=0.51), waiting time in the office (ρ=0.62), other staff (ρ=0.54-0.58; P<.001).

CONCLUSIONS

The practice scale of the web-based ratings has adequate psychometric performance, while the GP suffers from important limitations. The associations with survey-based patient experience indicators were accordingly mostly weak to modest. Our study underlines the importance of interpreting web-based ratings with caution and the need to further develop rating sites.

Interventions to reduce cancer screening inequities: the perspective and role of patients, advocacy groups, and empowerment organizations

BACKGROUND

Health inequities lead to low rates of cancer screening in certain populations, such as low-income and ethnic minority groups. Different interventions to address this have been developed with mixed results. However, interventions are not always developed in collaboration with the people they target. The aim of our article is to present the viewpoint of patients, survivors, advocates, and lay persons on interventions to increase cancer screening from a health inequity perspective.

METHODS

We prepared talking points to guide discussions between coauthors, who included representatives from nine patient and survivor advocacy groups, organizations working for citizen/patient empowerment, and health equity experts. Perspectives and opinions were first collected through video conferencing meetings and a first draft of the paper was prepared. All authors, read through, revised, and discussed the contents to reach an agreement on the final perspectives to be presented.

RESULTS

Several themes were identified: it is important to not view screening as a discrete event; barriers underlying an individual's access and willingness to undergo screening span across a continuum; individually tailored interventions are likely to be more effective than a one-size fits-all approach because they may better accommodate the person's personal beliefs, knowledge, behaviors, and preferences; targeting people who are unknown to medical services and largely unreachable is a major challenge; including professional patient advocacy groups and relevant lay persons in the cocreation of interventions at all stages of design, implementation, and evaluation is essential along with relevant stakeholders (healthcare professionals, researchers, local government and community organizations etc).

CONCLUSIONS

Interventions to address cancer screening inequity currently do not adequately solve the issue, especially from the viewpoint of patients, survivors, and lay persons. Several core pathways should be focused on when designing and implementing interventions: advancing individually tailored interventions; digital tools and social media; peer-based approaches; empowerment; addressing policy and system barriers; better design of interventions; and collaboration, including the involvement of patients and patient advocacy organizations.

Co-creation of a Patient-Reported Outcome Measure for Older People Living with Frailty Receiving Acute Care (PROM-OPAC)

Older people living with frailty emphasize autonomy and function as acute healthcare outcome goals. Existing Patient-Reported Outcome Measures (PROMs) measure function but do not comprehensively address autonomy. This initial development of a novel autonomy outcome measure used co-creation and cognitive interviews, working toward a PROM for Older People living with frailty receiving Acute Care (“PROM-OPAC”). Novel item question stems and responses considering autonomy were devised with lay research partners. Items were examined for content by lay volunteers, and then selected based on relevance, completeness, and accessibility. Retained items were cognitively tested with patient participants. Item selection considered content validity and feasibility and was undertaken collaboratively with lay research partners. The study involved 3 lay research partners and 4 further lay collaborators throughout all stages, and 14 patient participants were recruited for the cognitive interviews. Twenty-two novel items were appraised. Seven were selected for retention. This preliminary PROM-OPAC comprised 7 items to measure autonomy and was intended for administration alongside a function measure to capture meaningful acute healthcare outcomes. Development will continue with quantitative testing and validation.

Rural versus metropolitan comparison of processes of care in the community‐based management of TIA and minor stroke in Australia (an analysis from the INSIST study)

OBJECTIVES

To compare processes of care and clinical outcomes of community-based management of TIAs and minor strokes (TIAMS) between rural and metropolitan Australia.

DESIGN

Inception cohort study between 2012 and 2016 with 12-month follow-up after index event (sub-study of INSIST).

SETTING

Hunter and Manning valley regions of New South Wales, within the referral territory of the John Hunter Hospital Acute Neurovascular Clinic (JHHANC).

PARTICIPANTS

Consecutive patients of 16 participating general practices, presenting with possible TIAMS to either primary or secondary care.

MAIN OUTCOME MEASURES

Processes of care (referrals, key management processes, time-based metrics) and clinical outcomes.

RESULTS

Of 613 participants with possible TIAMS who completed the baseline interview, 298 were adjudicated as having TIAMS (119 from rural, 179 from metropolitan). Mean age was 72.3 years (SD, 10.7) and 127 (43%) were women. Rural participants were more likely to be managed solely by a general practitioner (GP) than metropolitan participants (34% v 20%) and less likely to be referred to a JHHANC specialist (13% v 38%) or have brain magnetic resonance imaging (MRI) [24% v 51%]. Those rural participants who were referred, also waited longer (both p < 0.001). Recurrent stroke, myocardial infarction and death at 12 months were not significantly different between rural and metropolitan participants.

CONCLUSIONS

Although TIAMS prognosis in rural settings where solely GP care is common is very good, the processes of care in such areas are inferior to metropolitan. This suggests there is further scope to support rural GPs to optimise care of TIAMS patients.

Patient experiences with general practitioners: psychometric performance of the generic PEQ-GP instrument among patients with chronic conditions

BACKGROUND

Most generic patient experience instruments have not been validated specifically for persons with chronic health problems, even though they are the dominant user of GPs/family physicians.

OBJECTIVES

To assess the psychometric properties of the generic Patient Experiences with GP Questionnaire (PEQ-GP) instrument (five scales: assessment of GP, coordination, patient enablement, accessibility, and practice) in persons with chronic conditions, and to develop a short version to maximize response rates and minimize respondent fatigue in future applications.

METHODS

Secondary analysis of data from a national survey of patient experiences with general practitioners in 2018-2019 (response rate: 42.6%). The psychometric properties of PEQ-GP were assessed with exploratory factor analysis and Cronbach's alpha, supplemented with confirmatory factor analysis (CFA) and item response theory (IRT). A short version was constructed and evaluated based on item performance.

RESULTS

Nine hundred and seventy persons reported a chronic condition(s), the most frequent being "musculoskeletal, arthritis, other back and joints" (n = 473, 48.8%). Factor analysis identified three scales with adequate psychometric results: GP (15 items; Cronbach's alpha: 0.96), practice (3 items; Cronbach's alpha: 0.87), and accessibility (2 items; Cronbach's alpha: 0.77). Evaluation of item performance identified a 7-item short version, including a 5-item GP scale with scores with strong concordance with the 15-item scale (Intraclass Correlation Coefficient: 0.97, P < 0.001).

CONCLUSIONS

The generic PEQ-GP exhibits adequate psychometric performance for persons with chronic conditions. Three empirically derived PEQ-GP scales cover evaluation of the GP, accessibility, and practice. The 7-item short form minimize respondent burden, but further validation work is warranted before large-scale use.

Cross-cultural adaptation of the Spanish MINICHAL instrument into English for use in the United Kingdom

Background

Hypertension is a highly prevalent condition, with optimal treatment to BP targets conferring significant gains in terms of cardiovascular outcomes. Understanding why some patients do not achieve BP targets would be enhanced through greater understanding of their health-related quality of life (HRQoL). However, the only English language disease-specific instruments for measurement of HRQoL in hypertension have not been validated in accordance with accepted standards. It is proposed that the Spanish MINICHAL instrument for the assessment of HRQoL in hypertension could be translated, adapted and validated for use in the United Kingdom. The aim of the study was therefore to complete this process.

Methods

The MINICHAL authors were contacted and the original instrument obtained. This was then translated into English by two independent English-speakers, with these versions then reconciled, before back-translation and subsequent production of a 2nd reconciled version. Thereafter, a final version was produced after cognitive debriefing, for administration and psychometric analysis in the target population of patients living in the Exeter area (Southwest UK) aged 18–80 years with treatment-naïve grade II-III hypertension, before, during and after 18 weeks’ intensive treatment.

Results

The English-language instrument was administered to 30 individuals (median age: 58.5 years, 53% male). Psychometric analysis demonstrated a floor effect, though no ceiling effect. Internal consistency for both state of mind (StM) and somatic manifestations (SM) dimensions of the instrument were acceptable (Cronbach’s alpha = 0.81 and 0.75), as was test–retest reliability (ICC = 0.717 and 0.961) and construct validity, which was measured through co-administration with the EQ-5D-5L and Bulpitt-Fletcher instruments. No significant associations were found between scores and patient characteristics known to affect HRQoL. The EQ-5D-5L instrument found an improvement in HRQoL following treatment, with the StM and SM dimensions of the English language MINICHAL trending to support this (d = 0.32 and 0.02 respectively).

Conclusions

The present study details the successful English translation and validation of the MINICHAL instrument for use in individuals with hypertension. The data reported also supports an improvement in HRQoL with rapid treatment of grade II-III hypertension, a strategy which has been recommended by contemporaneous European guidelines.

Trial registration ISRCTN registry number: 57475376 (assigned 25/06/2015).

One-Year Risk of Stroke After Transient Ischemic Attack or Minor Stroke in Hunter New England, Australia (INSIST Study)

Background: One-year risk of stroke in transient ischemic attack and minor stroke (TIAMS) managed in secondary care settings has been reported as 5-8%. However, evidence for the outcomes of TIAMS in community care settings is limited. Methods: The INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study was a prospective inception cohort community-based study of patients of 16 general practices in the Hunter-Manning region (New South Wales, Australia). Possible-TIAMS patients were recruited from 2012 to 2016 and followed-up for 12 months post-index event. Adjudication as TIAMS or TIAMS-mimics was by an expert panel. We established 7-days, 90-days, and 1-year risk of stroke, TIA, myocardial infarction (MI), coronary or carotid revascularization procedure and death; and medications use at 24 h post-index event. Results: Of 613 participants (mean age; 70 ± 12 years), 298 (49%) were adjudicated as TIAMS. TIAMS-group participants had ischemic strokes at 7-days, 90-days, and 1-year, at Kaplan-Meier (KM) rates of 1% (95% confidence interval; 0.3, 3.1), 2.1% (0.9, 4.6), and 3.2% (1.7, 6.1), respectively, compared to 0.3, 0.3, and 0.6% of TIAMS-mimic-group participants. At one year, TIAMS-group-participants had twenty-five TIA events (KM rate: 8.8%), two MI events (0.6%), four coronary revascularizations (1.5%), eleven carotid revascularizations (3.9%), and three deaths (1.1%), compared to 1.6, 0.6, 1.0, 0.3, and 0.6% of TIAMS-mimic-group participants. Of 167 TIAMS-group participants who commenced or received enhanced therapies, 95 (57%) were treated within 24 h post-index event. For TIAMS-group participants who commenced or received enhanced therapies, time from symptom onset to treatment was median 9.5 h [IQR 1.8-89.9]. Conclusion: One-year risk of stroke in TIAMS participants was lower than reported in previous studies. Early implementation of antiplatelet/anticoagulant therapies may have contributed to the low stroke recurrence.

Unicompartmental compared with total knee replacement for patients with multimorbidities: a cohort study using propensity score stratification and inverse probability weighting

BACKGROUND

Although routine NHS data potentially include all patients, confounding limits their use for causal inference. Methods to minimise confounding in observational studies of implantable devices are required to enable the evaluation of patients with severe systemic morbidity who are excluded from many randomised controlled trials.

OBJECTIVES

Stage 1 - replicate the Total or Partial Knee Arthroplasty Trial (TOPKAT), a surgical randomised controlled trial comparing unicompartmental knee replacement with total knee replacement using propensity score and instrumental variable methods. Stage 2 - compare the risk benefits and cost-effectiveness of unicompartmental knee replacement with total knee replacement surgery in patients with severe systemic morbidity who would have been ineligible for TOPKAT using the validated methods from stage 1.

DESIGN

This was a cohort study.

SETTING

Data were obtained from the National Joint Registry database and linked to hospital inpatient (Hospital Episode Statistics) and patient-reported outcome data.

PARTICIPANTS

Stage 1 - people undergoing unicompartmental knee replacement surgery or total knee replacement surgery who met the TOPKAT eligibility criteria. Stage 2 - participants with an American Society of Anesthesiologists grade of ≥ 3.

INTERVENTION

The patients were exposed to either unicompartmental knee replacement surgery or total knee replacement surgery.

MAIN OUTCOME MEASURES

The primary outcome measure was the postoperative Oxford Knee Score. The secondary outcome measures were 90-day postoperative complications (venous thromboembolism, myocardial infarction and prosthetic joint infection) and 5-year revision risk and mortality. The main outcome measures for the health economic analysis were health-related quality of life (EuroQol-5 Dimensions) and NHS hospital costs.

RESULTS

In stage 1, propensity score stratification and inverse probability weighting replicated the results of TOPKAT. Propensity score adjustment, propensity score matching and instrumental variables did not. Stage 2 included 2256 unicompartmental knee replacement patients and 57,682 total knee replacement patients who had severe comorbidities, of whom 145 and 23,344 had linked Oxford Knee Scores, respectively. A statistically significant but clinically irrelevant difference favouring unicompartmental knee replacement was observed, with a mean postoperative Oxford Knee Score difference of < 2 points using propensity score stratification; no significant difference was observed using inverse probability weighting. Unicompartmental knee replacement more than halved the risk of venous thromboembolism [relative risk 0.33 (95% confidence interval 0.15 to 0.74) using propensity score stratification; relative risk 0.39 (95% confidence interval 0.16 to 0.96) using inverse probability weighting]. Unicompartmental knee replacement was not associated with myocardial infarction or prosthetic joint infection using either method. In the long term, unicompartmental knee replacement had double the revision risk of total knee replacement [hazard ratio 2.70 (95% confidence interval 2.15 to 3.38) using propensity score stratification; hazard ratio 2.60 (95% confidence interval 1.94 to 3.47) using inverse probability weighting], but half of the mortality [hazard ratio 0.52 (95% confidence interval 0.36 to 0.74) using propensity score stratification; insignificant effect using inverse probability weighting]. Unicompartmental knee replacement had lower costs and higher quality-adjusted life-year gains than total knee replacement for stage 2 participants.

LIMITATIONS

Although some propensity score methods successfully replicated TOPKAT, unresolved confounding may have affected stage 2. Missing Oxford Knee Scores may have led to information bias.

CONCLUSIONS

Propensity score stratification and inverse probability weighting successfully replicated TOPKAT, implying that some (but not all) propensity score methods can be used to evaluate surgical innovations and implantable medical devices using routine NHS data. Unicompartmental knee replacement was safer and more cost-effective than total knee replacement for patients with severe comorbidity and should be considered the first option for suitable patients.

FUTURE WORK

Further research is required to understand the performance of propensity score methods for evaluating surgical innovations and implantable devices.

TRIAL REGISTRATION

This trial is registered as EUPAS17435.

FUNDING

This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 66. See the NIHR Journals Library website for further project information.

Development of a conceptual model for research on cyclical variation of patient reported outcome measurements (PROMs) in patients with chronic conditions: a scoping review

Background

Although circadian, seasonal, and other cycles have been observed for a number of chronic conditions, their impact on patient reported outcomes measurements (PROMs) has not been systematically explored, rendering our understanding of the effect of time of measurement on PROM scores very limited. The aim was to conduct a scoping review to determine what is known about how intra-individual cyclical variation might affect the way individuals with chronic conditions respond to patient-reported outcome measures.

Methods

A protocol of a systematic scoping review was registered on PROSPERO (CRD42017058365). We developed a search strategy based on previous relevant reviews and implemented it in: MEDLINE, Embase, PsycINFO, and CINAHL. No restrictions were placed on article types and backward and forward citation searches were conducted. Screening and data extraction were independently completed by up to four reviewers. An adapted version of CASP criteria was used to appraise the quality of included articles. Concepts that were important in understanding the impact of cyclical variation on PROM scores were elicited from the papers and iteratively refined through discussion amongst the authors.

Results

2420 references resulted from the searches, with 33 articles meeting the inclusion criteria. Most study designs included observational research (particularly ecological momentary assessment), 2 were RCTs and 2 were systematic reviews. Studies mainly focused on specific health conditions: mental health, respiratory and musculoskeletal. There was a lack of qualitative research and theoretical framework to explore these concepts more fully. Five overarching concepts emerged: variation in outcomes, variation of scores, psychological status, individual factors, and environmental/situational factors. A conceptual model was developed outlining the relationships between these concepts.

Conclusions

There is empirical evidence that supports cyclical variation in PROM scores across different chronic conditions, with potential very significant implications for administration and interpretation of PROMs. The proposed conceptual model can support further research in this area.

Supplementary Information

The online version contains supplementary material available at 10.1186/s41687-021-00395-x.

A Standard Set of Value-Based Patient-Centered Outcomes and Measures of Overall Health in Adults

Background

The definition of population-specific outcomes is an essential precondition for the implementation of value-based health care. We developed a minimum standard outcome set for overall adult health (OAH) to facilitate the implementation of value-based health care in tracking, comparing, and improving overall health care outcomes of adults across multiple conditions, which would be of particular relevance for primary care and public health populations.

Methods

The International Consortium for Health Outcomes Measurement (ICHOM) convened an international panel (patients, clinicians, and topic experts). Following the development of a conceptual framework, a modified Delphi method (supported by public consultations) was implemented to identify, in sequence, the relevant domains, the best instruments for measuring them, the timing of measurement, and the relevant adjustment variables.

Findings

Outcomes were identified in relation to overall health status and the domains of physical, mental, and social health. Three instruments covering these domains were identified: PROMIS Scale v1.2—Global Health (10 items), WHO Wellbeing Index (5 items), and the WHO Disability Assessment Schedule 2.0 (12 items). Case-mix variables included a range of sociodemographic and biometric measures. Yearly measurement was proposed for all outcomes and most case-mix variables.

Interpretation

The ICHOM OAH Standard Set has been developed through consensus-based methods based on predefined criteria following high standards for the identification and selection of high-quality measures The involvements of a wide range of stakeholders supports the acceptability of the set, which is readily available for use and feasibility testing in clinical settings.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40271-021-00554-8.

STOPP/START interventions to improve medicines management for people aged 65 years and over: a realist synthesis

Background

Drug-related problems and potentially inappropriate prescribing impose a huge burden on patients and the health-care system. The most widely used tools for appropriate prescription in older adults in England and in other European countries are the Screening Tool of Older People’s Prescriptions (STOPP)/Screening Tool to Alert to the Right Treatment (START) tools. STOPP/START tools support medicines optimisation for older adults.

Objectives

To identify, test and refine the programme theories underlying how interventions based on the STOPP/START tools are intended to work, for whom, in what circumstances and why, as well as the resource use and cost requirements or impacts.

Design

A realist synthesis.

Setting

Primary care, hospital care and nursing homes.

Patients

Patients aged ≥ 65 years.

Interventions

Any intervention based on the use of the STOPP/START tools.

Review methods

Database and web-searching was carried out to retrieve relevant evidence to identify and test programme theories about how interventions based on the use of the STOPP/START tools work. A project reference group made up of health-care professionals, NHS decision-makers, older people, carers and members of the public was set up. In phase 1 we identified programme theories about STOPP/START interventions on how, for whom, in what contexts and why they are intended to work. We searched the peer-reviewed and grey literature to identify documents relevant to the research questions. We interviewed experts in the field in our reference group to gain input on our list of candidate context–mechanism–outcome configurations, to identify additional context–mechanism–outcome configurations and to identify additional literature and/or relevant concepts. In phase 2 we reviewed and synthesised relevant published and unpublished empirical evidence and tested the programme theories using evidence from a larger set of empirical studies.

Results

We developed a single logic model structured around three key mechanisms: (1) personalisation, (2) systematisation and (3) evidence implementation. Personalisation: STOPP/START-based interventions are based on shared decision-making, taking into account patient preferences, experiences and expectations (mechanisms), leading to increased patient awareness, adherence, satisfaction, empowerment and quality of life (outcomes). Systematisation: STOPP/START tools provide a standardised/systematic approach for medication reviews (mechanisms), leading to changes in professional and organisational culture and burden/costs (outcomes). Evidence implementation: delivery of STOPP/START-based interventions is based on the implementation of best evidence (mechanisms), reducing adverse outcomes through appropriate prescribing/deprescribing (outcomes). For theory testing, we identified 40 studies of the impact of STOPP/START-based interventions in hospital settings, nursing homes, primary care and community pharmacies. Most of the interventions used multiple mechanisms. We found support for the impact of the personalisation and evidence implementation mechanisms on selected outcome variables, but similar impact was achieved by interventions not relying on these mechanisms. We also observed that the impact of interventions was linked to the proximity of the selected outcomes to the intervention in the logic model, resulting in a clearer benefit for appropriateness of prescribing, adverse drug events and prescription costs.

Limitations

None of the available studies had been explicitly designed for evaluating underlying causal mechanisms, and qualitative information was sparse.

Conclusions

No particular configuration of the interventions is associated with a greater likelihood of improved outcomes in given settings.

Study registration

This study is registered as PROSPERO CRD42018110795.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 9, No. 23. See the NIHR Journals Library website for further project information.

Prevalence of Major Depressive Episode in 27 European Countries

Background

Information about the prevalence of current Major Depressive Episode (MDE) across European countries is essential for its monitoring and for the development of evidence- based mental health policies. The aims were to: 1) estimate the prevalence of MDE by country in Europe; and 2) assess variations in prevalence between countries.

Methods

Data from participants of 27 countries that completed the questionnaire of the second wave of the European Health Interview Survey (EHIS-2) were analysed (n = 258,888). The prevalence of MDE was quantified using the Patient Health Questionnaire-8 (PHQ-8) with a cut-off score of ≥ 10. Prevalence and 95% Confidence Intervals (CI) were estimated for each country. Variation in prevalence (country vs the rest) was evaluated using bivariable and multivariable negative binomial regression models considering the specific country as the main explanatory variable. From these models, crude Prevalence Ratios (PR) and adjusted Prevalence Ratios (aPR) were obtained.

Results

The overall prevalence of current MDE in Europe was 6.38% (6.24%-6.52%). The country with the lowest prevalence was the Czech Republic (2.58%, 2.14%-3.02%) and the country with highest prevalence Iceland (10.33%, 9.33%-11.32%). In all the countries (except for Finland and Croatia) prevalence was higher in women than in men. The countries with the highest aPR were Germany (aPR: 1.80, 95% CI: 1.71-1.89) and Luxembourg (aPR: 1.50, 95% CI: 1.35-1.66), while Slovakia (aPR: 0.28, 95% CI: 0.24-0.33) and the Czech Republic (aPR: 0.32, 95% CI: 0.27-0.38) exhibited the lowest aPR.

Conclusions

Considerable variability in the prevalence of MDE by country in Europe was observed without a clear pattern. These results serve as baseline for monitoring the prevalence of MDE at a European level and suggest a need for developing preventive strategies against depression, particularly in those countries identified with the highest prevalence.

Key messages

The results of this study show that the overall prevalence of MDE is high (6.38%), with important variation across countries (ranging from 2.58% in the Czech Republic to 10.33% in Iceland). The results found could serve as a reference for the monitoring of MDE in Europe and for the development of screening and preventive strategies both at European level as well as at a country level.

Routine provision of feedback from patient-reported outcome measurements to healthcare providers and patients in clinical practice

BACKGROUND

Patient-reported outcomes measures (PROMs) assess a patient's subjective appraisal of health outcomes from their own perspective. Despite hypothesised benefits that feedback  on PROMs can support decision-making in clinical practice and improve outcomes, there is uncertainty surrounding the effectiveness of PROMs feedback.

OBJECTIVES

To assess the effects of PROMs feedback to patients, or healthcare workers, or both on patient-reported health outcomes and processes of care.

SEARCH METHODS

We searched MEDLINE, Embase, CENTRAL, two other databases and two clinical trial registries on 5 October 2020. We searched grey literature and consulted experts in the field.

SELECTION CRITERIA

Two review authors independently screened and selected studies for inclusion. We included randomised trials directly comparing the effects on outcomes and processes of care of PROMs feedback to healthcare professionals and patients, or both with the impact of not providing such information.

DATA COLLECTION AND ANALYSIS

Two groups of two authors independently extracted data from the included studies and evaluated study quality. We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. We conducted meta-analyses of the results where possible.

MAIN RESULTS

We identified 116 randomised trials which assessed the effectiveness of PROMs feedback in improving processes or outcomes of care, or both in a broad range of disciplines including psychiatry, primary care, and oncology. Studies were conducted across diverse ambulatory primary and secondary care settings in North America, Europe and Australasia. A total of 49,785 patients were included across all the studies. The certainty of the evidence varied between very low and moderate. Many of the studies included in the review were at risk of performance and detection bias. The evidence suggests moderate certainty that PROMs feedback probably improves quality of life (standardised mean difference (SMD) 0.15, 95% confidence interval (CI) 0.05 to 0.26; 11 studies; 2687 participants), and leads to an increase in patient-physician communication (SMD 0.36, 95% CI 0.21 to 0.52; 5 studies; 658 participants), diagnosis and notation (risk ratio (RR) 1.73, 95% CI 1.44 to 2.08; 21 studies; 7223 participants), and disease control (RR 1.25, 95% CI 1.10 to 1.41; 14 studies; 2806 participants). The intervention probably makes little or no difference for general health perceptions (SMD 0.04, 95% CI -0.17 to 0.24; 2 studies, 552 participants; low-certainty evidence), social functioning (SMD 0.02, 95% CI -0.06 to 0.09; 15 studies; 2632 participants; moderate-certainty evidence), and pain (SMD 0.00, 95% CI -0.09 to 0.08; 9 studies; 2386 participants; moderate-certainty evidence). We are uncertain about the effect of PROMs feedback on physical functioning (14 studies; 2788 participants) and mental functioning (34 studies; 7782 participants), as well as fatigue (4 studies; 741 participants), as the certainty of the evidence was very low. We did not find studies reporting on adverse effects defined as distress following or related to PROM completion.

AUTHORS' CONCLUSIONS

PROM feedback probably produces moderate improvements in communication between healthcare professionals and patients as well as in diagnosis and notation, and disease control, and small improvements to quality of life. Our confidence in the effects is limited by the risk of bias, heterogeneity and small number of trials conducted to assess outcomes of interest. It is unclear whether   many of these improvements are clinically meaningful or sustainable in the long term. There is a need for more high-quality studies in this area, particularly studies which employ cluster designs and utilise techniques to maintain allocation concealment.

Prevalence and variability of current depressive disorder in 27 European countries: a population-based study

BACKGROUND

We aimed to estimate the prevalence of current depressive disorder in 27 European countries, and to explore differences in prevalence between European countries and by gender.

METHODS

In this population-based study, we analysed data from respondents living in 27 European countries who were included in the second wave of the European Health Interview Survey, collected between 2013 and 2015. We assessed the prevalence of current depressive disorder using the eight-item Patient Health Questionnaire (PHQ-8), with depressive disorder defined as a PHQ-8 score of 10 or higher. Prevalence estimates and 95% CIs were calculated for all 27 countries overall and for each country individually. We assessed variation in prevalence (country vs the rest of Europe) using crude and adjusted prevalence ratios obtained from negative binomial regression models. We did all analyses for the total sample and stratified by gender.

FINDINGS

Our analysis sample comprised 258 888 individuals, of whom 117 310 (weighted proportion 47·8%) were men and 141 578 (52·2%) were women. The overall prevalence of current depressive disorder was 6·38% (95% CI 6·24-6·52) with important variation across countries, ranging from 2·58% (2·14-3·02) in the Czech Republic to 10·33% (9·33-11·32) in Iceland. Prevalence was higher in women (7·74% [7·53-7·95]) than in men (4·89% [4·71-5·08]), with clear gender differences for all countries except Finland and Croatia. Compared with the other European countries in our sample, those with the highest adjusted prevalence ratios were Germany (1·80 [1·71-1·89]) and Luxembourg (1·50 [1·35-1·66]), and those with the lowest adjusted prevalence ratios were Slovakia (0·28 [0·24-0·33]) and the Czech Republic (0·32 [0·27-0·38]).

INTERPRETATION

Depressive disorders, although common across Europe, vary substantially in prevalence between countries. These results could be a baseline for monitoring the prevalence of current depressive disorder both at a country level in Europe and for planning health-care resources and services.

FUNDING

UK Medical Research Council and CIBER Epidemiology and Public Health (CIBERESP).

The Severe Asthma Questionnaire: sensitivity to change and minimal clinically important difference

The Severe Asthma Questionnaire (SAQ) is a validated measure of the health-related quality of life of people living with severe asthma [1]. The minimal clinically important difference (MCID) of the SAQ has not been calculated. The MCID is useful for representing clinical as opposed to statistical significance. There are two main ways of calculating the MCID. Distribution methods define the MCID in terms of the relationship between the distribution of scores and mean change score. These methods are purely statistical and the relationship and formulae that constitute the MCID is determined by convention. By contrast, the anchor method [2] defines the MCID in terms of an independent anchor or criterion. When the anchor is the patient's perception of a just noticeable difference in their condition, then the anchor method has two advantages over the distribution method. First, the MCID is defined by a criterion and, therefore, has criterion validity rather than being only a convention. Second, the MCID is defined in terms of the patient's perception of treatment, and the patient's perception of their treatment is recognised as being an important outcome for clinical decision-making [2]. In this letter we present the MCID of the SAQ using the anchor method.

The Severe Asthma Questionnaire (SAQ) is sensitive to change and clinically significant improvement was detected within 4 weeks of starting biologic therapy. The MCID of the SAQ is 0.5 and of the SAQ-global is 11.https://bit.ly/3poJqcG

Diagnostic promiscuity: the use of real-world data to study multimorbidity in mental health

Mental health-related multimorbidity can be considered as multimorbidity in the presence of a mental disorder. Some knowledge gaps on the study of mental health-related multimorbidity were identified. These knowledge gaps could be potentially addressed with real-world data.

Integrating Patient Reported Outcome Measures (PROMs) into routine nurse-led primary care for patients with multimorbidity: a feasibility and acceptability study

BACKGROUND

The use of Patient Reported Outcome Measures (PROMS) in clinical practice has the potential to promote patient-centred care and improve patients' quality of life. Individualized PROMs may be particularly helpful in identifying, prioritizing and monitoring health problems of patients with multimorbidity. We aimed to develop an intervention centred around PROMs feedback as part of Primary Care annual reviews for patients with multimorbidity and evaluate its feasibility and acceptability.

METHODS

We developed a nurse-oriented intervention including (a) training of nurses on PROMs; (b) administration to patients with multimorbidity of individualized and standardized PROMS; and (c) feedback to both patients and nurses of PROMs scores and interpretation guidance. We then tailored the intervention to patients with two or more highly prevalent conditions (asthma, COPD, diabetes, heart failure, depression, and hip/knee osteoarthritis) and designed a non-controlled feasibility and acceptability evaluation in a convenience sample of primary care practices (5). PROMs were administered and scores fed back immediately ahead of scheduled annual reviews with nurses. Patients and nurses rated the acceptability of the intervention using with a brief survey including optional free comments. Thematic analysis of qualitative interviews with a sample of participating patients (10) and nurses (4) and of survey free comments was conducted for further in-depth evaluation of acceptability. Feasibility was estimated based on rates of participation and completion.

RESULTS

Out of 68 recruited patients (mean age 70; 47% female), 68 completed the PROMs (100%), received feedback (100%) and confirmed nurse awareness of their scores (100%). Most patients (83%) "agreed"/"strongly agreed" that the PROMs feedback had been useful, a view supported by nurses in 89% of reviews. Thematic analysis of rich qualitative data on PROMS administration, feedback and role in annual reviews indicated that both patients and nurses perceived the intervention as acceptable and promising, emphasizing its comprehensiveness and patient-centredness.

CONCLUSIONS

We have developed and tested an intervention focusing on routine PROM assessment of patients with multimorbidity in Primary Care. Preliminary findings support its feasibility and a high degree of acceptability from both patients and nurses. The next step is to conduct a full-scale trial for evaluating the effectiveness of the proposed intervention.

Assessing the Impact of Multi-Morbidity and Related Constructs on Patient Reported Safety in Primary Care: Generalized Structural Equation Modelling of Observational Data

We aimed to examine the complex relationships between patient safety processes and outcomes and multimorbidity using a comprehensive set of constructs: multimorbidity, polypharmacy, discordant comorbidity (diseases not sharing either pathogenesis nor management), morbidity burden and patient complexity. We used cross-sectional data from 4782 patients in 69 primary care centres in Spain. We constructed generalized structural equation models to examine the associations between multimorbidity constructs and patient-reported patient safety (PREOS-PC questionnaire). These associations were modelled through direct and indirect (mediated by increased interactions with healthcare) pathways. For women, a consistent association between higher levels of the multimorbidity constructs and lower levels of patient safety was observed via either pathway. The findings for men replicated these observations for polypharmacy, morbidity burden and patient complexity via indirect pathways. However, direct pathways showed unexpected associations between higher levels of multimorbidity and better safety. The consistent association between multimorbidity constructs and worse patient safety among women makes it advisable to target this group for the development of interventions, with particular attention to the role of comorbidity discordance. Further research, particularly qualitative research, is needed for clarifying the complex associations among men.

Prevalence and age patterns of depression in the United Kingdom. A population-based study

METHODS

A representative sample of the UK population (n=17,152) from the European Health Interview Survey of 2014 was included in the analyses. The Patient Health Questionnaire (PHQ-8) was used to assess the prevalence of depressive symptoms and of probable depressive disorder. Prevalence estimates (95%CI) were calculated. The association between prevalence and age was assessed using multivariable multinomial logistic and logistic regression models. All analyses were carried out for the total sample and stratified by sex.

RESULTS

The prevalence of depressive symptoms ranged from 11.3% (10.6-11.9) for mild, to 3.3% (3.0-3.7) for severe symptoms. The prevalence of probable depressive disorder was 7.5% (95%CI: 7.0-8.0). A significantly higher prevalence of probable depressive disorder was found in those aged 45 to 59 years old compared with those aged 16 to 29. For the prevalence of severe depressive symptoms those age differences were even higher: 2.55 times higher (5.38 for men and 1.75 for women).

LIMITATIONS

The cross-sectional design precludes stablishing the direction of the relationship between age and the prevalence.

CONCLUSIONS

The prevalence and age patterns of depression in the UK were described. A peak in the prevalence was identified during middle adulthood. These results could serve as a reference for the monitoring of depression in the UK and the development of preventive strategies, particularly in the high-risk population groups identified.

Predicting EQ-5D-5L crosswalk from the PROMIS-29 profile for the United Kingdom, France, and Germany

Background

EQ-5D health state utilities (HSU) are commonly used in health economics to compute quality-adjusted life years (QALYs). The EQ-5D, which is country-specific, can be derived directly or by mapping from self-reported health-related quality of life (HRQoL) scales such as the PROMIS-29 profile. The PROMIS-29 from the Patient Reported Outcome Measures Information System is a comprehensive assessment of self-reported health with excellent psychometric properties. We sought to find optimal models predicting the EQ-5D-5L crosswalk from the PROMIS-29 in the United Kingdom, France, and Germany and compared the prediction performances with that of a US model.

Methods

We collected EQ-5D-5L and PROMIS-29 profiles and three samples representative of the general populations in the UK (n = 1509), France (n = 1501), and Germany (n = 1502). We used stepwise regression with backward selection to find the best models to predict the EQ-5D-5L crosswalk from all seven PROMIS-29 domains. We investigated the agreement between the observed and predicted EQ-5D-5L crosswalk in all three countries using various indices for the prediction performance, including Bland–Altman plots to examine the performance along the HSU continuum.

Results

The EQ-5D-5L crosswalk was best predicted in France (nRMSE_FRA = 0.075, nMAE_FRA = 0.052), followed by the UK (nRMSE_UK = 0.076, nMAE_UK = 0.053) and Germany (nRMSE_GER = 0.079, nMAE_GER = 0.051). The Bland–Altman plots show that the inclusion of higher-order effects reduced the overprediction of low HSU scores.

Conclusions

Our models provide a valid method to predict the EQ-5D-5L crosswalk from the PROMIS-29 for the UK, France, and Germany.

Accuracy of Self-Reported Items for the Screening of Depression in the General Population

INTRODUCTION

Though self-reported items (SRD, self-reported depression) are commonly used in health surveys and cohort studies, their metric properties as a depression indicator remain unclear. The aims were to evaluate the measurement properties of SRD using the Patient Health Questionnaire-8 (PHQ-8) as reference and to identify factors related to the agreement between both indicators.

METHODS

Data from the European Health Interview Survey in Spain in 2014/2015 (n = 22,065) were analyzed. Two indicators of depression were considered: SRD based on two items yes/no (positive: both yes), and the PHQ-8 (positive ≥ 10). Socioeconomic factors and use of health services were considered as independent variables. The prevalence of depression, sensitivity, specificity, global agreement, and positive and negative predictive values (PPV and NPV) of SRDs were evaluated using the PHQ-8 as a reference. Logistic regression models were fitted to determine factors associated with the agreement between indicators.

RESULTS

The prevalence of depression was lower when assessed with PHQ-8 (5.9%) than with SRD (7.7%). SRD sensitivity and PPV were moderate-low (52.9% and 40.4%, respectively) whereas global agreement, specificity, and NPV were high (92.7%, 95.1%, and 97.0%, respectively). Positive agreement was associated with marital status, country of birth, employment status, and social class. Negative agreement was related to all independent variables except country of birth.

CONCLUSIONS

SRD items tend to overestimate the current prevalence of depression. While its use in health surveys and cohorts may be appropriate as a quick assessment of possible depression, due to their low sensitivity, its use in clinical contexts is questionable.

Five-year trajectories of multimorbidity patterns in an elderly Mediterranean population using Hidden Markov Models

This study aimed to analyse the trajectories and mortality of multimorbidity patterns in patients aged 65 to 99 years in Catalonia (Spain). Five year (2012–2016) data of 916,619 participants from a primary care, population-based electronic health record database (Information System for Research in Primary Care, SIDIAP) were included in this retrospective cohort study. Individual longitudinal trajectories were modelled with a Hidden Markov Model across multimorbidity patterns. We computed the mortality hazard using Cox regression models to estimate survival in multimorbidity patterns. Ten multimorbidity patterns were originally identified and two more states (death and drop-outs) were subsequently added. At baseline, the most frequent cluster was the Non-Specific Pattern (42%), and the least frequent the Multisystem Pattern (1.6%). Most participants stayed in the same cluster over the 5 year follow-up period, from 92.1% in the Nervous, Musculoskeletal pattern to 59.2% in the Cardio-Circulatory and Renal pattern. The highest mortality rates were observed for patterns that included cardio-circulatory diseases: Cardio-Circulatory and Renal (37.1%); Nervous, Digestive and Circulatory (31.8%); and Cardio-Circulatory, Mental, Respiratory and Genitourinary (28.8%). This study demonstrates the feasibility of characterizing multimorbidity patterns along time. Multimorbidity trajectories were generally stable, although changes in specific multimorbidity patterns were observed. The Hidden Markov Model is useful for modelling transitions across multimorbidity patterns and mortality risk. Our findings suggest that health interventions targeting specific multimorbidity patterns may reduce mortality in patients with multimorbidity.

Patient-reported outcome and experience measures in geriatric emergency medicine

Older people with frailty and health crises have complex physical and social needs. Modern emergency care systems are fast-flowing, using protocols optimised for single-problem presentations. Systems must incorporate individualised care to best serve people with multiple problems. Healthcare quality is typically appraised with service metrics, such as department length of stay and mortality. Worldwide, patient-reported outcome measures (PROM) and patient-reported experience measures (PREM) are increasingly used in research, service development and performance evaluation, paving the ground for their use to support individual clinical decision-making. The PROMs and PREMs are person-centred metrics, which inform healthcare decisions at the individual level and which at the strategic level drive improvement through comparison of interprovider effectiveness. To date, there is no PROM or PREM specifically developed for older people with frailty and emergency care needs.

Depression and physical multimorbidity during the adulthood. Cross-sectional associations

Introduction

The prevalence of depression and physical multimorbidity (pMM) might vary over the life course in a non-random fashion. The aims of our study were to: 1) assess the prevalence of depression and pMM over the life course; and 2) estimate changes in their pattern of association at different ages.

Methods

Data from 13,736 participants aged 26, 30, 34, 38, 42 and 46 years old of the British Child Study cohort was used. Individuals with information on current self-reported depression were selected as study sample. pMM (yes/no) caseness was defined as the coexistence of 2 or more self-reported physical conditions (e.g. asthma, diabetes, epilepsy). The prevalence of depression and pMM was calculated for each wave. To assess their relationship, prevalence ratios (PR) adjusted by gender, socioeconomic (e.g. educational level) and health-related variables (e.g. BMI and smoking status) and their 95% Confidence Intervals (95%CI) were obtained at each wave from multivariable Poisson models.

Results

Prevalence of depression varied with age (10.0% at age 26, 7.8% at age 38 and 18.3% at age 46) as did prevalence of pMM (37% at age 26, 15.6% at age 34, and 20.2% at age 46). A non-linear trend in the prevalence both of depression and pMM was observed with a decrease from age 26 to age 38 (34 for pMM) followed by a consistent increment to age 46. In all ages depression was significantly associated with pMM the magnitude ranging from PR: 1.52 (95%CI 1.41-1.65) at age 26 to PR: 1.96 (95%CI 1.72-2.23) at age 38.

Conclusions

There is consistent association between the prevalence of depression and pMM over different ages during adulthood. The non-linear pattern suggests differences in the type of conditions contributing to pMM at different ages (non-chronic in young adulthood vs chronic from middle adulthood). Further research on clusters and trajectories of different conditions over life course might be valuable to understand the association between depression and pMM.

Key messages

There is consistent association between the prevalence of depression and pMM over different ages during adulthood. They could be differences in the type of conditions contributing to depression related pMM at different ages (non-chronic in young adulthood vs chronic from middle adulthood).

Relationship Between Depression and the Use of Mobile Technologies and Social Media Among Adolescents: Umbrella Review

BACKGROUND

Despite the relevance of mobile technologies and social media (MTSM) for adolescents, their association with depressive disorders in this population remains unclear. While there are previous reviews that have identified the use of MTSM as a risk factor for developing depression, other reviews have indicated their possible preventive effect.

OBJECTIVE

The aim of this review was to synthesize the current evidence on the association between MTSM use and the development or prevention of depressive disorders in adolescents.

METHODS

An umbrella review was conducted using information published up to June 2019 from PubMed/MEDLINE, PsycINFO, Web of Science, and The Cochrane Library. Systematic reviews focusing on the adolescent population (up to 20 years old) and depression and its potential relationship with MTSM use were included. Screening of titles, abstracts, and full texts was performed. After selecting the reviews and given the heterogeneity of the outcome variables and exposures, a narrative synthesis of the results was carried out.

RESULTS

The search retrieved 338 documents, from which 7 systematic reviews (3 meta-analyses) were selected for data extraction. There were 11-70 studies and 5582-46,015 participants included in the 7 reviews. All reviews included quantitative research, and 2 reviews also included qualitative studies. A statistically significant association between social media and developing depressive symptoms was reported in 2 reviews, while 5 reviews reported mixed results.

CONCLUSIONS

Excessive social comparison and personal involvement when using MTSM could be associated with the development of depressive symptomatology. Nevertheless, MTSM might promote social support and even become a point of assistance for people with depression. Due to the mixed results, prospective research could be valuable for providing stronger evidence.

The Characteristics of Patients With Possible Transient Ischemic Attack and Minor Stroke in the Hunter and Manning Valley Regions, Australia (the INSIST Study)

Background: Transient ischemic attack (TIA) and minor stroke (TIAMS) are risk factors for stroke recurrence. Some TIAMS may be preventable by appropriate primary prevention. We aimed to recruit “possible-TIAMS” patients in the INternational comparison of Systems of care and patient outcomes In minor Stroke and TIA (INSIST) study.

Methods: A prospective inception cohort study performed across 16 Hunter–Manning region, Australia, general practices in the catchment of one secondary-care acute neurovascular clinic. Possible-TIAMS patients were recruited from August 2012 to August 2016. We describe the baseline demographics, risk factors and pre-event medications of participating patients.

Results: There were 613 participants (mean age; 69 ± 12 years, 335 women), and 604 (99%) were Caucasian. Hypertension was the most common risk factor (69%) followed by hyperlipidemia (52%), diabetes mellitus (17%), atrial fibrillation (AF) (17%), prior TIA (13%) or stroke (10%). Eighty-nine (36%) of the 249 participants taking antiplatelet therapy had no known history of cardiovascular morbidity. Of 102 participants with known AF, 91 (89%) had a CHA2DS2-VASc score ≥ 2 but only 47 (46%) were taking anticoagulation therapy. Among 304 participants taking an antiplatelet or anticoagulant agent, 30 (10%) had stopped taking these in the month prior to the index event.

Conclusion: This study provides the first contemporary data on TIAMS or TIAMS-mimics in Australia. Community and health provider education is required to address the under-use of anticoagulation therapy in patients with known AF, possibly inappropriate use of antiplatelet therapy and possibly inappropriate discontinuation of antiplatelet or anticoagulation therapy.

Impact of comorbidity on the short- and medium-term risk of revision in total hip and knee arthroplasty

Background

The impact of comorbidity on the risk of revision in patients undergoing Total Knee arthroplasty (TKA) and Total Hip Arthroplasty (THA) is not currently well known. The aim of this study was to analyze the impact of comorbidity on the risk of revision in TKA and THA.

Methods

Patients recorded in the Catalan Arthroplasty Register (RACat) between 01/01/2005 and 31/12/2016 undergoing TKA (n = 49,701) and THA (n = 17,923) caused by osteoarthritis were included. As main explanatory factors, comorbidity burden was assessed by the Elixhauser index, categorized, and specific comorbidities from the index were taken into account. Descriptive analyses for comorbidity burden and specific conditions were done. Additionally, incidence at 1 and 5 years’ follow-up was calculated, and adjusted Competing Risks models were fitted.

Results

A higher incidence of revision was observed when the number of comorbidities was high, both at 1 and 5 years for THA, but only at 1 year for TKA. Of the specific conditions, only obesity was related to the incidence of revision at 1 year in both joints, and at 5 years in TKA. The risk of revision was related to deficiency anemia and liver diseases in TKA, while in THA, it was related to peripheral vascular disorders, metastatic cancer and psychoses.

Conclusions

Different conditions, depending on the joint, might be related to higher revision rates. This information could be relevant for clinical decision-making, patient-specific information and improving the results of both TKA and THA.

Differences in Results and Related Factors Between Hospital-at-Home Modalities in Catalonia: A Cross-Sectional Study

Hospital-at-home (HaH) is a healthcare modality that provides active treatment by healthcare staff in the patient’s home for a condition that would otherwise require hospitalization. The aims were to describe the characteristics of different types of hospital-at-home (HaH), assess their results, and examine which factors could be related to these results. A cross-sectional study based on data from all 2014 HaH contacts from Catalonia was designed. The following HaH modalities were considered—admission avoidance (n = 7214; 75.1%) and early assisted discharge (n = 2387; 24.9%). The main outcome indicators were readmission, mortality, and length of stay (days). Multivariable models were fitted to assess the association between explanatory factors and outcomes. Hospital admission avoidance is a scheme in which, instead of being admitted to acute care hospitals, patients are directly treated in their own homes. Early assisted discharge is a scheme in which hospital in-care patients continue their treatment at home. In the hospital avoidance modality, there were 8.3% readmissions, 0.9% mortality, and a mean length of stay (SD) of 9.6 (10.6) days. In the early assisted discharge modality, these figures were 7.9%, 0.5%, and 9.8 (11.1), respectively. In both modalities, readmission and mean length of stay were related to comorbidity and type of hospital, and mortality with age. The results of HaH in Catalonia are similar to those observed in other contexts. The factors related to these results identified might help to improve the effectiveness and efficiency of the different HaH modalities.

Social Prescribing Programmes to Prevent or Delay Frailty in Community-Dwelling Older Adults

The increasing incidence of frailty is a health and social care challenge. Social prescription is advocated as an important approach to allow health professionals to link patients with sources of support in the community. This study aimed to determine the current evidence on the effectiveness of social prescribing programmes, to delay or reduce frailty in frail older adults living in the community. A systematic literature review of published (DARE, Cochrane Database of Systematic Reviews, MEDLINE, EMBASE, CINAHL, NICE and SCIE, National Health Service (NHS) Economic Evaluation Database) and unpublished databases (OpenGrey; WHO Clinical Trial Registry; ClinicalTrials.gov) were searched to July 2019. Studies were eligible if they reported health, social or economic outcomes on social prescribing, community referral, referral schemes, wellbeing programmes or interventions when a non-health link worker was the intervention provider, to people who are frail living in the community. We screened 1079 unique studies for eligibility. No papers were eligible. There is therefore a paucity of evidence reporting the effectiveness of social prescribing programmes for frail older adults living in the community. Given that frailty is a clinical priority and social prescribing is considered a key future direction in the provision of community care, this is a major limitation.

Differences in Risk of Revision and Mortality Between Total and Unicompartmental Knee Arthroplasty. The Influence of Hospital Volume

BACKGROUND

The volume of arthroplasties performed in a hospital by year has an influence on the outcomes of total knee arthroplasty (TKA) and unicompartmental knee arthroplasty (UKA). The aims of this study are (1) to evaluate and compare the risk of revision and mortality of TKA and UKA and (2) to assess whether hospital volume is related to differences in revision risk and mortality.

METHODS

All individuals recorded in the Catalan Arthroplasty Register between 1/1/2005 and 31/12/2016, diagnosed with osteoarthritis, undergoing cemented TKA and UKA were included. A propensity score matching method was used to obtain comparable cohorts, including 2374 matched prostheses overall. Hospital volume was considered as a dichotomous variable (lower/higher). Descriptive analyses were done before and after matching. Risks of revision and mortality at 30 days, 90 days, 1, 3, and 5 years were calculated and competing risks models and Cox models were fitted.

RESULTS

For the population as a whole, higher risk of revision (sub-hazard ratio, 1.98; 95% confidence interval, 1.25-3.17) was found in UKA than in TKA but higher mortality was not. Considering the volume groups, significantly higher risk of revision in UKA than TKA was found in the lower-volume group only (sub-hazard ratio, 1.95; 95% confidence interval, 1.11-3.44). No differences in mortality between TKA and UKA were found in either group.

CONCLUSION

Mortality and revision rates after TKA and UKA at higher-volume hospitals are similar. UKAs performed at lower-volume hospitals have higher revision rates. Volume-dependent specialization thus might help to reduce revision and mortality after surgery.

Assessing Patient-Centred Outcomes in Lateral Elbow Tendinopathy: A Systematic Review and Standardised Comparison of English Language Clinical Rating Systems

Background

Lateral elbow tendinopathy (LET) is a common condition affecting adults. Although a lack of treatment consensus continues to prompt numerous effectiveness studies, there is a paucity of clear guidance on the choice of outcome measure. Our aim was to undertake a standardised evaluation of the available clinical rating systems that report patient-centred outcomes in LET.

Methods

A systematic review of studies reporting the development, assessment of metric properties and/or use of instruments aiming to quantify LET-specific patient-centred outcome measures was conducted in MEDLINE, Embase and CINAHL (inception-2017) adhering to PRISMA guidance. The evidence for each instrument was independently assessed by two reviewers using the standardised evaluating measures of patient-reported outcomes (EMPRO) method evaluating overall and attribute-specific instrument performance (metric properties and usability). EMPRO scores > 50/100 were considered indicative of high performance.

Results

Out of 7261 references, we identified 105 articles reporting on 15 instruments for EMPRO analysis. Median performance score was 41.6 (range 21.6–72.5), with four instruments meeting high-performance criteria: quick Disabilities of the Arm Shoulder and Hand score (qDASH) (72.5), DASH (66.9), Oxford Elbow Score (OES) (66.6) and Patient-Rated Tennis Elbow Evaluation (PRTEE) (57.0). One hundred seventy-nine articles reported instrument use internationally with DASH as the most frequent (29.7% articles) followed by PRTEE (25.6%), MEPS (15.1%) and qDASH (8.1%). The correlation between frequency of use and performance was r = 0.35 (95%CI − 0.11; 0.83).

Conclusions

This is the first study to provide standardised guidance on the choice of measures for LET. A large number of clinical rating systems are both available and being used for patients with LETs. Robust evidence is available for four measures, the DASH, QDASH, PRTEE and OES. The use of instruments in the literature is only in part explained by instrument performance.

Electronic supplementary material

The online version of this article (10.1186/s40798-019-0183-2) contains supplementary material, which is available to authorized users.