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Fisher AJ, White M, Goudie N, Kershaw A, Phillipson J, Bardgett M, Lally J, Bevin-Nicholls A, Chadwick T, Bryant A, Russell S, Smith H, Frisby L, Errington R, Carby M, Thompson R, Santhanakrishnan K, Parmar J, Lordan JL, Vale L, Hancock H, Exley C, Gennery AR, Wason JM. Extracorporeal photopheresis (ECP) in the treatment of chronic lung allograft dysfunction (CLAD): a prospective, multicentre, open-label, randomised controlled trial studying the addition of ECP to standard care in the treatment of bilateral lung transplant patients with CLAD (E-CLAD UK). BMJ Open Respir Res 2024; 11:e001995. [PMID: 38724453 PMCID: PMC11086459 DOI: 10.1136/bmjresp-2023-001995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 04/22/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Long-term survival after lung transplantation is limited compared with other organ transplants. The main cause is development of progressive immune-mediated damage to the lung allograft. This damage, which can develop via multiple immune pathways, is captured under the umbrella term chronic lung allograft dysfunction (CLAD). Despite the availability of powerful immunosuppressive drugs, there are presently no treatments proven to reverse or reliably halt the loss of lung function caused by CLAD. The aim of the E-CLAD UK trial is to determine whether the addition of immunomodulatory therapy, in the form of extracorporeal photopheresis (ECP), to standard care is more efficacious at stabilising lung function in CLAD compared with standard care alone. METHODS AND ANALYSIS E-CLAD UK is a Phase II clinical trial of an investigational medicinal product (Methoxsalen) delivered to a buffy coat prepared via an enclosed ECP circuit. Target recruitment is 90 bilateral lung transplant patients identified as having CLAD and being treated at one of the five UK adult lung transplant centres. Participants will be randomised 1:1 to intervention plus standard of care, or standard of care alone. Intervention will comprise nine ECP cycles spread over 20 weeks, each course involving two treatments of ECP on consecutive days. All participants will be followed up for a period of 24 weeks.The primary outcome is lung function stabilisation derived from change in forced expiratory volume in one second and forced vital capacity at 12 and 24 weeks compared with baseline at study entry. Other parameters include change in exercise capacity, health-related quality of life and safety. A mechanistic study will seek to identify molecular or cellular markers linked to treatment response and qualitative interviews will explore patient experiences of CLAD and the ECP treatment.A patient and public advisory group is integral to the trial from design to implementation, developing material to support the consent process and interview materials. ETHICS AND DISSEMINATION The East Midlands-Derby Research Ethics Committee has provided ethical approval (REC 22/EM/0218). Dissemination will be via publications, patient-friendly summaries and presentation at scientific meetings. TRIAL REGISTRATION NUMBER EudraCT number 2022-002659-20; ISRCTN 10615985.
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Affiliation(s)
- Andrew J Fisher
- Faculty of Medical Sciences, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Michael White
- Newcastle Clinical Trials Unit, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Nicola Goudie
- Newcastle Clinical Trials Unit, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Anneka Kershaw
- Newcastle Clinical Trials Unit, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Julia Phillipson
- Newcastle Clinical Trials Unit, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Michelle Bardgett
- Newcastle Clinical Trials Unit, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Joanne Lally
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Alex Bevin-Nicholls
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Thomas Chadwick
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Andrew Bryant
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Sian Russell
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Hesther Smith
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Laura Frisby
- Joint Research Office, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Rebecca Errington
- Joint Research Office, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Martin Carby
- Royal Brompton and Harefield Hospitals, London, UK
| | - Richard Thompson
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | | | - Jasvir Parmar
- Royal Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - James L Lordan
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Luke Vale
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Helen Hancock
- Newcastle Clinical Trials Unit, University of Newcastle upon Tyne, Newcastle upon Tyne, UK
| | - Catherine Exley
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
| | - Andrew R Gennery
- Faculty of Medical Sciences, Newcastle University Translational and Clinical Research Institute, Newcastle upon Tyne, UK
| | - James Ms Wason
- Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, UK
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Joseph N, Robertson F, Lucocq J, Pande R, Powell-Brett S, Swainston K, Sharp L, Exley C, Roberts K, Pandanaboyana S. A multicentre prospective evaluation of health-related quality of life and patient related outcomes in pancreatic and peripancreatic cancer: PROMCAN study. HPB (Oxford) 2024; 26:648-655. [PMID: 38350737 DOI: 10.1016/j.hpb.2024.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 01/21/2024] [Accepted: 01/26/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND The temporal evolution of HRQoL and the importance of other PROs to patients, following resection for pancreatic and peripancreatic malignancy remains unexplored. METHODS Patients undergoing pancreatic resection between 2021 and 2022 were enrolled from 2 UK HPB centres. Patients completed the EORTC QLQ-C30, QLQ-PAN26 tools and rated 56 PROs preoperatively (T1), at discharge (T2), 6-weeks (T3), 3-months (T4) and 6-months (T5) postoperatively. ANOVA followed by post-hoc analysis was used to examine patterns in HRQoL through time. Multivariable ANOVA was used to identify impact of clinical factors on HRQoL. RESULTS 63 patients were recruited [median age, 72 (IQR 41-85); 39/63 male]. Physical functioning declined from 70.4 (26.2) at T1 to 53.5 (20.9) at T2 (p = 0.016). Global QoL score increased significantly from 41.0 (23.0) at T2 to 60.0 (26.1) at T5 (p = 0.007), as did role functioning [21.1 (27.9) at T2 to 59.4 (32.8) at T5, p < 0.001]. Chemotherapy status and the postoperative complications did not significantly change HRQoL. General QoL and health were the only PROs rated as 'very important' (scores 7-9) by more than 80 % of participants at five time-points. CONCLUSION Recuperation of HRQoL measures is seen at 6-months postoperative and was not affected by chemotherapy or postoperative complications. Notably, PROs important to patients varied over time.
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Affiliation(s)
- Nejo Joseph
- Department of Surgery, University of Auckland, Auckland, New Zealand
| | - Francis Robertson
- Department of HPB Surgery, Glenfield Hospital, Leicester, United Kingdom
| | - James Lucocq
- Department of General Surgery, NHS Lothian, United Kingdom
| | - Rupaly Pande
- HPB and Transplant Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Sarah Powell-Brett
- HPB and Transplant Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Kate Swainston
- School of Psychology, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Linda Sharp
- School of Psychology, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Exley
- School of Psychology, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Keith Roberts
- HPB and Transplant Unit, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | - Sanjay Pandanaboyana
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, United Kingdom; Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
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Rimmer B, Jenkins R, Russell S, Craig D, Sharp L, Exley C. Assessing quality of life in solid organ transplant recipients: A systematic review of the development, content, and quality of available condition- and transplant-specific patient-reported outcome measures. Transplant Rev (Orlando) 2024; 38:100836. [PMID: 38359538 DOI: 10.1016/j.trre.2024.100836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 02/08/2024] [Accepted: 02/11/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE We aimed to identify the condition- and transplant-specific patient-reported outcome measures (PROMs) available to measure quality of life (QoL) in solid organ transplant (SOT) recipients, examine their development and content, and critically appraise the quality of their measurement properties, to inform recommendations for clinical and research use. METHODS We systematically searched MEDLINE, Embase, CINAHL, PsycINFO, Cochrane CENTRAL, and Scopus from inception to 27th January 2023. Search hits were screened for eligibility by two independent reviewers; papers reporting the development and/or validation of condition- and transplant-specific PROMs measuring QoL in adult SOT recipients were considered eligible. We abstracted and synthesised data on PROM characteristics, development (item generation and/or reduction), and content (QoL dimensions). Quality appraisal and synthesis were informed by the Consensus-based Standards for the Selection of Health Measurement Instruments (COSMIN) guidelines, and included methodological and quality assessment of measurement properties, GRADE levels of evidence, feasibility and interpretability. RESULTS We identified 33 papers reporting 26 QoL PROMs validated in SOT recipients (kidney n = 10 PROMs; liver n = 6; lung n = 3; heart n = 2; pancreas n = 1; multiple organs n = 4). Patient discussions (n = 17 PROMs) and factor analysis (n = 11) were the most common item generation and reduction techniques used, respectively. All PROMs measured ≥3 of nine QoL dimensions (all measured emotional functioning); KDQoL-SF and NIDDK-QA measured all nine. Methodological quality was variable; no PROM had low evidence or better for all measurement properties. All PROMs were COSMIN recommendation category 'B', primarily because none had sufficient content validity. CONCLUSIONS There are many condition- and transplant-specific QoL PROMs validated in SOT recipients, particularly kidney. These findings can help inform PROM selection for clinicians and researchers. However, caution is required when adopting measures, due to the substantial heterogeneity in development, content, and quality. Each PROM has potential but requires further research to be recommendable. Greater consideration of patient and professional involvement in PROM development in this setting is needed to ensure sufficient content validity.
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Affiliation(s)
- Ben Rimmer
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
| | - Rebeka Jenkins
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom; Statistics and Clinical Studies, NHS Blood and Transplant, Bristol, United Kingdom
| | - Siân Russell
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Dawn Craig
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
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Geddis-Regan A, Wassall RR, Abley C, Exley C. Exploring dental treatment decision-making experiences of people living with dementia and family carers. Gerodontology 2024; 41:83-93. [PMID: 37036039 DOI: 10.1111/ger.12687] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2023] [Indexed: 04/11/2023]
Abstract
INTRODUCTION People living with dementia can have complex dental care needs. Dentists and patients should make treatment decisions together, yet some people living with dementia may be unable to make their own decisions about their dental care. Dental treatment decision-making and patients' experiences of this process have not been comprehensively researched. OBJECTIVE This study aimed to explore the dental treatment decision-making perspectives and experiences of people living with dementia and their family members. METHODS Semi-structured interviews were undertaken with 8 people living with dementia and 17 family caregivers. A constructivist grounded theory approach was adopted, using a maximum variation sample. Qualitative data collection and analysis occurred concurrently. Data underwent initial open coding followed by more focused coding, supported by reflexive memo writing, which supported data categorisation. RESULTS People living with dementia reported wanting to be understood as unique individuals with specific needs. All participants described wanting to be actively involved in dental treatment decisions. However, many felt that they were insufficiently involved in treatment decision-making. This perceived underinvolvement meant that some people living with dementia and family members felt the treatment outcomes they sought were neither discussed nor considered. CONCLUSION People living with dementia and carers had specific expectations of dental care yet felt passive in decision-making despite their desire to be involved in this process. Dentists should seek to actively establish patients' preferences, regardless of mental capacity and consider these in discussions and decisions about dental treatment.
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Affiliation(s)
- Andrew Geddis-Regan
- School of Dental Sciences, Newcastle University, Newcastle Upon Tyne, UK
- North Cumbria Integrated Care NHS Foundation Trust, Carlisle Dental Centre, Carlisle, UK
| | - Rebecca R Wassall
- School of Dental Sciences, Newcastle University, Newcastle Upon Tyne, UK
- Newcastle Dental Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Clare Abley
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
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Faraday J, Abley C, Patterson JM, Exley C. An ethnography of mealtime care for people living with dementia in care homes. Dementia (London) 2024:14713012241234160. [PMID: 38380645 DOI: 10.1177/14713012241234160] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/22/2024]
Abstract
Many people living with dementia have difficulties at mealtimes, which can result in serious complications for physical and mental health, leading to hospital admissions and even death. However, current training in mealtime care for staff working with this population has been found to be poorly reported, with variable effectiveness. It is essential that care home staff are able to provide good care at mealtimes. This study used ethnography to explore current practice in mealtime care for this population, identify good practice, and understand the factors influencing mealtime care. Approximately 28 h of mealtime observations were conducted in two UK care homes with diverse characteristics. Observations focused on interactions between care staff and residents living with dementia. Twenty-five semi-structured interviews were carried out with care home staff, family carers, and visiting health and social care professionals, to explore mealtime care from their perspectives. A constant comparative approach was taken, to probe emergent findings and explore topics in greater depth. Key thematic categories were identified, including: tensions in mealtime care; the symbolic nature of mealtime care; navigating tensions via a person-centred approach; contextual constraints on mealtime care; and teamwork in mealtime care. The findings indicated that a person-centred approach helps carers to find the right balance between apparently competing priorities, and teamwork is instrumental in overcoming contextual constraints. This evidence has contributed to development of a training intervention for care home staff. Future research should investigate the feasibility of mealtime care training in care homes.
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Affiliation(s)
- James Faraday
- Population Health Sciences Institute, Newcastle University, UK
- Adult Speech and Language Therapy, The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK
| | - Clare Abley
- Population Health Sciences Institute, Newcastle University, UK
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Mahendran B, Tingle SJ, Malik AK, Figueiredo R, Hammond JS, Sen G, Amer A, Talbot D, Manas DM, Sharp L, Exley C, White S, Wilson CH. Racial disparities in outcomes after liver transplantation in the UK: registry analysis. Br J Surg 2024; 111:znae020. [PMID: 38364060 DOI: 10.1093/bjs/znae020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Revised: 12/20/2023] [Accepted: 01/06/2024] [Indexed: 02/18/2024]
Affiliation(s)
- Balaji Mahendran
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Samuel J Tingle
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Abdullah K Malik
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Rodrigo Figueiredo
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - John S Hammond
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Gourab Sen
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Aimen Amer
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - David Talbot
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
| | - Derek M Manas
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Linda Sharp
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Steven White
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Colin H Wilson
- Department of HPB & Transplant Surgery, Freeman Hospital, Newcastle upon Tyne Hospitals NHS Trust, Newcastle upon Tyne, UK
- NIHR Blood and Transplant Research Unit, Newcastle University, Newcastle upon Tyne, UK
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Geddis-Regan A, Abley C, Exley C, Wassall R. Dentists' Approaches to Treatment Decision-Making for People with Dementia: A Qualitative Study. JDR Clin Trans Res 2023:23800844231199385. [PMID: 37775967 DOI: 10.1177/23800844231199385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/01/2023] Open
Abstract
INTRODUCTION Globally, the number of people living with dementia (PLwD) is projected to increase substantially. Dentists will encounter an increasing number of PLwD retaining natural teeth who need dental care. Dental treatment planning can be complex for PLwD as both oral diseases and dental treatment can be detrimental to patients' oral and social function and comfort. In addition, patients may lack the capacity to make decisions about their treatment, posing further challenges for dentists. OBJECTIVE This study aimed to explore dentists' approach to treatment decision-making with or for PLwD. METHODS Semistructured one-to-one interviews were completed with 22 dentists between April 2020 and March 2021. Data generation and analysis followed the principles of constructivist grounded theory with data being collected and analyzed simultaneously using a maximum variation sample. Interviews were recorded, transcribed verbatim, and then analyzed, leading to a theoretical understanding of how dentists approach treatment decisions for PLwD. RESULTS Four data categories describe dentists' approaches to treatment decision-making for PLwD. Dentists sought to provide individualized care for PLwD. However, they described planning care based on risk-benefit analyses that primarily considered biomedical factors and generic assumptions. There was an underemphasis on the psychological or social implications of dental care or its delivery. Furthermore, while some dentists attempted to involve patients in treatment decisions, they reported fewer attempts to identify the views and preferences of PLwD identified as lacking decisional capacity. In this scenario, dentists reported leading the decision-making process with little regard for patients' known or identified preferences and minimal involvement of PLwD's family. CONCLUSIONS Dentists acknowledge the complexity in treatment decision-making for PLwD yet focused heavily on biomedical considerations, with an underemphasis on individuals' preferences and autonomy. Considering psychosocial aspects of care alongside biomedical factors is essential to support holistic person-centered care for this growing patient cohort. KNOWLEDGE TRANSFER STATEMENT This study highlighted that dentists may only be considering biomedical aspects of care when considering what treatment is appropriate for people living with dementia. When making or supporting treatment decisions, dentists should explore patients' preferences and actively consider relevant psychosocial factors. These can be actively identified through considered discussions with patients as well as their family members. Gathering this information should support more person-centered and value-concordant decision-making for people living with dementia.
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Affiliation(s)
- A Geddis-Regan
- University Dental Hospital of Manchester, Manchester University NHS Foundation Trust, Manchester, UK
| | - C Abley
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Freeman Hospital, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - C Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - R Wassall
- School of Dental Sciences, Newcastle University, Newcastle Upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Dental Hospital, Newcastle upon Tyne, UK
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Sharp L, Mentor K, Deane J, Watson E, Roberts KJ, Silva M, Phillips M, Siriwardena AK, Hammond J, Bradshaw A, Exley C, Pandanaboyana S. Assessing impact, needs and quality-of-life among informal carers of people with pancreatic cancer, a prospective study: the PAN-CARER study protocol. BMJ Open 2023; 13:e068178. [PMID: 37188466 DOI: 10.1136/bmjopen-2022-068178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
INTRODUCTION Approximately 10 300 people are diagnosed with pancreatic cancer each year in the UK. The cancer and its treatment inflict a significant physical, functional and emotional burden on patients. Research suggests that patients have many ongoing needs for support and care, but that these needs are not met by existing services. Family members often step in to fill this gap and provide support and care during and after treatment. Research in other cancers shows that this informal caregiving can place a very heavy burden on carers. However, there are few studies in the international literature that have focused on informal carers in pancreatic cancer; none have been conducted in the UK. METHODS AND ANALYSIS Two complementary research methods will be utilised. First, a longitudinal quantitative study of 300 carers investigating, using validated questionnaires to assess the impact of caregiving (Caregiver Reaction Assessment), the unmet needs of carers (Supportive Care Needs Survey) and the quality-of-life (Short Form 12-item health survey), will be conducted. Second, qualitative interviews will be conducted with up to 30 carers to explore their experiences in more depth. Mixed-effects regression models will be applied to survey results to determine how impact, needs and quality-of-life vary over time, compare outcomes between carers of patients with operable and inoperable disease and identify social factors which affect outcomes. Interview data will undergo reflexive thematic analysis. ETHICS AND DISSEMINATION The protocol has been approved by the Health Research Authority of the UK (Ethical approval IRAS ID 309503). Findings will be published in peer-reviewed journals and presented at national and international conferences.
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Affiliation(s)
- Linda Sharp
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Keno Mentor
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
- HPB and Transplant Unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Jennifer Deane
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Eila Watson
- Clinical Health Care, Oxford Brookes University, Oxford, UK
| | - Keith J Roberts
- Liver Unit, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Michael Silva
- Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | | | | | - John Hammond
- HPB and Transplant unit, Freeman Hospital, Newcastle upon Tyne, UK
| | - Alex Bradshaw
- Sunderland Royal Hospital, Sunderland, Tyne and Wear, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
| | - Sanjay Pandanaboyana
- Population Health Sciences Institute, Newcastle University, Newcastle Upon Tyne, UK
- HPB and Transplant unit, Freeman Hospital, Newcastle upon Tyne, UK
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Lloyd C, Leighton J, Wong LL, Goulding A, Brownlee A, Gray P, Culver E, Halliday N, Thorburn D, Heneghan MA, Jones DEJ, Exley C, Dyson JK. Patient Priorities in Autoimmune Hepatitis: The Need for Better Treatments, More Education and Challenging Stigma. Dig Dis Sci 2023; 68:87-97. [PMID: 35579795 PMCID: PMC9112273 DOI: 10.1007/s10620-022-07525-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 04/18/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Data show that patients with autoimmune hepatitis have significantly reduced quality-of-life and that corticosteroids carry marked side effects. AIMS This study explored patients' experiences of autoimmune hepatitis and its treatments; key aspects for developing safe and effective new approaches to therapy. METHODS An anonymised, internet-based survey collected data including patient demographics, treatments, side-effects, impact on day-to-day life, sources of support and attitudes towards autoimmune hepatitis between December 2019-January 2020. Semi-structured interviews were conducted with 13 patients to further explore their support networks, treatment experiences and health priorities. Descriptive and quantitative analyses were undertaken using R and free text responses were subject to thematic analysis. RESULTS In total, 270 survey responses were received (median age 55 years and 94% female). Perceived medication side-effects were reported by 66% (169/257) and 73% responded negatively about their experience of corticosteroids. The majority (62·3% [(109/175]) would 'definitely' or 'probably' consider clinical trial participation to improve their care. Only 18·7% (31/166) reported access to a specialist liver nurse and nearly half were involved in support groups. Interview and survey data suggested that major issues were stigma, loss of control and fatigue. CONCLUSIONS This study provides insights into the realities of living with autoimmune hepatitis with clear issues around lack of support networks, need for patient empowerment and stigma surrounding liver disease. Patient priorities are better therapies to slow disease progression, avoiding corticosteroids and minimising side-effects. Patient willingness to participate in trials suggests that they are achievable provided they have the right design and clinical endpoints.
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Affiliation(s)
- Charlotte Lloyd
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jessica Leighton
- Translational and Clinical Research Institute, Newcastle University and Liver Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN UK
| | | | - Anna Goulding
- School of Medical Education, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | | | | | - Neil Halliday
- Institute for Liver and Digestive Health, University College London and Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | - Doug Thorburn
- Institute for Liver and Digestive Health, University College London and Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK
| | | | - David E. J. Jones
- Translational and Clinical Research Institute, Newcastle University and Liver Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Jessica K. Dyson
- Translational and Clinical Research Institute, Newcastle University and Liver Unit, Freeman Hospital, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, NE7 7DN UK
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Palmer E, Kavanagh E, Visram S, Bourke AM, Forrest I, Exley C. When should palliative care be introduced for people with progressive fibrotic interstitial lung disease? A meta-ethnography of the experiences of people with end-stage interstitial lung disease and their family carers. Palliat Med 2022; 36:1171-1185. [PMID: 35694777 PMCID: PMC9446428 DOI: 10.1177/02692163221101753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
BACKGROUND Little is currently known about the perspectives of people with interstitial lung disease and their carers in relation to the timing of palliative care conversations. AIM To establish patients' and carers' views on palliative care in interstitial lung disease and identify an optimum time to introduce the concept of palliative care. DESIGN Meta-ethnography of qualitative evidence. The review protocol was prospectively registered with PROSPERO (CRD42021243179). DATA SOURCES Five electronic healthcare databases were searched (Medline, Embase, CINAHL, Scopus and Web of Science) from 1st January 1996 to 31st March 2022. Studies were included that used qualitative methodology and included patients' or carers' perspectives on living with end-stage disease or palliative care. Quality was assessed using the Critical Appraisal Skills Programme checklist. RESULTS About 1779 articles were identified by initial searches. Twelve met the inclusion criteria, providing evidence from 266 individuals across five countries. Three stages were identified in the illness journey of a person with interstitial lung disease: (1) Information seeking, (2) Grief and adjustment, (3) Fear of the future. Palliative care involvement was believed to be most appropriate in the latter two stages and should be prompted by changes in patients' health such as respiratory infections, onset of new symptoms, hospital admission, decline in physical function and initiation of oxygen. CONCLUSIONS Patients and carers prefer referral to palliative care services to be prompted by changes in health status. Future research should focus on supporting timely recognition of changes in patients' health status and how to respond in a community setting.
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Affiliation(s)
- Evelyn Palmer
- Royal Victoria Infirmary, Newcastle upon Tyne, UK.,Marie Curie Hospice Newcastle, Newcastle upon Tyne, UK.,Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
| | | | - Shelina Visram
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Anne-Marie Bourke
- Royal Victoria Infirmary, Newcastle upon Tyne, UK.,Marie Curie Hospice Newcastle, Newcastle upon Tyne, UK
| | - Ian Forrest
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Catherine Exley
- Population Health Sciences, Newcastle University, Newcastle upon Tyne, UK
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11
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Hamilton DW, Heaven B, Thomson R, Wilson J, Exley C. How do patients make decisions in the context of a multidisciplinary team: an ethnographic study of four head and neck cancer centres in the north of England. BMJ Open 2022; 12:e061654. [PMID: 36002202 PMCID: PMC9413178 DOI: 10.1136/bmjopen-2022-061654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
OBJECTIVES To describe how patients are engaged with cancer decisions in the context of multidisciplinary team (MDT) and how MDT recommendations are operationalised in the context of a shared decision. DESIGN Ethnographic qualitative study. SETTING Four head and neck cancer centres in the north of England. PARTICIPANTS Patients with a diagnosis of new or recurrent head and neck cancer; non-participant observation of 35 MDT meetings and 37 MDT clinics, informal interviews, and formal, semistructured interviews with 20 patients and 9 MDT staff members. METHODS Ethnographic methods including non-participant observation of MDT meetings and clinic appointments, informal interviews, field notes and formal semistructured interviews with patients and MDT members. RESULTS MDT discussions often conclude with a firm recommendation for treatment. When delivered to a patient in clinic, this recommendation is often accepted by the patient, but this response may result from the disempowered position in which they find themselves. While patient behaviour may thus appear to endorse clinicians' views that a paternalistic approach is desired by patients (creating a 'cycle of paternalism'), the rigidity of the MDT treatment recommendation can act as a barrier to discussion of options and the exploration of patient values. CONCLUSIONS The current model of MDT decision-making does not support shared decision-making and may actively undermine it. A model should be developed whereby the individual patient perspective has more input into MDT discussions, and where decisions are made on potential treatment options rather than providing a single recommendation for discussion with the patient. Deeper consideration should be given to how the MDT incorporates the patient perspective and/or delivers its discussion of options to the patient. In order to achieve these objectives, a new model of MDT working is required.
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Affiliation(s)
- David Winston Hamilton
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
- ENT, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Benjamin Heaven
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Richard Thomson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Janet Wilson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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12
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Price CI, White P, Balami J, Bhattarai N, Coughlan D, Exley C, Flynn D, Halvorsrud K, Lally J, McMeekin P, Shaw L, Snooks H, Vale L, Watkins A, Ford GA. Improving emergency treatment for patients with acute stroke: the PEARS research programme, including the PASTA cluster RCT. Programme Grants Appl Res 2022. [DOI: 10.3310/tzty9915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
Intravenous thrombolysis and intra-arterial thrombectomy are proven emergency treatments for acute ischaemic stroke, but they require rapid delivery to selected patients within specialist services. National audit data have shown that treatment provision is suboptimal.
Objectives
The aims were to (1) determine the content, clinical effectiveness and day 90 cost-effectiveness of an enhanced paramedic assessment designed to facilitate thrombolysis delivery in hospital and (2) model thrombectomy service configuration options with optimal activity and cost-effectiveness informed by expert and public views.
Design
A mixed-methods approach was employed between 2014 and 2019. Systematic reviews examined enhanced paramedic roles and thrombectomy effectiveness. Professional and service user groups developed a thrombolysis-focused Paramedic Acute Stroke Treatment Assessment, which was evaluated in a pragmatic multicentre cluster randomised controlled trial and parallel process evaluation. Clinicians, patients, carers and the public were surveyed regarding thrombectomy service configuration. A decision tree was constructed from published data to estimate thrombectomy eligibility of the UK stroke population. A matching discrete-event simulation predicted patient benefits and financial consequences from increasing the number of centres.
Setting
The paramedic assessment trial was hosted by three regional ambulance services (in north-east England, north-west England and Wales) serving 15 hospitals.
Participants
A total of 103 health-care representatives and 20 public representatives assisted in the development of the paramedic assessment. The trial enrolled 1214 stroke patients within 4 hours of symptom onset. Thrombectomy service provision was informed by a Delphi exercise with 64 stroke specialists and neuroradiologists, and surveys of 147 patients and 105 public respondents.
Interventions
The paramedic assessment comprised additional pre-hospital information collection, structured hospital handover, practical assistance up to 15 minutes post handover, a pre-departure care checklist and clinician feedback.
Main outcome measures
The primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included day 90 health (poor status was a modified Rankin Scale score of > 2). Economic outputs reported the number of cases treated and cost-effectiveness using quality-adjusted life-years and Great British pounds.
Data sources
National registry data from the Sentinel Stroke National Audit Programme and the Scottish Stroke Care Audit were used.
Review methods
Systematic searches of electronic bibliographies were used to identify relevant literature. Study inclusion and data extraction processes were described using Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.
Results
The paramedic assessment trial found a clinically important but statistically non-significant reduction in thrombolysis among intervention patients, compared with standard care patients [197/500 (39.4%) vs. 319/714 (44.7%), respectively] (adjusted odds ratio 0.81, 95% confidence interval 0.61 to 1.08; p = 0.15). The rate of poor health outcomes was not significantly different, but was lower in the intervention group than in the standard care group [313/489 (64.0%) vs. 461/690 (66.8%), respectively] (adjusted odds ratio 0.86, 95% confidence interval 0.60 to 1.2; p = 0.39). There was no difference in the quality-adjusted life-years gained between the groups (0.005, 95% confidence interval –0.004 to 0.015), but total costs were significantly lower for patients in the intervention group than for those in the standard care group (–£1086, 95% confidence interval –£2236 to –£13). It has been estimated that, in the UK, 10,140–11,530 patients per year (i.e. 12% of stroke admissions) are eligible for thrombectomy. Meta-analysis of published data confirmed that thrombectomy-treated patients were significantly more likely to be functionally independent than patients receiving standard care (odds ratio 2.39, 95% confidence interval 1.88 to 3.04; n = 1841). Expert consensus and most public survey respondents favoured selective secondary transfer for accessing thrombectomy at regional neuroscience centres. The discrete-event simulation model suggested that six new English centres might generate 190 quality-adjusted life-years (95% confidence interval –6 to 399 quality-adjusted life-years) and a saving of £1,864,000 per year (95% confidence interval –£1,204,000 to £5,017,000 saving per year). The total mean thrombectomy cost up to 72 hours was £12,440, mostly attributable to the consumables. There was no significant cost difference between direct admission and secondary transfer (mean difference –£368, 95% confidence interval –£1016 to £279; p = 0.26).
Limitations
Evidence for paramedic assessment fidelity was limited and group allocation could not be masked. Thrombectomy surveys represented respondent views only. Simulation models assumed that populations were consistent with published meta-analyses, included limited parameters reflecting underlying data sets and did not consider the capital costs of setting up new services.
Conclusions
Paramedic assessment did not increase the proportion of patients receiving thrombolysis, but outcomes were consistent with improved cost-effectiveness at day 90, possibly reflecting better informed treatment decisions and/or adherence to clinical guidelines. However, the health difference was non-significant, small and short term. Approximately 12% of stroke patients are suitable for thrombectomy and widespread provision is likely to generate health and resource gains. Clinician and public views support secondary transfer to access treatment.
Future work
Further evaluation of emergency care pathways will determine whether or not enhanced paramedic assessment improves hospital guideline compliance. Validation of the simulation model post reconfiguration will improve precision and describe wider resource implications.
Trial registration
This trial is registered as ISRCTN12418919 and the systematic review protocols are registered as PROSPERO CRD42014010785 and PROSPERO CRD42015016649.
Funding
The project was funded by the National Institute for Health and Care Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Phil White
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joyce Balami
- Department of Stroke Medicine, Norfolk and Norwich University Teaching Hospital NHS Trust, Norwich, UK
| | - Nawaraj Bhattarai
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Diarmuid Coughlan
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- School of Health & Life Sciences, Teesside University, Middlesbrough, UK
| | - Kristoffer Halvorsrud
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Lally
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Peter McMeekin
- School of Health, Community and Education Studies, Northumbria University, Newcastle upon Tyne, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Snooks
- Centre for Health Information Research and Evaluation, Medical School, Swansea University, Swansea, UK
| | - Luke Vale
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Alan Watkins
- Centre for Health Information Research and Evaluation, Medical School, Swansea University, Swansea, UK
| | - Gary A Ford
- Oxford Academic Health Science Network, Oxford University and Oxford University Hospitals, Oxford, UK
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13
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Palmer E, Kavanagh E, Visram S, Bourke AM, Forrest I, Exley C. Which factors influence the quality of end-of-life care in interstitial lung disease? A systematic review with narrative synthesis. Palliat Med 2022; 36:237-253. [PMID: 34920685 PMCID: PMC8894683 DOI: 10.1177/02692163211059340] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND People dying from interstitial lung disease experience considerable symptoms and commonly die in an acute healthcare environment. However, there is limited understanding about the quality of their end-of-life care. AIM To synthesise evidence about end-of-life care in interstitial lung disease and identify factors that influence quality of care. DESIGN Systematic literature review and narrative synthesis. The review protocol was prospectively registered with PROSPERO (CRD42020203197). DATA SOURCES Five electronic healthcare databases were searched (Medline, Embase, PubMed, Scopus and Web of Science) from January 1996 to February 2021. Studies were included if they focussed on the end-of-life care or death of patients with interstitial lung disease. Quality was assessed using the Critical Appraisal Skills Programme checklist for the relevant study design. RESULTS A total of 4088 articles were identified by initial searches. Twenty-four met the inclusion criteria, providing evidence from 300,736 individuals across eight countries. Most patients with interstitial lung disease died in hospital, with some subjected to a high burden of investigations or life-prolonging treatments. Low levels of involvement with palliative care services and advance care planning contributed to the trend of patients dying in acute environments. This review identified a paucity of research that addressed symptom management in the last few days or weeks of life. CONCLUSIONS There is inadequate knowledge regarding the most appropriate location for end-of-life care for people with interstitial lung disease. Early palliative care involvement can improve accordance with end-of-life care wishes. Future research should consider symptom management at the end-of-life and association with location of death.
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Affiliation(s)
- Evelyn Palmer
- Royal Victoria Infirmary, Newcastle upon Tyne, UK.,Marie Curie Hospice Newcastle, Newcastle upon Tyne, UK.,Newcastle University, Population Health Sciences, Newcastle upon Tyne, UK
| | | | - Shelina Visram
- Newcastle University, Population Health Sciences, Newcastle upon Tyne, UK
| | - Anne-Marie Bourke
- Royal Victoria Infirmary, Newcastle upon Tyne, UK.,Marie Curie Hospice Newcastle, Newcastle upon Tyne, UK
| | - Ian Forrest
- Royal Victoria Infirmary, Newcastle upon Tyne, UK
| | - Catherine Exley
- Newcastle University, Population Health Sciences, Newcastle upon Tyne, UK
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14
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Faraday J, Abley C, Exley C, Patterson J. Improving mealtime care for people with dementia: A training intervention for care home staff. Alzheimers Dement 2021. [DOI: 10.1002/alz.051104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- James Faraday
- Newcastle University Newcastle upon Tyne United Kingdom
- The Newcastle upon Tyne Hospitals NHS Foundation Trust Newcastle upon Tyne United Kingdom
| | - Clare Abley
- Newcastle University Newcastle upon Tyne United Kingdom
- The Newcastle upon Tyne Hospitals NHS Foundation Trust Newcastle upon Tyne United Kingdom
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15
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Vernazza C, Carr K, Holmes R, Wildman J, Gray J, Exley C, Smith R, Donaldson C. Resource Allocation in a National Dental Service Using Program Budgeting Marginal Analysis. JDR Clin Trans Res 2021; 8:23800844211056241. [PMID: 34844457 PMCID: PMC9772892 DOI: 10.1177/23800844211056241] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION In any health system, choices must be made about the allocation of resources (budget), which are often scarce. Economics has defined frameworks to aid resource allocation, and program budgeting marginal analysis (PBMA) is one such framework. In principle, patient and public values can be incorporated into these frameworks, using techniques such as willingness to pay (WTP). However, this has not been done before, and few formal resource allocation processes have been undertaken in dentistry. This study aimed to undertake a PBMA with embedded WTP values in a national dental setting. METHODS The PBMA process was undertaken by a panel of participant-researchers representing commissioners, dentists, dental public health staff, and academics. The panel reviewed current allocations and generated a set of weighted criteria to evaluate services against. Services to be considered for removal and investment were determined by the panel and wider discussion and then scored against the criteria. Values from a nationally representative WTP survey of the public contributed to the scores for interventions. Final decisions on removal and investment were taken after panel discussion using individual anonymous electronic voting. RESULTS The PBMA process resulted in recommendations to invest in new program components to improve access to general dentists, care home dentistry, and extra support for dental public health input into local government decisions. Disinvestments were recommended in orthodontics and to remove routine scaling and polishing of teeth. DISCUSSION The PBMA process was successful in raising awareness of resource allocation issues. Implementation of findings will depend on the ability of decision makers to find ways of operationalizing the decisions. The process illustrates practical aspects of the process that future dental PBMAs could learn from. KNOWLEDGE TRANSFER STATEMENT This study illustrates a framework for resource allocation in dental health services and will aid decision makers in implementing their own resource allocation systems.
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Affiliation(s)
- C.R. Vernazza
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - K. Carr
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - R.D. Holmes
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - J. Wildman
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - J. Gray
- Nursing, Midwifery & Health, Northumbria University, Newcastle-upon-Tyne, UK
| | - C. Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - R.A. Smith
- ScHARR, University of Sheffield, Regent Court, Sheffield, UK
| | - C. Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
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16
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Standing H, Thomson RG, Flynn D, Hughes J, Joyce K, Lobban T, Lord S, Matlock DD, McComb JM, Paes P, Wilkinson C, Exley C. 'You can't start a car when there's no petrol left': a qualitative study of patient, family and clinician perspectives on implantable cardioverter defibrillator deactivation. BMJ Open 2021; 11:e048024. [PMID: 34230020 PMCID: PMC8261879 DOI: 10.1136/bmjopen-2020-048024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
OBJECTIVE To explore the attitudes towards implantable cardioverter defibrillator (ICD) deactivation and initiation of deactivation discussions among patients, relatives and clinicians. DESIGN A multiphase qualitative study consisting of in situ hospital ICD clinic observations, and semistructured interviews of clinicians, patients and relatives. Data were analysed using a constant comparative approach. SETTING One tertiary and two district general hospitals in England. PARTICIPANTS We completed 38 observations of hospital consultations prior to ICD implantation, and 80 interviews with patients, family members and clinicians between 2013 and 2015. Patients were recruited from preimplantation to postdeactivation. Clinicians included cardiologists, cardiac physiologists, heart failure nurses and palliative care professionals. RESULTS Four key themes were identified from the data: the current status of deactivation discussions; patients' perceptions of deactivation; who should take responsibility for deactivation discussions and decisions; and timing of deactivation discussions. We found that although patients and doctors recognised the importance of advance care planning, including ICD deactivation at an early stage in the patient journey, this was often not reflected in practice. The most appropriate clinician to take the lead was thought to be dependent on the context, but could include any appropriately trained member of the healthcare team. It was suggested that deactivation should be raised preimplantation and regularly reviewed. Identification of trigger points postimplantation for deactivation discussions may help ensure that these are timely and inappropriate shocks are avoided. CONCLUSIONS There is a need for early, ongoing and evolving discussion between ICD recipients and clinicians regarding the eventual need for ICD deactivation. The most appropriate clinician to instigate deactivation discussions is likely to vary between patients and models of care. Reminders at key trigger points, and routine discussion of deactivation at implantation and during advance care planning could prevent distressing experiences for both the patient and their family at the end of life.
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Affiliation(s)
- Holly Standing
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Richard G Thomson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Darren Flynn
- Centre for Rehabilitation, Exercise and Sports Science, Teesside University, Middlesbrough, UK
| | - Julian Hughes
- Department of Population and Health Sciences, University of Bristol, Bristol, UK
| | - Kerry Joyce
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Stephen Lord
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, Newcastle upon Tyne, UK
| | - Dan D Matlock
- School of Medicine, University of Colorado, Denver, Colorado, USA
| | - Janet M McComb
- Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, Newcastle upon Tyne, UK
| | - Paul Paes
- Northumbria Healthcare NHS Foundation Trust, North Shields, UK
| | - Chris Wilkinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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17
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Faraday J, Abley C, Exley C, Patterson J. 37 Factors Influencing Mealtime Care for People with Dementia Living in Care Homes: An Ethnographic Study. Age Ageing 2021. [DOI: 10.1093/ageing/afab029.16] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Introduction
More and more people with dementia are living in care homes. Often they depend on care home staff for help with eating and drinking. It is essential that care home staff are able to provide good care at mealtimes. This study used ethnography to identify factors influencing mealtime care for this population.
Methods
Over twenty-five hours of mealtime observations were conducted in two UK care homes with diverse characteristics. Observations focused on interactions between care home staff and residents living with dementia. Twenty-two semi-structured interviews were carried out with care home staff, family carers, and visiting health and social care professionals, to explore mealtime care from their perspectives. The study used a constant comparison approach, so that data from early observations and interviews were explored in more depth subsequently.
Results
Five factors were identified which influenced mealtime care for people with dementia living in care homes. These were: environment (such as background music and building layout); kitchen and food (including connectivity between kitchen staff and others); staffing (for example: staff ratios and allocation); knowledge and support (including training, resources and supportive culture); and relationship with wider care team (such as family involvement, and the role of visiting health and social care professionals).
Conclusions
This study is part of a bigger project which will develop a staff training intervention to improve mealtime care for people with dementia living in care homes. The intervention will be informed by these findings, and by complementary evidence on good practice in mealtime care (from primary and secondary studies). It is anticipated that good mealtime care may improve quality of life for care home residents, and reduce hospital admissions.
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Affiliation(s)
- J Faraday
- The Newcastle upon Tyne Hospitals NHS Foundation Trust
| | - C Abley
- The Newcastle upon Tyne Hospitals NHS Foundation Trust
| | - C Exley
- Faculty of Medical Sciences, Newcastle University
| | - J Patterson
- Institute of Population Health, University of Liverpool
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Abstract
In qualitative research, the researcher is the research instrument. Therefore, a qualitative researcher who is also a clinician must consider how their dual position informs participant consent, data collection, and analysis. This reflexivity is essential in research design to effectively respond to ethical questions around role, authenticity, trust, and transparency around disclosing their clinician status to participants.
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Affiliation(s)
- A.R. Geddis-Regan
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - C. Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - G.D. Taylor
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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19
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Price CI, Shaw L, Islam S, Javanbakht M, Watkins A, McMeekin P, Snooks H, Flynn D, Francis R, Lakey R, Sutcliffe L, McClelland G, Lally J, Exley C, Rodgers H, Russell I, Vale L, Ford GA. Effect of an Enhanced Paramedic Acute Stroke Treatment Assessment on Thrombolysis Delivery During Emergency Stroke Care: A Cluster Randomized Clinical Trial. JAMA Neurol 2021; 77:840-848. [PMID: 32282015 PMCID: PMC7154959 DOI: 10.1001/jamaneurol.2020.0611] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Question Can hospital stroke thrombolysis treatment rates be increased by an enhanced paramedic assessment that includes additional prehospital information collection, a structured hospital handover, practical assistance after handover, a predeparture care checklist, and clinician feedback? Findings In this cluster randomized clinical trial, fewer patients in the intervention group (39.4%) received thrombolysis vs those in the standard care group (44.7%), but there were fewer poor health outcomes (disability or death) after 90 days (intervention group, 64.0% vs standard care group, 66.8%). The results were not statistically significant. Meaning This study found that the enhanced paramedic assessment should not be used to increase thrombolysis volume but may influence the quality of treatment decisions. Importance Rapid thrombolysis treatment for acute ischemic stroke reduces disability among patients who are carefully selected, but service delivery is challenging. Objective To determine whether an enhanced Paramedic Acute Stroke Treatment Assessment (PASTA) intervention increased hospital thrombolysis rates. Design, Setting, and Participants This multicenter, cluster randomized clinical trial took place between December 2015 and July 2018 in 3 ambulance services and 15 hospitals. Clusters were paramedics based within ambulance stations prerandomized to PASTA or standard care. Patients attended by study paramedics were enrolled after admission if a hospital specialist confirmed a stroke and paramedic assessment started within 4 hours of onset. Allocation to PASTA or standard care reflected the attending paramedic’s randomization status. Interventions The PASTA intervention included additional prehospital information collection, a structured hospital handover, practical assistance up to 15 minutes after handover, a predeparture care checklist, and clinician feedback. Standard care reflected national guidelines. Main Outcomes and Measures Primary outcome was the proportion of patients receiving thrombolysis. Secondary outcomes included time intervals and day 90 health (with poor status defined as a modified Rankin Score >2, to represent dependency or death). Results A total of 11 478 patients were screened following ambulance transportation; 1391 were eligible and approached, but 177 did not consent. Of 1214 patients enrolled (mean [SD] age, 74.7 [13.2] years; 590 women [48.6%]), 500 were assessed by 242 paramedics trained in the PASTA intervention and 714 were assessed by 355 paramedics continuing with standard care. The paramedics trained in the PASTA intervention took a mean of 13.4 (95% CI, 9.4-17.4) minutes longer (P < .001) to complete patient care episodes. There was less thrombolysis among the patients in the PASTA group, but this was not significant (PASTA group, 197 of 500 patients [39.4%] vs the standard care group, 319 of 714 patients [44.7%]; adjusted odds ratio, 0.81 [95% CI, 0.61-1.08]; P = .15). Time from a paramedic on scene to thrombolysis was a mean of 8.5 minutes longer in the PASTA group (98.1 [37.6] minutes) vs the standard care group (89.4 [31.1] minutes; P = .01). Poor health outcomes did not differ significantly but occurred less often among patients in the PASTA group (313 of 489 patients [64.0%]) vs the standard care group (461 of 690 patients [66.8%]; adjusted odds ratio, 0.86 [95% CI, 0.60-1.20]; P = .39). Conclusions and Relevance An enhanced paramedic assessment did not facilitate thrombolysis delivery. The unexpected combination of thrombolysis and health outcomes suggests possible alternative influences on treatment decisions by the intervention, requiring further evaluation. Trial Registration ISRCTN Registry Identifier: ISRCTN12418919
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Saiful Islam
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Mehdi Javanbakht
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Alan Watkins
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Helen Snooks
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Rachel Lakey
- Newcastle Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Lou Sutcliffe
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom
| | | | - Joanne Lally
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom.,Newcastle upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Ian Russell
- Swansea University Medical School, Swansea, Wales, United Kingdom
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, Oxford, United Kingdom.,Oxford University Hospitals National Health Service Foundation Trust, Oxford, United Kingdom
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20
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Faraday J, Abley C, Exley C, Patterson J. Mealtime Care for People With Dementia: What Do Nursing Home Staff Think? Innov Aging 2020. [PMCID: PMC7740585 DOI: 10.1093/geroni/igaa057.591] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
More and more people with dementia are living in nursing homes (NH). Often, they depend on NH staff for help with eating and drinking. It is important that staff have the skills and support they need to provide good care at mealtimes. This qualitative study explores mealtime care for people with dementia, from the perspective of NH staff. Semi-structured interviews with NH staff (n=16) were carried out in two nursing homes. The homes were chosen to have diverse characteristics: one home had a large number of beds and was part of a small local organization; the other had a small number of beds and was part of a large national organization. Various staff members were interviewed, including direct care staff, senior carers, nurses, managers, and kitchen staff. Interviews were audio-recorded and transcribed verbatim. A constant comparison approach was taken, so that data from early interviews were explored in more depth subsequently. From the analysis, five themes emerged as important in mealtime care for people with dementia living in nursing homes: Setting the right tone; Working well as a team; Knowing the residents; Promoting autonomy and independence; Gently persevering. This work forms part of a larger ethnographic study on the topic, which includes data from residents with dementia, and family carers. Results will inform the development of a staff training intervention to optimize mealtime care for this population.
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Affiliation(s)
- James Faraday
- Newcastle University, UK, Newcastle upon Tyne, United Kingdom
| | - Clare Abley
- The Newcastle upon Tyne Hospitals NHS Foundation Trust, UK, Newcastle upon Tyne, United Kingdom
| | - Catherine Exley
- Newcastle University, UK, Newcastle upon Tyne, United Kingdom
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21
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Geddis‐Regan A, Errington L, Abley C, Wassall R, Exley C, Thomson R. Enhancing shared and surrogate decision making for people living with dementia: A systematic review of the effectiveness of interventions. Health Expect 2020; 24:19-32. [PMID: 33248009 PMCID: PMC7879553 DOI: 10.1111/hex.13167] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Revised: 10/27/2020] [Accepted: 11/05/2020] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Dementia can have a profound impact on decision making. People living with dementia (PLwD) often need to make decisions about health care, and, as dementia progresses, decisions may need to be made on their behalf. Specific interventions may support this process. REVIEW QUESTION What interventions are effective in improving shared decision making or surrogate decision making on the health care of PLwD? METHODS A narrative systematic review of existing literature was conducted. Seven databases, grey literature and key journals were searched. After exclusion by title, abstracts then full texts were reviewed collaboratively to manage any disagreements. RESULTS Eight studies met the inclusion criteria. Two articles, including one RCT, evaluated decision aids regarding the use of enteral feeding in advanced dementia. Six further articles, including five RCTs, were found which evaluated the effectiveness of interventions supporting patients or carers with advance care planning. CONCLUSION Decision-making interventions typically consist of multiple components which aim to establish preferences for future health care. Advance care planning interventions supported aspects of the decision-making processes but their impact on decision quality was rarely evaluated. Interventions did not increase the concordance of decisions with a person's values. The decision-specific interventions are unlikely to produce benefit in other decision contexts. PATIENT INVOLVEMENT Two caregivers, a public stakeholder group and a carer group were consulted in the design of the wider study to which this review relates. Six PLwD refined the research questions addressed in this paper.
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Affiliation(s)
- Andrew Geddis‐Regan
- School of Dental SciencesNewcastle UniversityNewcastle upon TyneUK
- Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Linda Errington
- Faculty of Medical SciencesNewcastle UniversityNewcastle upon TyneUK
| | - Clare Abley
- Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Rebecca Wassall
- School of Dental SciencesNewcastle UniversityNewcastle upon TyneUK
- Newcastle upon Tyne Hospitals NHS Foundation TrustNewcastle upon TyneUK
| | - Catherine Exley
- Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Richard Thomson
- Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
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22
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van der Zande MM, Exley C, Wilson SA, Harris RV. Disentangling a web of causation: An ethnographic study of interlinked patient barriers to planned dental visiting, and strategies to overcome them. Community Dent Oral Epidemiol 2020; 49:144-157. [PMID: 33104275 DOI: 10.1111/cdoe.12586] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 08/07/2020] [Accepted: 10/04/2020] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To explore barriers to planned dental visiting, investigating how barriers interlink, how they accumulate and change, and how individuals envisage overcoming their combination of barriers through personal strategies. METHODS An ethnographic study was conducted of adult urgent dental care attenders who did not have a dentist, including 155 hours of nonparticipant observations, 97 interviews and 19 follow-up interviews in six urgent dental care settings. Data were analysed using constant comparison, first identifying barriers and personal strategies to overcome them, and subsequently analysing interlinks between barriers and personal strategies. RESULTS Accounts of barriers to planned dental visiting encompassed multiple barriers, which related to socioeconomic circumstances as well as experiences of oral health care. Barriers were multi-layered and more difficult to overcome when occurring together. Personal strategies to overcome diverse barriers often hinged on increasing importance of oral health to individuals, yet this was not always sufficient. The combination of barriers participants experience was dynamic, changing due to personal, family, or employment circumstances, and with increasing severity of barriers over time. Over time, this could lead to higher cost, and additional barriers, particularly embarrassment. CONCLUSION Barriers to planned dental visiting are complex, multi-layered and change over time, constituting a 'web of causation'. This adds a novel perspective to the literature on barriers to dental visiting, and requires that researchers, dental practitioners and policy makers remain open to barriers' interlinked effects, changes in primacy among individual patients' barriers, and their accumulation over time to better support uptake of planned dental visiting.
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Affiliation(s)
- Marieke M van der Zande
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Samantha A Wilson
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
| | - Rebecca V Harris
- Department of Public Health, Policy and Systems, Institute of Population Health, University of Liverpool, Liverpool, UK
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23
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Standing H, Patterson R, Lee M, Dalkin SM, Lhussier M, Bate A, Exley C, Brittain K. Information sharing challenges in end-of-life care: a qualitative study of patient, family and professional perspectives on the potential of an Electronic Palliative Care Co-ordination System. BMJ Open 2020; 10:e037483. [PMID: 33020093 PMCID: PMC7537426 DOI: 10.1136/bmjopen-2020-037483] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
OBJECTIVES To explore current challenges in interdisciplinary management of end-of-life care in the community and the potential of an Electronic Palliative Care Co-ordination System (EPaCCS) to facilitate the delivery of care that meets patient preferences. DESIGN Qualitative study using interviews and focus groups. SETTING Health and Social Care Services in the North of England. PARTICIPANTS 71 participants, 62 health and social care professionals, 9 patients and family members. RESULTS Four key themes were identified: information sharing challenges; information sharing systems; perceived benefits of an EPaCCS and barriers to use and requirements for an EPaCCS. Challenges in sharing information were a source of frustration for health and social care professionals as well as patients, and were suggested to result in inappropriate hospital admissions. Current systems were perceived by participants to not work well-paper advance care planning (ACP) documentation was often unavailable or inaccessible, meaning it could not be used to inform decision-making at the point of care. Participants acknowledged the benefits of an EPaCCS to facilitate information sharing; however, they also raised concerns about confidentiality, and availability of the increased time and resources required to access and maintain such a system. CONCLUSIONS EPaCCS offer a potential solution to information sharing challenges in end-of-life care. However, our findings suggest that there are issues in the initiation and documentation of end-of-life discussions that must be addressed through investment in training in order to ensure that there is sufficient information regarding ACP to populate the system. There is a need for further qualitative research evaluating use of an EPaCCS, which explores benefits and challenges, uptake and reasons for disparities in use to better understand the potential utility and implications of such systems.
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Affiliation(s)
- Holly Standing
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | - Rebecca Patterson
- Research and Innovation Services, Northumbria University, Newcastle upon Tyne, UK
| | - Mark Lee
- St Benedict's Hopsice and Specialist Palliative Care Centre, Sunderland, UK
| | - Sonia Michelle Dalkin
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Monique Lhussier
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Angela Bate
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Katie Brittain
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
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24
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Robinson L, Poole M, McLellan E, Lee R, Amador S, Bhattarai N, Bryant A, Coe D, Corbett A, Exley C, Goodman C, Gotts Z, Harrison-Dening K, Hill S, Howel D, Hrisos S, Hughes J, Kernohan A, Macdonald A, Mason H, Massey C, Neves S, Paes P, Rennie K, Rice S, Robinson T, Sampson E, Tucker S, Tzelis D, Vale L, Bamford C. Supporting good quality, community-based end-of-life care for people living with dementia: the SEED research programme including feasibility RCT. Programme Grants Appl Res 2020. [DOI: 10.3310/pgfar08080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Background
In the UK, most people with dementia die in the community and they often receive poorer end-of-life care than people with cancer.
Objective
The overall aim of this programme was to support professionals to deliver good-quality, community-based care towards, and at, the end of life for people living with dementia and their families.
Design
The Supporting Excellence in End-of-life care in Dementia (SEED) programme comprised six interlinked workstreams. Workstream 1 examined existing guidance and outcome measures using systematic reviews, identified good practice through a national e-survey and explored outcomes of end-of-life care valued by people with dementia and family carers (n = 57) using a Q-sort study. Workstream 2 explored good-quality end-of-life care in dementia from the perspectives of a range of stakeholders using qualitative methods (119 interviews, 12 focus groups and 256 observation hours). Using data from workstreams 1 and 2, workstream 3 used co-design methods with key stakeholders to develop the SEED intervention. Worksteam 4 was a pilot study of the SEED intervention with an embedded process evaluation. Using a cluster design, we assessed the feasibility and acceptability of recruitment and retention, outcome measures and our intervention. Four general practices were recruited in North East England: two were allocated to the intervention and two provided usual care. Patient recruitment was via general practitioner dementia registers. Outcome data were collected at baseline, 4, 8 and 12 months. Workstream 5 involved economic modelling studies that assessed the potential value of the SEED intervention using a contingent valuation survey of the general public (n = 1002). These data informed an economic decision model to explore how the SEED intervention might influence care. Results of the model were presented in terms of the costs and consequences (e.g. hospitalisations) and, using the contingent valuation data, a cost–benefit analysis. Workstream 6 examined commissioning of end-of-life care in dementia through a narrative review of policy and practice literature, combined with indepth interviews with a national sample of service commissioners (n = 20).
Setting
The workstream 1 survey and workstream 2 included services throughout England. The workstream 1 Q-sort study and workstream 4 pilot trial took place in North East England. For workstream 4, four general practices were recruited; two received the intervention and two provided usual care.
Results
Currently, dementia care and end-of-life care are commissioned separately, with commissioners receiving little formal guidance and training. Examples of good practice rely on non-recurrent funding and leadership from an interested clinician. Seven key components are required for good end-of-life care in dementia: timely planning discussions, recognising end of life and providing supportive care, co-ordinating care, effective working with primary care, managing hospitalisation, continuing care after death, and valuing staff and ongoing learning. Using co-design methods and the theory of change, the seven components were operationalised as a primary care-based, dementia nurse specialist intervention, with a care resource kit to help the dementia nurse specialist improve the knowledge of family and professional carers. The SEED intervention proved feasible and acceptable to all stakeholders, and being located in the general practice was considered beneficial. None of the outcome measures was suitable as the primary outcome for a future trial. The contingent valuation showed that the SEED intervention was valued, with a wider package of care valued more than selected features in isolation. The SEED intervention is unlikely to reduce costs, but this may be offset by the value placed on the SEED intervention by the general public.
Limitations
The biggest challenge to the successful delivery and completion of this research programme was translating the ‘theoretical’ complex intervention into practice in an ever-changing policy and service landscape at national and local levels. A major limitation for a future trial is the lack of a valid and relevant primary outcome measure to evaluate the effectiveness of a complex intervention that influences outcomes for both individuals and systems.
Conclusions
Although the dementia nurse specialist intervention was acceptable, feasible and integrated well with existing care, it is unlikely to reduce costs of care; however, it was highly valued by all stakeholders (professionals, people with dementia and their families) and has the potential to influence outcomes at both an individual and a systems level.
Future work
There is no plan to progress to a full randomised controlled trial of the SEED intervention in its current form. In view of new National Institute for Health and Care Excellence dementia guidance, which now recommends a care co-ordinator for all people with dementia, the feasibility of providing the SEED intervention throughout the illness trajectory should be explored. Appropriate outcome measures to evaluate the effectiveness of such a complex intervention are needed urgently.
Trial registration
Current Controlled Trials ISRCTN21390601.
Funding
This project was funded by the National Institute for Health Research (NIHR) Programme Grants for Applied Research programme and will be published in full in Programme Grants for Applied Research, Vol. 8, No. 8. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Louise Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Marie Poole
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Emma McLellan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Richard Lee
- Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Sarah Amador
- Division of Psychiatry, University College London, London, UK
| | - Nawaraj Bhattarai
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Andrew Bryant
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Dorothy Coe
- North East and North Cumbria Local Clinical Research Network, Newcastle upon Tyne, UK
| | - Anne Corbett
- College of Medicine and Health, University of Exeter, Exeter, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Claire Goodman
- School of Health and Social Work, University of Hertfordshire, Hatfield, UK
| | - Zoe Gotts
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Sarah Hill
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Denise Howel
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Susan Hrisos
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Ashleigh Kernohan
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | | | - Helen Mason
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Christopher Massey
- Cumbria, Northumberland, Tyne and Wear NHS Foundation Trust, Newcastle upon Tyne, UK
| | | | - Paul Paes
- Northumbria Healthcare NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Katherine Rennie
- Faculty of Medical Sciences, Professional Services, Newcastle University, Newcastle upon Tyne, UK
| | - Stephen Rice
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Tomos Robinson
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Elizabeth Sampson
- Marie Curie Palliative Care Research Department, University College London, London, UK
| | | | - Dimitrios Tzelis
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Claire Bamford
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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25
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Standing H, Patterson R, Dalkin S, Exley C, Brittain K. A critical exploration of professional jurisdictions and role boundaries in inter-professional end-of-life care in the community. Soc Sci Med 2020; 266:113300. [PMID: 32992263 DOI: 10.1016/j.socscimed.2020.113300] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Revised: 08/04/2020] [Accepted: 08/13/2020] [Indexed: 11/17/2022]
Abstract
This article critically examines how professional boundaries and hierarchies influence how end-of-life care is managed and negotiated between health and social care professionals. Our findings suggest there is uncertainty and lack of clarity amongst health and social care professionals regarding whose responsibility it is to engage, and document, the wishes of patients who are dying, which can lead to ambiguity in treatment decisions. We go on to explore the potential role of a new electronic system, designed to facilitate information sharing across professional boundaries, in shaping and bridging professional boundaries in the delivery of end-of-life care. We highlight potential negative impacts that may arise when health and social care groups are permitted varying levels of access to the system, and how this may be seen to reflect the value placed on their role in end-of-life care.
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Affiliation(s)
- Holly Standing
- Department of Nursing, Midwifery and Health, Northumbria University, UK.
| | | | - Sonia Dalkin
- Department of Social Work, Education and Community Wellbeing, Northumbria University, UK
| | - Catherine Exley
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK
| | - Katie Brittain
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, UK
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26
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Tang EYH, Robinson L, Exley C, Flynn D, Stephan BCM, Price C. Care priorities for stroke patients developing cognitive difficulties: a Delphi survey of UK professional views. BMC Health Serv Res 2020; 20:717. [PMID: 32758214 PMCID: PMC7404922 DOI: 10.1186/s12913-020-05558-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2019] [Accepted: 07/20/2020] [Indexed: 11/30/2022] Open
Abstract
Background Post stroke cognitive difficulties are common but generally prioritised below other impairments. In the UK, clinical guidelines recommend a holistic review at six-months post-stroke including an assessment of cognitive function. In order to assist clinicians to provide better care for patients with post-stroke cognitive deficits and assist with service planning, our aim was to establish professional consensus on key actions at the six-month review. Methods An electronic Delphi survey was developed with ten potential actions for clinicians to prioritise across five different clinical scenarios describing patients with cognitive difficulties. Scenarios varied in terms of age of the stroke-survivor, stroke severity and use of dementia risk assessment. A panel of professional volunteers was obtained through the British Association of Stroke Physicians and the UK National Stroke Nursing Forum. Results Forty-five stroke clinicians completed round one, with 21 participants completing round two. Priorities consistently supported by professionals included access to psychological services, screening for a mood disorder and ensuring multi-professional input. Direct access to specialist memory services was not generally supported unless a dementia risk assessment tool indicated that the individual was at high risk of dementia. Conclusions Assessment of post-stroke cognitive deficits needs to be routinely considered during the six-month review. A formal risk assessment tool could be a way to streamline direct access to memory clinic services to ensure that individuals at-risk of dementia receive ongoing care.
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Affiliation(s)
- Eugene Y H Tang
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Level 2, Newcastle Biomedical Research Building, Newcastle upon Tyne, NE4 5PL, UK.
| | - Louise Robinson
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Level 2, Newcastle Biomedical Research Building, Newcastle upon Tyne, NE4 5PL, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Level 2, Newcastle Biomedical Research Building, Newcastle upon Tyne, NE4 5PL, UK
| | - Darren Flynn
- Centre for Rehabilitation, Exercise and Sports Science, School of Health & Life Sciences, Teesside University, Middlesbrough, Tees Valley, TS1 3BX, UK
| | - Blossom C M Stephan
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, School of Medicine, University of Nottingham, Innovation Park, Nottingham, NG7 2TU, UK
| | - Christopher Price
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Level 2, Newcastle Biomedical Research Building, Newcastle upon Tyne, NE4 5PL, UK
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27
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Tang EYH, Price C, Stephan BCM, Robinson L, Exley C. Impact of Memory Problems Post-stroke on Patients and Their Family Carers: A Qualitative Study. Front Med (Lausanne) 2020; 7:267. [PMID: 32637417 PMCID: PMC7317277 DOI: 10.3389/fmed.2020.00267] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Accepted: 05/15/2020] [Indexed: 11/18/2022] Open
Abstract
Background: Memory problems post-stroke are common and for some, these problems could then progress to a dementia illness. Once in the community, stroke-survivors are looked after by their family doctors although there is evidence that these patients may struggle to access appropriate help in the community for these problems. Although a stroke-survivor may be physically capable of performing daily tasks, they and their families may have to learn to manage and adapt to their new memory deficits. There is often less focus on cognitive recovery post-stroke from clinical services perhaps because of the lack of awareness and evidence of these adaptations. There is also good evidence that organized stroke care improves physical recovery but no equivalent evidence for the effectiveness of cognitive rehabilitation. The aim of this qualitative study was to report the impact of memory problems on the stroke-survivor and their family once they are living in the community. Methods: Semi-structured interviews were conducted with patients and family carers to gain an in-depth understanding of their experiences. Participants were invited to take part in an interview at around six and 12-months post-stroke. A topic guide was developed to explore participant's care experiences post-stroke when they have also presented with memory difficulties. Data collection and analysis were iterative; all transcripts were anonymized. The data were thematically analyzed. Results: Twenty-two interviews were conducted. Five family carers and ten stroke-survivors were interviewed at six-months post-stroke, of these eight stroke-survivors and four family carers agreed to a 12-month follow-up interview. They identified several areas of impact: (1) impact on daily life; (2) emotional impact; and (3) compensating strategies implemented in response to impact. Conclusion: Living with stroke combined with memory impairment can have negative effects on the stroke-survivor and their family once in the community. Health professionals and services in the community need to recognize the burden of managing symptoms post-stroke for these individuals and their families. Understanding the impact can enable more effective community and specialist support to be provided particularly if we were to also identify those who may then be at risk of a future dementia illness.
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Affiliation(s)
- Eugene Y H Tang
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, United Kingdom
| | - Christopher Price
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, United Kingdom
| | - Blossom C M Stephan
- Division of Psychiatry and Applied Psychology, Institute of Mental Health, School of Medicine, University of Nottingham, Innovation Park, Nottingham, United Kingdom
| | - Louise Robinson
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, United Kingdom
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, United Kingdom
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28
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Tang EYH, Price CI, Robinson L, Exley C, Desmond DW, Köhler S, Staals J, Yin Ka Lam B, Wong A, Mok V, Bordet R, Bordet AM, Dondaine T, Lo JW, Sachdev PS, Stephan BCM. Assessing the Predictive Validity of Simple Dementia Risk Models in Harmonized Stroke Cohorts. Stroke 2020; 51:2095-2102. [PMID: 32568644 PMCID: PMC7306263 DOI: 10.1161/strokeaha.120.027473] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Stroke is associated with an increased risk of dementia. To assist in the early identification of individuals at high risk of future dementia, numerous prediction models have been developed for use in the general population. However, it is not known whether such models also provide accurate predictions among stroke patients. Therefore, the aim of this study was to determine whether existing dementia risk prediction models that were developed for use in the general population can also be applied to individuals with a history of stroke to predict poststroke dementia with equivalent predictive validity.
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Affiliation(s)
- Eugene Y H Tang
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Newcastle Upon Tyne, United Kingdom (E.Y.H.T., C.I.P., L.R., C.E.)
| | - Christopher I Price
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Newcastle Upon Tyne, United Kingdom (E.Y.H.T., C.I.P., L.R., C.E.)
| | - Louise Robinson
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Newcastle Upon Tyne, United Kingdom (E.Y.H.T., C.I.P., L.R., C.E.)
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Campus for Ageing and Vitality, Newcastle Upon Tyne, United Kingdom (E.Y.H.T., C.I.P., L.R., C.E.)
| | | | - Sebastian Köhler
- School for Mental Health and Neuroscience, Maastricht University, the Netherlands (S.K.)
| | - Julie Staals
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands (J.S.)
| | - Bonnie Yin Ka Lam
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, Gerald Choa Neuroscience Centre, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong SAR (B.Y.K.L., A.W., V.M.)
| | - Adrian Wong
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, Gerald Choa Neuroscience Centre, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong SAR (B.Y.K.L., A.W., V.M.)
| | - Vincent Mok
- Division of Neurology, Department of Medicine and Therapeutics, Faculty of Medicine, Gerald Choa Neuroscience Centre, Therese Pei Fong Chow Research Centre for Prevention of Dementia, Lui Che Woo Institute of Innovative Medicine, The Chinese University of Hong Kong SAR (B.Y.K.L., A.W., V.M.)
| | - Regis Bordet
- University Lille, Inserm, CHU Lille, U1171-Degenerative and Vascular Cognitive Disorders, France (R.B., A.-M.B., T.D.)
| | - Anne-Marie Bordet
- University Lille, Inserm, CHU Lille, U1171-Degenerative and Vascular Cognitive Disorders, France (R.B., A.-M.B., T.D.)
| | - Thibaut Dondaine
- University Lille, Inserm, CHU Lille, U1171-Degenerative and Vascular Cognitive Disorders, France (R.B., A.-M.B., T.D.)
| | - Jessica W Lo
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia (J.W.L., P.S.S.)
| | - Perminder S Sachdev
- Centre for Healthy Brain Ageing, School of Psychiatry, University of New South Wales, Sydney, Australia (J.W.L., P.S.S.).,Neuropsychiatric Institute, Prince of Wales Hospital, Sydney (P.S.S.)
| | - Blossom C M Stephan
- Institute of Mental Health, Division of Psychiatry and Applied Psychology, School of Medicine, Nottingham University, UK (B.C.M.S.)
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Lewney J, Holmes RD, Rankin J, Exley C. Health visitors' views on promoting oral health and supporting clients with dental health problems: a qualitative study. J Public Health (Oxf) 2020; 41:e103-e108. [PMID: 29924348 DOI: 10.1093/pubmed/fdy107] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2017] [Revised: 05/05/2018] [Accepted: 05/29/2018] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Inequalities in dental decay in young children persist, resulting in high admission rates for general anaesthetics for tooth extractions. Health visitors have the potential to improve dental attendance and oral health in families least likely to engage with dental services. There is little evidence on health visitor views on this. METHODS Semi-structured interviews were conducted with a purposive sample of 17 health visitors working in both affluent and deprived areas in a single UK city. Interviews were audio recorded, transcribed, anonymized and analysed following a constructivist grounded theory approach. RESULTS Knowledge of oral health was high and health visitors requested oral health education specific to the communities they worked in. Health visitors reported effective, formal referral processes to other health services but not to primary NHS dental services even when dealing with infants in pain. Health visitors interviewed were largely unaware of specific NHS dental services which reduce barriers to dental care including interpreting services and dental services for children with additional needs. CONCLUSIONS Health visitors interviewed were knowledgeable and enthusiastic about oral health but not about dental services. Inadequate links with NHS dental services may limit their effectiveness in oral health improvement and this needs to be addressed.
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Affiliation(s)
- J Lewney
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - R D Holmes
- School of Dental Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - J Rankin
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - C Exley
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
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Lally J, Vaittinen A, McClelland G, Price CI, Shaw L, Ford GA, Flynn D, Exley C. Paramedic experiences of using an enhanced stroke assessment during a cluster randomised trial: a qualitative thematic analysis. Emerg Med J 2020; 37:480-485. [PMID: 32546477 PMCID: PMC7418592 DOI: 10.1136/emermed-2019-209392] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 03/21/2020] [Accepted: 05/02/2020] [Indexed: 11/25/2022]
Abstract
Background Intravenous thrombolysis is a key element of emergency treatment for acute ischaemic stroke, but hospital service delivery is variable. The Paramedic Acute Stroke Treatment Assessment (PASTA) multicentre cluster randomised controlled trial evaluated whether an enhanced paramedic-initiated stroke assessment pathway could improve thrombolysis volume. This paper reports the findings of a parallel process evaluation which explored intervention paramedics’ experience of delivering the enhanced assessment. Methods Interviewees were recruited from 453 trained intervention paramedics across three UK ambulance services hosting the trial: North East, North West and Welsh Ambulance Services. A semistructured interview guide aimed to (1) explore the stroke-specific assessment and handover procedures which were part of the PASTA pathway and (2) enable paramedics to share relevant views about expanding their role and any barriers/enablers they encountered. Interviews were audiorecorded, transcribed verbatim and analysed following the principles of the constant comparative method. Results Twenty-six interviews were conducted (11 North East, 10 North West and 5 Wales). Iterative data analysis identified four key themes, which reflected paramedics’ experiences at different stages of the care pathway: (1) Enhanced assessment at scene: paramedics felt this improved their skillset and confidence. (2) Prealert to hospital: a mixed experience dependent on receiving hospital staff. (3) Handover to hospital team: standardisation of format was viewed as the primary benefit of the PASTA pathway. (4) Assisting in hospital and feedback: due to professional boundaries, paramedics found these aspects harder to achieve, although feedback from the clinical team was valued when available. Conclusion Paramedics believed that the PASTA pathway enhanced their skills and the emergency care of stroke patients, but a continuing clinical role postadmission was challenging. Future studies should consider whether interdisciplinary training is needed to enable more radical extension of professional boundaries for paramedics.
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Affiliation(s)
- Joanne Lally
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Anu Vaittinen
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Graham McClelland
- Research and Development, North East Ambulance Service NHS Foundation Trust, Newcastle upon Tyne, Tyne and Wear, UK
| | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Oxford, Oxfordshire, UK
| | - Darren Flynn
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
| | - Catherine Exley
- Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, Tyne and Wear, UK
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31
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Affiliation(s)
- C Exley
- The Birchall Centre, Lennard-Jones Laboratories, Keele University, Staffordshire, UK
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Bradley J, Gardner G, Rowland MK, Fay M, Mann K, Holmes R, Foster E, Exley C, Don Bosco A, Hugueniot O, Moynihan P. Impact of a health marketing campaign on sugars intake by children aged 5-11 years and parental views on reducing children's consumption. BMC Public Health 2020; 20:331. [PMID: 32223751 PMCID: PMC7104521 DOI: 10.1186/s12889-020-8422-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 02/27/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The association between Free Sugars intake and non-communicable diseases such as obesity and dental caries is well documented and several countries are taking measures to reduce sugars intakes. Public Health England (PHE) instigated a range of approaches to reduce sugars, including a national health marketing campaign (Sugar Smart). The campaign aimed to raise awareness of the amount of sugars in foods and drinks and to encourage parents to reduce their children's intake. The aim of this study was to determine whether the campaign was effective in altering dietary behaviour, by assessing any impact of the campaign on sugars intake among children aged 5-11 years. Parental perceptions of the campaign and barriers to reducing sugars intake were also explored. METHODS Parents of 873 children aged 5-11 years, identified from an existing PHE database, were invited to take part. Dietary information was collected online using Intake24 before, during, and at 1, 10 and 12 months following the campaign. Change in sugars intake was assessed using mixed effects linear regression models. One-to-one telephone interviews were conducted with a purposive sample of parents to explore perceptions of the campaign and identify barriers and facilitators to reducing children's sugars intake. RESULTS Completion rates for dietary assessment ranged from 61 to 72% across the follow up time points. Qualitative telephone interviews were conducted with 20 parents. Total sugars intake decreased on average by ~ 6.2 g/day (SD 43.8) at peak campaign and the percentage of energy from total sugars significantly decreased immediately and 1 year post campaign. The percentage of energy from Free Sugars significantly decreased across all time points with the exception of the long term follow up at 12-months post campaign. The percentage of energy intake from total fat increased. Parents expressed a willingness to reduce sugars intakes, however, identified barriers including time constraints, the normalisation of sugary treats, and confusing information. CONCLUSIONS A health marketing campaign had a positive impact in reducing sugars intake but reductions in sugars were not sustained. Parents want to reduce their child's sugars intake but societal barriers and confusion over which sources of sugars to avoid hamper efforts to change.
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Affiliation(s)
- Jennifer Bradley
- Human Nutrition Research Centre, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.
| | - Grace Gardner
- Human Nutrition Research Centre, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK.,School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4BW, UK
| | - Maisie K Rowland
- Human Nutrition Research Centre, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Michaela Fay
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Kay Mann
- The Australian e-Health Research Centre, CSIRO, Brisbane, QLD, 4029, Australia
| | - Richard Holmes
- School of Dental Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4BW, UK
| | - Emma Foster
- Human Nutrition Research Centre, Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Catherine Exley
- Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4HH, UK
| | - Ann Don Bosco
- Public Health England, 133 - 155 Waterloo Road, London, SE1 8UG, UK
| | - Orla Hugueniot
- Public Health England, 133 - 155 Waterloo Road, London, SE1 8UG, UK
| | - Paula Moynihan
- Adelaide Dental School, Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, 5005, Australia
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Patterson R, Standing H, Lee M, Dalkin S, Lhussier M, Exley C, Brittain K. Paramedic information needs in end-of-life care: a qualitative interview study exploring access to a shared electronic record as a potential solution. BMC Palliat Care 2019; 18:108. [PMID: 31805917 PMCID: PMC6896500 DOI: 10.1186/s12904-019-0498-2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2019] [Accepted: 12/02/2019] [Indexed: 12/03/2022] Open
Abstract
Background Limited access to, understanding of, and trust in paper-based patient information is a key factor influencing paramedic decisions to transfer patients nearing end-of-life to hospital. Practical solutions to this problem are rarely examined in research. This paper explores the extent to which access to, and quality of, patient information affects the care paramedics provide to patients nearing end-of-life, and their views on a shared electronic record as a means of accessing up-to-date patient information. Method Semi-structured interviews with paramedics (n = 10) based in the north of England, drawn from a group of health and social care professionals (n = 61) participating in a study exploring data recording and sharing practices in end-of-life care. Data were analysed using thematic analysis. Results Two key themes were identified regarding paramedic views of patient information: 1) access to information on patients nearing end-of-life, and 2) views on the proposed EPaCCS. Paramedics reported they are typically unable to access up-to-date patient information, particularly advance care planning documents, and consequently often feel they have little option but to actively treat and transport patients to hospital – a decision not always appropriate for, or desired by, the patient. While paramedics acknowledged a shared electronic record (such as EPaCCs) could support them to provide community-based care where desired and appropriate, numerous practical and technical issues must be overcome to ensure the successful implementation of such a record. Conclusions Access to up-to-date patient information is a barrier to paramedics delivering appropriate end-of-life care. Current approaches to information recording are often inconsistent, inaccurate, and inaccessible to paramedics. Whilst a shared electronic record may provide paramedics with greater and timelier access to patient information, meaning they are better able to facilitate community-based care, this is only one of a series of improvements required to enable this to become routine practice.
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Affiliation(s)
- Rebecca Patterson
- Research and Innovation Services, Northumbria University, Pandon Building, Camden Street, Newcastle upon Tyne, NE2 1XE, UK.
| | - Holly Standing
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | - Mark Lee
- St Benedict's Hospice and Specialist Palliative Care Centre, Sunderland, UK
| | - Sonia Dalkin
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Monique Lhussier
- Department of Social Work, Education and Community Wellbeing, Northumbria University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK
| | - Katie Brittain
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
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34
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Holmes RD, Steele JG, Exley C, Vernazza CR, Donaldson C. Use of programme budgeting and marginal analysis to set priorities for local NHS dental services: learning from the north east of England. J Public Health (Oxf) 2019; 40:e578-e585. [PMID: 29726998 DOI: 10.1093/pubmed/fdy075] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 04/13/2018] [Indexed: 11/12/2022] Open
Abstract
Background Priority setting is necessary where competing demands exceed the finite resources available. The aim of the study was to develop and test a prioritization framework based upon programme budgeting and marginal analysis (PBMA) as a tool to assist National Health Service (NHS) commissioners in their management of resources for local NHS dental services. Methods Twenty-seven stakeholders (5 dentists, 8 commissioners and 14 patients) participated in a case-study based in a former NHS commissioning organization in the north of England. Stakeholders modified local decision-making criteria and applied them to a number of different scenarios. Results The majority of financial resources for NHS dental services in the commissioning organization studied were allocated to primary care dental practitioners' contracts in perpetuity, potentially constraining commissioners' abilities to shift resources. Compiling the programme budget was successful, but organizational flux and difficulties engaging local NHS commissioners significantly impacted upon the marginal analysis phase. Conclusions NHS dental practitioners' contracts resemble budget-silos which do not facilitate local resource reallocation. 'Context-specific' factors significantly challenged the successful implementation and impact of PBMA. A local PBMA champion embedded within commissioning organizations should be considered. Participants found visual depiction of the cost-value ratio helpful during their initial priority setting deliberations.
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Affiliation(s)
- R D Holmes
- Centre for Oral Health Research, Newcastle University, School of Dental Sciences, Framlington Place, Newcastle upon Tyne, UK
| | - J G Steele
- Centre for Oral Health Research, Newcastle University, School of Dental Sciences, Framlington Place, Newcastle upon Tyne, UK
| | - C Exley
- Faculty of Health and Life Sciences, Northumbria University, Northumberland Building, Newcastle upon Tyne, UK
| | - C R Vernazza
- Centre for Oral Health Research, Newcastle University, School of Dental Sciences, Framlington Place, Newcastle upon Tyne, UK
| | - C Donaldson
- Yunus Centre for Social Business & Health, Glasgow Caledonian University, Cowcaddens Road, Glasgow, UK
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Abstract
BACKGROUND Memory and cognitive deficits post stroke are common and associated with increased risk of future dementia. Rehabilitation tends to focus on physical recovery; however, once in the community, it is unclear what happens in the longer term to the stroke-survivor with new memory difficulties. OBJECTIVE The aim of this qualitative study was to examine in stroke-survivors what factors influence contact with health professionals. METHOD Semi-structured interviews were conducted with stroke-survivors and their family carers where memory difficulties were reported at 6 months post stroke. A topic guide was used which sought to critically examine participants care experience following their stroke diagnosis. All participants were interviewed at baseline (around 6 months post stroke) and offered an interview at around 12 months post stroke. All interviews were conducted in the North East of England. All transcripts were coded and thematically analysed. RESULTS Ten stroke-survivors (age range 72-84 years) were interviewed alongside five carers at baseline; eight stroke-survivors and four carers agreed to a follow-up interview. Three main barriers were identified: (i) fear of a dementia diagnosis; (ii) denial or minimization of symptoms leading to adaptation and (iii) obstacles to seeking help in the community. CONCLUSIONS With an ageing population and increase in stroke-survival, the burden of post-stroke cognitive impairment and dementia will only increase. Stroke-survivors and their family carers in this study have identified issues that may hinder their presentation to health care professionals at a personal and organizational level. Health professionals need to be aware of these potential issues when planning services for stroke-survivors.
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Affiliation(s)
- Eugene Y H Tang
- Institute of Health and Society, Newcastle University, Baddiley-Clark, Richardson Road, Newcastle upon Tyne, UK.,Newcastle University Institute of Ageing, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Christopher Price
- Institute of Neuroscience, Stroke Research Group, Newcastle University, Newcastle, UK
| | - Blossom C M Stephan
- Institute of Health and Society, Newcastle University, Baddiley-Clark, Richardson Road, Newcastle upon Tyne, UK.,Newcastle University Institute of Ageing, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Louise Robinson
- Institute of Health and Society, Newcastle University, Baddiley-Clark, Richardson Road, Newcastle upon Tyne, UK.,Newcastle University Institute of Ageing, Newcastle University, Campus for Ageing and Vitality, Newcastle upon Tyne, UK
| | - Catherine Exley
- Faculty of Health and Life Sciences, Northumberland Building, Northumbria University, Newcastle upon Tyne, UK
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36
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Exley C. Aluminium release during fluid warming. Anaesthesia 2019; 74:819. [DOI: 10.1111/anae.14673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- C. Exley
- Keele University Newcastle‐under‐Lime UK
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Abstract
OBJECTIVE Stroke-survivors are at increased risk of future dementia. Assessment to identify those at high risk of developing a disease using predictive scores has been utilised in different areas of medicine. A number of risk assessment scores for dementia have been developed but none has been recommended for use clinically. The aim of this qualitative study was to assess the acceptability and feasibility of using a risk assessment tool to predict post-stroke dementia. DESIGN Qualitative semi-structured interviews were conducted and analysed thematically. The patients and carers were offered interviews at around 6 (baseline) and 12 (follow-up) months post-stroke; clinicians were interviewed once. SETTING The study was conducted in the North-East of England with stroke patients, family carers and healthcare professionals in primary and secondary care. PARTICIPANTS Thirty-nine interviews were conducted (17 clinicians and 15 stroke patients and their carers at baseline. Twelve stroke patients and their carers were interviewed at follow-up, some interviews were conducted in pairs). RESULTS Barriers and facilitators to risk assessment were discussed. For the patients and carers the focus for facilitators were based on the outcomes of risk assessment for example assistance with preparation, diagnosis and for reassurance. For clinicians, facilitators were focused on the process that is, familiarity in primary care, resource availability in secondary care and collaborative care. For barriers, both groups focused on the outcome including for example, the anxiety generated from a potential diagnosis of dementia. For the patients/carers a further barrier included concerns about how it may affect their recovery. For clinicians there were concerns about limited interventions and how it would be different from standard care. CONCLUSIONS Risk assessment for dementia post-stroke presents challenges given the ramifications of a potential diagnosis of dementia. Attention needs to be given to how information is communicated and strategies developed to support the patients and carers if risk assessment is used.
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Affiliation(s)
- Eugene Tang
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Christopher Price
- Institute of Neuroscience, Stroke Research Group, Newcastle University, Newcastle, UK
| | - Blossom Stephan
- Institute of Health and Society, Newcastle University, Newcastle, UK
| | - Louise Robinson
- Institute of Health and Society, Newcastle University, Newcastle, UK
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Vernazza CR, Taylor G, Donaldson C, Gray J, Holmes R, Carr K, Exley C. How does priority setting for resource allocation happen in commissioning dental services in a nationally led, regionally delivered system: a qualitative study using semistructured interviews with NHS England dental commissioners. BMJ Open 2019; 9:e024995. [PMID: 30904857 PMCID: PMC6475363 DOI: 10.1136/bmjopen-2018-024995] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVES To understand approaches to priority setting for healthcare service resource allocation at an operational level in a nationally commissioned but regionally delivered service. DESIGN Qualitative study using semistructured interviews and a Framework analysis. SETTING National Health Service dentistry commissioning teams within subregional offices in England. PARTICIPANTS All 31 individuals holding the relevant role (dental lead commissioner in subregional offices) were approached directly and from this 14 participants were recruited, with 12 interviews completed. Both male and female genders and all regions were represented in the final sample. RESULTS Three major themes arose. First, 'Methods of priority setting and barriers to explicit approaches' was a common theme, specifically identifying the main methods as: perpetuating historical allocations, pressure from politicians and clinicians and use of needs assessments while barriers were time and skill deficits, a lack of national guidance and an inflexible contracting arrangements stopping resource allocation. Second, 'Relationships with key stakeholders and advisors' were discussed, showing the important nature of relationships with clinical advisors but variation in the quality of these relationships was noted. Finally, 'Tensions between national and local responsibilities' were illustrated, where there was confusion about where power and autonomy lay. CONCLUSIONS Commissioners recognised a need for resource allocation but relied on clinical advice and needs assessment in order to set priorities. More explicit priority setting was prevented by structure of the commissioning system and standard national contracts with providers. Further research is required to embed and simplify adoption of tools to aid priority setting.
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Affiliation(s)
- Christopher Robert Vernazza
- Centre for Oral Health Research, Newcastle University, Newcastle upon Tyne, UK
- Child Dental Health, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Greig Taylor
- Centre for Oral Health Research, Newcastle University, Newcastle upon Tyne, UK
- Child Dental Health, Newcastle Upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
| | - Cam Donaldson
- Social Business and Health, Glasgow Caledonian University, Glasgow, UK
| | - Joanne Gray
- Department of Nursing, Midwifery and Health, Northumbria University, Newcastle upon Tyne, UK
| | - Richard Holmes
- Centre for Oral Health Research, Newcastle University, Newcastle upon Tyne, UK
| | - Katherine Carr
- Centre for Oral Health Research, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
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Price CI, Shaw L, Dodd P, Exley C, Flynn D, Francis R, Islam S, Javanbakht M, Lakey R, Lally J, McClelland G, McMeekin P, Rodgers H, Snooks H, Sutcliffe L, Tyrell P, Vale L, Watkins A, Ford GA. Paramedic Acute Stroke Treatment Assessment (PASTA): study protocol for a randomised controlled trial. Trials 2019; 20:121. [PMID: 30755249 PMCID: PMC6373128 DOI: 10.1186/s13063-018-3144-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2018] [Accepted: 12/17/2018] [Indexed: 11/10/2022] Open
Abstract
Background Despite evidence from clinical trials that intravenous (IV) thrombolysis is a cost-effective treatment for selected acute ischaemic stroke patients, there remain large variations in the rate of IV thrombolysis delivery between stroke services. This study is evaluating whether an enhanced care pathway delivered by paramedics (the Paramedic Acute Stroke Treatment Assessment (PASTA)) could increase the number of patients who receive IV thrombolysis treatment. Methods Study design: Cluster randomised trial with economic analysis and parallel process evaluation. Setting: National Health Service ambulance services, emergency departments and hyper-acute stroke units within three geographical regions of England and Wales. Randomisation: Ambulance stations within each region are the units of randomisation. According to station allocation, paramedics based at a station deliver the PASTA pathway (intervention) or continue with standard stroke care (control). Study intervention: The PASTA pathway includes structured pre-hospital information collection, prompted pre-notification, structured handover of information in hospital and assistance with simple tasks during the initial hospital assessment. Study-trained intervention group paramedics deliver this pathway to adults within 4 h of suspected stroke onset. Study control: Standard stroke care according to national and local guidelines for the pre-hospital and hospital assessment of suspected stroke. Participants: Participants enrolled in the study are adults with confirmed stroke who were assessed by a study paramedic within 4 h of symptom onset. Primary outcome: Proportion of participants receiving IV thrombolysis. Sample size: 1297 participants provide 90% power to detect a 10% difference in the proportion of patients receiving IV thrombolysis. Discussion The results from this trial will determine whether an enhanced care pathway delivered by paramedics can increase thrombolysis delivery rates. Trial registration ISRCTN registry, ISRCTN12418919. Registered on 5 November 2015. Electronic supplementary material The online version of this article (10.1186/s13063-018-3144-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christopher I Price
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.
| | - Lisa Shaw
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.
| | - Peter Dodd
- Lay investigator. Contact via: Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK
| | - Catherine Exley
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Darren Flynn
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Richard Francis
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK
| | - Saiful Islam
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, Wales
| | - Mehdi Javanbakht
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Rachel Lakey
- Newcastle Clinical Trials Unit, Newcastle University, 1-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK
| | - Joanne Lally
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Graham McClelland
- North East Ambulance Service, Bernicia House, Goldcrest Way, Newburn Riverside, Newcastle upon Tyne, NE15 8NY, UK
| | - Peter McMeekin
- Faculty of Health & Life Sciences, Northumbria University, 2nd floor Northumberland Building, Newcastle upon Tyne, NE1 8ST, UK
| | - Helen Rodgers
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK.,Newcastle upon Tyne Hospitals NHS Foundation Trust, Royal Victoria Hospital, Queen Victoria Road, Newcastle upon Tyne, NE1 4LP, UK
| | - Helen Snooks
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, Wales
| | - Louise Sutcliffe
- Stroke Research Group, Institute of Neuroscience, Newcastle University, 3-4 Claremont Terrace, Newcastle upon Tyne, NE2 4AE, UK
| | - Pippa Tyrell
- Stroke Medicine, Clinical Sciences Building, Salford Royal Hospitals' NHS Foundation Trust, Salford, M6 8HD, UK
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - Alan Watkins
- College of Medicine, Swansea University, Singleton Park, Swansea, SA2 8PP, Wales
| | - Gary A Ford
- Medical Sciences Division, University of Oxford, and Oxford University Hospitals NHS Foundation Trust, Level 3, John Radcliffe Hospital, Oxford, OX3 9DU, UK
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Bamford C, Lee R, McLellan E, Poole M, Harrison-Dening K, Hughes J, Robinson L, Exley C. What enables good end of life care for people with dementia? A multi-method qualitative study with key stakeholders. BMC Geriatr 2018; 18:302. [PMID: 30514221 PMCID: PMC6280541 DOI: 10.1186/s12877-018-0983-0] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2018] [Accepted: 11/15/2018] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND People with advanced dementia often experience suboptimal end of life care (EoLC) with inadequate pain control, increased hospitalisation, and fewer palliative care interventions compared to those with cancer. Existing policy, guidance and recommendations are based largely on expert opinion because of a shortage of high quality, empirical research. Previous studies have tended to consider the views and experience of particular groups. Whilst providing important evidence, they do not take into account the diversity of perspectives of different stakeholders. The Supporting Excellence in End of life care in Dementia (SEED) programme involved multiple stakeholder groups and an integrative analysis to identify key components of good EoLC for people with dementia and to inform a new intervention. METHODS The views of national experts, service managers, frontline staff, people with dementia and family carers were explored using a range of qualitative methods (semi-structured interviews, focus groups, discussions and observations of routine care). The large dataset comprises 116 interviews, 12 focus groups and 256 h of observation. Each dataset was initially analysed thematically prior to an integrative analysis, which drew out key themes across stakeholder groups. RESULTS Through the integrative analysis seven key factors required for the delivery of good EoLC for people with dementia were identified: timely planning discussions; recognition of end of life and provision of supportive care; co-ordination of care; effective working relationships with primary care; managing hospitalisation; continuing care after death; and valuing staff and ongoing learning. These factors span the entire illness trajectory from planning at a relatively early stage in the illness to continuing care after death. CONCLUSIONS This unique study has confirmed the relevance of much of the content of existing end of life frameworks to dementia. It has highlighted seven key areas that are particularly important in dementia care. The data are being used to develop an evidence-based intervention to support professionals to deliver better EoLC in dementia.
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Affiliation(s)
- Claire Bamford
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Richard Lee
- Department of Social Work, Education and Community Wellbeing, Faculty of Health & Life Sciences, Northumbria University, Newcastle-upon-Tyne, UK
| | - Emma McLellan
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Marie Poole
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | | | - Julian Hughes
- Bristol Medical School, Population and Health Sciences, University of Bristol, Bristol, BS8 2PS UK
| | - Louise Robinson
- Institute of Health and Society, Newcastle University, 2nd Floor, Newcastle Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL UK
| | - Catherine Exley
- Health and Life Sciences, Northumbria University, Room NB266, Northumberland Building, College Street, Newcastle upon Tyne, NE1 8ST UK
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Vernazza CR, Carr K, Wildman J, Gray J, Holmes RD, Exley C, Smith RA, Donaldson C. Resource allocation in NHS dentistry: recognition of societal preferences (RAINDROP): study protocol. BMC Health Serv Res 2018; 18:487. [PMID: 29929516 PMCID: PMC6013861 DOI: 10.1186/s12913-018-3302-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2018] [Accepted: 06/15/2018] [Indexed: 01/16/2023] Open
Abstract
Background Resources in any healthcare systems are scarce relative to need and therefore choices need to be made which often involve difficult decisions about the best allocation of these resources. One pragmatic and robust tool to aid resource allocation is Programme Budgeting and Marginal Analysis (PBMA), but there is mixed evidence on its uptake and effectiveness. Furthermore, there is also no evidence on the incorporation of the preferences of a large and representative sample of the general public into such a process. The study therefore aims to undertake, evaluate and refine a PBMA process within the exemplar of NHS dentistry in England whilst also using an established methodology (Willingness to Pay (WTP)) to systematically gather views from a representative sample of the public. Methods Stakeholders including service buyers (commissioners), dentists, dental public health representatives and patient representatives will be recruited to participate in a PBMA process involving defining current spend, agreeing criteria to judge services/interventions, defining areas for investment and disinvestment, rating these areas against the criteria and making final recommendations. The process will be refined based on participatory action research principles and evaluated through semi-structured interviews, focus groups and observation of the process by the research team. In parallel a representative sample of English adults will be recruited to complete a series of four surveys including WTP valuations of programmes being considered by the PBMA panel. In addition a methodological experiment comparing two ways of eliciting WTP will be undertaken. Discussion The project will allow the PBMA process and particularly the use of WTP within it to be investigated and developed. There will be challenges around engagement with the task by the panel undertaking it and with the outputs by stakeholders but careful relationship building will help to mitigate this. The large volume of data will be managed through careful segmenting of the analysis and the use of the well-established Framework approach to qualitative data analysis. WTP has various potential biases but the elicitation will be carefully designed to minimise these and some methodological investigation will take place. Electronic supplementary material The online version of this article (10.1186/s12913-018-3302-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Christopher R Vernazza
- Centre for Oral Health Research, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4BW, UK.
| | - Katherine Carr
- Centre for Oral Health Research, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4BW, UK
| | - John Wildman
- Newcastle University Business School, Newcastle University, Room 7.20, 7th Floor, 5 Barrack Road, Newcastle upon Tyne, NE1 4SE, UK
| | - Joanne Gray
- Nursing, Midwifery & Health, Northumbria University, Sutherland Building, Newcastle-upon-Tyne, NE1 8ST, UK
| | - Richard D Holmes
- Centre for Oral Health Research, Newcastle University, Framlington Place, Newcastle upon Tyne, NE2 4BW, UK
| | - Catherine Exley
- Faculty of Health and Life Sciences, Northumbria University, NB266, 2nd Floor, Northumberland Building, Newcastle upon Tyne, NE1 8ST, UK
| | - Robert A Smith
- ScHARR, University of Sheffield, Regent Court, 30 Regent Street, Sheffield, S1 4DA, UK
| | - Cam Donaldson
- Yunus Centre for Social Business and Health, Glasgow Caledonian University, M201, George Moore Building, Glasgow, G4 0BA, UK
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Poole M, Bamford C, McLellan E, Lee RP, Exley C, Hughes JC, Harrison-Dening K, Robinson L. End-of-life care: A qualitative study comparing the views of people with dementia and family carers. Palliat Med 2018; 32:631-642. [PMID: 29020864 DOI: 10.1177/0269216317736033] [Citation(s) in RCA: 63] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND In recent years, UK policy has increasingly recognised the importance of end-of-life care in dementia. While professional consensus on optimal palliative care in dementia has been reported, little is known about the perspectives of people with dementia and family carers. AIM To compare the views of people with dementia and family carers of people with dementia (current and recently bereaved) on optimal end-of-life care. DESIGN Qualitative interviews (32) and a focus group were conducted. Data were thematically analysed. SETTING/PARTICIPANTS Participants comprised people with early stage dementia, living at home in the north-east of England ( n = 11); and current and bereaved carers ( n = 25) from six services providing end-of-life care in England. FINDINGS Seven areas were identified as important to end-of-life care for people with dementia and/or family carers. People with dementia and carers expressed the need for receiving care in place, ensuring comfort and a skilled care team. However, they disagreed about the importance of planning for the future and the role of families in organising care and future decision-making. CONCLUSION Further comparison of our findings with expert consensus views highlighted key areas of divergence and agreement. Discordant views concerning perceptions of dementia as a palliative condition, responsibility for future decision-making and the practical co-ordination of end-of-life care may undermine the provision of optimal palliative care. Professionals must explore and recognise the individual perspectives of people with dementia and family carers.
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Affiliation(s)
- Marie Poole
- 1 Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Claire Bamford
- 1 Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Emma McLellan
- 1 Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Richard P Lee
- 1 Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- 2 Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Julian C Hughes
- 3 School of Clinical Sciences, University of Bristol, Bristol, UK
| | | | - Louise Robinson
- 1 Institute of Health & Society, Newcastle University, Newcastle upon Tyne, UK
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Fisher A, Andreasson A, Chrysos A, Lally J, Mamasoula C, Exley C, Wilkinson J, Qian J, Watson G, Lewington O, Chadwick T, McColl E, Pearce M, Mann K, McMeekin N, Vale L, Tsui S, Yonan N, Simon A, Marczin N, Mascaro J, Dark J. An observational study of Donor Ex Vivo Lung Perfusion in UK lung transplantation: DEVELOP-UK. Health Technol Assess 2018; 20:1-276. [PMID: 27897967 DOI: 10.3310/hta20850] [Citation(s) in RCA: 85] [Impact Index Per Article: 14.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Many patients awaiting lung transplantation die before a donor organ becomes available. Ex vivo lung perfusion (EVLP) allows initially unusable donor lungs to be assessed and reconditioned for clinical use. OBJECTIVE The objective of the Donor Ex Vivo Lung Perfusion in UK lung transplantation study was to evaluate the clinical effectiveness and cost-effectiveness of EVLP in increasing UK lung transplant activity. DESIGN A multicentre, unblinded, non-randomised, non-inferiority observational study to compare transplant outcomes between EVLP-assessed and standard donor lungs. SETTING Multicentre study involving all five UK officially designated NHS adult lung transplant centres. PARTICIPANTS Patients aged ≥ 18 years with advanced lung disease accepted onto the lung transplant waiting list. INTERVENTION The study intervention was EVLP assessment of donor lungs before determining suitability for transplantation. MAIN OUTCOME MEASURES The primary outcome measure was survival during the first 12 months following lung transplantation. Secondary outcome measures were patient-centred outcomes that are influenced by the effectiveness of lung transplantation and that contribute to the health-care costs. RESULTS Lungs from 53 donors unsuitable for standard transplant were assessed with EVLP, of which 18 (34%) were subsequently transplanted. A total of 184 participants received standard donor lungs. Owing to the early closure of the study, a non-inferiority analysis was not conducted. The Kaplan-Meier estimate of survival at 12 months was 0.67 [95% confidence interval (CI) 0.40 to 0.83] for the EVLP arm and 0.80 (95% CI 0.74 to 0.85) for the standard arm. The hazard ratio for overall 12-month survival in the EVLP arm relative to the standard arm was 1.96 (95% CI 0.83 to 4.67). Patients in the EVLP arm required ventilation for a longer period and stayed longer in an intensive therapy unit (ITU) than patients in the standard arm, but duration of overall hospital stay was similar in both groups. There was a higher rate of very early grade 3 primary graft dysfunction (PGD) in the EVLP arm, but rates of PGD did not differ between groups after 72 hours. The requirement for extracorporeal membrane oxygenation (ECMO) support was higher in the EVLP arm (7/18, 38.8%) than in the standard arm (6/184, 3.2%). There were no major differences in rates of chest radiograph abnormalities, infection, lung function or rejection by 12 months. The cost of EVLP transplants is approximately £35,000 higher than the cost of standard transplants, as a result of the cost of the EVLP procedure, and the increased ECMO use and ITU stay. Predictors of cost were quality of life on joining the waiting list, type of transplant and number of lungs transplanted. An exploratory model comparing a NHS lung transplant service that includes EVLP and standard lung transplants with one including only standard lung transplants resulted in an incremental cost-effectiveness ratio of £73,000. Interviews showed that patients had a good understanding of the need for, and the processes of, EVLP. If EVLP can increase the number of usable donor lungs and reduce waiting, it is likely to be acceptable to those waiting for lung transplantation. Study limitations include small numbers in the EVLP arm, limiting analysis to descriptive statistics and the EVLP protocol change during the study. CONCLUSIONS Overall, one-third of donor lungs subjected to EVLP were deemed suitable for transplant. Estimated survival over 12 months was lower than in the standard group, but the data were also consistent with no difference in survival between groups. Patients receiving these additional transplants experience a higher rate of early graft injury and need for unplanned ECMO support, at increased cost. The small number of participants in the EVLP arm because of early study termination limits the robustness of these conclusions. The reason for the increased PGD rates, high ECMO requirement and possible differences in lung injury between EVLP protocols needs evaluation. TRIAL REGISTRATION Current Controlled Trials ISRCTN44922411. FUNDING This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 20, No. 85. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Andrew Fisher
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Anders Andreasson
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Alexandros Chrysos
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Joanne Lally
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Catherine Exley
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | | | - Jessica Qian
- Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Gillian Watson
- Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | | | - Thomas Chadwick
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Elaine McColl
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.,Clinical Trials Unit, Newcastle University, Newcastle upon Tyne, UK
| | - Mark Pearce
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Kay Mann
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Nicola McMeekin
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Luke Vale
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Steven Tsui
- Papworth Hospital NHS Foundation Trust, Cambridge, UK
| | - Nizar Yonan
- University Hospital of South Manchester NHS Foundation Trust, Manchester, UK
| | - Andre Simon
- Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Nandor Marczin
- Royal Brompton and Harefield Hospital NHS Foundation Trust, London, UK
| | - Jorge Mascaro
- Queen Elizabeth Hospital NHS Foundation Trust, Birmingham, UK
| | - John Dark
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK.,Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
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Abstract
Background: Ventricular assist devices (VADs) are a relatively new development in the management of advanced heart failure. In the UK, VAD recipients comprise a unique group of less than 200 patients. This is the first paper to explore the experience of VAD communities, the extent to which communities are developed around the device, and how these influence the experience of living with the VAD. Methods: Qualitative interviews were conducted with 20 VAD recipients (implanted as a bridge to transplantation), 11 interviews also included the VAD recipients’ partners. Interpretive phenomenology was employed as the theoretical basis guiding the analysis of the interviews. Results: Four key themes emerged from the data: the existence of VAD communities; experiential knowledge and understanding; social comparisons; and the impacts of deaths within the VAD community. Many of the interviewees valued the VAD communities and the relationships they had formed with fellow recipients. The beneficial impacts of the VAD communities included offering recently implanted patients a realistic view of what to expect from life with a VAD; this could aid them in accepting and adapting to the changes imparted by the device. However, negative impacts of the VAD communities were also reported, in particular following deaths within the group, which were a source of distress for many of the interviewees. Conclusions: In general, the VAD communities appeared to be a beneficial source of support for the majority of interviewees. Consideration should be given to how these communities could be supported by clinicians.
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Affiliation(s)
| | - Catherine Exley
- Faculty of Health and Life Sciences, Northumbria University, UK
| | - Guy A MacGowan
- Department of Cardiology, Freeman Hospital, UK
- Institute of Genetic Medicine, Newcastle University, UK
| | - Tim Rapley
- Faculty of Health and Life Sciences, Northumbria University, UK
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45
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Patterson JM, Fay M, Exley C, McColl E, Breckons M, Deary V. Feasibility and acceptability of combining cognitive behavioural therapy techniques with swallowing therapy in head and neck cancer dysphagia. BMC Cancer 2018. [PMID: 29291726 DOI: 10.1186/s12885‐017‐3892‐2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Head and neck cancer squamous cell carcinoma (HNSSC) patients report substantial rates of clinically significant depression and/or anxiety, with dysphagia being a predictor of distress and poorer quality of life. Evidence-based dysphagia interventions largely focus on the remediation of physical impairment. This feasibility study evaluates an intervention which simultaneously uses a psychological therapy approach combined with swallowing impairment rehabilitation. METHODS This prospective single cohort mixed-methods study, recruited HNSCC patients with dysphagia, from two institutions. The intervention combined Cognitive Behavioural Therapy with swallowing therapy (CB-EST), was individually tailored, for up to 10 sessions and delivered by a speech and language therapist. Primary acceptability and feasibility measures included recruitment and retention rates, data completion, intervention fidelity and the responsiveness of candidate outcome measures. Measures included a swallowing questionnaire (MDADI), EORTC-QLQH&N35, dietary restrictions scale, fatigue and function scales and the Hospital Anxiety and Depression Scale (HADS), administered pre-, post-CB-EST with three month follow-up and analysed using repeated measures ANOVA. Qualitative interviews were conducted to evaluate intervention processes. RESULTS A total of 30/43 (70%) eligible patients agreed to participate and 25 completed the intervention. 84% were male, mean age 59 yrs. Patients were between 1 and 60 months (median 4) post-cancer treatment. All patients had advanced stage disease, treated with surgery and radiotherapy (38%) or primary chemoradiotherapy (62%). Pre to post CB-EST data showed improvements in MDADI scores (p = 0.002), EORTC-QLQH&N35 (p = 0.006), dietary scale (p < 0.0001), fatigue (p = 0.002) but no change in function scales or HADS. Barriers to recruitment were the ability to attend regular appointments and patient suitability or openness to a psychological-based intervention. CONCLUSIONS CB-EST is a complex and novel intervention, addressing the emotional, behavioural and cognitive components of dysphagia alongside physical impairment. Preliminary results are promising. Further research is required to evaluate efficacy and effectiveness.
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Affiliation(s)
- J M Patterson
- Institute of Health and Society, Newcastle University, The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK. .,Speech & Language Therapy Department, Sunderland Royal Hospital, Sunderland, UK.
| | | | - C Exley
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - E McColl
- Institute of Health and Society, Newcastle University, The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - M Breckons
- Institute of Health and Society, Newcastle University, The Baddiley-Clark Building, Richardson Road, Newcastle upon Tyne, NE2 4AX, UK
| | - V Deary
- Psychology Department, Northumbria University, Newcastle upon Tyne, UK
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46
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Asín J, Molín J, Pérez M, Pinczowski P, Gimeno M, Navascués N, Muniesa A, de Blas I, Lacasta D, Fernández A, de Pablo L, Mold M, Exley C, de Andrés D, Reina R, Luján L. Studies on Injection Site Reactions Caused by Aluminium-Containing Products in Sheep. J Comp Pathol 2018. [DOI: 10.1016/j.jcpa.2017.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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47
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Avery L, Exley C, McPherson S, Trenell MI, Anstee QM, Hallsworth K. Lifestyle Behavior Change in Patients With Nonalcoholic Fatty Liver Disease: A Qualitative Study of Clinical Practice. Clin Gastroenterol Hepatol 2017. [PMID: 28624648 DOI: 10.1016/j.cgh.2017.06.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- Leah Avery
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Catherine Exley
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, United Kingdom
| | - Stuart McPherson
- Liver Unit, Newcastle Upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Michael I Trenell
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Quentin M Anstee
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Liver Unit, Newcastle Upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom
| | - Kate Hallsworth
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, United Kingdom; Liver Unit, Newcastle Upon Tyne Hospitals National Health Service Foundation Trust, Newcastle upon Tyne, United Kingdom.
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Standing HC, Rapley T, MacGowan GA, Exley C. ‘Being’ a ventricular assist device recipient: A liminal existence. Soc Sci Med 2017; 190:141-148. [DOI: 10.1016/j.socscimed.2017.08.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Revised: 08/08/2017] [Accepted: 08/16/2017] [Indexed: 10/19/2022]
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Tang EYH, Price C, Stephan BCM, Robinson L, Exley C. Gaps in care for patients with memory deficits after stroke: views of healthcare providers. BMC Health Serv Res 2017; 17:634. [PMID: 28886738 PMCID: PMC5591549 DOI: 10.1186/s12913-017-2569-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2017] [Accepted: 08/25/2017] [Indexed: 11/14/2022] Open
Abstract
Background Stroke is a common cause of physical disability but is also strongly associated with cognitive impairment and a risk for future dementia. Despite national clinical guidelines, the service provided for stroke survivors with cognitive and memory difficulties varies across localities. This study critically evaluated the views of healthcare professionals about barriers and facilitators to their care. Methods Seventeen semi-structured individual interviews were conducted by a single interviewer with both primary and secondary care clinicians in regular contact with stroke-survivors. This included stroke medicine specialists, specialist nurses, physiotherapists, occupational therapists, general practitioners and primary care nurses. Topics included individual experiences of the current care offered to patients with cognitive impairment, assessment processes and inter-professional communication. Interviews were audio recorded and transcribed verbatim. Transcripts were thematically analysed and themes grouped into broad categories to facilitate interpretation. Results Data analysis identified four key themes as barriers to optimal care for stroke-survivors with memory difficulties: 1) Less focus on memory and cognition in post-stroke care; 2) Difficulties bringing up memory and cognitive problems post-stroke; 3) Lack of clarity in current services; and, 4) Assumptions made by healthcare professionals introducing gaps in care. Facilitators included stronger links between primary and secondary care in addition to information provision at all stages of care. Conclusions The care provided by stroke services is dominated by physical impairments. Clinicians are unsure who should take responsibility for follow-up of patients with cognitive problems. This is made even more difficult by the lack of experience in assessment and stigma surrounding potential diagnoses associated with these deficits. Service development should focus on increased cohesiveness between hospital and community care to create a clear care pathway for post-stroke cognitive impairment.
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Affiliation(s)
- Eugene Yee Hing Tang
- Institute of Health and Society and Newcastle University Institute for Ageing, Newcastle University, Level 2, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK.
| | - Christopher Price
- Institute of Neuroscience, Stroke Research Group, Newcastle University, Newcastle upon Tyne, UK
| | - Blossom Christa Maree Stephan
- Institute of Health and Society and Newcastle University Institute for Ageing, Newcastle University, Level 2, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK
| | - Louise Robinson
- Institute of Health and Society and Newcastle University Institute for Ageing, Newcastle University, Level 2, Biomedical Research Building, Campus for Ageing and Vitality, Newcastle upon Tyne, NE4 5PL, UK
| | - Catherine Exley
- Faculty of Health & Life Sciences, Northumbria University, Newcastle upon Tyne, UK
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50
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Standing H, Jarvis H, Orr J, Exley C, Hudson M, Kaner E, Hanratty B. How can primary care enhance end-of-life care for liver disease? Qualitative study of general practitioners' perceptions and experiences. BMJ Open 2017; 7:e017106. [PMID: 28864486 PMCID: PMC5588936 DOI: 10.1136/bmjopen-2017-017106] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
BACKGROUND Liver disease is the third most common cause of premature death in the UK. The symptoms of terminal liver disease are often difficult to treat, but very few patients see a palliative care specialist and a high proportion die in hospital. Primary care has been identified as a setting where knowledge and awareness of liver disease is poor. Little is known about general practitioners' (GPs) perceptions of their role in managing end-stage liver disease. OBJECTIVE To explore GPs' experiences and perceptions of how primary care can enhance end-of-life care for patients with liver disease. DESIGN Qualitative interview study, thematic analysis. PARTICIPANTS Purposive sample of 25 GPs from five regions of England. RESULTS GPs expressed a desire to be more closely involved in end-of-life care for patients with liver disease but identified a number of factors that constrained their ability to contribute. These fell into three main areas; those relating directly to the condition, (symptom management and the need to combine a palliative care approach with ongoing medical interventions); issues arising from patients' social circumstances (stigma, social isolation and the social consequences of liver disease) and deficiencies in the organisation and delivery of services. Collaborative working with support from specialist hospital clinicians was regarded as essential, with GPs acknowledging their lack of experience and expertise in this area. CONCLUSIONS End-of-life care for patients with liver disease merits attention from both primary and secondary care services. Development of care pathways and equitable access to symptom relief should be a priority.
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Affiliation(s)
- Holly Standing
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Helen Jarvis
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - James Orr
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
| | - Catherine Exley
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Mark Hudson
- Institute of Cellular Medicine, Newcastle University, Newcastle upon Tyne, UK
- Liver Unit, Freeman Hospital, High Heaton, Newcastle upon Tyne, UK
| | - Eileen Kaner
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
| | - Barbara Hanratty
- Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK
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