Imperial College London

DrGevaGreenfield

Faculty of MedicineSchool of Public Health

Research Fellow in Public Health
 
 
 
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Contact

 

+44 (0)20 7594 8595g.greenfield Website

 
 
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Location

 

314Reynolds BuildingCharing Cross Campus

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Summary

 

Publications

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54 results found

Greenfield G, Ramzan FA, Newson RB, Majeed A, Gnani Set al., 2015, Frequent attendances to National Health Service general practitioner-led urgent care centres in London: an observational study, Publisher: ELSEVIER SCIENCE INC, Pages: S40-S40, ISSN: 0140-6736

Conference paper

Kassianos A, Ignatowicz, Greenfield, Majeed, Car, Pappaset al., 2015, ‘Partners rather than just providers…’: A qualitative study on healthcare professionals’ views on implementation of multidisciplinary group meetings in the North West London Integrated Care Pilot, International Journal of Integrated Care, Vol: 15, ISSN: 1568-4156

Introduction: Multidisciplinary group meetings are one of the key drivers of facilitating integrated care. Health care professionals attending such groups have a key role in the success of these discussions and hence, in the forming of multi-professional integrated care. The study aimed to explore the professionals’ experiences and views of participating and implementing the groups in integrated care context.Methods: A qualitative study including 25 semi-structured interviews with professionals participating in the Northwest London Integrated Care Pilot analysed using thematic content analysis.Results: Participants mentioned a number of benefits of participating in the meetings, including shared learning and shared decision-making between different services and specialties. Yet, they perceived barriers that diminish the efficiency of the groups, such as time constraints, group dynamics and technicalities. The participants felt that the quality of discussions and facilitation could be improved, as well as technical arrangements that would make them easier to participate. Most of the participants perceived the groups to be beneficial for providers mostly questioning the benefits for patient care.Conclusion: Findings provide an insight into how health professionals’ views of their participation to the multidisciplinary group meetings can be more effectively translated into more tangible benefits to the patients. To benefit patient care, the multidisciplinary groups need to be more patient-oriented rather than provider-oriented, while overcoming professional boundaries for participating.

Journal article

Ignatowicz A, Greenfield G, Pappas Y, Car J, Majeed A, Harris Met al., 2014, Achieving Provider Engagement: Providers' Perceptions of Implementing and Delivering Integrated Care, Qualitative Health Research, Vol: 24, Pages: 1711-1720, ISSN: 1552-7557

The literature on integrated care is limited with respect to practical learning and experience. Although some attention has been paid to organizational processes and structures, not enough is paid to people, relationships, and the importance of these in bringing about integration. Little is known, for example, about provider engagement in the organizational change process, how to obtain and maintain it, and how it is demonstrated in the delivery of integrated care. Based on qualitative data from the evaluation of a large-scale integrated care initiative in London, United Kingdom, we explored the role of provider engagement in effective integration of services. Using thematic analysis, we identified an evolving engagement narrative with three distinct phases: enthusiasm, antipathy, and ambivalence, and argue that health care managers need to be aware of the impact of professional engagement to succeed in advancing the integrated care agenda.

Journal article

Greenfield G, Ignatowicz AM, Belsi A, Pappas Y, Car J, Majeed A, Harris Met al., 2014, Wake up, wake up! It's me! It's my life! patient narratives on person-centeredness in the integrated care context: a qualitative study., BMC Health Services Research, Vol: 14, ISSN: 1472-6963

BackgroundPerson-centered care emphasizes a holistic, humanistic approach that puts patients first, at the center of medical care. Person-centeredness is also considered a core element of integrated care. Yet typologies of integrated care mainly describe how patients fit within integrated services, rather than how services fit into the patient¿s world. Patient-centeredness has been commonly defined through physician¿s behaviors aimed at delivering patient-centered care. Yet, it is unclear how `person-centeredness¿ is realized in integrated care through the patient voice. We aimed to explore patient narratives of person-centeredness in the integrated care context.MethodsWe conducted a phenomenological, qualitative study, including semi-structured interviews with 22 patients registered in the Northwest London Integrated Care Pilot. We incorporated Grounded Theory approach principles, including substantive open and selective coding, development of concepts and categories, and constant comparison.ResultsWe identified six themes representing core `ingredients¿ of person-centeredness in the integrated care context: ¿Holism¿, ¿Naming¿, ¿Heed¿, ¿Compassion¿, ¿Continuity of care¿, and ¿Agency and Empowerment¿, all depicting patient expectations and assumptions on doctor and patient roles in integrated care. We bring examples showing that when these needs are met, patient experience of care is at its best. Yet many patients felt `unseen¿ by their providers and the healthcare system. We describe how these six themes can portray a continuum between having own physical and emotional `Space¿ to be `seen¿ and heard vs. feeling `translucent¿, `unseen¿, and unheard. These two conflicting experiences raise questions about current typologies of the patient-physician relationship as a `dyad¿, the meanings patients attributed to `care&

Journal article

Greenfield G, Ignatowicz AM, Majeed A, Harris Met al., 2014, Patient narratives on person-centeredness in the integrated care context, INTERNATIONAL JOURNAL OF INTEGRATED CARE, Vol: 14, ISSN: 1568-4156

Journal article

Marcano Belisario JS, Huckvale K, Greenfield G, Car J, Gunn LHet al., 2013, Smartphone and tablet self management apps for asthma, Cochrane Database of Systematic Reviews

Journal article

Harris M, Greaves F, Gunn L, Patterson S, Greenfield G, Car J, Majeed A, Pappas Yet al., 2013, Multidisciplinary integration in the context of integrated care - results from the North West London Integrated Care Pilot, INTERNATIONAL JOURNAL OF INTEGRATED CARE, Vol: 13, ISSN: 1568-4156

Background:In the context of integrated care, Multidisciplinary Group meetings involve participants from diverse professional groupsand organisations and are potential vehicles to advance efficiency improvements within the local health economy. We advance a novelmethod to characterise the communication within Multidisciplinary Group meetings measuring the extent to which participants integrateand whether this integration leads to improved working.Methods:We purposively selected four Multidisciplinary Group meetings and conducted a content analysis of audio-recorded and tran-scribed Case Discussions. Two coders independently coded utterances according to their‘integrative intensity’which was defined againstthree a-priori independent domains - the Level (i.e. Individual, Collective and Systems); the Valence (Problem, Information and Solution);the Focus (Concrete and Abstract). Inter- and intra-rater reliability was tested with Kappa scores on one randomly selected Case Discus-sion. Standardised weighted mean integration scores were calculated for Case Discussions across utterance deciles, indicating how inte-grative intensity changed during the conversations.Results:Twenty-three Case Discussions in four different Multidisciplinary Groups were transcribed and coded. Inter- and intra-rater relia-bility was good as shown by the Prevalence and Bias-Adjusted Kappa Scores for one randomly selected Case Discussion. There were differences in the proportion of utterances per participant type (Consultant 14.6%; presenting general practitioner 38.75%; Chair 7.8%; non-presenting general practitioner 2.25%; Allied Health Professional 4.8%). Utterances were predominantly coded at low levels of integrativeintensity; however, there was a gradual increase (R2= 0.71) in integrative intensity during the Case Discussions. Based on the analysis ofthe minutes and action points arising from the Case Discussions, this improved integration did not translate into actions moving for

Journal article

Curry N, Harris M, Gunn LH, Pappas Y, Blunt I, Soljak M, Mastellos N, Holder H, Smith J, Majeed A, Ignatowicz A, Greaves F, Belsi A, Costin-Davis N, Jones Nielsen JD, Greenfield G, Cecil E, Patterson S, Car J, Bardsley Met al., 2013, Integrated care pilot in north west London: a mixed methods evaluation, International Journal of Integrated Care, Vol: 13, ISSN: 1568-4156

Journal article

Kellman S, Bitan Y, Greenfield G, Nunnally MEet al., 2013, PORTABLE SIMULATION CREATES A TOOL TO ANALYZE EXPERT COGNITION IN A BUSY WORK ENVIRONMENT, Annual Meeting of the International-Anesthesia-Research-Society, Publisher: LIPPINCOTT WILLIAMS & WILKINS, Pages: 309-309, ISSN: 0003-2999

Conference paper

Harris M, Greaves F, Gunn L, Patterson S, Vaschitz G, Car J, Majeed A, Pappas Yet al., 2013, Multidisciplinary group performance – measuring integration intensity in the context of the North West London Integrated Care Pilot, International Journal of Integrated Care, Vol: 13, ISSN: 1568-4156

Introduction: Multidisciplinary Group meeting (MDGs) are seen as key facilitators of integration, moving from individual to multi-disciplinary decision making, and from a focus on individual patients to a focus on patient groups. We have developed a method for coding MDG transcripts to identify whether they are or are not vehicles for delivering the anticipated efficiency improvements across various providers and apply it to a test case in the North West London Integrated Care Pilot. Methods: We defined 'integrating' as the process within the MDG meeting that enables or promotes an improved collaboration, improved understanding, and improved awareness of self and others within the local healthcare economy such that efficiency improvements could be identified and action taken. Utterances within the MDGs are coded according to three distinct domains grounded in concepts from communication, group decision-making, and integrated care literatures - the Valence, the Focus, and the Level. Standardized weighted integrative intensity scores are calculated across ten time deciles in the Case Discussion providing a graphical representation of its integrative intensity.Results: Intra- and Inter-rater reliability of the coding scheme was very good as measured by the Prevalence and Bias-adjusted Kappa Score. Standardized Weighted Integrative Intensity graph mirrored closely the verbatim transcript and is a convenient representation of complex communication dynamics. Trend in integrative intensity can be calculated and the characteristics of the MDG can be pragmatically described.Conclusion: This is a novel and potentially useful method for researchers, managers and practitioners to better understand MDG dynamics and to identify whether participants are integrating. The degree to which participants use MDG meetings to develop an integrated way of working is likely to require management, leadership and shared values.

Journal article

Greenfield G, Pliskin JS, Wientroub S, Davidovitch Net al., 2012, Orthopedic surgeons’ and neurologists’ attitudes towards second opinions in the Israeli healthcare system: A qualitative study, Israel Journal of Health Policy Research, Vol: 1, ISSN: 2045-4015

BackgroundSecond opinion is a treatment ratification tool that may critically influence diagnosis, treatment, and prognosis. Second opinions constitute one of the largest expenditures of the supplementary health insurance programs provided by the Israeli health funds. The scarcity of data on physicians’ attitudes toward second opinion motivated this study to explore those attitudes within the Israeli healthcare system.MethodsWe interviewed 35 orthopedic surgeons and neurologists in Israel and qualitatively analyzed the data using the Grounded Theory approach.ResultsAs a common tool, second opinion reflects the broader context of the Israeli healthcare system, specifically tensions associated with health inequalities. We identified four issues: (1) inequalities between central and peripheral regions of Israel; (2) inequalities between private and public settings; (3) implementation gap between the right to a second opinion and whether it is covered by the National Health Insurance Law; and (4) tension between the authorities of physicians and religious leaders. The physicians mentioned that better mechanisms should be implemented for guiding patients to an appropriate consultant for a second opinion and for making an informed choice between the two opinions.ConclusionsWhile all the physicians agreed on the importance of the second opinion as a tool, they raised concerns about the way it is provided and utilized. To be optimally implemented, second opinion should be institutionalized and regulated. The National Health Insurance Law should strive to provide the mechanisms to access second opinion as stipulated in the Patient’s Rights Law. Further studies are needed to assess the patients' perspectives.

Journal article

Vashitz G, Pliskin JS, Parmet Y, Kosashvili Y, Ifergane G, Wientroub S, Davidovitch Net al., 2012, Do First Opinions Affect Second Opinions?, Journal of general internal medicine, ISSN: 1525-1497

BACKGROUND: Second medical opinions have become commonplace and even mandatory in some health-care systems, as variations in diagnosis, treatment or prognosis may emerge among physicians. OBJECTIVE: To evaluate whether physicians' judgment is affected by another medical opinion given to a patient. DESIGN: Orthopedic surgeons and neurologists filled out questionnaires presenting eight hypothetical clinical scenarios with suggested treatments. One group of physicians (in each specialty) was told what the other physician's opinion was (study group), and the other group was not told what it was (control group). PARTICIPANTS: A convenience sample of 332 physicians in Israel: 172 orthopedic surgeons (45.9% of their population) and 160 neurologists (64.0% of their population). MEASUREMENTS: Scoring was by choice of less or more interventional treatment in the scenarios. We used χ(2) tests and repeated measures ANOVA to compare these scores between the two groups. We also fitted a cumulative ordinal regression to account for the dependence within each physician's responses. RESULTS: Orthopedic surgeons in the study group chose a more interventionist treatment when the other physician suggested an intervention than those in the control group [F (1, 170) = 4.6, p = 0.03; OR = 1.437, 95% CI 1.115-1.852]. Evaluating this effect separately in each scenario showed that in four out of the eight scenarios, they chose a more interventional treatment when the other physician suggested an intervention (scenario 1, p = 0.039; scenario 2, p < 0.001; scenario 3, p = 0.033; scenario 6, p < 0.001). These effects were insignificant among the neurologists [F (1,158) = 0.44, p = 0.51; OR = 1.087, 95% CI 0.811-1.458]. In both specialties there were no differences in responses by level of clinical experience [orthopedic surgeons: F (2, 166)&thinsp

Journal article

Harris M, Greaves F, Patterson S, Greenfield G, Gunn L, Car J, Majeed A, Pappas Yet al., 2012, Multidisciplinary group performance in the context of Integrated Care - measuring integration intensity, Public health science: A national conference dedicated to new research in public health. Lancet/RSM

Conference paper

Marcano-Belisario JS, Greenfield G, Huckvale K, Gunn L, Car Jet al., 2012, Smartphone and tablet self-management apps for asthma [Intervention Protocol], Cochrane Database of Systematic Reviews

Journal article

Greenfield G, Pliskin JS, Feder-Bubis P, Wientroub S, Davidovitch Net al., 2012, Patient-physician relationships in second opinion encounters - the physicians’ perspective, Soc Sci Med

Journal article

Vashitz G, Meyer J, Parmet Y, Henkin Y, Peleg R, Liebermann N, Gilutz Het al., 2011, Adherence by primary care physicians to guidelines for the clinical management of dyslipidemia, Isr. Med. Assoc. J., Vol: 13, Pages: 657-662, ISSN: 1565-1088

BACKGROUND There is a wide treatment gap between evidence-based guidelines and their implementation in primary care. OBJECTIVE To evaluate the extent to which physicians "literally" follow guidelines for secondary prevention of dyslipidemia and the extent to which they practice "substitute" therapeutic measures. METHODS We performed a post hoc analysis of data collected in a prospective cluster randomized trial. The participants were 130 primary care physicians treating 7745 patients requiring secondary prevention of dyslipidemia. The outcome measure was physician literal adherence or substitute adherence. We used logistic regressions to evaluate the effect of various clinical situations on literal and substitute adherence. RESULTS Literal adherence was modest for ordering a lipoprotein profile (35.1%) and for pharmacotherapy initiations (26.0%), but rather poor for drug up-titrations (16.1%) and for referrals for specialist consultation (3.8%). In contrast, many physicians opted for substitute adherence for up-titrations (75.9%) and referrals for consultation (78.7%). Physicians tended to follow the guidelines literally in simple clinical situations (such as the need for lipid screening) but to use substitute measures in more complex cases (when dose up-titration or metabolic consultation was required). Most substitute actions were less intense than the actions recommended by the guidelines. CONCLUSIONS Physicians often do not blindly follow guidelines, but rather evaluate their adequacy for a particular patient and adjust the treatment according to their assessment. We suggest that clinical management be evaluated in a broader sense than strict guideline adherence, which may underestimate physicians' efforts.

Journal article

Vashitz G, Meyer J, Parmet Y, Henkin Y, Peleg R, Gilutz Het al., 2011, Physician adherence to the dyslipidemia guidelines is as challenging an issue as patient adherence, Fam Pract, Vol: 28, Pages: 524-531, ISSN: 1460-2229

BACKGROUND A wide therapeutic gap exists between evidence-based guidelines and their practice in the primary care, which is primarily attributed to physician and patient adherence. OBJECTIVE This study aims to differentiate physician and patient adherence to dyslipidemia secondary prevention guidelines and various factors affecting it. METHODS A post hoc analysis of data collected by a prospective cluster randomized trial with 7041 patients diagnosed with clinical atherosclerosis requiring secondary prevention of dyslipidemia and 127 primary care physicians over an 18-month period. Adherence was measured by physicians' and patients' actions taken according to the guidelines and correlated using multivariate logistic regressions. RESULTS Physician adherence was 36.9% for lipid profile screening, 27.6% for pharmacotherapy up-titration and 21.0% for pharmacotherapy initiation. Physician adherence was positively correlated with frequent patient visits [odds ratios (OR = 1.304)], having more dyslipidemic patients (OR = 1.304) and treating immigrants (OR = 1.268). Patient adherence was 83.8%, 71.9% and 62.6% for medication up-titration, lipid profile screening and pharmacotherapy initiation, respectively. Patient adherence was affected by attending clinics with many dyslipidemic patients (OR = 1.542), being older (OR = 1.271) and being treated by a male physician (OR = 0.870). CONCLUSIONS We learn from this study that (i) physician non-adherence was a major cause for the failure to follow guidelines, (ii) pharmacotherapy initiation was the most challenging issue to tackle and (iii) greater adherence occurred mainly in high volume conditions (patients and visits). Practical implications are designated focus on metabolic condition prevention in primary care by cardiologists or primary care clinics specializing in metabolic conditions and the need to facilitate more frequent follow-up visits.

Journal article

Vashitz G, Nunnally M, Bitan Y, Parmet Y, OConnor M, Cook Ret al., 2011, Making sense of diseases in medication reconciliation, Cognition, Technology & Work, Vol: 13, Pages: 151-158, ISSN: 1435-5558

Journal article

Vashitz G, Davidovitch N, Pliskin JS, 2011, [Second medical opinions], Harefuah, Vol: 150, Pages: 105-110, 207-105-110, 207, ISSN: 0017-7768

Second opinion is a decision-support tool for ratification or modification of a suggested treatment, by another physician. Second opinion may have a critical influence on the diagnosis, treatment and prognosis. The patient can benefit from treatment optimization and avoid unnecessary risks. The physician can benefit from less exposure to legal claims, and healthcare organizations can benefit from increased treatment, quality assurance and costs saving from unnecessary surgery and treatments. Nevertheless, injudicious use of this tool can provoke unnecessary medical costs. In recent years, many patients prefer to seek a second opinion on their disease and available treatments. Private and public insurance companies are trying to control surgery costs by urging and even demanding a second opinion before surgery. Although second opinions are common in medical practice, relatively little is known on this subject. Most of the studies reviewed in this article evaluated the clinical benefit of second opinions, the reasons patients seek a second opinion and the characteristics of these patients, as well as technological interventions to promote second opinions, and ethical or legal issues related to second opinions. Yet, there are opportunities for further studies about physicians attitudes and barriers towards second opinions, their effect on patient-physician communication and cost-effectiveness analyses of second opinions. Due to the relevance of second opinions for public heath, this review aims to summarize the current research on second opinions.

Journal article

Vashitz G, Meyer J, Parmet Y, Liebermann N, Gilutz Het al., 2010, Factors affecting physicians compliance with enrollment suggestions into a clinical reminders intervention, Stud Health Technol Inform, Vol: 160, Pages: 796-800, ISSN: 0926-9630

Clinical reminders can promote adherence with evidence-based clinical guidelines, but they may also have unintended consequences such as alert fatigue, false alarms and increased workload, which cause clinicians to ignore them. The described clinical reminder system identifies patients eligible for primary prevention of cardiovascular diseases and lets the physician to choose which patients will be included in the reminders intervention. We analyzed data of 87,165 visits of 35,699 patients and evaluated factors which may affect clinicians' decision to enroll patients to the intervention. The physicians included most of the patients suggested for inclusion (85.7%). Yet, they skipped the enrollment suggestion in 62.6% of the visits. Patients with a cardiovascular disease, dyslipidemia, diabetes, or hypertension were more likely to be included in the intervention, while older patients were less likely to be included. Insights regarding the usability of clinical reminders are discussed.

Journal article

Vashitz G, Meyer J, Parmet Y, Peleg R, Goldfarb D, Porath A, Gilutz Het al., 2009, Defining and measuring physicians' responses to clinical reminders, J Biomed Inform, Vol: 42, Pages: 317-326, ISSN: 1532-0480

Decision-support systems, and specifically rule-based clinical reminders, are becoming common in medical practice. Despite their potential to improve clinical outcomes, physicians do not always use information from these systems. Concepts from the cognitive engineering literature on users' responses to warning systems may help to define physicians' responses to reminders. Based on this literature, we suggest an exhaustive set of possible responses to clinical reminders, consisting of four responses named "Compliance", "Reliance", "Spillover" and "Reactance". We suggest statistical measures to estimate these responses and empirically demonstrate them on data from a large-scale clinical reminder system for secondary prevention of cardiovascular diseases. There was evidence for Compliance, probably since the physicians found the reminders informative, but not for Reliance, in line with the notion that Compliance and Reliance are two distinct types of trust in information from decision-support systems. Our research supports the notion that CDSS can promote closing the treatment gap and improve physicians' adherence to guidelines.

Journal article

Vashitz G, Shinar D, Blum Y, 2008, In-vehicle information systems to improve traffic safety in road tunnels, TRANSPORTATION RESEARCH PART F-TRAFFIC PSYCHOLOGY AND BEHAVIOUR, Vol: 11, Pages: 61-74, ISSN: 1369-8478

Journal article

Vashitz G, Meyer J, Gilutz H, 2007, General practitioners' adherence with clinical reminders for secondary prevention of dyslipidemia, Pages: 766-770, ISSN: 1942-597X

A variety of computer-based applications, including computerized clinical reminders, are intended to increase adherence to evidence-based clinical guidelines. The value of these systems in clinical practice is still unclear. One reason for the limited success of clinical reminders may be physicians' low tendency to adhere to their advice. We studied the determinants of physicians' adherence to clinical advice regarding the management of dyslipidemia. Overall, the clinical reminders increased physicians' adherence to the clinical guidelines. Physicians were more compliant with the reminders when they experienced a greater patients' load, when they were less acquainted with the patient, and when more time has passed since the last major cardiac event. These findings can help to predict physicians' adherence and to improve the usage of clinical reminders for the benefit of patients, physicians and HMOs.

Conference paper

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