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

Publication Type
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68 results found

Greenfield G, Okoli O, Quezada Yamamoto H, Blair M, Saxena S, Majeed F, Hayhoe Bet al., 2021, Characteristics of frequently attending children in hospital emergency departments: a systematic review, BMJ Open, ISSN: 2044-6055

Objective: To summarise the literature on frequent attendances to hospital emergency departments and describe sociodemographic and clinical characteristics of children who attend EDs frequently.Setting: Hospital emergency departments.Participants: Children <21 years, attending hospital emergency departments frequently.Primary outcome measures: Outcomes measures were defined separately in each study, and were predominantly the number of ED attendances per year.Results: We included 21 studies representing 6,513,627 children. Between 0.3% to 75% of all paediatric ED users were frequent users. Most studies defined 4 or more visits per year as a “frequent ED” usage. Children who were frequent ED users were more likely to be less than 5 years old. In the US, patients with public insurance were more likely to be frequent attenders. Frequent ED users more likely to be frequent users of primary care and have long-term conditions; the most common diagnoses were infections and gastroenteritis.Conclusions: The review included a wide range of information across various health systems, however children who were frequent ED users have some universal characteristics in common. Policies to reduce frequent attendance might usefully focus on preschool children and supporting primary care in responding to primary-care oriented conditions.

Journal article

Greenfield G, Shmueli L, Harvey A, Quezada-Yamamoto H, Davidovitch N, Pliskin J, Rawaf S, Majeed FAA, Hayhoe Bet al., 2021, Patient-initiated second medical consultations: patient characteristics and motivating factors, impact on care and satisfaction: A systematic review, BMJ Open, ISSN: 2044-6055

Objectives: To review the characteristics and motivations of patients seeking second opinions, and the impact of such opinions on patient management, satisfaction, and cost-effectiveness. Data sources: Embase, Medline, PsycINFO and HMIC databases.Study design: A systematic literature search was performed for terms related to second opinion and patient characteristics. Study quality was assessed using the National Institutes of Health (NIH) Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Data collection / Extraction methods: We included articles focused on patient-initiated second opinions, which provided quantitative data on their impact on diagnosis, treatment, prognosis or patient satisfaction, described the characteristics or motivating factors of patients who initiated a second opinion, or the cost-effectiveness of patient-initiated second opinions. Principal findings: Thirty-one articles were included in the review. 27 studies considered patient characteristics, 18 patient motivating factors, 10 patient satisfaction, and 17 clinical agreement between the first and second opinion. Seeking a second opinion was more common in women, middle age patients, more educated patients; and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain more information or reassurance about their diagnosis or treatment. While many second opinions confirm the original diagnosis or treatment, discrepancies in opinions had a potential major impact on patient outcomes in up to 58% of cases. No studies reporting on the cost-effectiveness of patient initiated second opinions.Conclusions: Seeking a second opinion was more common in women, middle-age patients, and more educated patients, and in people having a chronic condition, with higher income or socioeconomic status or living in central urban areas. Patients seeking a second opinion sought to gain m

Journal article

Hargreaves D, Mates E, Menon P, Alderman H, Devakumar D, Fawzi W, Greenfield G, Hammoudeh W, He S, Lahiri A, Liu Z, Nguyen P, Sethi V, Wang H, Neufeld L, Patton Get al., 2021, Strategies and interventions for healthy adolescent growth, nutrition and development, The Lancet, ISSN: 0140-6736

Adolescence is a pivotal point in the life-course, characterised by transformative physical, cognitive and emotional growth, an openness to change and a drive to reshape the social environment. It offers unique opportunities to adopt changes in diet and physical activity that can persist into later life. Yet pre-existing nutritional problems including micronutrient deficiencies, food insecurity and poor-quality diets persist at the same time as adolescents face the rapid emergence of an obesity epidemic. Adolescent growth and nutrition has been largely overlooked in intervention and policy research. Most intervention studies have emphasised micronutrient supplementation with few taking into account the multiple drivers of adolescent diets. Effective interventions and policies will need to cut across sectors, be supported by multifaceted and multilevel policy and extend across education, health, food systems, social protection and digital media. Better data standardisation and systems will be essential in coordinating and monitoring these responses. In a context of shifts in planetary ecosystems and commercial drivers, resilient food systems will need to both ensure access to healthy and affordable foods and provide the infrastructure and incentives for continuing physical activity. Intergenerational partnerships with young people will be essential in bringing about transformative change and ensuring that food policies reflect their needs and aspirations.

Journal article

Greenfield G, Blair M, Aylin P, Saxena S, Majeed F, Bottle Ret al., 2021, Characteristics of frequent paediatric users of emergency departments in England: an observational study using routine national data, Emergency Medicine Journal, Vol: 38, Pages: 146-150, ISSN: 1472-0205

BACKGROUND:Frequent attendances of the same users in emergency departments (ED) can intensify workload pressures and are common among children, yet little is known about the characteristics of paediatric frequent users in EDs. AIM:To describe the volume of frequent paediatric attendance in England and the demographics of frequent paediatric ED users in English hospitals. METHOD:We analysed the Hospital Episode Statistics dataset for April 2014-March 2017. The study included 2 308 816 children under 16 years old who attended an ED at least once. Children who attended four times or more in 2015/2016 were classified as frequent users. The preceding and subsequent years were used to capture attendances bordering with the current year. We used a mixed effects logistic regression with a random intercept to predict the odds of being a frequent user in children from different sociodemographic groups. RESULTS:One in 11 children (9.1%) who attended an ED attended four times or more in a year. Infants had a greater likelihood of being a frequent attender (OR 3.24, 95% CI 3.19 to 3.30 vs 5 to 9 years old). Children from more deprived areas had a greater likelihood of being a frequent attender (OR 1.57, 95% CI 1.54 to 1.59 vs least deprived). Boys had a slightly greater likelihood than girls (OR 1.05, 95% CI 1.04 to 1.06). Children of Asian and mixed ethnic groups were more likely to be frequent users than those from white ethnic groups, while children from black and 'other' had a lower likelihood (OR 1.03, 95% CI 1.01 to 1.05; OR 1.04, 95% CI 1.01 to 1.06; OR 0.88, 95% CI 0.86 to 0.90; OR 0.90, 95% CI 0.87 to 0.92, respectively). CONCLUSION:One in 11 children was a frequent attender. Interventions for reducing paediatric frequent attendance need to target infants and families living in deprived areas.

Journal article

Woods J-B, Greenfield G, Majeed A, Hayhoe Bet al., 2020, Clinical effectiveness and cost effectiveness of individual mental health workers colocated within primary care practices: a systematic literature review, BMJ Open, Vol: 10, ISSN: 2044-6055

Objectives Mental health disorders contribute significantly to the global burden of disease and lead to extensive strain on health systems. The integration of mental health workers into primary care has been proposed as one possible solution, but evidence of clinical and cost effectiveness of this approach is unclear. We reviewed the clinical and cost effectiveness of mental health workers colocated within primary care practices.Design Systematic literature review.Data sources We searched the Medline, Embase, PsycINFO, Healthcare Management Information Consortium (HMIC) and Global Health databases.Eligibility criteria All quantitative studies published before July 2019 were eligible for the review; participants of any age and gender were included. Studies did not need to report a certain outcome measure or comparator in order to be eligible.Data extraction and synthesis Data were extracted using a standardised table; however, pooled analysis proved unfeasible. Studies were assessed for risk of bias using the Risk Of Bias In Non-randomised Studies - of Interventions (ROBINS-I) tool and the Cochrane collaboration’s tool for assessing risk of bias in randomised trials.Results Fifteen studies from four countries were included. Mental health worker integration was associated with mental health benefits to varied populations, including minority groups and those with comorbid chronic diseases. Furthermore, the interventions were correlated with high patient satisfaction and increases in specialist mental health referrals among minority populations. However, there was insufficient evidence to suggest clinical outcomes were significantly different from usual general practitioner care.Conclusions While there appear to be some benefits associated with mental health worker integration in primary care practices, we found insufficient evidence to conclude that an onsite primary care mental health worker is significantly more clinically or cost effective when compared with u

Journal article

Neves AL, Lawrence-Jones A, Naar L, Greenfield G, Sanderson F, Hyde T, Wingfield D, Cassidy I, Mayer Eet al., 2020, Multidisciplinary teams must work together to co-develop inclusive digital primary care for older people, British Journal of General Practice, Vol: 70, Pages: 582-582, ISSN: 0960-1643

Journal article

Han SM, Greenfield G, Majeed F, Hayhoe Bet al., 2020, Impact of Remote Consultations on Antibiotic Prescribing in Primary Healthcare: Systematic Review, Journal of Medical Internet Research, Vol: 22, ISSN: 1438-8871

Background: There has been growing international interest in performing remote consultations in primary care, particularly amidst the current COVID-19 pandemic. Despite this, the evidence surrounding the safety of remote consultations is inconclusive. The appropriateness of antibiotic prescribing in remote consultations is an important aspect of patient safety that needs to be addressed.Objective: This study aimed to summarize evidence on the impact of remote consultation in primary care with regard to antibiotic prescribing.Methods: Searches were conducted in MEDLINE, Embase, HMIC, PsycINFO, and CINAHL for literature published since the databases’ inception to February 2020. Peer-reviewed studies conducted in primary health care settings were included. All remote consultation types were considered, and studies were required to report any quantitative measure of antibiotic prescribing to be included in this systematic review. Studies were excluded if there were no comparison groups (face-to-face consultations).Results: In total, 12 studies were identified. Of these, 4 studies reported higher antibiotic-prescribing rates, 5 studies reported lower antibiotic-prescribing rates, and 3 studies reported similar antibiotic-prescribing rates in remote consultations compared with face-to-face consultations. Guideline-concordant prescribing was not significantly different between remote and face-to-face consultations for patients with sinusitis, but conflicting results were found for patients with acute respiratory infections. Mixed evidence was found for follow-up visit rates after remote and face-to-face consultations.Conclusions: There is insufficient evidence to confidently conclude that remote consulting has a significant impact on antibiotic prescribing in primary care. However, studies indicating higher prescribing rates in remote consultations than in face-to-face consultations are a concern. Further, well-conducted studies are needed to inform safe and appropri

Journal article

Al-Saffar M, Hayhoe B, Harris M, Majeed A, Greenfield Get al., 2020, Children as frequent attenders in primary care: a systematic review, BJGP Open, Vol: 4, ISSN: 2398-3795

Background: Frequent paediatric attendances make up a large proportion of the general practitioner (GP) workload. Currently no systematic reviews on frequent paediatric attendances in primary care exists. Aim: To identify the socio-demographic and clinical characteristics of children who attend primary care frequently. Design and setting: A systematic review.Methods: The electronic databases MEDLINE, EMBASE and PsycINFO were searched up to January 2020, using terms relating to frequent attendance in primary care settings. Studies were eligible if they considered children frequently attending in primary care (0-19 years). Relevant data were extracted and analysed by narrative synthesis.Results: Six studies, of overall fair quality, were included in the review. Frequent attendance was associated with presence of psycho-social and mental health problems, younger age, school absence, presence of chronic conditions, and high level of anxiety in their parents.Conclusions: Various sociodemographic and medical characteristics of children were associated with frequent attendance in primary care. Research on interventions needs to account for the social context and community characteristics. Integrating GP services with mental health and social care could potentially provide a response to medical and psycho-social needs of frequently attending children and their families.

Journal article

Greenfield G, Blair M, Aylin P, Saxena S, Majeed F, Hoffman M, Bottle Aet al., 2020, Frequent attendances at emergency departments in England, Emergency Medicine Journal, Vol: 37, Pages: 597-599, ISSN: 1472-0205

Background: A small proportion of patients referred to as ‘frequent attenders’ account for a large proportion of hospital activity such as emergency departments (ED) attendances and admissions. There is lack of recent, national estimates of the volume of frequent ED attenders. We aimed to estimate the volume and age distribution of frequent ED attenders in English hospitals.Method: We included all attendances at all major EDs across England in the financial year 2016–2017. Patients who attended 3 times or more were classified as frequent attenders. We used a logistic regression model to predict the odds of being a frequent attender by age group.Results: 14,829,519 attendances were made by 10,062,847 patients who attended at least once. 73.5% of ED attenders attended once and accounted for 49.8% of the total ED attendances. 9.5% of ED attenders attended 3 times or more; they accounted for 27.1% of the ED attendances. While only 1.2% attended 6 times or more, their contribution was 7.6% of the total attendances. Infants and adults aged over 80 years were significantly more likely to be frequent attenders than adults aged 30-59 years (OR=2.11, 95% CI 2.09 to 2.13, OR=2.22, 95% CI 2.20 to 2.23, respectively). The likelihood of hospital admission rose steeply with the number of attendances a patient had.Conclusion: One in ten patients attending the ED are frequent attenders and account for over a quarter of attendances. Emergency care systems should consider better ways of reorganising health services to meet the needs of patients who attend EDs frequently.

Journal article

Alturkistani A, Qavi A, Anyanwu PE, Greenfield G, Greaves F, Costelloe Cet al., 2020, Patient portal functionalities and patient outcomes among diabetes patients: a systematic, Journal of Medical Internet Research, Vol: 22, Pages: 1-9, ISSN: 1438-8871

Background:Patient portal use could help improve diabetes patients’ care and health outcomes due to the functionalities such as appointment booking, e-messaging, repeat prescription ordering that enable patient-centred care and improve the patient’s self-management of the disease.Objective:To summarise the evidence regarding the use of patient portal (portals that are connected to the electronic healthcare record) or patient portal functionality (e.g. appointment booking or e-messages) and their reported associations with health and healthcare quality outcomes among adult diabetes patients.Methods:We searched the databases including Medline, Embase and Scopus and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed full-texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NHLBI) Study Quality Assessment Tools to assess the risk of bias of the included studies. Data was summarised through narrative synthesis.Results:Twelve studies were included in this review. Five studies reported overall patient portal use and its association with diabetes health and healthcare quality outcomes. Six studies reported E-messaging or email use associated outcomes and two studies reported prescription refill associated outcomes. Reported associations included the association between patient portal use and blood pressure, LDL cholesterol or BMI. Few studies reported outcomes regarding the use of patient portals and healthcare utilisation measures such as office visits, emergency department visits and hospitalisations. Limited number of studies reported overall quality of care for diabetes patients who used patient portals.Conclusions:The included studies mostly r

Journal article

Alturkistani A, Qavi A, Anyanwu PE, Greenfield G, Greaves F, Costelloe Cet al., 2020, Patient portal functionalities and patient outcomes among patients with diabetes: systematic review (Preprint), Publisher: JMIR Publications

Background:Patient portal use could help improve diabetes patients’ care and health outcomes due to the features such as appointment booking, e-messaging, repeat prescription ordering that enable patient-centred care and improved patient self-management of the disease.Objective:To assess health and healthcare quality outcomes associated with the use of tethered (portals that are connected to the electronic healthcare record) patient portals by adult patients (18 years or older) with diabetes.Methods:We searched the databases including Medline, Embase and Scopus and reported the review methodology using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Three independent reviewers screened titles and abstracts, and two reviewers assessed full-texts of relevant studies and performed data extraction and quality assessments of the included studies. We used the Cochrane Collaboration Risk of Bias Tool and the National Heart, Lung and Blood Institute (NIH) Study Quality Assessment Tools to assess the risk of bias of the included studies. Data were summarised through narrative synthesis.Results:Twelve studies were included in this review. Nine studies reported outcomes related to glycaemic control and most of them found statistically significant associations between using a patient portal and glycaemic control. Some studies also found an inverse association or no association between patient portal use and blood pressure, LDL cholesterol or BMI. Studies reported mixed outcomes regarding the use of patient portals and healthcare utilisation measures such as office visits, emergency department visits and hospitalisations. Few studies reported overall improved quality of care for diabetes patients who used patient portals.Conclusions:Studies mostly reported improved health outcomes for diabetes patients who used patient portals. However, the limitations of studying the effects of patient portals exist that do not guarantee whether

Working paper

Alturkistani A, Greenfield G, Greaves F, Aliabadi S, Jenkins RH, Costelloe Cet al., 2020, Patient portal functionalities and uptake: a systematic review protocol, JMIR Research Protocols, Vol: 9, ISSN: 1929-0748

Background: Patient portals are digital health tools adopted by healthcare organisations. The portals are generally connected to the electronic health record of the healthcare organisation and offer patients functionalities such as access to the medical record, ability to order repeat prescriptions, make appointments or message the healthcare provider. Patient portals may be beneficial for patients and for the healthcare system. Patient portals can widely differ from one context to another due to the differences in the portal functionalities and capabilities and it is anticipated that outcomes associated with the functionalities to differ as well. Current systematic reviews report outcomes associated with patient portal uptake but do not explicitly specify the patient portal functionalities. Objective: The aim of this systematic review is to synthesise the evidence on health and healthcare quality outcomes associated with patient portal use among adult (18 years or older) patients. The review research questions are: What kind of health outcomes do tethered patient portals and patient portal functionalities contribute to in adult patients (18 years or older)? and What kind of healthcare quality outcomes including healthcare utilisation outcomes, do tethered patient portals and patient portal functionalities contribute to in adult patients (18 years or older)? Methods: The systematic review will be conducted by searching the Medline, Embase, and Scopus databases for relevant literature. The review inclusion criteria will be studies about adult patients (18 years or older), studies only about tethered patient portals and studies with or without a comparator. We will report patient portal-associated health and healthcare quality outcomes based on the patient portal functionalities. All quantitative primary study types will be included. Risk of bias of included studies will be assessed using the Cochrane Collaboration’s tool for assessing risk of bias in randomised

Journal article

Ruzangi J, Blair M, Cecil E, Greenfield G, Bottle R, Hargreaves D, Saxena Set al., 2020, Trends in healthcare use in children aged less than 15 years; a population-based cohort study in England from 2007 to 2017, BMJ Open, Vol: 10, ISSN: 2044-6055

Objective To describe changing use of primary care in relation to use of urgent care and planned hospital services by children aged less than 15 years in England in the decade following major primary care reforms from 2007 to 2017Design Population-based retrospective cohort study.Methods We used linked data from the Clinical Practice Research Datalink to study children’s primary care consultations and use of hospital care including emergency department (ED) visits, emergency and elective admissions to hospital and outpatient visits to specialists.Results Between 1 April 2007 and 31 March 2017, there were 7 604 024 general practitioner (GP) consultations, 981 684 ED visits, 287 719 emergency hospital admissions, 2 253 533 outpatient visits and 194 034 elective admissions among 1 484 455 children aged less than 15 years. Age-standardised GP consultation rates fell (−1.0%/year) to 1864 per 1000 child-years in 2017 in all age bands except infants rising by 1%/year to 6722 per 1000/child-years in 2017. ED visit rates increased by 1.6%/year to 369 per 1000 child-years in 2017, with steeper rises of 3.9%/year in infants (780 per 1000 child-years in 2017). Emergency hospital admission rates rose steadily by 3%/year to 86 per 1000 child-years and outpatient visit rates rose to 724 per 1000 child-years in 2017.Conclusions Over the past decade since National Health Service primary care reforms, GP consultation rates have fallen for all children, except for infants. Children’s use of hospital urgent and outpatient care has risen in all ages, especially infants. These changes signify the need for better access and provision of specialist and community-based support for families with young children.

Journal article

Bitan Y, Parmet Y, Greenfield G, Teng S, Cook RI, Nunnally MEet al., 2019, Making sense of the cognitive task of medication reconciliation using a card sorting task, Human Factors, Vol: 61, Pages: 1315-1325, ISSN: 0018-7208

OBJECTIVE:: To explore cognitive strategies clinicians apply while performing a medication reconciliation task, handling incomplete and conflicting information. BACKGROUND:: Medication reconciliation is a method clinicians apply to find and resolve inconsistencies in patients' medications and medical conditions lists. The cognitive strategies clinicians use during reconciliation are unclear. Controlled lab experiments can explore how clinicians make sense of uncertain, missing, or conflicting information and therefore support the development of a human performance model. We hypothesize that clinicians apply varied cognitive strategies to handle this task and that profession and experience affect these strategies. METHOD:: 130 clinicians participated in a tablet-based experiment conducted in a large American teaching hospital. They were asked to simulate medication reconciliation using a card sorting task (CaST) to organize medication and medical condition lists of a specific clinical case. Later on, they were presented with new information and were asked to add it to their arrangements. We quantitatively and qualitatively analyzed the ways clinicians arranged patient information. RESULTS:: Four distinct cognitive strategies were identified ("Conditions first": n = 76 clinicians, "Medications first": n = 7, "Crossover": n = 17, and "Alternating": n = 10). The strategy clinicians applied was affected by their experience ( p = .02) but not by their profession. At the appearance of new information, clinicians moved medication cards more frequently (75.2 movements vs. 49.6 movements, p < .001), suggesting that they match medications to medical conditions. CONCLUSION:: Clinicians apply various cognitive strategies while reconciling medications and medical conditions. APPLICATION:: Clinical information systems should support multiple cognitive strategies, allowing flexibility in organizing information.

Journal article

Pappas Y, Všetečková J, Mastellos N, Greenfield G, Randhawa Get al., 2019, Diagnosis and decision-making in telemedicine, Journal of Patient Experience, Vol: 6, Pages: 296-304, ISSN: 2374-3735

This article provides an analysis of the skills that health professionals and patients employ in reaching diagnosis and decision-making in telemedicine consultations. As governmental priorities continue to emphasize patient involvement in the management of their disease, there is an increasing need to accurately capture the provider–patient interactions in clinical encounters. Drawing on conversation analysis of 10 video-mediated consultations in 3 National Health Service settings in England, this study examines the interaction between patients, General Practitioner (GPs), nurses, and consultants during diagnosis and decision-making, with the aim to identify the range of skills that participants use in the process and capture the interprofessional communication and patient involvement in the diagnosis and decision-making phases of telemedicine consultations. The analysis shows that teleconsultations enhance collaborative working among professionals and enable GPs and nurses to develop their skills and actively participate in diagnosis and decision-making by contributing primary care–specific knowledge to the consultation. However, interprofessional interaction may result in limited patient involvement in decision-making. The findings of this study can be used to inform training programs in telemedicine that focus on the development of effective skills for professionals and the provision of information to patients.

Journal article

Hayhoe B, Acuyo Cespedes J, Foley K, Majeed F, Ruzangi J, Greenfield Get al., 2019, Impact of integrating pharmacists into primary care teams on health systems indicators: a systematic review, British Journal of General Practice, Vol: 69, Pages: e665-e674, ISSN: 0960-1643

Background: Evidence suggests that pharmacists integrated in primary care can improve patient outcomes and satisfaction, but their impact on healthcare systems is unclear. Aim: To identify key impacts of integration of pharmacists in primary care on health system indicators such as healthcare utilisation and costs.Design and setting: A systematic review of literature.Method: We examined EMBASE, MEDLINE, SCOPUS, HMIC, CINAHL and CENTRAL, and reference lists of relevant studies. RCTs and observational studies were included, published up to June 2018, which considered health system outcomes of integration of pharmacists in primary care. Risk of bias assessment used the Cochrane Risk of Bias Quality Assessment tool for RCTs, and the NIH National Heart, Lung and Blood Institute quality assessment tool for observational studies. Data were extracted from published reports and findings synthesized.Results: Searches identified 3,058 studies; 28 met the inclusion criteria. Most included studies were of fair quality. Pharmacists in primary care resulted in reduced use of GP appointments and reduced emergency department attendance, but increased overall primary care use. There was no impact on hospitalisations, but some evidence of savings in overall health system costs and medication costs.Conclusion: Integration of pharmacists in primary care may reduce GP workload, as well emergency department use. Further higher quality studies are needed, including research to clarify cost-effectiveness and long-term impact on health system outcomes.

Journal article

Greenfield G, 2019, Second opinion utilization by healthcare insurance type in a mixed private-public healthcare system: a population-based study, BMJ Open, Vol: 9, Pages: 1-10, ISSN: 2044-6055

Objectives: To evaluate the utilization (overall and by specialty) and the characteristics ofsecond-opinion seekers by insurance type (either health-fund or supplementary insurance) ina mixed private-public healthcare.Design: An observational study.Setting: Secondary care visits provided by a large public health-fund and a largesupplementary health insurance in Israel.Participants: The entire sample included 1,392,907 patients age 21 and above who visited atleast one specialist over an 18-months period, either in the secondary care or privately via thesupplementary insurance.Outcomes measures: An algorithm was developed to identify potential second-opinioninstances in the dataset using visits and claims data. Multivariate logistic regression was usedto identify characteristics of second-opinion seekers by the type of insurance they utilized.Results: 143,371 (13%) out of 1,080,892 patients who had supplementary insurance sought asingle second-opinion, mostly from orthopedic surgeons. Relatively to patients who soughtsecond-opinion via the supplementary insurance, second-opinion seekers via the health-fundtended to be females (OR=1.2, 95% CI 1.17–1.23), of age 40-59 (OR= 1.36, 95% CI 1.31–1.42) and with chronic conditions (OR=1.13, 95% CI 1.08–1.18). In contrast, second-opinionseekers via the supplementary insurance tended to be native-born and established immigrants(OR=0.79, 95% CI 0.76–0.84), in a high socio-economic level (OR= 0.39, 95% CI 0.37–0. 4)and living in central areas (OR= 0.88, 95% CI 0.85–0.9).Conclusions: Certain patient profiles tended to seek second-opinions via the supplementaryinsurance more than others. People from the center of the country and with a high socioeconomic status tended to do so, as medical specialists tend to reside in central urban areas.

Journal article

Alturkistani A, Greenfield G, Greaves F, Aliabadi S, Jenkins RH, Costelloe Cet al., 2019, Patient portal functionalities and uptake: systematic review protocol (Preprint), Publisher: JMIR Publications

Background:Patient portals are digital health tools adopted by healthcare organisations. The portals are generally connected to the electronic health record of the healthcare organisation and offer patients functionalities such as access to the medical record, ability to order repeat prescriptions, make appointments or message the healthcare provider. Research shows that there are many potential benefits of using patient portals both for patients and for the healthcare system. Patient portals can widely differ from one context to another due to differences in the portal functionalities and capabilities. Current research reports patient portal uptake but does not explicitly specify the patient portal functionalities.Objective:The aim of the review is to identify the functionalities of electronic patient portals offered globally in primary care and secondary care both and determine its association with patient portal uptake and facilitators and barriers of its use.Methods:Medline, Embase, Scopus, PsycINFO, IEEE Xplore Digital Library, and CINAHL will be searched for relevant literature. The review inclusion criteria will be studies about patients or other portal users such as carers, studies only about tethered patient portals, studies with or without a comparator. We will report patient portal uptake numbers based on the patient portal functionalities. We will also look at facilitators and barriers to using patient portals. All primary study types will be included. Risk of bias of included studies will be assessed using the Cochrane Collaboration’s tool for assessing risk of bias in randomised trials and the National Heart, Lung, and Blood Institute Institute’ quality assessment tools. Data will be synthesised using narrative synthesis and will be reported according to the patient portal functionalities, country and healthcare system model.Results:Searches will be conducted in June 2019, and the review is anticipated to be complete by November 2019.Conclu

Working paper

Greenfield G, Majeed B, Hayhoe B, Rawaf S, Majeed Aet al., 2019, Rethinking primary care user fees: is charging a fee for appointments a solution to NHS underfunding?, Br J Gen Pract, Vol: 69, Pages: 280-281

Journal article

Sripa P, Hayhoe B, Garg P, Majeed A, Greenfield Get al., 2019, Impact of GP gatekeeping on quality of care, and health outcomes, use, and expenditure: a systematic review, British Journal of General Practice, Vol: 69, Pages: e294-e303, ISSN: 0960-1643

BACKGROUND: GPs often act as gatekeepers, authorising patients' access to specialty care. Gatekeeping is frequently perceived as lowering health service use and health expenditure. However, there is little evidence suggesting that gatekeeping is more beneficial than direct access in terms of patient- and health-related outcomes. AIM: To establish the impact of GP gatekeeping on quality of care, health use and expenditure, and health outcomes and patient satisfaction. DESIGN AND SETTING: A systematic review. METHOD: The databases MEDLINE, PreMEDLINE, Embase, and the Cochrane Library were searched for relevant articles using a search strategy. Two authors independently screened search results and assessed the quality of studies. RESULTS: Electronic searches identified 4899 studies (after removing duplicates), of which 25 met the inclusion criteria. Gatekeeping was associated with better quality of care and appropriate referral for further hospital visits and investigation. However, one study reported unfavourable outcomes for patients with cancer under gatekeeping, and some concerns were raised about the accuracy of diagnoses made by gatekeepers. Gatekeeping resulted in fewer hospitalisations and use of specialist care, but inevitably was associated with more primary care visits. Patients were less satisfied with gatekeeping than direct-access systems. CONCLUSION: Gatekeeping was associated with lower healthcare use and expenditure, and better quality of care, but with lower patient satisfaction. Survival rate of patients with cancer in gatekeeping schemes was significantly lower than those in direct access, although primary care gatekeeping was not otherwise associated with delayed patient referral. The long-term outcomes of gatekeeping arrangements should be carefully studied before devising new gatekeeping policies.

Journal article

Shmueli L, Davidovitch N, Pliskin JS, Hekselman I, Balicer RD, Greenfield Get al., 2019, Reasons, perceived outcomes and characteristics of second-opinion seekers: Are there differences in private vs. public settings?, BMC Health Services Research, Vol: 19, ISSN: 1472-6963

BackgroundIn most countries, patients can get a second opinion (SO) through public or private healthcare systems. There is lack of data on SO utilization in private vs. public settings. We aim to evaluate the characteristics of people seeking SOs in private vs. public settings, to evaluate their reasons for seeking a SO from a private physician and to compare the perceived outcomes of SOs given in a private system vs. a public system.MethodsA cross-sectional national telephone survey, using representative sample of the general Israeli population (n = 848, response rate = 62%). SO utilization was defined as seeking an additional clinical opinion from a specialist within the same specialty, on the same medical concern. We modeled SO utilization in a public system vs. a private system by patient characteristics using a multivariate logistic regression model.Results214 of 339 respondents who obtained a SO during the study period, did so in a private practice (63.1%). The main reason for seeking a SO from a private physician rather than a physician in the public system was the assumption that private physicians are more professional (45.7%). However, respondents who obtained a private SO were neither more satisfied from the SO (p = 0.45), nor felt improvement in their perceived clinical outcomes after the SO (p = 0.37). Low self-reported income group, immigrants (immigrated to Israel after 1989) and religious people tended to seek SOs from the public system more than others.ConclusionsThe main reason for seeking a SO from private physicians was the assumption that they are more professional. However, there were no differences in satisfaction from the SO nor perceived clinical improvement. As most of SOs are sought in the private system, patient misconceptions about the private market superiority may lead to ineffective resource usage and increase inequalities in access to SOs. Ways to improve public services should

Journal article

Hayhoe BWJ, Greenfield G, Majeed A, 2019, Is it getting easier to obtain antibiotics in the UK?, British Journal of General Practice, ISSN: 0960-1643

Public knowledge and understanding of antibiotics is poor, with only 56% of the UK general public aware that antibiotics cannot kill viruses,(1) and those with poorer knowledge are more likely to use them.(1) Clinical assessment therefore remains a vital step in assessing the need for and safety of antibiotics, and an essential opportunity for education about appropriate use, antimicrobial resistance (AMR), and self-care. In the UK, antibiotics are with very few exceptions only prescribable by doctors or other health professionals with prescribing qualifications. This has meant that until recently access to antibiotics has been possible only through face to face medical assessment in primary or secondary care, providing a significant disincentive to seeking antibiotics unnecessarily.Inappropriate prescribing of antibiotics in UK primary care remains of concern,(2) but antimicrobial stewardship (AMS) initiatives are having a measurable effect, with prescribing rates falling in response to interventions.(3) However, novel routes to obtaining antibiotics, associated with either a lower threshold for prescribing or issuing of antibiotics without medical assessment, undermine these strategies and are likely to increase inappropriate use.

Journal article

Woringer M, Dharmayat KI, Greenfield G, Bottle A, Ray KKet al., 2019, American Heart Association's Cholesterol CarePlan as a smartphone-delivered web app for patients prescribed cholesterol-lowering medication: Protocol for an observational feasibility study, JMIR Research Protocols, Vol: 8, ISSN: 1929-0748

Background: Adoption of healthy lifestyle and compliance with cholesterol-lowering medication reduces the risk of cardiovascular disease (CVD). The use of digital tools and mobile technology may be important for sustaining positive behavioral change.Objective: The primary objective of this study is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan Web app developed by the American Heart Association aimed at improving lifestyle and medication adherence among patients prescribed cholesterol-lowering medication. The secondary objective is to assess the Web app’s efficacy.Methods: A prospective, observational feasibility study will be conducted to demonstrate whether the Web app may be successfully taken up by patients and will be associated with improved clinical and behavioral outcomes. The study will aim to recruit 180 study participants being prescribed cholesterol-lowering medication for at least 30 days across 14 general practices in London, England. Potentially eligible patients will be invited to use the Web app on a smartphone and visit general practice for three 20-minute clinical assessments of blood pressure, height, weight, smoking, and nonfasting cholesterol over 24 weeks. The feasibility of administering the Web app will be judged by recruitment and dropout statistics and the sociodemographic and comorbidity profile of consenting study participants, consenting nonparticipants, and all potentially eligible patients. Acceptability will be assessed using patients’ readiness to embrace new technologies, the usability of the Web app, and patient satisfaction. The efficacy of the Web app will be assessed by changes in medication adherence and clinical risk factors by levels of the Web app compliance.Results: This study is currently funded by the American Heart Association. Initial study recruitment will take place between February and July 2018 followed by patient follow-up. Patient level data will be obtained i

Journal article

Amati Sculfor F, Banks C, Greenfield G, Green Jet al., 2018, Predictors of outcomes for patients with common mental health disorders receiving psychological therapies in community settings: a systematic review, Journal of Public Health, Vol: 40, Pages: e375-e387, ISSN: 1741-3842

BackgroundPsychological therapies are increasingly delivered in community care settings. In existing literature, patient, disorder and service variables are known to have a significant impact on the recovery outcomes for patients undergoing psychological treatment in secondary care. The aim of this review is to establish which predictors have a significant impact on recovery from common mental health disorders in community settings.MethodsA systematic review of the literature was conducted according to PRISMA guidelines to identify variables with a predictive power on psychological therapy outcomes. We searched databases using key words and MeSH terms and a strict scoring system and bias check were used.ResultsA total of 486 unique references were identified from the search. Overall, 19 papers met the inclusion criteria. These reported on a total of 34 778 patients from five countries in various community care settings. Predictive factors identified and found to be significant were initial severity and comorbid depression (11/19 studies), which negatively impacted outcome in all studies.ConclusionsWe identified key predictors for recovery in a community settings from five countries. The evidence currently available for this setting is limited, so this review serves as a starting point to highlight key factors that warrant further investigation.

Journal article

Sripa P, Hayhoe BWJ, Garg P, Majeed FA, Greenfield Get al., 2018, Impact of general practitioner gatekeeping on quality, health outcomes, utilisation and expenditure: a systematic review, British Journal of General Practice, ISSN: 0960-1643

Journal article

Greenfield G, Lee P, Pappas Y, 2018, Patients’ perception of using telehealth for type 2 diabetes management: a phenomenological study, BMC Health Services Research, Vol: 18, ISSN: 1472-6963

Background:There is a growing body of evidence that supports the uses of telehealth to monitor and manage people with diabetes at a distance. Despite this, the uptake of telehealth has been low. The objective of this study is to explore patients’ perceptions of using telehealth for type 2 diabetes management.Methods:Semi-structured interviews were undertaken with 10 patients from the NHS Newham area in London, UK. Data were collected using recorded semi-structured interviews. The interviews were transcribed verbatim and the analysis was guided by the phenomenological analysis approach.Results:We identified three main themes for facilitating positive patient experience or acceptance of telehealth and these included: technology consideration, service perceptions and empowerment. All patients asserted that they were pleased with the technology and many also proclaimed that they could not see themselves being without it. Moreover, very few negative views were reported with respect to the use of telehealth.Conclusion:The patients’ perceived telehealth as a potential to enhance their quality of life, allow them to live independently at home as well as help them take and be in more control over their own health state. The findings of this study therefore supports the use of telehealth for the routine care of people with type 2 diabetes. However, one must interpret the results with caution due to limitations identified in the sample.

Journal article

Lee PA, Greenfield G, Pappas Y, 2018, The impact of telehealth remote patient monitoring on glycemic control in type 2 diabetes: a systematic review and meta-analysis of systematic reviews of randomised controlled trials, BMC Health Services Research, Vol: 18, ISSN: 1472-6963

BackgroundThere is a growing body of evidence to support the use of telehealth in monitoring HbA1c levels in people living with type 2 diabetes. However, the overall magnitude of effect is yet unclear due to variable results reported in existing systematic reviews. The objective of this study is to conduct a systematic review and meta-analysis of systematic reviews of randomised controlled trials to create an evidence-base for the effectiveness of telehealth interventions on glycemic control in adults with type 2 diabetes.MethodsElectronic databases including The Cochrane Library, MEDLINE, EMBASE, HMIC, and PsychINFO were searched to identify relevant systematic reviews published between 1990 and April 2016, supplemented by references search from the relevant reviews. Two independent reviewers selected and reviewed the eligible studies. Of the 3279 references retrieved, 4 systematic reviews reporting in total 29 unique studies relevant to our review were included. Both conventional pairwise meta-analyses and network meta-analyses were performed.ResultsEvidence from pooling four systematic reviews found that telehealth interventions produced a small but significant improvement in HbA1c levels compared with usual care (MD: -0.55, 95% CI: -0.73 to − 0.36). The greatest effect was seen in telephone-delivered interventions, followed by Internet blood glucose monitoring system interventions and lastly interventions involving automatic transmission of SMBG using a mobile phone or a telehealth unit.ConclusionCurrent evidence suggests that telehealth is effective in controlling HbA1c levels in people living with type 2 diabetes. However there is need for better quality primary studies as well as systematic reviews of RCTs in order to confidently conclude on the impact of telehealth on glycemic control in type 2 diabetes.

Journal article

Woringer M, Dharmayat KI, Greenfield G, Bottle A, Ray KKet al., 2018, American Heart Association’s Cholesterol CarePlan as a Smartphone-Delivered Web App for Patients Prescribed Cholesterol-Lowering Medication: Protocol for an Observational Feasibility Study (Preprint), JMIR Research Protocols, ISSN: 1929-0748

<sec> <title>BACKGROUND</title> <p>Adoption of healthy lifestyle and compliance with cholesterol-lowering medication reduces the risk of cardiovascular disease (CVD). The use of digital tools and mobile technology may be important for sustaining positive behavioral change.</p> </sec> <sec> <title>OBJECTIVE</title> <p>The primary objective of this study is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan Web app developed by the American Heart Association aimed at improving lifestyle and medication adherence among patients prescribed cholesterol-lowering medication. The secondary objective is to assess the Web app’s efficacy.</p> </sec> <sec> <title>METHODS</title> <p>A prospective, observational feasibility study will be conducted to demonstrate whether the Web app may be successfully taken up by patients and will be associated with improved clinical and behavioral outcomes. The study will aim to recruit 180 study participants being prescribed cholesterol-lowering medication for at least 30 days across 14 general practices in London, England. Potentially eligible patients will be invited to use the Web app on a smartphone and visit general practice for three 20-minute clinical assessments of blood pressure, height, weight, smoking, and nonfasting cholesterol over 24 weeks. The feasibility of administering the Web app will be judged by recruitment and dropout statistics and the sociodemographic and comorbidity profile of consenting study participants, consenting nonparticipants, and all potentially eligible patients. Acceptability will be assessed using patients’ readiness to embrace new technologies, the usa

Journal article

Peters L, Greenfield G, Majeed A, Hayhoe BWJet al., 2018, The impact of private online video consulting in primary care, Journal of the Royal Society of Medicine, Vol: 111, Pages: 162-166, ISSN: 1758-1095

Workforce and resource pressures in the UK National Health Service mean that it is currently unable to meet patients’ expectations of access to primary care.1 In an era of near-instant electronic communication, with mobile online access available for most shopping and banking services, people expect similar convenience in healthcare. Consequently, increasing numbers of web-based and smartphone apps now offer same-day ‘virtual consulting’ in the form of Internet video conferencing with private general practitioners.2While affordable and accessible private primary care may be attractive to many patients, the existence of these services raises several questions. A particular concern, given continued development of antimicrobial resistance,3 is that some companies appear to use ease of access to treatment with antibiotics as an advertising strategy. We examine online video consulting with private general practitioners in the UK, considering its potential impact on patients and the National Health Service, and its particular relevance to antimicrobial stewardship.

Journal article

Komwong D, Greenfield G, Zaman H, Majeed A, Hayhoe BWJet al., 2018, Clinical Pharmacists in primary care: a safe solution to the workforce crisis?, Journal of the Royal Society of Medicine, Vol: 111, Pages: 120-124, ISSN: 1758-1095

Journal article

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