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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.
Bitan Y, Parmet Y, Greenfield G, et 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.
Hayhoe B, Acuyo Cespedes J, Foley K, et 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.
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.
Greenfield G, Majeed B, Hayhoe B, et 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
Sripa P, Hayhoe B, Garg P, et 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.
Shmueli L, Davidovitch N, Pliskin JS, et 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
Hayhoe BWJ, Greenfield G, Majeed A, 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.
Woringer M, Dharmayat KI, Greenfield G, et 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
Amati Sculfor F, Banks C, Greenfield G, et 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.
Sripa P, Hayhoe BWJ, Garg P, et al., Impact of general practitioner gatekeeping on quality, health outcomes, utilisation and expenditure: a systematic review, British Journal of General Practice, ISSN: 0960-1643
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.
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.
Woringer M, Dharmayat K, Greenfield G, et al., Feasibility study protocol: The use of American Heart Association’s Cholesterol CarePlan to be delivered as a web application on a smartphone to patients prescribed cholesterol lowering medication, JMIR Research Protocols, 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 behavioural change. Objectives:Primary objective is to evaluate the feasibility and acceptability of administering the Cholesterol CarePlan web application (app) developed by the American Heart Association (AHA) aimed at improving lifestyle and medication adherence among patients prescribed cholesterol lowering medication. Secondary objective is to assess web app efficacy. Methods:To demonstrate whether the web app may be successfully taken up by patients and be associated with improved clinical and behavioural outcomes, a prospective observational feasibility study will be conducted. 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. Eligible patients will be invited to use the web app on a smartphone and to come in to general practice for three 20 minute clinical assessments of blood pressure, height, weight, smoking, non-fasting cholesterol over 24 weeks. The feasibility of administering the web app will be judged by recruitment and dropout statistics and by the socio-demographic and co-morbidity profile of study participants, invited patients and all eligible patients. Acceptability will be assessed using patients’ readiness to embrace new technologies, usability of the web app and patient satisfaction. Efficacy of the web app will be assessed by changes in medication adherence and clinical risk factors by levels of web app compliance. Results: Study recruitment will commence in February 2018 and results will be reported in December 2018.
Woringer M, Dharmayat KI, Greenfield G, et al., 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
Peters L, Greenfield G, Majeed A, et 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.
Komwong D, Greenfield G, Zaman H, et 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
Rosenberg-Wohl S, Greenfield G, Majeed A, et al., 2018, Seven day access to NHS primary care: how does England compare with Europe?, JRSM, Vol: 111, Pages: 88-91, ISSN: 2042-5333
Healthcare systems globally are facing an increasing demand for care under stable or decreasing resources. It is often assumed that providing easier access to community-based general practice during evenings and weekends can reduce demand for emergency and other unscheduled care services, promoting more appropriate care and reducing the costs associated with expensive hospital-based treatment. However, evidence for this is mixed.1–3 In England’s NHS there is political pressure to expand general practice surgeries’ opening hours to progress towards a ‘seven-day NHS’.4When considering extension of primary care opening hours in England, it is useful to compare primary care access across other countries in the European Union. Despite differences in healthcare commissioning and funding, European countries face comparable challenges such as ageing populations and increases in chronic conditions and mental health problems, all of particular relevance to primary care.5 This paper examines England’s current in-hours general practice services relative to those of European countries in order to better contextualise the debate on extending general practice opening hours.
Shmueli L, Davidovitch N, Pliskin JS, et al., 2017, Seeking a second medical opinion: composition, reasons and perceived outcomes in Israel., Israel Journal of Health Policy Research, Vol: 6, ISSN: 2045-4015
Background: Seeking a second-opinion (SO) is a common clinical practice that can optimize treatment and reduceunnecessary procedures and risks. We aim to characterize the composition of the population of SO seekers, their reasonsfor seeking a SO and choosing a specific physician, and their perceived outcomes following the SO.Methods: A cross-sectional national telephone survey, using a 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 withinthe same specialty, for the same medical concern. We describe the characteristics of respondents who obtained SOs, theirreasons for doing so and their perceived outcomes: (1) Satisfaction with the SO; (2) Experiencing health improvementafter receiving a SO; (3) A difference in the diagnosis or treatment suggested in the first opinions and the secondopinions; (4) Preference of the SO over the first one.Results: Most of the respondents who sought a SO (n = 344) were above 60 years old, secular, living with a partner,perceived their income to be above average and their health status to be not so good. For the patients who utilizedSOs, orthopedic surgeons were sought out more than any other medical professional.Reasons for seeking a SO includeddoubts about diagnosis or treatment (38%), search for a sub-specialty expert (19%) and dissatisfaction withcommunication (19%). SO seekers most frequently chose a specific specialist based on a recommendation from afriend or a relative (33%). About half of the SO seekers also searched for information on the internet. Most of therespondents who sought a SO mentioned that they were satisfied with it (84%), felt health improvement (77%),mentioned that there was a difference between the diagnosis or treatment between the first opinion and the SO(56%) and preferred the SO over the first one (91%).Conclusions: Clinical uncertainty or dissatisfaction with patient-physician commun
Blair M, Poots A, Lim V, et al., 2017, Pre-school children who are frequent attenders in Emergency Departments: an observational study of associated demographics and clinical characteristics, Archives of Disease in Childhood, Vol: 103, Pages: 19-23, ISSN: 0003-9888
Background: Unscheduled visits to emergency departments (ED) have increased in the UK in recent years. Children who are repeat attenders are relatively understudied. Aims: To describe the socio-demographic and clinical characteristics of pre-schoolers who attend ED a large District General Hospital.Method/Study Design: Observational study analysing routinely collected ED operational data. Children attending 4 or more visits per year were considered as “frequent attenders”. Poisson regression was used with demographic details (age, sex, ethnicity, socio-demographic status), to predict number of attendances seen in the year. We further analysed detailed diagnostic characteristics of a random sample of 10% of attendees. Main findings: 10,169 patients visited in the 12 month period with 16,603 attendances. 655 individuals attended on 3,335 occasions. 6.4% of this population accounted for 20.1% of total visits. In the 10% sample, there were 304 attendances, and 69(23%) had an underlying chronic longstanding illness. This group were 2.4 times more likely to be admitted as in-patients compared to those without such conditions , median length of stay of 6.2 hours vs. 2.5 hrs (p=NS).Conclusions: Frequent ED attenders fall broadly into two distinct clinical groups: those who habitually return with self- limiting conditions and those with or without exacerbation of underlying chronic longstanding illness. Both groups may be amenable to both additional nursing and other forms of community support to enhance self-care and continuity of care. Further research is required to increase our understanding of specific individual family and health system factors that predict repeat attendance in this age group.
Greenfield G, 2017, Rethinking primary care’s gatekeeper role, BMJ-BRITISH MEDICAL JOURNAL, Vol: 356, ISSN: 1756-1833
Poots AJ, Amati F, Greenfield G, et al., 2016, Improving access and outcomes in community psychological therapies, ISQua 33rd International Conference, Publisher: Oxford University Press (OUP), Pages: 43-43, ISSN: 1464-3677
Greenfield G, Foley K, Majeed A, 2016, Rethinking primary care's gatekeeper role., BMJ, Vol: 354, ISSN: 0959-8138
Gatekeeping is the term used to describe the role of primary care physicians or general practitioners (GPs) in authorising access to specialty care, hospital care, and diagnostic tests.1 Gatekeeping has crucial influences on service utilisation, health outcomes, healthcare costs, and patient satisfaction.In the UK access to NHS and private specialists is generally possible only after a referral from a GP. Gatekeeping was developed as a response to a shortage of specialists and a desire to control healthcare spending2 and has been an accepted practice in the UK for over 100 years.3 The NHS is under considerable pressure to use its resources efficiently, and primary care has helped the NHS to achieve this goal through its gatekeeping function.4 Yet direct access could help reduce GP workload and facilitate greater patient choice. We look at the pros and cons of gatekeeping, describe gatekeeping policies in various countries, and highlight the need for more evidence to devise policy.
Shmueli L, Shmueli E, Pliskin JS, et al., Second Medical Opinion: Utilization Rates And Characteristics of Seekers In A General Population, ISPOR Europe, Publisher: Elsevier, ISSN: 1098-3015
Greenfield R, Busink E, Wong CP, et al., 2016, Truck drivers' perceptions on wearable devices and health promotion: a qualitative study., BMC Public Health, Vol: 16, ISSN: 1471-2458
BACKGROUND: Professional truck drivers, as other shift workers, have been identified as a high-risk group for various health conditions including cardiovascular disease, obesity, diabetes, sleep apnoea and stress. Mobile health technologies can potentially improve the health and wellbeing of people with a sedentary lifestyle such as truck drivers. Yet, only a few studies on health promotion interventions related to mobile health technologies for truck drivers have been conducted. We aimed to explore professional truck drivers' views on health promotion delivered via mobile health technologies such as wearable devices. METHODS: We conducted a phenomenological qualitative study, consisting of four semi-structured focus groups with 34 full-time professional truck drivers in the UK. The focus groups were audio-taped, transcribed verbatim and analysed using thematic content analysis. We discussed drivers' perceptions of their health, lifestyle and work environment, and their past experience and expectations from mobile health technologies. RESULTS: The participants viewed their lifestyle as unhealthy and were aware of possible consequences. They expressed the need and wish to change their lifestyle, yet perceived it as an inherent, unavoidable outcome of their occupation. Current health improvement initiatives were not always aligned with their working conditions. The participants were generally willing to use mobile health technologies such as wearable devices, as a preventive measure to avoid prospect morbidity, particularly cardiovascular diseases. They were ambivalent about privacy and the risk of their employer's monitoring their clinical data. CONCLUSIONS: Wearable devices may offer new possibilities for improving the health and wellbeing of truck drivers. Drivers were aware of their unhealthy lifestyle. They were interested in changing their lifestyle and health. Drivers raised concerns regarding being continuously monitored by their employer. Health improvement i
Morton S, Igantowicz A, Gnani S, et al., 2016, Describing team development within a novel GP-led urgent care centre model: a qualitative study, BMJ Open, Vol: 6, ISSN: 2044-6055
Objective: Urgent care centres (UCCs) co-located within an Emergency Department were developed to reduce the numbers of inappropriate emergency department admissions. Since then various UCCmodels have developed, including a novel general practitioner (GP)-led UCC that incorporates bothGPs and Emergency Nurse Practitioners (ENPs). Traditionally these two groups do not workalongside each other within an emergency setting. Although good teamwork is crucial to better patient outcomes, there is little within the literature about the development of a team consisting of different healthcare professionals in a novel healthcare setting. Our aim was therefore to describe staff members’ perspectives of team development within the GP-led UCC model.Design: Open-ended semi-structured interviews, analysed using thematic content analysis.Setting: GP-led urgent care centres in two academic teaching hospitals in London.Participants: Fifteen UCC staff members including six GPs, four ENPs, two receptionists and threemanagers.Results: Overall participants were positive about the inter-professional team that had developedand recognised that this process had taken time. Hierarchy within the UCC setting has diminishedwith time, although some residual hierarchical beliefs do appear to remain. Staff appreciated interdisciplinarycollaboration was likely to improve patient care. Eight key facilitating factors for theteam were identified: appointment of leaders, perception of fair workload, education on roles/skillsets and development of these, shared professional understanding, inter-disciplinary working, EDcollaboration, clinical guidelines and social interactions.Conclusions: A strong inter-professional team has evolved within the GP-led UCCs over time,breaking down traditional professional divides. Future implementation of UCC models should proactivelyincorporate the eight facilitating factors identified from the outset, to enable effectiveteams to develop more quickly.
Shmueli L, Shmueli E, Pliskin JS, et al., 2016, Second medical opinion: utilization rates and characteristics of seekers in a general population, Medical Care, Vol: 54, Pages: 921-928, ISSN: 1537-1948
Background: Second opinion (SO) is common in medical practice and can reduce unnecessary risks and costs. To date, there is no population-based estimation of how many people seek SOs and what the characteristics of second-opinion seekers are.Objectives: To estimate how many people seek SOs, and what the characteristics of second-opinion seekers are.Methods: We conducted both a medical records analysis (n=1,392,907) and a cross-sectional national telephone survey with a representative sample of the general Israeli population (n=848, response rate=62%). In the medical records analysis, we linked consultations with specialists at community secondary care and private consultations using claims data. We developed a time-sensitive algorithm that identified potential SO instances. In both methods, we predicted the characteristics of second-opinion seekers using multivariate logistic regressions.Results: The medical records analysis and the survey findings were highly consistent, and showed that about sixth (14.9% in the medical records vs. 17.2% in the survey) of a general population sought a SO, mostly from orthopedic surgeons. Women, native-born, and established immigrants, people living in central urban areas or close to central urban areas, people with chronic conditions, and those who perceived their health status as not very good, were more likely to seek SOs than others.Conclusions: A considerable amount of people sought a SO. Certain patient profiles tended to seek SOs more than others. Such utilization patterns are important to devise policy regarding SOs, due to their implications on expenditure, policy, clinical outcomes, and patient satisfaction.
Ramchandani P, wilkinson E, O'Mahen H, et al., 2016, Adapting and testing a brief intervention to reduce maternal anxiety during pregnancy (ACORN): study protocol for a randomized controlled trial, Trials, Vol: 17, ISSN: 1745-6215
BackgroundNational guidelines in the United Kingdom, United States of America, Canada, and Australia haverecently stressed the importance of identifying and treating antenatal anxiety and depression.However, there is little research into the most effective and acceptable ways of helping womenmanage their symptoms of anxiety and stress during pregnancy. Research indicates the necessity toconsider the unique needs and concerns of perinatal populations to ensure treatment engagement,highlighting the need to develop specialised treatments which could be integrated within routineantenatal healthcare services. This trial aims to develop a brief intervention for antenatal anxiety,with a focus on embedding the delivery of the treatment within routine antenatal care.Methods/DesignThis study is a two-phase feasibility trial. In phase one we will develop and pilot a brief interventionfor antenatal anxiety, blended with group support, to be led by midwives. This intervention will drawon cognitive behavioural principles and wider learning from existing interventions that have beenused to reduce anxiety in expectant mothers. The intervention will then be tested in a pilotrandomised controlled trial in phase two. The following outcomes will be assessed: i) number ofparticipants meeting eligibility criteria; ii) number of participants consenting to the study; iii) numberof participants randomised; iv) number of sessions completed by those in the intervention arm; andv) number of participants completing the post-intervention outcome measures. Secondary outcomescomprise: detailed feedback on acceptability, which will guide further development of theintervention; and outcome data on symptoms of maternal and paternal anxiety and depression,maternal quality of life, quality of couple relationship, mother-child bonding, infant temperamentand infant sleep.2DiscussionThe study will provide important data to inform the design of a future full-scale randomisedcontrolled trial of a brief inte
Greenfield G, Ignatowicz A, Gnani S, et al., 2016, Staff perceptions on patient motives for attending GP-led urgent care centres in London: A qualitative study, BMJ Open, Vol: 6, ISSN: 2044-6055
Objectives General practitioner (GP)-led urgent care centres were established to meet the growing demand for urgent care. Staff members working in such centres are central in influencing patients’ choices about which services they use, but little is known about staff perceptions of patients’ motives for attending urgent care. We hence aimed to explore their perceptions of patients’ motives for attending such centres.Design A phenomenological, qualitative study, including semistructured interviews. The interviews were analysed using thematic content analysis.Setting 2 GP-led urgent care centres in 2 academic hospitals in London.Participants 15 staff members working at the centres including 8 GPs, 5 emergency nurse practitioners and 2 receptionists.Results We identified 4 main themes: ‘Confusion about choices’, ‘As if increase of appetite had grown; By what it fed on’, ‘Overt reasons, covert motives’ and ‘A question of legitimacy’. The participants thought that the centres introduce convenient and fast access for patients. So convenient, that an increasing number of patients use them as a regular alternative to their community GP. The participants perceived that patients attend the centres because they are anxious about their symptoms and view them as serious, cannot get an appointment with their GP quickly and conveniently, are dissatisfied with the GP, or lack self-care skills. Staff members perceived some motives as legitimate (an acute health need and difficulties in getting an appointment), and others as less legitimate (convenience, minor illness, and seeking quicker access to hospital facilities).Conclusions The participants perceived that patients attend urgent care centres because of the convenience of access relative to primary care, as well as sense of acuity and anxiety, lack self-care skills and other reasons. They perceived some motives as more legitimate than others. Attention to unmet ne
Bitan Y, Parmet Y, Greenfield G, et al., 2016, The cognitive task of medication reconciliation - Clinicians' approaches to the arrangement of medical condition and medication history information, Human Factors Engineering, Pages: 538-540, ISSN: 1071-1813
Copyright 2016 by Human Factors and Ergonomics Society. We report the results of a study which aims to improve our understanding of how clinicians make sense of medication and disease information (medical reconciliation), performed by clinicians in a major US hospital. A card sorting simulation experiment running on an Android tablet was utilized to record the steps taken by 130 clinicians to reconcile and better understand the clinical information they received about a simulated patient. Evaluating the order in which the clinicians processed the information shows that most clinicians sorted medical condition information before medication history. Clinicians use diverse strategies to arrange the information. This study allows us to expend our understanding of the cognitive task of medication reconciliation, adding to the knowledge that might assist in data presentation in future medical information software. Such an understanding has the potential to provide clinicians with better tools to capture and reconcile clinical information which may ultimately improve patient safety.
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