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The Centre for Evidence-Based Medicine (CEBM) at Oxford University develops, promotes and disseminates better evidence for health care.
Research inefficiencies in external validation studies of the Framingham Wilson coronary heart disease risk rule: A systematic review
Background External validation studies create evidence about a clinical prediction rule's (CPR's) generalizability by evaluating and updating the CPR in populations different from those used in the derivation, and also by contributing to estimating its overall performance when metaanalysed in a systematic review. While most cardiovascular CPRs do not have any external validation, some CPRs have been externally validated repeatedly. Hence, we examined whether external validation studies of the Framingham Wilson coronary heart disease (CHD) risk rule contributed to generating evidence to their full potential. Methods A forward citation search of the Framingham Wilson CHD risk rule's derivation study was conducted to identify studies that evaluated the Framingham Wilson CHD risk rule in different populations. For external validation studies of the Framingham Wilson CHD risk rule, we examined whether authors updated the Framingham Wilson CHD risk rule when it performed poorly. We also assessed the contribution of external validation studies to understanding the Predicted/Observed (P/O) event ratio and c statistic of the Framingham Wilson CHD risk rule. Results We identified 98 studies that evaluated the Framingham Wilson CHD risk rule; 40 of which were external validation studies. Of these 40 studies, 27 (67.5%) concluded the Framingham Wilson CHD risk rule performed poorly but did not update it. Of 23 external validation studies conducted with data that could be included in meta-analyses, 13 (56.5%) could not fully contribute to the meta-analyses of P/O ratio and/or c statistic because these performance measures were neither reported nor could be calculated from provided data. Discussion Most external validation studies failed to generate evidence about the Framingham Wilson CHD risk rule's generalizability to their full potential. Researchers might increase the value of external validation studies by presenting all relevant performance measures and by updating the CPR when it performs poorly.
Outcomes for older people with screening detected versus existing chronic kidney disease: Cohort study with data linkage.
BACKGROUND: Chronic Kidney Disease (CKD) is a common health problem, associated with increased risk of cardiovascular disease (CVD), end stage kidney disease (ESKD), and premature death. A third of people aged≥70 years have CKD, many of whom are undiagnosed, but little is known about the value of screening. AIM: To compare the risk of adverse health outcomes between people with an existing diagnosis of CKD and those identified on screening. To identify factors associated with mortality in CKD. DESIGN & SETTING: Prospective cohort study of 892 primary care patients aged≥60 years with CKD (existing and screening detected) in Oxfordshire, with data linkage to civil death registry and secondary care. METHOD: Hazard Ratios (HR) and 95% Confidence Intervals (CI) were estimated using Cox proportional-hazard models to compare the risk of all-cause mortality, hospitalisation, CVD, ESKD separately, and as a composite between CKD groups, as well as to identify factors associated with mortality. RESULTS: After a median follow-up of 3-5 years, 49 people died, 493 were hospitalised, 57 had an incident CVD event, and 0 had an ESKD event. There was no difference in the composite outcome between those existing CKD and those identified on screening (HR 0.94, CI 0.67-1.33). Older age (HR 1.10, CI 1.06-1.15), male sex (HR 2.31, CI 1.26-4.24), and heart failure (HR 5.18, CI 2.45-10.97) were associated with increased risk of death. CONCLUSION: Screening older people for CKD may be of value, as their risk of short-term mortality, hospitalisation, and CVD is comparable to people routinely diagnosed. Larger studies with longer follow-up in more diverse and representative populations of older adults are needed to corroborate these findings.
Experiences of integrating social prescribing link workers into primary care in England: Bolting on, fitting in or belonging.
BACKGROUND: Following the 2019 NHS Long-Term Plan, link workers (LWs) have been employed across primary care in England to deliver social prescribing (SP). AIM: To understand and explain how the LW role is being implemented in primary care in England. DESIGN AND SETTING: Realist evaluation undertaken in England. METHOD: Focused ethnographies around seven LWs from different parts of England. As part of this, we interviewed 61 patients and 93 professionals from healthcare and the voluntary, community and social enterprise (VCSE) sector. We reinterviewed 41 patients, seven LWs and a LW manager 9-12 months after their first interview. RESULTS: We developed four concepts around how LWs are integrated (or not) within primary care: Centralising or diffusing power; Forging an identity in general practice; Demonstrating effect; Building a facilitative infrastructure. These concepts informed the development of a programme theory around a continuum of integration of LWs into primary care - from being 'bolted on' to existing provision, without much consideration, to 'fitting in', shaping what is delivered to be accommodating, through to 'belonging', whereby they are accepted as a legitimate source of support, making a valued contribution to patients' broader well-being. CONCLUSION: SP was introduced into primary care to promote greater attention to the full range of factors affecting patients' health and well-being, beyond biomedicine. For that to happen, our analysis highlights the need for a whole system approach to defining, delivering and maintaining this new part of practice.
Integrated Diagnosis in Africa's Low- and Middle-Income Countries: What Is It, What Works, and for Whom? A Realist Synthesis.
INTRODUCTION: Integrated diagnosis can improve health outcomes and patient experiences through early diagnosis and identification of cases that could otherwise be overlooked. Although existing research highlight the feasibility of integrated diagnosis across various conditions, a significant evidence gap remains regarding its direct impact on patient experiences and health outcomes. This review explores the conceptualizations of integrated diagnosis by different stakeholders along the healthcare pathway and examines the necessary contexts and mechanisms crucial for its effectiveness. METHODS: This study adopts a realist methodology to explore integrated diagnosis. Using a systematic approach, the research aims to collect, assess, and synthesize existing evidence on integrated diagnosis, guided by a program theory developed through literature review and expert consultations. Primary studies and reviews related to integrated diagnosis, multi-disease testing, or integrated healthcare with a diagnostic focus were sourced from major databases and global health organization websites. The collected evidence was used to construct and refine the evolving theoretical framework. RESULTS: This study identified three models of integrated diagnosis interventions: individual/human resource integration, facility or mobile-based integration, and technology integration. Successful implementation of these models relies on understanding the values and perceptions of both healthcare workers and patients/clients. This research emphasizes a holistic approach that considers all elements within the health system and underscores their interdependence. Using the WHO health systems framework to contextualise factors, the study positions diagnosis as an integral component of the broader health ecosystem. A key finding of the research is the importance of addressing the barriers and facilitators of integrated diagnosis interventions. This includes policy frameworks, diagnostic tools, funding mechanisms, treatment pathways, and human resource issues. Improving patient experiences requires cultivating positive relationships with healthcare workers ensuring elements such as respect, confidentiality, accessibility, and timeliness of services are prioritised. DISCUSSION AND CONCLUSION: The diverse conceptualisations of integrated diagnosis highlight the importance of clear definitions for each intervention. This clarity is essential for transferring lessons learned, comparing programs, and effectively measuring results. The success of integrated diagnosis is not a one-size-fits-all scenario; decisions regarding the approach, conditions to be integrated, and timing of integration must be guided by local contexts to ensure sustainable outcomes. The review findings suggest that integrated diagnosis may be suitable at the primary care level in LMICs under specific circumstances. Successful implementation hinges on addressing the perspectives of healthcare workers and patients/clients alike, requiring adequate time, resources, and a well-defined intervention model.
Developing a data-enabled nudge intervention for childhood antibiotics in primary care: a qualitative study
BackgroundPreschool children (aged≤5 years old) have the highest antibiotic prescribing rate in general practice, mostly for self-limiting acute respiratory tract infections (RTIs). Research from over 250 000 UK children suggests that a child’s antibiotic history for RTI may be a good predictor for re-consulting a health professional for the same illness episode and increase clinical workload.AimTo develop a data-enabled nudge intervention to optimise antibiotic prescribing for acute RTI based on a child’s antibiotic history in general practiceDesign & settingTwo phase qualitative study with parents/carers of preschool children and primary care cliniciansMethodIn phase 1, through an initial focus group with eight parents/carers and ‘think aloud’ interviews with 11 clinicians, we co-designed the intervention (computer screen prompt and personalised consultation leaflet). In phase 2, 13 clinicians used the intervention, integrated into the GP computer software, and share their feedback through ‘think aloud’ interviews. Interviews were audio-recorded, transcribed, and analysed thematically.ResultsWe co-created a data-driven intervention that automatically integrates a child’s antibiotic history for acute RTI and personalised leaflet into the electronic medical records. We found that parents and clinicians found this intervention, in principle, acceptable and feasible to use in primary care consultations.ConclusionDelivering such interventions, integrated into practice workflow, could be efficiently scaled up to promote effective antimicrobial stewardship and reduce unnecessary antibiotic use in primary care. Further research will test this intervention in a future trial.
The consequences of micro-discretions and boundaries in the social prescribing link worker role in England: a realist evaluation.
BACKGROUND: Social prescribing addresses non-medical factors affecting health and well-being. Link workers are key to its delivery by connecting people to relevant support, often in the voluntary, community and social enterprise sector. Funding from the National Health Service means that link workers are becoming a common part of primary care in England. OBJECTIVE: To explore and understand the implementation of link workers in primary care in England. DESIGN: A realist evaluation addressed the question - When implementing link workers in primary care to sustain outcomes - what works, for whom, why and in what circumstances? SETTING: Link workers and staff associated with seven primary care sites across England. METHODS: Researchers spent 3 weeks with each link worker, going to meetings with them, watching them interact with patients, with healthcare staff and with voluntary, community and social enterprise organisations. In addition, interviews were conducted with 61 patients and 93 professionals (voluntary, community and social enterprise representatives and healthcare staff, including link workers). Follow-up interviews were conducted with 41 patients and with link workers 9-12 months later. Data were coded and developed into statements to identify how context around the link worker triggers mechanisms that lead to intended and unintended outcomes. RESULTS: We found that link workers exercise micro-discretions in their role - actions and advice-giving based on personal judgement of a situation, which may not always reflect explicit guidance or protocols. Our analysis highlighted that micro-discretions engender positive connections (with patients, healthcare staff, the voluntary, community and social enterprise sector) and promote buy-in to the link worker role in primary care. Micro-discretions supported delivery of person-centred care and enhanced job satisfaction. Data also highlighted that lack of boundaries could place link workers at risk of overstepping their remit. LIMITATIONS: Our research focused on link workers attached to primary care; findings may not be applicable to those working in other settings. Data were collected around seven link worker cases, who were selected purposively for variation in terms of geographical spread and how/by whom link workers were employed. However, these link workers were predominately white females. CONCLUSIONS: Enabling link workers to exercise micro-discretions allows for responsiveness to individual patient needs but can result in uncertainty and to link workers feeling overstretched. FUTURE WORK: Poor link worker retention may, in part, be associated with a lack of clarity around their role. Research to explore how this shapes intention to leave their job is being conducted by authors of this paper. FUNDING: This article presents independent research funded by the National Institute for Health and Care Research (NIHR) Health and Social Care Delivery Research programme as award number NIHR130247.
A Thematic Synthesis of the Experiences of Social Prescribing Among Patients in the UK
Background: Social prescribing connects patients to resources or activities to meet their non-medical needs. In the UK, it is often implemented in primary care. In the social prescribing pathway, patients are directed to link workers to identify suitable solutions for their needs such as art workshops or welfare benefit guidance. Social prescribing marks a notable transition from traditional medical treatments to more comprehensive strategies focusing on holistic health and wellbeing strategies. Insights from patient experiences can improve the development of social prescribing to better meet their needs. This understanding can aid in improving the delivery and outcomes of social prescribing. Aim: To synthesise qualitative research on the experiences of social prescribing among patients in the UK. Design and Setting: A qualitative systematic review – using thematic synthesis for peer-reviewed papers focused on experiences of social prescribing users in the UK. Method: An exhaustive search was performed in six databases: ASSIA, CINAHL, EMBASE, MEDLINE, PSYCINFO, and SOCIAL SCIENCE CITATION INDEX via Web of Science. The CASP tool for qualitative research was used for quality assessment and PRISMA 2020 Checklist was used to ensure the report transparency. Result: Titles and abstracts of 1,269 papers were screened. In total, 85 papers were full text-screened, and 19 studies were included in the review. Five analytical themes were developed from these papers: (a) Searching for hope in times of adversity; (b) Variability in temporal responsiveness; (c) Feeling supported and empowered by the social prescribing pathway; (d) Sustained change from a positive response; (e) Misalignment producing no response. Conclusion: Patients might experience lasting advantages from social prescribing if it aligns with their needs and expectations. Results highlighted the importance of matching social prescribing referral with patients’ readiness to engage. Therefore, it is recommended that healthcare professionals evaluate patient suitability prior to beginning a social prescribing referral.
Applying an equity lens to social prescribing
Background Social prescribing is often described as an intervention that can help reduce health inequalities yet there is little evidence exploring this. This study aimed to assess the feasibility of accessing and analysing social prescribing (SP) service user data to demonstrate the impact of SP on health inequalities. Methods The sample size consisted of records for 276 individuals in Site 1 and 1644 in Site 2. Descriptive analyses were performed to assess the characteristics of people accessing SP, the consistency of data collected and the missingness across both sites. Results Both sites collected basic demographic data (age gender, ethnicity and deprivation). However, data collection was inconsistent; issues included poor recording of ethnicity in Site 2, and for both sites, referral source data and health and well-being outcome measures were missing. There was limited data on the wider determinants of health. These data gaps mean that impacts on health inequalities could not be fully explored. Conclusions It is essential that SP data collection includes information on user demographics and the wider determinants of health in line wit PROGRESS Plus factors. Considering equity around who is accessing SP, how they access it and the outcomes is essential to evidencing how S affects health inequalities and ensuring equitable service delivery.
A meta-ethnography of the factors that shape link workers’ experiences of social prescribing
Background: Social prescribing is gaining traction internationally. It is an approach which seeks to address non-medical and health-related social needs through taking a holistic person-centred and community-based approach. This involves connecting people with and supporting them to access groups and organisations within their local communities. It is hoped that social prescribing might improve health inequities and reduce reliance on healthcare services. In the UK, social prescribing link workers have become core parts of primary care teams. Despite growing literature on the implementation of social prescribing, to date there has been no synthesis that develops a theoretical understanding of the factors that shape link workers’ experiences of their role. Methods: We undertook a meta-ethnographic evidence synthesis of qualitative literature to develop a novel conceptual framework that explains how link workers experience their roles. We identified studies using a systematic search of key databases, Google alerts, and through scanning reference lists of included studies. We followed the eMERGe guidance when conducting and reporting this meta-ethnography. Results: Our synthesis included 21 studies and developed a “line of argument” or overarching conceptual framework which highlighted inherent and interacting tensions present at each of the levels that social prescribing operates. These tensions may arise from a mismatch between the policy logic of social prescribing and the material and structural reality, shaped by social, political, and economic forces, into which it is being implemented. Conclusions: The tensions highlighted in our review shape link workers’ experiences of their role. They may call into question the sustainability of social prescribing and the link worker role as currently implemented, as well as their ability to deliver desired outcomes such as reducing health inequities or healthcare service utilisation. Greater consideration should be given to how the link worker role is defined, deployed, and trained. Furthermore, thought should be given to ensuring that the infrastructure into which social prescribing is being implemented is sufficient to meet needs. Should social prescribing seek to improve outcomes for those experiencing social and economic disadvantage, it may be necessary for social prescribing models to allow for more intensive and longer-term modes of support.
Weight change, cardio-metabolic risk factors and cardiovascular incidence in people with serious mental illness: Protocol of a population-based cohort study in the UK from 1998 to 2020
Introduction People with serious mental illness (SMI), which includes people with diagnoses of schizophrenia spectrum and bipolar disorders, face significant health inequality. This includes a life expectancy reduced by 15-20 years mostly due to premature cardiovascular disease (CVD) compared with the general population. Excess weight gain and related comorbidities are preventable risk factors for CVD. To improve the understanding and management of CVD in people with SMI, we will examine the association between SMI and: (1) weight change; (2) cardio-metabolic risk factors for CVD; and (3) incidence of and mortality from CVD. We will also (4) examine the incidence of referral to weight management services for people with SMI compared with people without SMI. Methods and analysis In this retrospective cohort study, we will link general practice records from the UK Clinical Practice Research Datalink Aurum database. We will establish a cohort of patients diagnosed with SMI between 1998 and 2020 who are matched with up to four controls on age, sex, general practice and calendar year. We will use multivariable mixed-effects linear regression models and Cox proportional hazard models with sequential adjustment for potential confounders identified by separate directed acyclic graphs. Ethics and dissemination This study has been reviewed and approved by the Independent Scientific Advisory Committee for Medicines and Healthcare products Regulatory Agency database research. The results will be published in a peer-reviewed journal.
Consultations for clinical features of possible cancer and associated urgent referrals before and during the COVID-19 pandemic: an observational cohort study from English primary care
Background: It remains unclear to what extent reductions in urgent referrals for suspected cancer during the COVID-19 pandemic were the result of fewer patients attending primary care compared to GPs referring fewer patients. Methods: Cohort study including electronic health records data from 8,192,069 patients from 663 English practices. Weekly consultation rates, cumulative consultations and referrals were calculated for 28 clinical features from the NICE suspected cancer guidelines. Clinical feature consultation rate ratios (CRR) and urgent referral rate ratios (RRR) compared time periods in 2020 with 2019. Findings: Consultations for cancer clinical features decreased by 24.19% (95% CI: 24.04–24.34%) between 2019 and 2020, particularly in the 6–12 weeks following the first national lockdown. Urgent referrals for clinical features decreased by 10.47% (95% CI: 9.82–11.12%) between 2019 and 2020. Overall, once patients consulted with primary care, GPs urgently referred a similar or greater proportion of patients compared to previous years. Conclusion: Due to the significant fall in patients consulting with clinical features of cancer there was a lower than expected number of urgent referrals in 2020. Sustained efforts should be made throughout the pandemic to encourage the public to consult their GP with cancer clinical features.
Informal carer involvement in the transition of medicines-related care for patients moving from hospital to home: a realist review protocol
IntroductionTransition of care for a patient between hospital and home can cause disruption to normal routines, increasing the risk of medicines-related harm. The transition from hospital to home is more complex when a patient does not self-manage their medicines but relies on an informal or unpaid carer (eg, spouse, family member or friend) to provide support. Given the day-to-day medicines-related support provided by informal carers, there is a need to understand how informal carers manage the transition of care from hospital to home; what aspects of hospital discharge act as barriers and facilitators to their involvement and when, how and why these impact patients.Methods and analysisA realist review will be undertaken to develop a programme theory. The programme theory will theorise which medicines-related interventions are useful to carers, and how they are useful. It will outline what aspects of those interventions are the most useful and why, and how context influences engagement and medicine-related outcomes. The review will be reported in line with the Realist and Meta-narrative Evidence Syntheses: Evolving Standards guidelines. Data will be selected, screened and extracted based on defined inclusion and exclusion criteria and relevance to the developing programme theory with the involvement of at least two authors acting independently. Inclusion criteria relate to the relevance to hospital discharge where patients move back to their home, where a carer is involved and where interventions relate to medicines use. Searches will be conducted in PubMed, CINAHL (via EBSCOhost) and EMBASE databases (see supplementary materials for a draft search strategy).Patients and public, participation, involvement and engagement (PPIE) will be incorporated into all stages of the review through iterative engagement and discussion with patient, carers and representatives from carer organisations. The review will follow four steps: (1) development of the initial programme theory, (2) evidence search, (3) selection, extracting, and organising data and (4) synthesising evidence and drawing conclusions.Informal carer involvement in transitions of care is a complex and varied phenomena. The programme theory will be shaped by sustained PPIE reflecting the priorities and experiences of lived experience. The realist review be progressively focused so we can develop a better understanding of carer involvement in patient transitions when moving from hospital to home relating to medicines use.Ethics and disseminationEthical approval is not required. The findings of the review will be disseminated via journal articles and through patient and public facing resources such as a visual patient–public-carer focused summary.PROSPERO registration numberCRD42021262827.