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Experiences of integrating social prescribing link workers into primary care in England — bolting on, fitting in, or belonging: a realist evaluation
Background Following the 2019 NHS Long Term Plan, link workers have been employed across primary care in England to deliver social prescribing. Aim To understand and explain how the link worker role is being implemented in primary care in England. Design and setting This was a realist evaluation undertaken in England, focusing on link workers based in primary care. Method The study used focused ethnographies around seven link workers from different parts of England. As part of this, we interviewed 61 patients and 93 professionals from health care and the voluntary, community, and social enterprise sector. We reinterviewed 41 patients, seven link workers, and a link worker manager 9–12 months after their first interview. Results We developed four concepts from the codes developed during the project on the topic around how link workers are integrated (or not) within primary care: (or not) within primary care: centralising or diffusing power; forging an identity in general practice; demonstrating effect; and building a facilitative infrastructure. These concepts informed the development of a programme theory around a continuum of integration of link workers 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 wellbeing. Conclusion Social prescribing was introduced into primary care to promote greater attention to the full range of factors affecting patients’ health and wellbeing, 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.
Cancer inequalities in the United Kingdom and the data used to measure them: a scoping review
Significant cancer inequalities may exist across the United Kingdom (UK). Data are required to delineate and quantify these inequalities. This scoping review was undertaken to map the research evidence on UK cancer inequalities and determine the current data available, and the data gaps, that, if filled, could inform a strategy to reduce them. 444 studies were included. Their distribution across inequality domains, care pathways and cancer sites was uneven. The majority of studies were based on administrative datasets, notably cancer registry data, with a wide-range of methods used to define inequality groups. No UK-wide population-based evidence was identified. The landscape of data available in the UK to study cancer inequalities is uneven. Although there is a large volume of evidence available, there remain major gaps in both the data available and the knowledge base they are deployed to generate. This deficit needs to be addressed as a matter of urgency.
Benefits of aldosterone receptor antagonism in chronic kidney disease: the BARACK-D RCT.
BACKGROUND: Chronic kidney disease affects around 10% of the global population and is associated with significant risk of progression to end-stage renal disease and vascular events. Aldosterone receptor antagonists such as spironolactone have shown prognostic benefits in patients with heart failure, but effects on patients with chronic kidney disease are uncertain. OBJECTIVES: To determine the effect of low-dose spironolactone on mortality and cardiovascular outcomes in people with chronic kidney disease stage 3b. DESIGN: Prospective randomised open blinded end-point trial. SETTINGS: Three hundred and twenty-nine general practitioner practices throughout the United Kingdom. PARTICIPANTS: Patients meeting the criteria for chronic kidney disease stage 3b (estimated glomerular filtration rate 30-44 ml/minute/1.73 m2) according to National Institute for Health and Care Excellence guidelines were recruited. Due to the higher than anticipated measurement error/fluctuations, the eligible range was extended to 30-50 ml/minute/1.73 m2 following the initial recruitment period. INTERVENTION: Participants were randomised 1 : 1 to receive either spironolactone 25 mg once daily in addition to standard care, or standard care only. OUTCOME MEASURES: Primary outcome was the first occurring of all-cause mortality, first hospitalisation for heart disease (coronary heart disease, arrhythmia, atrial fibrillation, sudden death, failed sudden death), stroke, heart failure, transient ischaemic attack or peripheral arterial disease, or first occurrence of any condition not listed at baseline. Secondary outcome measures included changes in blood pressure, renal function, B-type natriuretic peptide, incidence of hyperkalaemia and treatment costs and benefits. RESULTS: One thousand four hundred and thirty-four participants were randomised of the 3022 planned. We found no evidence of differences between the intervention and control groups in terms of effectiveness with the primary combined vascular end points, nor with the secondary clinical outcomes, including progression in renal decline. These results were similar for the total treatment periods or a 3-year follow-up period as originally planned. More adverse events were experienced and more participants discontinued treatment in the intervention group. Two-thirds of participants randomised to spironolactone stopped treatment within six months because they met pre-specified safety stop criteria. The addition of low-dose spironolactone was estimated to have a cost per quality-adjusted life-year gained value above the National Institute for Health and Care Excellence's threshold of £30,000. LIMITATIONS: Main limitations were difficulties in recruiting eligible participants resulting in an underpowered trial with poor ethnic diversity taking twice as long as planned to complete. We have explored the data in secondary analyses that indicate that, despite these difficulties, the findings were reliable. CONCLUSIONS: The benefits of aldosterone receptor antagonism in chronic kidney disease trial found no evidence to support adding low-dose spironolactone (25 mg daily) in patients with chronic kidney disease stage 3b: there were no changes to cardiovascular events during the trial follow-up, either for the combined primary or individual components. There was also no evidence of benefit observed in rates of renal function decline over the trial, but much higher initial creatinine rise and estimated glomerular filtration rate decline, and to a higher percentage rate, in the intervention arm in the first few weeks of spironolactone treatment, which resulted in a high proportion of participants discontinuing spironolactone treatment at an early stage. These higher rates of negative renal change reduced in scale over the study but did not equalise between arms. The addition of 25 mg of spironolactone therefore provided no reno- or cardio-protection and was associated with an increase in adverse events. FUTURE WORK: These findings might not be applicable to different mineralocorticoid receptor antagonists. STUDY REGISTRATION: Current Controlled Trials ISRCTN44522369. FUNDING: This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 12/01/52) and is published in full in Health Technology Assessment; Vol. 29, No. 5. See the NIHR Funding and Awards website for further award information.
The Pandemic EVIDENCE Collaboration Pillar 1: Diagnostics and Transmission
The COVID-19 pandemic starkly revealed a lack of high-quality evidence for non-pharmacological interventions (NPIs). The evidence produced to support the optimal deployment of NPIs in an effort to reduce transmission of SARS-CoV-2 was often of poor quality, and decisions were made without considering the wealth of previous research on respiratory virus transmission from human challenge studies. Respiratory virus infections cause illnesses varying from the “common cold” to invasive pneumonitis with multisystem involvement with severity dependent on the host-virus-immune response interaction. Despite the learnings from the recent pandemic, significant gaps remain in our understanding of the diagnosis of acute respiratory viral infections and their sequelae, the modes of transmission, and how to effectively synthesise the existing evidence from the past 70 years of research on respiratory viruses. It is crucial to examine further the evidence on how common respiratory viral agents are transmitted. The transmission dynamics to allow for a replication-competent virus to move from a reservoir to a susceptible host and establish an invasive infection is complex and it is likely multiple modes of transmission exist from direct reservoir-to-host (contact, droplet deposition, transplacental) and indirect reservoir-to-intermediary-to- host (vehicle-borne, foodborne, waterborne, and airborne) routes. To enhance our understanding of both diagnostics and transmission, we need to characterise viral entry and attachment, viral load dynamics, duration of virus infectivity both inside and outside the host, duration of viral nucleic acid shedding using molecular testing, the role of whole genome sequencing, and factors that may affect the duration of infectivity and transmission. There are still uncertainties surrounding current testing strategies and their connection to NPIs, as well as fundamental issues such as the accuracy of symptom reporting during acute respiratory infections. The importance of animal-to-animal, human-to-animal and human-to-human challenge studies in expanding our knowledge of the transmission of respiratory viruses cannot be overstated.
The impact of paramedics working in primary care teams on other professionals and patient experiences: a qualitative study.
BACKGROUND: Paramedics are among the professional groups identified in recent policy initiatives aimed at addressing the unsustainable workload and workforce crises in primary care. Their support aims to enhance patient access to care and alleviate the burden of workload pressures. AIM: To explore the impact of paramedics working in primary care on primary care teams and the experiences of patients who have a clinical consultation with a paramedic in primary care. DESIGN & SETTING: Focused observations and interviews involving fifteen geographically dispersed sites across the United Kingdom. METHOD: Data were collected between May 2022 and January 2023, incorporating 60 semi-structured interviews and 60 hours of observations of paramedics. Transcripts were thematically analysed. RESULTS: Patients, GPs and other staff in primary care perceive that the paramedic role enhances healthcare availability in primary care by increasing workforce capacity. This is especially prevalent when paramedics work in a clinical capacity that complements the GP role. However, successful integration into the primary care team relies on paramedics having significant clinical experience and receiving clinical supervision from GPs. Patients are trusting of the paramedic role when they have positive clinical consultations. CONCLUSION: Paramedics have potential to improve access to the primary care workforce. However, attention to supportive transition processes (such as clinical supervision) are required for the paramedic to successfully be integrated into the primary care team.
Prevalence and patterns of testing for anaemia in primary care in England.
Background Despite epidemiological data on anaemia being available on a global scale, its prevalence in the United Kingdom is not well described. Aim To investigate anaemia prevalence and testing patterns for haemoglobin and other blood parameters. Design and Setting A population-based cohort study using data drawn from the Clinical Practice Research Datalink Aurum database in 2019. Method We extracted demographic data for each person who was registered at their current practice during 2019, including linked data on Index of Multiple Deprivation. We calculated anaemia prevalence in 2019 based on World Health Organization specified age and gender thresholds for haemoglobin. We classified anaemia based on mean corpuscular volume and ferritin. We followed up people with anaemia for up to one year to investigate longitudinal testing patterns for haemoglobin. Results The cohort contained 14 million people. Anaemia prevalence in 2019 was 4.1% (5.1 % females and 3.1% males). Prevalence was higher in people aged >65 years, Black and Asian ethnicities, and people living in areas with higher social deprivation. Only half of people with anaemia and a mean corpuscular volume of ≤100 fL had an accompanying ferritin value recorded. About half of people with anaemia had a follow-up haemoglobin test within one-year, most of which still indicated anaemia. Conclusion Anaemia is prevalent in the UK with large disparities between levels of demographic variables. Investigation and follow-up of anaemia is suboptimal in many patients. Health interventions aimed at improving anaemia investigation and treatment are needed, particularly in these at-risk groups.
Oral nicotine pouches for cessation or reduction of use of other tobacco or nicotine products.
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: Primary objectives To evaluate the benefits and harms of oral nicotine pouches when used to help people transition away from combustible tobacco use (smoking) To evaluate the impact of oral nicotine products on the prevalence of combustible tobacco use Secondary objectives To evaluate the benefits and harms of oral nicotine pouches when used to help people transition away from other non-combustible tobacco/commercial nicotine product use To evaluate the impact of oral nicotine products on the prevalence of use of other non-combustible tobacco/commercial nicotine products.
The impacts of e-cigarette flavours: An overview of systematic reviews.
BACKGROUND AND AIMS: E-cigarette flavours have the potential to impact the appeal, harms and use of e-cigarettes and combustible tobacco. Systematic reviews have synthesised evidence on their impacts but have always focused on specific outcomes or populations. This overview aimed to draw together syntheses from past systematic reviews of e-cigarette flavours to provide a holistic, population-wide view. METHODS: Overview of systematic reviews investigating the impacts of e-cigarette flavours on any outcome. We searched six databases to February 2024, and appraised reviews using AMSTAR2. We used association direction plots and narratively synthesised results. RESULTS: We included 32 reviews (11 higher quality; 21 lower). Reviews reported impacts of e-cigarette flavours on: appeal/perceptions of vaping (13 reviews); harms (12); smoking (7); and vaping (13) behaviours. Availability of non-tobacco e-cigarette flavours may increase the appeal of (8 reviews) and motivation to try/continue using e-cigarettes (5) and decrease harm perceptions (5). There were no clear differences in impacts based on age or history of combustible tobacco use, and little difference in findings between higher and lower quality reviews. Two reviews indicated that among adolescents, experimenting with different flavours increased e-cigarette appeal. Twelve reviews indicated that a range of specific flavours (including cinnamon, menthol and various sweet/fruity flavours) may be harmful; this often came from in vitro experiments and chemical analyses. Findings were inconclusive on the impact of e-cigarette flavours on smoking cessation (six reviews not showing clear impact), smoking initiation (two reviews not showing clear impact) and vaping initiation (two reviews showing increased initiation and two not showing clear impact). CONCLUSIONS: Non-tobacco flavourings for e-cigarettes may increase e-cigarette appeal and harms; this increase may vary by flavour and apply across different population groups. The impacts of e-cigarette flavours on e-cigarette and cigarette use are inconclusive.
Factors associated with link workers considering leaving their role: a cross-sectional survey.
BACKGROUND: Social prescribing (SP) link workers (LWs) listen to patients' concerns and difficulties, and connect them to relevant community assets (groups/organisations/charities) that can help with their non-medical issues (eg, loneliness, debt, housing). LW retention is key to sustaining SP within primary care. AIM: To examine occupational self-efficacy, job discrepancy and other factors as potential predictors of LWs' intentions to leave or remain in their post. DESIGN & SETTING: Cross-sectional survey involving LWs from the United Kingdom. METHOD: An online questionnaire was distributed via SP-related organisations. Questions were on: a) intention to leave the role, b) demographics, and c) role experience, including occupational self-efficacy and discrepancy between expectations and reality of the job. Questions were mainly closed, although some allowed LWs to provide a written response. Logistic regression models were fitted to identify predictors, and content analysis used to categorise open ended responses. RESULTS: 342 questionnaire responses were included in the analysis. Higher job discrepancy was associated with past (odds ratio [OR] per 30 unit increase=6.86; 95% CI: 3.91 to 12.0; P=0.003) and future (OR=4.86; 95% CI: 2.70 to 8.72; P<0.001) intentions to leave, whilst lower occupational self-efficacy was associated only with past intentions to leave (OR per 10 unit decrease=1.91; 95% CI: 1.24 to 2.93; P=0.003). CONCLUSION: Findings highlight factors influencing LW retention, offering a foundation for targeted interventions, which could include clearer communication about the role during recruitment, and adjusting job descriptions and support when required.
Incentives for smoking cessation
Background: Financial incentives (money, vouchers, or self-deposits) can be used to positively reinforce smoking cessation. They may be used as one-off rewards, or in various schedules to reward steps towards sustained smoking abstinence (known as contingency management). They have been used in workplaces, clinics, hospitals, and community settings, and to target particular populations. This is a review update. The previous version was published in 2019. Objectives: Primary. To assess the long-term effects of incentives and contingency management programmes for smoking cessation in mixed and pregnant populations. Secondary. To assess the long-term effects of incentives and contingency management programmes for smoking cessation in mixed populations, considering whether incentives were offered at the final follow-up point. To assess the difference in outcomes for pregnant populations, considering whether rewards were contingent on abstinence or guaranteed. Search methods: For this update, we searched CENTRAL, MEDLINE, Embase, PsycINFO, and two trials registers on 2 November 2023, and the Cochrane Tobacco Addiction Group Specialised Register on March 2023, together with reference checking, citation searching, and contact with study authors to identify additional studies. Selection criteria: We considered only randomised controlled trials (RCTs), allocating individuals, workplaces, groups within workplaces, or communities to smoking cessation incentive schemes or control conditions. We included studies in a mixed-population setting (e.g. community-, work-, clinic- or institution-based), studies with specific populations (e.g. those with diagnosed mental health conditions), and studies in pregnant people who smoke. Data collection and analysis: We used standard Cochrane methods. The primary outcome measure in the mixed-population studies was abstinence from smoking at longest follow-up (at least six months from the start of the intervention). In the trials of pregnant people, we used abstinence from smoking measured at the longest follow-up, and at least to the end of the pregnancy. Where available, we pooled outcome data using a Mantel-Haenszel random-effects model, with results reported as risk ratios (RRs) and 95% confidence intervals (CIs), using adjusted estimates for cluster-randomised trials. We analysed studies carried out in mixed populations separately from those carried out in pregnant populations. Main results: Forty-eight mixed-population studies met our inclusion criteria, recruiting more than 21,924 participants; 15 of these are new to this version of the review. Studies were set in varying locations, including community settings, clinics or health centres, workplaces, and outpatient drug clinics. We judged eight studies to be at low risk of bias, and 16 to be at high risk of bias, with the remaining 24 studies at unclear risk. Thirty-three of the trials were run in the USA, two in Thailand, one in the Philippines, one in Hong Kong, and one in South Africa. The rest were European. Incentives offered included cash payments, self-deposits, or vouchers for goods and groceries, offered directly or collected and redeemable online. The pooled RR for quitting with incentives at longest follow-up (six months or more) compared with controls was 1.52 (95% CI 1.33 to 1.74; I2 = 23%; 39 studies, 18,303 participants; high-certainty evidence). Results were not sensitive to the exclusion of seven studies that offered an incentive for cessation at long-term follow-up (result excluding those studies: RR 1.46, 95% CI 1.23 to 1.73; I2 = 26%; 32 studies, 15,082 participants), suggesting the impact of incentives continues for at least some time after incentives cease (at least six months). For this update, we included an adjusted analysis incorporating three cluster-RCTs. The pooled odds ratio was 1.57 (95% CI 1.37 to 1.79; I2 = 30%; 43 studies, 23,960 participants; high-certainty evidence). Although not always clearly reported, the total financial amount of incentives varied considerably between trials, from zero (self-deposits), to a range of between 45 US dollars (USD) and USD 1185. There was no clear difference in effect between trials offering low or high total value of incentives, nor those encouraging redeemable self-deposits. We ran an updated exploratory meta-regression and found no significant association between the outcome and the total value of the financial incentive (P = 0.963). Any such indirect comparison is particularly crude in this context, due to differences in the cultural significance of financial amounts (e.g. USD 50 might have different significance in different contexts). We included 14 studies of 4314 pregnant people (11 conducted in the USA, one in France, and two in the UK). We judged four studies to be at low risk of bias, two at high risk of bias, and eight at unclear risk. When pooled, the 13 trials with usable data delivered a risk ratio at longest follow-up (up to 48 weeks postpartum) of 2.13 (95% CI 1.58 to 2.86; I2 = 31%; 13 studies, 3942 participants; high-certainty evidence), in favour of incentives. Authors' conclusions: Overall, our conclusion from this latest review update remains that there is high-certainty evidence that incentives improve smoking cessation rates at long-term follow-up in mixed population studies. The evidence demonstrates that the effectiveness of incentives is sustained even when the last follow-up occurs after the withdrawal of incentives. There is also now high-certainty evidence that incentive schemes conducted amongst pregnant people who smoke improve smoking cessation rates, both at the end of pregnancy and postpartum. This represents a change from the previous update in which we rated this evidence as moderate certainty. Current and future research might more precisely explore differences between trials offering low or high cash incentives and self-incentives (deposits), within a variety of smoking populations, focusing on low- and middle-income countries where the burden of tobacco use remains high.