BackgroundWe evaluated end of life care services in two English counties including: coordination centres, telephone advice line, ‘Discharge in Reach’ nurses, a specialist community personal care team and community nurse educators. Elsewhere, we published findings detailing high family carer satisfaction and fewer hospital admissions, Accident and Emergency attendances and hospital deaths for service users compared to controls. The aim of this paper is to discuss what contributed to those outcomes.MethodsUsing realist evaluation, data collection included documentation (e.g. referral databases), 15 observations of services and interviews with 43 family carers and 105 professionals. Data were analysed using framework analysis, applying realist evaluation concepts. Findings were discussed at successive team meetings and further data was collected until team consensus was reached.ResultsServices ‘worked’ primarily for those with cancer with ‘fast track’ funding who were close to death. Factors contributing to success included services staffed with experienced palliative care professionals with dedicated (and sufficient) time for difficult conversations with family carers, patients and/or clinical colleagues about death and the practicalities of caring for the dying. Using their formal and informal knowledge of the local healthcare system, they accessed community resources to support homecare and delivered excellent services. This engendered confidence and reassurance for staff, family carers and patients, possibly contributing to less hospital admissions and A&E attendances and more home deaths.ConclusionsWith demand for 24-hour end of life care growing and care provision fragmented across health and social care boundaries, services like these that cut across organisational sectors may become more important. They offer an overview to help navigate those desiring a home death through the system.
ObjectivesThe Marie Curie Cancer Care Delivering Choice Programme (DCP) aims to help palliative patients be cared for in their place of choice. In this study, new palliative care services delivered in two counties in England included end-of-life care coordination centres, an out-of-hours telephone line and discharge in-reach nurses. The study aimed to investigate the impact of DCP on place of death and hospital usage (emergency department (ED) and admissions).MethodsRetrospective cohort of all eligible palliative patients who died over a 6-month period in two counties (n=3594). Participants were those who died of conditions considered to be eligible for end-of-life care, as defined by the Public Health England National End of Life Care Intelligence Network. The sample included people who did and did not access DCP services. DCP service, hospital admission and ED use data, demographic and death data were collected on all eligible participants. Data were analysed using descriptive statistics and logistic regression.ResultsAfter adjusting for potential confounders, those using Delivering Choice were at least 30% less likely to die in hospital or have an emergency hospital admission or ED visit in the last 30 or 7 days of life than those who did not.ConclusionsRecipients of DCP services were less likely to die in or use hospital services. Those considering new ways of providing end-of-life care could explore the possibility of adopting similar services and evaluating the outcomes from patient, carer and system perspectives.
Background: Health services are increasingly using digital tools to deliver care and online consultations are being widely adopted in primary care settings. The intended consequences of online consultations are to increase patient access to care and increase the efficiency of care. Aim: To identify and understand the unintended consequences of online consultations in primary care. Design and Setting: Qualitative interview study in eight general practices using online consultation tools in South West and North West England. Method: Thematic analysis of semi-structured interviews with 19 patients and 18 general practice staff. Results: We identified consequences of online consultations that restricted patient access to care by making it difficult for some patients to communicate effectively with a GP and disadvantaging digitally-excluded patients. This stemmed from patient uncertainty about how their queries were dealt with and whether practices used online consultations as their preferred method for patients to contact the practice. We identified consequences that limited increases in practice efficiency by creating additional work, isolation and dissatisfaction for some staff. Conclusion: Unintended consequences often present operational challenges that are foreseeable and partly preventable. However these challenges must be recognised and solutions resourced sufficiently. Not everyone may benefit and local decisions will need to be made about trade-offs. Bespoke process change is critical to making effective use of online consultation tools. Unintended consequences also present clinical challenges that result from asynchronous communication. Online consultation tools favour simple, well-formulated, information exchange that leads to diffuse relationships and a more transactional style of medicine.
Background Evidence highlights the disproportionate impact of measures that have been introduced to reduce the spread of coronavirus on individuals from Black, Asian and minority ethnic (BAME) communities, and among those on a low income. An understanding of barriers to adherence in these populations is needed. In this qualitative study, we examined the patterns of adherence to mitigation measures and reasons underpinning these behaviors. Methods Semi-structured interviews were conducted with 20 participants from BAME and low-income White backgrounds. The topic guide was designed to explore how individuals are adhering to social distancing and self-isolation during the pandemic and to explore the reasons underpinning this behavior. Results We identified three categories of adherence to lockdown measures: (i) caution-motivated super-adherence (ii) risk-adapted partial-adherence and (iii) necessity-driven partial-adherence. Decisions about adherence considered potential for exposure to the virus, ability to reduce risk through use of protective measures and perceived importance of/need for the behavior. Conclusions This research highlights a need for a more nuanced understanding of adherence to lockdown measures. Provision of practical and financial support could reduce the number of people who have to engage in necessity-driven partial-adherence. More evidence is required on population level risks of people adopting risk-adapted partial-adherence.
Summary Background Most patients are prescribed Helicobacter pylori treatment without culture and antibiotic susceptibility testing, as current guidance recommends that patients with recurrent dyspepsia should be tested for H. pylori using a non‐invasive breath or faecal antigen test. Aims To determine the prevalence of H. pylori antibiotic resistance in patients attending endoscopy in England and Wales, and the feasibility of an antibiotic resistance surveillance programme testing. Methods We tested the antibiotic susceptibility of H. pylori isolates from biopsy specimens from 2063 of 7791 (26%) patients attending for endoscopy in Gloucester and Bangor, and 339 biopsy specimens sent to the Helicobacter Reference Unit (HRU) in London. Culture and susceptibility testing was undertaken in line with National and European methods. Results Helicobacter pylori were cultured in 6.4% of 2063 patients attending Gloucester and Bangor hospitals. Resistance to amoxicillin, tetracycline and rifampicin/rifabutin was below 3% at all centres. Clarithromycin, metronidazole and quinolone resistance was significantly higher in HRU (68%, 88%, 17%) and Bangor isolates (18%, 43%, 13%) than Gloucester (3%, 22%, 1%). Each previous course of these antibiotics is associated with an increase in the risk of antibiotic resistance to that agent [clarithromycin: RR = 1.5 (P = 0.12); metronidazole RR = 1.6 (P = 0.002); quinolone RR = 1.8 (P = 0.01)]. Conclusions Helicobacter pylori infection is now uncommon in dyspeptic patients at endoscopy. A surveillance system is feasible and necessary to inform dyspepsia management guidance. Clinicians should take a thorough antibiotic history before prescribing metronidazole, clarithromycin or levofloxacin for H. pylori.
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