BackgroundTo investigate organisational factors influencing the implementation challenges of redesigning services for people with long term conditions in three locations in England, using remote care (telehealth and telecare).MethodsCase-studies of three sites forming the UK Department of Health’s Whole Systems Demonstrator (WSD) Programme. Qualitative research techniques were used to obtain data from various sources, including semi-structured interviews, observation of meetings over the course programme and prior to its launch, and document review. Participants were managers and practitioners involved in the implementation of remote care services.ResultsThe implementation of remote care was nested within a large pragmatic cluster randomised controlled trial (RCT), which formed a core element of the WSD programme. To produce robust benefits evidence, many aspect of the trial design could not be easily adapted to local circumstances. While remote care was successfully rolled-out, wider implementation lessons and levels of organisational learning across the sites were hindered by the requirements of the RCT.ConclusionsThe implementation of a complex innovation such as remote care requires it to organically evolve, be responsive and adaptable to the local health and social care system, driven by support from front-line staff and management. This need for evolution was not always aligned with the imperative to gather robust benefits evidence. This tension needs to be resolved if government ambitions for the evidence-based scaling-up of remote care are to be realised.

Despite strong support for the provision of memory assessment services (MASs) in England and other countries, their effectiveness in improving patient outcomes is uncertain. We aimed to describe change in patients' health related quality of life (HRQL) six months after referral to MASs and to examine associations with patient characteristics and use of postdiagnostic interventions.Data from 883 patients referred to 69 MASs and their informal caregivers (n=569) were collected at referral and 6 months later. Multivariable linear regression was used to examine associations of change in HRQL (DEMQOL, DEMQOL-Proxy) with patient characteristics (age, sex, ethnicity, socioeconomic deprivation and comorbidity) and use of post-diagnostic interventions (anti-dementia medications and non-pharmacological therapies).Mean HRQL improved, irrespective of diagnosis: self-reported HRQL increased 3.4 points (95% CI 2.7 to 4.1), proxy-reported HRQL 1.3 points (95% CI 0.5 to 2.1). HRQL change was not associated with any of the patient characteristics studied. Patients with dementia (54%) receiving anti-dementia drugs reported greater improvement in their HRQL but those using non-pharmacological therapies reported less improvement than those not.HRQL improves in the first 6 months after referral to MASs. Research is needed to determine longer-term sustainability of the benefits and the cost-effectiveness of MASs.

In the absence of any clear typology, evaluation of MASs will need to focus on the impact of individual structural and process characteristics on outcomes.

If you would like to write for this, or any other Emerald publication, then please use our Emerald for Authors service information about how to choose which publication to write for and submission guidelines are available for all. Please visit www.emeraldinsight.com/authors for more information. About Emerald www.emeraldinsight.comEmerald is a global publisher linking research and practice to the benefit of society. The company manages a portfolio of more than 290 journals and over 2,350 books and book series volumes, as well as providing an extensive range of online products and additional customer resources and services.Emerald is both COUNTER 4 and TRANSFER compliant. The organization is a partner of the Committee on Publication Ethics (COPE) and also works with Portico and the LOCKSS initiative for digital archive preservation. ABSTRACTThe greater availability of life-sustaining technology, such as cardiopulmonary resuscitation, and the medical, legal and moral pressures to use them, often enable the prolongation of lives of older people. The dying process can be extended regardless of quality of life. Further, there is much public debate on the increasing emphasis on individual rights and personal autonomy in the dying process. This qualitative study examined older people's perspectives on end-of-life decision-making and advance care planning. A sample of 12 older people living in the community was recruited and studied in-depth. A semi-structured interview explored patients' conceptualisations of decision-making in the later stages of life and the significant others they would like involved in the process. The data were analysed using 'content analysis'. The resulting broad categories, themes and sub-themes formed the foundation of an emerging model of older people talking about end-of-life care. Finally, results were discussed with regard to practice and policy development. KEYWORDS older people advance care planning end-of-life care communication living wills decision-making

BackgroundDEMQOL and DEMQOL-Proxy are widely used patient reported outcome measures (PROMs) of health related quality of life in people with dementia (PWD). Growing interest in routine use of PROMs in health care calls for more robust instruments that are potentially fit for reliable and valid comparisons at the micro-level (patients) and meso-level (clinics, hospitals, care homes).MethodsWe used modern psychometric methods (based on the Rasch model) to re-evaluate DEMQOL (1428 PWDs) and DEMQOL-Proxy (1022 carers) to ensure they are fit for purpose. We evaluated scale to sample targeting, ordering of item thresholds, item fit to the model, and differential item functioning (sex, age, relationship), local independence, unidimensionality and reliability on the full set of items and a smaller item set.ResultsFor both DEMQOL and DEMQOL-Proxy the smaller item set performed better than the original item set. We developed revised scores using the items from the smaller set.ConclusionsWe have improved the scoring of DEMQOL and DEMQOL-Proxy using the Rasch measurement model. Future work should focus on the problems identified with content and response options.