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Adam Steventon,
Martin Bardsley,
John Billings,
Jennifer Dixon,
Helen Doll,
Michelle Beynon,
Shashi Hirani,
Martin Cartwright,
Lorna Rixon,
Martin Knapp,
Catherine Henderson, Anne Rogers,
Jane Hendy,
Ray Fitzpatrick,
Stanton Newman
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ABSTRACT: OBJECTIVE: to assess the impact of telecare on the use of social and health care. Part of the evaluation of the Whole Systems Demonstrator trial.Participants and setting: a total of 2,600 people with social care needs were recruited from 217 general practices in three areas in England. DESIGN: a cluster randomised trial comparing telecare with usual care, general practice being the unit of randomisation. Participants were followed up for 12 months and analyses were conducted as intention-to-treat.Data sources: trial data were linked at the person level to administrative data sets on care funded at least in part by local authorities or the National Health Service.Main outcome measures: the proportion of people admitted to hospital within 12 months. Secondary endpoints included mortality, rates of secondary care use (seven different metrics), contacts with general practitioners and practice nurses, proportion of people admitted to permanent residential or nursing care, weeks in domiciliary social care and notional costs. RESULTS: 46.8% of intervention participants were admitted to hospital, compared with 49.2% of controls. Unadjusted differences were not statistically significant (odds ratio: 0.90, 95% CI: 0.75-1.07, P = 0.211). They reached statistical significance after adjusting for baseline covariates, but this was not replicated when adjusting for the predictive risk score. Secondary metrics including impacts on social care use were not statistically significant. CONCLUSIONS: telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use, at least in terms of results assessed over 12 months.International Standard Randomised Controlled Trial Number Register ISRCTN43002091.
Age and Ageing 02/2013; · 3.09 Impact Factor
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Christian Blickem,
Tom Blakeman,
Anne Kennedy,
Peter Bower,
David Reeves,
Caroline Gardner,
Victoria Lee,
Carolyn Chew-Graham,
Gerry Richardson,
Helen Brooks,
Shoba Dawson,
Rahena Mossabir,
Praksha Jariwala,
Angela Swallow,
Evan Kontopantelis,
Hannah Gaffney,
Nicola Small,
Eldon Spackman, Anne Rogers
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ABSTRACT: BACKGROUND: Improving the quality of care for people with vascular disease is a key priority. Chronic kidney disease (CKD) has recently been included as a target condition for general practices to add to registers of chronic conditions as part of the Quality and Outcome Framework. This paper outlines the implementation and evaluation of a self-management intervention involving an information guidebook, tailored access to local resources and telephone support for people with stage 3 chronic kidney disease. METHODS: The study involves a multi-site, longitudinal patient-level randomized controlled trial. The study will evaluate the clinical use and cost-effectiveness of a complex self-management intervention for people with stage 3 chronic kidney disease in terms of self-management capacity, health-related quality of life and blood pressure control compared to care as usual. We describe the methods of the patient-level randomized controlled trial. DISCUSSION: The management of chronic kidney disease is a developing area of research. The BRinging Information and Guided Help Together (BRIGHT) trial aims to provide evidence that a complementary package of support for people with vascular disease that targets both clinical and social need broadens the opportunities of self-management support by addressing problems related to social disadvantage.Trial registration: Trial registration reference: ISRCTN45433299.
Trials 01/2013; 14(1):28. · 2.02 Impact Factor
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Martin Cartwright,
Shashivadan P Hirani,
Lorna Rixon,
Michelle Beynon,
Helen Doll,
Peter Bower,
Martin Bardsley,
Adam Steventon,
Martin Knapp,
Catherine Henderson, Anne Rogers,
Caroline Sanders,
Ray Fitzpatrick,
James Barlow,
Stanton P Newman
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ABSTRACT: To assess the effect of second generation, home based telehealth on health related quality of life, anxiety, and depressive symptoms over 12 months in patients with long term conditions.
A study of patient reported outcomes (the Whole Systems Demonstrator telehealth questionnaire study; baseline n=1573) was nested in a pragmatic, cluster randomised trial of telehealth (the Whole Systems Demonstrator telehealth trial, n=3230). General practice was the unit of randomisation, and telehealth was compared with usual care. Data were collected at baseline, four months (short term), and 12 months (long term). Primary intention to treat analyses tested treatment effectiveness; multilevel models controlled for clustering by general practice and a range of covariates. Analyses were conducted for 759 participants who completed questionnaire measures at all three time points (complete case cohort) and 1201 who completed the baseline assessment plus at least one other assessment (available case cohort). Secondary per protocol analyses tested treatment efficacy and included 633 and 1108 participants in the complete case and available case cohorts, respectively.
Provision of primary and secondary care via general practices, specialist nurses, and hospital clinics in three diverse regions of England (Cornwall, Kent, and Newham), with established integrated health and social care systems. PARTICIPANTS : Patients with chronic obstructive pulmonary disease (COPD), diabetes, or heart failure recruited between May 2008 and December 2009.
Generic, health related quality of life (assessed by physical and mental health component scores of the SF-12, and the EQ-5D), anxiety (assessed by the six item Brief State-Trait Anxiety Inventory), and depressive symptoms (assessed by the 10 item Centre for Epidemiological Studies Depression Scale).
In the intention to treat analyses, differences between treatment groups were small and non-significant for all outcomes in the complete case (0.480≤P≤0.904) or available case (0.181≤P≤0.905) cohorts. The magnitude of differences between trial arms did not reach the trial defined, minimal clinically important difference (0.3 standardised mean difference) for any outcome in either cohort at four or 12 months. Per protocol analyses replicated the primary analyses; the main effect of trial arm (telehealth v usual care) was non-significant for any outcome (complete case cohort 0.273≤P≤0.761; available case cohort 0.145≤P≤0.696).
Second generation, home based telehealth as implemented in the Whole Systems Demonstrator Evaluation was not effective or efficacious compared with usual care only. Telehealth did not improve quality of life or psychological outcomes for patients with chronic obstructive pulmonary disease, diabetes, or heart failure over 12 months. The findings suggest that concerns about potentially deleterious effect of telehealth are unfounded for most patients. TRIAL REGISTRATION : ISRCTN43002091.
BMJ (Clinical research ed.). 01/2013; 346:f653.
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Catherine Henderson,
Martin Knapp,
José-Luis Fernández,
Jennifer Beecham,
Shashivadan P Hirani,
Martin Cartwright,
Lorna Rixon,
Michelle Beynon, Anne Rogers,
Peter Bower,
Helen Doll,
Ray Fitzpatrick,
Adam Steventon,
Martin Bardsley,
Jane Hendy,
Stanton P Newman
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ABSTRACT: To examine the costs and cost effectiveness of telehealth in addition to standard support and treatment, compared with standard support and treatment.
Economic evaluation nested in a pragmatic, cluster randomised controlled trial.
Community based telehealth intervention in three local authority areas in England.
3230 people with a long term condition (heart failure, chronic obstructive pulmonary disease, or diabetes) were recruited into the Whole Systems Demonstrator telehealth trial between May 2008 and December 2009. Of participants taking part in the Whole Systems Demonstrator telehealth questionnaire study examining acceptability, effectiveness, and cost effectiveness, 845 were randomised to telehealth and 728 to usual care.
Intervention participants received a package of telehealth equipment and monitoring services for 12 months, in addition to the standard health and social care services available in their area. Controls received usual health and social care.
Primary outcome for the cost effectiveness analysis was incremental cost per quality adjusted life year (QALY) gained.
We undertook net benefit analyses of costs and outcomes for 965 patients (534 receiving telehealth; 431 usual care). The adjusted mean difference in QALY gain between groups at 12 months was 0.012. Total health and social care costs (including direct costs of the intervention) for the three months before 12 month interview were £1390 (€1610; $2150) and £1596 for the usual care and telehealth groups, respectively. Cost effectiveness acceptability curves were generated to examine decision uncertainty in the analysis surrounding the value of the cost effectiveness threshold. The incremental cost per QALY of telehealth when added to usual care was £92 000. With this amount, the probability of cost effectiveness was low (11% at willingness to pay threshold of £30 000; >50% only if the threshold exceeded about £90 000). In sensitivity analyses, telehealth costs remained slightly (non-significantly) higher than usual care costs, even after assuming that equipment prices fell by 80% or telehealth services operated at maximum capacity. However, the most optimistic scenario (combining reduced equipment prices with maximum operating capacity) eliminated this group difference (cost effectiveness ratio £12 000 per QALY).
The QALY gain by patients using telehealth in addition to usual care was similar to that by patients receiving usual care only, and total costs associated with the telehealth intervention were higher. Telehealth does not seem to be a cost effective addition to standard support and treatment.
ISRCTN43002091.
BMJ (Clinical research ed.). 01/2013; 346:f1035.
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ABSTRACT: Self-management support forms a central aspect of chronic Illness management nationally and globally. Evidence for the success of self-management support has mainly focussed on individually-centred outcomes of behavioural change. While it is recognised that social network members play an important role there is currently a gap in knowledge regarding who provides what type of support and under what circumstances. This is relevant for understanding the division of labour and the meeting of needs for those living with a long-term condition. We therefore took a network approach to explore self-management support conceptualising it as types of illness 'work' undertaken within peoples' social networks. 300 people from deprived areas and with chronic illnesses took part in a survey conducted in 2010 in the North West of England. A concentric circles diagram was used as a research tool with which participants identified 2,544 network members who contributed to illness management. The results provide an articulation of how social network members are substantially involved in illness management. Whilst partners and close family make the highest contributions there is evidence of inputs from a wide range of relationships. Network member characteristics (type of relationship, proximity, frequency of contact) impact on the amount of illness work undertaken in peoples' networks. In networks with 'no partner' other people tend to contribute more in the way of illness related work than in networks with a partner. This indicates a degree of substitutability between differently constituted networks, and that the level and type of input by different members of a network might change according to circumstances. A network perspective offers an opportunity to redress the balance of an exclusively individual focus on self-management because it addresses the broader set of contributions and resources available to people in need of chronic illness management and support.
PLoS ONE 01/2013; 8(4):e59723. · 4.09 Impact Factor
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ABSTRACT: OBJECTIVES: A lack of agreement between clinician and patient priorities can impact on the clinician-patient relationship, treatment concordance and potentially health outcomes. Studies have suggested that patients with OA may prioritise co-morbidities over their OA, but as yet no explicit systematic exploration of OA patients' priorities in relation to co-morbidities exists. This paper aims to explore how patients prioritise OA amongst their conditions, what factors underlie this prioritisation and whether and why these priorities change over time. METHODS: A secondary analysis of qualitative data was conducted utilising 4 existing datasets collated from the 3 research centres involved. Purposive sampling provided a sample of 30 participants who all had OA and co-morbidities. The research team collectively coded and analysed the data thematically. RESULTS: Three groups of patient emerged from the analysis. The two smaller groups had stable priorities (where OA was or was not prioritised) and illustrated the importance of factors such as personal social context and the specific nature of the co-morbid conditions. The third and largest group reported priorities that shifted over time. Shifting appeared to be influenced by participants' perceptions of control and/or interactions with clinical professionals, and could have important consequences for self-management behaviour. CONCLUSIONS: The various factors underlying patients' priorities amongst their conditions and the fluctuating nature of these priorities highlights the importance of regular assessments during clinician-patient consultations to allow better communication and treatment planning and ultimately optimise patient outcomes. © 2012 by the American College of Rheumatology.
Arthritis care & research. 11/2012;
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Jane Hendy,
Theopisti Chrysanthaki,
James Barlow,
Martin Knapp, Anne Rogers,
Caroline Sanders,
Peter Bower,
Robert Bowen,
Ray Fitzpatrick,
Martin Bardsley,
Stanton Newman
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ABSTRACT: BACKGROUND: To 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). METHODS: Case-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. RESULTS: The 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. CONCLUSIONS: The 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.
BMC Health Services Research 11/2012; 12(1):403. · 1.66 Impact Factor
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ABSTRACT: BACKGROUND: Shared decision making (SDM) and patient self-management support are key components of US and UK policy for chronic disease management, whereby SDM is seen as enhancing physician-patient negotiation around self-management. The WISE trial is implementing training in self-management support for primary care physicians in one UK region. This article describes preintervention levels of patient-reported SDM and explores how this varies with patient and practice characteristics. METHODS: . We analyzed baseline data from a cluster randomized controlled trial for 2965 patients with diabetes, chronic obstructive pulmonary disease, and irritable bowel syndrome (IBS) from 29 family practices. Patient-level measures included self-report of chronic conditions, SDM (Health Care Climate Questionnaire [HCCQ]), health status, and demographic characteristics. Area and practice characteristics included chronic disease workload and socioeconomic deprivation. RESULTS: . The mean SDM score was 75 (out of 100), but the range was wide. The mean score was lower for IBS patients but did not vary with other disease conditions. Younger patients and those with poorer health status reported lower degrees of SDM. No associations were found with practice characteristics. Limitations. The study was restricted to one socioeconomically deprived region, and hence results may not be nationally representative of the United Kingdom. Ceiling effects on SDM scores may limit the utility of the HCCQ. CONCLUSIONS: . Lower ratings from some patient groups may reflect differences in expectations rather than differences in physician behavior. Overall levels of SDM were high, and no patient or practice characteristic represented a serious barrier to SDM. However, we cannot say to what extent SDM in this chronic population addressed self-management issues rather than clinical care. More nuanced measures of SDM are required that distinguish between different forms of care.
Medical Decision Making 11/2012; · 2.33 Impact Factor
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ABSTRACT: Participation in health care is an important element of self-management in chronic illness, and policy emphasises patient's choice. Evidence suggests that this may be inequitable and inadequate, since active participation is strongly associated with socio-demographic variables. This qualitative study explores the perceptions of participation in people with differing socio-economic status with themes related to health literacy and relationship with health-care professionals. Patients perceive participation in different ways, related to their prior expectations of a health-care consultation, cultural expectations and social position. Policies aimed at simply improving 'health literacy' and choice will not be successful if these broader disparities are not addressed.
Journal of Health Psychology 10/2012; · 1.22 Impact Factor
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Linda Gask,
Peter Bower,
Jon Lamb,
Heather Burroughs,
Carolyn Chew-Graham,
Suzanne Edwards,
Derek Hibbert,
Marija Kovand 382 I,
Karina Lovell, Anne Rogers,
Waquas Waheed,
Christopher Dowrick,
Amp Group
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ABSTRACT: BACKGROUND: In the United Kingdom and worldwide, there is significant policy interest in improving the quality of care for patients with mental health disorders and distress. Improving quality of care means addressing not only the effectiveness of interventions but also the issue of limited access to care. Research to date into improving access to mental health care has not been strongly rooted within a conceptual model, nor has it systematically identified the different elements of the patient journey from identification of illness to receipt of care. This paper set out to review core concepts underlying patient access to mental health care, synthesise these to develop a conceptual model of access, and consider the implications of the model for the development and evaluation of interventions for groups with poor access to mental health care such as older people and ethnic minorities. METHODS: Narrative review of the literature to identify concepts underlying patient access to mental health care, and synthesis into a conceptual model to support the delivery and evaluation of complex interventions to improve access to mental health care. RESULTS: The narrative review adopted a process model of access to care, incorporating interventions at three levels. The levels comprise (a) community engagement (b) addressing the quality of interactions in primary care and (c) the development and delivery of tailored psychosocial interventions. CONCLUSIONS: The model we propose can form the basis for the development and evaluation of complex interventions in access to mental health care. We highlight the key methodological challenges in evaluating the overall impact of access interventions, and assessing the relative contribution of the different elements of the model.
BMC Health Services Research 08/2012; 12(1):249. · 1.66 Impact Factor
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Caroline Sanders, Anne Rogers,
Robert Bowen,
Peter Bower,
Shashivadan Hirani,
Martin Cartwright,
Ray Fitzpatrick,
Martin Knapp,
James Barlow,
Jane Hendy,
Theti Chrysanthaki,
Martin Bardsley,
Stanton P Newman
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ABSTRACT: Telehealth (TH) and telecare (TC) interventions are increasingly valued for supporting self-care in ageing populations; however, evaluation studies often report high rates of non-participation that are not well understood. This paper reports from a qualitative study nested within a large randomised controlled trial in the UK: the Whole System Demonstrator (WSD) project. It explores barriers to participation and adoption of TH and TC from the perspective of people who declined to participate or withdrew from the trial.
Qualitative semi-structured interviews were conducted with 22 people who declined to participate in the trial following explanations of the intervention (n = 19), or who withdrew from the intervention arm (n = 3). Participants were recruited from the four trial groups (with diabetes, chronic obstructive pulmonary disease, heart failure, or social care needs); and all came from the three trial areas (Cornwall, Kent, east London). Observations of home visits where the trial and interventions were first explained were also conducted by shadowing 8 members of health and social care staff visiting 23 people at home. Field notes were made of observational visits and explored alongside interview transcripts to elicit key themes.
Barriers to adoption of TH and TC associated with non-participation and withdrawal from the trial were identified within the following themes: requirements for technical competence and operation of equipment; threats to identity, independence and self-care; expectations and experiences of disruption to services. Respondents held concerns that special skills were needed to operate equipment but these were often based on misunderstandings. Respondents' views were often explained in terms of potential threats to identity associated with positive ageing and self-reliance, and views that interventions could undermine self-care and coping. Finally, participants were reluctant to risk potentially disruptive changes to existing services that were often highly valued.
These findings regarding perceptions of potential disruption of interventions to identity and services go beyond more common expectations that concerns about privacy and dislike of technology deter uptake. These insights have implications for health and social care staff indicating that more detailed information and time for discussion could be valuable especially on introduction. It seems especially important for potential recipients to have the opportunity to discuss their expectations and such views might usefully feed back into design and implementation.
BMC Health Services Research 07/2012; 12:220. · 1.66 Impact Factor
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ABSTRACT: The prevalence and impact of long term conditions continues to rise. Care planning for people with long term conditions has been a policy priority in England for chronic disease management. However, it is not clear how care planning is currently understood, translated and implemented in primary care. This study explores experience of care planning in patients with long term conditions in three areas in England.
We conducted semi-structured interviews with 23 predominantly elderly patients with multiple long term conditions. The interviews were designed to explore variations in and emergent experiences of care planning. Qualitative analysis of interview transcripts involved reflexively coding and re-coding data into categories and themes.
No participants reported experiencing explicit care planning discussions or receiving written documentation setting out a negotiated care plan and they were unfamiliar with the term 'care planning'. However, most described some components of care planning which occurred over a number of contacts with health care professionals which we term"reactive" care planning. Here, key elements of care planning including goal setting and action planning were rare. Additionally, poor continuity and coordination of care, lack of time in consultations, and patient concerns about what was legitimate to discuss with the doctor were described.
Amongst this population, elements of care planning were present in their accounts, but a structured, comprehensive process and consequent written record (as outlined in English Department of Health policy) was not evident. Further research needs to explore the advantages and disadvantages of different approaches to care planning for different patient groups.
BMC Family Practice 07/2012; 13:71. · 1.80 Impact Factor
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ABSTRACT: OBJECTIVES: To explore in the context of peoples' personal social networks, the contribution that pets make to 'the work' associated with the management of long-term conditions. METHOD: Mixed methods survey with nested parallel qualitative study; 300 participants were drawn from diabetes and chronic heart disease registers of General Practices across Greater Manchester in the North West of England. Notions of 'work' were used to describe the illness and everyday activities associated with chronic illness. RESULTS: Nineteen percent of participants identified at least one pet within their network. Pets contributed mostly to managing emotions (emotional work), to enhancing a sense of self identity (biographical work) and to a lesser extent practical tasks (everyday work). There were indicators that pets mediated relationships for people living with a long-term condition through very weak ties with others in domestic and community settings. CONCLUSION: The findings suggest that pets have unique qualities and are not simply substitutes for human relationships in long-term condition management. The study has potential implications for furthering a social contextual analysis of chronic illness, the understanding of relationships, and the meaning and the role of companion animals in long-term condition management.
Chronic Illness 07/2012;
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ABSTRACT: Primary care is recognised to have an important role in the delivery of care for people with chronic kidney disease (CKD). However, there is evidence that CKD management is currently suboptimal, with a range of practitioner concerns about its management.
To explore processes underpinning the implementation of CKD management in primary care.
Qualitative study in general practices participating in a chronic kidney disease collaborative undertaken as part of the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) for Greater Manchester.
Semi-structured interviews were conducted with GPs and practice nurses (n = 21). Normalisation Process Theory provided a framework for generation and analysis of the data.
A predominant theme was anxiety about the disclosure of early-stage CKD with patients. The tensions experienced related to identifying and discussing CKD in older people and patients with stage 3A, embedding early-stage CKD within vascular care, and the distribution of work within the practice team. Participants provided accounts of work undertaken to resolve the difficulties encountered, with efforts having tended to focus on reassuring patients. Analysis also highlighted how anxiety surrounding disclosure influenced, and was shaped by, the organisation of care for people with CKD and associated long-term conditions.
Offering reassurance alone may be of limited benefit, and current management of early-stage CKD in primary care may miss opportunities to address susceptibility to kidney injury, improve self-management of vascular conditions, and improve the management of multimorbidity.
British Journal of General Practice 04/2012; 62(597):e233-42. · 1.83 Impact Factor
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Adam Steventon,
Martin Bardsley,
John Billings,
Jennifer Dixon,
Helen Doll,
Shashi Hirani,
Martin Cartwright,
Lorna Rixon,
Martin Knapp,
Catherine Henderson, Anne Rogers,
Ray Fitzpatrick,
Jane Hendy,
Stanton Newman
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ABSTRACT: To assess the effect of home based telehealth interventions on the use of secondary healthcare and mortality.
Pragmatic, multisite, cluster randomised trial comparing telehealth with usual care, using data from routine administrative datasets. General practice was the unit of randomisation. We allocated practices using a minimisation algorithm, and did analyses by intention to treat. SETTING : 179 general practices in three areas in England. PARTICIPANTS : 3230 people with diabetes, chronic obstructive pulmonary disease, or heart failure recruited from practices between May 2008 and November 2009.
Telehealth involved remote exchange of data between patients and healthcare professionals as part of patients' diagnosis and management. Usual care reflected the range of services available in the trial sites, excluding telehealth.
Proportion of patients admitted to hospital during 12 month trial period.
Patient characteristics were similar at baseline. Compared with controls, the intervention group had a lower admission proportion within 12 month follow-up (odds ratio 0.82, 95% confidence interval 0.70 to 0.97, P = 0.017). Mortality at 12 months was also lower for intervention patients than for controls (4.6% v 8.3%; odds ratio 0.54, 0.39 to 0.75, P < 0.001). These differences in admissions and mortality remained significant after adjustment. The mean number of emergency admissions per head also differed between groups (crude rates, intervention 0.54 v control 0.68); these changes were significant in unadjusted comparisons (incidence rate ratio 0.81, 0.65 to 1.00, P = 0.046) and after adjusting for a predictive risk score, but not after adjusting for baseline characteristics. Length of hospital stay was shorter for intervention patients than for controls (mean bed days per head 4.87 v 5.68; geometric mean difference -0.64 days, -1.14 to -0.10, P = 0.023, which remained significant after adjustment). Observed differences in other forms of hospital use, including notional costs, were not significant in general. Differences in emergency admissions were greatest at the beginning of the trial, during which we observed a particularly large increase for the control group.
Telehealth is associated with lower mortality and emergency admission rates. The reasons for the short term increases in admissions for the control group are not clear, but the trial recruitment processes could have had an effect.
International Standard Randomised Controlled Trial Number Register ISRCTN43002091.
BMJ (Clinical research ed.). 01/2012; 344:e3874.
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Peter Bower,
Anne Kennedy,
David Reeves, Anne Rogers,
Tom Blakeman,
Carolyn Chew-Graham,
Robert Bowen,
Martin Eden,
Caroline Gardner,
Mark Hann,
Victoria Lee,
Rebecca Morris,
Joanne Protheroe,
Gerry Richardson,
Caroline Sanders,
Angela Swallow,
David Thompson
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ABSTRACT: Patients with long-term conditions are increasingly the focus of quality improvement activities in health services to reduce the impact of these conditions on quality of life and to reduce the burden on care utilisation. There is significant interest in the potential for self-management support to improve health and reduce utilisation in these patient populations, but little consensus concerning the optimal model that would best provide such support. We describe the implementation and evaluation of self-management support through an evidence-based 'whole systems' model involving patient support, training for primary care teams, and service re-organisation, all integrated into routine delivery within primary care.
The evaluation involves a large-scale, multi-site study of the implementation, effectiveness, and cost-effectiveness of this model of self-management support using a cluster randomised controlled trial in patients with three long-term conditions of diabetes, chronic obstructive pulmonary disease (COPD), and irritable bowel syndrome (IBS). The outcome measures include healthcare utilisation and quality of life. We describe the methods of the cluster randomised trial.
If the 'whole systems' model proves effective and cost-effective, it will provide decision-makers with a model for the delivery of self-management support for populations with long-term conditions that can be implemented widely to maximise 'reach' across the wider patient population.
ISRCTN: ISRCTN90940049.
Implementation Science 01/2012; 7:7. · 3.10 Impact Factor
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ABSTRACT: Two key elements to improve the quality of care for people with long-term conditions in primary care are improved clinical information systems to support delivery of evidence-based care, and enhanced self-management support. Although both elements are viewed as necessary, their interaction is not well understood.
To explore the use of computer-based 'disease management' templates and their relevance to self-management dialogue within clinical encounters.
Qualitative study of general practices located in three primary care trusts in the north of England.
A qualitative mixed methods study was conducted that included comparative analysis of (1) observations of general practice consultations (n = 86); and (2) interviews with health professionals in general practice (n = 17).
The analysis suggested that use of the computer templates reinforced a checklist approach to consultations, which included professionals working through several self-management topics framed as discrete behaviours. As a consequence, conversation tended to become focused on the maintenance of the professional-patient relationship at the expense of expansion in self-management dialogue. The computer templates also shaped how patient-initiated self-management dialogue was managed when it arose, with a shift towards discussion around medical agendas.
In order to enhance the management of long-term conditions in primary care, the design and implementation of clinical information systems to improve evidence-based care need to take into account their potential impact on supporting self-management.
British Journal of General Practice 10/2011; 61(591):e666-73. · 1.83 Impact Factor
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Peter Bower,
Martin Cartwright,
Shashivadan P Hirani,
James Barlow,
Jane Hendy,
Martin Knapp,
Catherine Henderson, Anne Rogers,
Caroline Sanders,
Martin Bardsley,
Adam Steventon,
Raymond Fitzpatrick,
Helen Doll,
Stanton Newman
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ABSTRACT: It is expected that increased demands on services will result from expanding numbers of older people with long-term conditions and social care needs. There is significant interest in the potential for technology to reduce utilisation of health services in these patient populations, including telecare (the remote, automatic and passive monitoring of changes in an individual's condition or lifestyle) and telehealth (the remote exchange of data between a patient and health care professional). The potential of telehealth and telecare technology to improve care and reduce costs is limited by a lack of rigorous evidence of actual impact.
We are conducting a large scale, multi-site study of the implementation, impact and acceptability of these new technologies. A major part of the evaluation is a cluster-randomised controlled trial of telehealth and telecare versus usual care in patients with long-term conditions or social care needs. The trial involves a number of outcomes, including health care utilisation and quality of life. We describe the broad evaluation and the methods of the cluster randomised trial
If telehealth and telecare technology proves effective, it will provide additional options for health services worldwide to deliver care for populations with high levels of need.
Current Controlled Trials ISRCTN43002091.
BMC Health Services Research 08/2011; 11:184. · 1.66 Impact Factor
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ABSTRACT: Estimates of cost-effectiveness analyses are typically obtained either directly from 'trial' based analyses or indirectly via surrogate endpoints in 'model' based analyses. Data from clinical trials that include both surrogate and final endpoints can be used in a joint analysis that combines these two approaches. This joint approach allows the inclusion of information regarding the effects of treatment on surrogate endpoints while relaxing the strong assumption of 'conditional independence' associated with indirect model-based analyses. An example cost-effectiveness analysis of Chronic Disease Self-Management Programme is used to compare the different approaches. It is shown that despite using a common data set, the different analytic approaches produce differing estimates of the cost-effectiveness of the intervention and the value of future research. The paper concludes by discussing the selection of the appropriate analytic approach.
Health Economics 07/2011; 21(6):742-56. · 2.12 Impact Factor
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ABSTRACT: Patients accessing the chronic disease self-management programme (CDSMP) often report multiple long-term conditions (multimorbidity). Although multimorbidity often predicts poor outcomes, CDSMP effectiveness may be enhanced in multimorbidity via synergies between self-management for different conditions. This study assessed whether CDSMP benefits varied by patterns of multimorbidity.
The study was based on a secondary analysis of an RCT. Patients with long-term conditions (n=629) were randomised to CDSMP or wait-list and completed baseline and 6 month assessments. We identified four multimorbidity groups: (1) single physical condition; (2) multiple physical conditions; (3) single physical condition plus 'probable depression'; (4) multiple physical conditions plus 'probable depression'.
Multimorbidity group significantly moderated the effect of CDSMP on vitality, health-related quality of life, and mental well-being, with the greatest benefit found for patients with multiple physical conditions plus 'probable depression'.
The coexistence of depression and multiple physical conditions is associated with increased illness burden, but such patients benefit more from the CDSMP. The mechanisms underlying this effect are unclear, but it does not appear to be through self-management or self-efficacy.
The presence of multimorbidity in combination with depression may be a useful criteria for referral to the CDSMP.
Patient Education and Counseling 07/2011; 87(1):67-73. · 2.31 Impact Factor
