Analysing the role of complexity in explaining the fortunes of technology programmes : empirical application of the NASSS framework

Background: Failures and partial successes are common in technology-supported innovation programmes in health and social care. Complexity theory can help explain why. Phenomena may be simple (straightforward, predictable, few components), complicated (multiple interacting components or issues) or complex (dynamic, unpredictable, not easily disaggregated into constituent components). The recently published NASSS framework applies this taxonomy to explain Non-adoption or Abandonment of technology by individuals and difficulties achieving Scale-up, Spread and Sustainability. This paper reports the first empirical application of the NASSS framework. Methods: Six technology-supported programmes were studied using ethnography and action research for up to 3 years across 20 health and care organisations and 10 national-level bodies. They comprised video outpatient consultations, GPS tracking technology for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organising software and integrated case management via data warehousing. Data were collected at three levels: micro (individual technology users), meso (organisational processes and systems) and macro (national policy and wider context). Data analysis and synthesis were guided by socio-technical theories and organised around the seven NASSS domains: (1) the condition or illness, (2) the technology, (3) the value proposition, (4) the adopter system (professional staff, patients and lay carers), (5) the organisation(s), (6) the wider (institutional and societal) system and (7) interaction and mutual adaptation among all these domains over time. Results: The study generated more than 400 h of ethnographic observation, 165 semi-structured interviews and 200 documents. The six case studies raised multiple challenges across all seven domains. Complexity was a common feature of all programmes. In particular, individuals’ health and care needs were often complex and hence unpredictable and ‘off algorithm’. Programmes in which multiple domains were complicated proved difficult, slow and expensive to implement. Those in which multiple domains were complex did not become mainstreamed (or, if mainstreamed, did not deliver key intended outputs). Conclusion: The NASSS framework helped explain the successes, failures and changing fortunes of this diverse sample of technology-supported programmes. Since failure is often linked to complexity across multiple NASSS domains, further research should systematically address ways to reduce complexity and/or manage programme implementation to take account of it

Patient-initiated cardiovascular monitoring with commercially available devices: how useful is it in a cardiology outpatient setting? Mixed methods, observational study

Background: The availability, affordability and utilisation of commercially available self-monitoring devices is increasing, but their impact on routine clinical decision-making remains little explored. We sought to examine how patient-generated cardiovascular data influenced clinical evaluation in UK cardiology outpatient clinics and to understand clinical attitudes and experiences with using data from commercially available self-monitoring devices. Methods: Mixed methods study combining: a) quantitative and qualitative content analysis of 1373 community cardiology clinic letters, recording consultations between January–September 2020 including periods with different Covid-19 related restrictions, and b) semi-structured qualitative interviews and group discussions with 20 cardiology-affiliated clinicians at the same NHS Trust. Results: Patient-generated cardiovascular data were described in 185/1373 (13.5%) clinic letters overall, with the proportion doubling following onset of the first Covid-19 lockdown in England, from 8.3% to 16.6% (p < 0.001). In 127/185 (69%) cases self-monitored data were found to: provide or facilitate cardiac diagnoses (34/127); assist management of previously diagnosed cardiac conditions (55/127); be deployed for cardiovascular prevention (16/127); or be recommended for heart rhythm evaluation (10/127). In 58/185 (31%) cases clinicians did not put the self-monitored data to any evident use and in 12/185 (6.5%) cases patient-generated data prompted an unnecessary referral. In interviews and discussions, clinicians expressed mixed views on patient-generated data but foresaw a need to embrace and plan for this information flow, and proactively address challenges with integration into traditional care pathways. Conclusions: This study suggests patient-generated data are being used for clinical decision-making in ad hoc and opportunistic ways. Given shifts towards remote monitoring in clinical care, accelerated by the pandemic, there is a need to consider how best to incorporate patient-generated data in clinical processes, introduce relevant training, pathways and governance frameworks, and manage associated risks

Blood pressure measurement: a call to arms

Our hard-pressed workforce may view the linked article by Clark and colleagues with a mixture of interest and trepidation. Their systematic review builds on earlier work to estimate the prevalence of inter-arm difference (IAD) in blood pressure (BP) in populations relevant to primary care. Pooled estimates of prevalence for systolic IAD of ≥10 mmHg were 11% in patients with hypertension, 7% for those with diabetes, and just under 4% in the general adult population. GPs are masters of distilling from their training and experience the shortest route to a clinical decision. This does not generally involve checking BP in both arms. Yet, paradoxically, this new evidence could reduce workload, because accurate identification of IAD in a minority of patients, and the exclusion of this condition in the majority, might inform a more rational and streamlined approach to blood pressure management in both groups

SCALS : a fourth-generation study of assisted living technologies in their organisational, social, political and policy context

Introduction: Research to date into assisted living technologies broadly consists of 3 generations: technical design, experimental trials and qualitative studies of the patient experience. We describe a fourth generation paradigm: studies of assisted living technologies in their organisational, social, political and policy context. Fourth-generation studies are necessarily organic and emergent; they view technology as part of a dynamic, networked and potentially unstable system. They use co-design methods to generate and stabilise local solutions, taking account of context. Methods and analysis: SCALS (Studies in Co-creating Assisted Living Solutions) consists (currently) of 5 organisational case studies, each an English health or social care organisation striving to introduce technology-supported services to support independent living in people with health and/or social care needs. Treating these cases as complex systems, we seek to explore interdependencies, emergence and conflict. We employ a co-design approach informed by the principles of action research to help participating organisations establish, refine and evaluate their service. To that end, we are conducting in-depth ethnographic studies of people’s experience of assisted living technologies (micro level), embedded in evolving organisational case studies that use interviews, ethnography and document analysis (meso level), and exploring the wider national and international context for assisted living technologies and policy (macro level). Data will be analysed using a sociotechnical framework developed from structuration theory. Ethics and dissemination: Research ethics approval for the first 4 case studies has been granted. An important outcome will be lessons learned from individual co-design case studies. We will document the studies’ credibility and rigour, and assess the transferability of findings to other settings while also recognising unique aspects of the contexts in which they were generated. Academic outputs will include a cross-case analysis and progress in theory and method of fourth-generation assisted living technology research. We will produce practical guidance for organisations, policymakers, designers and service users

Long-Term Conditions Questionnaire (LTCQ): initial validation survey among primary care patients and social care recipients in England

The aim of this study was to validate a new generic patient-reported outcome measure, the Long-Term Conditions Questionnaire (LTCQ), among a diverse sample of health and social care users in England.Cross-sectional validation survey. Data were collected through postal surveys (February 2016-January 2017). The sample included a healthcare cohort of patients recruited through primary care practices, and a social care cohort recruited through local government bodies that provide social care services.1211 participants (24% confirmed social care recipients) took part in the study. Healthcare participants were recruited on the basis of having one of 11 specified long-term conditions (LTCs), and social care participants were recruited on the basis of receiving social care support for at least one LTC. The sample exhibited high multimorbidity, with 93% reporting two or more LTCs and 43% reporting a mental health condition.The LTCQ's construct validity was tested with reference to the EQ-5D (5-level version), the Self-Efficacy for Managing Chronic Disease scale, an Activities of Daily Living scale and the Bayliss burden of morbidity scale.Low levels of missing data for each item indicate acceptability of the LTCQ across the sample. The LTCQ exhibits high internal consistency (Cronbach's α=0.95) across the scale's 20 items and excellent test-retest reliability (intraclass correlation coefficient=0.94, 95% CI 0.93 to 0.95). Associations between the LTCQ and all reference measures were moderate to strong and in the expected directions, indicating convergent construct validity.This study provides evidence for the reliability and validity of the LTCQ, which has potential for use in both health and social care settings. The LTCQ could meet a need for holistic outcome measurement that goes beyond symptoms and physical function, complementing existing measures to capture fully what it means to live well with LTCs

The Long-Term Conditions Questionnaire: conceptual framework and item development

Purpose To identify the main issues of importance when living with long-term conditions to refine a conceptual framework for informing the item development of a patientreported outcome measure for long-term conditions. Methods Semi-structured qualitative interviews (n=48) were conducted with people living with at least one long-term condition. Participants were recruited through primary care. The interviews were transcribed verbatim and analysed by thematic analysis. The analysis served to refine the conceptual framework, based on reviews of the literature and stakeholder consultations, for developing candidate items for a new measure for longterm conditions. ResultsThree main organising concepts were identified ‘Impact of long-term conditions’, ‘Experience of services and support’ and ‘Self-care’. The findings helped to refine a conceptual framework leading to the development of 23 items that represent issues of importance in long-term conditions. The 23 candidate items formed the first draft of the measure, currently named the Long-Term Conditions Questionnaire (LTCQ). Conclusions The aim of this study was to refine the conceptual framework and develop items for a patient-reported outcome measure for long-term conditions, including single and multiple morbidities, and physical and mental health conditions. Qualitative interviews 3 identified the key themes for assessing outcomes in long-term conditions and these underpinned the development of the initial draft of the measure. These initial items will undergo cognitive testing to refine the items prior to further validation in a survey

“It's no good but at least I've always got it round my neck”: A postphenomenological analysis of reassurance in assistive technology use by older people

© 2021 Published by Elsevier Ltd. This is the accepted manuscript version of an article which has been published in final form at https://doi.org/10.1016/j.socscimed.2021.114553The provision of reassurance is seen as a goal and benefit of the use of assistive technology (AT) in supporting people to manage their health and care needs at a distance. Conceptually, reassurance in health and care settings remains under-theorised with the benefits of experiencing reassurance through technology use assumed rather than understood. UK health and social care service goals of managing safety and risk have largely been equated with providing reassurance to users of AT and their carers. What has not been explored is how reassurance is experienced variably by users of different types of technology-enabled care. We present data from 3 case studies of different technologies in use in health and social care provision, analysed through a postphenomenology and sociomaterial lens. Our findings point to reassurance as an important facet of AT provision but the intended functions and uses of technological devices alone did not account for people's experiences of reassurance. Participant narratives referred variously to the comfort of being monitored, having their illness/wellness verified by the device, feeling reassured by the promise of help if needed, and imbuing the device with symbolic meaning (when the user associated the device with meanings and functions other than its technical capabilities). The different ways in which reassurance was experienced provides a useful way of understanding the potential tensions with AT policy goals as well as the positive meaning attributed to devices in some cases. This study reaffirms the importance of AT implementation being anchored in what matters to the user.Peer reviewe

Management of post-acute covid-19 in primary care

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