Do people with intellectual disabilities understand their prescription medication? A scoping review

© 2019 The Authors. Journal of Applied Research in Intellectual Disabilities Published by John Wiley & Sons Ltd.Background: People with intellectual disabilities are more likely to experience poor health than the general population and are frequently prescribed multiple medications. Therefore, it is important that people with intellectual disabilities understand their medication and potential adverse effects. Method: A scoping review explored people with intellectual disabilities' knowledge of prescription medications, their risks and how medication understanding can be improved. Results: Ten journal articles were included. People with intellectual disabilities often lacked understanding of their medication, including its name, purpose and when and how to take it. Participants were often confused or unaware of adverse effects associated with their medication. Information was sometimes explained to carers rather than people with intellectual disabilities. Some interventions and accessible information helped to improve knowledge in people with intellectual disabilities. Conclusion: There is a need for accessible and tailored information about medication to be discussed with people with intellectual disabilities in order to meet legal and best practice standards.Peer reviewe

An evaluation of the effectiveness of annual health checks and quality of health care for adults with intellectual disability: an observational study using a primary care database

Background People with intellectual disability (ID) have poorer health than the general population; however, there is a lack of comprehensive national data describing their health-care needs and utilisation. Annual health checks for adults with ID have been incentivised through primary care since 2009, but only half of those eligible for such a health check receive one. It is unclear what impact health checks have had on important health outcomes, such as emergency hospitalisation. Objectives To evaluate whether or not annual health checks for adults with ID have reduced emergency hospitalisation, and to describe health, health care and mortality for adults with ID. Design A retrospective matched cohort study using primary care data linked to national hospital admissions and mortality data sets. Setting A total of 451 English general practices contributing data to Clinical Practice Research Datalink (CPRD). Participants A total of 21,859 adults with ID compared with 152,846 age-, gender- and practice-matched controls without ID registered during 2009–13. Interventions None. Main outcome measures Emergency hospital admissions. Other outcomes – preventable admissions for ambulatory care sensitive conditions, and mortality. Data sources CPRD, Hospital Episodes Statistics and Office for National Statistics. Results Compared with the general population, adults with ID had higher levels of recorded comorbidity and were more likely to consult in primary care. However, they were less likely to have long doctor consultations, and had lower continuity of care. They had higher mortality rates [hazard ratio (HR) 3.6, 95% confidence interval (CI) 3.3 to 3.9], with 37.0% of deaths classified as being amenable to health-care intervention (HR 5.9, 95% CI 5.1 to 6.8). They were more likely to have emergency hospital admissions [incidence rate ratio (IRR) 2.82, 95% CI 2.66 to 2.98], with 33.7% deemed preventable compared with 17.3% in controls (IRR 5.62, 95% CI 5.14 to 6.13). Health checks for adults with ID had no effect on overall emergency admissions compared with controls (IRR 0.96, 95% CI 0.87 to 1.07), although there was a relative reduction in emergency admissions for ambulatory care-sensitive conditions (IRR 0.82, 95% CI 0.69 to 0.99). Practices with high health check participation also showed a relative fall in preventable emergency admissions for their patients with ID, compared with practices with minimal participation (IRR 0.73, 95% CI 0.57 to 0.95). There were large variations in the health check-related content that was recorded on electronic records. Limitations Patients with milder ID not known to health services were not identified. We could not comment on the quality of health checks. Conclusions Compared with the general population, adults with ID have more chronic diseases and greater primary and secondary care utilisation. With more than one-third of deaths potentially amenable to health-care interventions, improvements in access to, and quality of, health care are required. In primary care, better continuity of care and longer appointment times are important examples that we identified. Although annual health checks can also improve access, not every eligible adult with ID receives one, and health check content varies by practice. Health checks had no impact on overall emergency admissions, but they appeared influential in reducing preventable emergency admissions. Future work No formal cost-effectiveness analysis of annual health checks was performed, but this could be attempted in relation to our estimates of a reduction in preventable emergency admissions. Funding The National Institute for Health Research Health Services and Delivery Research programme

Stop smoking practitioner consensus on barriers and facilitators to smoking cessation in pregnancy and how to address these: A modified Delphi survey.

Introduction Pregnant women can experience barriers and facilitators towards achieving smoking cessation. We sought consensus from smoking cessation practitioners on how influential pre-identified barriers and facilitators can be on pregnant women's smoking behaviour, and how difficult these might be to manage. Suggestions for techniques that could help overcome the barriers or enhance the facilitators were elicited and consensus sought on the appropriateness for their use in practice. Methods Forty-four practitioners who provided cessation support to pregnant women completed a three-round modified Delphi survey. Round one sought consensus on the ‘influence’ and ‘difficulty’ of the barriers and facilitators, and gathered respondents' suggestions on ways to address these. Rounds two and three sought further consensus on the barriers and facilitators and on ‘appropriateness’ of the respondent-suggested techniques. The techniques were coded for behaviour change techniques (BCTs) content using existing taxonomies. Results Barriers and facilitators considered to be the most important mainly related to the influence of significant others and the women's motivation & self-efficacy. Having a supportive partner was considered the most influential, whereas lack of support from partner was the only barrier that reached consensus as being difficult to manage. Barriers relating to social norms were also considered influential, however these received poor coverage of respondent-suggested techniques. Those considered the easiest to address mainly related to aspects of cessation support, including misconceptions surrounding the use of nicotine replacement therapy (NRT). Barriers and facilitators relating to the women's motivation & self-efficacy, such as the want to protect the baby, were also considered as being particularly easy to address. Fifty of the 54 respondent-suggested techniques reached consensus as being appropriate. Those considered the most appropriate ranged from providing support early, giving correct information on NRT, highlighting risks and benefits and reinforcing motivating beliefs. Thirty-three BCTs were identified from the respondent-suggested techniques. ‘Social support (unspecified)’, ‘Tailor interactions appropriately’ and ‘Problem solving’ were the most frequently coded BCTs. Conclusions Involving partners in quit attempts was advocated. Existing support could be potentially improved by establishing appropriate ways to address barriers relating to pregnant smokers' ‘social norms’. In general, providing consistent and motivating support seemed favourable

Preferences for interventions designed to increase cervical screening uptake in non-attending young women: how findings from a discrete choice experiment compare with observed behaviours in a trial

Background Young women’s attendance at cervical screening in the UK is continuing to fall, and the incidence of invasive cervical cancer is rising. Objectives We assessed the preferences of non‐attending young women for alternative ways of delivering cervical screening. Design Postal discrete choice experiment (DCE) conducted during the STRATEGIC study of interventions for increasing cervical screening uptake. Attributes included action required to arrange a test, location of the test, availability of a nurse navigator and cost to the National Health Service. Setting and participants Non‐attending young women in two UK regions. Main outcome measures Responses were analysed using a mixed multinomial logit model. A predictive analysis identified the most preferable strategy compared to current screening. Preferences from the DCE were compared with observed behaviours during the STRATEGIC trial. Results The DCE response rate was 5.5% (222/4000), and 94% of respondents agreed screening is important. Preference heterogeneity existed around attributes with strong evidence for test location. Relative to current screening, unsolicited self‐sampling kits for home use appeared most preferable. The STRATEGIC trial showed this same intervention to be most effective although many women who received it and were screened, attended for conventional cytology instead. Conclusions The DCE and trial identified the unsolicited self‐sampling kit as the most preferred/effective intervention. The DCE suggested that the decision of some women receiving the kit in the trial to attend for conventional cytology may be due to anxieties around home testing coupled with a knowledge that ignoring the kit could potentially have life‐changing consequences

Novel insights into the aetiology of granulomatosis with polyangiitis—a case–control study using the Clinical Practice Research Datalink

Objectives We aimed to provide insights into the aetiology of granulomatosis with polyangiitis (GPA), by conducting a large case–control study using a general population-based, prospectively collected database of healthcare records. Methods We compared all incident cases of GPA in the Clinical Practice Research Datalink 1990–2014, with up to 10 age-, sex- and general practice-matched controls. We identified potential risk factors, recorded numbers of cases and controls exposed to each, and calculated odds ratios (ORs) using conditional logistic regression. Our main analysis excluded data recorded during 1 year before diagnosis, to prevent early symptoms being mistaken for risk factors. Results We identified 757 people with GPA and matched 7546 controls. People with GPA were five times more likely to have a previous diagnosis of bronchiectasis (OR = 5.1, 95% CI: 2.7, 9.4; P 5 years prior to diagnosis. People with GPA were two to three times more likely than controls to have previous diagnoses of autoimmune diseases or chronic renal impairment, and these effects also remained stable >5 years prior to diagnosis. People with GPA were more likely to have a diagnosis of pulmonary fibrosis (OR = 5.7, 95% CI: 1.7, 19.5; P = 0.01) and sinus infections (OR = 2.7, 95% CI: 1.8, 4.2; P < 0.0001) recorded in the 3 years before diagnosis, but not before this. We also found former smoking, some medications and higher socio-economic status significantly, but less strongly, associated. Conclusion We found novel long-term associations between GPA and pre-existing bronchiectasis and autoimmune diseases

The comparative effectiveness and efficiency of cognitive behaviour therapy and generic counselling in the treatment of depression: evidence from the 2(nd) UK National Audit of psychological therapies.

BACKGROUND: Cognitive Behaviour Therapy (CBT) is the front-line psychological intervention for step 3 within UK psychological therapy services. Counselling is recommended only when other interventions have failed and its effectiveness has been questioned. METHOD: A secondary data analysis was conducted of data collected from 33,243 patients across 103 Improving Access to Psychological Therapies (IAPT) services as part of the second round of the National Audit of Psychological Therapies (NAPT). Initial analysis considered levels of pre-post therapy effect sizes (ESs) and reliable improvement (RI) and reliable and clinically significant improvement (RCSI). Multilevel modelling was used to model predictors of outcome, namely patient pre-post change on PHQ-9 scores at last therapy session. RESULTS: Counselling received more referrals from patients experiencing moderate to severe depression than CBT. For patients scoring above the clinical cut-off on the PHQ-9 at intake, the pre-post ES (95% CI) for CBT was 1.59 (1.58, 1.62) with 46.6% making RCSI criteria and for counselling the pre-post ES was 1.55 (1.52, 1.59) with 44.3% of patients meeting RCSI criteria. Multilevel modelling revealed a significant site effect of 1.8%, while therapy type was not a predictor of outcome. A significant interaction was found between the number of sessions attended and therapy type, with patients attending fewer sessions on average for counselling [M = 7.5 (5.54) sessions and a median (IQR) of 6 (3-10)] than CBT [M = 8.9 (6.34) sessions and a median (IQR) of 7 (4-12)]. Only where patients had 18 or 20 sessions was CBT significantly more effective than counselling, with recovery rates (95% CIs) of 62.2% (57.1, 66.9) and 62.4% (56.5, 68.0) respectively, compared with 44.4% (32.7, 56.6) and 42.6% (30.0, 55.9) for counselling. Counselling was significantly more effective at two sessions with a recovery rate of 34.9% (31.9, 37.9) compared with 22.2% (20.5, 24.0) for CBT. CONCLUSIONS: Outcomes for counselling and CBT in the treatment of depression were comparable. Research efforts should focus on factors other than therapy type that may influence outcomes, namely the inherent variability between services, and adopt multilevel modelling as the given analytic approach in order to capture the naturally nested nature of the implementation and delivery of psychological therapies. It is of concern that half of all patients, regardless of type of intervention, did not show reliable improvement

Alcohol misuse and injury outcomes in young people aged 10-24: a cohort analysis using linked primary and secondary care data in England

Purpose: The burden of alcohol-attributable disease is a global problem. Young people often present to emergency health-care services with alcohol intoxication but little is known about how best to intervene at that point to improve future health outcomes. This study aimed to assess whether young people with an alcohol-specific hospital admission are at increased risk of injury following discharge. Methods: A cohort study was conducted using a general population of 10- to 24-year-olds identified using primary care medical records with linked hospital admission records between 1998 and 2013. Exposed individuals had an alcohol-specific admission. Unexposed individuals did not and were frequency matched by age (±5 years) and general practice (ratio 10:1). Incidence rates of injury-related hospital admission post discharge were calculated, and hazard ratios (HR) were estimated by Cox regression. Results: The cohort comprised 11,042 exposed and 110,656 unexposed individuals with 4,944 injury-related admissions during follow-up (2,092 in exposed). Injury rates were six times higher in those with a prior alcohol admission (73.92 per 1,000 person-years, 95% confidence interval (CI) 70.82–77.16 vs. 12.36, 11.91–12.81). The risk of an injury admission was highest in the month following an alcohol-specific admission (adjusted HR = 15.62, 95% CI 14.08–17.34), and remained higher compared to those with no previous alcohol-specific admission at 1 year (HR 5.28 (95% CI 4.97–5.60)) and throughout follow-up. Conclusions: Young people with an alcohol-specific admission are at increased risk of subsequent injury requiring hospitalization, especially immediately post discharge, indicating a need for prompt intervention as soon as alcohol misuse behaviors are identified

Home-based health promotion for older people with mild frailty: the HomeHealth intervention development and feasibility RCT.

BACKGROUND: Mild frailty or pre-frailty is common and yet is potentially reversible. Preventing progression to worsening frailty may benefit individuals and lower health/social care costs. However, we know little about effective approaches to preventing frailty progression. OBJECTIVES: (1) To develop an evidence- and theory-based home-based health promotion intervention for older people with mild frailty. (2) To assess feasibility, costs and acceptability of (i) the intervention and (ii) a full-scale clinical effectiveness and cost-effectiveness randomised controlled trial (RCT). DESIGN: Evidence reviews, qualitative studies, intervention development and a feasibility RCT with process evaluation. INTERVENTION DEVELOPMENT: Two systematic reviews (including systematic searches of 14 databases and registries, 1990-2016 and 1980-2014), a state-of-the-art review (from inception to 2015) and policy review identified effective components for our intervention. We collected data on health priorities and potential intervention components from semistructured interviews and focus groups with older people (aged 65-94 years) (n = 44), carers (n = 12) and health/social care professionals (n = 27). These data, and our evidence reviews, fed into development of the 'HomeHealth' intervention in collaboration with older people and multidisciplinary stakeholders. 'HomeHealth' comprised 3-6 sessions with a support worker trained in behaviour change techniques, communication skills, exercise, nutrition and mood. Participants addressed self-directed independence and well-being goals, supported through education, skills training, enabling individuals to overcome barriers, providing feedback, maximising motivation and promoting habit formation. FEASIBILITY RCT: Single-blind RCT, individually randomised to 'HomeHealth' or treatment as usual (TAU). SETTING: Community settings in London and Hertfordshire, UK. PARTICIPANTS: A total of 51 community-dwelling adults aged ≥ 65 years with mild frailty. MAIN OUTCOME MEASURES: Feasibility - recruitment, retention, acceptability and intervention costs. Clinical and health economic outcome data at 6 months included functioning, frailty status, well-being, psychological distress, quality of life, capability and NHS and societal service utilisation/costs. RESULTS: We successfully recruited to target, with good 6-month retention (94%). Trial procedures were acceptable with minimal missing data. Individual randomisation was feasible. The intervention was acceptable, with good fidelity and modest delivery costs (£307 per patient). A total of 96% of participants identified at least one goal, which were mostly exercise related (73%). We found significantly better functioning (Barthel Index +1.68; p = 0.004), better grip strength (+6.48 kg; p = 0.02), reduced psychological distress (12-item General Health Questionnaire -3.92; p = 0.01) and increased capability-adjusted life-years [+0.017; 95% confidence interval (CI) 0.001 to 0.031] at 6 months in the intervention arm than the TAU arm, with no differences in other outcomes. NHS and carer support costs were variable but, overall, were lower in the intervention arm than the TAU arm. The main limitation was difficulty maintaining outcome assessor blinding. CONCLUSIONS: Evidence is lacking to inform frailty prevention service design, with no large-scale trials of multidomain interventions. From stakeholder/public perspectives, new frailty prevention services should be personalised and encompass multiple domains, particularly socialising and mobility, and can be delivered by trained non-specialists. Our multicomponent health promotion intervention was acceptable and delivered at modest cost. Our small study shows promise for improving clinical outcomes, including functioning and independence. A full-scale individually RCT is feasible. FUTURE WORK: A large, definitive RCT of the HomeHealth service is warranted. STUDY REGISTRATION: This study is registered as PROSPERO CRD42014010370 and Current Controlled Trials ISRCTN11986672. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 21, No. 73. See the NIHR Journals Library website for further project information

Sex differences in national rates of repair of emergency abdominal aortic aneurysm

Background The aim of this study was to assess the sex differences in both the rate and type of repair for emergency abdominal aortic aneurysm (AAA) in England. Methods Hospital Episode Statistics (HES) data sets from April 2002 to February 2015 were obtained. Clinical and administrative codes were used to identify patients who underwent primary emergency definitive repair of ruptured or intact AAA, and patients with a diagnosis of AAA who died in hospital without repair. These three groups included all patients with a primary AAA who presented as an emergency. Sex differences between repair rates and type of surgery (endovascular aneurysm repair (EVAR) versus open repair) over time were examined. Results In total, 15 717 patients (83·3 per cent men) received emergency surgical intervention for ruptured AAA and 10 276 (81·2 per cent men) for intact AAA; 12 767 (62·0 per cent men) died in hospital without attempted repair. The unadjusted odds ratio for no repair in women versus men was 2·88 (95 per cent c.i. 2·75 to 3·02). Women undergoing repair of ruptured AAA were older and had a higher in‐hospital mortality rate (50·0 versus 41·0 per cent for open repair; 30·9 versus 23·5 per cent for EVAR). After adjustment for age, deprivation and co‐morbidities, the odds ratio for no repair in women versus men was 1·34 (1·28 to 1·40). The in‐hospital mortality rate after emergency repair of an intact AAA was also higher among women. Conclusion Women who present as an emergency with an AAA are less likely to undergo repair than men. Although some of this can be explained by differences in age and co‐morbidities, the differences persist after case‐mix adjustment

Obesity and caries in four-to-six year old English children: a cross-sectional study.

BACKGROUND: Obesity and caries are common conditions in childhood and can have significant implications on children's wellbeing. Evidence into their association remains conflicting. Furthermore, studies examining the ssociation between obesity and caries commonly focus on individual-level determinants. The present study aimed to examine the association between obesity and caries in young English children and to determine the impact of deprivation and area-level characteristics on the distribution of the two conditions. METHODS: This was a cross-sectional study among children in Plymouth city aged four-to-six years. Anthropometric measurements included weight and height (converted to Body Mass Index centiles and z-scores), and waist circumference. Caries was assessed by using the sum of the number of teeth that were decayed, missing or filled. A questionnaire was used to obtain information on children's demographic characteristics, oral hygiene, and dietary habits. The impact of deprivation on anthropometric variables and caries was determined using Linear and Poisson regression models, respectively. Multiple logistic regression was used to assess the association between different anthropometric measures and caries. Logistic regression models were also used to examine the impact of several demographic characteristics and health behaviours on the presence of obesity and caries. RESULTS: The total sample included 347 children aged 5.10 ± 0.31 (mean ± SD). Deprivation had a significant impact on caries and BMI z-scores (p < 0.05). Neither BMI- nor waist circumference z-scores were shown to be significantly associated with dental caries. Among the neighbourhood characteristics examined, the percentage of people dependent on benefits was found to have a significant impact on caries rates (p < 0.05). Household's total annual income was inversely related to caries risk and parental educational level affected children's tooth brushing frequency. CONCLUSIONS: No associations between any measure of obesity and caries were found. However, deprivation affected both obesity and caries, thus highlighting the need to prioritise disadvantaged children in future prevention programmes