Predictors of Cardiac Rehabilitation Utilization in England: Results From the National Audit

Background-—Cardiac rehabilitation (CR) is grossly underused, with major inequities in access. However, use of CR and predictors of initiation in England where CR contracting is available is unknown. The aims were (1) to investigate CR utilization rates in England, and (2) to determine sociodemographic and clinical factors associated with CR initiation including social deprivation. Methods and Results-—Data from the National Audit of CR, between January 2012 and November 2015, were used. Utilization rates overall and by deprivation quintile were derived. Logistic regression was performed to identify predictors of initiation among enrollees,using the Huber–White–sandwich estimator robust standard errors method to account for the nested nature of the data. Of the 234 736 (81.5%) patients referred to CR, 141 648 enrolled, 97 406 initiated CR, and of those initiating, 37.2% completed a program of ≥8 weeks duration. The significant characteristics associated with CR initiation were younger age (odds ratio [OR] 0.98, 95% CI 0.98–0.99), having a partner (OR 1.31, 95% CI 1.17–1.48), not being employed (OR 0.86, 95% CI 0.77–0.96), not having diabetes mellitus (OR 0.84, 95% CI 0.77–0.92), greater anxiety (OR 1.02, 95% CI 1.003–1.04), not being a medically managed myocardial infarction patient (OR 0.57, 95% CI 0.42–0.76), and having had coronary artery bypass graft surgery (OR 1.64, 95% CI 1.09–2.47). Conclusions-—CR enrollment does not meet English National Health Service targets; however it compares with that in other countries. Evidence-based approaches increasing CR enrollment and initiation should be applied, focusing on the identified characteristics associated with CR initiation, specifically older, single, employed individuals with diabetes mellitus and those not revascularized

Are practical recommendations practiced? A national multi-centre cross-sectional study on frequency of visual field testing in glaucoma

Aim: To estimate current clinical practice for frequency of visual field (VF) monitoring in glaucoma in England. Methods: A cross-sectional review of all patients with chronic open angle glaucoma (COAG) attending specialist glaucoma clinics at six hospitals in England was performed. The number of VF tests undertaken prior to the study date and during the first 2 years since diagnosis were recorded and compared with European Glaucoma Society (EGS) guidelines for newly-diagnosed patients. Clinician-requested monitoring intervals were compared with intervals from the National Institute of Clinical Excellence (NICE) guidelines, and the relationships with disease severity, intraocular pressure (IOP) and glaucoma progression status were reviewed. Results: One-hundred and four patients with COAG were included. 73 patients had at least 2 years of follow-up. Median (IQR) total number of VF tests and in the first 2 years of diagnosis were 4 (2–7) and 2 (2–3), respectively. No patients met EGS guidelines, but 87% of patients had their monitoring intervals requested in accordance with NICE guidelines. These intervals were not related to disease severity or VF stability (Kruskal–Wallis test, p=0.25) but shortened significantly when IOP control was inadequate or when the overall clinical impression was disease progression (p<0.001). Conclusions Most newly-diagnosed COAG patients receive less than three VFs in the first 2 years following diagnosis and an average of 0.7 VF per year over the duration of follow-up

Systematic review assessing the measurement properties of patient-reported outcomes for venous leg ulcers

Background: A variety of instruments have been used to assess outcomes for patients with venous leg ulcers. This study sought to identify, evaluate and recommend the most appropriate patient reported outcomes (PROMs) for English-speaking patients with venous leg ulcers (VLUs). Method: This systematic review used a two-staged approach. Electronic searches of major databases including MEDLINE were completed in October 2015 and then updated in July 2016. Additional studies were identified from citation checking. Study selection, data extraction and quality assessment were undertaken independently by at least two reviewers. Evaluation and summary of measurement properties of identified PROMs were undertaken using standard and adapted study-relevant criteria. Results: Ten studies with data for three generic PROMS and six condition-specific measures were identified. No generic PROM showed adequate content and criterion validity; however the EQ-5D, Nottingham Health Profile (NHP) and 12-item Health Survey Short-Form had good acceptability with scores ranging from 80% to 91%. In general, the EQ-5D showed poor responsiveness in patients with VLUs. Condition-specific PROMs demonstrated poor criterion and construct validity. Overall, good internal consistency was demonstrated for the Venous Leg Ulcer Quality of Life (VLU-QOL) and the Sheffield Preference-based Venous Ulcer questionnaire (SPVU-5D). Test re-test reliability was also satisfactory for SPVU-5D and VeLUSET measures. Conclusions: The NHP and VLU-QOL seemed the most suitable PROMs for use by clinicians. A valid condition-specific PROM is still required

"Waste the Waist": The development of an intervention to promote changes in diet and physical activity for people with high cardiovascular risk.

This is the accepted version of the article which has been published in final form in the British Journal of Health Psychology, which can be accessed via the DOI in this record.Objectives. To identify an evidence-based intervention to promote changes in diet and physical activity and adapt it for a UK primary care setting for people with high cardiovascular risk. Design. A three-stage mixed-methods design was used to facilitate a strategic approach to programme selection and adaptation. Method. Stage 1: Criteria for scientific quality and local appropriateness were developed for the selection/adaptation of an intervention to promote lifestyle change in people of high cardiovascular risk through (1) patient interviews, (2) a literature search to extract evidence-based criteria for behavioural interventions, and (3) stakeholder consultation. Stage 2: Potential interventions for adaptation were identified and ranked according to their performance against the criteria developed in Stage 1. Stage 3: Intervention mapping (IM) techniques were used to (1) specify the behavioural objectives that participants would need to reach in order to attain programme outcomes, and (2) adapt the selected intervention to ensure that evidence-based strategies to target all identified behavioural objectives were included. Results. Four of 23 potential interventions identified met the 11 essential criteria agreed by a multi-disciplinary stakeholder committee. Of these, the Greater Green Triangle programme (Laatikainen et al., 2007) was ranked highest and selected for adaptation. The IM process identified 13 additional behaviour change strategies that were used to adapt the intervention for the local context. Conclusions. IM provided a useful set of techniques for the systematic adaptation of an existing lifestyle intervention to a new population and context, and facilitated transparent working processes for a multi-disciplinary team.Department of Healt

Validating epilepsy diagnoses in routinely collected data

Purpose: Anonymised, routinely-collected healthcare data is increasingly being used for epilepsy research. We validated algorithms using general practitioner (GP) primary healthcare records to identify people with epilepsy from anonymised healthcare data within the Secure Anonymised Information Linkage (SAIL) databank in Wales, UK. Method: A reference population of 150 people with definite epilepsy and 150 people without epilepsy was ascertained from hospital records and linked to records contained within SAIL (containing GP records for 2.4 million people). We used three different algorithms, using combinations of GP epilepsy diagnosis and anti-epileptic drug (AED) prescription codes, to identify the reference population. Results: Combining diagnosis and AED prescription codes had a sensitivity of 84% (95% ci 77–90) and specificity of 98% (95–100) in identifying people with epilepsy; diagnosis codes alone had a sensitivity of 86% (80–91) and a specificity of 97% (92–99); and AED prescription codes alone achieved a sensitivity of 92% (70–83) and a specificity of 73% (65–80). Using AED codes only was more accurate in children achieving a sensitivity of 88% (75–95) and specificity of 98% (88–100). Conclusion: GP epilepsy diagnosis and AED prescription codes can be confidently used to identify people with epilepsy using anonymised healthcare records in Wales, U

Developing core elements and checklist items for global hospital antimicrobial stewardship programmes:a consensus approach

International audienc

Development and Implementation of Clinical Practice Guidelines: Current Status in Korea

Documentation of unexplained geographic variations in medical practices and use of inappropriate interventions has led to the proliferation of clinical practice guidelines. With increased enthusiasm for guidelines, evidence exists that clinical practice guidelines often influence clinical practices or health outcomes. Their successful implementation may improve the quality of care by decreasing in appropriate variation and expediting the application of effective advances to healthcare practices. In Korea, physicians and healthcare professionals have begun to take interests in clinical practice guidelines. Currently, over 50 practice guidelines have been developed through professional academic organizations or via other routes; however, the quality of the guidelines is unsatisfactory, implementation in clinical settings is incomplete, and there is insufficient infrastructure to develop clinical practice guidelines. Korea must develop policies and invest resources to enhance the development and implementation of clinical practice guidelines

The Rehabilitation Effectiveness for Activities for Life (REAL) study: a national programme of research into NHS inpatient mental health rehabilitation services across England

Background: The REAL (Rehabilitation Effectiveness for Activities for Life) research programme, funded by the National Institute for Heath Research (NIHR) from 2009 to 2015, investigated NHS mental health rehabiliation services across England. The users of these services are people with longer-term, complex mental health problems, such as schizophrenia, who have additional problems that complicate recovery. Although only around 10% of people with severe mental illness require inpatient rehabilitation, because of the severity and complexity of their problems they cost 25–50% of the total mental health budget. Despite this, there has been little research to help clinicians and commissioners to plan and deliver effective treatments and services. This research aimed to address this gap. Methods: The programme had four phases. (1) A national survey, using quantitative and qualitative methods, was used to provide a detailed understanding of the scope and quality of NHS mental health rehabilitation services in England and the characteristics of those who use them. (2) We developed a training intervention for staff of NHS inpatient mental health rehabilitation units to facilitate service users’ activities. (3) The clinical effectiveness and cost-effectiveness of the staff training programme was evaluated through a cluster randomised controlled trial involving 40 units that scored below average on our quality assessment tool in the national survey. A qualitative process evaluation and a realistic evaluation were carried out to inform our findings further. (4) A naturalistic cohort study was carried out involving 349 service users of 50 units that scored above average on our quality assessment tool in the national survey, who were followed up over 12 months. Factors associated with better clinical outcomes were investigated through exploratory analyses. Results: Most NHS trusts provided inpatient mental health rehabilitation services. The quality of care provided was higher than that in similar facilities across Europe and was positively associated with service users’ autonomy. Our cluster trial did not find our staff training intervention to be clinically effective [coefficient 1.44, 95% confidence interval (CI) –1.35 to 4.24]; staff appeared to revert to previous practices once the training team left the unit. Our realistic review suggested that greater supervision and senior staff support could help to address this. Over half of the service users in our cohort study were successfully discharged from hospital over 12 months. Factors associated with this were service users’ activity levels [odds ratio (OR) 1.03, 95% CI 1.01 to 1.05] and social skills (OR 1.13, 95% CI 1.04 to 1.24), and the ‘recovery’ orientation of the unit (OR 1.04, 95% CI 1.00 to 1.08), which includes collaborative care planning with service users and holding hope for their progress. Quality of care was not associated with costs of care. A relatively small investment (£67 per service user per month) was required to achieve the improvement in everyday functioning that we found in our cohort study. Conclusions: People who require inpatient mental health rehabilitation are a ‘low-volume, high-needs’ group. Despite this, these services are able to successfully discharge most to the community within 18 months. Our results suggest that this may be facilitated by recovery-orientated practice that promotes service users’ activities and social skills. Further research is needed to identify effective interventions that enhance such practice to deliver these outcomes. Our research provides evidence that NHS inpatient mental health rehabilitation services deliver high-quality care that successfully supports service users with complex needs in their recovery. Main limitation: Our programme included only NHS, non-secure, inpatient mental health rehabilitation services. Trial registration: Current Controlled Trials ISRCTN25898179. Funding: The NIHR Programme Grants for Applied Research programme

Reasonable adjustments to provide equitable and inclusive assessment, screening and treatment of osteoporosis for adults with intellectual disabilities: a feasibility study

Background: People with intellectual disabilities are a high risk population for developing osteoporosis and fragility fractures, yet they experience barriers to accessing dual‐energy x‐ray absorptiometry (DXA) bone mineral density (BMD) screening and fracture assessment. Reasonable adjustments are a statutory requirement in the UK, but there is a paucity of evidence‐based examples to assist their identification, implementation and evaluation. Method: Thirty adults with intellectual disabilities underwent DXA BMD screening and fracture risk assessment. Reasonable adjustments were identified and implemented. Results: The presence of osteopenia or osteoporosis was detected in 23 out of 29 (79%) participants. Osteoporosis professionals report that 17 of 18 reasonable adjustments identified and implemented are both important and easy to implement. Conclusion: Adults across all levels of intellectual disabilities can complete DXA BMD screening with reasonable adjustments. Widely implementing these reasonable adjustments would contribute to reducing inequalities in health care for adults with intellectual disabilities