Background: Despite evidence demonstrating the utility of using Person-Centred Outcome Measures within palliative care settings, implementing them into routine practice is challenging. Most research has described barriers to, without explaining the causal mechanisms underpinning, implementation. Implementation theories explain how, why, and in which contexts specific relationships between barriers/enablers might improve implementation effectiveness but have rarely been used in palliative care outcomes research. Aim: To use Normalisation Process Theory to understand and explain the causal mechanisms that underpin successful implementation of Person-Centred Outcome Measures within palliative care. Design: Exploratory qualitative study. Data collected through semi-structured interviews and analysed using a Framework approach. Setting/participants: 63 healthcare professionals, across 11 specialist palliative care services, were purposefully sampled by role, experience, seniority, and settings (inpatient, outpatient/day therapy, home-based/community). Results: Seven main themes were developed, representing the causal mechanisms and relationships underpinning successful implementation of outcome measures into routine practice. Themes were: Subjectivity of measures; Frequency and version of Integrated Palliative care Outcome Scale; Training, education, and peer support; Building and sustaining community engagement; Electronic system readiness; The art of communication; Reinforcing use through demonstrating value. Conclusions: Relationships influencing implementation resided at individual and organisational levels. Addressing these factors is key to driving the implementation of outcome measures into routine practice so that those using palliative care services can benefit from the systematic identification, management, and measurement of their symptoms and concerns. We provide key questions that are essential for those implementing and using outcome measures to consider in order to facilitate the integration of outcome measures into routine palliative care practice.
BackgroundDespite increasing prevalence of gout in the UK (1), a variety of barriers result in suboptimal care (1,2) with only 40% of gout patients receiving urate-lowering therapy (ULT), usually at fixed dose without titration to a serum uric acid (SUA) target (1,2). Nurses successfully manage many chronic diseases in the community, and we have shown that when people with gout are fully informed and involved in management decisions uptake of ULT is high and subsequent adherence under nurse-led care is excellent (3).ObjectivesTo directly compare nurse-led care to general practitioner (GP) care of people with gout in a 2 year randomised controlled trial (NIHR CRN Portfolio No.12943)Methods517 participants with acute gout in the previous year were identified from 56 local GP practices and randomised to nurse-led or continuing GP care. The nurses were trained about gout and its management according to recommended best practice (EULAR and BSR guidelines) involving full information, addressing illness perceptions, and involving patients in management decisions. Assessments were undertaken at 1 and 2 years. Analysis was intention to treat (last observation carried forward).ResultsNurse (n=255) and GP (n=262) groups were well matched at baseline for mean age (62 v 64yrs), sex (90% v 89% men), mean disease duration (11.6 v 12.7yrs), mean gout attack frequency in prior year (4.2 v. 3.8), tophi (13.7% v. 8.8%), mean SUA (443 v. 439 μmol/L), mean eGFR (71.5 v. 70.2) and ULT use (40% v. 39%) (all p>0.05). By 2yrs, 22 (8.6%) and 54 (20.6%) participants had discontinued the nurse and GP groups (p<0.001), including 2 v. 8 deaths respectively. Comparing nurse and GP groups at 2yrs: 95% v. 29% had SUA <360 μmol/L (primary outcome); 88% v. 16% had SUA <300 μmol/L; mean (SD) SUA was 252±73 v. 418±106; 97% v. 54% were on ULT; and mean (SD) dose of allopurinol was 470 (140) v. 240 (107) mg/day (all p<0.001). Mean (SD) attack frequency during the 2nd year was 0.33 (0.93) in the nurse v. 0.94 (2.03) in the GP group (p<0.001), and at 2yrs tophi were present in 2.6% (reduced) v. 9.6% respectively (p<002). Although equivalent at baseline, mean (SD) SF-36 norm-based physical component scores were better at 2yrs in the nurse group (41.31 (16.76) v. 37.87 (14.31); p<0.05).ConclusionsNurse-led care of people with gout in the UK community can result in high uptake and excellent adherence to ULT over a 2yr period, achievement of target SUA in >9/10 cases and consequent improvements in patient-centred outcomes and quality of life. This study reinforces the benefits of “treat-to-target”. Compared to standard GP care this model is likely to be cost effective long-term and merits further consideration.References Doherty M. et al. Ann Rheum Dis 2012;71:1765–70.Kuo C-F. et al. Ann Rheum Dis 2015;74:661–7.Rees F. et al. Ann Rheum Dis 2013:72:826–30. AcknowledgementsArthritis Research UK (Award No.19703) funded this study.Disclosure of InterestM. Doherty Grant/research support from: AstraZeneca, Consultant for: AstraZeneca, Grunenthal, Mallinckrodt and ...
PurposeTo determine the average time-point at which it is best to define 'sub-optimal response' after ranibizumab treatment for diabetic macular edema (DME) based on the data obtained from real-life clinical practice.MethodsIn this retrospective observational study, 322 consecutive treatment naïve eyes with DME were treated with three loading doses of intravitreal ranibizumab followed by re-treatment based on decision of the treating physician on a case-by-case basis. The demographic data, clinic-based visual acuity measurements and central subfield thickness (CST) assessed on spectral domain optical coherence tomography (OCT) were evaluated at baseline (month 0), 1, 2, 3, 6, and 12 months.ResultsOn an average, the improvement in visual acuity and CST was first seen after the loading dose. However, the maximal response in terms of proportion of patients with improvement in visual acuity and/ or CST in this cohort was observed at 12 months. Patients who presented with low visual acuity at baseline (<37 ETDRS letters) were unlikely to attain driving vision with ranibizumab therapy.ConclusionsOn an average, a 'sub-optimal response' after ranibizumab therapy is best defined at month 12 as patients may continue to improve with treatment.
Although anti-VEGF drugs have shown mild-term good efficacy and safety profile in the treatment of neovascular AMD, they are far away from being a perfect therapy. Pharmacological research should focus on finding new molecular targets in the AMD pathogenetical pathway and on developing longer lasting agents or new drug delivery systems. Besides the development of new drugs, a better characterization of patients is also needed, taking into account variables such as choroidal neovascularization subtypes and genetic factors, in order to identify a tailored treatment for each patient.
IntroductionPerson-centred outcome measures improve quality of care and patient outcomes but are used inconsistently in palliative care practice. To address this implementation gap, we developed the ‘RESOLVE Implementation Strategy’. This protocol describes a process evaluation to explore mechanisms through which this strategy does, or does not, support the implementation of outcome measures in routine palliative care practice.Methods and analysisMultistrand, mixed-methods process evaluation. Strand one will collect routine outcomes data (palliative Phase of Illness, Integrated Palliative care Outcomes Scale, Australia-modified Karnofsky Performance Status) to map the changes in use of outcome measures over 12 months (July 2021–July 2022). Strand two will collect survey data over the same 12-month period to explore how professionals’ understandings of, skills in using and ability to build organisational practices around, outcome measures change over time. Strand three will collect interview data to understand the mechanisms underpinning/affecting our implementation strategy. Thematic framework analysis and descriptive statistics will be used to analyse qualitative and quantitative data, respectively.Ethics and disseminationFor strand one, ethical approval has been obtained (Cambridge REC, REF: 20/EE/0188). For strands two and three, ethical approval has been obtained from Hull York Medical School ethics committee (2105). Tailored feedback of study findings will be provided to participating sites. Abstracts and papers will be submitted to national/international conferences and peer-reviewed journals. Lay and policy briefings and newsletters will be shared through patient and public involvement and project networks, plus via the project website.
ObjectivesHealth utility combines health related quality of life and mortality to produce a generic outcome measure reflecting both morbidity and mortality. It has not been widely used as an outcome measure in evaluations of emergency care and little is known about the feasibility of measurement, typical values obtained or baseline factors that predict health utility. We aimed to measure health utility after emergency medical admission, to compare health utility to age, gender and regional population norms, and identify independent predictors of health utility.MethodsWe selected 5760 patients across three hospitals who were admitted to hospital by ambulance as a medical emergency. The EQ-5D questionnaire was mailed to all who were still alive 30 days after admission. Health utility was estimated by applying tariff values to the EQ-5D responses or imputing a value of zero for those who had died. Multivariable analysis was used to identify independent predictors of health utility at 30 days.ResultsResponses were received from 2488 (47.7%) patients, while 541 (9.4%) had died. Most respondents reported some or severe problems with each aspect of health. Mean health utility was 0.49 (standard deviation 0.35) in survivors and 0.45 (0.36) including non-survivors. Some 75% had health utility below their expected value (mean loss 0.32, 95% confidence interval 0.31 to 0.33) and 11% had health utility below zero (worse than death). On multivariable modelling, reduced health utility was associated with increased age and lower GCS, varied according to ICD10 code and was lower among females, patients with recent hospital admission, steroid therapy, or history of chronic respiratory disease, malignancy, diabetes or epilepsy.ConclusionsHealth utility can be measured after emergency medical admission, although responder bias may be significant. Health utility after emergency medical admission is poor compared to population norms. We have identified independent predictors or health utility that need to be measured and taken into account in non-randomized evaluations of emergency care.
Background Psychological distress is common in patients with cancer; interfering with physical and psychological wellbeing, and hindering management of physical symptoms. Our aim was to systematically review published evidence on non-pharmacological interventions for cancer-related psychological distress, at all stages of the disease. Methods We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The review was registered on PROSPERO (CRD42022311729). Searches were made using eight online databases to identify studies meeting our inclusion criteria. Data were collected on outcome measures, modes of delivery, resources and evidence of efficacy. A meta-analysis was planned if data allowed. Quality was assessed using the Mixed Methods Appraisal Tool (MMAT). Results Fifty-nine studies with 17,628 participants were included. One third of studies included mindfulness, talking or group therapies. Half of all studies reported statistically significant improvements in distress. Statistically significant intervention effects on distress were most prevalent for mindfulness techniques. Four of these mindfulness studies had moderate effect sizes (d = -0.71[95% CI: -1.04, -0.37] p < 0.001) (d = -0.60 [95% CI: -3.44, -0.89] p < 0.001) (d = -0.77 [CI: -0.146, -1.954] p < 0.01) (d = -0.69 [CI: -0.18, -1.19] p = 0.008) and one had a large effect size (d = -1.03 [95% CI: -1.51, -0.54] p < 0.001). Heterogeneity of studies precluded meta-analysis. Study quality was variable and some had a high risk of bias. Conclusions The majority of studies using a mindfulness intervention in this review are efficacious at alleviating distress. Mindfulness—including brief, self-administered interventions—merits further investigation, using adequately powered, high-quality studies. Systematic review registration This systematic review is registered on PROSPERO, number CRD42022311729.
Purpose: To investigate the relationship among functional and morphological findings before and after macular pucker surgery. Methods: Thirty-eight eyes with idiopathic macular pucker that underwent 25-gauge vitrectomy and infracyanine green-assisted internal limiting membrane peeling were prospectively enrolled. Main outcome measures were best-corrected visual acuity (BCVA), spectral-domain optical coherence tomography findings and MP-1 microperimetry findings. Results: Mean BCVA improvement was 0.34 logMAR (p < 0.0001). Mean central retinal thickness (CRT) reduction was 50 µm (p = 0.0041). Mean retinal sensitivity improvement was 0.9. Patients with a greater improvement of postoperative BCVA showed worse baseline BCVA (p < 0.001), shorter final inner/outer segment (IS/OS) interruption length (p = 0.039) and thinner final CRT (p = 0.035). Furthermore, final BCVA was correlated with baseline IS/OS interruption length (p = 0.001). Conclusion: Baseline BCVA, CRT and IS/OS integrity can be used to predict the functional outcomes after macular pucker surgery.
scite is a Brooklyn-based organization that helps researchers better discover and understand research articles through Smart Citations–citations that display the context of the citation and describe whether the article provides supporting or contrasting evidence. scite is used by students and researchers from around the world and is funded in part by the National Science Foundation and the National Institute on Drug Abuse of the National Institutes of Health.
hi@scite.ai
10624 S. Eastern Ave., Ste. A-614
Henderson, NV 89052, USA
Copyright © 2024 scite LLC. All rights reserved.
Made with 💙 for researchers
Part of the Research Solutions Family.