Research Posters 2000 – 2006

Research Posters 2000 – 2006

2000 Online diabetes self-management education: a pilot study

Shoba Poduval

Aims/Objectives: This is a mixed methods pilot study of an online self-management program for type 2 diabetes (T2DM). The aim is to determine acceptability and effectiveness of the program, and to use the results to optimise the program and inform the design of a feasibility trial.

Relevance/Impact: The number of people in England with T2DM is rising rapidly. Structured education reduces the risk of complications and improves outcomes, but uptake is low. In 2012-13 only 3.6% of those offered structured education attended. The internet could help make structured education easier to access.

Content of Presentation: HeLP-Diabetes: Starting Out is a program informed by theory and developed significant input from patients, healthcare professionals, academics and IT specialists. We are carrying out a 12 month pilot study using mixed methods, combining quantitative data (referral rates, uptake, completion, self-reported outcomes) and qualitative (interview) data.

Outcomes: An iterative approach is recommended in the MRC guidance on the development of complex interventions. We have seen improvements in Diabetes Self-Management Self-Efficacy Scale (DSMSES) scores, showing that patients become more confident about being able to manage their condition. Qualitative data also confirms that patients find the program useful. We have started optimising the program and have a more stream-lined course structure, improved referral system and facilitation package.

Discussion: The intervention is likely to appeal to commissioners due to the need for cost-effective alternatives to face-to-face education, the potential for rapid implementation and the benefit to patients.

2001 Identifying Non-Cancer Patients for the Palliative Care Register in General Practice

Rachel Fardon

NICE guidelines and the Gold Standard Framework encourage GPs to identify patients approaching the end of their lives for inclusion on a Palliative Care Register (PCR). However, identifying when patients become palliative is widely recognised as challenging, resulting in the under-representation of organ failure patients on PCRs. This study aimed to develop a simple search code for use in the EMIS IT system to identify patients with end-stage Heart Failure (HF) and Chronic Obstructive Pulmonary Disease (COPD) for PCR inclusion.

Two separate searches for COPD and HF were designed based on indicators from the literature. Examination of the identified patient records enabled patients to be classified as PCR appropriate or inappropriate, cross-matched by the GP’s own assessment of the identified patients. Of the 40 patients identified by the search code, 47.5% were PCR appropriate, with the COPD search identifying 15% more patients for PCR inclusion than the HF search. The sensitivity and specificity of individual search criteria are identified and discussed. The main limitations of the search were absent or out-dated data in patient records and an inability to test the accuracy of the code due to time constraints. Specific recommendations to improve the accuracy of the search code and for the practice involved in the study are made.

The study concurs with the literature that patients with organ failure are under-represented on practice PCRs and demonstrates the potential use of structured identification searches in practically addressing this problem.

2002 General Practitioners’ role in lowering risk of premature death in patients following self-harm: lessons from a nationally representative cohort study

Carolyn Chew-Graham

Aims/objectives To describe the epidemiology of self-harm presentations to primary care.

Content of presentation Self-harm is a major risk factor for suicide. Most epidemiological research has been undertaken in secondary healthcare settings, little is known about the frequency, clinical management and outcomes in primary care. Using the Clinical Practice Research Datalink (CPRD), a nationally representative electronic repository of patient records, we calculated directly standardised incidence and annual presentation rates during 2001-2013, examined clinical management in the year following an index self-harm episode, and estimated cause-specific mortality risks.

Outcomes Self-harm occurred more frequently in Northern Ireland, Scotland, and Wales than in England, and at practices in more deprived localities; females aged 15-24 years were at greatest risk. Across the UK there was a temporal trend in rising annual presentation rates. Self-harm repetition occurred among a fifth of cohort members within a year. Patients at practices in more deprived areas were less likely to be referred to mental health services, and a tenth of cohort members were prescribed psychotropic medication without a psychiatric diagnosis or mental health referral. Premature mortality risk was elevated, particularly so during the first follow-up year, with markedly increased risks of suicide, accidental death and alcohol-related death.

Relevance/Impact GPs can intervene and potentially make a difference in preventing self-harm repetition and premature death among these patients.

Discussion Clinically significant alcohol misuse was the strongest modifiable predictor of premature mortality, emphasising the need for GPs to assess the risk of self-harm in patients with alcohol problems.

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2003 Increasing physical activity in older people with pain (iPoPP): Development of an intervention delivered by Health Care Assistants in Primary Care

Carolyn Chew-Graham

Aims/Objectives To test the feasibility and acceptability of a Health Care Assistant (HCA) led intervention to promote walking in older people with chronic musculoskeletal (MSK) pain.

Content of Presentation To describe development of the intervention and application of an implementation of change model. 1) A “concrete proposal” for the intervention was devised (evidence synthesis, stakeholder workshop and nominal group). 2) A “target group analysis” (focus group with HCAs) identified current practice and barriers to delivery of the intervention. Data analysed thematically, then mapped to the Theoretical Domains Framework (TDF). 3) Training needs to address barriers to iPOPP delivery were identified and integrated into a training programme for the pilot trial.

Relevance/Impact Physical activity rates are low in people aged 65 and over and those with chronic musculoskeletal pain. Increasing activity such as walking can lead to a reduction in pain.

Outcomes The iPOPP intervention includes action planning and motivational components, goal setting, provision of a pedometer, walking diary, and signposting to local walking opportunities. HCAs highlighted concerns over competence to deliver the intervention. Knowledge, confidence and skills for behaviour change techniques, engaging patients, and ability to structure consultations to deliver the intervention identified as training needs.

Discussion An implementation of change model, using evidence synthesis, a stakeholder workshop, nominal group and focus group has enabled co-design of a brief walking intervention for older people with chronic MSK pain, and the development of a training programme for HCAs to be tested in a pilot trial.

2004 Development of a psychosocial intervention for older people with anxiety and depression to be delivered by third sector practitioners: a qualitative study

Carolyn Chew-Graham

Aims/Objectives To describe the development of a psychosocial intervention to be delivered by third sector practitioners.

Content of Presentation We will describe how findings from this qualitative study have informed the design of the psychosocial intervention and the training required for third sector practitioners, to be evaluated in a feasibility study.

Relevance/Impact Anxiety and depression are prevalent among older people; however, both are sub-optimally managed, leading to increased use of health and social care services and mortality. Increasingly the third sector supports the management of older people, but there is limited evidence of the effectiveness of such providers in improving patient outcomes.

Outcomes Nineteen older people and nine third sector workers were interviewed. Initial analysis from interviews with older people indicates the importance of group activities in the prevention and management of symptoms of anxiety and/or depression, but “grim determination” was needed to overcome multiple barriers to accessing such groups. Workers talked abut supporting older people with anxiety and/or depression as part of their routine work but rarely received formal training. They identified key competencies, suggested methods of training, and highlighted the importance of supervision. Using the ‘Theoretical Domains Framework’ we identified the key components of training for the third sector practitioners, and optimal mode of delivery of training.

Discussion Preliminary qualitative work contributed to the development of a psycho-social intervention and related training. If the feasibility study demonstrates that third sector practitioners can deliver an intervention acceptable to patients, this will have implications for commissioning third sector services.

2005 A qualitative study of the barriers to a healthy lifestyle in patients with type 2 diabetes mellitus

Harley Fuller

Aims/objectives The aim of this study was to explore the perceived barriers to lifestyle changes of people with type 2 diabetes from a relatively deprived area of North East England.

Content of presentation This is an explorative, qualitative study involving semi-structured interviews of eight patients with established type 2 diabetes. Participants were recruited from routine primary care review appointments and each underwent a recorded interview lasting approximately 20-30 minutes with a 4th year medical student. Notes were systemically made and thematically analysed to identify common and contrasting themes.

Relevance The number of people with type 2 diabetes in the UK is growing and is more common in lower socioeconomic groups. Once they have diabetes, people from more deprived backgrounds are also more likely to develop complications. The reasons for this are unclear but maybe related to lifestyle factors (smoking, exercise, diet).

Outcomes The results highlighted four common themes: Education: participants appeared surprisingly unaware that weight and diet were important causes of both diabetes and poor control of diabetes. Behaviour: participants struggling with the motivation to make behavioural changes. Support: family and friends support or otherwise were key perceived factors. Finally, health: the impact of co-morbidities was highlighted.

Discussion The results suggest that more emphasis on the level of support provided to patients with type 2 diabetes in primary care may potentially improve care for those from more deprived backgrounds. Further research and a deeper understanding of the concepts highlighted is recommended to address this relatively neglected area.

2006 Integrating case-finding and management of joint pain, anxiety and depression into long-term condition reviews: consultation analysis

Carolyn Chew-Graham

Aims and objectives To test the feasibility of a practice nurse (PN)-led enhanced review for identifying, assessing and supporting the management of osteoarthritis (OA), anxiety and/or depression in long-term condition (LTC) consultations.

Content of presentation We report analysis of audio recorded ENHANCE reviews undertaken as part of a process evaluation within a pilot trial, which aims to develop and test the feasibility and acceptability of a PN-led ENHANCE review.

Relevance/impact Pain due to OA and mental health problems are common and often co-exist in patients with other LTCs, but are under-detected and sub-optimally managed in primary care.

Outcomes ENHANCE review recordings ranged between 10 and 50 minutes. The extent to which PNs integrated ENHANCE components varied. PNs and patients normalised symptoms of low mood, anxiety and pain, there were missed opportunities to respond to patient cues, and sometimes patients accepted the PN’s offer of referral to other services, but a referral was not made. However, there were examples of integrated consultations where PNs incorporated ENHANCE case-finding questions within a patient-centred discourse and offered support and further management. The importance of exercise was emphasised, with PNs demonstrating particular exercises; information about anxiety and depression was given, with referral of some patients to their GP.

Discussion The complexity of LTC reviews poses a challenge for integrating identification and assessment of OA, anxiety and/or depression within these consultations. Despite the challenges, integration can be achieved, but further work around countering normalisation of OA and mental health symptoms within primary care consultations is required.