Amy M. Russell

The effects of financial incentives for case finding for depression in patients with diabetes and coronary heart disease: interrupted time series analysis

Objective To evaluate the effects of Quality and Outcomes Framework (QOF) incentivised case finding for depression on diagnosis and treatment in targeted and non-targeted long-term conditions. Design Interrupted time series analysis. Setting General practices in Leeds, UK. Participants 65 (58%) of 112 general practices shared data on 37u2005229 patients with diabetes and coronary heart disease targeted by case finding incentives, and 101u2005008 patients with four other long-term conditions not targeted (hypertension, epilepsy, chronic obstructive pulmonary disease and asthma). Intervention Incentivised case finding for depression using two standard screening questions. Main outcome measures Clinical codes indicating new depression-related diagnoses and new prescriptions of antidepressants. We extracted routinely recorded data from February 2002 through April 2012. The number of new diagnoses and prescriptions for those on registers was modelled with a binomial regression, which provided the strength of associations between time periods and their rates. Results New diagnoses of depression increased from 21 to 94/100u2005000 per month in targeted patients between the periods 2002–2004 and 2007–2011 (OR 2.09; 1.92 to 2.27). The rate increased from 27 to 77/100u2005000 per month in non-targeted patients (OR 1.53; 1.46 to 1.62). The slopes in prescribing for both groups flattened to zero immediately after QOF was introduced but before incentivised case finding (p<0.01 for both). Antidepressant prescribing in targeted patients returned to the pre-QOF secular upward trend (Wald test for equivalence of slope, z=0.73, p=0.47); the slope was less steep for non-targeted patients (z=−4.14, p<0.01). Conclusions Incentivised case finding increased new depression-related diagnoses. The establishment of QOF disrupted rising trends in new prescriptions of antidepressants, which resumed following the introduction of incentivised case finding. Prescribing trends are of concern given that they may include people with mild-to-moderate depression unlikely to respond to such treatment.

Incentivised case finding for depression in patients with chronic heart disease and diabetes in primary care: an ethnographic study

Objective To examine the process of case finding for depression in people with diabetes and coronary heart disease within the context of a pay-for-performance scheme. Design Ethnographic study drawing on observations of practice routines and consultations, debriefing interviews with staff and patients and review of patient records. Setting General practices in Leeds, UK. Participants 12 purposively sampled practices with a total of 119 staff; 63 consultation observations and 57 patient interviews. Main outcome measure Audio recorded consultations and interviews with patients and healthcare professionals along with observation field notes were thematically analysed. We assessed outcomes of case finding from patient records. Results Case finding exacerbated the discordance between patient and professional agendas, the latter already dominated by the tightly structured and time-limited nature of chronic illness reviews. Professional beliefs and abilities affected how case finding was undertaken; there was uncertainty about how to ask the questions, particularly among nursing staff. Professionals were often wary of opening an emotional ‘can of worms’. Subsequently, patient responses potentially suggesting emotional problems could be prematurely shut down by professionals. Patients did not understand why they were asked questions about depression. This sometimes led to defensive or even defiant answers to case finding. Follow-up of patients highlighted inconsistent systems and lines of communication for dealing with positive results on case finding. Conclusions Case finding does not fit naturally within consultations; both professional and patient reactions somewhat subverted the process recommended by national guidance. Quality improvement strategies will need to take account of our results in two ways. First, despite their apparent simplicity, the case finding questions are not consultation-friendly and acceptable alternative ways to raise the issue of depression need to be supported. Second, case finding needs to operate within structured pathways which can be accommodated within available systems and resources.

Embodiment and Abjection: Trafficking for Sexual Exploitation

Research into human trafficking for sexual exploitation often conceptualizes the experience through the lens of migration and/or sex work. Women’s bodies are often politicized and the corporeal experiences of trafficking are neglected. The gendered stigma attached to women who have been trafficked for sexual exploitation is clearly evident across cultures and requires further analysis as part of wider societal responses to sexual violence. Through the analysis of letters written by women who have been trafficked and sexually exploited from post-Soviet countries to Israel, this article argues that conceptualizing women’s bodies as bounded spaces allows an investigation of the transgression of those boundaries and opens up a thought-provoking framework for theorizing experiences of, and social responses to, sexual violence, stigma and social exclusion. It explores themes of pollution and dirt as ways to communicate social exclusion through references to boundaries crossed and spaces rendered abject. Women’s narratives of trafficking are examined utilizing the theory of abjection, and the embodied effects of sexual violence and body boundary transgression are elucidated. This analysis shows that the women in this study articulate an embodied narrative of trafficking that is experienced in relation to body boundaries and expressed through motifs of dirt, smell, disgust and pollution.

Supported self-management for adults with type 2 diabetes and a learning disability (OK-Diabetes): study protocol for a randomised controlled feasibility trial

BackgroundIndividuals with a learning disability (LD) are at higher risk of developing type 2 diabetes, but LD is not straightforward to define or identify, especially at the milder end of the spectrum, which makes case finding difficult. While supported self-management of health problems is now established, current material is largely educational and didactic with little that facilitates behavioural change. The interaction between the person with diabetes and others supporting their care is also largely unknown. For these reasons, there is considerable work needed to prepare for a definitive trial. The aim of this paper is to publish the abridged protocol of this preparatory work.Methods/DesignPhase I is a prospective case-finding study (target n = 120 to 350) to identify and characterise potential participants, while developing a standardised supported self-management intervention. Phase II is a randomised feasibility trial (target n = 80) with blinded outcome assessment. Patients identified in Phase I will be interviewed and consented prior to being randomised to (1) standard treatment, or (2) supported self-management. Both arms will also be provided with an ‘easy read’ accessible information resource on managing type 2 diabetes. The intervention will be standardised but delivered flexibly depending on patient need, including components for the participant, a supporter, and shared activities. Outcomes will be (i) robust estimates of eligibility, consent and recruitment rates with refined recruitment procedures; (ii) characterisation of the eligible population; (iii) a standardised intervention with associated written materials, (iv) adherence and negative outcomes measures; (v) preliminary estimates of adherence, acceptability, follow-up and missing data rates, along with refined procedures; and (vi) description of standard treatment.DiscussionOur study will provide important information on the nature of type 2 diabetes in adults with LD living in the community, on the challenges of identifying those with milder LD, and on the possibilities of evaluating a standardised intervention to improve self-management in this population.Trial registrationCurrent Controlled Trials ISRCTN41897033 (registered 21 January 2013).

Measurement of adherence in a randomised controlled trial of a complex intervention: supported self-management for adults with learning disability and type 2 diabetes

BackgroundReporting adherence to intervention delivery and uptake is a detailed way of describing what was actually delivered and received, in comparison to what was intended. Measuring and reporting adherence is not routinely done well in complex interventions. The OK Diabetes trial (ISRCTN41897033) aimed to develop and subsequently test the feasibility of implementing a supported self-management intervention in adults with a learning disability and type 2 diabetes. A key study objective was to develop a measure of adherence to the intervention.MethodsWe conducted a systematic review of published literature, extracting data from included papers using a standardised proforma. We undertook a narrative synthesis of papers to determine the form and content of methods for adherence measurement for self-management interventions in this population that had already been developed. We used the framework and data extraction form developed for the review as the basis for an adherence measurement tool that we applied in the OK Diabetes trial.ResultsThe literature review found variability in the quality and content of adherence measurement and reporting, with no standardised approach. We were able to develop an adherence measure based upon the review, and populate it with data collected during the OK Diabetes trial. The adherence tool proved satisfactory for recording and measuring adherence in the trial.ConclusionThere remains a need for a standardised approach to adherence measurement in the field of complex interventions. We have shown that it is possible to produce a simple, feasible measure for assessing adherence in the OK Diabetes trial.

Randomized controlled feasibility trial of supported self-management in adults with Type 2 diabetes mellitus and an intellectual disability: OK Diabetes

To undertake a feasibility randomized controlled trial of supported self‐management vs treatment as usual in a population of adults with obesity, Type 2 diabetes and an intellectual disability.

Identifying people with a learning disability: an advanced search for general practice

Background People with learning disabilities (LD) have poor physical and mental health when compared with the general population. They are also likely to find it more difficult than others to describe their symptoms adequately. It is therefore harder for healthcare workers to identify the health needs of those with learning disabilities, with the danger of some problems being left unrecognised. Practice registers record only a proportion of those who are eligible, making it difficult to target improvements in their health care. Aim To test a Read Code search supporting the identification of people with a mild-to-moderate learning disability who are not currently on the learning disability register. Design and setting An observational study in primary care in West Yorkshire. Method Read Code searches were created to identify individuals with a learning disability not on the LD register; they were field tested and further refined before testing in general practice. Results Diagnostic codes identified small numbers of individuals who should have been on the LD register. Functional and service use codes often created large numbers of false-positive results. The specific descriptive codes ‘Learning difficulties’ and ‘Referral to learning disability team’ needed follow-up review, and then identified some individuals with LD who were not on the register. Conclusion The Read Code search supported practices to populate their registers and was quick to run and review, making it a viable choice to support register revalidation. However, it did not find large numbers of people eligible for the LD register who were previously unidentified by their practice, suggesting that additional complementary methods are required to support practices to validate their registers.

Managing with Learning Disability and Diabetes: OK-Diabetes – a case-finding study and feasibility randomised controlled trial

BACKGROUNDnObesity and type 2 diabetes are common in adults with a learning disability. It is not known if the principles of self-management can be applied in this population.nnnOBJECTIVESnTo develop and evaluate a case-finding method and undertake an observational study of adults with a learning disability and type 2 diabetes, to develop a standardised supported self-management (SSM) intervention and measure of adherence and to undertake a feasibility randomised controlled trial (RCT) of SSM versus treatment as usual (TAU).nnnDESIGNnObservational study and an individually randomised feasibility RCT.nnnSETTINGnThree cities in West Yorkshire, UK.nnnPARTICIPANTSnIn the observational study: adults aged >u200918 years with a mild or moderate learning disability, who have type 2 diabetes that is not being treated with insulin and who are living in the community. Participants had mental capacity to consent to research and to the intervention. In the RCT participants had glycated haemoglobin (HbA1c) levels of >u20096.5% (48u2009mmol/mol), a body mass index (BMI) of >u200925u2009kg/m2 or self-reported physical activity below national guideline levels.nnnINTERVENTIONSnStandardised SSM. TAU supported by an easy-read booklet.nnnMAIN OUTCOME MEASURESn(1) The number of eligible participants identified and sources of referral; (2) current living and support arrangements; (3) current health state, including level of HbA1c, BMI and waist circumference, blood pressure and lipids; (4) mood, preferences for change; (5) recruitment and retention in RCT; (6) implementation and adherence to the intervention; (7) completeness of data collection and values for candidate primary outcomes; and (8) qualitative data on participant experience of the research process and intervention.nnnRESULTSnIn the observational study we identified 147 eligible consenting participants. The mean age was 54.4 years. In total, 130 out of 147 (88%) named a key supporter, with 113 supporters (77%) being involved in diabetes management. The mean HbA1c level was 54.5u2009mmol/mol [standard deviation (SD) 14.8u2009mmol/mol; 7.1%, SD 1.4%]. The BMI of 65% of participants was >u200930u2009kg/m2 and of 21% was >u200940u2009kg/m2. Many participants reported low mood, dissatisfaction with lifestyle and diabetes management and an interest in change. Non-response rates were high (45/147, 31%) for medical data requested from the primary care team. In the RCT, 82 participants were randomised. The mean baseline HbA1c level was 56u2009mmol/mol (SD 16.5u2009mmol/mol; 7.3%, SD 1.5%) and the mean BMI was 34u2009kg/m2 (SD 7.6u2009kg/m2). All SSM sessions were completed by 35 out of 41 participants. The adherence measure was obtained in 37 out of 41 participants. The follow-up HbA1c level and BMI was obtained for 75 out of 82 (91%) and 77 out of 82 (94%) participants, respectively. Most participants reported a positive experience of the intervention. A low response rate and difficulty understanding the EuroQol-5 Dimensions were challenges in obtaining data for an economic analysis.nnnLIMITATIONSnWe recruited from only 60% of eligible general practices, and 90% of participants were on a general practice learning disability register, which meant that we did not recruit many participants from the wider population with milder learning disability.nnnCONCLUSIONSnA definitive RCT is feasible and would need to recruit 194 participants per arm. The main barrier is the resource-intensive nature of recruitment. Future research is needed into the effectiveness of obesity treatments in this population, particularly estimating the longer-term outcomes that are important for health benefit. Research is also needed into improving ways of assessing quality of life in adults with a learning disability.nnnTRIAL REGISTRATIONnCurrent Controlled Trials ISRCTN41897033.nnnFUNDINGnThis 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. 22, No. 26. See the NIHR Journals Library website for further project information.

Characterizing adults with Type 2 diabetes mellitus and intellectual disability: outcomes of a case‐finding study

To report the results of a case‐finding study conducted during a feasibility trial of a supported self‐management intervention for adults with mild to moderate intellectual disability and Type 2 diabetes mellitus, and to characterize the study sample in terms of diabetes control, health, and access to diabetes management services and support.

The boundaries of belonging: gender, human trafficking and embodied citizenship

A ‘victim of trafficking’ is an identity that an individual can adopt to access legal resources that would otherwise not be open to them. However, this identity contains certain implicit assumptions about that individual and their experiences. This article analyses 12 applications for a one-year visa, written by women from the former Soviet Union who were trafficked to Israel and forced to sell sex. To apply for a visa as a ‘victim of trafficking’ applicants assert certain narrative tropes to emphasise their desire to belong in Israel. These tropes obscure the complexities of their experiences by emphasising themes of naivety and innocence, a commitment to familial obligations and a lack of agency. They reject the alternative identity of a migrant sex worker and distance themselves from any implication of a desire to illegally cross national borders. When they describe their hopes for the future, they assert normative gendered desires to marry and have children. This article argues that by closely aligning themselves with gender norms, these women seek to respond to conceptualisations of individuals who transgress gender and moral norms and who pose a threat to national borders and integrity.