Annemieke Bikker

General Practitioners’ Empathy and Health Outcomes: A Prospective Observational Study of Consultations in Areas of High and Low Deprivation

PURPOSE We set out to compare patients’ expectations, consultation characteristics, and outcomes in areas of high and low socioeconomic deprivation, and to examine whether the same factors predict better outcomes in both settings. METHODS Six hundred fifty-nine patients attending 47 general practitioners in high- and low-deprivation areas of Scotland participated. We assessed patients’ expectations of involvement in decision making immediately before the consultation and patients’ perceptions of their general practitioners’ empathy immediately after. Consultations were video recorded and analyzed for verbal and non-verbal physician behaviors. Symptom severity and related well-being were measured at baseline and 1 month post-consultation. Consultation factors predicting better outcomes at 1 month were identified using backward selection methods. RESULTS Patients in deprived areas had less desire for shared decision-making (P <.001). They had more problems to discuss (P = .01) within the same consultation time. Patients in deprived areas perceived their general practitioners (GPs) as less empathic (P = .02), and the physicians displayed verbal and nonverbal behaviors that were less patient centered. Outcomes were worse at 1 month in deprived than in affluent groups (70% response rate; P <.001). Perceived physician empathy predicted better outcomes in both groups. CONCLUSIONS Patients’ expectations, GPs’ behaviors within the consultation, and health outcomes differ substantially between high- and low-deprivation areas. In both settings, patients’ perceptions of the physicians’ empathy predict health outcomes. These findings are discussed in the context of inequalities and the “inverse care law.”

Readiness for Delivering Digital Health at Scale: Lessons From a Longitudinal Qualitative Evaluation of a National Digital Health Innovation Program in the United Kingdom

Background Digital health has the potential to support care delivery for chronic illness. Despite positive evidence from localized implementations, new technologies have proven slow to become accepted, integrated, and routinized at scale. Objective The aim of our study was to examine barriers and facilitators to implementation of digital health at scale through the evaluation of a £37m national digital health program: ‟Delivering Assisted Living Lifestyles at Scale” (dallas) from 2012-2015. Methods The study was a longitudinal qualitative, multi-stakeholder, implementation study. The methods included interviews (n=125) with key implementers, focus groups with consumers and patients (n=7), project meetings (n=12), field work or observation in the communities (n=16), health professional survey responses (n=48), and cross program documentary evidence on implementation (n=215). We used a sociological theory called normalization process theory (NPT) and a longitudinal (3 years) qualitative framework analysis approach. This work did not study a single intervention or population. Instead, we evaluated the processes (of designing and delivering digital health), and our outcomes were the identified barriers and facilitators to delivering and mainstreaming services and products within the mixed sector digital health ecosystem. Results We identified three main levels of issues influencing readiness for digital health: macro (market, infrastructure, policy), meso (organizational), and micro (professional or public). Factors hindering implementation included: lack of information technology (IT) infrastructure, uncertainty around information governance, lack of incentives to prioritize interoperability, lack of precedence on accountability within the commercial sector, and a market perceived as difficult to navigate. Factors enabling implementation were: clinical endorsement, champions who promoted digital health, and public and professional willingness. Conclusions Although there is receptiveness to digital health, barriers to mainstreaming remain. Our findings suggest greater investment in national and local infrastructure, implementation of guidelines for the safe and transparent use and assessment of digital health, incentivization of interoperability, and investment in upskilling of professionals and the public would help support the normalization of digital health. These findings will enable researchers, health care practitioners, and policy makers to understand the current landscape and the actions required in order to prepare the market and accelerate uptake, and use of digital health and wellness services in context and at scale.

Alternatives to the face-to-face consultation in general practice: focused ethnographic case study

Background NHS policy encourages general practices to introduce alternatives to the face-to-face consultation, such as telephone, email, e-consultation systems, or internet video. Most have been slow to adopt these, citing concerns about workload. This project builds on previous research by focusing on the experiences of patients and practitioners who have used one or more of these alternatives. Aim To understand how, under what conditions, for which patients, and in what ways, alternatives to face-to-face consultations present benefits and challenges to patients and practitioners in general practice. Design and setting Focused ethnographic case studies took place in eight UK general practices between June 2015 and March 2016. Method Non-participant observation, informal conversations with staff, and semi-structured interviews with staff and patients were conducted. Practice documents and protocols were reviewed. Data were analysed through charting and the ‘one sheet of paper’ mind-map method to identify the line of argument in each thematic report. Results Case study practices had different rationales for offering alternatives to the face-to-face consultation. Beliefs varied about which patients and health issues were suitable. Co-workers were often unaware of each other’s practice; for example, practice policies for use of e-consultations systems with patients were not known about or followed. Patients reported benefits including convenience and access. Staff and some patients regarded the face-to-face consultation as the ideal. Conclusion Experience of implementing alternatives to the face-to-face consultation suggests that changes in patient access and staff workload may be both modest and gradual. Practices planning to implement them should consider carefully their reasons for doing so and involve the whole practice team.

Multimorbidity and Socioeconomic Deprivation in Primary Care Consultations

PURPOSE The influence of multimorbidity on the clinical encounter is poorly understood, especially in areas of high socioeconomic deprivation where burdensome multimorbidity is concentrated. The aim of the current study was to examine the effect of multimorbidity on general practice consultations, in areas of high and low deprivation. METHODS We conducted secondary analyses of 659 video-recorded routine consultations involving 25 general practitioners (GPs) in deprived areas and 22 in affluent areas of Scotland. Patients rated the GP’s empathy using the Consultation and Relational Empathy (CARE) measure immediately after the consultation. Videos were analyzed using the Measure of Patient-Centered Communication. Multilevel, multi-regression analysis identified differences between the groups. RESULTS In affluent areas, patients with multimorbidity received longer consultations than patients without multimorbidity (mean 12.8 minutes vs 9.3, respectively; P = .015), but this was not so in deprived areas (mean 9.9 minutes vs 10.0 respectively; P = .774). In affluent areas, patients with multimorbidity perceived their GP as more empathic (P = .009) than patients without multimorbidity; this difference was not found in deprived areas (P = .344). Video analysis showed that GPs in affluent areas were more attentive to the disease and illness experience in patients with multimorbidity (P < .031) compared with patients without multimorbidity. This was not the case in deprived areas (P = .727). CONCLUSIONS In deprived areas, the greater need of patients with multimorbidity is not reflected in the longer consultation length, higher GP patient centeredness, and higher perceived GP empathy found in affluent areas. Action is required to redress this mismatch of need and service provision for patients with multimorbidity if health inequalities are to be narrowed rather than widened by primary care.

A flexible toolkit for evaluating person-centred digital health and wellness at scale

The Delivering Assisted Living Lifestyles at Scale (dallas) program was a large-scale, nationwide deployment of digital health and wellbeing products and services in the UK. Telehealth, telecare, mobile apps, personal health records, and assisted living technology were implemented by four large multi-stakeholder consortia and a multidimensional evaluation was carried out across the lifecycle from examining co-design and redesign of services through to rolling out services via statutory, private and consumer routes. A flexible toolkit of descriptive, process and outcome measures was developed and iteratively refined throughout the program. This approach enabled a longitudinal mixed-methods evaluation, underpinned by a robust social theory of implementation called ‘Normalization Process Theory’. There remains uncertainty about the best approaches to real world digital health evaluation. This program provided a unique opportunity to develop the knowledge base and toolkit of qualitative and quantitative methods necessary to evaluate person-centered digital health technologies deployed at scale.

A thematic comparison of religiosity profiles between Christians with low and high schizotypy

This exploratory qualitative study aimed to identify themes relevant to the elements constituting a religiosity profile that, at least among Christians, appears to enhance both aspects of mental health and fundamental components of psychological well‐being. Semi‐structured interviews were conducted with eight participants, who were classified as having either high or low levels of schizotypy. Following an inductive thematic analysis approach, the results identified four interrelated, superordinate themes, which revealed a clear difference between the two groups. The main bottom‐up elements of a well‐being‐enhancing religiosity appear to involve (a) a personal relationship with a loving God; (b) religious beliefs that act as guidance, providing meaningful purpose to life; (c) a conviction that religious beliefs are a result of choice or revelation; and (d) a relative absence of religious doubt.

Receptionists’ role in new approaches to consultations in primary care: a focused ethnographic study

Background The receptionist is pivotal to the smooth running of general practice in the UK, communicating with patients and booking appointments. Aim The authors aimed to explore the role of the receptionist in the implementation of new approaches to consultations in primary care. Design and setting The authors conducted a team-based focused ethnography. Three researchers observed eight general practices across England and Scotland between June 2015 and May 2016. Method Interviews were conducted with 39 patients and 45 staff in the practices, all of which had adopted one or more methods (telephone, email, e-consultation, or internet video) for providing an alternative to face-to-face consultation. Results Receptionists have a key role in facilitating patient awareness regarding new approaches to consultations in primary care, while at the same time ensuring that patients receive a consultation appropriate to their needs. In this study, receptionists’ involvement in implementation and planning for the introduction of alternative approaches to face-to-face consultations was minimal, despite the expectation that they would be involved in delivery. Conclusion A shared understanding within practices of the potential difficulties and extra work that might ensue for reception staff was lacking. This might contribute to the low uptake by patients of potentially important innovations in service delivery. Involvement of the wider practice team in planning and piloting changes, supporting team members through service reconfiguration, and providing an opportunity to discuss and contribute to modifications of any new system would ensure that reception staff are suitably prepared to support the introduction of a new approach to consultations.

Pathways to diagnosis of a second primary cancer: protocol for a mixed-methods systematic review

Introduction As cancer survivors continue to live longer, the incidence of second primary cancers (SPCs) will also rise. Relatively little is understood about the diagnostic pathway for SPCs, how people appraise, interpret symptoms and seek help for a second different cancer and the experiences (including challenges) of healthcare providers relating to SPCs. This study aims to systematically appraise and synthesise the literature on the pathways to diagnosis of an SPC and the associated patient and healthcare provider experiences. Methods The approach taken includes systematic searches of published and unpublished literature without any date or language restrictions. MEDLINE, Embase, CAB Abstracts, MEDLINE In-Process and non-indexed citations, PsycINFO, Epub Ahead of Print, In-Process and other non-indexed citations, Ovid MEDLINE Daily, CINAHL, ASSIA, Sociological Abstracts, Web of Science, PROSPERO and grey literature will be searched to identify observational, systematic reviews, mixed methods and qualitative studies of interest. Titles, abstracts and full texts will be screened against the inclusion–exclusion criteria by at least two reviewers independently. Relevant outcomes of interest and study and population characteristics will be extracted. Synthesis will be used guided by the Pathways to Treatment model and the Olesen model of time intervals. Ethics and dissemination Ethical approval is not required. This systematic review will provide a deeper understanding of the complex and heterogeneous diagnostic pathways of SPCs, while identifying common themes across the diagnostic interval, routes to diagnosis and patient and healthcare provider experiences. These findings will help provide a nuanced picture of the diagnostic pathway for SPCs that may inform policy and consistent practice. In particular, approaches to early diagnosis for an SPC; including the timing and reasons behind the decision by the patient to seek care,the challenges faced by healthcare providers, and in the development of future interventions to reduce the delay in patient time-to-presentation. PROSPERO registration number CRD42016051692.

A Flexible Toolkit for Evaluating Person-Centred Digital Health and Wellness at Scale

The Delivering Assisted Living Lifestyles at Scale (dallas) program was a large-scale, nationwide deployment of digital health and wellbeing products and services in the UK. Telehealth, telecare, mobile apps, personal health records, and assisted living technology were implemented by four large multi-stakeholder consortia and a multidimensional evaluation was carried out across the lifecycle from examining co-design and redesign of services through to rolling out services via statutory, private and consumer routes. A flexible toolkit of descriptive, process and outcome measures was developed and iteratively refined throughout the program. This approach enabled a longitudinal mixed-methods evaluation, underpinned by a robust social theory of implementation called ‘Normalization Process Theory’. There remains uncertainty about the best approaches to real world digital health evaluation. This program provided a unique opportunity to develop the knowledge base and toolkit of qualitative and quantitative methods necessary to evaluate person-centered digital health technologies deployed at scale.

Advances in Human Factors and Ergonomics in Healthcare

The Delivering Assisted Living Lifestyles at Scale (dallas) program was a large-scale, nationwide deployment of digital health and wellbeing products and services in the UK. Telehealth, telecare, mobile apps, personal health records, and assisted living technology were implemented by four large multi-stakeholder consortia and a multidimensional evaluation was carried out across the lifecycle from examining co-design and redesign of services through to rolling out services via statutory, private and consumer routes. A flexible toolkit of descriptive, process and outcome measures was developed and iteratively refined throughout the program. This approach enabled a longitudinal mixed-methods evaluation, underpinned by a robust social theory of implementation called ‘Normalization Process Theory’. There remains uncertainty about the best approaches to real world digital health evaluation. This program provided a unique opportunity to develop the knowledge base and toolkit of qualitative and quantitative methods necessary to evaluate person-centered digital health technologies deployed at scale.