Christine A'Court

Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies

Background Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level. Objective Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program. Methods The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs—video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing—using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback. Results The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs. Conclusions Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.

Type and accuracy of sphygmomanometers in primary care: A cross-sectional observational study

BACKGROUND Previous studies identified worrying levels of sphygmomanometer inaccuracy and have not been repeated in the era of digital measurement of blood pressure. AIM To establish the type and accuracy of sphygmomanometers in current use. DESIGN AND SETTING Cross-sectional, observational study in 38 Oxfordshire primary care practices. METHOD Sphygmomanometers were evaluated between 50 and 250 mmHg, using Omron PA350 or Scandmed 950831-2 pressure meters. RESULTS Six hundred and four sphygmomanometers were identified: 323 digital (53%), 192 aneroid (32%), 79 mercury (13%), and 10 hybrid (2%) devices. Of these, 584 (97%) could be fully tested. Overall, 503/584 (86%) were within 3 mmHg of the reference, 77/584 (13%) had one or more error of 4-9 mmHg, and 4/584 (<1%) had one or more error of more than 10 mmHg. Mercury (71/75, 95%) and digital (272/308, 88%) devices were more likely to be within 3 mmHg of the reference standard than aneroid models (150/191, 78%) (Fishers exact test P = 0.001). Donated aneroid devices from the pharmaceutical industry performed significantly worse: 10/23 (43%) within 3 mmHg of standard compared to 140/168 (83%) aneroid models from recognised manufacturers (Fishers exact test P<0.001). No significant difference was found in performance between manufacturers within each device type, for either aneroid (Fishers exact test P = 0.96) or digital (Fishers exact test P = 0.7) devices. CONCLUSION Digital sphygmomanometers have largely replaced mercury models in primary care and have equivalent accuracy. Aneroid devices have higher failure rates than other device types; this appears to be largely accounted for by models from indiscernible manufacturers. Given the availability of inexpensive and accurate digital models, GPs could consider replacing aneroid devices with digital equivalents, especially for home visiting.

Doctor on a mountaineering expedition.

Doctors are welcome members on mountaineering expeditions to remote areas, but practical advice on how to prepare and what kit to take can be difficult to find. This article is a ragbag of useful advice on diverse topics. It explains the necessary preparation, provides tips for a healthy expedition, and summarises the common disorders encountered at high altitude. The comprehensive drug and equipment lists and first aid kit for climbers were used for the 1992 Everest in winter expedition. They are there to be sacrificed to personal preference and the experience and size of individual expeditions.

SCALS: a fourth-generation study of assisted living technologies in their organisational, social, political and policy context

Introduction Research to date into assisted living technologies broadly consists of 3 generations: technical design, experimental trials and qualitative studies of the patient experience. We describe a fourth-generation paradigm: studies of assisted living technologies in their organisational, social, political and policy context. Fourth-generation studies are necessarily organic and emergent; they view technology as part of a dynamic, networked and potentially unstable system. They use co-design methods to generate and stabilise local solutions, taking account of context. Methods and analysis SCALS (Studies in Co-creating Assisted Living Solutions) consists (currently) of 5 organisational case studies, each an English health or social care organisation striving to introduce technology-supported services to support independent living in people with health and/or social care needs. Treating these cases as complex systems, we seek to explore interdependencies, emergence and conflict. We employ a co-design approach informed by the principles of action research to help participating organisations establish, refine and evaluate their service. To that end, we are conducting in-depth ethnographic studies of peoples experience of assisted living technologies (micro level), embedded in evolving organisational case studies that use interviews, ethnography and document analysis (meso level), and exploring the wider national and international context for assisted living technologies and policy (macro level). Data will be analysed using a sociotechnical framework developed from structuration theory. Ethics and dissemination Research ethics approval for the first 4 case studies has been granted. An important outcome will be lessons learned from individual co-design case studies. We will document the studies’ credibility and rigour, and assess the transferability of findings to other settings while also recognising unique aspects of the contexts in which they were generated. Academic outputs will include a cross-case analysis and progress in theory and method of fourth-generation assisted living technology research. We will produce practical guidance for organisations, policymakers, designers and service users.

Severe non‐diabetic keto‐acidosis causing intrauterine death

A 22-year-old woman (pre-pregnancy weight 52 kg and body mass index 19.1) with a twin pregnancy at 32 weeks gestation (pregnancy weight gain 14.1 kg) was referred in preterm labour from a peripheral hospital where she had been given a single subcutaneous dose of terbutaline 250 pg, a beta-adrenoceptor stimulant (P-agonist). Painful uterine contractions were continuing when she arrived in Oxford. Intravenous ritodrine, another P-agonist, was therefore begun at 50 pg/min, increasing over 1 h to 150 pg/min until the contractions stopped. Over the next 2 h the infusion rate was reduced to 50 Ng/min and was continued at this dose for a further 10 h. Subsequently, to reduce the likelihood of further contractions, oral salbutamol 8 mg 8-hourly was prescribed. Apart from a transient tachycardia in Twin I1 at the higher ritodrine infusion rate, there was no cardiotocographic evidence of fetal distress. However, while on oral salbutamol the woman developed nausea and vomiting and intermittent tachypnoea. The salbutamol was therefore stopped after four doses. Over the following 12 h severe maternal distress, hyperventilation and confusion developed. Blood gas analysis showed a profound acidaemia due to a metabolic acidosis with incomplete respiratory compensation. Arterial blood gas values were pH 7.02, Pco, 0.9 kPa, Po, 19 kPa and base excess -28.8 mEq/l while the patient breathed air. Her blood glucose was 3.7 mmo2/l. A screening blood glucose earlier in the pregnancy had been normal and glycated haemoglobin (59%) was not raised. There was no clinical or biochemical evidence of renal or liver failure. She denied ingestion of drugs or toxins and salicylate was not detected in the plasma. When the acidosis was noted neither of the fetal heart beats could be detected with a fetal heart monitor and intrauterine death of both twins was confirmed by ultrasound scanning. Although the woman was apyrexial and she had a normal blood pressure and normal urine output, the possibility of septicaemia causing

The Long-Term Conditions Questionnaire: conceptual framework and item development

Purpose To identify the main issues of importance when living with long-term conditions to refine a conceptual framework for informing the item development of a patient-reported outcome measure for long-term conditions. Materials and methods Semi-structured qualitative interviews (n=48) were conducted with people living with at least one long-term condition. Participants were recruited through primary care. The interviews were transcribed verbatim and analyzed by thematic analysis. The analysis served to refine the conceptual framework, based on reviews of the literature and stakeholder consultations, for developing candidate items for a new measure for long-term conditions. Results Three main organizing concepts were identified: impact of long-term conditions, experience of services and support, and self-care. The findings helped to refine a conceptual framework, leading to the development of 23 items that represent issues of importance in long-term conditions. The 23 candidate items formed the first draft of the measure, currently named the Long-Term Conditions Questionnaire. Conclusion The aim of this study was to refine the conceptual framework and develop items for a patient-reported outcome measure for long-term conditions, including single and multiple morbidities and physical and mental health conditions. Qualitative interviews identified the key themes for assessing outcomes in long-term conditions, and these underpinned the development of the initial draft of the measure. These initial items will undergo cognitive testing to refine the items prior to further validation in a survey.

Why are doctors still measuring blood pressure

Blood pressure measured by a professional in clinic surroundings is systematically different from the same measurement undertaken in different settings and has worse prognostic accuracy for cardiovascular events.1 Current knowledge on the impact of setting, presence of a professional, accuracy of measurement devices, and technique could, if translated into practice transform the provision and potentially the effectiveness of blood pressure management, as illustrated by the findings of Clark and colleagues’ systematic review concerning nurse- and doctor-measured blood pressure.2 Several studies have reported a systematic difference between doctor- and nurse-obtained blood pressures, and Clark and colleagues have now provided an authoritative quantification of the effect.2 The authors drew on studies from 10 countries, across primary and secondary care, and all but one of 14 studies included found a difference, the pooled effect size being that nurse-measured blood pressure is 7/4 mmHg lower. It is assumed that these differences are due to doctors eliciting a greater ‘white coat effect’ — that is, an ‘alert reaction’ (similar to fight–flight response) on blood pressure measurement — than nurses. Interpretation of Clark and colleagues’ results requires careful checking of the methodology in the underlying studies; in particular, repeating measurement can have a large effect: an average 14 mmHg systolic drop on repeated measurement over 12 minutes in one recent study; hence if two people measure, the order in which this is done is important.3 Only one-third of included studies randomised the order of measurement, potentially biasing results. Similarly the population chosen can influence the white coat effect: it …

Are there enough GPs in England to detect hypertension and maintain access

We read with interest the paper by Baker et al exploring the interrelationship between size of hypertension register, GP provision, and access (defined as the ability to get an appointment within 48 hours), assessed in 8052 practices.1 It suggests a conundrum in primary care: the ‘better’ a practice’s recognition and presumably management of hypertension, the worse the access, …

Technology-Enhanced Consultations in Diabetes, Cancer, and Heart Failure: Protocol for the Qualitative Analysis of Remote Consultations (QuARC) Project

Background Remote videoconsulting is promoted by policy makers as a way of delivering health care efficiently to an aging population with rising rates of chronic illness. As a radically new service model, it brings operational and interactional challenges in using digital technologies. In-depth research on this dynamic is needed before remote consultations are introduced more widely. Objective The objective of this study will be to identify and analyze the communication strategies through which remote consultations are accomplished and to guide patients and clinicians to improve the communicative quality of remote consultations. Methods In previous research, we collected and analyzed two separate datasets of remote consultations in a National Institute for Health Research–funded study of clinics in East London using Skype and a Wellcome Trust–funded study of specialist community heart failure teams in Oxford using Skype or FaceTime. The Qualitative Analysis of Remote Consultations (QuARC) study will combine datasets and undertake detailed interactional microanalysis of up to 40 remote consultations undertaken by senior and junior doctors and nurse specialists, including consultations with adults with diabetes, women who have diabetes during pregnancy, people consulting for postoperative cancer surgery and community-based patients having routine heart failure reviews along with up to 25 comparable face-to-face consultations. Drawing on established techniques (eg, conversation analysis), analysis will examine the contextual features in remote consultations (eg, restricted visual field) combined with close analysis of different modes of communication (eg, speech, gesture, and gaze). Results Our findings will address the current gap in knowledge about how technology shapes the fine detail of communication in remote consultations. Alongside academic outputs, findings will inform the coproduction of information and guidance about communication strategies to support successful remote consultations. Conclusions Identifying the communication strategies through which remote consultations are accomplished and producing guidance for patients and clinicians about how to use this kind of technology successfully in consultations is an important and timely goal because roll out of remote consultations is planned across the National Health Service. Registered Report Identifier RR1-10.2196/10913

Long-Term Conditions Questionnaire (LTCQ): initial validation survey among primary care patients and social care recipients in England.

Objective The aim of this study was to validate a new generic patient-reported outcome measure, the Long-Term Conditions Questionnaire (LTCQ), among a diverse sample of health and social care users in England. Design Cross-sectional validation survey. Data were collected through postal surveys (February 2016–January 2017). The sample included a healthcare cohort of patients recruited through primary care practices, and a social care cohort recruited through local government bodies that provide social care services. Participants 1211 participants (24% confirmed social care recipients) took part in the study. Healthcare participants were recruited on the basis of having one of 11 specified long-term conditions (LTCs), and social care participants were recruited on the basis of receiving social care support for at least one LTC. The sample exhibited high multimorbidity, with 93% reporting two or more LTCs and 43% reporting a mental health condition. Outcome measures The LTCQ’s construct validity was tested with reference to the EQ-5D (5-level version), the Self-Efficacy for Managing Chronic Disease scale, an Activities of Daily Living scale and the Bayliss burden of morbidity scale. Results Low levels of missing data for each item indicate acceptability of the LTCQ across the sample. The LTCQ exhibits high internal consistency (Cronbach’s α=0.95) across the scale’s 20 items and excellent test–retest reliability (intraclass correlation coefficient=0.94, 95% CI 0.93 to 0.95). Associations between the LTCQ and all reference measures were moderate to strong and in the expected directions, indicating convergent construct validity. Conclusions This study provides evidence for the reliability and validity of the LTCQ, which has potential for use in both health and social care settings. The LTCQ could meet a need for holistic outcome measurement that goes beyond symptoms and physical function, complementing existing measures to capture fully what it means to live well with LTCs.