David Heaney

Effectiveness of a smartphone application to promote physical activity in primary care: the SMART MOVE randomised controlled trial

BACKGROUND Physical inactivity is a major, potentially modifiable, risk factor for cardiovascular disease, cancer, and other chronic diseases. Effective, simple, and generalisable interventions that will increase physical activity in populations are needed. AIM To evaluate the effectiveness of a smartphone application (app) to increase physical activity in primary care. DESIGN AND SETTING An 8-week, open-label, randomised controlled trial in rural, primary care in the west of Ireland. METHOD Android smartphone users >16 years of age were recruited. All participants were provided with similar physical activity goals and information on the benefits of exercise. The intervention group was provided with a smartphone app and detailed instructions on how to use it to achieve these goals. The primary outcome was change in physical activity, as measured by a daily step count between baseline and follow-up. RESULTS A total of 139 patients were referred by their primary care health professional or self-referred. In total, 37 (27%) were screened out and 12 (9%) declined to participate, leaving 90 (65%) patients who were randomised. Of these, 78 provided baseline data (intervention = 37; control = 41) and 77 provided outcome data (intervention = 37; control = 40). The mean daily step count at baseline for intervention and control groups was 4365 and 5138 steps per day respectively. After adjusting, there was evidence of a significant treatment effect (P = 0.009); the difference in mean improvement in daily step count from week 1 to week 8 inclusive was 1029 (95% confidence interval 214 to 1843) steps per day, favouring the intervention. Improvements in physical activity in the intervention group were sustained until the end of the trial. CONCLUSION A simple smartphone app significantly increased physical activity over 8 weeks in a primary care population.

Telephone consulting in primary care: a triangulated qualitative study of patients and providers

BACKGROUND Internationally, there is increasing use of telephone consultations, particularly for triaging requests for acute care. However, little is known about how this mode of consulting differs from face-to-face encounters. AIM To understand patient and healthcare-staff perspectives on how telephone consulting differs from face-to-face consulting in terms of content, quality, and safety, and how it can be most appropriately incorporated into routine health care. DESIGN OF STUDY Focus groups triangulated by a national questionnaire. SETTING Primary care in urban and rural Scotland. METHOD Fifteen focus groups (n = 91) were conducted with GPs, nurses, administrative staff, and patients, purposively sampled to attain a maximum-variation sample. Findings were triangulated by a national questionnaire. RESULTS Telephone consulting evolved in urban areas mainly to manage demand, while in rural areas it developed to overcome geographical problems and maintain continuity of care for patients. While telephone consulting was generally seen to provide improved access, clinicians expressed strong concerns about safety potentially being compromised, largely as a result of lack of formal and informal examination. Concerns were, to an extent, allayed when clinicians and patients knew each other well. CONCLUSION Used appropriately, telephone consulting enhances access to health care, aids continuity, and saves time and travelling for patients. The current emphasis on use for acute triage, however, worried clinicians and patients. Given these findings, and until the safe use of telephone triage is fully understood and agreed upon by stakeholders, policymakers and clinicians should consider using the telephone primarily for managing follow-up appointments when diagnostic assessment has already been undertaken.

SMART MOVE - a smartphone-based intervention to promote physical activity in primary care: study protocol for a randomized controlled trial

BackgroundSedentary lifestyles are now becoming a major concern for governments of developed and developing countries with physical inactivity related to increased all-cause mortality, lower quality of life, and increased risk of obesity, diabetes, hypertension and many other chronic diseases. The powerful onboard computing capacity of smartphones, along with the unique relationship individuals have with their mobile phones, suggests that mobile devices have the potential to influence behavior. However, no previous trials have been conducted using smartphone technology to promote physical activity. This project has the potential to provide robust evidence in this area of innovation. The aim of this study is to evaluate the effectiveness of a smartphone application as an intervention to promote physical activity in primary care.Methods/designA two-group, parallel randomized controlled trial (RCT) with a main outcome measure of mean difference in daily step count between baseline and follow up over eight weeks. A minimum of 80 active android smartphone users over 16 years of age who are able to undertake moderate physical activity are randomly assigned to the intervention group (n = 40) or to a control group (n = 40) for an eight week period. After randomization, all participants will complete a baseline period of one week during which a baseline mean daily step count will be established. The intervention group will be instructed in the usability features of the smartphone application, will be encouraged to try to achieve 10,000 steps per day as an exercise goal and will be given an exercise promotion leaflet. The control group will be encouraged to try to walk an additional 30 minutes per day along with their normal activity (the equivalent of 10,000 steps) as an exercise goal and will be given an exercise promotion leaflet. The primary outcome is mean difference in daily step count between baseline and follow-up. Secondary outcomes are systolic and diastolic blood pressure, resting heart rate, mental health score using HADS and quality of life score using Euroqol. Randomization and allocation to the intervention and groups will be carried out by an independent researcher, ensuring the allocation sequence is concealed from the study researchers until the interventions are assigned. The primary analysis is based on mean daily step count, comparing the mean difference in daily step count between the baseline and the trial periods in the intervention and control groups at follow up.Trial registrationCurrent Controlled Trials ISRCTN99944116

Patients’ experiences of using a smartphone application to increase physical activity: the SMART MOVE qualitative study in primary care

Background Regular physical activity is known to help prevent and treat numerous non-communicable diseases. Smartphone applications (apps) have been shown to increase physical activity in primary care but little is known regarding the views of patients using such technology or how such technology may change behaviour. Aim To explore patients’ views and experiences of using smartphones to promote physical activity in primary care. Design and setting This qualitative study was embedded within the SMART MOVE randomised controlled trial, which used an app (Accupedo-Pro Pedometer) to promote physical activity in three primary care centres in the west of Ireland. Method Taped and transcribed semi-structured interviews with a purposeful sample of 12 participants formed the basis of the investigation. Framework analysis was used to analyse the data. Results Four themes emerged from the analysis: transforming relationships with exercise; persuasive technology tools; usability; and the cascade effect. The app appeared to facilitate a sequential and synergistic process of positive change, which occurred in the relationship between the participants and their exercise behaviour; the study has termed this the ‘Know-Check-Move’ effect. Usability challenges included increased battery consumption and adjusting to carrying the smartphone on their person. There was also evidence of a cascade effect involving the families and communities of participants. Conclusion Notwithstanding technological challenges, an app has the potential to positively transform, in a unique way, participants’ relationships with exercise. Such interventions can also have an associated cascade effect within their wider families and communities.

Evaluating care of patients reporting pain in fundholding practices.

Abstract Objective: To compare quality of care between 1990 and 1992 in patients with self diagnosed joint pain. Design: Questionnaire and record based study. Subjects: Patients identified at consecutive consultations during two weeks in 1990, 1991, and 1992. Setting: Six practice groups in pilot fundholding scheme in Scotland. Main outcome measures: Length of consultation; numbers referred or investigated or prescribed drugs; responses to questions about enablement and satisfaction. Results: About 15% of patients consulted with joint pain each year. 25% (316) of them had social problems in 1990 and 37% (370) in 1992, about a fifth wanted to discuss their social problems. Social problems were associated with a raised general health questionnaire score. The mean length of consultation for patients with pain was 7.6 min in 1990 and 7.7 min in 1992. Patients wishing to discuss social problems received longer consultations (8.5 min 1990; 10.4 min 1992); but other patients with social problems received shorter consultations (7.4 min; 7.2 min). The level of prescribing was stable but the proportion of patients having investigations or attending hospital fell significantly from 1990 to 1992 (31% to 24%; 31% to 13% respectively). Fewer patients responded “much better” to six questions about enablement in 1992 than in 1990. Enablement was better after longer than shorter consultations for patients with social problems. Conclusions: Quality of care for patients with pain has been broadly maintained in terms of consultation times. The effects of lower rates of investigation and referral need to be investigated further.

Implementing transnational telemedicine solutions: a connected health project in rural and remote areas of six Northern Periphery countries Series on European collaborative projects.

Abstract This is the first article in a Series on collaborative projects between European countries, relevant for general practice/family medicine and primary healthcare. Telemedicine, in particular the use of the Internet, videoconferencing and handheld devices such as smartphones, holds the potential for further strides in the application of technology for the delivery of healthcare, particularly to communities in rural and remote areas within and without the European Union where this study is taking place. The Northern Periphery Programme has funded the ‘Implementing Transnational Telemedicine Solutions’ (ITTS) project from September 2011 to December 2013, led by the Centre for Rural Health in Inverness, Scotland. Ten sustainable projects based on videoconsultation (speech therapy, renal services, emergency psychiatry, diabetes), mobile patient self-management (physical activity, diabetes, inflammatory bowel disease) and home-based health services (medical and social care emergencies, rehabilitation, multi-morbidity) are being implemented by the six partner countries: Scotland, Finland, Ireland, Northern Ireland, Norway and Sweden. In addition, an International Telemedicine Advisory Service, created for the project, provides business expertise and advice. Community panels contribute feedback on the design and implementation of services and ensure ‘user friendliness’. The project goals are to improve accessibility of healthcare in rural and remote communities, reducing unnecessary hospital visits and travel in a sustainable way. Opportunities will be provided for comparative research studies. This article provides an introduction to the ITTS project and how it aims to fulfil these needs. The ITTS team encourage all healthcare providers to at least explore possible technological solutions within their own context.

Exploring public perspectives on e-health: findings from two citizen juries.

Background  Interest and investment in e‐health continue to grow world‐wide, but there remains relatively little engagement with the public on this subject, despite calls for more public involvement in health‐care planning.

Boundaries and e-health implementation in health and social care

BackgroundThe major problem facing health and social care systems globally today is the growing challenge of an elderly population with complex health and social care needs. A longstanding challenge to the provision of high quality, effectively coordinated care for those with complex needs has been the historical separation of health and social care. Access to timely and accurate data about patients and their treatments has the potential to deliver better care at less cost.MethodsTo explore the way in which structural, professional and geographical boundaries have affected e-health implementation in health and social care, through an empirical study of the implementation of an electronic version of Single Shared Assessment (SSA) in Scotland, using three retrospective, qualitative case studies in three different health board locations.ResultsProgress in effectively sharing electronic data had been slow and uneven. One cause was the presence of established structural boundaries, which lead to competing priorities, incompatible IT systems and infrastructure, and poor cooperation. A second cause was the presence of established professional boundaries, which affect staffs’ understanding and acceptance of data sharing and their information requirements. Geographical boundaries featured but less prominently and contrasting perspectives were found with regard to issues such as co-location of health and social care professionals.ConclusionsTo provide holistic care to those with complex health and social care needs, it is essential that we develop integrated approaches to care delivery. Successful integration needs practices such as good project management and governance, ensuring system interoperability, leadership, good training and support, together with clear efforts to improve working relations across professional boundaries and communication of a clear project vision. This study shows that while technological developments make integration possible, long-standing boundaries constitute substantial risks to IT implementations across the health and social care interface which those initiating major changes would do well to consider before committing to the investment.

Community hospitals – the place of local service provision in a modernising NHS: an integrative thematic literature review

BackgroundRecent developments within the United Kingdoms (UK) health care system have re-awakened interest in community hospitals (CHs) and their role in the provision of health care. This integrative literature review sought to identify and assess the current evidence base for CHs.MethodsA range of electronic reference databases were searched from January 1984 to either December 2004 or February 2005: Medline, Embase, Web of Knowledge, BNI, CINAHL, HMIC, ASSIA, PsychInfo, SIGLE, Dissertation Abstracts, Cochrane Library, Kings Fund website, using both keywords and text words. Thematic analysis identified recurrent themes across the literature; narrative analyses were written for each theme, identifying unifying concepts and discrepant issues.ResultsThe search strategy identified over 16,000 international references. We included papers of any study design focussing on hospitals in which care was led principally by general practitioners or nurses. Papers from developing countries were excluded. A review of titles revealed 641 potentially relevant references; abstract appraisal identified 161 references for review. During data extraction, a further 48 papers were excluded, leaving 113 papers in the final review. The most common methodological approaches were cross-sectional/descriptive studies, commentaries and expert opinion. There were few experimental studies, systematic reviews, economic studies or studies that reported on longer-term outcomes. The key themes identified were origin and location of CHs; their place in the continuum of care; services provided; effectiveness, efficiency and equity of CHs; and views of patients and staff.In general, there was a lack of robust evidence for the role of CHs, which is partly due to the ad hoc nature of their development and lack of clear strategic vision for their future. Evidence for the effectiveness and efficiency of the services provided was limited. Most people admitted to CHs appeared to be older, suggesting that admittance to CHs was age-related rather than condition-related.ConclusionOverall the literature surveyed was long on opinion and short of robust studies on CHs. While lack of evidence on CHs does not imply lack of effect, there is an urgent need to develop a research agenda that addresses the key issues of health care delivery in the CH setting.

What does GP out of hours care cost? An analysis of different models of out of hours care in Scotland.

Background: The changes to out of hours care provided by General Practitioners have led to wide variation in the types and costs of out of hours care across the country. Aim: To examine the costs of different models of service delivery for GP out of hours organisations. Methods: This was a prospective cross-sectional survey of eight GP out of hours organisations and samples of their patients. A deputising service, rotas, and various types of GP co-operative across Scotland were surveyed. Information on the quantities of resources used by each organisation was combined with unit costs. Costs incurred by patients and other NHS costs subsequent to the out of hours contact were also calculated. Results: Annual costs incurred by the GP out of hours organisation per 1,000 population ranged from £2,916 to £12,120. There was no relationship between costs and type and size of organisation. There was a three-fold variation in total costs per out of hours contact (£15 to £51). Costs per phone contact were lowest (£6 to £11), followed by cost per centre contact (£10 to £16) and cost per home contact (£21 to £60). Total costs per episode ranged from £78 to £136 for centre contacts, from £130 to £303 for home contacts, and from £70 to £553 for telephone contacts. Home contacts had the highest average cost per episode (£212), followed by telephone contacts (£117) and centre contacts (£85). Conclusions: There are wide variations in the costs of operating GP out of hours services. It is likely that the context in which organisations were set up and local geography influence variations in costs, as well as the level of GP cover.