Fiona Barker

Patients' online access to their electronic health records and linked online services: a systematic interpretative review

Objectives To investigate the effect of providing patients online access to their electronic health record (EHR) and linked transactional services on the provision, quality and safety of healthcare. The objectives are also to identify and understand: barriers and facilitators for providing online access to their records and services for primary care workers; and their association with organisational/IT system issues. Setting Primary care. Participants A total of 143 studies were included. 17 were experimental in design and subject to risk of bias assessment, which is reported in a separate paper. Detailed inclusion and exclusion criteria have also been published elsewhere in the protocol. Primary and secondary outcome measures Our primary outcome measure was change in quality or safety as a result of implementation or utilisation of online records/transactional services. Results No studies reported changes in health outcomes; though eight detected medication errors and seven reported improved uptake of preventative care. Professional concerns over privacy were reported in 14 studies. 18 studies reported concern over potential increased workload; with some showing an increase workload in email or online messaging; telephone contact remaining unchanged, and face-to face contact staying the same or falling. Owing to heterogeneity in reporting overall workload change was hard to predict. 10 studies reported how online access offered convenience, primarily for more advantaged patients, who were largely highly satisfied with the process when clinician responses were prompt. Conclusions Patient online access and services offer increased convenience and satisfaction. However, professionals were concerned about impact on workload and risk to privacy. Studies correcting medication errors may improve patient safety. There may need to be a redesign of the business process to engage health professionals in online access and of the EHR to make it friendlier and provide equity of access to a wider group of patients. A1. Systematic review registration number PROSPERO CRD42012003091.

Applying the COM-B behaviour model and behaviour change wheel to develop an intervention to improve hearing-aid use in adult auditory rehabilitation

Abstract Objectives: To introduce a psychological model of behaviour; the COM-B model and describe how this has been used in combination with the behaviour change wheel (BCW) in developing an intervention which aims to promote regular, long-term use of hearing aids by adults with acquired hearing loss. Design: Qualitative structured interview study using the COM-B model to identify the determinants of behavioural planning on the part of audiologists; a potentially important factor in encouraging long-term hearing-aid use. Study sample: Ten audiologists drawn from a random sample of five English audiology departments. Results: The analysis suggests that behavioural planning might be more likely to occur if audiologists’ psychological capability, physical and social opportunity, and reflective and automatic motivation were addressed. This analysis forms the basis of an intervention design, using the BCW, to encourage behavioural planning by audiologists and subsequent hearing-aid use by people with hearing loss. Conclusions: The COM-B model and BCW can be applied successfully in the context of audiology to analyse the behaviour of both people with hearing loss and professionals working with them, supplying information that is being used in intervention design. The effectiveness of the intervention will be tested in a clinical trial.

A study of the relationship between the video head impulse test and air calorics

The video head impulse test (vHIT) has been proposed as an objective approach to detect peripheral vestibular disorder in a clinical setting. Data from several studies indicate that the vHIT is a useful addition to the vestibular test battery and can give complementary information to caloric testing. This study explores the relationship between lateral canal vestibular occular reflex gain measured using the vHIT system and canal paresis indicated using air calorics in a sample of patients attending a clinic for balance disorder. Sensitivity and specificity of the vHIT test relative to calorics was studied for a clinical sample of 51 patients (20 male, 31 female) who attended a private clinic for balance disorders. vHIT gains were compared to the manufacturer’s normative range and to data from a normative study using 30 young volunteers. Of 14 patients in the clinical sample that had significant canal paresis indicated by air calorics, only 4 showed a significant abnormality in either canal using a measurement of vHIT gain. vHIT gain does not correlate with canal paresis as indicated by air caloric testing. vHIT gain appears relatively insensitive to peripheral vestibular disorder as indicated by air caloric testing, although patients that had no caloric response on one side showed abnormal vHIT gain. vHIT testing may be a useful addition to the existing vestibular test battery, but it does not appear to be an alternative to it.

The derivation of optimum criteria for use in the monothermal caloric screening test.

Objective: The aim of this study was to determine whether it is possible to predict a normal outcome of the bithermal caloric test by testing at a single temperature and if so, what criteria are most appropriate to use. Design: A total of 490 patients were considered candidates for the bithermal test and 414 completed the four necessary components, their nystagmus being measured using videonystagmography. Results: Clinical decision analysis revealed that the cool monothermal test does not provide an adequate combination of sensitivity and specificity for us to recommend its clinical use. However, the warm monothermal test offers a sensitivity of 95% with 29% of patients with normal bithermal results having to undergo the bithermal test (specificity = 71%) if a combination of three criteria are used: a normal bithermal caloric test outcome can be anticipated and testing curtailed after the first temperature if (a) the warm monothermal caloric asymmetry (MCA) is <15% and (b) the two warm results are each >8 degrees per sec (°/sec), and (c) any spontaneous nystagmus is <4 °/sec. Conclusions: When appropriate criteria are used, the warm monothermal caloric test offers a performance that is acceptable for routine clinical use, sparing a considerable proportion of patients from unnecessary tests at the cool temperature. We believe that the warm/cool monothermal test difference is probably a consequence of the interrelationship between canal paresis and directional preponderance.

Outcome Measurement in Adult Auditory Rehabilitation: A Scoping Review of Measures Used in Randomized Controlled Trials.

Objectives: This review documented the range and nature of reported outcome measures in the context of adult auditory rehabilitative research. Design: A scoping review conducted as a part of the development of a systematic review of the effect of interventions to improve hearing aid use. The authors searched the Cochrane Ear, Nose and Throat Disorders Group Trials Register; the Cochrane Central Register of Controlled Trials; PubMed; EMBASE; CINAHL; Web of Science; Cambridge Scientific Abstracts; ICTRP; and additional sources for published and unpublished randomized control trials. The date of the search was November 6, 2013. Outcomes were grouped using a framework suggested by the Cochrane Effective Practice and Organization of Care group. Results: Patient outcomes included adherence to hearing aid use, daily hours of aid use, hearing handicap, hearing aid benefit, quality of life, and communication and psychological outcome. Satisfaction and speech perception were frequent secondary outcomes. There was diversity in measures used to report patient outcomes. Outcome categories other than patient health status and behavior were rarely reported. The timing of outcome measurement was often short term (<12 weeks), with a relative lack of evidence on long-term outcomes (>1 year). Conclusions: This review has highlighted considerable diversity in patient-reported outcome measurements in randomized control trials in the context of adult auditory rehabilitation. In addition, there are gaps in the literature with respect to measurement of other outcome types of potential interest to stakeholders, including policymakers and commissioners. Long-term outcome assessment is rare.

Supporting living well with hearing loss: A Delphi review of self-management support.

Abstract Objectives: To assess consensus amongst stakeholders in adult auditory rehabilitation on what processes might support self-management. Design: A three-round Delphi review was conducted online. Participants responded to five questions relating to living well with a hearing loss and the clinical processes that might support living well. Responses were analysed using thematic analysis. In further rounds, statements arising from the analysis were scored using a nine-point Likert scale, independently and then in the light of the collated panel responses. Statements reaching pre-defined criteria for consensus were identified. Study sample: A panel of 26 stakeholders in adult auditory rehabilitation were consulted, including people with hearing loss and researchers and professionals who design and implement process change. Results: There was consensus on clinical skills and behaviours that might help individuals live well, including processes that inform and involve the individual with the hearing loss (e.g. providing information about hearing and collaborative goal setting, respectively). The panel identified potential emotional, cognitive, and behavioural markers for living well with a hearing loss. Conclusions: The results of this review provide a rationale for the development and evaluation of interventions that include collaborative clinical behaviours as part of self-management support.

Improving Collaborative Behaviour Planning in Adult Auditory Rehabilitation: Development of the I-PLAN Intervention Using the Behaviour Change Wheel

BackgroundThe consequences of poorly managed hearing loss can be ameliorated with hearing aid use but rates of use are sub-optimal. The impact of audiologist behaviour on subsequent use, particularly over the long term, is unknown.PurposeThis study aimed to describe the role of the behaviour change wheel in developing an intervention to introduce and embed particular clinical behaviours into adult hearing aid fitting consultations, within the framework of the Medical Research Council guidance on complex interventions.MethodsFollowing the steps of the behaviour change wheel, audiologist behaviours that might influence hearing aid use were identified based on a systematic review and qualitative work with audiologists. An analysis, using the COM-B model, identified potential drivers of the target behaviours. This was used to select intervention functions and behaviour change techniques likely to influence behaviour in this context.ResultsThe target behaviours were as follows: giving information about the benefits of hearing aid use and the negative consequences of non-use, providing prompts for use and engaging in collaborative behavioural planning for use. The behavioural analysis suggested that psychological capability, opportunity and motivation were potential drivers of these behaviours. The intervention functions of education, coercion, training, environmental restructuring, modelling and enablement were selected and combined to develop a single complex intervention that seeks to address the target behaviours.ConclusionsThis is the first study to use the behaviour change wheel to develop a complex intervention in the context of audiology. The theory-based development of the intervention will facilitate evaluation of its feasibility and effectiveness.

Minimally disruptive medicine is needed for patients with multimorbidity: time to develop computerised medical record systems to meet this requirement

Background Minimally disruptive medicine (MDM) is proposed as a method for more appropriately managing people with multiple chronic disease. Much clinical management is currently single disease focussed, with people with multimorbidity being managed according to multiple single disease guidelines. Current initiatives to improve care include education about individual conditions and creating an environment where multiple guidelines might be simultaneously supported. The patient-centred medical home (PCMH) is an example of the latter. However, educational programmes and PCMH may increase the burden on patients. Problem The cumulative workload for patients in managing the impact of multiple disease-specific guidelines is only relatively recently recognised. There is an intellectual vacuum as to how best to manage multimorbidity and how informatics might support implementing MDM. There is currently no alternative to multiple singlecondition- specific guidelines and a lack of certainty, should the treatment burden need to be reduced, as to which guideline might be ‘dropped’. Action The best information about multimorbidity is recorded in primary care computerised medical record (CMR) systems and in an increasing number of integrated care organisations. CMR systems have the potential to flag individuals who might be in greatest need. However, CMR systems may also provide insights into whether there are ameliorating factors that might make it easier for them to be resilient to the burden of care. Data from such CMR systems might be used to develop the evidence base about how to better manage multimorbidity. Conclusions There is potential for these information systems to help reduce the management burden on patients and clinicians. However, substantial investment in research-driven CMR development is needed if we are to achieve this.

Current process in hearing-aid fitting appointments: An analysis of audiologists’ use of behaviour change techniques using the behaviour change technique taxonomy (v1)

Abstract Objectives: To observe and analyse the range and nature of behaviour change techniques (BCTs) employed by audiologists during hearing-aid fitting consultations to encourage and enable hearing-aid use. Design: Non-participant observation and qualitative thematic analysis using the behaviour change technique taxonomy (version 1) (BCTTv1). Study sample: Ten consultations across five English NHS audiology departments. Results: Audiologists engage in behaviours to ensure the hearing-aid is fitted to prescription and is comfortable to wear. They provide information, equipment, and training in how to use a hearing-aid including changing batteries, cleaning, and maintenance. There is scope for audiologists to use additional BCTs: collaborating with patients to develop a behavioural plan for hearing-aid use that includes goal-setting, action-planning and problem-solving; involving significant others; providing information on the benefits of hearing-aid use or the consequences of non-use and giving advice about using prompts/cues for hearing-aid use. Conclusions: This observational study of audiologist behaviour in hearing-aid fitting consultations has identified opportunities to use additional behaviour change techniques that might encourage hearing-aid use. This information defines potential intervention targets for further research with the aim of improving hearing-aid use amongst adults with acquired hearing loss.

An evaluation of audiology service improvement documentation in England using the chronic care model and content analysis.

Abstract Objective: Implementation of the chronic care model (CCM) is associated with improved outcomes for patients. It follows that any proposed policy or implementation plan that maps highly onto the CCM is more likely to lead to improved outcomes. The aim of this study was to compare long-term condition (LTC) policy documents and audiology quality standard documents with the CCM and to highlight the need for further research in service implementation and clinical outcome. Design: We carried out a keyword-in-context content analysis of relevant documents. Study sample: Documents relating to health department policy on LTCs, audiology service improvement initiatives in England and the CCM. Results: This analysis shows that current audiology implementation documents in England map poorly onto the CCM compared to health policy documents relating to the management of LTCs. The biggest discrepancies occur in self-management support, delivery system design, and decision support. These elements are supported by the best evidence of potential improvements in clinical outcome. Conclusions: Our content analysis of audiology service quality improvement documents in England suggests they compare poorly to some elements of the CCM. We discuss the implications this might have for future research.