Fiona MacKichan

Self-care in people with long term health problems: a community based survey.

BackgroundSelf-care is a key component of current policies to manage long term conditions. Although most people with long-term health problems care for themselves within lay networks, consultation rates for long-term undifferentiated illness remain high. Promotion of self-care in these individuals requires an understanding of their own self-care practices and needs to be understood in the context of health care pluralism. The aim was to investigate the extent and nature of self-care practices in patients experiencing long term health problems, sources of information used for self-care, and use of other forms of health care (conventional health care and complementary and alternative medicine).MethodsThe study involved a cross-sectional community-based survey set in three general practices in South West England: two in urban areas, one in a rural area. Data were collected using a postal questionnaire sent to a random sample of 3,060 registered adult patients. Respondents were asked to indicate which of six long term health problems they were experiencing, and to complete the questionnaire in reference to a single (most bothersome) problem only.ResultsOf the 1,347 (45% unadjusted response rate) who responded, 583 reported having one or more of the six long term health problems and 572 completed the survey questionnaire. Use of self-care was notably more prevalent than other forms of health care. Nearly all respondents reported using self-care (mean of four self-care practices each). Predictors of high self-care reported in regression analysis included the reported number of health problems, bothersomeness of the health problem and having received a diagnosis. Although GPs were the most frequently used and trusted source of information, their advice was not associated with greater use of self-care.ConclusionsThis study reveals both the high level and wide range of self-care practices undertaken by this population. It also highlights the importance of GPs as a source of trusted information and advice. Our findings suggest that in order to increase self-care without increasing consultation rates, GPs and other health care providers may need more resources to help them to endorse appropriate self-care practices and signpost patients to trusted sources of self-care support.

The Assessment of Musculoskeletal Pain in the Clinical Setting

Pain is a primary symptom in musculoskeletal conditions, and aspects of the pain experience (eg, severity) are key considerations in clinical decision-making and in the outcome of trials and interventions. Consequently, appropriate assessment of pain is essential. This article reviews the measures most commonly used in rheumatology practice, arguing that many are significantly limited in their ability to reflect the complexity of the patients experience. The authors provide examples of alternative approaches, concluding that there is real scope for improving assessment and measurement of musculoskeletal pain in the clinical setting.

Why do patients seek primary medical care in emergency departments? An ethnographic exploration of access to general practice

Objectives To describe how processes of primary care access influence decisions to seek help at the emergency department (ED). Design Ethnographic case study combining non-participant observation, informal and formal interviewing. Setting Six general practitioner (GP) practices located in three commissioning organisations in England. Participants and methods Reception areas at each practice were observed over the course of a working week (73 hours in total). Practice documents were collected and clinical and non-clinical staff were interviewed (n=19). Patients with recent ED use, or a carer if aged 16 and under, were interviewed (n=29). Results Past experience of accessing GP care recursively informed patient decisions about where to seek urgent care, and difficulties with access were implicit in patient accounts of ED use. GP practices had complicated, changeable systems for appointments. This made navigating appointment booking difficult for patients and reception staff, and engendered a mistrust of the system. Increasingly, the telephone was the instrument of demand management, but there were unintended consequences for access. Some patient groups, such as those with English as an additional language, were particularly disadvantaged, and the varying patient and staff semantic of words like ‘urgent’ and ‘emergency’ was exacerbated during telephone interactions. Poor integration between in-hours and out-of-hours care and patient perceptions of the quality of care accessible at their GP practice also informed ED use. Conclusions This study provides important insight into the implicit role of primary care access on the use of ED. Discourses around ‘inappropriate’ patient demand neglect to recognise that decisions about where to seek urgent care are based on experiential knowledge. Simply speeding up access to primary care or increasing its volume is unlikely to alleviate rising ED use. Systems for accessing care need to be transparent, perceptibly fair and appropriate to the needs of diverse patient groups.

Exploring the Relationship between General Practice Characteristics and Attendance at Walk-in Centres, Minor Injuries Units and Emergency Departments in England 2009/10 - 2012/2013: a Longitudinal Study

BackgroundThe UK National Health Service Emergency Departments (ED) have recently faced increasing attendance rates. This study investigated associations of general practice and practice population characteristics with emergency care service attendance rates.MethodsA longitudinal design with practice-level measures of access and continuity of care, patient population demographics and use of emergency care for the financial years 2009/10 to 2012/13. The main outcome measures were self-referred discharged ED attendance rate, and combined self-referred discharged ED, self-referred Walk-in Centre (WiC) and self-referred Minor Injuries Unit (MIU) attendance rate per 1000 patients. Multilevel models estimated adjusted regression coefficients for relationships between patients’ emergency attendance rates and patients’ reported satisfaction with opening hours and waiting time at the practice, proportion of patients having a preferred GP, and use of WiC and MIU, both between practices, and within practices over time.ResultsPractice characteristics associated with higher ED attendance rates included lower percentage of patients satisfied with waiting time (0.22 per 1% decrease, 95%CI 0.02 to 0.43) and lower percentage having a preferred GP (0.12 per 1% decrease, 95%CI 0.02 to 0.21). Population influences on higher attendance included more elderly, more female and more unemployed patients, and lower male life-expectancy and urban conurbation location. Net reductions in ED attendance were only seen for practices whose WiC or MIU attendance was high, above the 60th centile for MIU and above the 75th centile for WiC. Combined emergency care attendance fell over time if more patients within a practice were satisfied with opening hours (−0.26 per 1% increase, 95%CI −0.45 to −0.08).ConclusionPractices with more patients satisfied with waiting time, having a preferred GP, and using MIU and WIC services, had lower ED attendance. Increases over time in attendance at MIUs, and patient satisfaction with opening hours was associated with reductions in service use.

Continuity of Primary Care and Emergency Hospital Admissions Among Older Patients in England

PURPOSE Secondary health care services have been under considerable pressure in England as attendance rates increase, resulting in longer waiting times and greater demands on staff. This study’s aim was to examine the association between continuity of care and risk of emergency hospital admission among older adults. METHODS We analyzed records from 10,000 patients aged 65 years and older in 2012 within 297 English general practices obtained from the Clinical Practice Research Datalink and linked with Hospital Episode Statistics. We used the Bice and Boxerman (BB) index and the appointed general practitioner index (last general practitioner consulted before hospitalization) to quantify patient-physician continuity. The BB index was used in a prospective cohort approach to assess impact of continuity on risk of admission. Both indices were used in a separate retrospective nested case-control approach to test the effect of changing physician on the odds of hospital admission in the following 30 days. RESULTS In the prospective cohort analysis, the BB index showed a graded, non-significant inverse relationship of continuity of care with risk of emergency hospital admission, although the hazard ratio for patients experiencing least continuity was 2.27 (95% CI, 1.37–3.76) compared with those having complete continuity. In the retrospective nested case-control analysis, we found a graded inverse relationship between continuity of care and emergency hospital admission for both BB and appointed general practitioner indices: for the latter, the odds ratio for those experiencing least continuity was 2.32 (95% CI, 1.48–3.63) relative to those experiencing most continuity. CONCLUSIONS Marked discontinuity of care might contribute to increased unplanned hospital admissions among patients aged 65 years and older. Schemes to enhance continuity of care have the potential to reduce hospital admissions.

34 Stories from the fourth age

Introduction Most older care home residents will die in the care home environment. The majority of older people would like the opportunity to discuss end-of-life care, though this rarely happens. The current model of palliative care does not cater well for care home residents. This study explores the narratives shared by older people living in care homes. Aims 1. What are the issues facing elderly people in the last years of life? 2. What are the key events that shape this phase and how do their interactions and relationships with carers, healthcare professionals, family and friends affect this? Methods Five participants were recruited from two care homes in the South West of England. Each participant was interviewed at least three times over ten months. A structural narrative analysis was performed and a typology generated to present the different narratives that might constrain and/or empower the participants in relation to their ageing process. Results Participants’ narratives are presented in three different contexts: Becoming a care home resident, living in a care home and death and dying. A variety of narrative types emerged, but the concept of “imposed dependency” was a key thread. In addition to presenting the findings in the traditional academic format, 5 illustrations have been commissioned to bring some of the relevant themes to life. Conclusions The narratives constructed suggest that there is still much to be done in order to improve transition into a care home and to promote autonomy and choice, particularly at the end of life. References . Bingley AF, Thomas C, Brown J, Reeve J & Payne S (2008) Developing narrative research in supportive and palliative care: the focus on illness narratives, Palliative Medicine, 22: 653–658. . Borgstrom E (2015) Social death in end-of-life care policy. Contemporary Social Science, 10(3): 272–283 . Cornwell J (1984) Hard-Earned Lives: Accounts of Health and Illness from East London, London: Tavistock. . Gilleard C & Higgs P (2010) Ageing without agency: Theorising the fourth age, Ageing & Mental Health, 14(2): 121–128. . Gott M, Small N, Barnes S, Payne S & Seamark D (2008) Older people’s views of good death in heart failure: implications for palliative care provision. Social Science & Medicine, 67: 1113–1121. . Greenhalgh T & Hurwitz B (1999) Narrative based medicine: Why study narrative?BMJ, 318:48. . Higgs P and Rees Jones I. (2009) Medical Sociology and Old Age: Towards a sociology of health in later life, Abingdon: Routledge. . Kelly CN. (2013) Moving to Manage: A mixed methods study of later life relocation into supported housing. Edinburgh Napier University. PhD thesis. . Kinley J, Hockley J, Stone L, Dewey M, Hansford P, Stewart R, McCrone P, Begum A, Sykes N. (2014) The provision of care for residents dying in UK nursing care homes. Age and Ageing, 43(3):375–379. . Lloyd L, Calnan M, Cameron A, Seymour J & Smith R (2014) Identity in the fourth age: perseverance, adaptation and maintaining dignity. Ageing and Society, 34:1–19. . Mathie E, Goodman C, Crang C, Froggatt K, Iliffe S, Manthorpe J & Barclay S (2012) An uncertain future: The unchanging views of care home residents about living and dying, Palliative Medicine, 26: 734 . National End of Life Care Intelligence Network (2013) What We Know Now 2013: New Information Collated by the National End of Life Care Intelligence Network. London: Public Health England. . Phoenix C, Smith B & Sparkes AC (2010) Narrative analysis in ageing studies: A typology for consideration. Journal of Ageing Studies 24: 1–11. . Public Health England (2017) End of Life Care Profiles: Place of Death. Available at: http://fingertips.phe.org.uk/profile/end-of-life/data#page/0/gid/1938132883/pat/6/par/E12000004/ati/102/are/E06000015 (Accessed 24/01/17) . Riessman C. (2008) Narrative methods for the human sciences. London: Sage. . Shepherd V, Wood F & Hood K (2017) Establishing a set of research priorities in care homes for older people in the UK: a modified Delphi consensus study with care home staff. Age and Ageing 46 (2): 284–290

Can continuity of primary care decrease emergency care use? A nested case-control study

Abstract Background National Health Service emergency departments have been under considerable pressure. Many patients presenting to emergency departments could be managed in primary care, suggesting that aspects of general practice might be associated with unplanned hospital admission. Recently a government scheme introduced the concept of a named GP (general practitioner) responsible for the care of patients aged 75 and older to reduce unplanned hospital admission. We aimed to investigate whether better continuity of care is associated with lower risk of emergency hospital admission. Methods We used records from 10 000 patients aged 65 years and over randomly selected from the Clinical Practice Research Datalink, linked with Hospital Episode Statistics. Using a nested-case control approach, we identified 769 patients with an emergency hospital admission between April 1, 2012, and March 31, 2014, and at least two GP consultations in the previous 2 years, of which the last was within 30 days before hospital admission. 2123 controls were matched on age group, last consultation within the same time-period as the case, and GP practice to account for practice composition, deprivation level, and services such as out-of-hours. For both cases and controls we calculated two longitudinal measures of continuity of care—namely, Bice and Boxermans index, which quantifies the extent to which the patient saw the same GP, and proportion of times seen by an index GP (ie, last GP seen before admission). Conditional logistic regression models were applied to estimate the odds ratio (OR) associated with continuity of care, adjusting for sex, number of consultations, previous hospital admission, and a range of comorbidities. Findings Both the Bice and Boxerman and the appointed index GP measures showed a graded inverse association between lower continuity of care and higher risk of emergency hospital admission (OR for those experiencing the least continuity of care 2·1 [95% CI 1·3–3·2] and 2·3 [1·6–2·9], respectively, compared with those who always saw the same GP). Interpretation Better continuity of care might reduce emergency hospital admission. More research is needed to understand this association including distinguishing between GP-referred emergency hospital admissions and admissions through the emergency department. Such an analysis requires a bigger data set. Funding National Institute for Health Research School of Primary Care Research grant (round 9, project number 246).