Joyce Kenkre

Current utility of the ankle-brachial index (ABI) in general practice: implications for its use in cardiovascular disease screening

BackgroundPeripheral arterial disease (PAD) is a marker of systemic atherosclerosis and associated with a three to six fold increased risk of death from cardiovascular causes. Furthermore, it is typically asymptomatic and under-diagnosed; this has resulted in escalating calls for the instigation of Primary Care PAD screening via Ankle Brachial Index (ABI) measurement. However, there is limited evidence regarding the feasibility of this and if the requisite core skills and knowledge for such a task already exist within primary care. This study aimed to determine the current utility of ABI measurement in general practices across Wales, with consideration of the implications for its use as a cardiovascular risk screening tool.MethodA self-reporting questionnaire was distributed to all 478 General Practices within Wales, sent via their responsible Health Boards.ResultsThe survey response rate was 20%. ABI measurement is primarily performed by nurses (93%) for the purpose of wound management (90%). It is infrequently (73% < 4 times per month) and often incorrectly used (42% out of compliance with current ABI guidance). Only 52% of general practitioners and 16% of nurses reported that patients with an ABI of ≤ 0.9 require aggressive cardiovascular disease risk factor modification (as recommended by current national and international guidelines).ConclusionABI measurement is an under-utilised and often incorrectly performed procedure in the surveyed general practices. Prior to its potential adoption as a formalised screening tool for cardiovascular disease, there is a need for a robust training programme with standardised methodology in order to optimise accuracy and consistency of results. The significance of a diagnosis of PAD, in terms of associated increased cardiovascular risk and the necessary risk factor modification, needs to be highlighted.

Occupational health for humanitarian aid workers in an Ebola outbreak

The recent Ebola outbreak has caused worldwide consternation due to the spread of the disease and the high fatality rate, especially within the health care profession. Unfortunately this exacerbated the already limited health care infrastructure within Guinea, Liberia and Sierra Leone. Recruitment and the ability to respond by humanitarian aid organisations were impaired due to lack of willing delegates, facilities and equipment. This investigative qualitative study of International Federation of the Red Cross and Red Crescent staff was conducted in three West African countries to assess the current staff health situation and make recommendations for improvement to issues and needs that may impact staff capacity to deliver services during deployment. A field visit was conducted in September 2014 during which a diary of interviews, notes and logged events was taken. The information will be used to inform a modified Delphi study for the development of minimum standards for occupational health for humanitarian aid workers. A total of 24 delegates were interviewed in Conakry (Guinea), Freetown and Kenema (Sierra Leone) and Monrovia (Liberia). The issues raised during the interviews covered pre-deployment, deployment, post-deployment and various issues related to work and life as a delegate in an Ebola operation. Pre-deployment issues raised were: addressing the concerns expressed by family, friends and employer, the importance of medical clearance and receiving health briefing prior to deployment and appropriate special training. Deployment raised different issues regarding ability to maintain personal health, location and acceptability of accommodation, new ways of living and working, including development of standard operating procedures to ensure quality of care and safety, security and travel restrictions and communication with family, friends and colleagues. Post-deployment concerns included media-related issues impacting on family, alienation instead of admiration, quarantine and ability to go home, and coming to terms with their experiences. The Ebola outbreak posed a huge challenge to the deploying humanitarian organisations in terms of recruiting, preparing, deploying, post-deployment and supporting their delegates through this process. The lessons learnt from this study and recommendations made to improve the future health and safety of humanitarian aid workers will inform the development of minimum standards for occupational health for these professions.

Primary care screening for peripheral arterial disease: a cross-sectional observational study.

Background Early identification of peripheral arterial disease (PAD) and subsequent instigation of risk modification strategies could minimise disease progression and reduce overall risk of cardiovascular (CV) mortality. However, the feasibility and value of primary care PAD screening is uncertain. Aim This study (the PIPETTE study — Peripheral arterial disease In Primary carE: Targeted screening and subsequenT managEment) aimed to determine the value of a proposed primary care PAD screening strategy. Outcomes assessed were: prevalence of PAD and agreement of ankle– brachial index (ABI)-defined PAD (ABI ≤0.9) with QRISK®2-defined high CV risk (≥20). Design and setting A cross-sectional observational study was undertaken in a large general practice in Merthyr Tydfil, Wales. Method In total, 1101 individuals with ≥2 pre-identified CV risk factors but no known CV disease or diabetes were invited to participate. Participants underwent ABI measurement and QRISK2 assessment, and completed Edinburgh Claudication Questionnaires. Results A total of 368 people participated in the study (participation rate: 33%). Prevalence of PAD was 3% (n = 12). The number needed to screen (NNS) to detect one new case of PAD was 31. Refining the study population to those aged ≥50 years with a smoking history reduced the NNS to 14, while still identifying 100% of PAD cases. Of participants with PAD, 33% reported severe lifestyle-limiting symptoms of intermittent claudication that warranted subsequent endovascular intervention, yet had not previously presented to their GP. The QRISK2 score predicted high CV risk in 92% of participants with PAD. Conclusion The low PAD yield and the fact that QRISK2 was largely comparable to the ABI in predicting high CV risk suggests that routine PAD screening may be unwarranted. Instead, strategies to improve public awareness of PAD are needed.

Assessing the medium-term impact of a home-visiting programme on child maltreatment in England: protocol for a routine data linkage study

Introduction Child maltreatment involves acts of omission (neglect) or commission (abuse) often by caregivers that results in potential or actual harm to a child. The Building Blocks trial (ISRCTN23019866) assessed the short-term impact of an intensive programme of antenatal and postnatal visiting by specially trained nurses to support young pregnant women in England. The Building Blocks: 2–6 Study will assess the medium-term impacts of the programme for mothers and children (n=1562), through the linkage of routinely collected data to the trial data, with a particular emphasis on the programme’s impact on preventing child maltreatment. Methods and analysis We have developed a bespoke model of data linkage whereby outcome data for the trial cohort will be retrieved by linked anonymous data abstraction from NHS Digital, Office for National Statistics and the Department for Education’s National Pupil Database. Participants will be given reasonable opportunity to opt out of this study prior to data transfer. The information centres will match participants to the information held in their databases using standard identifiers and send extracts to a third-party safe haven. The study will have 80% power to detect a 4% difference (4%vs8%) for the binary primary outcome of child in need status (from birth to key stage 1) at a two-sided 5% alpha level by following up 602 children in each trial arm. Analysis will be by intention to treat using logistic multilevel modelling. A cost-and-consequences analysis will extend the time frame of the economic analysis from the original trial. Ethics and dissemination The study protocol has been approved by the National Health Service Wales Research Ethics Committee and the Health Research Authority’s Confidentiality Advisory Group. Methods of innovative study design and findings will be disseminated through peer-reviewed journals and conferences; results will be of interest to clinical and policy stakeholders in the UK. Trial registration number ISRCTN23019866.

Assessing the impact of specialist home visiting upon maltreatment in England: a feasibility study of data linkage from a public health trial to routine health and social care data

BackgroundFollow-up for public health trials may benefit from greater use of routine data. Our trial of a home-visiting intervention for first-time teenage mothers assessed outcomes to the child’s second birthday. To examine its medium-term impact, particularly upon maltreatment outcomes, we designed a study using routine records.MethodsWe aimed to establish the feasibility of our study design, which combines trial data with routine health, social care and education data using a dissent-based linkage model. Trial participant identifiers were linked to routine health, social care and education data if women did not dissent. Data were forwarded to a safe haven and further linked to de-identified trial outcome data. The feasibility study aimed first to establish the acceptability of data linkage through a discussion group of young mothers and by levels of dissent received by the research team. Second, we assessed levels of accurate linkage to both health (via NHS Digital) and education and social care (both via National Pupil Database, NPD). Third, we assessed the availability of data and levels of missingness for key outcomes received for a sample of target study years.ResultsOf 1545 mother-child dyads contacted, eight women opted out. The engagement exercise with stakeholders found support for the principle of data linkage, including in the context of maltreatment. Some contributors preferred opt-in consent. Most (99.9%) health records were matched on either three or all four identifiers. Fifty participants were not matched to any health data. Primary outcome data from NPD are derived from any one of three fields, all of which were satisfactorily returned and provided an indication of cases for analysis. Missing data for secondary outcomes varied from 0% (Child looked after status) to 70% (Anatomical Area A&E diagnosis) however when combined with other variables the levels of missingness for outcome decrease.ConclusionsThrough study set-up and in this pilot, we provide evidence that the main study is feasible, satisfies governance requirements and is likely to generate data of sufficient quality to address our main research questions. Observed levels of missingness or low event rates are likely to affect some secondary analysis (e.g. state transition modelling) although overall were satisfactory.

Coproduction and health: Public and clinicians’ perceptions of the barriers and facilitators

Coproduction is an approach increasingly recognized across public services internationally. However, awareness of the term and the barriers and facilitators to its implementation in the NHS are not widely understood. This study examines clinician and public perceptions of coproduction within the context of the Prudent Healthcare initiative.

2 Sub-optimal care for patients in the out of hours primary care setting at the end of life: a mixed methods study

Background Patients receiving palliative care are often at increased risk of unsafe care, (Mazzocato and Stiefel 1997; Dietz et al. 2014) and the identification of improved ways of delivering palliative care outside working hours is a priority area. (Best et al. 2015) Aim To explore the nature and causes of unsafe care delivered to patients receiving palliative care from primary care services outside normal working hours. Methods The National Reporting and Learning System (NRLS) collates patient safety incident reports written by healthcare professionals in England and Wales. We characterised reports, identified by keyword searches, using codes to describe what happened, underlying causes, harm outcome, and severity. Exploratory descriptive and thematic analyses identified factors underpinning unsafe care. Findings We identified 1072 incidents of suboptimal care, which included: medication-related issues (n=613); access to timely care (n=123); and or non-medication related treatment such as pressure ulcer relief or catheter care. (n=102). Almost two thirds of reports (n=695) described harm with outcomes including increased pain, emotional and psychological distress and dying in a place not of their choosing. Commonly identified contributory factors to these incidents were a failure to follow protocol (n=282); lack of skills/confidence of staff (n=156) and patients requiring medication delivered via a syringe driver (n=80). Conclusions This study is the largest characterisation of unsafe care for patients requiring palliative care in the community, outside working hours. Possible targets for organisations looking to improve care include improved communication between providers; better knowledge of commonly used medications and routes and easier access to medications and equipment. References 1. Mazzocato C, Stiefel F. How safe are opioids in palliative care?Supportive care in cancer: official journal of the Multinational Association of Supportive Care in Cancer 1997;5(6):427–427. 2. Dietz I, et al. “Please describe from your point of view a typical case of an error in palliative care”: Qualitative data from an exploratory cross-sectional survey study among palliative care professionals. Journal of palliative medicine2014;17(3):331–337. 3. Best S, et al. Research priority setting in palliative and end of life care: the James Lind Alliance approach consulting patinets carers and clinicians. BMJ supportive & palliative care2015;5(1):102.1–102.