Vari Drennan

End of life care for community dwelling older people with dementia: an integrated review

To review the evidence for end‐of‐life care for community dwelling older people with dementia (including those resident in care homes).

Primary care and dementia

To write a narrative review of the role of primary care physicians in the long‐term care of people with dementia living at home, with a focus on psychosocial interventions, the provision of information and carer support, behavioural and psychological symptoms and case management.

Assessing the contribution of prescribing in primary care by nurses and professionals allied to medicine: a systematic review of literature

BackgroundSafe and timely access to effective and appropriate medication through primary care settings is a major concern for all countries addressing both acute and chronic disease burdens. Legislation for nurses and other professionals allied to medicine to prescribe exists in a minority of countries, with more considering introducing legislation. Although there is variation in the range of medicines permitted to be prescribed, questions remain as to the contribution prescribing by nurses and professionals allied to medicine makes to the care of patients in primary care and what is the evidence on which clinicians, commissioners of services and policy makers can consider this innovation.MethodsA integrative review of literature on non-medical prescribing in primary care was undertaken guided by dimensions of health care quality: effectiveness, acceptability, efficiency and access.Results19 papers of 17 empirical studies were identified which provided evidence of patient outcome of non medical prescribing in primary care settings. The majority were undertaken in the UK with only one each from the USA, Canada, Botswana and Zimbabwe. Only two studies investigated clinical outcomes of non-medical prescribing. Seven papers reported on qualitative designs and four of these had fewer than ten participants. Most studies reported that non medical prescribing was widely accepted and viewed positively by patients and professionals.ConclusionsPrimary health care is the setting where timely access to safe and appropriate medicines is most critical for the well-being of any population. The gradual growth over time of legislative authority and in the numbers of non-medical prescribers, particularly nurses, in some countries suggests that the acceptability of non-medical prescribing is based on the perceived value to the health care system as a whole. Our review suggests that there are substantial gaps in the knowledge base to help evidence based policy making in this arena. We suggest that future studies of non-medical prescribing in primary care focus on the broad range of patient and health service outcomes and include economic dimensions.

The effectiveness of inter-professional working for older people living in the community: a systematic review

Health and social care policy in the UK advocates inter-professional working (IPW) to support older people with complex and multiple needs. Whilst there is a growing understanding of what supports IPW, there is a lack of evidence linking IPW to explicit outcomes for older people living in the community. This review aimed to identify the models of IPW that provide the strongest evidence base for practice with community dwelling older people. We searched electronic databases from 1 January 1990-31 March 2008. In December 2010 we updated the findings from relevant systematic reviews identified since 2008. We selected papers describing interventions that involved IPW for community dwelling older people and randomised controlled trials (RCT) reporting user-relevant outcomes. Included studies were classified by IPW models (Case Management, Collaboration and Integrated Team) and assessed for risk of bias. We conducted a narrative synthesis of the evidence according to the type of care (interventions delivering acute, chronic, palliative and preventive care) identified within each model of IPW. We retrieved 3211 records and included 37 RCTs which were mapped onto the IPW models: Overall, there is weak evidence of effectiveness and cost-effectiveness for IPW, although well-integrated and shared care models improved processes of care and have the potential to reduce hospital or nursing/care home use. Study quality varied considerably and high quality evaluations as well as observational studies are needed to identify the key components of effective IPW in relation to user-defined outcomes. Differences in local contexts raise questions about the applicability of the findings and their implications for practice. We need more information on the outcomes of the process of IPW and evaluations of the effectiveness of different configurations of health and social care professionals for the care of community dwelling older people.

The contribution of physician assistants in primary care: a systematic review

BackgroundPrimary care provision is important in the delivery of health care but many countries face primary care workforce challenges. Increasing demand, enlarged workloads, and current and anticipated physician shortages in many countries have led to the introduction of mid-level professionals, such as Physician Assistants (PAs). Objective: This systematic review aimed to appraise the evidence of the contribution of PAs within primary care, defined for this study as general practice, relevant to the UK or similar systems.MethodsMedline, CINAHL, PsycINFO, BNI, SSCI and SCOPUS databases were searched from 1950 to 2010. Eligibility criteria: PAs with a recognised PA qualification, general practice/family medicine included and the findings relevant to it presented separately and an English language journal publication. Two reviewers independently identified relevant publications, assessed quality using Critical Appraisal Skills Programme tools and extracted findings. Findings were classified and synthesised narratively as factors related to structure, process or outcome of care.Results2167 publications were identified, of which 49 met our inclusion criteria, with 46 from the United States of America (USA). Structure: approximately half of PAs are reported to work in primary care in the USA with good support and a willingness to employ amongst doctors. Process: the majority of PAs’ workload is the management of patients with acute presentations. PAs tend to see younger patients and a different caseload to doctors, and require supervision. Studies of costs provide mixed results. Outcomes: acceptability to patients and potential patients is consistently found to be high, and studies of appropriateness report positively. Overall the evidence was appraised as of weak to moderate quality, with little comparative data presented and little change in research questions over time.Limitations: identification of a broad range of studies examining ‘contribution’ made meta analysis or meta synthesis untenable.ConclusionsThe research evidence of the contribution of PAs to primary care was mixed and limited. However, the continued growth in employment of PAs in American primary care suggests that this professional group is judged to be of value by increasing numbers of employers. Further specific studies are needed to fill in the gaps in our knowledge about the effectiveness of PAs’ contribution to the international primary care workforce.

Dementia, dignity and quality of life: nursing practice and its dilemmas

AIMS The need for healthcare practitioners to respect the dignity of older people is widely recognised in England, where it has been given attention by politicians, professionals and health service regulators. This article aims to provide examples of how such ambitions may be used in practice development. METHODS This article reports the use of five vignettes discussed by dementia care practitioners that explored the areas of dementia diagnosis, lying, incontinence, behavioural and psychological distress, and end of life care. FINDINGS Each vignette promoted discussion of differences of perspectives about the ways to enhance the dignity of people with dementia in hospital, care home and community settings. The discussion confirmed that while dignity may be one quality indicator of good care potentially enhancing quality of life, it is not always straightforward. It may be more easily conceptualised when talking of physical care and treatment than other areas. CONCLUSION The opportunity to debate the subject and to discuss practice examples revealed differences of opinion and moral perspectives between practitioners about the use and relevance of the term dignity. These need to be acknowledged in any debates about objective and subjective definitions of quality of life.

Physician associates and GPs in primary care: a comparison

Background Physician associates [PAs] (also known as physician assistants) are new to the NHS and there is little evidence concerning their contribution in general practice. Aim This study aimed to compare outcomes and costs of same-day requested consultations by PAs with those of GPs. Design and setting An observational study of 2086 patient records presenting at same-day appointments in 12 general practices in England. Method PA consultations were compared with those of GPs. Primary outcome was re-consultation within 14 days for the same or linked problem. Secondary outcomes were processes of care. Results There were no significant differences in the rates of re-consultation (rate ratio 1.24, 95% confidence interval [CI] = 0.86 to 1.79, P = 0.25). There were no differences in rates of diagnostic tests ordered (1.08, 95% CI = 0.89 to 1.30, P = 0.44), referrals (0.95, 95% CI = 0.63 to 1.43, P = 0.80), prescriptions issued (1.16, 95% CI = 0.87 to 1.53, P = 0.31), or patient satisfaction (1.00, 95% CI = 0.42 to 2.36, P = 0.99). Records of initial consultations of 79.2% (n = 145) of PAs and 48.3% (n = 99) of GPs were judged appropriate by independent GPs (P<0.001). The adjusted average PA consultation was 5.8 minutes longer than the GP consultation (95% CI = 2.46 to 7.1; P<0.001); cost per consultation was GBP £6.22, (US

Physician assistants in English general practice: a qualitative study of employers' viewpoints

10.15) lower (95% CI = −7.61 to −2.46, P<0.001). Conclusion The processes and outcomes of PA and GP consultations for same-day appointment patients are similar at a lower consultation cost. PAs offer a potentially acceptable and efficient addition to the general practice workforce.

Conservative interventions for incontinence in people with dementia or cognitive impairment, living at home: a systematic review

Objective: Effective use of staff is a major aim in all health-care systems both to maximize their impact and to minimize costs. In England, a few general practitioners (GPs) have been recruiting physician assistants (PAs) to work in their practices, independent of any pilot schemes. Our objective was to study the motivation of GPs and practice managers who employed PAs and to understand the factors that sustained their employment. Methods: A qualitative study using semi-structured interviews, analysed thematically, was carried out with 13 GPs and three practice managers from 15 general practices employing PAs in five areas of England. Results: All practices were employing USA-trained PAs. Motivating factors for their employment included increasing the general practice capacity to manage patient demand within government targets for access, broaden the skill-mix in the practice team and financial considerations. The issues that needed to be taken into account in employing PAs included: the requirement for medical supervision; the PAs current lack of a regulatory framework and prescribing authority; and some patients’ lack of familiarity with the concept of the PA. Conclusions: General practice employers view PAs as a positive addition to a mixed skill team for meeting patient demand within a practices finances. There is a need to develop stronger governance and regulatory frameworks for this emerging profession.

Specialist nursing and community support for the carers of people with dementia living at home: an evidence synthesis

BackgroundDementia is a distressing and disabling illness with worldwide estimates of increased numbers of people with the condition. Two thirds of people with dementia live at home and policies in many countries seek to support more people for longer in this setting. Incontinence both contributes to carer burden and is also a significant factor in the decision to move into care homes. A review was conducted for evidence of effectiveness for conservative interventions, which are non-pharmacological and non-surgical interventions, for the prevention or management of incontinence in community dwelling people with dementia.MethodFourteen electronic databases were searched, including MEDLINE, EMBASE and CINAHL (from inception to 2012). Assessments of risk of bias were made. Meta-analysis was inappropriate due to the heterogeneity of the interventions and outcome measurements. A narrative analysis was undertaken.ResultsFrom 427 identified abstracts, 56 studies were examined but only three met the inclusion criteria, all more than a decade old. All three focused on urinary incontinence. Two studies were exploratory or pilot studies. All had a control arm. The interventions were of advice for the carer to implement. Two included toileting education of prompted voiding or an individualised toileting schedule. There was insufficient evidence to support or rule out effectiveness of any of these interventions. Some interventions were unacceptable for some carers. None specifically reported the perspective of the person with dementia.ConclusionsThere was insufficient evidence from any studies to recommend any strategies. There remains an urgent need for both research and also clinical guidance for health professionals tailored to community settings where the majority of people with dementia live.