Abstract
Background
The availability, affordability and utilisation of commercially available self-monitoring devices is increasing, but their impact on routine clinical decision-making remains ...little explored. We sought to examine how patient-generated cardiovascular data influenced clinical evaluation in UK cardiology outpatient clinics and to understand clinical attitudes and experiences with using data from commercially available self-monitoring devices.
Methods
Mixed methods study combining: a) quantitative and qualitative content analysis of 1373 community cardiology clinic letters, recording consultations between January–September 2020 including periods with different Covid-19 related restrictions, and b) semi-structured qualitative interviews and group discussions with 20 cardiology-affiliated clinicians at the same NHS Trust.
Results
Patient-generated cardiovascular data were described in 185/1373 (13.5%) clinic letters overall, with the proportion doubling following onset of the first Covid-19 lockdown in England, from 8.3% to 16.6% (p < 0.001). In 127/185 (69%) cases self-monitored data were found to: provide or facilitate cardiac diagnoses (34/127); assist management of previously diagnosed cardiac conditions (55/127); be deployed for cardiovascular prevention (16/127); or be recommended for heart rhythm evaluation (10/127). In 58/185 (31%) cases clinicians did not put the self-monitored data to any evident use and in 12/185 (6.5%) cases patient-generated data prompted an unnecessary referral. In interviews and discussions, clinicians expressed mixed views on patient-generated data but foresaw a need to embrace and plan for this information flow, and proactively address challenges with integration into traditional care pathways.
Conclusions
This study suggests patient-generated data are being used for clinical decision-making in ad hoc and opportunistic ways. Given shifts towards remote monitoring in clinical care, accelerated by the pandemic, there is a need to consider how best to incorporate patient-generated data in clinical processes, introduce relevant training, pathways and governance frameworks, and manage associated risks.
People with severe mental illness (SMI) are two to three times more likely to be overweight and obese than the general population and this is associated with significant morbidity and premature ...mortality. Although lifestyle interventions can support people with SMI to lose weight, some are unable to make the necessary lifestyle changes or, despite making the changes, continue to gain weight.
To assess the feasibility and acceptability of delivering a full-scale trial evaluating whether liraglutide 3.0 mg, a once-daily injectable therapy, may be an effective treatment of overweight and obesity in people with schizophrenia, schizoaffective disorder and first-episode psychosis.
Design: a single-centre, double-blind, randomised, placebo-controlled trial.
mental health facilities within Southern Health NHS Trust.
60 adults with schizophrenia, schizoaffective or first-episode psychosis prescribed antipsychotic medication will be recruited. Participants will be overweight or obese, defined by their baseline BMI which will be: • BMI ≥ 30 kg/m
or • BMI ≥ 27 kg/m
to < 30 kg/m
in the presence of at least one weight-related consequence. This is in concordance with the current EU licence for liraglutide (maximum dosage 3.0 mg).
participants will be allocated in a 1:1 ratio using a computer-based randomisation programme to either once-daily subcutaneously administered liraglutide or placebo, titrated to 3.0 mg daily, for 6 months. All participants will receive standardised written information about healthy eating and exercise at their randomisation visit.
the main aim of the study is to gather data on recruitment, consent, retention and adherence. Qualitative interviews with a purposive sub-sample of participants and healthcare workers will provide data on intervention feasibility and acceptability. Secondary clinical outcome measurements will be assessed at 3 and 6 months and will include: weight, fasting plasma glucose, lipid profile, HbA
level; and the Brief Psychiatric Rating Scale.
This study should provide evidence of the potential benefits of liraglutide (maximum dosage 3.0 mg daily) on body weight and metabolic variables in people with schizophrenia, schizoaffective disorder and first-episode psychosis. It will also address the feasibility and acceptability of the use of liraglutide in mental health settings. This will inform the design of a longer outcome study that will be needed to determine whether any weight loss can be maintained in the long term.
Universal Trial Number (UTN), ID: U1111-1203-0068. Registered on on 2/10/2017. European Clinical Trials Database (EudraCT), ID: 2017-004064-35. Registered on 3/10/2017.
Background
Internet of Things (IoT) innovations such as wearables and sensors promise improved health outcomes and service efficiencies. Yet, most applications remain experimental with little routine ...use in health and care settings. We sought to examine the multiple interacting influences on IoT implementation, spread and scale-up, including the role of regional innovation ‘ecosystems’ and the impact of the COVID-19 context.
Methods
Qualitative study involving 20 participants with clinical, entrepreneurial and broader innovation experience in 18 in-depth interviews, focusing primarily on heart monitoring and assistive technology applications. Data analysis was informed by the NASSS (non-adoption, abandonment, scale-up, spread, sustainability) framework.
Results
Interviewees discussed multiple tensions and trade-offs, including lack of organisational capacity for routine IoT use, limited ability to receive and interpret data, complex procurement and governance processes, and risk of health disparities and inequalities without system support and funding. Although the pandemic highlighted opportunities for IoT use, it was unclear whether these would be sustained, with framings of innovation as ‘disruption’ coming at odds with immediate needs in healthcare settings. Even in an ‘ecosystem’ with strong presence of academic and research institutions, support was viewed as limited, with impressions of siloed working, conflicting agendas, fragmentation and lack of collaboration opportunities.
Conclusions
IoT development, implementation and roll-out require support from multiple ecosystem actors to be able to articulate a value proposition beyond experimental or small-scale applications. In contexts where clinical, academic and commercial worlds collide, sustained effort is needed to align needs, priorities and motives, and to strengthen potential for good value IoT innovation.
Type 1 diabetes (T1D) requires intensive self-management (SM). An insulin pump is designed to better support personal T1D management, but at the same time, it exacerbates the complexity and ...requirements of SM. Research shows that people with diabetes are likely to benefit from navigating and connecting to local means of social support and resources through web-based interventions that offer flexible, innovative, and accessible SM. However, questions remain as to which behavior change mechanisms within such resources benefit patients most and how to foster engagement with and endorsement of SM interventions.
The aim of this study was to evaluate the perspectives and experiences of people with T1D using an insulin pump and specialist health care professionals (HCPs) and determine what behavior change characteristics and strategies are required to inform the optimization of an existing web-based social network (SN) intervention to support SM.
Focus groups with insulin pump users (n=19) and specialist HCPs (n=20) in 6 National Health Service (NHS) trusts across the south of England examined the barriers and enablers to incorporating and self-managing an insulin pump. An analysis was undertaken using the Behavior Change Wheel and Theoretical Domains Framework, followed by a taxonomy of behavior change techniques (BCTs) to identify the contents of and strategies for the implementation of a complex health intervention.
A total of 4 themes represent the SM perspectives and experiences of stakeholders: (1) a desire for access to tailored and appropriate resources and information-the support and information required for successful SM are situational and contextual, and these vary according to time and life circumstances, and therefore, these need to be tailored and appropriate; (2) specific social support preferences-taking away isolation as well as providing shared learnings and practical tips, but limitations included the fear of judgment from others and self-pity from peers; (3) the environmental context, that is, capacity and knowledge of pump clinic HCPs-HCPs acknowledge the patient's need for holistic support but lack confidence in providing it; and (4) professional responsibility and associated risks and dangers, whereas HCPs are fearful of the consequences of promoting non-NHSSM support, and they question whether SM support fits into their role. BCTs were identified to address these issues.
The use of behavioral theory and a validated implementation framework provided a comprehensive approach for systematically identifying barriers and enablers of self-managing T1D with an insulin pump. A web-based SN intervention appears to offer additional forms of SM support while complementing NHS services. However, for intervention implementation, HCPs' apprehensions about responsibility when signposting to non-NHS SM support would need to be addressed, and opportunistic features would need to be added, through which pump users could actively engage with other people living with T1D.
Background
Insulin pump therapy (IPT) is a technological advancement that has been developed to help people manage Type 1 diabetes (T1D). However, ways of managing diabetes requiring the ...implementation of health technologies bring new complexities and a need to understand the factors which enable people with T1D to incorporate a novel device. This new comprehension could provide an exemplar for people with long‐term conditions to incorporate new technologies more generally.
Objective
To determine what influences the incorporation, adaptation and use of IPT into the everyday lives of people living with diabetes.
Design
Critical interpretive synthesis (CIS) using systematic searches undertaken in 7 electronic databases of literature, published 2008 onwards.
Results
A total of 4998 titles were identified, 274 s reviewed, 39 full articles retrieved and 22 papers selected for analysis. Three themes emerged which were of relevance to the introduction and use of IPT; Tensions between expectations and experiences in adoption and early adaptation; Negotiation of responsibility and accessing support; Reflexivity, active experimentation and feedback.
Conclusions
This CIS builds on earlier reviews on lived experiences of IPT. Novel insights are offered through examination of the experiences of pump users from children through to adults, their families and health‐care professionals. Expectations of what the device can do to improve self‐management impacts on the early stages of adoption as the reality of the technology requires substantial thought and action. Areas for intervention to improve IPT incorporation include establishing who is responsible for management tasks of the device and enabling navigation to further means of support and resources.
•Partners often involved in consultations with implications for treatment decisions.•Literature lacks direct observation and analysis of communicative processes.•Research should explore: partner ...involvement vs. other companion types in triads.•relationships between partner involvement and decision-making processes.
Explore how partners are involved in treatment-related decision-making within triadic clinical encounters.
Studies were identified via database searches and reference lists. One author assessed eligibility of studies, which were verified by an additional co-author. Data were extracted by one author and cross-checked for accuracy by a second. Quality of articles was assessed using Qualsyst. Retrieved studies were categorised by one author, and agreed through discussion.
From 2442 records, 14 studies were included and categorised as: (1) Descriptions of partner role and behaviour; (2) Role intentions of partners; (3) Relationship between partner and patient behaviour; (4) HCP-Partner interactions.
Partners are often involved in triadic clinical consultations that have implications for treatment-related decision making. Most studies offered general descriptions but lacked detailed investigation of communicative processes in triads and how these may operate with partners vs. other companions.
Existing studies lack detailed investigation through direct observation of the processes of partner involvement. Research in other areas of clinical communication suggests that future interventions could be informed by attention to the following areas: partner behaviour vs. other companion types in triads; relationships between partner involvement and decision-making processes; partner involvement in triads vs. other groups (e.g. quadratic).
Meetings can occur face to face (eg, coaching and information sharing), virtually (blogs or online communities, following tags or specific members of the community, or by accessing group talks or ...podcasts), or in formal groups (self-management education, semi-structured support groups, group consultations/clinics). Easy-to-use interface Peer led group self-management education Clearly defined outcomes, high level of quality assurance for many programmes, can be generic, allowing people with different or multiple conditions to benefit Requires high standards and time commitment to train facilitators Delivered by trained facilitators with lived experience using evidence-based materials Group consultations/clinics Allows people to hear questions asked/answered that they may not feel able to ask, creates a shared purpose, enables health beliefs to be addressed Requires high level of training and facilitation skills, and awareness of boundaries. For people who have a chronic health condition, talking to others can provide access to clinical care and resources, mutual encouragement, accessibility, relatability, and ongoing informational, instrumental, and emotional support.5131415 Support from peers can unlock opportunities to enhance healthcare provision, eg, through the provision of practical tips and examples to manage day-to-day challenges, and improving knowledge of the medical condition.1622 Support from peers can also help reduce depression, improve quality of life, and reduce levels of distress and anxiety for those experiencing mental health difficulties.1718 Further, this collective support, which encompasses beneficial emotional, practical and illness related “work”619 may contribute to improved clinical outcomes for people living with a long term condition by ameliorating the effects of condition-related distress.20 Peer support can enable people to feel in control and supported, and can provide a perception of choice around which self-management practices to undertake.20 A systematic review of randomised controlled trials found that telephone delivered self-management support for people with diabetes and vascular diseases, delivered by lay and peer support workers, significantly improved blood glucose levels and self-management behaviours.2122 The benefits of peer support extend to family carers,11 and some studies have also shown that peer support can help clinicians meet the needs of underserved populations.2425 What are the challenges and how can we address them? ...we have seen examples of clinicians engaging with groups and responding to needs, hosting online sessions for groups about particular topics or concerns that have arisen in the group (eg, managing sickness or travelling), or offering support from the NHS relating to self-management education, mental health, or different treatment options.2731 Clinicians can also support patients by providing a meeting space, facilitating engagement between patients who may wish to run a peer support group, and exploring how much involvement patients may want from the clinic or service, as well as the clinician’s capacity to provide this support.
The NHS App was launched as a 'front door' to digitally enabled health services, offering a range of services including appointment booking and ordering prescriptions. The extent of App use and its ...impacts on digital inclusion is under-explored.
To evaluate patterns of App uptake and adoption among different population groups.
Interrupted time series analyses explored aggregate monthly App usage from January 2019 - May 2021. Regression model assessed differences in App registration by markers of GP level socio-demographic variables. Qualitative interviews and focus groups involving 83 participants were conducted and analysed thematically.
There were 8,524,882 App downloads and 4,449,869 registrations. Negative binomial models found 25% less registrations in the most deprived practices (
<0.001) and 44% more registrations in the largest practices (
<0.001). Registration was 36% more in practices with the highest percentage of White patients (
<0.001) and 23% more in practices with highest percentage of 15-34-year-olds (
<0.001). In contrast, App registration was 13% less in practices with highest percentage of males (
<0.001) and 2% less in those with highest percentage of people with long-term care needs (
<0.001). Qualitative evaluation found that the App was not perceived as relevant or accessible for all and there are important cultural considerations (for example, language barriers and some restrictions in symptom checking for non-White skin). However, it can enable patients to hold services accountable.
There is high uptake of the NHS App but there are differences in adoption rates among different population groups and issues of relevance and accessibility, that warrant further work.
Social media provides a platform for easily accessible, relevant health information and emotional and practical support at the touch of a button for millions of people with diabetes. Therein however ...lies a challenge. The accuracy and reliability of such information is often unknown and unverified, not all interactions are deemed supportive; practically or emotionally, and not all members of society have equitable access. Cyber bullying, requests for personal information and uninvited sharing are among the risks associated with social media, yet the use of online social media is increasing exponentially. Such reliance on web-based health information has given rise to concerns about patients’ ability to accurately assess the credibility of online sources as well as the potential detrimental effect on personal well-being and patient-provider relations. In addition, there are rising digital disparities for particular subpopulations. Further, these concerns apply to where and how health care professionals should engage or refer patients to in terms of platforms of online support. There is little doubt regarding the popularity of social media, both within and outside of the health arena but there are also concerns. This article outlines five key areas associated with social media use in people living with diabetes and presents potential considerations moving forward. We focus on (1) social media as a platform for information and support; (2) social media interactions that are not supportive; (3) lessons from the DOC; (4) concerns about accuracy, reliability, and accessibility of information; and (5) differing priorities of health care professionals and patients.
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