Secondary Care Need Research Articles

Barriers and potential solutions for collaboration between primary and secondary care in patients with persistent somatic symptoms and functional disorders: A nominal group technique study

Background Persistent somatic symptoms and functional disorders (PSS/FD) are complex conditions requiring collaboration between healthcare professionals. This is especially true at the interface between primary and secondary care interface. The current fragmentation of care is a major barrier to this, leading to poor experiences and outcomes and high costs for healthcare and society. Objectives The aim is to identify barriers and possible solutions for collaboration between primary and secondary care in patients with PSS/FD. Methods In two sessions, using the nominal group technique, a mix of primary and secondary care professionals identified barriers and possible solutions to collaboration between primary and secondary care in PSS/FD care. Barriers to collaboration were identified during session one, with potential solutions identified during session two in response to the top eight barriers. Each session ended with a voting round ranking the barriers and solutions. Results A total of 102 healthcare professionals participated in two sessions. In the first session, 55 participants provided a list of 22 barriers, while in the second session, 47 participants provided 18 possible solutions. The top barriers related to shared language and protocols, referral quality, expectations and responsibilities between healthcare professionals and patients, and time pressure. The top solutions identified related to general practitioners using electronic consultations with specialists and shared terminology with patients. Conclusion The identified barriers and possible solutions for collaboration between primary and secondary care need attention when considering collaboration in PSS/FD care and related settings, both in new and ongoing collaborations.

P115 Healthcare professionals' perspectives on integrating predictive and emerging preventive approaches in rheumatoid arthritis care: A qualitative investigation

Abstract Background/Aims There is an increasing interest in treating individuals at risk of rheumatoid arthritis (RA) with preventive drugs and several clinical trials have already reported results. Once developed, a successful predictive and preventive strategy needs to be integrated in the healthcare system. The current research explores the perceptions of health care professionals (HCPs) regarding this, and factors that may affect this integration. Methods We conducted one-to-one semi-structured qualitative interviews (either face-to-face or by telephone) with HCPs based in the West Midlands (UK). Audio recordings of the interviews were transcribed, coded and the data were analysed by thematic analysis facilitated by NVIVO. Results Nineteen HCPs (11 female, 8 male) were interviewed, including ten GPs, six rheumatologists and three rheumatology nurse specialists. The coding and thematic analysis of the transcripts identified four organising themes: Attributes of predictive and preventive approaches; Ethical and psychological concerns; Implementation issues; and Learning from management of other conditions. Theme 1 described necessary attributes of predictive and preventive approaches that interviewees highlighted, including the type and performance of the predictive test, the need for a clear evidence base for preventive approaches and consideration of the risks and benefits associated with the preventive treatment. Theme 2 described the ethical and psycho-social concerns that interviewees raised, including the potential negative economic, financial and psychological effects of risk disclosure for ‘at-risk' individuals and uncertainty around the development of RA and the potential for benefit associated with the treatments being considered. Theme 3 describes the implementation issues HCPs considered, including knowledge and training needs, the costs and resource implications of implementing predictive testing and preventive treatment, the role of different types of HCPs, guidelines and tools needed for implementation and patient characteristics, such as age and family history on appropriateness of prescribing preventive treatments. Theme 4 related to the lessons that could be learned from interviewees’ experiences of prediction and prevention in other disease areas, including relevant knowledge, of how preventive treatment is prescribed, existing guidelines and tools for other diseases which could be adapted for RA prevention and issues relating to risk communication. Conclusion For the successful implementation of predictive and preventative approaches in RA, HCPs across primary and secondary care need appropriate training about predictive tests, test interpretation, communication of results to at-risk individuals, and intervention options. Evidence of cost-efficiency, appropriate resource allocation, adaptation of official guidelines and careful consideration of the at-risk individuals’ psycho-social needs are also needed. Disclosure G. Simons: None. I. Wells: None. J.P. Kanacherril: None. C.D. Mallen: Grants/research support; CM is funded by the NIHR School for Primary Care Research and the NIHR ARC West Midlands. K. Raza: Grants/research support; K.R. is supported by the National Institute for Health Research Birmingham Biomedical Research Centre. M. Falahee: None.

Detection and treatment of mental disorders in patients with coronary heart disease (MenDis-CHD): A cross-sectional study.

Mental disorders (MD) are associated with an increased risk of developing coronary heart disease (CHD) and with higher CHD-related morbidity and mortality. There is a strong recommendation to routinely screen CHD patients for MDs, diagnosis, and treatment by recent guidelines. The current study aimed at mapping CHD patients' (1) state of diagnostics and, if necessary, treatment of MDs, (2) trajectories and detection rate in healthcare, and (3) the influence of MDs and its management on quality of life and patient satisfaction. The design was a cross-sectional study in three settings (two hospitals, two rehabilitation clinics, three cardiology practices). CHD patients were screened for MDs with the Hospital Anxiety and Depression Scale (HADS), and, if screened-positive, examined for MDs with the Structured Clinical Interview for DSM-IV (SCID-I). Quality of Life (EQ-5D), Patient Assessment of Care for Chronic Conditions (PACIC), and previous routine diagnostics and treatment for MDs were examined. Descriptive statistics, Chi-squared tests, and ANOVA were used for analyses. Analyses of the data of 364 patients resulted in 33.8% positive HADS-screenings and 28.0% SCID-I diagnoses. The detection rate of correctly pre-diagnosed MDs was 49.0%. Physicians actively approached approximately thirty percent of patients on MDs; however, only 6.6% of patients underwent psychotherapy and 4.1% medication therapy through psychotherapists/psychiatrists. MD patients scored significantly lower on EQ-5D and the PACIC. The state of diagnostic and treatment of comorbid MDs in patients with CHD is insufficient. Patients showed a positive attitude towards addressing MDs and were satisfied with medical treatment, but less with MD-related advice. Physicians in secondary care need more training inadequately addressing mental comorbidity.

Does the quality and outcomes framework reduce psychiatric admissions in people with serious mental illness? A regression analysis

BackgroundThe Quality and Outcomes Framework (QOF) incentivises general practices in England to provide proactive care for people with serious mental illness (SMI) including schizophrenia, bipolar disorder and other psychoses. Better...

Do higher primary care practice performance scores predict lower rates of emergency admissions for persons with serious mental illness? An analysis of secondary panel data

BackgroundSerious mental illness (SMI) is a set of chronic enduring conditions including schizophrenia and bipolar disorder. SMIs are associated with poor outcomes, high costs and high levels of disease burden. Primary care plays a central role in the care of people with a SMI in the English NHS. Good-quality primary care has the potential to reduce emergency hospital admissions, but also to increase elective admissions if physical health problems are identified by regular health screening of people with SMIs. Better-quality primary care may reduce length of stay (LOS) by enabling quicker discharge, and it may also reduce NHS expenditure.ObjectivesWe tested whether or not better-quality primary care, as assessed by the SMI quality indicators measured routinely in the Quality and Outcomes Framework (QOF) in English general practice, is associated with lower rates of emergency hospital admissions for people with SMIs, for both mental and physical conditions and with higher rates of elective admissions for physical conditions in people with a SMI. We also tested the impact of SMI QOF indicators on LOS and costs.DataWe linked administrative data from around 8500 general practitioner (GP) practices and from Hospital Episode Statistics for the study period 2006/7 to 2010/11. We identified SMI admissions by a mainInternational Classification of Diseases, 10th revision (ICD-10) diagnosis of F20–F31. We included information on GP practice and patient population characteristics, area deprivation and other potential confounders such as access to care. Analyses were carried out at a GP practice level for admissions, but at a patient level for LOS and cost analyses.MethodsWe ran mixed-effects count data and linear models taking account of the nested structure of the data. All models included year indicators for temporal trends.ResultsContrary to expectation, we found a positive association between QOF achievement and admissions, for emergency admissions for both mental and physical health. An additional 10% in QOF achievement was associated with an increase in the practice emergency SMI admission rate of approximately 1.9%. There was no significant association of QOF achievement with either LOS or cost. All results were robust to sensitivity analyses.ConclusionsPossible explanations for our findings are (1) higher quality of primary care, as measured by QOF may not effectively prevent the need for secondary care; (2) patients may receive their QOF checks post discharge, rather than prior to admission; (3) people with more severe SMIs, at a greater risk of admission, may select into practices that are better organised to provide their care and which have better QOF performance; (4) better-quality primary care may be picking up unmet need for secondary care; and (5) QOF measures may not accurately reflect quality of primary care. Patient-level data on quality of care in general practice is required to determine the reasons for the positive association of QOF quality and admissions. Future research should also aim to identify the non-QOF measures of primary care quality that may reduce unplanned admissions more effectively and could potentially be incentivised.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Which patients with type 2 diabetes attend secondary care clinics?

AbstractThe aim of this study was to investigate the reasons for patients with type 2 diabetes continuing to attend a specialist clinic with an active discharge policy.Clinic letters of 526 patients with type 2 diabetes who attended annual review over one year were audited to identify the major reasons for them remaining in the clinic.The majority of patients (97.3%) fulfilled current specialist clinic criteria for remaining in the clinic. Poor glycaemic control, nephropathy, ongoing changes to management and diabetes foot problems were common reasons found. In 9% of cases, patient choice was identified as a factor. For 2.7% of patients no clear reason could be identified.It was concluded that while most patients fulfilled the criteria to continue attending the clinic at that time, some patients chose to remain even though they were fit for discharge. The reasons why patients choose to remain under secondary care need to be investigated as they could guide how primary and secondary care should work together. Copyright © 2013 John Wiley & Sons.

G238 Make Love Not War: Bridging the Gap Between Primary and Secondary Paediatric Care

AimTo determine the number of presentations to a new Children’s Emergency Department (CED) that could have been managed in primary care.MethodsAll Patients were assessed to determine the appropriateness of attendance....

Are Family Doctors Compliant with Breast Family History Guidelines?

Introduction: Optimizing breast cancer care involves accurate risk assessment. Referrals to secondary care need to be appropriate both in terms of healthcare resource utilisation and the reduction of unnecessary patient anxiety. Aim: This study undertook an evaluation of family doctors compliance with NICE guidelines for asymptomatic family history referrals to a breast unit. Methods: A retrospective audit of general practice in County Donegal was carried out between January 2010 and May 2011. NICE guidelines and IBIS computerised model were used to assess whether referrals were appropriate. Results: 77.6% (90/116) met a criterion for secondary care referral. 51.7% (60/116) met the NICE criteria and 64.7% (75/116) met the IBIS criteria for referral to secondary care. 38.8% (45/116) met both. 6 were of low risk, 45 were of moderate risk and 1 was of high risk. 80.4% (45/56) of the patients who did not meet the NICE criteria, failed to do so because they had one 1st degree relative with breast cancer who was over the age of 40. Conclusion: 77.6% of referrals complied with international criteria for referral to secondary care. A greater understanding of what constitutes appropriate referral of 1st degree relatives would enhance the referral process.

Physical health and severe mental illness: If we don't do something about it, who will?

Physical health and severe mental illness: If we don't do something about it, who will?

Socioeconomic and ethnic group differences in self reported health status and use of health services by children and young people in England: cross sectional study

Objectives: To examine whether self reported health status and use of health services varies in children of different social class and ethnic group.Design: Cross sectional study from the 1999 health...

Stresses and coping strategies of mothers living with a child with cystic fibrosis: implications for nursing professionals.

Cystic fibrosis (CF) is the most common inherited disease of childhood. Caring for a child with CF is stressful and this has implications for the main carer, the parental relationship, well siblings, family functioning as well as the affected child. This study aimed to explore current stresses and coping strategies used by mothers and to identify roles and strategies that nursing professionals could extend or adopt to support them and families of children with CF. Semi-structured interviews were carried out with 17 mothers of children with CF who attended the regional cystic fibrosis hospital clinic. Interviews were analysed using the Framework method of analysis. The study suggests that major stresses for many mothers are feeling in the middle in terms of decision-making particularly concerning the genetic implications of CF, the burden of responsibility for parenting a child with a chronic illness, and coming to terms with a personal change in identity. The most commonly used coping strategy was seeking support from others including nursing professionals. Relationships with health professionals in secondary care were generally positive, with nurses often the first people mothers turned to when they had concerns and also key in interpreting medical information. Relationships with primary care health professionals appeared to be more limited with a role reversal described by some mothers who felt it their responsibility to educate and inform primary care professionals about CF. This study suggests that nursing professionals in primary and secondary care need to look beyond the care of the child to the needs of the mother. It provides evidence to suggest that nursing professionals in primary and secondary care have a number of important roles to play as holders of hope, bridge builders and in providing continuity of care for such families. It also suggests strategies to strengthen nurse-patient relationship.

Failing to take the medicine

Prescribing, purchasing and taking medication is a major component of healthcare provision in UK. The effectiveness of medication depends on both the appropriateness of the medication and the regimen used. Thus failure to take medication appropriately is likely to result in therapeutic failure such as a continued infective state and unrelieved symptoms. However, inappropriate use of medication also has major economic consequences at national and individual levels, e.g. misuse of expensive drugs, the social and economic costs of ill health and increased health needs which may result in the need for secondary care. Nonetheless, the evidence suggests that many clients do not follow the terms of their prescriptions and this is particularly true in chronic illness.