Variations In Service Delivery Research Articles

Closing the Tobacco Treatment Gap: A Qualitative Study of Tobacco Cessation Service Implementation in Community Pharmacies.

Tobacco use remains a leading preventable cause of morbidity and mortality, with pharmacotherapy and counseling recognized as effective cessation aids. Yet, the potential role of pharmacists and pharmacy technicians in tobacco cessation services is underutilized. This study explores the integration of such services in community pharmacies, identifying facilitators and barriers to their implementation. A qualitative study was conducted across seven community pharmacies in California that were affiliated with the Community Pharmacy Enhanced Services Network. Participants included 22 pharmacists and 26 pharmacy technicians/clerks who completed tobacco cessation training. Data were collected through semi-structured interviews, focusing on experiences with implementing cessation services. The analysis was guided by Rogers' Diffusion of Innovations Theory. MAXQDA software was used for data management and thematic analysis. Sixteen pharmacy personnel participated in the study, highlighting key themes around the integration of cessation services. Compatibility with existing workflows, the importance of staff buy-in, and the crucial role of pharmacy technicians emerged as significant facilitators. Challenges included the complexity of billing for services, software limitations for documenting tobacco use and cessation interventions, and gaps in training for handling complex patient cases. Despite these barriers, pharmacies successfully initiated cessation services, with variations in service delivery and follow-up practices. Community pharmacies represent viable settings for delivering tobacco cessation services, with pharmacists and technicians playing pivotal roles. However, systemic changes are needed to address challenges related to billing, documentation, and training. Enhancing the integration of cessation services in community pharmacies could significantly impact public health by increasing access to effective cessation support.

Green Procurement and Service Delivery of County Governments in Western Region, Kenya

The framers of the Public Procurement Law envisaged to streamline how public procurement should be conducted in order to realize value for money in public procuring entities. The primary objective of the research thus was to determine the effect of green procurement on service delivery of County Governments in Western Region, Kenya. The study adopted a positivist research approach and was informed by ecological modernization theory. The study was conducted in Western Region, Kenya in the Counties of Kakamega, Busia, Vihiga, and Bungoma. The study's target population of 228 officials was broken down into chief officers, directors, finance officers, and procurement officers. The study selected 174 participants as its sample. Primary data was gathered through interview schedules and a questionnaire. A pilot study was carried out to test for validity and reliability. The data analysis made use of both descriptive and inferential statistics. SPSS version 26 was used to analyse quantitative data while qualitative data was analysed thematically alongside study objectives. Green procurement was found to be a significant predictor of service delivery in County Governments. Specifically the study's findings showed that Green Procurement explains 23% of variation in service delivery of County Governments in western Kenya Region. Green Procurement had unstandardized regression value of 0.368. This suggested that County Governments in the Western Region, Kenya will boost the delivery of services by 36.8% for each additional unit in green procurement. The study came to the conclusion that there is need for the County Governments to ensure legislation, enforcement and adherence to environmental laws and policies.

Reanalysis of genomic data, how do we do it now and what if we automate it? A qualitative study

Automating reanalysis of genomic data for undiagnosed rare disease patients presents a paradigm shift in how clinical genomics is delivered. We aimed to map the current manual and proposed automated approach to reanalysis and identify possible implementation strategies to address clinical and laboratory staff’s perceived challenges to automation. Fourteen semi-structured interviews guided by a simplified process map were conducted with clinical and laboratory staff across Australia. Individual process maps were integrated into an overview of the current process, noting variation in service delivery. Participants then mapped an automated approach and were invited to discuss perceived challenges and possible supports to automation. Responses were analysed using the Consolidated Framework for Implementation Research, linking to the Expert Recommendations for Implementing Change framework to identify theory-informed implementation strategies. Process mapping demonstrates how automation streamlines processes with eleven steps reduced to seven. Although participants welcomed automation, challenges were raised at six of the steps. Strategies to overcome challenges include embedding project champions, developing education materials, facilitating clinical innovation and quality monitoring tools, and altering reimbursement structures. Future work can build on these findings to develop context specific implementation strategies to guide translation of an automated approach to reanalysis to improve clinical care and patient outcomes.

Norwegian speech-language pathologists treatment practices for preschool children who stutter: An explorative study

PurposeThis study investigated the treatment practices of speech-language pathologists (SLPs) with preschool children who stutter to explore variations in service delivery and, consequently to better inform and support evidence-based practice. Method121 Norwegian SLPs completed an online survey about stuttering treatment for preschool children aged up to six years. They reported on treatment training, choices, setting, dosage, and outcomes. Data was analysed descriptively. Correlation analyses between years of clinical experience and clinician perceived outcomes were conducted. ResultSixty-eight percent of SLPs were trained in one or more stuttering treatment programs. The majority of SLPs (83 %) provided treatment in person in preschool centers; 59 % reported providing treatment once a week. Thirty-four percent of SLPs reported that they often or always delivered the whole treatment program. Treatment practice addressed various elements, including advising parents about language and communication strategies, supporting the child's self-image, and perceived outcomes. The SLPs reported their clinician perceived outcomes as ‘always’ or ‘often’ reduction of audible stuttering (70 %), reduced cognitive and emotional reactions (55 %), and improved communication skills (58 %). Factors influencing treatment choices were identified at the systemic level (e.g., work place regulations) and individual level (e.g., SLPs competency, child’s best). ConclusionStuttering treatment services in Norway differ from those reported in existing literature as treatment is given in preschool settings, only 34 % of SLPs deliver programs as intended whilst the majority use treatment elements only, and still experience positive changes. Provision is variable, and seems influenced by SLP training and competence.

Digital service technologies, service robots, AI, and the strategic pathways to cost-effective service excellence

ABSTRACT Recent research has shown that the trade-off between customer satisfaction and productivity can be mitigated through three strategic pathways: the (1) operations management (OM) approach, (2) focused service factory, and (3) dual culture strategy, which allow firms to achieve cost-effective service excellence (CESE). We advance that these strategies are also excellent enablers for the development, implementation, and use of digital service technologies, service robots, and artificial intelligence (AI). First, the OM approach reduces process variations in service delivery, creating opportunities for leveraging technology to automate processes. Second, the focused service factory strategy enables high volumes of largely identical service transactions with minimized customer-induced variability, easing service automation. Third, the dual culture strategy ensures that digital automation is firmly customer-centric and achieves service excellence. We advance a set of propositions and research questions aimed at stimulating research at the intersection of the two streams of literature on digital service technologies and CESE.

Accompanying mental health problems at home: Preliminary data from a crisis resolution and home treatment team in Catalonia.

INTRODUCTION: Crisis resolution and home treatment teams (CRHTTs) provide intensive home care to people in a mental health crisis, becoming an increasingly widespread alternative to hospital admissions. However, there are wide variations in service delivery, organization, and outcomes, and little literature on how these teams work in clinical practice and different settings. To share the organizational functioning, the therapeutic approach, and the outcomes obtained in a CRHTT in Catalonia, Spain. A descriptive analysis of the functioning of a home treatment team, the characteristics of the people served, and the clinical results from November 2017 to December 2019 are presented. One hundred and five people were served, with an average stay of 57 days. And 55.24% were women, and the mean age was 41. Most people could overcome the crisis at home, and 5.71% required hospital admission during home care. A statistically significant improvement was observed in the results of the GAF and HoNOS scales at admission and discharge. Despite reduced staff, home care was an alternative to hospital admission for most people treated. Flexibility, teamwork, and collaboration with the social network are relevant factors when accompanying the recovery process at home.

Health System Factors Affecting the Experience of Non-Invasive Ventilation Provision of People with Neuromuscular Disorders in New Zealand

Non-invasive ventilation (NIV) is a critical therapy for many patients with neuromuscular disorders (NMD), supporting those with respiratory failure to achieve adequate respiration and improve their quality of life. The aim of this study was to explore the experiences of access to, consent, uptake, maintenance and safe use of non-invasive ventilation by people with NMD. Semi-structured individual interviews were conducted with 11 people with NMD, each using NIV for more than 12 months. A critical realism ontological paradigm with contextualism epistemology guided the Reflexive Thematic Analysis. An Equity of Health Care Framework underpinned the analysis. Three themes were interpreted: Uptake and informed consent for NIV therapy; Practicalities of NIV; and Patient-clinician relationships. We identified issues at the system, organization and health professional levels. Conclusions: We recommend the development of national service specifications with clear standards and dedicated funding for patients with NMD and call on the New Zealand Ministry of Health to proactively investigate and monitor the variations in service delivery identified. The specific areas of concern for patients with NMD suggest the need for NMD-related NIV research and service provision responsive to the distinct needs of this population.

Leg ulcer service provision in NHS hospitals.

To explore the service provision for compression therapy for inpatients with leg ulcers in UK hospitals. An online survey was carried out to explore the service provision in hospital settings. It was distributed to Wounds UK National Conference delegates and to wound care specialist groups using social media. The authors received 101 responses from health professionals in the UK. Of these, 67.3% reported there was no dedicated service for inpatients with leg ulceration and only 32% said compression therapy was provided in their hospitals. This survey confirmed there is a significant shortfall in care provision for patients with leg ulcers in secondary care and highlighted the wide variations in service delivery in hospitals. Further research is needed to understand the reasons for these variations.

Factors associated with attendance at screening for breast cancer: a systematic review and meta-analysis

ObjectiveAttendance at population-based breast cancer (mammographic) screening varies. This comprehensive systematic review and meta-analysis assesses all identified patient-level factors associated with routine population breast screening attendance.DesignCINAHL, Cochrane Library, Embase, Medline,...

Is England's public health nutrition system in crisis? A qualitative analysis of the capacity to feed all in need during the COVID-19 pandemic

Methodology: An exploratory methodology was adopted to examine experiences relating to capability and capacity among formal and informal helpers within the PHN domain. An online survey, mainly open-ended questions, was used to capture experiences over the period 2010 - 2020. A mixed sampling strategy, including snowball and convenience sampling, via social media and social network contact-sharing approaches, was adopted. Data was analysed using an inductive thematic approach.
 Results: A total of 89 participants representing the PHN system in England were recruited over two months. Three main themes and eight sub-themes were identified. The first reflected unequivocal accounts of the impact of austerity and the inability of PHN services to meet demand for food security. The second articulated capacity and capability issues within the system, with geographical variations in service delivery, and a lack of connectivity between central, local government, and third sector providers. These were attributed to widening nutrition and health inequalities. Participants felt that the government needed to invest more technical and financial resources to support public health nutrition. They also felt that schools could play a larger role at local level, but there was a need for a clear national recovery plan, setting out a comprehensive and fully supported national strategy to eradicate food insecurity in England
 Conclusions: Further in-depth research is needed to continue to track the impact of recovery strategies on food insecure people and the capacity of the PHN system. Urgent investment in the capacity and coordination of PHN services is needed to support food insecure people in England. The UK could include the ratification of the right to food in national laws, in line with global commitments already agreed to by the UK State Party.

Dysphagia and mealtime difficulties in dementia: Speech and language therapists' practices and perspectives.

There is increasing recognition of the impact that dementia has upon swallowing and at mealtimes, and the significant effect this can have on people with dementia's health and well-being. However, there remains a paucity of evidence for assessment and intervention practices for dysphagia and mealtime difficulties. Furthermore, there is a limited understanding of how speech and language therapists (SLTs) support people with these dementia-related issues and what are the barriers and facilitators to practice. Further research is therefore needed to guide policy as well as service guideline and delivery development. To establish the current practices of SLTs managing dementia-related dysphagia and mealtime difficulties in the UK and Republic of Ireland (ROI), and to establish their opinions and experiences of what challenges or supports to practice they have encountered. An anonymous, cross-sectional web-based survey was developed and distributed to SLTs working in the UK and ROI. Respondents completed a questionnaire that consisted of open and closed questions across nine topic areas. Closed responses were evaluated using descriptive statistics; open-ended questions were analysed using conventional content analysis. A total of 310 people accessed the survey, and 125 respondents completed it fully. While respondents agreed on their role in dysphagia management, they varied in their views on the extent of their role in managing mealtime difficulties. Additionally, their self-rated knowledge of mealtime difficulties in dementia was lower than their dysphagia knowledge. The respondents predominantly based their management decisions on their clinical experience of working with people with dementia. They primarily used compensatory strategies and frequently cited the need for family and care staff training. Respondents also highlighted barriers to effective management and training provision such as inefficient referral systems, a lack of carer knowledge and lack of SLT resources. The results provide valuable insight into the issues facing SLTs practising in this area. The SLTs surveyed considered dysphagia a core part of their role when supporting people with dementia; however, respondents' views on mealtime difficulties varied. This highlights the need to establish consensus guidelines on the SLT's role in order to avoid variations in service delivery that could negatively impact the health and well-being of people with dementia. Moreover, further research to develop efficient and effective training for care staff supporting mealtime difficulties and dysphagia is essential. What this paper adds What is already known on the subject Research indicates that people with dementia develop dysphagia and mealtime difficulties as dementia progresses. SLTs often manage these, but there is no research on the effective assessment and management procedures, or guidance on best practice. What this paper adds to existing knowledge This paper provides an understanding of the variation in practice across the UK and ROI. Respondents described barriers to delivering an effective service and frequently linked these to the SLTs' resources as well as service constraints. What are the potential or actual clinical implications of this work? These findings support the need for future research to develop guidelines for SLT practice in this area. They also support the need to examine resource allocation and workforce management to enable SLTs to manage dementia-related dysphagia and mealtime difficulties effectively.

Evaluating alcohol intoxication management services: the EDARA mixed-methods study

Background Front-line health-care services are under increased demand when acute alcohol intoxication is most common, which is in night-time environments. Cities have implemented alcohol intoxication management services to divert the intoxicated away from emergency care. Objectives To evaluate the effectiveness, cost-effectiveness and acceptability to patients and staff of alcohol intoxication management services and undertake an ethnographic study capturing front-line staff’s views on the impact of acute alcohol intoxication on their professional lives. Methods This was a controlled mixed-methods longitudinal observational study with an ethnographic evaluation in parallel. Six cities with alcohol intoxication management services were compared with six matched control cities to determine effects on key performance indicators (e.g. number of patients in the emergency department and ambulance response times). Surveys captured the impact of alcohol intoxication management services on the quality of care for patients in six alcohol intoxication management services, six emergency departments with local alcohol intoxication management services and six emergency departments without local alcohol intoxication management services. The ethnographic study considered front-line staff perceptions in two cities with alcohol intoxication management services and one city without alcohol intoxication management services. Results Alcohol intoxication management services typically operated in cities in which the incidence of acute alcohol intoxication was greatest. The per-session average number of attendances across all alcohol intoxication management services was low (mean 7.3, average minimum 2.8, average maximum 11.8) compared with the average number of emergency department attendances per alcohol intoxication management services session (mean 78.8), and the number of patients diverted away from emergency departments, per session, required for services to be considered cost-neutral was 8.7, falling to 3.5 when ambulance costs were included. Alcohol intoxication management services varied, from volunteer-led first aid to more clinically focused nurse practitioner services, with only the latter providing evidence for diversion from emergency departments. Qualitative and ethnographic data indicated that alcohol intoxication management services are acceptable to practitioners and patients and that they address unmet need. There was evidence that alcohol intoxication management services improve ambulance response times and reduce emergency department attendance. Effects are uncertain owing to the variation in service delivery. Limitations The evaluation focused on health service outcomes, yet evidence arose suggesting that alcohol intoxication management services provide broader societal benefits. There was no nationally agreed standard operating procedure for alcohol intoxication management services, undermining the evaluation. Routine health data outcomes exhibited considerable variance, undermining opportunities to provide an accurate appraisal of the heterogenous collection of alcohol intoxication management services. Conclusions Alcohol intoxication management services are varied, multipartner endeavours and would benefit from agreed national standards. Alcohol intoxication management services are popular with and benefit front-line staff and serve as a hub facilitating partnership working. They are popular with alcohol intoxication management services patients and capture previously unmet need in night-time environments. However, acute alcohol intoxication in emergency departments remains an issue and opportunities for diversion have not been entirely realised. The nurse-led model was the most expensive service evaluated but was also the most likely to divert patients away from emergency departments, suggesting that greater clinical involvement and alignment with emergency departments is necessary. Alcohol intoxication management services should be regarded as fledgling services that require further work to realise benefit. Future work Research could be undertaken to determine if a standardised model of alcohol intoxication management services, based on the nurse practitioner model, can be developed and implemented in different settings. Future evaluations should go beyond the health service and consider outcomes more generally, especially for the police. Future work on the management of acute alcohol intoxication in night-time environments could recognise the partnership between health-care, police and ambulance services and third-sector organisations in managing acute alcohol intoxication. Trial registration Current Controlled Trials ISRCTN63096364. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 24. See the NIHR Journals Library website for further project information.

The Effect of Procurement Practices on Service Delivery: A Case Study of VRA, Ghana

This study was conducted to determine the effect of procurement policy, procurement planning and sustainable procurement on service delivery. The study employed a quantitative research approach and explanatory design. The target population for the study was staff and management of the Volta River Authority. Structured questionnaire was used to gather primary data. The study used SPSS version 32.0 for the data analyses. The study found that 73.6% variations in service delivery were explained by Procurement Policy, Procurement Planning and Sustainable Procurement. The study found that Procurement Policy (β = 0.623 ρ=0.000< 0.05) are significant determinants of service delivery thus a unit change in procurement policy will result in 62.3% change in service delivery. Procurement Planning (β = 0.027, ρ=0.080< 0.05) are significant determinants of service delivery thus a unit change in procurement planning will result in 2.7% change in service delivery. Sustainable Procurement (β = 0.39 ρ=0.000 < 0.05) are a significant determinant of service delivery. Thus a unit change in Sustainable Procurement will result in 39% change in service delivery. From the model estimation, procurement policy was the strongest predictor of service delivery followed by sustainable procurement and lastly procurement planning. The study revealed a strong significant positive correlation between procurement policy and service delivery. Moreover, the result showed a strong significant positive correlation between procurement planning and service delivery. Again the study found a significant positive correlation between sustainable procurement and service delivery. The study concludes that Procurement Policy, Procurement Planning and Sustainable Procurement significantly predict service delivery of VRA. The study recommends that the management of VRA must continuously invest in sustainable procurement, procurement planning and procurement policy to enhance service delivery to the public.

INFRASTRUCTURE, RESOURCES, SERVICES EVALUATION AND GAP ANALYSIS OF INTEGRATED MATERNAL AND CHILD DEVELOPMENT SERVICES IN INDIA

Background. Integrated Child Development Services (ICDS) is an Indian community-centric government program organized under Anganwadi centres catering to supplementary nutrition, health and preschool education, primary healthcare, growth monitoring and counselling the children under six years old along with their mothers. It is the world’s largest outreach program in a developing country covering a population of 1.35 billion; the variations in service delivery were analysed involving cross-sectional rural and urban Anganwadi centers in New Delhi.
 Methods. Data were collected by assessment of children and mothers, interview of Anganwadi workers and observation of service delivery parameters and conduction of activities. Infrastructural, beneficiaries, services and content were evaluated by a suitable pre-tested questionnaire based on the National Institute of Public Cooperation and Child Development (NIPCCD) evaluation proforma. The data was analysed by a descriptive statistics.
 Results. Gaps were found in respect of infrastructure, resources, health and nutrition facilities especially at rural Anganwadi centre which was inadequate in terms of implementation of nutrition and health program, supplementary nutrition, preschool education and nutrition rehabilitation centre for existing beneficiaries. Both Anganwadi centres were not catering for new WHO growth standards and adolescent health.
 Conclusions. Gaps found in respect of infrastructure, resources, health and nutrition facilities can affect performance of ICDS program and the services delivered by Anganwadi centres, which need a boost. Both urban and rural centres have a direct opportunity towards delivering adolescent health program focusing on nutrition and education of girls prior to their pregnancy, and adoption of new WHO growth standards.

Core vocabulary therapy for the treatment of inconsistent phonological disorder: Variations in service delivery

Approximately 10% of children with a speech sound disorder present with an inconsistent phonological disorder, characterized by inconsistent production of words across multiple trials. A number of studies have provided evidence of the efficacy of core vocabulary therapy for the remediation of this speech sound disorder with a dosage of two speech-language therapy sessions per week. The present study aimed to investigate if two variations of core vocabulary therapy under real world conditions were effective in improving consistency in the speech of children with inconsistent phonological disorder. Variation A was based on standard administration of core vocabulary therapy (with the addition of a third session per week) and Variation B involved one therapy session per week with a speech-language therapist and an imitation based home program delivered by caregivers. This effectiveness study involved five participants (four males, one female) with inconsistent phonological disorder. The ages of the participants ranged from 39 to 59 months at baseline. One child participated in Variation A and four children participated in Variation B. Changes in consistency of speech between baseline and post-therapy were analysed using the Wilcoxon signed-rank test. Consistency of speech improved significantly between and pre- and post-test assessment for four out of five participants treated with either variation A or B. These results suggest that core vocabulary therapy delivered once per week with a speech language therapist and using imitation home practice may be an alternative therapy option for children with inconsistent phonological disorder, with implications for the cost and time required. These findings also challenge our theoretical understanding of the locus of impairment in inconsistent phonological disorder. Given the small number of participants in the study, there is a need for replication of these research findings using a larger number of participants.

Self‐reported optometric practise patterns in age‐related macular degeneration

BackgroundThe use of advanced imaging in clinical practice is emerging and the use of this technology by optometrists in assessing patients with age‐related macular degeneration is of interest. Therefore, this study explored contemporary, self‐reported patterns of practice regarding age‐related macular degeneration diagnosis and management using a cross‐sectional survey of optometrists in Australia and New Zealand.MethodsPractising optometrists were surveyed on four key areas, namely, demographics, clinical skills and experience, assessment and management of age‐related macular degeneration. Questions pertaining to self‐rated competency, knowledge and attitudes used a five‐point Likert scale.ResultsCompleted responses were received from 127 and 87 practising optometrists in Australia and New Zealand, respectively. Advanced imaging showed greater variation in service delivery than traditional techniques (such as slitlamp funduscopy) and trended toward optical coherence tomography, which was routinely performed in age‐related macular degeneration by 49 per cent of respondents. Optical coherence tomography was also associated with higher self‐rated competency, knowledge and perceived relevance to practice than other modalities. Most respondents (93 per cent) indicated that they regularly applied patient symptoms, case history, visual function results and signs from traditional testing, when queried about their management of patients with age‐related macular degeneration. Over half (63 per cent) also considered advanced imaging, while 31 per cent additionally considered all of these as well as the disease stage and clinical guidelines. Contrary to the evidence base, 68 and 34 per cent rated nutritional supplements as highly relevant or relevant in early age‐related macular degeneration and normal aging changes, respectively.ConclusionsThese results highlight the emergence of multimodal and advanced imaging (especially optical coherence tomography) in the assessment of age‐related macular degeneration by optometrists. Clinically significant variations in self‐rated test competency and the understanding regarding nutritional supplements for different stages of age‐related macular degeneration suggest that further work to up‐skill optometrists may be required.

Parent experiences of variations in service delivery of Rapid Syllable Transition (ReST) treatment for childhood apraxia of speech

ABSTRACTPurpose: To understand parents’ perceptions of Rapid Syllable Transition (ReST) treatment and their experience of either telehealth or combined parent-clinician delivery of speech–language pathology. Method: Thematic analyses of semi-structured interviews were conducted with 10 parents (5 telehealth, 5 parent-clinician) after their child completed 12 sessions of ReST treatment. Results: Three themes were unique to telehealth: “telehealth was a million times easier,” “technical problems weren’t deal breakers,” and “telehealth therapy has different boundaries.” Three themes were unique to parent-clinician delivery: “therapy is something to get over and done with,” “I wasn’t very good at doing therapy,” and “my child doesn’t like me as his therapist.” Both groups had themes related to the significance of childhood apraxia of speech, the importance of specialist treatment, and ReST being a “different way forward.” Conclusions: Speech–language pathologists should carefully consider the suitability of caregiver-provided ReST treatment, and increase telehealth delivery of ReST treatment.

A High-Touch Model of Community-Based Specialist Palliative Care: Latent Class Analysis Identifies Distinct Patient Subgroups

ContextCommunity-based palliative care may support seriously ill homebound patients. Programs vary widely, and few studies have described the heterogeneity of the populations served or service delivery models. ObjectivesTo evaluate a diverse population served by an interdisciplinary model of community-based specialist palliative care and the variation in service delivery over time and identify subgroups with distinct illness burden profiles. MethodsA retrospective cohort study evaluated longitudinal electronic health record data from 894 patients served during 2010–2013. Illness burden was defined by measures of performance status (Karnofsky Performance Status scale), symptom distress (Condensed Memorial Symptom Assessment Scale), palliative care needs (Palliative Outcome Scale), and quality of life (Spitzer Quality of Life Index). Service utilization included the frequency of visits received and calls made or received by patients. Latent class analysis identified patient subgroups with distinct illness burden profiles, and mixed-effects modeling was used to evaluate associations between patient characteristics and service utilization. ResultsThe mean age was 72.3 years (SD = 14.0); 56.2% were women; 67.5% were English speaking; and 22.2% were Spanish speaking. Most had congestive heart failure (36.4%) or cancer (30.4%); 98.0% had a Karnofsky Performance Status score of 40–70. Four patient subgroups were identified: very low illness burden (26.2%); low burden (39.5%); moderate burden (13.5%); and high burden (20.8%). The subgroups differed in both baseline characteristics and palliative care service utilization over time. ConclusionThe population served by a community-based specialist palliative care program manages patients with different levels of illness burden, which are associated with patient characteristics and service utilization.

A new primary dental care service compared with standard care for child and family to reduce the re-occurrence of childhood dental caries (Dental RECUR): study protocol for a randomised controlled trial.

BackgroundIn England and Scotland, dental extraction is the single highest cause of planned admission to the hospital for children under 11 years. Traditional dental services have had limited success in reducing this disease burden. Interventions based on motivational interviewing have been shown to impact positively dental health behaviours and could facilitate the prevention of re-occurrence of dental caries in this high-risk population. The objective of the study is to evaluate whether a new, dental nurse-led service, delivered using a brief negotiated interview based on motivational interviewing, is a more cost-effective service than treatment as usual, in reducing the re-occurrence of dental decay in young children with previous dental extractions.Methods/DesignThis 2-year, two-arm, multicentre, randomised controlled trial will include 224 child participants, initially aged 5 to 7 years, who are scheduled to have one or more primary teeth extracted for dental caries under general anaesthesia (GA), relative analgesia (RA: inhalation sedation) or local anaesthesia (LA). The trial will be conducted in University Dental Hospitals, Secondary Care Centres or other providers of dental extraction services across the United Kingdom. The intervention will include a brief negotiated interview (based on the principles of motivational interviewing) delivered between enrolment and 6 weeks post-extraction, followed by directed prevention in primary dental care. Participants will be followed up for 2 years. The main outcome measure will be the dental caries experienced by 2 years post-enrolment at the level of dentine involvement on any tooth in either dentition, which had been caries-free at the baseline assessment.DiscussionThe participants are a hard-to-reach group in which secondary prevention is a challenge. Lack of engagement with dental care makes the children and their families scheduled for extraction particularly difficult to recruit to an RCT. Variations in service delivery between sites have also added to the challenges in implementing the Dental RECUR protocol during the recruitment phase.Trial registrationISRCTN24958829 (date of registration: 27 September 2013), Current protocol version: 5.0.Electronic supplementary materialThe online version of this article (doi:10.1186/s13063-015-1010-9) contains supplementary material, which is available to authorized users.

Supporting Workers with Musculoskeletal Conditions: A Survey of United Kingdom Occupational Therapists' Communications with Clients and Their Employers

Introduction: Musculoskeletal conditions are a common cause of sickness absence and work disability. Little is known about the work-related advice and support that occupational therapists provide to this client group and their employers. The purpose of this study was to report on current occupational therapy practice in this area in the United Kingdom. Method: A questionnaire survey was conducted, of United Kingdom occupational therapists treating employed clients with musculoskeletal conditions in community or outpatient settings. Questionnaires were posted to 960 hospitals or units, identified through National Health Service websites to reach as many respondents as possible, and the survey was also available online. Findings: 257 respondents reported on their provision of work-related advice and support. Of these, over 30% (n = 82) reported that this involved a moderate amount of their time; 60% (n = 154) had experience of contacting employers and 21% (n = 55) had met with clients' employers in the previous year. Time and resources, concern about legal implications, and having the appropriate skills had an impact on communication between therapists and employers. Conclusion: The findings demonstrate considerable variations in service delivery, interventions, and the contact made with employers. These need urgent attention if the profession is to meet the challenges of the government's agenda for improving health at work.