bluuebunny/crossref_metadata_2025_split huggingface dataset:
HOW DO PEOPLE WITH CHRONIC CONDITIONS EXPERIENCE CARE IN THE HYWEL DDA HEALTH BOARD AREA? FINDINGS FROM INTERVIEWS WITH PATIENTS
Authors: Evans B A , Morrison-Rees S , Harris-Mayes R , Hurlin C 
Published: April 2015

BackgroundThe Welsh Government's strategy to improve Chronic Conditions Management includes improving care coordination and patient self-management to reduce unscheduled care use. Welsh health boards have responsibility for implementing the strategy since 2008. In 2011, integrated working between health and social care professionals was piloted in Carmarthenshire, part of Hywel Dda Health Board.ObjectiveTo describe how people with chronic conditions experience care in Hywel Dda Health Board including changes due to integrated working by professionals.MethodWe conducted semi-structured telephone interviews with chronic conditions patients with multiple and complex conditions. Interviews were recorded, transcribed and analysed using a framework approach. The research team comprised two academic members, two service users and one manager of local health services.ResultsThirty interviews were undertaken. Experience of care had a big effect on quality of life and helped ability to self-manage, alongside personal outlook, support and information. When missing, patients struggled to manage medication and symptoms. Patients reported variation in coordination between conditions. Respondents with stable or few conditions did not generally identify gaps between different services providing their care. Patients with very poor health appeared to have well integrated care. People with multiple conditions identified lack of communication, slow information exchange and a condition-specific not person-focused approach to care. Difficulties travelling to hospital caused worry and patients missed appointments. It was difficult to discern differences in how care was delivered between Carmarthenshire and other parts of Hywel Dda Health Board.ConclusionPeople with multiple and complex chronic conditions appear confident about self managing their health. Integrated working across providers seems to work best for patients who are least or most ill; otherwise people with multiple conditions complain that care is disease-specific not patient-focused. Accessing treatment should be considered as a component of care because difficult travel arrangements are preventing people attending appointments.
STROKE MIMICS IN THE PRE-HOSPITAL SETTING
Authors: Edwards M J , Fothergill R T , Williams J , Gompertz P 
Published: April 2015

Accurate identification of stroke patients is essential to ensure appropriate and timely treatment. Stroke mimics—patients initially suspected to have suffered a stroke who are subsequently diagnosed with a condition other than stroke—are estimated to account for 5–33% of suspected stroke patients conveyed by paramedics to a hospital stroke unit. The prevalence of stroke mimics in London has not been investigated although pan-London hospital data suggests that one quarter of all patients admitted to hyper-acute stroke units (HASUs) are stroke mimics.Participants were recruited as part of a larger study investigating whether the use of the Recognition of Stroke in the Emergency Room (ROSIER) tool by ambulance crews improved pre-hospital stroke recognition. Only patients indicated by the ROSIER to have potentially suffered a stroke and conveyed to a participating HASU (n=256) were included.A final diagnosis of stroke was received by 160 patients (“strokes”) while 96 patients received a final diagnosis of non-stroke (“mimics”), resulting in a stroke mimic rate of 38%. Mimics received a wide range of diagnoses, including seizure, syncope, brain tumour, non-organic stroke/symptoms, sepsis, somatisation, and migraine. Compared to strokes, mimics had a lower total ROSIER score, displayed fewer stroke-related symptoms, and presented with more symptoms not indicative of a stroke (e.g. loss of consciousness/syncope, seizure).The stroke mimic rate is higher than reported by previous studies and pan-London hospital data. It is unlikely this higher rate is due to the use of the ROSIER since the specificity of the ROSIER is equal to the FAST in the pre-hospital setting (Fothergillet al, submitted). Stroke recognition in the pre-hospital setting needs to be improved in order to reduce the number of non-strokes falsely identified as stroke and to ensure these patients are taken to the appropriate facility for treatment.
LEADERSHIP, INNOVATION AND ENGAGEMENT IN QUALITY IMPROVEMENT IN THE AMBULANCE SERVICES CARDIOVASCULAR QUALITY INITIATIVE: CROSS SECTIONAL STUDY
Authors: Essam Nadya , Phung Viet-Hai , Asghar Zahid , Spaight Anne , Siriwardena Aloysius Niroshan 
Published: April 2015

IntroductionClinical leadership and organisational culture are important contextual factors for successful Quality Improvement (QI) programmes. The relationship between these and with organisational performance is complex and poorly understood. We aimed to explore the relationship between leadership, culture of innovation, and clinical engagement in QI for organisations participating in a large-scale national ambulance Quality Improvement Collaborative (QIC).MethodsWe used a cross sectional survey design. An online questionnaire was distributed to 22,117 frontline ambulance staff across all 12 ambulance services in England. Scores (0–100%) were derived for each key aspect: clinical leadership; culture of innovation; use of QI methods; and effectiveness of QI methods. Responses to an open-ended question were analysed and complemented the quantitative findings.ResultsThere were 2,743 (12%) responses from 11 of 12 participating ambulance services. Despite only a small proportion of responders (3%) being directly involved with ASCQI, leadership behaviour was significantly higher for ASCQI members than for non-ASCQI members. Involvement in ASCQI was not significantly associated with responders' perceptions of the culture of innovation of their organisation, which was generally considered to be poor. ASCQI members were significantly more likely to use QI methods but overall uptake of QI methods was low. The use of QI methods was also significantly associated with leadership behaviour and service tenure.LimitationsThere was a low response rate, although sufficient responses to enable comparison of those who participated in ASCQI with those who did not.Conclusion and recommendationsAlthough participants reported a lack of organisational culture of innovation, considered a prerequisite for QI, the collaborative achieved significant wide-scale improvements in prehospital care for myocardial infarction and stroke. We postulate that improvement was mediated through a ‘QI subculture’ developed from ASCQI's distributed leadership and network. Further research is needed to understand success factors for QI in different complex healthcare environments.
AMBULANCE SERVICE TREAT AND REFER GUIDELINES: A QUALITAIVE INVESTIGATION INTO THE USE OF TREAT AND REFER GUIDELINES BY AMBULANCE CLINICIANS
Authors: Colver Keith , Abhyankar Purva , Niven Catherine 
Published: April 2015

BackgroundOver the last decade there has been a steadily increasing demand for unscheduled healthcare services, including the ambulance services. To address this demand, various projects have been developed to reduce admissions to the emergency department. One of these was the introduction of Treat and Refer (T&R) guidelines, to allow ambulance clinicians to treat certain groups of patients in the community without the need to convey them to hospital. Aims: This study aims to explore the challenges and barriers faced by ambulance clinicians in the use of T&R guidelines, to inform the future development and governance of non-conveyance guidelines and interventions.MethodsSemi-structured interviews were conducted with 18 ambulance clinicians. Data were analysed using framework analysis. Setting: A national UK NHS ambulance service.ResultsThere was a broad support for the concept and policy of T&R; however the participants had mixed views with respect to the actual practice of treating and referring patients. Participants acknowledged the potential benefits of T&R for patients and the NHS, but identified several risks in using T&R in routine practice. Their perceptions of risk seemed to determine whether and how the guidelines were used. Challenges in the use of T&R included: lack of training and knowledge, fear of litigation, a lack of support from the management and difficulties in decision-making.ConclusionsThis study and the supporting literature do not support the use of T&R guidelines in their current format by traditionally trained ambulance clinicians. Ambulance clinicians have identified the need for further education and support. The conceptual support for T&R may provide a foundation to develop and improve the education and support for ambulance clinicians. This should be combined with implementation/review strategies, clinician-led decision support and management support which can provide the ambulance clinician with the skills and confidence to take responsibility for non-conveyance.
PREHOSPITAL OUTCOMES FOR AMBULANCE SERVICE CARE: SYSTEMATIC REVIEW
Authors: Phung Viet-Hai , Booth Andrew , Coster Joanne , Turner Janette , Wilson Richard , Niroshan Siriwardena A. 
Published: April 2015

BackgroundAmbulance service performance measurement has previously focused on response times and survival. We conducted a systematic review of the international literature on quality measures and outcomes relating to pre-hospital ambulance service care, aiming to identify a broad range of outcome measures to provide a more meaningful assessment of ambulance service care.MethodsWe searched a number of electronic databases including CINAHL, the Cochrane Library, EMBASE, Medline, and Web of Science. For inclusion, studies had to report either research or evaluation conducted in a pre-hospital setting, published in the English language from 1982 to 2011, and reporting either outcome measures or specific outcome instruments.ResultsOverall, 181 full-text articles were included: 83 (46%) studies from North America, 50 (28%) from Europe and 21 (12%) from the UK. A total of 176 articles were obtained after examining 257 full-text articles in detail from 5,088 abstracts screened. A further five papers were subsequently identified from references of the articles examined and studies known to the authors. There were 140 articles (77%) which contained at least one survival-related measure, 47 (34%) which included information about length of stay and 87 (48%) which identified at least one place of discharge as an outcome.LimitationsWe encountered the problem of incomplete information, for instance studies not specifying which pain scales when these had been used or using survival without a specific time period.Conclusion and recommendationsIn addition to measures relating to survival, length of stay and place of discharge, we identified 247 additional outcome measures. Few studies included patient reported or cost outcomes. By identifying a wide range of outcome measures this review will inform further research looking at the feasibility of using a wider range of outcome measures and developing new outcome measures in prehospital research and quality improvement.
BARRIERS AND FACILITATORS FOR PEOPLE IN BME GROUPS ACCESSING PRE-HOSPITAL CARE AND CAUSES AND CONSEQUENCES OF ANY DIFFERENCES IN DELIVERY: SYSTEMATIC REVIEW AND NARRATIVE SYNTHESIS
Authors: Windle Karen , Niroshan Siriwardena A , Barot Mukesh , Essam Nadya , Johnson Mark , Kai Joe , Ortega Marishona 
Published: April 2015

IntroductionResearch addressing inequalities has focused predominantly on primary and community care; few initiatives relate to the pre-hospital environment. We aimed to identify in the literature barriers or facilitators experienced by patients from BME communities in accessing pre-hospital care and to explore the causes and consequences of any differences in delivery.MethodsWe conducted a systematic literature review and narrative synthesis. Electronic and journal hand searches from 2003 through 2013 identified relevant evaluative studies (systematic reviews, randomised controlled trials, quasi-experimental, case and observational studies). A researcher extracted data to determine characteristics, results and quality, each checked by a second reviewer. The main outcome measures were delays in patient calls, mortality rates and 30-days survival post discharge.ResultsEighteen studies met criteria for the review: two concerned services in England and Wales and 15 were United States based. Reported barriers to accessing care were generic (and well-known) given the heterogeneity of BME groups: difficulties in communication where English was the patient's second language; new migrants' lack of knowledge of the health care system leading to inappropriate emergency calls; and cultural assumptions among clinical staff resulting in inappropriate diagnoses and treatment. There were limited reported facilitators to improvement, such as the need for translation services and staff education, but the latter were poorly described or developed. Where outcomes were discussed, there was evidence for race-related disparity in mortality and survival rates. This could reflect differences in condition severity, delays between onset and initiation of calls, or the scope of response and assistance.ConclusionThe paucity of literature and difficulties of transferring findings from US to UK context identified an important research gap. Further studies should be undertaken to investigate UK differences in prehospital care and outcomes for BME groups, followed by qualitative approaches to understand barriers and enablers to equitable access.
INTRODUCTION OF A PREDICTIVE RISK TOOL IN PRIMARY CARE: CONTEXT AND EXPECTATIONS
Authors: Kingston Mark Rhys , Evans Bridie Angela 
Published: April 2015

IntroductionPatients with chronic conditions account for a third of emergency hospital admissions, many of which are not life-threatening and result in unnecessary hospital stays. Focussed primary and community care could prevent one-in-five emergency admissions, improving health outcomes and saving money. Predictive risk models which use routine data to identify at risk populations for targeted care aim to reduce emergency admissions but we do not know how GPs react to their introduction.The Prism tool predicts likelihood of patient's emergency admission to hospital and divides the entire practice population into risk categories low to high. Swansea University is leading the PRISMATIC trial, evaluating the introduction of Prism into 32 Welsh GP practices.Prism, and other similar tools, effectively predict admissions but questions remain over their adoption. We asked potential users of Prism how they expect its introduction to affect patient care and emergency admissions.Methods43 GPs, practice managers and nurses from 32 general practices participated in one of four focus groups or an interview before receiving Prism. We recorded the groups and interviews, with participants' consent, and carried out thematic analysis of transcripts.ResultsWe found that respondents supported the principle of proactively identifying at risk patients and were willing to trial Prism. It appealed to their desire to improve care through targeting patients who could become emergencies. Perceived challenges included: integrating Prism with existing practice; limited time and community staff to follow up identified patients.SummaryRisk predictions tools like Prism effectively predict hospital emergency admissions and are increasingly being introduced. Without sufficient evidence about how practitioners perceive and use these tools, their introduction is unlikely to make a difference to patients—nor have the desired effect on resources. PRISMATIC will provide evidence about how context and expectations can affect implementation.
INVESTIGATING THE VOLUME OF MENTAL HEALTH EMERGENCY CALLS IN THE WELSH AMBULANCE SERVICE TRUST (WAST) AND DEVELOPING A PRE-HOSPITAL MENTAL HEALTH MODEL OF CARE FOR APPLICATION AND TESTING
Authors: Morisson-Rees Sian , Whitfield Richard , Evans Sherrill , Snooks Helen , Huxley Peter , John Ann , Baker Chris , Engamba Serge , Rees Nigel 
Published: April 2015

BackgroundLimited published evidence indicates a significant impact from mental health related calls on ambulance services (AS), however available routine data appear to underestimate the amount of these calls and the resources spent in response.Paramedics have reported feeling ill-equipped for informed clinical decision-making in mental health cases: leaving at home can risk self harm, but conveying to an emergency departments is often not the most appropriate place for patients with mental distress and unnecessarily ties up resources.ObjectiveTo investigate mental health 999 calls in WAST and design a relevant model-of-care for testing.MethodWe examined the Patient Clinical Records (PCR) completed by paramedics on scene for all calls handled by WAST in April 2012. We extracted an electronically generated 10% random sample and coded the narrative section based upon ICD 10 codes.We mapped statutory mental health services in three different ambulance trusts. A panel of experts identified the critical factors and devised a generic model of care based upon an ideal model to support paramedics and the pragmatics of existing services.ResultsIn April 2012 WAST handled 28,328 999 calls, with 1642 (5.8%) recorded with a mental health condition code. In the random sample we found 164 (10.5%) calls related to mental health problems and estimate the volume to be 2974 per month. Each category of mental health problem had a conveyance rate of over 80%, with the exception of anxiety (61.6%)The alternative statutory services available varies by AS area, however enough commonality existed to reach consensus and design a generic mental health model of care.ConclusionBoth dispatch and on-scene condition codes underestimate the volume of mental health related emergency calls by nearly half. Our model of care provides considerable potential to support paramedics to assess and reduce transfers to emergency departments through access to pre-existing community care provision.
SINGLE DOSE ACTIVATED CHARCOAL FOR PRE-HOSPITAL USE, A FEASIBILITY STUDY BY SOUTH WESTERN AMBULANCE SERVICE NHS FOUNDATION TRUST
Authors: Walker Richard , Black Sarah 
Published: April 2015

In 2004 The National Institute for Health and Care Excellence (NICE) recommended in that ambulance services should carry Single Dose Activated Charcoal (SDAC) as an antidote to self-poisoning.A survey of ambulance services conducted a year later found a strong reluctance by services to carry the medication.As a result of a research project supporting the recommendation of NICE the South Western Ambulance Service conducted a six month trial of SDAC in two of its zones.A Patient Group Directive was produced and an education programme put in place.Patient Report Forms coded for overdose or where SDAC had been used were retrieved and examined for data. An on-line survey was completed by staff who had been involved in the trial.Paramedic crews attending cases of self-poisoning within one hour of ingestion offered SDAC to those patients.Of 69 occasions on which the medication was offered the uptake rate was 94%.54% of administrations (n=38) were for hepatotoxic overdoses of paracetamol with a further 3 administrations for lethal doses of other types of drug.Crews used Toxbase on 13 occasions finding their advice extremely clear and helpful. This resulted in SDAC administration on all 13 occasions where crews were uncertain about its suitability on grounds of type of toxin ingested or because the one hour window had been exceeded..Average time from ingestion to SDAC administration was 23 minutes and 26 seconds.Time on scene where SDAC was offered was 20 minutes and 24 seconds compared with 23 minutes and 26 seconds where SDAC was not offered.Vomiting post administration occurred in only 11% of cases and crews reported no problems encountered in managing patients.Concerns of ambulance services in 2005 of prolonged on-scene times, poor take-up and time required to clean ambulances appear unfounded.
Women's economic activity trajectories over the life course: implications for the self-rated health of women aged 64+ in England
Authors: Stone Juliet , Evandrou Maria , Falkingham Jane , Vlachantoni Athina 
Published: April 2015

BackgroundPrevious research has highlighted the importance of accumulated life-course labour market status and the balancing of multiple roles for understanding inequalities in health in later life. This may be particularly important for women, who are increasingly required to balance work and family life in liberal welfare contexts, such as in Britain.MethodsThis study analyses retrospective life history data for 2160 women aged 64+ years (born 1909–1943) from the English Longitudinal Study of Ageing, collected in 2006–2007 as part of an ongoing panel study. Optimal matching and cluster analyses are used to produce a taxonomy of women's life-course economic activity trajectories based on their experiences between ages 16 and 64 years. This classification is then used in logistic regression analysis to investigate associations with self-rated health in later life.ResultsA set of five trajectories emerge as the dominant patterns of women's economic activity over the life course for those cohorts of English women born prior to 1943: (1) full-time workers; (2) family carers; (3) full-time returners; (4) part-time returners; (5) atypical/inactive. Regression analyses show that women who experience defined periods of full-time work both before and after focusing on family life appear to have the most favourable later life health outcomes.ConclusionsThe findings are discussed with reference to the accumulation of social and economic resources over the life course and the balancing of multiple roles in work and family domains. In conclusion, the development of policies that facilitate women, if they wish, to successfully combine paid employment with family life could have a positive impact on their health in later life.
Effect of a community intervention programme promoting social interactions on functional disability prevention for older adults: propensity score matching and instrumental variable analyses, JAGES Taketoyo study
Authors: Hikichi Hiroyuki , Kondo Naoki , Kondo Katsunori , Aida Jun , Takeda Tokunori , Kawachi Ichiro 
Published: April 2015

BackgroundThe efficacy of promoting social interactions to improve the health of older adults is not fully established due to residual confounding and selection bias.MethodsThe government of Taketoyo town, Aichi Prefecture, Japan, developed a resident-centred community intervention programme called ‘community salons’, providing opportunities for social interactions among local older residents. To evaluate the impact of the programme, we conducted questionnaire surveys for all older residents of Taketoyo. We carried out a baseline survey in July 2006 (prior to the introduction of the programme) and assessed the onset of functional disability during March 2012. We analysed the data of 2421 older people. In addition to the standard Cox proportional hazard regression, we conducted Cox regression with propensity score matching (PSM) and an instrumental variable (IV) analysis, using the number of community salons within a radius of 350 m from the participant's home as an instrument.ResultsIn the 5 years after the first salon was launched, the salon participants showed a 6.3% lower incidence of functional disability compared with non-participants. Even adjusting for sex, age, equivalent income, educational attainment, higher level activities of daily living and depression, the Cox adjusted HR for becoming disabled was 0.49 (95% CI 0.33 to 0.72). Similar results were observed using PSM (HR 0.52, 95% CI 0.33 to 0.83) and IV-Cox analysis (HR 0.50, 95% CI 0.34 to 0.74).ConclusionsA community health promotion programme focused on increasing social interactions among older adults may be effective in preventing the onset of disability.