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Poole R.,University of Cardiff | Gamper A.,University of Cardiff | Porter A.,The Nuffield Trust | Egbunike J.,Picker Institute Europe | Edwards A.,University of Cardiff
Family Practice | Year: 2011

Background and objective: Out-of-hours services for primary care provision are increasing in policy relevance. The aim of this qualitative study was to explore service users' recent experiences of out-of-hours services and to identify suggestions for improvement for services and practitioners involved. Methods: We used data from a cross-sectional survey of service users' self-reported experiences of 13 out-of-hours centres in Wales. Three hundred and forty-one respondents provided free-text comments focusing on suggestions for improvement within the survey instrument (the Out-ofhours Patient Questionnaire). A coding framework was based on previous literature focusing on patients' experiences of out-of-hours services, built upon and refined as it was systematically applied to the data. Emergent themes and subthemes were charted and interpreted to comprise the findings. Results: Central themes emerged from users' perspectives of the structure of out-of-hours services, process of care and outcomes for users. Themes included long waiting times, perceived quality of service user-practitioner communication, consideration for parents and children and accessibility of the service and medication. Suggestions for improving care were made across these themes, including triaging patients more effectively and efficiently, addressing specific aspects of practitioners' communication with patients, reconsidering the size of areas covered by services and number of professionals required for the population covered, extending GP and pharmacy opening times and medication delivery services. Conclusions: It is important to consider ways to address service users' principal concerns surrounding out-of-hours services. Debate is required about prioritizing and implementing potential improvements to out-of-hours services in the light of resource constraints. © The Authors 2010. Published by Oxford University Press.

Lewis G.,NHS England | Vaithianathan R.,University of Auckland | Vaithianathan R.,Singapore Management University | Wright L.,NHS Blood and Transplant | And 4 more authors.
International Journal of Integrated Care | Year: 2013

Background: Patients at high risk of emergency hospitalisation are particularly likely to experience fragmentation care. The virtual ward model attempts to integrate health and social care by offering multidisciplinary case management to people at high predicted risk of unplanned hospitalisation. Objective: To describe the care practice in three virtual ward sites in England and to explore how well each site had achieved meaningful integration. Method: Case studies conducted in Croydon, Devon and Wandsworth during 2011-2012, consisting of semi-structured interviews, workshops, and site visits. Results: Different versions of the virtual wards intervention had been implemented in each site. In Croydon, multidisciplinary care had reverted back to one-to-one case management. Conclusions: To integrate successfully, virtual ward projects should safeguard the multidisciplinary nature of the intervention, ensure the active involvement of General Practitioners, and establish feedback processes to monitor performance such as the number of professions represented at each team meeting.

Candilio L.,University College London | Malik A.,University College London | Ariti C.,The Nuffield Trust | Khan S.A.,University College London | And 11 more authors.
Journal of Cardiothoracic Surgery | Year: 2015

Background: Retrograde perfusion into coronary sinus during coronary artery bypass graft (CABG) surgery reduces the need for cardioplegic interruptions and ensures the distribution of cardioplegia to stenosed vessel territories, therefore enhancing the delivery of cardioplegia to the subendocardium. Peri-operative myocardial injury (PMI), as measured by the rise of serum level of cardiac biomarkers, has been associated with short and long-term clinical outcomes. We conducted a retrospective analysis to investigate whether the combination of antegrade and retrograde techniques of cardioplegia delivery is associated with a reduced PMI than that observed with the traditional methods of myocardial preservation. Methods: Fifty-four consecutive patients underwent CABG surgery using either antegrade cold blood cardioplegia (group 1, n = 28) or cross-clamp fibrillation (group 2, n = 16) or antegrade retrograde warm blood cardioplegia (group 3, n = 10). The study primary end-point was PMI, evaluated with total area under the curve (AUC) of high-sensitivity Troponin-T (hsTnT), measured pre-operatively and at 6, 12, 24, 48 and 72 hours post-surgery. Secondary endpoints were acute kidney injury (AKI) and inotrope scores, length of intensive care unit (ICU) and hospital stay, new onset atrial fibrillation (AF) and clinical outcomes at 6 weeks (death, non-fatal myocardial infarction, coronary artery revascularization, stroke). Results: There was evidence that mean total AUC of hsTnT was different among the three groups (P = 0.050). In particular mean total AUC of hsTnT was significantly lower in group 3 compared to both group 1 (-16.55; 95% CI: -30.08, -3.01; P = 0.018) with slightly weaker evidence of a lower mean hsTnT in group 3 when compared to group 2 (-15.13; 95% CI -29.87, -0.39; P = 0.044). There was no evidence of a difference when comparing group 2 to group 1 (-1.42,; 95% CI: -12.95, 10.12, P = 0.806). Conclusions: Our retrospective analysis suggests that, compared to traditional methods of myocardial preservation, antegrade retrograde cardioplegia may reduce PMI in patients undergoing first time CABG surgery. © 2014 Candilio et al.; licensee BioMed Central.

Bardsley M.,The Nuffield Trust | Billings J.,New York University | Dixon J.,The Nuffield Trust | Georghiou T.,The Nuffield Trust | And 2 more authors.
Age and Ageing | Year: 2011

Background: the costs of delivering health and social care services are rising as the population ages and more people live with chronic diseases. Objectives: to determine whether predictive risk models can be built that use routine health and social care data to predict which older people will begin receiving intensive social care. Design: analysis of pseudonymous, person-level, data extracted from the administrative data systems of local health and social care organisations.Setting: five primary care trust areas in England and their associated councils with social services responsibilities.Subjects: people aged 75 or older registered continuously with a general practitioner in five selected areas of England (n = 155,905). Methods: multivariate statistical analysis using a split sample of data. Results: it was possible to construct models that predicted which people would begin receiving intensive social care in the coming 12 months. The performance of the models was improved by selecting a dependent variable based on a lower cost threshold as one of the definitions of commencing intensive social care. Conclusions: predictive models can be constructed that use linked, routine health and social care data for case finding in social care settings. © The Author 2011. Published by Oxford University Press on behalf of the British Geriatrics Society. All rights reserved.

Steventon A.,The Nuffield Trust | Bardsley M.,The Nuffield Trust | Billings J.,New York University | Dixon J.,The Nuffield Trust | And 12 more authors.
Age and Ageing | Year: 2013

Objective: to assess the impact of telecare on the use of social and health care. Part of the evaluation of the Whole Systems Demonstrator trial. Participants and setting: a total of 2,600 people with social care needs were recruited from 217 general practices in three areas in England. Design: a cluster randomised trial comparing telecare with usual care, general practice being the unit of randomisation. Participants were followed up for 12 months and analyses were conducted as intention-to-treat. Data sources: trial data were linked at the person level to administrative datasets on care funded at least in part by local authorities or the National Health Service. Main outcome measures: the proportion of people admitted to hospital within 12 months. Secondary endpointsincluded mortality, rates of secondary care use (seven different metrics), contacts with general practitioners and practice nurses, proportion of people admitted to permanent residential or nursing care, weeks in domiciliary social care and notional costs. Results: 46.8% of intervention participants were admitted to hospital, compared with 49.2% of controls. Unadjusted differences were notstatistically significant (odds ratio: 0.90, 95% CI: 0.75-1.07, P = 0.211). They reached statistical significance after adjusting for baseline covariates, but this was not replicated when adjusting for the predictive risk score. Secondary metrics including impacts on social care use were not statistically significant. Conclusions: telecare as implemented in the Whole Systems Demonstrator trial did not lead to significant reductions in service use, at least in terms of results assessed over 12 months. International Standard Randomised Controlled Trial Number Register ISRCTN43002091. © The Author 2013. Published by Oxford University Press on behalf of the British Geriatrics Society.

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