Publications by authors named "Barbara Hanratty"

85 Publications

Trends in health expectancies: a systematic review of international evidence.

BMJ Open 2021 05 25;11(5):e045567. Epub 2021 May 25.

Population & Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.

Objectives: A clear understanding of whether increases in longevity are spent in good health is necessary to support ageing, health and care-related policy.

Design: We conducted a systematic review to update and summarise evidence on trends in health expectancies, in Organisation for Economic Co-operation and Development (OECD) high-income countries.

Data Sources: Four electronic databases (MEDLINE, 1946-19 September 2019; Embase 1980-2019 week 38; Scopus 1966-22 September 2019, Health Management Information Consortium, 1979-September 2019), and the UK Office for National Statistics website (November 2019).

Eligibility Criteria: English language studies published from 2016 that reported trends in healthy, active and/or disability-free life expectancy in an OECD high-income country.

Data Extraction And Synthesis: Records were screened independently by two researchers. Study quality was assessed using published criteria designed to identify sources of bias in studies reporting trends, and evidence summarised by narrative synthesis.

Findings: Twenty-eight publications from 11 countries were included, covering periods from 6 to 40 years, between 1970 and 2017. In most countries, gains in healthy and disability-free life expectancy do not match the growth in total life expectancy. Exceptions were demonstrated for women in Sweden, where there were greater gains in disability-free years than life expectancy. Gains in healthy and disability-free life expectancy were greater for men than women in most countries except the USA (age 85), Japan (birth), Korea (age 65) and Sweden (age 77).

Conclusion: An expansion of disability in later life is evident in a number of high-income countries, with implications for the sustainability of health and care systems. The recent COVID-19 pandemic may also impact health expectancies in the longer term.
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http://dx.doi.org/10.1136/bmjopen-2020-045567DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154999PMC
May 2021

COVID-19 testing during care home outbreaks: the more the better?

Age Ageing 2021 May 12. Epub 2021 May 12.

Population Health Sciences Institute, Newcastle University.

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http://dx.doi.org/10.1093/ageing/afab100DOI Listing
May 2021

Future-proofing the primary care workforce: A qualitative study of home visits by emergency care practitioners in the UK.

Eur J Gen Pract 2021 Dec;27(1):68-76

Population Health Sciences Institute, Newcastle University, Newcastle-upon-Tyne, United Kingdom.

Background: Broadening the skill-mix in general practice is advocated to build resilience into the primary care workforce. However, there is little understanding of how extended-scope practitioners from different disciplines, such as paramedicine and nursing, embed into roles traditionally ascribed to general practitioners (GPs).

Objectives: This study sought to explore patients' and professionals' experiences of a primary care home visiting service delivered by emergency care practitioners (ECPs), in place of GPs; to determine positive impacts/unintended consequences and establish whether interdisciplinary working was achieved.

Methods: Three practices in England piloted an ECP (extended-scope practitioners with a paramedic or nursing background) home visiting service (November 2018-March 2019). Following the pilot, focus groups were conducted with each of the three primary healthcare teams (14 participants, including eight GPs), and one with ECPs (five participants) and nine individual patient interviews. Data were analysed using a modified framework approach.

Results: The impact of ECP home visiting on GP workload and patient care was perceived as positive by patients, GPs and ECPs. Initial preconceptions of GPs and patients about the ECP role and expertise, and reservations about the appropriacy of ECPs for home visiting, were perceived to have been overcome by the expertise and interpersonal skills of ECPs. Fostering a culture of collaboration between ECPs and GPs was instrumental to remodelling professional boundaries at the practice level.

Conclusion: Broadening the skill-mix to incorporate extended-scope practitioners such as ECPs, to deliver primary care home visiting, presents an opportunity to increase resilience in the general practice workforce.
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http://dx.doi.org/10.1080/13814788.2021.1909565DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8118426PMC
December 2021

Patient and public involvement in care home research: Reflections on the how and why of involving patient and public involvement partners in qualitative data analysis and interpretation.

Health Expect 2021 May 11. Epub 2021 May 11.

Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.

Background: There is limited evidence for the impact of involving patients and the public (PPI) in health research. Descriptions of the PPI process are seldom included in publications, particularly data analysis, yet an understanding of processes and impacts of PPI is essential if its contribution to research is to be evaluated.

Objective: To describe the 'how' of PPI in qualitative data analysis and critically reflect on potential impact.

Methods: We focus on the development and critical reflection of our step-by-step approach to collaborative qualitative data analysis (through a series of analysis workshops) in a specific care home study, and our long-term engagement model with patients and the public (termed PPI partners).

Results: An open access PPI group, with multiple events over time, sustained broad interest in care home research. Recordings of interview clips, role-play of interview excerpts and written theme summaries were used in workshops to facilitate PPI partner engagement with data analysis in a specific study. PPI resulted in changes to data interpretation and was perceived to make the research process accessible. We reflect on the challenge of judging the benefits of PPI and presenting PPI in research publications for critical commentary.

Conclusions: Patient and public involvement partners who are actively engaged with data analysis can positively influence research studies. However, guidance for researchers is needed on approaches to PPI, including appropriate levels and methods for evaluation. Without more systematic approaches, we argue that it is impossible to know whether PPI represents good use of resources and is generating a real impact.
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http://dx.doi.org/10.1111/hex.13269DOI Listing
May 2021

Changes in health and functioning of care home residents over two decades: what can we learn from population-based studies?

Age Ageing 2021 May;50(3):921-927

Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE4 5PL, UK.

Background: Care home residents have complex care and support needs. There is a perception that the needs of residents have increased, but the evidence is limited. We investigated changes in health and functioning of care home residents over two decades in England and Wales.

Methods: We conducted a repeated cross-sectional analysis over a 24 year period (1992-2016), using data from three longitudinal studies, the Cognitive Function and Ageing Studies (CFAS) I and II and the English Longitudinal Study of Ageing (ELSA). To adjust for ageing of respondents over time results are presented for the 75-84 age group.

Results: Analysis of 2,280 observations from 1,745 care home residents demonstrated increases in severe disability (difficulty in at least two from washing, dressing and toileting). The prevalence of severe disability increased from 63% in 1992 to 87% in 2014 (subsequent fall in 2016 although wide confidence intervals). The prevalence of complex multimorbidity (problems in at least three out of six body systems) increased within studies over time, from 33% to 54% in CFAS I/II between 1992 and 2012, and 26% to 54% in ELSA between 2006 and 2016.

Conclusion: Over two decades, there has been an increase in disability and the complexity of health problems amongst care home residents in England and Wales. A rise in support needs for residents places increasing demands on care home staff and health professionals, and should be an important consideration for policymakers and service commissioners.
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http://dx.doi.org/10.1093/ageing/afaa227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099147PMC
May 2021

Factors affecting primary care practitioners' alcohol-related discussions with older adults: Qualitative study.

Br J Gen Pract 2021 May 4. Epub 2021 May 4.

Newcastle University Population Health Sciences Institute, Newcastle upon Tyne, United Kingdom.

Background: Risk of harm from drinking is heightened in later life, due to age-related sensitivities to alcohol. Primary care services have a key role in supporting older people to make healthier decisions about alcohol.

Aim: To examine primary care practitioners' perceptions of factors that promote and challenge their work to support older people in alcohol risk-reduction.

Design And Setting: Qualitative study consisting of semi-structured interviews and focus groups with primary care practitioners in Northern England.

Method: Thirty-five practitioners (general practitioners, practice/district nurses, pharmacists, dentists, social care practitioners, domiciliary carers) participated in eight interviews and five focus groups. Data were analysed thematically, applying principles of constant comparison.

Results: Practitioners highlighted particular sensitivities amongst older people to discussing alcohol, and reservations about older people's resistance to making changes in old age; given drinking practices could be established, and promote socialisation and emotional wellbeing in later life. Age-related health issues increased older people's contact with practitioners; but management of older people's long-term conditions was prioritised over discussion of alcohol. Dedicated time to address alcohol in routine consultations with older people, and training in alcohol intervention facilitated practitioners; particularly pharmacists and practice nurses.

Conclusion: There are clear opportunities to support older people in primary care to make healthier decisions about alcohol. Dedicated time to address alcohol, training in identification of alcohol-related risks, particularly those associated with old age; and tailored interventions for older people, feasible to implement in practice settings, would support primary care practitioners to address older people's alcohol use.
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http://dx.doi.org/10.3399/BJGP.2020.1118DOI Listing
May 2021

The pathway to better primary care for chronic liver disease.

Br J Gen Pract 2021 Apr 26;71(705):180-182. Epub 2021 Mar 26.

Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne.

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http://dx.doi.org/10.3399/bjgp21X715553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8007265PMC
April 2021

Measuring frailty in younger populations: a rapid review of evidence.

BMJ Open 2021 03 22;11(3):e047051. Epub 2021 Mar 22.

National Institute for Health Research (NIHR) Older People and Frailty Policy Research Unit, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.

Objectives: Frailty is typically assessed in older populations. Identifying frailty in adults aged under 60 years may also have value, if it supports the delivery of timely care. We sought to identify how frailty is measured in younger populations, including evidence of the impact on patient outcomes and care.

Design: A rapid review of primary studies was conducted.

Data Sources: Four databases, three sources of grey literature and reference lists of systematic reviews were searched in March 2020.

Eligibility Criteria: Eligible studies measured frailty in populations aged under 60 years using experimental or observational designs, published after 2000 in English.

Data Extraction And Synthesis: Records were screened against review criteria. Study data were extracted with 20% of records checked for accuracy by a second researcher. Data were synthesised using a narrative approach.

Results: We identified 268 studies that measured frailty in samples that included people aged under 60 years. Of these, 85 studies reported evidence about measure validity. No measures were identified that were designed and validated to identify frailty in younger groups. However, in populations that included people aged over under 60 years, cumulative deficit frailty indices, phenotype measures, the FRAIL Scale, the Liver Frailty Index and the Short Physical Performance Battery all demonstrated predictive validity for mortality and/or hospital admission. Evidence of criterion validity was rare. The extent to which measures possess validity across the younger adult age (18-59 years) spectrum was unclear. There was no evidence about the impact of measuring frailty in younger populations on patient outcomes and care.

Conclusions: Limited evidence suggests that frailty measures have predictive validity in younger populations. Further research is needed to clarify the validity of measures across the adult age spectrum, and explore the utility of measuring frailty in younger groups.
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http://dx.doi.org/10.1136/bmjopen-2020-047051DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7986767PMC
March 2021

Associations of poor oral health with frailty and physical functioning in the oldest old: results from two studies in England and Japan.

BMC Geriatr 2021 03 18;21(1):187. Epub 2021 Mar 18.

Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, UK.

Background: Very few studies have examined the relationship of oral health with physical functioning and frailty in the oldest old (> 85 years). We examined the association of poor oral health with markers of disability, physical function and frailty in studies of oldest old in England and Japan.

Methods: The Newcastle 85+ Study in England (n = 853) and the Tokyo Oldest Old Survey on Total Health (TOOTH; n = 542) comprise random samples of people aged > 85 years. Oral health markers included tooth loss, dryness of mouth, difficulty swallowing and difficulty eating due to dental problems. Physical functioning was based on grip strength and gait speed; disability was assessed as mobility limitations. Frailty was ascertained using the Fried frailty phenotype. Cross-sectional analyses were undertaken using logistic regression.

Results: In the Newcastle 85+ Study, dry mouth symptoms, difficulty swallowing, difficulty eating, and tooth loss were associated with increased risks of mobility limitations after adjustment for sex, socioeconomic position, behavioural factors and co-morbidities [odds ratios (95%CIs) were 1.76 (1.26-2.46); 2.52 (1.56-4.08); 2.89 (1.52-5.50); 2.59 (1.44-4.65) respectively]. Similar results were observed for slow gait speed. Difficulty eating was associated with weak grip strength and frailty on full adjustment. In the TOOTH Study, difficulty eating was associated with increased risks of frailty, mobility limitations and slow gait speed; and complete tooth loss was associated with increased risk of frailty.

Conclusion: Different markers of poor oral health are independently associated with worse physical functioning and frailty in the oldest old age groups. Research to understand the underlying pathways is needed.
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http://dx.doi.org/10.1186/s12877-021-02081-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7977173PMC
March 2021

Understanding the staff behaviours that promote quality for older people living in long term care facilities: A realist review.

Int J Nurs Stud 2021 Feb 20;117:103905. Epub 2021 Feb 20.

School of Healthcare, Faculty of Medicine and Health, Baines Wing (Room 2,28), University of Leeds, Leeds LS2 9JT, United Kingdom; NIHR ARC Yorkshire and Humber. Electronic address:

Background: Little is known about how the workforce influences quality in long term care facilities for older people. Staff numbers are important but do not fully explain this relationship.

Objectives: To develop theoretical explanations for the relationship between long-term care facility staffing and quality of care as experienced by residents.

Design: A realist evidence synthesis to understand staff behaviours that promote quality of care for older people living in long-term care facilities.

Setting: Long-term residential care facilities PARTICIPANTS: Long-term care facility staff, residents, and relatives METHODS: The realist review, (i) was co-developed with stakeholders to determine initial programme theories, (ii) systematically searched the evidence to test and develop theoretical propositions, and (iii) validated and refined emergent theory with stakeholder groups.

Results: 66 research papers were included in the review. Three key findings explain the relationship between staffing and quality: (i) quality is influenced by staff behaviours; (ii) behaviours are contingent on relationships nurtured by long-term care facility environment and culture; and (iii) leadership has an important influence on how organisational resources (sufficient staff effectively deployed, with the knowledge, expertise and skills required to meet residents' needs) are used to generate and sustain quality-promoting relationships. Six theoretical propositions explain these findings.

Conclusion: Leaders (at all levels) through their role-modelling behaviours can use organisational resources to endorse and encourage relationships (at all levels) between staff, residents, co-workers and family (relationship centred care) that constitute learning opportunities for staff, and encourage quality as experienced by residents and families.
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http://dx.doi.org/10.1016/j.ijnurstu.2021.103905DOI Listing
February 2021

Palliative and end-of-life care in care homes: protocol for codesigning and implementing an appropriate scalable model of Needs Rounds in the UK.

BMJ Open 2021 02 22;11(2):e049486. Epub 2021 Feb 22.

Faculty of Social Sciences, University of Stirling, Stirling, UK

Introduction: Palliative and end-of-life care in care homes is often inadequate, despite high morbidity and mortality. Residents can experience uncontrolled symptoms, poor quality deaths and avoidable hospitalisations. Care home staff can feel unsupported to look after residents at the end of life. Approaches for improving end-of-life care are often education-focused, do not triage residents and rarely integrate clinical care. This study will adapt an evidence-based approach from Australia for the UK context called 'Palliative Care Needs Rounds' (Needs Rounds). Needs Rounds combine triaging, anticipatory person-centred planning, case-based education and case-conferencing; the Australian studies found that Needs Rounds reduce length of stay in hospital, and improve dying in preferred place of care, and symptoms at the end of life.

Methods And Analysis: This implementation science study will codesign and implement a scalable UK model of Needs Rounds. The Integrated Promoting Action on Research Implementation in Health Services (i-PARIHS) framework will be used to identify contextual barriers and use facilitation to enable successful implementation. Six palliative care teams, working with 4-6 care homes each, will engage in two phases. In phase 1 (February 2021), stakeholder interviews (n=40) will be used to develop a programme theory to meet the primary outcome of identifying what works, for whom in what circumstances for UK Needs Rounds. Subsequently a workshop to codesign UK Needs Rounds will be run. Phase 2 (July 2021) will implement the UK model for a year. Prospective data collection will focus on secondary outcomes regarding hospitalisations, residents' quality of death and care home staff capability of adopting a palliative approach.

Ethics And Dissemination: Frenchay Research Ethics Committee (287447) approved the study. Findings will be disseminated to policy-makers, care home/palliative care practitioners, residents/relatives and academic audiences. An implementation package will be developed for practitioners to provide the tools and resources required to adopt UK Needs Rounds.

Registration Details: Registration details: ISRCTN15863801.
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http://dx.doi.org/10.1136/bmjopen-2021-049486DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7903098PMC
February 2021

The monetary valuation of informal care to cancer decedents at end-of-life: Evidence from a national census survey.

Palliat Med 2021 04 21;35(4):750-758. Epub 2021 Jan 21.

School of Health Sciences, University of Manchester, Manchester, UK.

Background: Carers' end-of-life caregiving greatly benefits society but little is known about the monetary value of this care.

Aim: Within an end-of-life cancer setting: (1) to assess the feasibility and content validity of a post-bereavement measure of hours of care; and (2) to obtain a monetary value of this informal care and identify variation in this value among sub-groups.

Design And Setting: A census based cross-sectional survey of all cancer deaths from a 2-week period in England collected detailed data on caregiving activity (10 caregiving tasks and the time spent on each). We descriptively analyse the information carers provided in 'other' tasks to inform content validity. We assigned a monetary value of caregiving via the proxy good method and examined variation in the value via regression analysis.

Results: The majority of carers (89.9%) were able to complete the detailed questions about hours and tasks. Only 153 carers reported engaging in 'other' tasks. The monetary value of caregiving at end-of-life was £948.86 per week with social and emotional support and symptom management tasks representing the largest proportion of this monetary valuation. Time of recall did not substantially relate to variation in the monetary value, whereas there was a stronger association for the relationship between the carer and recipient, carer gender and recipient daily living restrictions.

Conclusion: The monetary valuation we produce for carers' work is substantial, for example the weekly UK Carers' Allowance only amounts to 7% of our estimated value of £948.86 per week. Our research provides further information on subgroup variation, and a valid carer time instrument and method to inform economic evaluation and policy.
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http://dx.doi.org/10.1177/0269216321989569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8022080PMC
April 2021

Characterising polypharmacy in the very old: Findings from the Newcastle 85+ Study.

PLoS One 2021 19;16(1):e0245648. Epub 2021 Jan 19.

Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.

Background: Polypharmacy is potentially harmful and under-researched amongst the fastest growing subpopulation, the very old (aged ≥85). We aimed to characterise polypharmacy using data from the Newcastle 85+ Study-a prospective cohort of people born in 1921 who turned 85 in 2006 (n = 845).

Methods: The prevalence of polypharmacy at baseline (mean age 85.5) was examined using cut-points of 0, 1, 2-4, 5-9 and ≥10 medicines-so-called 'no polypharmacy', 'monotherapy', 'minor polypharmacy', 'polypharmacy' and 'hyperpolypharmacy.' Cross-tabulations and upset plots identified the most frequently prescribed medicines and medication combinations within these categories. Mixed-effects models assessed whether gender and socioeconomic position were associated with prescribing changes over time (mean age 85.5-90.5). Participant characteristics were examined through descriptive statistics.

Results: Complex multimorbidity (44.4%, 344/775) was widespread but hyperpolypharmacy was not (16.0%, 135/845). The median medication count was six (interquartile range 4-8). Preventative medicines were common to all polypharmacy categories, and prescribing regimens were diverse. Nitrates and oral anticoagulants were more frequently prescribed for men, whereas bisphosphonates, non-opioid analgesics and antidepressants were more common in women. Cardiovascular medicines, including loop diuretics, tended to be more frequently prescribed for socioeconomically disadvantaged people (<25th centile Index of Multiple Deprivation (IMD)), despite no difference in the prevalence of cardiovascular disease (p = 0.56) and diabetes (p = 0.92) by IMD.

Conclusion: Considering their complex medical conditions, prescribing is relatively conservative amongst 85-year-olds living in North East England. Prescribing shows significant gender and selected socioeconomic differences. More support for managing preventative medicines, of uncertain benefit, might be helpful in this population.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0245648PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7815158PMC
January 2021

Changes in health and functioning of care home residents over two decades: what can we learn from population-based studies?

Age Ageing 2020 Nov 17. Epub 2020 Nov 17.

Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE4 5PL, UK.

Background: Care home residents have complex care and support needs. There is a perception that the needs of residents have increased, but the evidence is limited. We investigated changes in health and functioning of care home residents over two decades in England and Wales.

Methods: We conducted a repeated cross-sectional analysis over a 24 year period (1992-2016), using data from three longitudinal studies, the Cognitive Function and Ageing Studies (CFAS) I and II and the English Longitudinal Study of Ageing (ELSA). To adjust for ageing of respondents over time results are presented for the 75-84 age group.

Results: Analysis of 2,280 observations from 1,745 care home residents demonstrated increases in severe disability (difficulty in at least two from washing, dressing and toileting). The prevalence of severe disability increased from 63% in 1992 to 87% in 2014 (subsequent fall in 2016 although wide confidence intervals). The prevalence of complex multimorbidity (problems in at least three out of six body systems) increased within studies over time, from 33% to 54% in CFAS I/II between 1992 and 2012, and 26% to 54% in ELSA between 2006 and 2016.

Conclusion: Over two decades, there has been an increase in disability and the complexity of health problems amongst care home residents in England and Wales. A rise in support needs for residents places increasing demands on care home staff and health professionals, and should be an important consideration for policymakers and service commissioners.
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http://dx.doi.org/10.1093/ageing/afaa227DOI Listing
November 2020

Uptake and use of a minimum data set (MDS) for older people living and dying in care homes in England: a realist review protocol.

BMJ Open 2020 11 14;10(11):e040397. Epub 2020 Nov 14.

Centre for Research in Public health and Community Care (CRIPACC), School of Health and Social Work, University of Hertfordshire, Hatfield, United Kingdom

Introduction: Care homes provide nursing and social care for older people who can no longer live independently at home. In the UK, there is no consistent approach to how information about residents' medical history, care needs and preferences are collected and shared. This limits opportunities to understand the care home population, have a systematic approach to assessment and documentation of care, identifiy care home residents at risk of deterioration and review care. Countries with standardised approaches to residents' assessment, care planning and review (eg, minimum data sets (MDS)) use the data to understand the care home population, guide resource allocation, monitor services delivery and for research. The aim of this realist review is to develop a theory-driven understanding of how care home staff implement and use MDS to plan and deliver care of individual residents.

Methods And Analysis: A realist review will be conducted in three research stages.Stage 1 will scope the literature and develop candidate programme theories of what ensures effective uptake and sustained implementation of an MDS.Stage2 will test and refine these theories through further iterative searches of the evidence from the literature to establish how effective uptake of an MDS can be achieved.Stage 3 will consult with relevant stakeholders to test or refine the programme theory (theories) of how an MDS works at the resident level of care for different stakeholders and in what circumstances. Data synthesis will use realist logic to align data from each eligible article with possible context-mechanism-outcome configurations or specific elements that answer the research questions.

Ethics And Dissemination: The University of Hertfordshire Ethics Committee has approved this study (HSK/SF/UH/04169). Findings will be disseminated through briefings with stakeholders, conference presentations, a national consultation on the use of an MDS in UK long-term care settings, publications in peer-reviewed journals and in print and social media publications accessible to residents, relatives and care home staff.

Prospero Registration Number: CRD42020171323; this review protocol is registered on the International Prospective Register of Systematic Reviews.
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http://dx.doi.org/10.1136/bmjopen-2020-040397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7668360PMC
November 2020

Timing of GP end-of-life recognition in people aged ≥75 years: retrospective cohort study using data from primary healthcare records in England.

Br J Gen Pract 2020 12 26;70(701):e874-e879. Epub 2020 Nov 26.

Population and Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK.

Background: High-quality, personalised palliative care should be available to all, but timely recognition of end of life may be a barrier to end-of-life care for older people.

Aim: To investigate the timing of end-of-life recognition, palliative registration, and the recording of end-of-life preferences in primary care for people aged ≥75 years.

Design And Setting: Retrospective cohort study using national primary care record data, covering 34% of GP practices in England.

Method: ResearchOne data from electronic healthcare records (EHRs) of people aged ≥75 years who died in England between 1 January 2015 and 1 January 2016 were examined. Clinical codes relating to end-of-life recognition, palliative registration, and end-of-life preferences were extracted, and the number of months that elapsed between the code being entered and death taking place were calculated. The timing for each outcome and proportion of relevant EHRs were reported.

Results: Death was recorded for a total of 13 149 people in ResearchOne data during the 1-year study window. Of those, 6303 (47.9%) records contained codes suggesting end of life had been recognised at a point in time prior to the month of death. Recognition occurred ≥12 months before death in 2248 (17.1%) records. In total, 1659 (12.6%) people were on the palliative care register and 457 (3.5%) were on the register for ≥12 months before death; 2987 (22.7%) records had a code for the patient's preferred place of care, and 1713 (13.0%) had a code for the preferred place of death. Where preferences for place of death were recorded, a care, nursing, or residential home ( = 813, 47.5%) and the individual's home ( = 752, 43.9%) were the most common.

Conclusion: End-of-life recognition in primary care appears to occur near to death and for only a minority of people aged ≥75 years. The findings suggest that older people's deaths may not be anticipated by health professionals, compromising equitable access to palliative care.
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http://dx.doi.org/10.3399/bjgp20X713417DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7643820PMC
December 2020

Managing older people's perceptions of alcohol-related risk: a qualitative exploration in Northern English primary care.

Br J Gen Pract 2020 12 26;70(701):e916-e926. Epub 2020 Nov 26.

Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne.

Background: Risk of harm from drinking increases with age as alcohol affects health conditions and medications that are common in later life. Different types of information and experiences affect older people's perceptions of alcohol's effects, which must be navigated when supporting healthier decisions on alcohol consumption.

Aim: To explore how older people understand the effects of alcohol on their health; and how these perspectives are navigated in supportive discussions in primary care to promote healthier alcohol use.

Design And Setting: A qualitative study consisting of semi-structured interviews and focus groups with older, non-dependent drinkers and primary care practitioners in Northern England.

Method: A total of 24 older adults aged ≥65 years and 35 primary care practitioners participated in interviews and focus groups. Data were analysed thematically, applying principles of constant comparison.

Results: Older adults were motivated to make changes to their alcohol use when they experienced symptoms, and if they felt that limiting consumption would enable them to maintain their quality of life. The results of alcohol-related screening were useful in providing insights into potential effects for individuals. Primary care practitioners motivated older people to make healthier decisions by highlighting individual risks of drinking, and potential gains of limiting intake.

Conclusion: Later life is a time when older people may be open to making changes to their alcohol use, particularly when suggested by practitioners. Older people can struggle to recognise potential risks or perceive little gain in acting on perceived risks. Such perceptions may be challenging to navigate in supportive discussions.
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http://dx.doi.org/10.3399/bjgp20X713405DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7575405PMC
December 2020

Implementation of the National Early Warning Score in UK care homes: a qualitative evaluation.

Br J Gen Pract 2020 11 29;70(700):e793-e800. Epub 2020 Oct 29.

Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne.

Background: The National Early Warning Score (NEWS) is a tool for identifying and responding to acute illness. When used in care homes, staff measure residents' vital signs and record them on a tablet computer, which calculates a NEWS to share with health services. This article outlines an evaluation of NEWS implementation in care homes across one clinical commissioning group area in northern England.

Aim: To identify challenges to implementation of NEWS in care homes.

Design And Setting: Qualitative analysis of interviews conducted with 15 staff members from six care homes, five health professionals, and one clinical commissioning group employee.

Method: Interviews were intended to capture people's attitudes and experiences of using the intervention. Following an inductive thematic analysis, data were considered deductively against normalisation process theory constructs to identify the challenges and successes of implementing NEWS in care homes.

Results: Care home staff and other stakeholders acknowledged that NEWS could enhance the response to acute illness, improve communication with the NHS, and increase the confidence of care home staff. However, the implementation did not account for the complexity of either the intervention or the care home setting. Challenges to engagement included competing priorities, insufficient training, and shortcomings in communication.

Conclusion: This evaluation highlights the need to involve care home staff and the primary care services that support them when developing and implementing interventions in care homes. The appropriateness and value of NEWS in non-acute settings requires ongoing monitoring.
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http://dx.doi.org/10.3399/bjgp20X713069DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7537989PMC
November 2020

SEeking AnsweRs for Care Homes during the COVID-19 pandemic (COVID SEARCH).

Age Ageing 2021 02;50(2):335-340

School of Healthcare, University of Leeds, Leeds, UK.

The care and support of older people residing in long-term care facilities during the COVID-19 pandemic has created new and unanticipated uncertainties for staff. In this short report, we present our analyses of the uncertainties of care home managers and staff expressed in a self-formed closed WhatsApp™ discussion group during the first stages of the pandemic in the UK. We categorised their wide-ranging questions to understand what information would address these uncertainties and provide support. We have been able to demonstrate that almost one-third of these uncertainties could have been tackled immediately through timely, responsive and unambiguous fact-based guidance. The other uncertainties require appraisal, synthesis and summary of existing evidence, commissioning or provision of a sector- informed research agenda for medium to long term. The questions represent wider internationally relevant care home pandemic-related uncertainties.
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http://dx.doi.org/10.1093/ageing/afaa201DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7543248PMC
February 2021

Connecting at Local Level: Exploring Opportunities for Future Design of Technology to Support Social Connections in Age-Friendly Communities.

Int J Environ Res Public Health 2020 07 31;17(15). Epub 2020 Jul 31.

Population Health Sciences Institute, Campus for Ageing and Vitality, Newcastle University, Newcastle upon Tyne NE4 5PL, UK.

Social connectedness in later life is an important dimension of an age-friendly community, with associated implications for individual health and wellbeing. In contrast with prior efforts focusing on connections at a distance or online communities where the digital technology is the interface, we explore the design opportunities and role of technology for connectedness within a geographically local community context. We present findings from interviews with 22 older adults and a linked ideation workshop. Our analysis identified shared concerns and negative perceptions around local relationships, connections and characteristics of the geographical area. However, local connectedness through technology was largely absent from day-to-day life and even perceived as contributing to disconnection. By uncovering how older adults use and perceive technology in their social lives and combining these findings with their ideas for improving local connections, we highlight the need for thoughtful consideration of the role of technology in optimising social connections within communities. Our research highlights a need for design work to understand the specifics of the local context and reduce emphasis on technology as the interface between people. We introduce an amended definition-'underpinned by a commitment to respect and social inclusion, an age-friendly community is engaged in a strategic and ongoing process to facilitate active ageing by optimising the community's physical, social and digital environments and its supporting infrastructure'-to conceptualise our approach. We conclude by suggesting areas for future work in developing digitally connected age-friendly communities.
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http://dx.doi.org/10.3390/ijerph17155544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7432362PMC
July 2020

Covid-19 and lack of linked datasets for care homes.

BMJ 2020 06 24;369:m2463. Epub 2020 Jun 24.

School of Health Care, University of Leeds, Leeds, UK.

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http://dx.doi.org/10.1136/bmj.m2463DOI Listing
June 2020

Commentary: COVID in care homes-challenges and dilemmas in healthcare delivery.

Age Ageing 2020 08;49(5):701-705

School of Healthcare, University of Leeds, Leeds, UK.

The COVID-19 pandemic has disproportionately affected care home residents internationally, with 19-72% of COVID-19 deaths occurring in care homes. COVID-19 presents atypically in care home residents and up to 56% of residents may test positive whilst pre-symptomatic. In this article, we provide a commentary on challenges and dilemmas identified in the response to COVID-19 for care homes and their residents. We highlight the low sensitivity of polymerase chain reaction testing and the difficulties this poses for blanket screening and isolation of residents. We discuss quarantine of residents and the potential harms associated with this. Personal protective equipment supply for care homes during the pandemic has been suboptimal and we suggest that better integration of procurement and supply is required. Advance care planning has been challenged by the pandemic and there is a need to for healthcare staff to provide support to care homes with this. Finally, we discuss measures to implement augmented care in care homes, including treatment with oxygen and subcutaneous fluids, and the frameworks which will be required if these are to be sustainable. All of these challenges must be met by healthcare, social care and government agencies if care home residents and staff are to be physically and psychologically supported during this time of crisis for care homes.
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http://dx.doi.org/10.1093/ageing/afaa113DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239229PMC
August 2020

Metabolic risk factors and incident advanced liver disease in non-alcoholic fatty liver disease (NAFLD): A systematic review and meta-analysis of population-based observational studies.

PLoS Med 2020 04 30;17(4):e1003100. Epub 2020 Apr 30.

Population Health Sciences Institute, Faculty of Medical Sciences, Newcastle University, Newcastle upon Tyne, United Kingdom.

Background: Non-alcoholic fatty liver disease (NAFLD) is a leading cause of chronic liver disease worldwide. Many individuals have risk factors associated with NAFLD, but the majority do not develop advanced liver disease: cirrhosis, hepatic decompensation, or hepatocellular carcinoma. Identifying people at high risk of experiencing these complications is important in order to prevent disease progression. This review synthesises the evidence on metabolic risk factors and their potential to predict liver disease outcomes in the general population at risk of NAFLD or with diagnosed NAFLD.

Methods And Findings: We conducted a systematic review and meta-analysis of population-based cohort studies. Databases (including MEDLINE, EMBASE, the Cochrane Library, and ClinicalTrials.gov) were searched up to 9 January 2020. Studies were included that reported severe liver disease outcomes (defined as liver cirrhosis, complications of cirrhosis, or liver-related death) or advanced fibrosis/non-alcoholic steatohepatitis (NASH) in adult individuals with metabolic risk factors, compared with individuals with no metabolic risk factors. Cohorts selected on the basis of a clinically indicated liver biopsy were excluded to better reflect general population risk. Risk of bias was assessed using the QUIPS tool. The results of similar studies were pooled, and overall estimates of hazard ratio (HR) were obtained using random-effects meta-analyses. Of 7,300 unique citations, 22 studies met the inclusion criteria and were of sufficient quality, with 18 studies contributing data suitable for pooling in 2 random-effects meta-analyses. Type 2 diabetes mellitus (T2DM) was associated with an increased risk of incident severe liver disease events (adjusted HR 2.25, 95% CI 1.83-2.76, p < 0.001, I2 99%). T2DM data were from 12 studies, with 22.8 million individuals followed up for a median of 10 years (IQR 6.4 to 16.9) experiencing 72,792 liver events. Fourteen studies were included in the meta-analysis of obesity (BMI > 30 kg/m2) as a prognostic factor, providing data on 19.3 million individuals followed up for a median of 13.8 years (IQR 9.0 to 19.8) experiencing 49,541 liver events. Obesity was associated with a modest increase in risk of incident severe liver disease outcomes (adjusted HR 1.20, 95% CI 1.12-1.28, p < 0.001, I2 87%). There was also evidence to suggest that lipid abnormalities (low high-density lipoprotein and high triglycerides) and hypertension were both independently associated with incident severe liver disease. Significant study heterogeneity observed in the meta-analyses and possible under-publishing of smaller negative studies are acknowledged to be limitations, as well as the potential effect of competing risks on outcome.

Conclusions: In this review, we observed that T2DM is associated with a greater than 2-fold increase in the risk of developing severe liver disease. As the incidence of diabetes and obesity continue to rise, using these findings to improve case finding for people at high risk of liver disease will allow for effective management to help address the increasing morbidity and mortality from liver disease.

Trial Registration: PROSPERO CRD42018115459.
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http://dx.doi.org/10.1371/journal.pmed.1003100DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7192386PMC
April 2020

Patients' experiences of alcohol screening and advice in primary care: a qualitative study.

BMC Fam Pract 2020 04 22;21(1):68. Epub 2020 Apr 22.

Population Health Sciences Institute, Newcastle University, Baddiley-Clark Buiding, Richardson Road, Newcastle, NE2 4AX, UK.

Background: Despite evidence supporting the effectiveness of alcohol screening and brief advice to reduce heavy drinking, implementation in primary healthcare remains limited. The challenges that clinicians experience when delivering such interventions are well-known, but we have little understanding of the patient perspective. We used Normalization Process Theory (NPT) informed interviews to explore patients' views on alcohol screening and brief advice in routine primary healthcare.

Methods: Semi-structured qualitative interviews with 22 primary care patients who had been screened for heavy drinking and/or received brief alcohol advice were analysed thematically, informed by Normalisation Process Theory constructs (coherence, cognitive participation, collective action, reflexive monitoring).

Results: We found mixed understanding of the adverse health consequences of heavy drinking, particularly longer-term risks. There was some awareness of current alcohol guidelines but these were viewed flexibly, depending on the individual drinker and drinking context. Most described alcohol screening as routine, with clinicians viewed as trustworthy and objective. Patients enacted a range of self-regulatory techniques to limit their drinking but perceived such strategies as learned through experience rather than based on clinical advice. However, most saw alcohol advice as a valuable component of preventative healthcare, especially those experiencing co-occurring health conditions.

Conclusions: Despite strong acceptance of the screening role played by primary care clinicians, patients have less confidence in the effectiveness of alcohol advice. Primary care-based alcohol brief advice needs to reflect how individuals actually drink, and harness strategies that patients already commonly employ, such as self-regulation, to boost its relevance.
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http://dx.doi.org/10.1186/s12875-020-01142-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7178930PMC
April 2020

Health and social care providers' perspectives of older people's drinking: A systematic review and thematic synthesis of qualitative studies.

Age Ageing 2020 Feb 21. Epub 2020 Feb 21.

Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne NE4 5PL, UK.

Background: alcohol may increase risks to late-life health, due to its impact on conditions or medication. Older adults must weigh up the potential risks of drinking against perceived benefits associated with positive roles of alcohol in their social lives. Health and social care workers are in a key position to support older people's decisions about their alcohol use.

Objective: to systematically review and synthesise qualitative studies exploring health and social care providers' views and experiences of older people's drinking and its management in care services.

Method: a pre-specified search strategy was applied to five electronic databases from inception to June 2018. Grey literature, relevant journals, references and citations of included articles were searched. Two independent reviewers sifted and quality-appraised articles. Included study findings were analysed through thematic synthesis.

Results: 18 unique studies were included. Four themes explained findings: uncertainty about drinking as a legitimate concern in care provision for older people; the impact of preconceptions on work with older adults; sensitivity surrounding alcohol use in later life; and negotiating responsibility for older adults' alcohol use. Discipline- and country-specific patterns are highlighted.

Conclusions: reservations about addressing alcohol could mean that service providers do not intervene with older adults. Judgements of whether older care recipients' drinking warrants intervention are complex. Providers will need support and training to recognise and provide appropriate intervention for drinking amongst older care recipients.
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http://dx.doi.org/10.1093/ageing/afaa005DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7187873PMC
February 2020

Adverse Outcomes of Polypharmacy in Older People: Systematic Review of Reviews.

J Am Med Dir Assoc 2020 02 8;21(2):181-187. Epub 2020 Jan 8.

Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.

Objective: Polypharmacy is widespread among older people, but the adverse outcomes associated with it are unclear. We aim to synthesize current evidence on the adverse health, social, medicines management, and health care utilization outcomes of polypharmacy in older people.

Design: A systematic review, of systematic reviews and meta-analyses of observational studies, was conducted. Eleven bibliographic databases were searched from 1990 to February 2018. Quality was assessed using AMSTAR (A Measurement Tool to Assess Systematic Reviews).

Setting And Participants: Older people in any health care setting, residential setting, or country.

Results: Twenty-six reviews reporting on 230 unique studies were included. Almost all reviews operationalized polypharmacy as medication count, and few examined medication classes or disease states within this. Evidence for an association between polypharmacy and many adverse outcomes, including adverse drug events and disability, was conflicting. The most consistent evidence was found for hospitalization and inappropriate prescribing. No research had explored polypharmacy in the very old (aged ≥85 years), or examined the potential social consequences associated with medication use, such as loneliness and isolation.

Conclusions And Implications: The literature examining the adverse outcomes of polypharmacy in older people is complex, extensive, and conflicting. Until polypharmacy is operationalized in a more clinically relevant manner, the adverse outcomes associated with it will not be fully understood. Future studies should work toward this approach in the face of rising multimorbidity and population aging.
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http://dx.doi.org/10.1016/j.jamda.2019.10.022DOI Listing
February 2020

Distribution of the National Early Warning Score (NEWS) in care home residents.

Age Ageing 2019 12;49(1):141-145

Population Health Sciences Institute, Newcastle University.

Background: the National Early Warning Score (NEWS) is a tool based on vital signs that aims to standardise detection of, and response to, clinical deterioration in adults. NEWS has been adopted in hospitals but not adapted for other settings. This study aimed to explore the feasibility of measuring the NEWS in care homes and describe the distribution of NEWS readings amongst care home residents.

Methods: descriptive analysis of all NEWS readings recorded in a 30-month period (2016-19) across 46 care homes in one Clinical Commissioning Group in England. Comparisons were made between measurements taken as a routine reading and those prompted by concern about acute illness.

Results: a total of 19,604 NEWS were recorded from 2,424 older adults (≥65 years; mean age 85). Median NEWS was 2. Two thirds (66%) of residents had a low NEWS (≤2), and 28% had a score of 0. Of the total NEWS readings, 6,277 (32%) were known to be routine readings and 2,256 (12%) were measured because of staff concerns. Median NEWS was 1 for routine and 2 for concern recordings. Overall, only 12% of NEWS were high (≥5), but a higher proportion were elevated when there were concerns about acute illness (18%), compared with routine recordings (7%).

Conclusions: use of NEWS in care homes appears to be feasible. The majority of NEWS were not elevated, and the distribution of scores is consistent with other out-of-hospital settings. Further work is required to know if NEWS is triggering the most appropriate response and improving care home resident outcomes.
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http://dx.doi.org/10.1093/ageing/afz130DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6911654PMC
December 2019

Understanding the perspectives of care home managers when managing care of residents living with frailty.

Geriatr Nurs 2020 May - Jun;41(3):248-253. Epub 2019 Nov 6.

Institute of Health and Society, Newcastly University, Newcastle upon Tyne, UK; Institute of Health and Society Campus for Ageing and Vitality Newcastle University Newcastle upon Tyne NE4 5PL UK.

Identification of frailty is an increasingly prominent concept in healthcare policy that drives access to services and support, and frailty is common amongst care home residents. Care home managers play a central role in facilitating residents' access to healthcare, but utility and relevance of the term 'frailty' for care home managers, is unknown. In this exploratory qualitative study we used semistructured interviews to explore care home managers' perspectives of frailty and how that understanding influences residents' care. We found 'frailty' was not specific enough to be useful in a context where many are frail and individualised care is requisite. Care home managers' perceptions of their key role, holistic assessment of residents and facilitating access to external expertise, aligns with best practice guidelines on frailty care. If the term 'frailty' does not provide a common language for all caregivers and service providers, inequitable care of people with frailty may arise.
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http://dx.doi.org/10.1016/j.gerinurse.2019.10.003DOI Listing
March 2021

Impact of the introduction and withdrawal of financial incentives on the delivery of alcohol screening and brief advice in English primary health care: an interrupted time-series analysis.

Addiction 2020 01 9;115(1):49-60. Epub 2019 Oct 9.

Institute of Health and Society, Newcastle University, Newcastle upon Tyne, UK.

Aim: To evaluate the impact of the introduction and withdrawal of financial incentives on alcohol screening and brief advice delivery in English primary care.

Design: Interrupted time-series using data from The Health Improvement Network (THIN) database. Data were split into three periods: (1) before the introduction of financial incentives (1 January 2006-31 March 2008); (2) during the implementation of financial incentives (1 April 2008-31 March 2015); and (3) after the withdrawal of financial incentives (1 April 2015-31 December 2016). Segmented regression models were fitted, with slope and step change coefficients at both intervention points.

Setting: England.

Participants: Newly registered patients (16+) in 500 primary care practices for 2006-16 (n = 4 278 723).

Measurements: The outcome measures were percentage of patients each month who: (1) were screened for alcohol use; (2) screened positive for higher-risk drinking; and (3) were reported as having received brief advice on alcohol consumption.

Findings: There was no significant change in the percentage of newly registered patients who were screened for alcohol use when financial incentives were introduced. However, the percentage fell (P < 0.001) immediately when incentives were withdrawn, and fell by a further 2.96 [95% confidence interval (CI) = 2.21-3.70] patients per 1000 each month thereafter. After the introduction of incentives, there was an immediate increase of 9.05 (95% CI = 3.87-14.23) per 1000 patients screening positive for higher-risk drinking, but no significant further change over time. Withdrawal of financial incentives was associated with an immediate fall in screen-positive rates of 29.96 (95% CI = 19.56-40.35) per 1000 patients, followed by a rise each month thereafter of 2.14 (95% CI = 1.51-2.77) per 1000. Screen-positive patients recorded as receiving alcohol brief advice increased by 20.15 (95% CI = 12.30-28.00) per 1000 following the introduction of financial incentives, and continued to increase by 0.39 (95% CI = 0.26-0.53) per 1000 monthly until withdrawal. At this point, delivery of brief advice fell by 18.33 (95% CI = 11.97-24.69) per 1000 patients and continued to fall by a further 0.70 (95% CI = 0.28-1.12) per 1000 per month.

Conclusions: Removing a financial incentive for alcohol prevention in English primary care was associated with an immediate and sustained reduction in the rate of screening for alcohol use and brief advice provision. This contrasts with no, or limited, increase in screening and brief advice delivery rates following the introduction of the scheme.
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http://dx.doi.org/10.1111/add.14778DOI Listing
January 2020

Frailty, hospital use and mortality in the older population: findings from the Newcastle 85+ study.

Age Ageing 2019 11;48(6):797-802

Institute for Cell and Molecular Biosciences, Newcastle University, Newcastle upon Tyne, UK.

Background: Frailty is a significant determinant of health care utilisation and associated costs, both of which also increase with proximity to death. What is not known is how the relationships between frailty, proximity to death, hospital use and costs develop in a population aged 85 years and over.

Methods: This study used data from a prospective observational cohort, the Newcastle 85+ Study, linked with hospital episode statistics and death registrations. Using the Rockwood frailty index (cut off <0.25), we analysed the relationship between frailty and mortality, proximity to death, hospital use and hospital costs over 2, 5 and 7 years using descriptive statistics, Kaplan-Meier survival curves, Cox's proportional hazards and negative binomial regression models.

Results: Baseline frailty was associated with a more than two-fold increased risk of mortality after 7 years, compared to people who were non-frail. Participants classified as frail spent more time in hospital over 7 years than the non-frail, but this difference declined over time. Baseline frailty was not associated with increased time spent in hospital during the last 90 days of life.

Conclusion: Evidence continues to accrue on the impact of frailty on emergency health care use. Hospital and community services need to adapt to meet the challenge of introducing new proactive and preventative approaches, designed to achieve benefits in clinical and/or cost effectiveness of frailty management.
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http://dx.doi.org/10.1093/ageing/afz094DOI Listing
November 2019