Publications by authors named "Geoff Wong"

96 Publications

Supporting bereavement and complicated grief in primary care: a realist review.

BJGP Open 2021 Mar 2. Epub 2021 Mar 2.

General Practitioner and University Senior Lecturer, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK.

Background: Bereavement can have significant impacts on physical and mental health, and a minority of people experience complicated and prolonged grief responses. Primary care is ideally situated to offer bereavement care, yet UK provision remains variable and practitioners feel uncertain how best to support bereaved patients.

Aim: To identify what works, how, and for whom, in the management of complicated grief in primary care.

Design & Setting: A review of evidence on the management of complicated grief and bereavement in UK primary care settings.

Method: A realist approach was taken which aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes.

Results: Forty-two articles were included. Evidence on the primary care management of complicated or prolonged grief was limited. GPs and nurses view bereavement support as part of their role, yet experience uncertainty over the appropriate extent of their involvement. Patients and clinicians often have differing views on the role of primary care in bereavement. Training in bereavement, local systems for reporting deaths, practitioner time and resources can assist or hinder bereavement care provision. Practitioners find bereavement care can be emotionally challenging. Understanding patients' needs can encourage a proactive response and help identify appropriate support.

Conclusion: Bereavement care in primary care remains variable and practitioners feel unprepared to provide appropriate bereavement care. Patients at higher risk of complicated or prolonged grief may fail to receive the support they need from primary care. Further research is required to address the potential unmet needs of bereaved patients.
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http://dx.doi.org/10.3399/BJGPO.2021.0008DOI Listing
March 2021

Efficiency over thoroughness in laboratory testing decision making in primary care: findings from a realist review.

BJGP Open 2021 Feb 2. Epub 2021 Feb 2.

Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.

Background: Existing research demonstrates significant variation in test-ordering practice, and growth in the use of laboratory tests in primary care. Reviews of interventions designed to change test-ordering practice report heterogeneity in design and effectiveness. Improving understanding of clinicians' decision making in relation to laboratory testing is an important means of understanding practice patterns and developing theory-informed interventions.

Aim: To develop explanations for the underlying causes of patterns of variation and increasing use of laboratory tests in primary care, and make recommendations for future research and intervention design.

Design & Setting: Realist review of secondary data from primary care.

Method: Diverse evidence, including data from qualitative and quantitative studies, was gathered via systematic and iterative searching processes. Data were synthesised according to realist principles to develop explanations accounting for clinicians' decision making in relation to laboratory tests.

Results: A total of 145 documents contributed data to the synthesis. Laboratory test ordering can fulfil many roles in primary care. Decisions about tests are incorporated into practice heuristics and tests are deployed as a tool to manage patient interactions. Ordering tests may be easier than not ordering tests in existing systems. Alongside high workloads and limited time to devote to decision making, there is a common perception that laboratory tests are relatively inconsequential interventions. Clinicians prioritise efficiency over thoroughness in decision making about laboratory tests.

Conclusion: Interventions to change test-ordering practice can be understood as aiming to preserve efficiency or encourage thoroughness in decision making. Intervention designs and evaluations should consider how testing decisions are made in real-world clinical practice.
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http://dx.doi.org/10.3399/bjgpopen20X101146DOI Listing
February 2021

Towards an understanding of GPs' viewpoint on diagnosing postnatal depression in general practice: a small-scale realist evaluation.

Prim Health Care Res Dev 2020 10 9;21:e42. Epub 2020 Oct 9.

Department of Primary Care & Population Health, Institute of Epidemiology & Public Health, UCL Medical School, London, UK.

Background: Less than half of postnatal depression cases are identified in routine clinical assessment. Guidelines and current literature suggest that general practitioners (GPs) may have an opportunistic role in detecting postnatal depression due to their early contact and existing rapport with many new mothers. There is limited research on the diagnostic approaches chosen by GPs in different GP-patient contexts. Our small-scale study evaluates the thought processes of seven GPs based in one practice when forming a clinical diagnosis of postnatal depression under different contexts.

Methods: Seven GP participants were interviewed using case vignettes about postnatal depression, based on an adapted Johari's window framework. A realist approach to analysis was undertaken with the intention of understanding GPs' responses to different situations. Context-mechanism-outcome configurations were constructed, and a programme theory was formed to consolidate the findings.

Findings: Findings suggest that diagnoses may be a clinician-led or collaborative process between GP and patient. In collaborative contexts, stigmatising views were addressed by GPs, time for self-reflection was encouraged and mothers' views were accounted for. Clinician-led diagnoses often occurred in contexts where there was a lack of acknowledgement of symptoms on behalf of the patient or where safety was a concern. The personal and clinical experience of GPs themselves, as well as effective communication channels with other primary care professionals, was significant mechanisms.

Conclusion: GPs use a variety of strategies to support patient disclosure and acceptance of their condition. The complexity of GP-patient contexts may influence the clinical thought process. We address some of the gaps in existing literature by exploring postnatal depression diagnosis in primary care and provide tentative explanations to suggest what works, for whom and in what contexts.
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http://dx.doi.org/10.1017/S1463423620000316DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7576521PMC
October 2020

Lost in reviews: Looking for the involvement of stakeholders, patients, public and other non-researcher contributors in realist reviews.

Res Synth Methods 2020 Sep 28. Epub 2020 Sep 28.

Bodleian Health Care Libraries, University of Oxford, Oxford, UK.

The involvement of non-researcher contributors (eg, stakeholders, patients and the public, decision and policy makers, experts, lay contributors) has taken a variety of forms within evidence syntheses. Realist reviews are a form of evidence synthesis that involves non-researcher contributors yet this practice has received little attention. In particular, the role of patient and public involvement (PPI) has not been clearly documented. This review of reviews describes the ways in which contributor involvement, including PPI, is documented within healthcare realist reviews published over the last five years. A total of 448 papers published between 2014 and 2019 were screened, yielding 71 full-text papers included in this review. Statements about contributor involvement were synthesized across each review using framework analysis. Three themes are described in this article including nomenclature, nature of involvement, and reporting impact. Papers indicate that contributor involvement in realist reviews refers to stakeholders, experts, or advisory groups (ie, professionals, clinicians, or academics). Patients and the public are occasionally subsumed into these groups and in doing so, the nature and impact of their involvement become challenging to identify and at times, is lost completely. Our review findings indicate a need for the realist review community to develop guidance to support researchers in their future collaboration with contributors, including patients and the public.
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http://dx.doi.org/10.1002/jrsm.1459DOI Listing
September 2020

Towards an understanding of the burdens of medication management affecting older people: the MEMORABLE realist synthesis.

BMC Geriatr 2020 06 5;20(1):183. Epub 2020 Jun 5.

PPI representative, School of Life and Health Sciences, Aston University, Birmingham, B4 7ET, UK.

Background: More older people are living in the community with multiple diagnoses and medications. Managing multiple medications produces issues of unrivalled complexity for those involved. Despite increasing literature on the subject, gaps remain in understanding how, why and for whom complex medication management works, and therefore how best to improve practice and outcomes. MEMORABLE, MEdication Management in Older people: Realist Approaches Based on Literature and Evaluation, aimed to address these gaps.

Methods: MEMORABLE used realism to understand causal paths within medication management. Informed by RAMESES (Realist And Meta-narrative Evidence Synthesis: and Evolving Standards) guidelines, MEMORABLE involved three overlapping work packages: 1) Realist Review of the literature (24 articles on medication management exploring causality); 2) Realist Evaluation (50 realist-informed interviews with older people, family carers and health and care practitioners, explaining their experiences); and 3) data synthesis and theorising from 1) and 2).

Results: Medication management was viewed from the perspective of 'implementation' and structured into five stages: identifying a problem (Stage 1), getting a diagnosis and/or medications (Stage 2), starting, changing or stopping medications (Stage 3), continuing to take medications (Stage 4), and reviewing/reconciling medications (Stage 5). Three individual stages (1, 3 and 4) are conducted by the older person sometimes with family carer support when they balance routines, coping and risk. Stages 2 and 5 are interpersonal where the older person works with a practitioner-prescriber-reviewer, perhaps with carer involvement. Applying Normalisation Process Theory, four steps were identified within each stage: 1) sense making: information, clarification; 2) action: shared-decision-making; 3) reflection/monitoring; and 4) enduring relationships, based on collaboration and mutual trust. In a detailed analysis of Stage 5: Reviewing/reconciling medications, adopting the lens of 'burden', MEMORABLE identified five burdens amenable to mitigation: ambiguity, concealment, unfamiliarity, fragmentation and exclusion. Two initial improvement propositions were identified for further research: a risk screening tool and individualised information.

Conclusions: Older people and family carers often find medication management challenging and burdensome particularly for complex regimens. Practitioners need to be aware of this potential challenge, and work with older people and their carers to minimise the burden associated with medication management.

Trial Registration: PROSPERO 2016:CRD42016043506.
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http://dx.doi.org/10.1186/s12877-020-01568-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7272211PMC
June 2020

Contribution of paramedics in primary and urgent care: a systematic review.

Br J Gen Pract 2020 Jun 28;70(695):e421-e426. Epub 2020 May 28.

Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford.

Background: Within the UK, there are now opportunities for paramedics to work across a variety of healthcare settings away from their traditional ambulance service employer, with many opting to move into primary care.

Aim: To provide an overview of the types of clinical roles paramedics are undertaking in primary and urgent care settings within the UK.

Design And Setting: A systematic review.

Method: Searches were conducted of MEDLINE, CINAHL, Embase, the National Institute for Health and Care Excellence, the , and the Cochrane Database from January 2004 to March 2019 for papers detailing the role, scope of practice, clinician and patient satisfaction, and costs of paramedics in primary and urgent care settings. Free-text keywords and subject headings focused on two key concepts: paramedic and general practice/primary care.

Results: In total, 6765 references were screened by title and/or abstract. After full-text review, 24 studies were included. Key findings focused on the description of the clinical role, the clinical work environment, the contribution of paramedics to the primary care workforce, the clinical activities they undertook, patient satisfaction, and education and training for paramedics moving from the ambulance service into primary care.

Conclusion: Current published research identifies that the role of the paramedic working in primary and urgent care is being advocated and implemented across the UK; however, there is insufficient detail regarding the clinical contribution of paramedics in these clinical settings. More research needs to be done to determine how, why, and in what context paramedics are now working in primary and urgent care, and what their overall contribution is to the primary care workforce.
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http://dx.doi.org/10.3399/bjgp20X709877DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239041PMC
June 2020

Delegating home visits in general practice: a realist review on the impact on GP workload and patient care.

Br J Gen Pract 2020 Jun 28;70(695):e412-e420. Epub 2020 May 28.

Department of Primary Care and Population Health, University College London, London.

Background: UK general practice is being shaped by new ways of working. Traditional GP tasks are being delegated to other staff with the intention of reducing GPs' workload and hospital admissions, and improving patients' access to care. One such task is patient-requested home visits. However, it is unclear what impact delegated home visits may have, who might benefit, and under what circumstances.

Aim: To explore how the process of delegating home visits works, for whom, and in what contexts.

Design And Setting: A review of secondary data on home visit delegation processes in UK primary care settings.

Method: A realist approach was taken to reviewing data, which aims to provide causal explanations through the generation and articulation of contexts, mechanisms, and outcomes. A range of data has been used including news items, grey literature, and academic articles.

Results: Data were synthesised from 70 documents. GPs may believe that delegating home visits is a risky option unless they have trust and experience with the wider multidisciplinary team. Internal systems such as technological infrastructure might help or hinder the delegation process. Healthcare professionals carrying out delegated home visits might benefit from being integrated into general practice but may feel that their clinical autonomy is limited by the delegation process. Patients report short-term satisfaction when visited by a healthcare professional other than a GP. The impact this has on long-term health outcomes and cost is less clear.

Conclusion: The delegation of home visits may require a shift in patient expectation about who undertakes care. Professional expectations may also require a shift, having implications for the balance of staffing between primary and secondary care, and the training of healthcare professionals.
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http://dx.doi.org/10.3399/bjgp20X710153DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7239043PMC
June 2020

Optimising strategies to address mental ill-health in doctors and medical students: 'Care Under Pressure' realist review and implementation guidance.

BMC Med 2020 03 31;18(1):76. Epub 2020 Mar 31.

Wellcome Centre for Cultures and Environments of Health, University of Exeter, Exeter, UK.

Background: Mental ill-health in health professionals, including doctors, is a global and growing concern. The existing literature on interventions that offer support, advice and/or treatment to sick doctors has not yet been synthesised in a way that considers the complexity and heterogeneity of the interventions, and the many dimensions of the problem. We (1) reviewed interventions to tackle doctors' and medical students' mental ill-health and its impacts on the clinical workforce and patient care-drawing on diverse literature sources and engaging iteratively with diverse stakeholder perspectives-and (2) produced recommendations that support the tailoring, implementation, monitoring and evaluation of contextually sensitive strategies to tackle mental ill-health and its impacts.

Methods: Realist literature review consistent with the RAMESES quality and reporting standards. Sources for inclusion were identified through bibliographic database searches supplemented by purposive searches-resulting also from engagement with stakeholders. Data were extracted from included articles and subjected to realist analysis to identify (i) mechanisms causing mental ill-health in doctors and medical students and relevant contexts or circumstances when these mechanisms were likely to be 'triggered' and (ii) 'guiding principles' and features underpinning the interventions and recommendations discussed mostly in policy document, reviews and commentaries.

Results: One hundred seventy-nine records were included. Most were from the USA (45%) and were published since 2009 (74%). The analysis showed that doctors were more likely to experience mental ill-health when they felt isolated or unable to do their job and when they feared repercussions of help-seeking. Healthy staff were necessary for excellent patient care. Interventions emphasising relationships and belonging were more likely to promote wellbeing. Interventions creating a people-focussed working culture, balancing positive/negative performance and acknowledging positive/negative aspects of a medical career helped doctors to thrive. The way that interventions were implemented seemed critically important. Doctors and medical students needed to have confidence in an intervention for the intervention to be effective.

Conclusions: Successful interventions to tackle doctors' and students' mental ill-health are likely to be multidimensional and multilevel and involve multiple stakeholders. Evaluating and improving existing interventions is likely to be more effective than developing new ones. Our evidence synthesis provides a basis on which to do this.

Study Registration: PROSPERO CRD42017069870. Research project webpage http://sites.exeter.ac.uk/cup/.
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http://dx.doi.org/10.1186/s12916-020-01532-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7106831PMC
March 2020

Supporting social prescribing in primary care by linking people to local assets: a realist review.

BMC Med 2020 03 13;18(1):49. Epub 2020 Mar 13.

Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.

Background: Social prescribing is a way of addressing the 'non-medical' needs (e.g. loneliness, debt, housing problems) that can affect people's health and well-being. Connector schemes (e.g. delivered by care navigators or link workers) have become a key component to social prescribing's delivery. Those in this role support patients by either (a) signposting them to relevant local assets (e.g. groups, organisations, charities, activities, events) or (b) taking time to assist them in identifying and prioritising their 'non-medical' needs and connecting them to relevant local assets. To understand how such connector schemes work, for whom, why and in what circumstances, we conducted a realist review.

Method: A search of electronic databases was supplemented with Google alerts and reference checking to locate grey literature. In addition, we sent a Freedom of Information request to all Clinical Commissioning Groups in England to identify any further evaluations of social prescribing connector schemes. Included studies were from the UK and focused on connector schemes for adult patients (18+ years) related to primary care.

Results: Our searches resulted in 118 included documents, from which data were extracted to produce context-mechanism-outcome configurations (CMOCs). These CMOCs underpinned our emerging programme theory that centred on the essential role of 'buy-in' and connections. This was refined further by turning to existing theories on (a) social capital and (b) patient activation.

Conclusion: Our realist review highlights how connector roles, especially link workers, represent a vehicle for accruing social capital (e.g. trust, sense of belonging, practical support). We propose that this then gives patients the confidence, motivation, connections, knowledge and skills to manage their own well-being, thereby reducing their reliance on GPs. We also emphasise within the programme theory situations that could result in unintended consequences (e.g. increased demand on GPs).
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http://dx.doi.org/10.1186/s12916-020-1510-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7068902PMC
March 2020

GPs' understanding of the benefits and harms of treatments for long-term conditions: an online survey.

BJGP Open 2020 1;4(1). Epub 2020 May 1.

Professor of Primary Health Care, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK.

Background: GPs prescribe multiple long-term treatments to their patients. For shared clinical decision-making, understanding of the absolute benefits and harms of individual treatments is needed. International evidence shows that doctors' knowledge of treatment effects is poor but, to the authors knowledge, this has not been researched among GPs in the UK.

Aim: To measure the level and range of the quantitative understanding of the benefits and harms of treatments for common long-term conditions (LTCs) among GPs.

Design & Setting: An online cross-sectional survey was distributed to GPs in the UK.

Method: Participants were asked to estimate the percentage absolute risk reduction or increase conferred by 13 interventions across 10 LTCs on 17 important outcomes. Responses were collated and presented in a novel graphic format to allow detailed visualisation of the findings. Descriptive statistical analysis was performed.

Results: A total of 443 responders were included in the analysis. Most demonstrated poor (and in some cases very poor) knowledge of the absolute benefits and harms of treatments. Overall, an average of 10.9% of responses were correct allowing for ±1% margin in absolute risk estimates and 23.3% allowing a ±3% margin. Eighty-seven point seven per cent of responses overestimated and 8.9% of responses underestimated treatment effects. There was no tendency to differentially overestimate benefits and underestimate harms. Sixty-four point eight per cent of GPs self-reported 'low' to 'very low' confidence in their knowledge.

Conclusion: GPs' knowledge of the absolute benefits and harms of treatments is poor, with inaccuracies of a magnitude likely to meaningfully affect clinical decision-making and impede conversations with patients regarding treatment choices.
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http://dx.doi.org/10.3399/bjgpopen20X101016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7330197PMC
May 2020

Protocol for the impact of paramedics in NHS primary care: application of realist approaches to improve understanding and support intelligent policy and future workforce planning.

Br Paramed J 2019 Dec;4(3):35-42

University of Oxford: ORCID iD: https://orcid.org/0000-0002-7791-8552.

Introduction: In the United Kingdom, changing demands on ambulance services has caused a change in what is expected of a paramedic. As well as advanced life support, paramedics now need to be skilled in managing a range of urgent case presentations, with emphasis on treat-at-scene. The change in the scope of work paramedics can undertake has established their role within primary care. However, as paramedics transition to roles within primary care, their knowledge and skillset will undoubtedly need to change. The current opportunities for paramedics' employment in primary care require careful evaluation. In order to contribute to patients' and the NHS' primary care agenda, evidence must be generated to show how and why these changes would work, for whom, in what context and to what extent.

Methods And Analysis: The purpose of this research is to produce findings that will improve our understanding of the ways in which (i.e. how, why and in what contexts) paramedics impact on the primary care workforce. A theory-driven approach to evidence-synthesis will be conducted in a realist review, to produce a programme theory. This programme theory will be tested using empirical data collected through a realist evaluation. Survey and interview data will be collected from paramedics working in primary care, general practitioners and patients to assess under which contexts, and by which mechanisms, paramedics are working in primary care, and thus test the programme theory. Based on the findings, we will be able to highlight the role of paramedics in primary care, as well as how they operate and under what conditions.

Ethics And Dissemination: Formal ethics review is not required for the review, as it is secondary research, but will be sought for the evaluation. Findings will be disseminated in a peer-reviewed journal, at national and international conferences and to relevant professional associations.
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http://dx.doi.org/10.29045/14784726.2019.12.4.3.35DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7783924PMC
December 2019

Reorganisation of general practice: be careful what you wish for.

Br J Gen Pract 2019 10 26;69(687):517-518. Epub 2019 Sep 26.

Centre for Academic Primary Care, University of Bristol, Bristol.

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http://dx.doi.org/10.3399/bjgp19X705941DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6774680PMC
October 2019

Current understanding and implementation of 'care navigation' across England: a cross-sectional study of NHS clinical commissioning groups.

Br J Gen Pract 2019 Oct 26;69(687):e675-e681. Epub 2019 Sep 26.

Nuffield Department of Primary Care, University of Oxford, Oxford.

Background: Care navigation is an avenue to link patients to activities or organisations that can help address non-medical needs affecting health and wellbeing. An understanding of how care navigation is being implemented across primary care is lacking.

Aim: To determine how 'care navigation' is interpreted and currently implemented by clinical commissioning groups (CCGs).

Design And Setting: A cross-sectional study involving CCGs in England.

Method: A questionnaire was sent to all CCGs inviting them to comment on who provided care navigation, the type of patients for whom care navigation was provided, how individuals were referred, and whether services were being evaluated. Responses were summarised using descriptive statistics.

Results: The authors received usable responses from 83% of CCGs ( = 162), and of these >90% ( = 147) had some form of care navigation running in their area. A total of 75 different titles were used to describe the role. Most services were open to all adult patients, though particular groups may have been targeted; for example, people who are older and those with long-term conditions. Referrals tended to be made by a professional, or people were identified by a receptionist when they presented to a surgery. Evaluation of care navigation services was limited.

Conclusion: There is a policy steer to engaging patients in social prescribing, using some form of care navigator to help with this. Results from this study highlight that, although this type of role is being provided, its implementation is heterogeneous. This could make comparison and the pooling of data on care navigation difficult. It may also leave patients unsure about what care navigation is about and how it could help them.
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http://dx.doi.org/10.3399/bjgp19X705569DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6733589PMC
October 2019

A realist review of community engagement with health research.

Wellcome Open Res 2019 2;4:87. Epub 2019 Aug 2.

Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, OX1 3SY, UK.

: Community engagement is increasingly recognized as a critical aspect of global health. Recent years have seen an expansion of community engagement activities linked to health research, but debates and inconsistencies remain about the aims of different types of engagement, mechanisms underpinning their implementation and impact, and influential contextual factors. Greater commitment to and consistency around community engagement by health research programs, implementers and funders requires a more coherent evidence base. This realist review is designed to improve our understanding of how and why community engagement contributes to intended and unintended outcomes (including research and ethical outcomes) in different contexts. Given the breadth and diversity of the literature on community engagement in health research, the review will initially focus on malaria research in low- and middle-income countries (LMICs) and draw on wider global health literature where needed. : Community engagement in practice is often a complex set of interventions. We will conduct a realist review - a theory driven approach to evidence synthesis - to provide explanations for how and why community engagement with health research produces the pattern of outcomes observed across different contexts of application. We will consolidate evidence from a range of documents, including qualitative, quantitative and mixed method studies. The review will follow several stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesizing and refining the programme theory, and reiteration of these steps as needed. : A formal ethics review is not required for this literature review.  Findings will be disseminated in a peer reviewed journal, through national and international conferences, and through a set of short briefings tailored for audiences with an interest in community engagement. Outputs and presentations will be informed by and feed into our network of community engagement experts. CRD42019125687.
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http://dx.doi.org/10.12688/wellcomeopenres.15298.2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6611131PMC
August 2019

In search for gold - The relevance of realist reviews and evaluations to pharmacy research and policy development.

Res Social Adm Pharm 2020 Jun 3;16(6):836-839. Epub 2019 Jul 3.

Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, OX2 6GG, United Kingdom. Electronic address:

Pharmacy services and programs can be regarded as complex interventions which are developed and implemented within the open, complex system of overall healthcare. Realist research considers matters of complexity and provides insights into what programs and interventions work, why and in which contexts. Based on the philosophy of science of critical realism, realist evaluations and realist reviews generate causative explanations which inform pharmacy practitioners, educators and policy makers in which context programs and services achieve particular outcomes. This more nuanced understanding of how pharmacy services contribute to overall healthcare provides guidance for the refinement and targeting of programs, interventions and practice models. This article outlines key aspects of realist research approaches and provides insight into how realism can contribute to research in and the practice of pharmacy.
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http://dx.doi.org/10.1016/j.sapharm.2019.07.002DOI Listing
June 2020

Improving best practice for patients receiving hospital discharge letters: a realist review.

BMJ Open 2019 06 9;9(6):e027588. Epub 2019 Jun 9.

Unit of Academic Primary Care, Warwick Medical School, University of Warwick, Coventry, UK.

Objective: To understand how different outcomes are achieved from adult patients receiving hospital discharge letters from inpatient and outpatient settings.

Design: Realist review conducted in six main steps: (1) development of initial theory, (2) searching, (3) screening and selection, (4) data extraction and analysis, (5) data synthesis and (6) programme theory (PT) refinement.

Eligibility Criteria: Documents reporting evidence that met criteria for relevance to the PT. Documents relating solely to mental health or children aged <18 years were excluded.

Analysis: Data were extracted and analysed using a realist logic of analysis. Texts were coded for concepts relating to context, mechanism, outcome configurations (CMOCs) for the intervention of patients receiving discharge letters. All outcomes were considered. Based on evidence and our judgement, CMOCs were labelled 'positive' or 'negative' in order to clearly distinguish between contexts where the intervention does and does not work.

Results: 3113 documents were screened and 103 were included. Stakeholders contributed to refining the PT in step 6. The final PT included 48 CMOCs for how outcomes are affected by patients receiving discharge letters. 'Patient choice' emerged as a key influencer to the success (or not) of the intervention. Important contexts were identified for both 'positive' CMOCs (eg, no new information in letter) and 'negative' CMOCs (eg, letter sent without verifying patient contact details). Two key findings were that patient understanding is possibly greater than clinicians perceive, and that patients tend to express strong preference for receiving letters. Clinician concerns emerged as a barrier to wider sharing of discharge letters with patients, which may need to be addressed through organisational policies and direction.

Conclusions: This review forms a starting point for explaining outcomes associated with whether or not patients receive discharge letters. It suggests several ways in which current processes might be modified to support improved practice and patient experience.
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http://dx.doi.org/10.1136/bmjopen-2018-027588DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6561435PMC
June 2019

Atrial Tachycardia Arising From the Crista Terminalis, Detailed Electrophysiological Features and Long-Term Ablation Outcomes.

JACC Clin Electrophysiol 2019 04 27;5(4):448-458. Epub 2019 Mar 27.

Department of Cardiology, Royal Melbourne Hospital, Melbourne, Australia; Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Parkville, Victoria, Australia. Electronic address:

Objectives: The goal of this study was to characterize, in detail, focal atrial tachycardia (AT) arising from the crista terminalis to investigate associations with other atrial arrhythmia and to define long-term ablation outcomes.

Background: The crista terminalis is known to be the most common site of origin for focal AT, but it is not well characterized.

Methods: This study retrospectively identified a total of 548 ablation procedures for AT performed at a single center over a 16-year period, of which 171 were arising from the crista terminalis.

Results: Compared with patients with other AT sites of origin, crista terminalis AT patients were older (57.3 vs. 47.3 years), more commonly female (72.9% vs. 59.1%), were more commonly associated with coexistent atrioventricular nodal re-entry tachycardia (17.1% vs. 9.7%), and were more likely to be inducible with programmed stimulation (81.5% vs. 58.9%). There was preferential conduction in the superior-inferior axis along the crista terminalis. Acute ablation success rate was high (92.2%) and improved significantly when three-dimensional mapping was used (98.5%). Recurrence in the first 12 months after a successful ablation was 9.7%. Only 2 patients developed atrial fibrillation over the long-term follow-up of >7 years.

Conclusions: This large series characterized the clinical and electrophysiological features and immediate and long-term ablation outcomes for AT originating from the crista terminalis. Features of the tachycardia suggest that age-related localized remodeling of the crista terminalis causes a superficial endocardial zone of conduction slowing leading to re-entry. Ablation outcomes were good, with long-term freedom from atrial arrhythmia.
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http://dx.doi.org/10.1016/j.jacep.2019.01.014DOI Listing
April 2019

Underlying mechanisms of complex interventions addressing the care of older adults with multimorbidity: a realist review.

BMJ Open 2019 04 3;9(4):e025009. Epub 2019 Apr 3.

Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Ontario, Canada.

Objectives: To understand and effective multi-chronic disease management interventions influence health outcomes in older adults 65 years of age or older.

Design: A realist review.

Data Sources: Electronic databases including Medline and Embase (inception to December 2017); and the grey literature.

Eligibility Criteria For Selecting Studies: We considered any studies (ie, experimental quasi-experimental, observational, qualitative and mixed-methods studies) as long as they provided data to explain our programme theories and effectiveness review (published elsewhere) findings. The population of interest was older adults (age ≥65 years) with two or more chronic conditions.

Analysis: We used the Realist And MEta-narrative Evidence Syntheses: Evolving Standards (RAMESES) quality and publication criteria for our synthesis aimed at refining our programme theories such that they contained multiple context-mechanism-outcome configurations describing the ways different mechanisms fire to generate outcomes. We created a 3-step synthesis process grounded in meta-ethnography to separate units of data from articles, and to derive explanatory statements across them.

Results: 106 articles contributed to the analysis. We refined our programme theories to explain multimorbidity management in older adults: (1) care coordination interventions with the best potential for impact are team-based strategies, programmes and ; (2) optimised disease prioritisation involves ensuring that clinician work with patients to identify what symptoms are problematic and why, and to explore options that are acceptable to both clinicians and patients and (3) optimised patient self-management is dependent on patients' capacity for selfcare and to what extent, and establishing what patients need to enable selfcare.

Conclusions: To optimise care, both clinical management and patient self-management need to be considered from multiple perspectives (patient, provider and system). To mitigate the complexities of multimorbidity management, patients focus on reducing symptoms and preserving quality of life while providers focus on the condition that most threaten morbidity and mortality.

Prospero Registration Number: CRD42014014489.
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http://dx.doi.org/10.1136/bmjopen-2018-025009DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6500199PMC
April 2019

Improving primary care Access in Context and Theory (I-ACT trial): a theory-informed randomised cluster feasibility trial using a realist perspective.

Trials 2019 Apr 4;20(1):193. Epub 2019 Apr 4.

Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Norwich Medical School, University of East Anglia, Chancellors Drive, Norwich, NR4 7TJ, UK.

Background: Primary care access can be challenging for older, rural, socio-economically disadvantaged populations. Here we report the I-ACT cluster feasibility trial which aims to assess the feasibility of trial design and context-sensitive intervention to improve primary care access for this group and so expand existing theory.

Methods: Four general practices were recruited; three randomised to intervention and one to usual care. Intervention practices received £1500, a support manual and four meetings to develop local, innovative solutions to improve the booking system and transport. Patients aged over 64 years old and without household car access were recruited to complete questionnaires when booking an appointment or attending the surgery. Outcome measures at 6 months included: self-reported ease of booking an appointment and transport; health care use; patient activation; capability; and quality of life. A process evaluation involved observations and interviews with staff and participants.

Results: Thirty-four patients were recruited (26 female, eight male, mean age 81.6 years for the intervention group and 79.4 for usual care) of 1143 invited (3% response rate). Most were ineligible because of car access. Twenty-nine participants belonged to intervention practices and five to usual care. Practice-level data was available for all participants, but participant self-reported data was unavailable for three. Fifty-six appointment questionnaires were received based on 150 appointments (37.3%). Practices successfully designed and implemented the following context-sensitive interventions: Practice A: a stacked telephone system and promoting community transport; Practice B: signposting to community transport, appointment flexibility, mobility scooter charging point and promoting the role of receptionists; and Practice C: local taxi firm partnership and training receptionists. Practices found the process acceptable because it gave freedom, time and resource to be innovative or provided an opportunity to implement existing ideas. Data collection methods were acceptable to participants, but some found it difficult remembering to complete booking and appointment questionnaires. Expanded theory highlighted important mechanisms, such as reassurance, confidence, trust and flexibility.

Conclusions: Recruiting older participants without access to a car proved challenging. Retention of participants and practices was good but only about a third of appointment questionnaires were returned. This study design may facilitate a shift from one-size-fits-all interventions to more context-sensitive interventions.

Trial Registration: ISRCTN18321951 , Registered on 6 March 2017.
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http://dx.doi.org/10.1186/s13063-019-3299-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6449944PMC
April 2019

Giving permission to care for people with dementia in residential homes: learning from a realist synthesis of hearing-related communication.

BMC Med 2019 03 4;17(1):54. Epub 2019 Mar 4.

University of Nottingham, Nottingham, UK.

Background: Managing hearing communication for residents living with hearing loss and dementia in long-term care settings is challenging. This paper explores how care can be effective in optimising hearing communication for residents living with dementia. We argue that the underlying notion of permission or authorisation allows care staff to do what they know will be effective in providing person-centred care that enhances hearing communication. The paper also indicates that this notion of permission can usefully be applied to other areas of care home practice.

Methods: To address hearing-related communication in care homes, we conducted a realist synthesis (RS). As a theory-driven approach to reviewing literature, it also uses expert opinion to understand complex health situations. Using RS, we developed a theory surrounding the management of hearing-related communication in care homes. Applying formal processes to the literature search and data extraction, the analysis uncovered relevant mechanisms and contexts to help confirm, refute or refine our understanding of how hearing communication could be improved.

Results: Forty-three papers were selected for the realist synthesis. The documents were analysed to construct five context-mechanism-outcome configurations (CMOCs). The CMOCs represent possible care interventions to optimise hearing-related communication in care homes for person living with dementia and hearing loss (PLWDHL). They include leadership promoting positive regard and empathy through person-centred care, communication training for staff, 'knowing the person' and relationship building for responsive awareness of residents' hearing needs, maintaining and monitoring hearing communication through care planning, and managing noise in the care home environment.

Conclusions: Leadership that provides appropriate training and resources is likely to enhance knowledge and skills, leading to staff feeling able and equipped to respond to the hearing-related communication needs of PLWDHL. Collaboration with local hearing services is likely to raise awareness of hearing loss among care home staff. Importantly, care staff require a sense of permission from leadership, to work with knowledge and autonomy in the interest of residents living with dementia and hearing loss.
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http://dx.doi.org/10.1186/s12916-019-1286-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6398258PMC
March 2019

Understanding care when cure is not likely for young adults who face cancer: a realist analysis of data from patients, families and healthcare professionals.

BMJ Open 2019 01 28;9(1):e024397. Epub 2019 Jan 28.

University College London Hospitals NHS Foundation Trust, London, UK.

Objectives: To understand the experiences of young adults with cancer for whom cure is not likely, in particular what may be specific for people aged 16-40 years and how this might affect care.

Design: We used data from multiple sources (semi-structured interviews with people with cancer, nominated family members and healthcare professionals, and workshops) informed by a preliminary programme theory: realist analysis of data within these themes enabled revision of our theory. A realist logic of analysis explored contexts and mechanisms affecting outcomes of care.

Setting: Three cancer centres and associated palliative care services across England.

Participants: We aimed for a purposive sample of 45 people with cancer from two groups: those aged 16-24 years for whom there may be specialist cancer centres and those 16-40 years cared for through general adult services; each could nominate for interview one family member and one healthcare professional. We interviewed three people aged 16-24 years and 30 people 25-40 years diagnosed with cancer (carcinomas; blood cancers; sarcoma; central nervous system tumours) with a clinician-estimated prognosis of <12 months along with nominated family carers and healthcare professionals. 19 bereaved family members and 47 healthcare professionals participated in workshops.

Results: Data were available from 69 interviews (33 people with cancer, 14 family carers, 22 healthcare professionals) and six workshops. Qualitative analysis revealed seven key themes: loss of control; maintenance of normal life; continuity of care; support for professionals; support for families; importance of language chosen by professionals; and financial concerns.

Conclusions: Current care towards end of life for young adults with cancer and their families does not meet needs and expectations. We identified challenges specific to those aged 16-40 years. The burden that care delivery imposes on healthcare professionals must be recognised. These findings can inform recommendations for measures to be incorporated into services.
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http://dx.doi.org/10.1136/bmjopen-2018-024397DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6352841PMC
January 2019

Quality circles for quality improvement in primary health care: Their origins, spread, effectiveness and lacunae- A scoping review.

PLoS One 2018 17;13(12):e0202616. Epub 2018 Dec 17.

Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, United Kingdom.

Quality circles or peer review groups, and similar structured small groups of 6-12 health care professionals meet regularly across Europe to reflect on and improve their standard practice. There is debate over their effectiveness in primary health care, especially over their potential to change practitioners' behaviour. Despite their popularity, we could not identify broad surveys of the literature on quality circles in a primary care context. Our scoping review was intended to identify possible definitions of quality circles, their origins, and reported effectiveness in primary health care, and to identify gaps in our knowledge. We searched appropriate databases and included any relevant paper on quality circles published until December 2017. We then compared information we found in the articles to that we found in books and on websites. Our search returned 7824 citations, from which we identified 82 background papers and 58 papers about quality circles. We found that they originated in manufacturing industry and that many countries adopted them for primary health care to continuously improve medical education, professional development, and quality of care. Quality circles are not standardized and their techniques are complex. We identified 19 papers that described individual studies, one paper that summarized 3 studies, and 1 systematic review that suggested that quality circles can effectively change behaviour, though effect sizes varied, depending on topic and context. Studies also suggested participation may affirm self-esteem and increase professional confidence. Because reports of the effect of quality circles on behaviour are variable, we recommend theory-driven research approaches to analyse and improve the effectiveness of this complex intervention.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0202616PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6296539PMC
April 2019

Relation of Alcohol Consumption to Left Ventricular Fibrosis Using Cardiac Magnetic Resonance Imaging.

Am J Cardiol 2019 02 6;123(3):460-465. Epub 2018 Nov 6.

Department of Medicine, University of Melbourne, Melbourne, Australia; Baker Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, The Alfred Hospital, Melbourne, Australia. Electronic address:

Light-to-moderate regular alcohol consumption has been associated with reduced mortality, heart failure, and sudden death, with a well described "U-shaped" relationship. We sought to determine whether markers of diffuse ventricular fibrosis as assessed by cardiac magnetic resonance imaging (CMR) T mapping differ between nondrinkers and regular drinkers. We prospectively recruited 165 participants to undergo 3T CMR ventricular T1 mapping which included 120 regular light-to-moderate drinkers (7 to 28 standard drinks per week for >12 months) and 45 age and gender-matched nondrinking controls (1 standard drink ∼12 g alcohol). Diffuse ventricular fibrosis was assessed using ShMOLLI T1 mapping sequences performed in mid-short axis. Native T1, postcontrast T1 times and extracellular volume were compared in the left ventricle between regular drinkers and lifelong nondrinkers. In total 165 participants (mean age 59 ± 12 years, 70% male, 36% hypertension, mean LVEF 58 ± 11%) underwent CMR. Moderate alcohol intake (mean alcohol intake 16 ± 6 SDs/week) was associated with lower markers of diffuse ventricular fibrosis: native T1 time 1140 ± 47 vs 1173 ± 39 ms, p < 0.001; postcontrast T1 time 470 ± 47 vs 445 ± 43 ms, p = 0.01; extracellular volume 25.0 ± 2.7% vs 27.0 ± 2.8%, p = 0.003 despite similar LV size (p = 0.55) and mass compared with nondrinkers (p = 0.78). Quantity of alcohol intake and beverage type did not predict lower native T1 times. In conclusion, light-to-moderate or "social" alcohol consumption is associated with T1 changes on CMR suggestive of a reduction in diffuse ventricular fibrosis. These preliminary findings may provide some insights into the association between modest alcohol intake and reduction in sudden death and heart failure.
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http://dx.doi.org/10.1016/j.amjcard.2018.10.026DOI Listing
February 2019

Regular Alcohol Consumption Is Associated With Impaired Atrial Mechanical Function in the Atrial Fibrillation Population: A Cross-Sectional MRI-Based Study.

JACC Clin Electrophysiol 2018 11 26;4(11):1451-1459. Epub 2018 Sep 26.

Baker Heart & Diabetes Institute, Melbourne, Australia; Heart Centre, The Alfred Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia. Electronic address:

Objectives: This study sought to determine the impact of regular alcohol consumption on left atrial (LA) mechanical and reservoir function.

Background: Earlier studies suggest that regular alcohol intake is associated with increased atrial fibrillation (AF) and LA dilatation.

Methods: This study prospectively enrolled 160 patients with paroxysmal or persistent AF to undergo 3-T cardiac magnetic resonance (CMR) imaging in sinus rhythm. Patients self-reported alcohol consumption in standard drinks (∼12 g alcohol) per week over the preceding 12 months and were categorized into 4 groups: 1) lifelong nondrinkers; 2) mild drinkers (3 to 10 standard drinks/week); 3) moderate drinkers (11 to 20 standard drinks/week); 4) heavy drinkers (>20 standard drinks/week). Permanent AF and cardiomyopathy were excluded. On CMR, maximum LA volume (LA) and minimum LA volume (LA), global LA emptying fraction (LAEF) as (LA - LA) / LA, and LA reservoir function as (LA - LA) / LA were calculated.

Results: Regular alcohol consumption (mean 15.8 ± 6.9 standard drinks/week, n = 120) was associated with larger LA size (LA volume index 50 ± 13 ml/m vs. 43 ± 12 ml/m; p = 0.005), reduction in LAEF (40 ± 14% vs. 52 ± 15%; p < 0.001), and reduction in reservoir function (77 ± 48% vs. 119 ± 63%; p < 0.001) compared with lifelong nondrinkers (n = 40). There were progressive dose-related impairments in LAEF (mild 45.4 ± 13.5% vs. moderate 39.1 ± 14.7% vs. heavy drinkers 35.6 ± 12.6%; p < 0.01) and reservoir function (mild 95.8 ± 55.6% vs. moderate 74.8 ± 47.1% vs. heavy drinkers 61.7 ± 34.4%; p < 0.01). Predictors of atrial mechanical dysfunction included weekly alcohol intake (p = 0.001), older age (p = 0.018), and persistent AF (p = 0.016), but not binge drinking or beverage type.

Conclusions: In patients with AF, habitual alcohol consumption is associated with significantly increased LA size and atrial mechanical dysfunction compared with nondrinkers.
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http://dx.doi.org/10.1016/j.jacep.2018.07.010DOI Listing
November 2018

Remediating doctors' performance to restore patient safety: a realist review protocol.

BMJ Open 2018 10 28;8(10):e025943. Epub 2018 Oct 28.

Medicine and Dentistry, University of Plymouth, Plymouth, UK.

Introduction: Underperformance by doctors poses a risk to patient safety. Remediation is an intervention designed to remedy underperformance and return a doctor to safe practice. Remediation is widely used across healthcare systems globally, and has clear implications for both patient safety and doctor retention. Yet, there is a poor evidence base to inform remediation programmes. In particular, there is a lack of understanding as to why and how a remedial intervention may work to change a doctor's practice. The aim of this research is to identify why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to support patient safety.

Methods And Analysis: Realist review is an approach to evidence synthesis that seeks to develop programme theories about how an intervention works to produce its effects. The initial search strategy will involve: database and grey literature searching, citation searching and contacting authors. The evidence search will be extended as the review progresses and becomes more focused on the development of specific aspects of the programme theory. The development of the programme theory will involve input from a stakeholder group consisting of professional experts in the remediation process and patient representatives. Evidence synthesis will use a realist logic of analysis to interrogate data in order to develop and refine the initial programme theory into a more definitive realist programme theory of how remediation works. The study will follow and be reported according to Realist And Meta-narrative Evidence Syntheses-Evolving Standards (RAMESES).

Ethics And Dissemination: Ethical approval is not required. Our dissemination strategy will include input from our stakeholder group. Customised outputs will be developed using the knowledge-to-action cycle framework, and will be targeted to: policy-makers; education providers and regulators, the National Health Service, doctors and academics.

Prospero Registration Number: CRD42018088779.
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http://dx.doi.org/10.1136/bmjopen-2018-025943DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6224734PMC
October 2018

Effectiveness of interventions for managing multiple high-burden chronic diseases in older adults: a systematic review and meta-analysis.

CMAJ 2018 08;190(34):E1004-E1012

Knowledge Translation and Implementation unit (Kastner, Hayden), North York General Hospital, Li Ka Shing Knowledge Institute of St. Michael's Hospital (Kastner, Cardoso, Lai, Treister, Hamid, Straus); Institute of Health Policy, Management and Evaluation (Kastner), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Clinical Epidemiology and Biostatistics (Hamid), McMaster University, Hamilton, Ont.; Nuffield Department of Primary Care Health Sciences (Wong), University of Oxford, Oxford, UK; Family Practice Health Centre (Ivers), Women's College Research Institute, and Institute for Health System Solutions and Virtual Care, Women's College Hospital; Department of Family and Community Medicine and Institute of Health Policy (Ivers), Management and Evaluation, University of Toronto, Toronto; Regional Geriatric Program of Toronto (Liu), Sunnybrook Health Sciences, Geriatric Medicine, Toronto, Ont.; St. Peter's Hospital, Hamilton Health Sciences (Marr), Division of Geriatric Medicine (Marr), McMaster University, Hamilton, Ont.; Departments of Medicine and Community Health Sciences (Holroyd-Leduc), University of Calgary, Foothills Hospital, Calgary, Alta.; Department of Medicine (Straus), University of Toronto, Toronto, Ont.

Introduction: More than half of older adults (age ≥ 65 yr) have 2 or more high-burden multimorbidity conditions (i.e., highly prevalent chronic diseases, which are associated with increased health care utilization; these include diabetes [DM], dementia, depression, chronic obstructive pulmonary disease [COPD], cardiovascular disease [CVD], arthritis, and heart failure [HF]), yet most existing interventions for managing chronic disease focus on a single disease or do not respond to the specialized needs of older adults. We conducted a systematic review and meta-analysis to identify effective multimorbidity interventions compared with a control or usual care strategy for older adults.

Methods: We searched bibliometric databases for randomized controlled trials (RCTs) evaluating interventions for managing multiple chronic diseases in any language from 1990 to December 2017. The primary outcome was any outcome specific to managing multiple chronic diseases as reported by studies. Reviewer pairs independently screened citations and full-text articles, extracted data and assessed risk of bias. We assessed statistical and methodological heterogeneity and performed a meta-analysis of RCTs with similar interventions and components.

Results: We included 25 studies (including 15 RCTs and 6 cluster RCTs) (12 579 older adults; mean age 67.3 yr). In patients with [depression + COPD] or [CVD + DM], care-coordination strategies significantly improved depressive symptoms (standardized mean difference -0.41; 95% confidence interval [CI] -0.59 to -0.22; = 0%) and reduced glycosylated hemoglobin (HbA) levels (mean difference -0.51; 95% CI -0.90 to -0.11; = 0%), but not mortality (relative risk [RR] 0.79; 95% CI 0.53 to 1.17; = 0%). Among secondary outcomes, care-coordination strategies reduced functional impairment in patients with [arthritis + depression] (between-group difference -0.82; 95% CI -1.17 to -0.47) or [DM + depression] (between-group difference 3.21; 95% CI 1.78 to 4.63); improved cognitive functioning in patients with [DM + depression] (between-group difference 2.44; 95% CI 0.79 to 4.09) or [HF + COPD] ( = 0.006); and increased use of mental health services in those with [DM + (CVD or depression)] (RR 2.57; 95% CI 1.90 to 3.49; = 0%).

Interpretation: Subgroup analyses showed that older adults with diabetes and either depression or cardiovascular disease, or with coexistence of chronic obstructive pulmonary disease and heart failure, can benefit from care-coordination strategies with or without education to lower HbA, reduce depressive symptoms, improve health-related functional status, and increase the use of mental health services.

Protocol Registration: PROSPERO-CRD42014014489.
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http://dx.doi.org/10.1503/cmaj.171391DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6110649PMC
August 2018

Regression of Diffuse Ventricular Fibrosis Following Restoration of Sinus Rhythm With Catheter Ablation in Patients With Atrial Fibrillation and Systolic Dysfunction: A Substudy of the CAMERA MRI Trial.

JACC Clin Electrophysiol 2018 08 27;4(8):999-1007. Epub 2018 Jun 27.

Department of Cardiology, Alfred Hospital, Victoria, Australia; Baker IDI Heart and Diabetes Institute, Victoria, Australia; Faculty of Medicine, Dentistry, and Health Sciences, University of Melbourne, Victoria, Australia. Electronic address:

Objectives: This study sought to determine if diffuse ventricular fibrosis improves in patients with atrial fibrillation (AF)-mediated cardiomyopathy following the restoration of sinus rhythm.

Background: AF coexists in 30% of heart failure (HF) patients and may be an underrecognized reversible cause of left ventricular systolic dysfunction. Myocardial fibrosis is the hallmark of adverse cardiac remodeling in HF, yet its reversibility is unclear.

Methods: Patients with persistent AF and an idiopathic cardiomyopathy (left ventricular ejection fraction [LVEF] ≤45%) were randomized to catheter ablation (CA) or ongoing medical rate control as a pre-specified substudy of the CAMERA-MRI (Catheter Ablation versus Medical Rate Control in Atrial Fibrillation and Systolic Dysfunction-an MRI-Guided Multi-centre Randomised Controlled Trial) trial. All patients had cardiac magnetic resonance imaging scans (including myocardial T1 time), serum B-type natriuretic peptide, 6-min walk tests, and Short Form-36 questionnaires performed at baseline and 6 months. Sixteen patients with no history of AF or left ventricular systolic dysfunction were enrolled as normal controls for T1 time.

Results: Thirty-six patients (18 in each treatment arm) were included in this substudy. Demographics, comorbidities, and myocardial T1 times were well matched at baseline. At 6 months, patients in the CA group had a significant reduction in myocardial T1 time from baseline compared with the medical rate control group (-124 ms; 95% confidence interval [CI]: -23 to -225 ms; p = 0.0176), although it remained higher than that of normal controls at 6 months (p = 0.0017). Improvements in myocardial T1 time with CA were associated with significant improvements in absolute LVEF (+12.5%; 95% CI: 5.9% to 19.0%; p = 0.0004), left ventricular end-systolic volume (p = 0.0019), and serum B-type natriuretic peptide (-216 ng/l; 95% CI: -23 to -225 ng/l; p = 0.0125).

Conclusions: The improvement in LVEF and reverse ventricular remodeling following successful CA of AF-mediated cardiomyopathy is accompanied by a regression of diffuse fibrosis. This suggests timely treatment of arrhythmia-mediated cardiomyopathy may minimize irreversible ventricular remodeling.
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http://dx.doi.org/10.1016/j.jacep.2018.04.013DOI Listing
August 2018

Access to primary care for socio-economically disadvantaged older people in rural areas: exploring realist theory using structural equation modelling in a linked dataset.

BMC Med Res Methodol 2018 06 19;18(1):57. Epub 2018 Jun 19.

Norwich Medical School, University of East Anglia, Chancellor's Drive, Norwich, UK.

Background: Realist approaches seek to answer questions such as 'how?', 'why?', 'for whom?', 'in what circumstances?' and 'to what extent?' interventions 'work' using context-mechanism-outcome (CMO) configurations. Quantitative methods are not well-established in realist approaches, but structural equation modelling (SEM) may be useful to explore CMO configurations. Our aim was to assess the feasibility and appropriateness of SEM to explore CMO configurations and, if appropriate, make recommendations based on our access to primary care research. Our specific objectives were to map variables from two large population datasets to CMO configurations from our realist review looking at access to primary care, generate latent variables where needed, and use SEM to quantitatively test the CMO configurations.

Methods: A linked dataset was created by merging individual patient data from the English Longitudinal Study of Ageing and practice data from the GP Patient Survey. Patients registered in rural practices and who were in the highest deprivation tertile were included. Three latent variables were defined using confirmatory factor analysis. SEM was used to explore the nine full CMOs. All models were estimated using robust maximum likelihoods and accounted for clustering at practice level. Ordinal variables were treated as continuous to ensure convergence.

Results: We successfully explored our CMO configurations, but analysis was limited because of data availability. Two hundred seventy-six participants were included. We found a statistically significant direct (context to outcome) or indirect effect (context to outcome via mechanism) for two of nine CMOs. The strongest association was between 'ease of getting through to the surgery' and 'being able to get an appointment' with an indirect mediated effect through convenience (proportion of the indirect effect of the total was 21%). Healthcare experience was not directly associated with getting an appointment, but there was a statistically significant indirect effect through convenience (53% mediated effect). Model fit indices showed adequate fit.

Conclusions: SEM allowed quantification of CMO configurations and could complement other qualitative and quantitative techniques in realist evaluations to support inferences about strengths of relationships. Future research exploring CMO configurations with SEM should aim to collect, preferably continuous, primary data.
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http://dx.doi.org/10.1186/s12874-018-0514-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6006834PMC
June 2018