Vulnerable migrants' access to healthcare in the early stages of the COVID-19 pandemic in the UK.

OBJECTIVES: To understand the living conditions, changes in the service user profile, and needs of vulnerable migrants trying to access healthcare in the early stages of the COVID-19 pandemic. STUDY DESIGN: Mixed methods study; using quantitative questionnaire data collected from migrant service users of Doctors of the World UK (DOTW UK) with qualitative data from free-text notes. METHODS: DOTW UK provides drop-in clinics to vulnerable migrants. Consultations switched to remote during the UK's first lockdown. We compared patient profile, well-being, healthcare access and reason for consultations of individuals attending the virtual clinic between March and September 2020 to those of the prepandemic periods between 2011 and 2018. RESULTS: During the pandemic, consultations dropped to under half of the prepandemic numbers, with the shift to remote consultations attracting more users outside of London. DOTW UK's user base changed to include a greater proportion of asylum seekers, younger adults (18-34) and individuals reporting good health. Socio-economic conditions and housing stability deteriorated for the majority of users. Those in the greatest need of healthcare appeared to be less able to access remote services. General practitioner (GP) registration remained the most common reason for contacting the virtual clinic with a lack of knowledge of the healthcare system being the main barrier to access. CONCLUSION: The shift to virtual consultations may have exacerbated existing inequalities in healthcare access for vulnerable migrants. Given that many clinical services continue to operate remotely, it is important to consider the impact such actions have on vulnerable migrants and find ways to support access.

Implementation of a critical care outreach service: a qualitative study.

AIM: The aim of this study was to explore hospital staff perceptions of the perceived challenges and outcomes of implementing a critical care outreach service. BACKGROUND: A nurse-led critical care outreach service was designed and implemented to identify and treat acutely ill patients in a large tertiary care hospital in Iran. METHODS: A qualitative analysis of data from two focus groups and seven interviews was carried out using conventional content analyses techniques. A total of 24 hospital staff members participated, including critical care outreach team members, physicians, ward head nurses and ward staff. FINDINGS: Two main categories described the perceived challenges to the implementation of the critical care outreach service: 1) the hospital context, with four subcategories related to staff shortages, the instability of physician positions, the lack of specialized essential services and the absence of a system to establish do-not-resuscitate orders, and 2) staff resistance to different nursing priorities, routines and extra work. In two additional main categories, participants also described positive and negative perceived outcomes. The positive perceived outcomes included three subcategories of alleviating equipment shortages, improving nursing knowledge and patient care and improving patient and healthcare professional satisfaction. DISCUSSION: While critical care outreach has the potential to improve patient perceived outcomes and both patient and provider satisfaction with care, the contextual and clinical realities in hospitals are significant and must be examined during the planning and implementation of future outreach. CONCLUSION AND IMPLICATIONS FOR NURSING AND HEALTH POLICY: A critical care outreach service in the context of an Iranian hospital has the potential to improve ward nurse familiarity with the care of acutely ill patients and the quality of palliative care. However, attention ought to be paid to the hospital's structural and contextual factors. Alleviating nursing shortages, reducing staff resistance and preparing goals of care guidelines that address restrictions on resuscitation could facilitate implementation of critical care outreach services.

Prevalence and predictors of hospital prealerting in acute stroke: a mixed methods study.

BACKGROUND: Thrombolysis can significantly reduce the burden of stroke but the time window for safe and effective treatment is short. In patients travelling to hospital via ambulance, the sending of a 'prealert' message can significantly improve the timeliness of treatment. OBJECTIVE: Examine the prevalence of hospital prealerting, the extent to which prealert protocols are followed and what factors influence emergency medical services (EMS) staff's decision to send a prealert. METHODS: Cohort study of patients admitted to two acute stroke units in West Midlands (UK) hospitals using linked data from hospital and EMS records. A logistic regression model examined the association between prealert eligibility and whether a prealert message was sent. In semistructured interviews, EMS staff were asked about their experiences of patients with suspected stroke. RESULTS: Of the 539 patients eligible for this study, 271 (51%) were recruited. Of these, only 79 (29%) were eligible for prealerting according to criteria set out in local protocols but 143 (53%) were prealerted. Increasing number of Face, Arm, Speech Test symptoms (1 symptom, OR 6.14, 95% CI 2.06 to 18.30, p=0.001; 2 symptoms, OR 31.36, 95% CI 9.91 to 99.24, p<0.001; 3 symptoms, OR 75.84, 95% CI 24.68 to 233.03, p<0.001) and EMS contact within 5 h of symptom onset (OR 2.99, 95% CI 1.37 to 6.50 p=0.006) were key predictors of prealerting but eligibility for prealert as a whole was not (OR 1.92, 95% CI 0.85 to 4.34 p=0.12). In qualitative interviews, EMS staff displayed varying understanding of prealert protocols and described frustration when their interpretation of the prealert criteria was not shared by ED staff. CONCLUSIONS: Up to half of the patients presenting with suspected stroke in this study were prealerted by EMS staff, regardless of eligibility, resulting in disagreements with ED staff during handover. Aligning the expectations of EMS and ED staff, perhaps through simplified prealert protocols, could be considered to facilitate more appropriate use of hospital prealerting in acute stroke.

Attitudes, access and anguish: a qualitative interview study of staff and patients' experiences of diabetic retinopathy screening.

OBJECTIVE: To examine the experiences of patients, health professionals and screeners; their interactions with and understandings of diabetic retinopathy screening (DRS); and how these influence uptake. DESIGN: Purposive, qualitative design using multiperspectival, semistructured interviews and thematic analysis. SETTING: Three UK Screening Programme regions with different service-delivery modes, minority ethnic and deprivation levels across rural, urban and inner-city areas, in general practitioner practices and patients' homes. PARTICIPANTS: 62 including 38 patients (22 regular-screening attenders, 16 non-regular attenders) and 24 professionals (15 primary care professionals and 9 screeners). RESULTS: Antecedents to attendance included knowledge about diabetic retinopathy and screening; antecedents to non-attendance included psychological, pragmatic and social factors. Confusion between photographs taken at routine eye tests and DRS photographs was identified. The differing regional invitation methods and screening locations were discussed, with convenience and transport safety being over-riding considerations for patients. Some patients mentioned significant pain and visual disturbance from mydriasis drops as a deterrent to attendance. CONCLUSIONS: In this, the first study to consider multiperspectival experiential accounts, we identified that proactive coordination of care involving patients, primary care and screening programmes, prior to, during and after screening is required. Multiple factors, prior to, during and after screening, are involved in the attendance and non-attendance for DRS. Further research is needed to establish whether patient self-management educational interventions and the pharmacological reformulation of shorter acting mydriasis drops, may improve uptake of DRS. This might, in turn, reduce preventable vision loss and its associated costs to individuals and their families, and to health and social care providers, reducing current inequalities.

Oral health awareness and care preferences in patients with diabetes: a qualitative study.

BACKGROUND: People with type 2 diabetes have an increased risk of oral health problems; however, oral health is currently not included in structured diabetes reviews and education in the UK. AIM AND OBJECTIVES: This study explores the patient's experience related to oral health and diabetes, especially in relation to: • Awareness of the link between oral health and diabetes and oral self-care needs. • Interaction with health professionals in dental and general practice. • Preferences for receiving oral health information and education. Methods This nested qualitative study involved semi-structured telephone interviews with a purposive sample of 20 participants from a questionnaire study on oral health awareness in patients with diabetes. Interview transcripts were analysed using a thematic framework approach. RESULTS: Participants were mostly unaware of the link between oral health and diabetes. Those that had been made aware by a health professional were not given concrete self-care advice. Interactions with dental professionals were often limited to informing the dental practice of their diagnosis and current medication. Most participants were in favour of dentists screening for diabetes, but as their general practice was the hub for diabetes care, they felt GPs or nurses should provide oral health information and discuss oral health with patients. CONCLUSIONS: Written information regarding diabetes and its possible effects on oral health needs to be more readily available to people with diabetes, especially at diagnosis. There may be a place for introducing a structured oral health question in routine diabetes reviews.

An investigation of antibiotic prophylaxis in implant practice in the UK.

BACKGROUND: There is increasing evidence of the inappropriate use of antimicrobials in dentistry and this may contribute to the problem of antimicrobial resistance. The research to date with regard to efficacy of antimicrobial prophylaxis in reducing failure of integration and postoperative complications when placing dental implants remains equivocal. The aim of this study was to investigate how dentists in the UK use antimicrobials prophylactically in implant practice. METHOD: An e-mail link was provided in 2011 to an anonymous online (Smart-Survey) questionnaire using three databases of dentists who, by being on them, had registered an interest in placing dental implants. Absolute frequencies were used to describe the study sample demographics and examine the distribution of responses for all the variables investigated. RESULTS: One hundred and nine completed questionnaires were received. Seventy-two percent (n = 76) routinely prescribed prophylactic antibiotics for all procedures. There was a wide variation in the pre-operative and postoperative prescription regimens with the majority (84%) stating that it was to prevent infection at the site of surgery or to reduce a bacteraemia. CONCLUSIONS: Although this was a small study with a low response rate, wide variations in antibiotic prescribing regimens with respect to drug, dose and duration were found. Further research is needed and guidelines developed to prevent antibiotic overprescribing and misuse.

Oral health awareness in adult patients with diabetes: a questionnaire study.

OBJECTIVE: To investigate oral health awareness, oral hygiene and attitudes towards general dental practitioners' (GDP) involvement in diabetes screening in adults with diabetes. DESIGN: Self-completion questionnaire. SETTING: General medical practices in Warwickshire. SUBJECTS AND METHODS: Adults with diabetes attending clinics run by practice or diabetes nurses in general medical practices. RESULTS: Two hundred and twenty-nine of 615 (37.2%) questionnaires were completed in 14 general medical practices. The majority of respondents (79.8%, 178/223) visited a dentist once or twice a year, but oral care varied; 67.2% (133/198) reported brushing at least twice a day, whereas only 15.3% (29/190) flossed daily. Awareness of oral health risks was limited: 69.1% (150/217) had never received any oral health advice related to their diabetes. Over half of respondents supported the idea of dentists offering screening for diabetes (121/226, 53.5%). CONCLUSIONS: Many adults with diabetes have poor awareness of oral care and health complications associated with diabetes, and are receiving limited advice from healthcare professionals. Training and advice for both healthcare professionals and patients concerning the importance of good oral health in patients with diabetes is needed. The role of dentists in diabetes screening and support requires further investigation.

Interventions to improve adherence to medication in people with type 2 diabetes mellitus: a review of the literature on the role of pharmacists.

BACKGROUND AND OBJECTIVE: Pharmacists are now adopting a crucial role in the management of chronic illness in primary care, providing diabetes care and advice. This review aims to show whether a range of diabetes care interventions delivered by pharmacists is successful in improving adherence to medication. METHODS: The studies reviewed formed a subgroup of a Cochrane review on interventions to improve adherence to medication in people with type 2 diabetes. Search terms were 'type 2 diabetes mellitus' and 'compliance' or 'adherence'. Studies were included if they assessed adherence to medical treatment specifically, rather than other aspects of self-management. Out of the 21 studies selected for review, five described an intervention delivered by a pharmacist. RESULTS AND DISCUSSION: Two studies reported on attempts to improve adherence focused on the taking of medication. A system of reminders and packaging improved medication adherence, but measuring medicine taking through pill counts or Medication Event Monitoring System was not effective. Three studies evaluated pharmacist-led integrated management and education programmes designed to improve glycaemic control for under-served patient populations. They all succeeded in lowering glycated haemoglobin, but it remains unclear whether this resulted from improved patient adherence. CONCLUSION: This review indicates a potential benefit of pharmacist interventions to improve medication adherence in diabetes, especially in providing patient education.

What do we mean by adherence to treatment and advice for living with diabetes? A review of the literature on definitions and measurements.

AIMS: In order to measure the effectiveness of interventions claiming to improve adherence in diabetes, valid measurement of adherence is necessary. Any measurement must first be based on a definition. This study aimed to identify and categorize definitions and measurements of adherence in living with diabetes, from a review of the literature. METHODS: Publications were identified from the medline database. Adherence, compliance and concordance were used as terms in the search algorithm, along with diabetes, diabetes mellitus and treatment. Two hundred and ninety-three papers were identified. Abstracts of these papers were read by two researchers independently. Two hundred and thirty-nine papers did not contain definitions or measures of adherence and were discarded. Of the remaining 54 papers, 26 included definitions and 46 described measurements of adherence. RESULTS: Definitions and measurements fell into five categories: coincidence of behaviour with professional advice, relationship as part of the process of care, outcome and process targets, taking the medication as prescribed and others. No single definition of adherence emerged. Many authors did not provide definitions of adherence. Glycated haemoglobin was the most common measurement of adherence, although this can raise problems. CONCLUSIONS: Research which claims to show an intervention has, or has not, improved adherence must be interpreted cautiously. Interventions which appear to fail may actually succeed in aspects of adherence which were not defined or measured in the study. Clinicians and researchers could use clear definitions and measurements, such as the ones presented in this review.

Interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus.

BACKGROUND: Research suggests adherence to treatment recommendations is low. In type 2 diabetes, which is a chronic condition slowly leading to serious vascular, nephrologic, neurologic and ophthalmological complications, it can be assumed that enhancing adherence to treatment recommendations may lead to a reduction of complications. Treatment regimens in type 2 diabetes are complicated, encompassing life-style adaptations and medication intake. OBJECTIVES: To assess the effects of interventions for improving adherence to treatment recommendations in people with type 2 diabetes mellitus. SEARCH STRATEGY: Studies were obtained from searches of multiple electronic bibliographic databases supplemented with hand searches of references. Date of last search: November 2002. SELECTION CRITERIA: Randomised controlled and controlled clinical trials, before-after studies and epidemiological studies, assessing changes in adherence to treatment recommendations, as defined in the objectives section, were included. DATA COLLECTION AND ANALYSIS: Two teams of reviewers independently assessed the trials identified for inclusion. Three teams of two reviewers assessed trial quality and extracted data. The analysis for the narrative part was performed by one reviewer (EV), the meta-analysis by two reviewers (EV, JW). MAIN RESULTS: Twentyone studies assessing interventions aiming at improving adherence to treatment recommendations, not to diet or exercise recommendations, in people living with type 2 diabetes in primary care, outpatient settings, community and hospital settings, were included. Outcomes evaluated in these studies were heterogeneous, there was a variety of adherence measurement instruments. Nurse led interventions, home aids, diabetes education, pharmacy led interventions, adaptation of dosing and frequency of medication taking showed a small effect on a variety of outcomes including HbA1c. No data on mortality and morbidity, nor on quality of life could be found. AUTHORS' CONCLUSIONS: Current efforts to improve or to facilitate adherence of people with type 2 diabetes to treatment recommendations do not show significant effects nor harms. The question whether any intervention enhances adherence to treatment recommendations in type 2 diabetes effectively, thus still remains unanswered.