A community health worker led approach to cardiovascular disease prevention in the UK-SPICES-Sussex (scaling-up packages of interventions for cardiovascular disease prevention in selected sites in Europe and Sub-saharan Africa): an implementation research project.

Background: This paper describes a UK-based study, SPICES-Sussex, which aimed to co-produce and implement a community-based cardiovascular disease (CVD) risk assessment and reduction intervention to support under-served populations at moderate risk of CVD. The objectives were to enhance stakeholder engagement; to implement the intervention in four research sites and to evaluate the use of Voluntary and Community and Social Enterprises (VCSE) and Community Health Worker (CHW) partnerships in health interventions. Methods: A type three hybrid implementation study design was used with mixed methods data. This paper represents the process evaluation of the implementation of the SPICES-Sussex Project. The evaluation was conducted using the RE-AIM framework. Results: Reach: 381 individuals took part in the risk profiling questionnaire and forty-one women, and five men participated in the coaching intervention. Effectiveness: quantitative results from intervention participants showed significant improvements in CVD behavioural risk factors across several measures. Qualitative data indicated high acceptability, with the holistic, personalised, and person-centred approach being valued by participants. Adoption: 50% of VCSEs approached took part in the SPICES programme, The CHWs felt empowered to deliver high-quality and mutually beneficial coaching within a strong project infrastructure that made use of VCSE partnerships. Implementation: Co-design meetings resulted in local adaptations being made to the intervention. 29 (63%) of participants completed the intervention. Practical issues concerned how to embed CHWs in a health service context, how to keep engaging participants, and tensions between research integrity and the needs and expectations of those in the voluntary sector. Maintenance: Several VCSEs expressed an interest in continuing the intervention after the end of the SPICES programme. Conclusion: Community-engagement approaches have the potential to have positively impact the health and wellbeing of certain groups. Furthermore, VCSEs and CHWs represent a significant untapped resource in the UK. However, more work needs to be done to understand how links between the sectors can be bridged to deliver evidence-based effective alternative preventative healthcare. Reaching vulnerable populations remains a challenge despite partnerships with VCSEs which are embedded in the community. By showing what went well and what did not, this project can guide future work in community engagement for health.

Distinguishing emotional distress from mental disorder: A qualitative exploration of the Four-Dimensional Symptom Questionnaire (4DSQ).

BACKGROUND: Primary care clinicians see people experiencing the full range of mental health problems. Determining when symptoms reflect disorder is complex. The Four-Dimensional Symptom Questionnaire (4DSQ) uniquely distinguishes general distress from depressive and anxiety disorders. It may support diagnostic conversations and targeting of treatment. AIM: We aimed to explore peoples' experiences of completing the 4DSQ and their perceptions of their resulting score profile across distress, depression, anxiety and physical symptoms. DESIGN AND SETTING: A qualitative study conducted in the UK with people recruited from primary care and community settings. METHOD: Participants completed the 4DSQ then took part in semi-structured telephone interviews. They were interviewed about their experience of completing the 4DSQ, their perceptions of their scores across four dimensions, and the perceived utility if used with a clinician. Interviews were transcribed verbatim and data were analysed thematically. RESULTS: Twenty-four interviews were conducted. Most participants found the 4DSQ easy to complete and reported that scores across the four dimensions aligned well with their symptom experience. Distinct scores for distress, depression and anxiety appeared to support improved self-understanding. Some valued the opportunity to discuss their scores and provide relevant context. Many felt the use of the 4DSQ with clinicians would be helpful and likely to support treatment decisions, although some were concerned about time-limited consultations. CONCLUSION: Distinguishing general distress from depressive and anxiety disorders aligned well with people's experience of symptoms. Use of the 4DSQ as part of mental health consultations may support targeting of treatment and personalisation of care.

A systematic review of risk factors associated with depression and anxiety in cancer patients.

Depression and anxiety are common comorbid conditions associated with cancer, however the risk factors responsible for the onset of depression and anxiety in cancer patients are not fully understood. Also, there is little clarity on how these factors may vary across the cancer phases: diagnosis, treatment and depression. We aimed to systematically understand and synthesise the risk factors associated with depression and anxiety during cancer diagnosis, treatment and survivorship. We focused our review on primary and community settings as these are likely settings where longer term cancer care is provided. We conducted a systematic search on PubMed, PsychInfo, Scopus, and EThOS following the PRISMA guidelines. We included cross-sectional and longitudinal studies which assessed the risk factors for depression and anxiety in adult cancer patients. Quality assessment was undertaken using the Newcastle-Ottawa assessment checklists. The quality of each study was further rated using the Agency for Healthcare Research and Quality Standards. Our search yielded 2645 papers, 21 of these were eligible for inclusion. Studies were heterogenous in terms of their characteristics, risk factors and outcomes measured. A total of 32 risk factors were associated with depression and anxiety. We clustered these risk factors into four domains using an expanded biopsychosocial model of health: cancer-specific, biological, psychological and social risk factors. The cancer-specific risk factors domain was associated with the diagnosis, treatment and survivorship phases. Multifactorial risk factors are associated with the onset of depression and anxiety in cancer patients. These risk factors vary across cancer journey and depend on factors such as type of cancer and individual profile of the patients. Our findings have potential applications for risk stratification in primary care and highlight the need for a personalised approach to psychological care provision, as part of cancer care.

Safer Patients Empowered to Engage and Communicate about Health (SPEECH) in primary care: a feasibility study and process evaluation of an intervention for older people with multiple long-term conditions (multimorbidity).

BACKGROUND: Older people with multiple long-term conditions (multimorbidity) (MLTC-M) experience difficulties accessing and interacting with health and care services. Breakdowns in communication between patients and staff can threaten patient safety. To improve communication and reduce risks to patient safety in primary care, we developed an intervention: Safer Patients Empowered to Engage and Communicate about Health (SPEECH). SPEECH comprises a booklet for patients and an associated guide for staff. The booklet is designed to provide patients with information about staff and services, skills to prepare and explain, and confidence to speak up and ask. METHODS: A single-arm mixed methods feasibility study with embedded process evaluation. General practices in the North West of England were recruited. Participating practices invited patients aged 65+ with MLTC-M who had an appointment scheduled during the study period. Patients were asked to complete questionnaires at baseline and follow-up (four to eight weeks after being sent the patient booklet), including the Consultation and Relational Empathy measure, Empowerment Scale, Multimorbidity Treatment Burden Questionnaire, and Primary Care Patient Measure of Safety. Staff completed questionnaires at the end of the study period. A sub-sample of patients and staff were interviewed about the study processes and intervention. Patients and the public were involved in all aspects of the study, from generation of the initial idea to interpretation of findings. RESULTS: Our target of four general practices were recruited within 50 days of the study information being sent out. A fifth practice was recruited later to boost patient recruitment. We received expressions of interest from 55 patients (approx. 12% of those invited). Our target of 40 patient participants completed baseline questionnaires and were sent the SPEECH booklet. Of these, 38 (95%) completed follow-up. Patients found the intervention and study processes acceptable, and staff found the intervention acceptable and feasible to deliver. CONCLUSIONS: Our findings suggest the intervention is acceptable, and it would be feasible to deliver a trial to assess effectiveness. Prior to further evaluation, study processes and the intervention will be updated to incorporate suggestions from participants. TRIAL REGISTRATION: The study was registered on the ISRCTN registry (ISRCTN13196605: https://doi.org/10.1186/ISRCTN13196605 ).

What are the determinants of older people adopting communicative e-health services: a meta-ethnography.

BACKGROUND: Gradually, society has shifted more services online, with COVID-19 highlighting digital inequalities in access to services such as healthcare. Older adults can experience such digital inequalities, yet this group is also more likely to need medical appointments, compared to younger people. With the growing digitalisation of healthcare, it is increasingly important to understand how older people can best use communicative e-health services to interact with healthcare services. This is especially if older adults are to access, and actively interact with health professionals/clinicians due to their general health decline. This review aims to synthesise older adults' experiences and perceptions of communicative e-health services and, in turn, identify barriers and facilitators to using communicative e-health services. METHODS: A meta-ethnography was conducted to qualitatively synthesise literature on older adults' experiences of using communicative e-health services. A systematic search, with terms relating to 'older adults', 'e-health', 'technology', and 'communication', was conducted on six international databases between January 2014 and May 2022. The search yielded a total of 10 empirical studies for synthesis. RESULTS: The synthesis resulted in 10 themes that may impact older adults' perceptions and/or experiences of using communicative e-health services. These were: 1) health barriers, 2) support networks, 3) application interface/design, 4) digital literacy, 5) lack of awareness, 6) online security, 7) access to digital devices and the internet, 8) relationship with healthcare provider(s), 9) in-person preference and 10) convenience. These themes interlink with each other. CONCLUSION: The findings suggest older adults' experiences and perceptions of communicative e-health services are generally negative, with many reporting various barriers to engaging with online services. However, many of these negative experiences are related to limited support networks and low digital literacy, along with complicated application interfaces. This supports previous literature identifying barriers and facilitators in which older adults experience general technology adoption and suggests a greater emphasis is needed on providing support networks to increase the adoption and usage of communicative e-health services.

Cost-effectiveness of behavioral activation compared to treatment as usual for depressed older adults in primary care: A cluster randomized controlled trial.

INTRODUCTION: Depression in older adults is associated with decreased quality of life and increased utilization of healthcare services. Behavioral activation (BA) is an effective treatment for late-life depression, but the cost-effectiveness compared to treatment as usual (TAU) is unknown. METHODS: An economic evaluation was performed alongside a cluster randomized controlled multicenter trial including 161 older adults (≥65 years) with moderate to severe depressive symptoms (PHQ-9 ≥ 10). Outcome measures were depression (response on the QIDS-SR), quality-adjusted life-years (QALYs) and societal costs. Missing data were imputed using multiple imputation. Cost and effect differences were estimated using bivariate linear regression models, and statistical uncertainty was estimated with bootstrapping. Cost-effectiveness acceptability curves showed the probability of cost-effectiveness at different ceiling ratios. RESULTS: Societal costs were statistically non-significantly lower in BA compared to TAU (mean difference (MD) -€485, 95 % CI -3861 to 2792). There were no significant differences in response on the QIDS-SR (MD 0.085, 95 % CI -0.015 to 0.19), and QALYs (MD 0.026, 95 % CI -0.0037 to 0.055). On average, BA was dominant over TAU (i.e., more effective and less expensive), although the probability of dominance was only 0.60 from the societal perspective and 0.85 from the health care perspective for both QIDS-SR response and QALYs. DISCUSSION: Although the results suggest that BA is dominant over TAU, there was considerable uncertainty surrounding the cost-effectiveness estimates which precludes firm conclusions.

The Healthy Hearts Project: Development and evaluation of a website for cardiovascular risk assessment and visualisation and self-management through healthy lifestyle goal-setting.

Materially deprived communities in the UK have excess morbidity and mortality from cardiovascular disease (CVD) but are less likely to engage with formal care pathways. Community engagement and e-health may be more effective ways to promote risk-reducing lifestyle change. The "Healthy Hearts Project" website was designed for use by community health workers (CHWs) for cardiovascular risk assessment and lifestyle goal setting, or for independent use by community members. This paper describes the website's development and evaluation. The website was developed using interactive wire frame prototypes in a user-led approach. Qualitative evaluation of the completed website's usability and acceptability was conducted using the "Thinking Aloud" method in a purposive sample of 10 participants (one voluntary sector employee, three CHWs, two community members and four healthcare professionals). Thinking Aloud interview transcripts were thematically analysed using an inductive approach. A separate quantitative evaluation of usability and the effect of using the website on CVD knowledge and beliefs was conducted. A random sample of 134 participants, recruited using the online platform Prolific, completed the "Attitudes and Beliefs About Cardiovascular Disease" (ABCD) questionnaire before and after using the website, along with the System Usability Scale (SUS). Qualitative evaluation-Four key themes were identified: 1) Website functionality and design-participants generally found the website easy to use and understood the risk communication graphics and the feedback and goal-setting features,; 2) Inclusivity and representation-most participants considered the website inclusive of a range of users/cultures; 3) Language and comprehension-participants found the language used easy to understand but suggested reducing the amount of text; 4) Motivation and barriers to change-participants liked the personalized feedback and empowerment offered by goal-setting but commented on the need for self-motivation. Quantitative evaluation-The mean score across all domains of the ABCD questionnaire (from 2.99 to 3.11, p<0.001) and in the sub-domains relating to attitudes and beliefs around healthy eating and exercise increased after using the website. The mean(sd) score on the SUS was 77.5 (13.5). The website's usability was generally rated well by both quantitative and qualitative measures, and measures of CVD knowledge improved after use. A number of general recommendations for the design of eHealth behaviour change tools are made based on participants' suggestions to improve the website.

A virtuous cycle of co-production: Reflections from a community priority-setting exercise.

INTRODUCTION: Co-production is gaining increasing recognition as a good way of facilitating collaboration among different stakeholders, including members of the public. However, it remains an ambiguous concept as there is no definitive or universal model of co-production or clarity on what constitutes a good co-production approach. This paper draws on the reflections of the academic researchers, practitioners and public advisors involved in co-producing a priority-setting exercise. The exercise was conducted by the Primary and Community Health Services (PCHS) Theme of the National Institute for Health and Care Research Applied Research Collaboration for Kent, Surrey and Sussex (NIHR ARC KSS). METHODS: We collected data through written and verbal reflections from seven collaborators involved in the PCHS priority-setting exercise. We used Gibbs' model of reflection to guide the data collection. We then analysed the data through an inductive, reflexive thematic analysis. RESULTS: A common thread through our reflections was the concept of 'sharing'. Although co-production is inherently shared, we used the virtuous cycle to illustrate a sequence of sharing concepts during the research cycle, which provides the underpinnings of positive co-production outcomes. We identified six themes to denote the iterative process of a shared approach within the virtuous cycle: shared values, shared understanding, shared power, shared responsibilities, shared ownership and positive outcomes. CONCLUSION: Our results present a virtuous cycle of co-production, which furthers the conceptual underpinnings of co-production. Through our reflections, we propose that positive co-production outcomes require foundations of shared values and a shared understanding of co-production as a concept. These foundations facilitate a process of shared power, shared responsibilities and shared ownership. We argue that when these elements are present in a co-production exercise, there is a greater potential for implementable outcomes in the communities in which the research serves and the empowerment of collaborators involved in the co-production process. PUBLIC MEMBERS' CONTRIBUTIONS: Three members of the public who are public advisors in the NIHR ARC KSS were involved in the priority-setting exercise that informed this paper. The public advisors were involved in the design of the priority-setting exercise and supported participants' recruitment. They also co-facilitated the focus groups during data collection and were involved in the data analysis, interpretation and preparation of the priority-setting report. For this current manuscript, two of them are co-authors. They provided reflections and contributed to the writing and reviewing of this manuscript.

The Pre-Implementation Phase of a Project Seeking to Deliver a Community-Based CVD Prevention Intervention (SPICES-Sussex): A Qualitative Study Exploring Views and Experience Relating to Intervention Development.

BACKGROUND.: Community-led health care interventions may be an effective way to tackle cardiovascular disease (CVD) risk factors, especially in materially deprived communities where health care resources are stretched and engagement with institutions is often low. To do so effectively and equitably, interventions might be developed alongside community members through community engagement. OBJECTIVES.: The aim of this project was to carry out stakeholder mapping and partnership identification and to understand the views, needs, experiences of community members who would be involved in later stages of a community-based CVD prevention intervention's development and implementation. METHODS.: Stakeholder mapping was carried out to identify research participants in three communities in Sussex, United Kingdom. A qualitative descriptive approach was taken during the analysis of focus groups and interviews with 47 participants. FINDINGS.: Three themes were highlighted related to intervention design (a) Management: the suitability of the intervention for the community, management of volunteers, and communication; (b) Logistics: the structure and design of the intervention; and (c) Sociocultural issues, the social and cultural expectations/experiences of participants and implementers. CONCLUSIONS.: Study participants were open and willing to engage in the planned community-based intervention, particularly in elements of co-design and community-led delivery. They also highlighted the importance of sociocultural factors. Based on the findings, we developed recommendations for intervention design which included (but were not limited to): (a) a focus on a bottom-up approach to intervention design, (b) the recruitment of skilled local volunteers, and (c) the importance of fun and simplicity.

Behavioural Activation versus Treatment as Usual for Depressed Older Adults in Primary Care: A Pragmatic Cluster-Randomised Controlled Trial.

INTRODUCTION: Effective non-pharmacological treatment options for depression in older adults are lacking. OBJECTIVE: The effectiveness of behavioural activation (BA) by mental health nurses (MHNs) for depressed older adults in primary care compared with treatment as usual (TAU) was evaluated. METHODS: In this multicentre cluster-randomised controlled trial, 59 primary care centres (PCCs) were randomised to BA and TAU. Consenting older (≥65 years) adults (n = 161) with clinically relevant symptoms of depression (PHQ-9 ≥ 10) participated. Interventions were an 8-week individual MHN-led BA programme and unrestricted TAU in which general practitioners followed national guidelines. The primary outcome was self-reported depression (QIDS-SR16) at 9 weeks and 3, 6, 9, and 12-month follow-up. RESULTS: Data of 96 participants from 21 PCCs in BA and 65 participants from 16 PCCs in TAU, recruited between July 4, 2016, and September 21, 2020, were included in the intention-to-treat analyses. At post-treatment, BA participants reported significantly lower severity of depressive symptoms than TAU participants (QIDS-SR16 difference = -2.77, 95% CI = -4.19 to -1.35), p < 0.001; between-group effect size = 0.90; 95% CI = 0.42-1.38). This difference persisted up to the 3-month follow-up (QIDS-SR16 difference = -1.53, 95% CI = -2.81 to -0.26, p = 0.02; between-group effect size = 0.50; 95% CI = 0.07-0.92) but not up to the 12-month follow-up [QIDS-SR16 difference = -0.89 (-2.49 to 0.71)], p = 0.28; between-group effect size = 0.29 (95% CI = -0.82 to 0.24). CONCLUSIONS: BA led to a greater symptom reduction of depressive symptoms in older adults, compared to TAU in primary care, at post-treatment and 3-month follow-up, but not at 6- to 12-month follow-up.

A systematic literature review on the clinical efficacy of low dose naltrexone and its effect on putative pathophysiological mechanisms among patients diagnosed with fibromyalgia.

Background: Low dose naltrexone (LDN) is used off-label by many individuals with fibromyalgia to help manage their pain. There is no current systematic literature review summarising the evidence to support this use of LDN. The objectives of this study were to evaluate if patients with fibromyalgia prescribed LDN have reduced pain scores and greater quality of life compared with those allocated to placebo in randomized controlled trials. Secondly to determine if changes in inflammatory markers and brain structure and function are observed among patients with fibromyalgia taking LDN. Methods: Systematic literature searches were conducted in MEDLINE, Embase Classic + Embase, APA PsychInfo, and The Cochrane Library from inception to May 2022. Reference lists from the selected papers were cross-checked with database search results. Results: Three studies met our inclusion criteria for the assessment of efficacy, and two studies on potential LDN mechanisms. Results indicated some evidence to suggest LDN reduces pain and increases quality of life. One study reported baseline erythrocyte sedimentation rate (ESR) predicted LDN response (≥30% reduction in fibromyalgia symptoms) and a second study showed plasma concentrations of inflammatory biomarkers were lower after LDN treatment. To our knowledge, there are no brain imaging studies reporting the effect of LDN in patients with fibromyalgia. All studies were based on small sample sizes, were restricted to women and the risk of bias was assessed to be high. There is also some evidence of publication bias. Conclusion: The strength of evidence from randomized controlled trials to support the use of LDN among patients with fibromyalgia is low. Two small studies suggest ESR and cytokines may be involved in the mechanism by which LDN exerts its effects. Two trials (INNOVA and FINAL) are currently in progress, but further work is needed among men and different ethnic groups.

Understanding the implementation of interventions to improve the management of frailty in primary care: a rapid realist review.

OBJECTIVE: Identifying and managing the needs of frail people in the community is an increasing priority for policy makers. We sought to identify factors that enable or constrain the implementation of interventions for frail older persons in primary care. DESIGN: A rapid realist review. DATA SOURCES: Cochrane Library, SCOPUS and EMBASE, and grey literature. The search was conducted in September 2019 and rerun on 8 January 2022. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: We considered all types of empirical studies describing interventions targeting frailty in primary care. ANALYSIS: We followed the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication criteria for our synthesis to systematically analyse and synthesise the existing literature and to identify (intervention-context-mechanism-outcome) configurations. We used normalisation processes theory to illuminate mechanisms surrounding implementation. RESULTS: Our primary research returned 1755 articles, narrowed down to 29 relevant frailty intervention studies conducted in primary care. Our review identified two families of interventions. They comprised: (1) interventions aimed at the comprehensive assessment and management of frailty needs; and (2) interventions targeting specific frailty needs. Key factors that facilitate or inhibit the translation of frailty interventions into practice related to the distribution of resources; patient engagement and professional skill sets to address identified need. CONCLUSION: There remain challenges to achieving successful implementation of frailty interventions in primary care. There were a key learning points under each family. First, targeted allocation of resources to address specific needs allows a greater alignment of skill sets and reduces overassessment of frail individuals. Second, earlier patient involvement may also improve intervention implementation and adherence. PROSPERO REGISTRATION NUMBER: The published protocol for the review is registered with PROSPERO (CRD42019161193).

How to Realize the Benefits of Point-of-Care Testing at the General Practice: A Comparison of Four High-Income Countries.

BACKGROUND: In some countries, such as the Netherlands and Norway, point-of-care testing (POCT) is more widely implemented in general practice compared to countries such as England and Australia. To comprehend what is necessary to realize the benefits of POCT, regarding its integration in primary care, it would be beneficial to have an overview of the structure of healthcare operations and the transactions between stakeholders (also referred to as value networks). The aim of this paper is to identify the current value networks in place applying to POCT implementation at general practices in England, Australia, Norway and the Netherlands and to compare these networks in terms of seven previously published factors that support the successful implementation, sustainability and scale-up of innovations. METHODS: The value networks were described based on formal guidelines and standards published by the respective governments, organizational bodies and affiliates. The value network of each country was validated by at least two relevant stakeholders from the respective country. RESULTS: The analysis revealed that the biggest challenge for countries with low POCT uptake was the lack of effective communication between the several organizations involved with POCT as well as the high workload for general practitioners (GPs) aiming to implement POCT. It is observed that countries with a single national authority responsible for POCT have a better uptake as they can govern the task of POCT roll-out and management and reduce the workload for GPs by assisting with set-up, quality control, training and support. CONCLUSION: Setting up a single national authority may be an effective step towards realizing the full benefits of POCT. Although it is possible for day-to-day operations to fall under the responsibility of the GP, this is only feasible if support and guidance are readily available to ensure that the workload associated with POCT is limited and as low as possible.

Nine Forward-Backward Translations of the Hopkins Symptom Checklist-25 With Cultural Checks.

Introduction: The Hopkins Symptom Checklist-25 (HSCL-25) is an effective, reliable, and ergonomic tool that can be used for depression diagnosis and monitoring in daily practice. To allow its broad use by family practice physicians (FPs), it was translated from English into nine European languages (Greek, Polish, Bulgarian, Croatian, Catalan, Galician, Spanish, Italian, and French) and the translation homogeneity was confirmed. This study describes this process. Methods: First, two translators (an academic translator and an FP researcher) were recruited for the forward translation (FT). A panel of English-speaking FPs that included at least 15 experts (researchers, teachers, and practitioners) was organized in each country to finalize the FT using a Delphi procedure. Results: One or two Delphi procedure rounds were sufficient for each translation. Then, a different translator, who did not know the original version of the HSCL-25, performed a backward translation in English. An expert panel of linguists compared the two English versions. Differences were listed and a multicultural consensus group determined whether they were due to linguistic problems or to cultural differences. All versions underwent cultural check. Conclusion: All nine translations were finalized without altering the original meaning.

Identification and management of frail patients in English primary care: an analysis of the General Medical Services 2018/2019 contract dataset.

OBJECTIVES: The aim of this study was to explore the extent of implementation of the General Medical Services 2018/2019 'frailty identification and management' contract in general practitioner (GP) practices in England, and link implementation outcomes to a range of practice and Clinical Commissioning Group (CCG) factors. DESIGN: A cross-sectional study design using publicly available datasets relating to the year 2018 for all GP practices in England. SETTINGS: English general practices. DATA: The analysis was conducted across 6632 practices in 193 CCGs with 9 995 558 patients aged 65 years or older. OUTCOMES: Frailty assessment rates, frailty coding rates and frailty prevalence rates, plus rates of medication reviews, falls assessments and enriched Summary Care Records (SCRs). ANALYSIS: Summary statistics were calculated and multilevel negative binomial regression analysis was used to investigate relationships of the six outcomes with explanatory factors. RESULTS: 14.3% of people aged 65 years or older were assessed for frailty, with 35.4% of these-totalling 5% of the eligible population-coded moderately or severely frail. 59.2% received a medications review, but rates of falls assessments (3.7%) and enriched SCRs (21%) were low. However, percentages varied widely across practices and CCGs. Practice differences in contract implementation were most strongly accounted for by their grouping within CCGs, with weaker but still important associations with some practice and CCG factors, particularly healthcare demand-related factors of chronic caseload and (negatively) % of patients aged 65 years or older. CONCLUSION: CCG appears the strongest determinant of practice engagement with the frailty contract, and fuller implementation may depend on greater engagement of CCGs themselves, particularly in commissioning suitable interventions. Practices understandably targeted frailty assessments at patients more likely to be found severely frail, resulting in probable underidentification of moderately frail individuals who might benefit most from early interventions. Frailty prevalence estimates based on the contract data may not reflect actual rates.

Interventions Using Wearable Physical Activity Trackers Among Adults With Cardiometabolic Conditions: A Systematic Review and Meta-analysis.

Importance: Wearable physical activity (PA) trackers, such as accelerometers, fitness trackers, and pedometers, are accessible technologies that may encourage increased PA levels in line with current recommendations. However, whether their use is associated with improvements in PA levels in participants who experience 1 or more cardiometabolic conditions, such as diabetes, prediabetes, obesity, and cardiovascular disease, is unknown. Objective: To assess the association of interventions using wearable PA trackers (accelerometers, fitness trackers, and pedometers) with PA levels and other health outcomes in adults with cardiometabolic conditions. Data Sources: For this systematic review and meta-analysis, searches of MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and PsycINFO were performed from January 1, 2000, until December 31, 2020, with no language restriction. A combination of Medical Subject Heading terms and text words of diabetes, obesity, cardiovascular disease, pedometers, accelerometers, and Fitbits were used. Study Selection: Randomized clinical trials or cluster randomized clinical trials that evaluated the use of wearable PA trackers, such as pedometers, accelerometers, or fitness trackers, were included. Trials were excluded if they assessed the trackers only as measuring tools of PA before and after another intervention, they required participants to be hospitalized, assessors were not blinded to the trackers, or they used a tracker to measure the effect of a pharmacological treatment on PA among individuals. Data Extraction and Synthesis: The study followed the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) reporting guideline. A random-effects model was used for the meta-analysis. Main Outcomes and Measures: The primary outcome was mean difference in PA levels. When the scale was different across studies, standardized mean differences were calculated. Heterogeneity was quantified using the I2 statistic and explored using mixed-effects metaregression. Results: A total of 38 randomized clinical trials with 4203 participants were eligible in the systematic review; 29 trials evaluated pedometers, and 9 evaluated accelerometers or fitness trackers. Four studies did not provide amenable outcome data, leaving 34 trials (3793 participants) for the meta-analysis. Intervention vs comparator analysis showed a significant association of wearable tracker use with increased PA levels overall (standardized mean difference, 0.72; 95% CI, 0.46-0.97; I2 = 88%; 95% CI, 84.3%-90.8%; P < .001) in studies with short to medium follow-up for median of 15 (range, 12-52) weeks. Multivariable metaregression showed an association between increased PA levels and interventions that involved face-to-face consultations with facilitators (23 studies; ß = -0.04; 95% CI, -0.11 to -0.01), included men (23 studies; ß = 0.48; 95% CI, 0.01-0.96), and assessed pedometer-based interventions (26 studies; ß = 0.20; 95% CI, 0.02-0.32). Conclusions and Relevance: In this systematic review and meta-analysis, interventions that combined wearable activity trackers with health professional consultations were associated with significant improvements in PA levels among people with cardiometabolic conditions.

Barriers and facilitators to the adoption of electronic clinical decision support systems: a qualitative interview study with UK general practitioners.

BACKGROUND: Well-established electronic data capture in UK general practice means that algorithms, developed on patient data, can be used for automated clinical decision support systems (CDSSs). These can predict patient risk, help with prescribing safety, improve diagnosis and prompt clinicians to record extra data. However, there is persistent evidence of low uptake of CDSSs in the clinic. We interviewed UK General Practitioners (GPs) to understand what features of CDSSs, and the contexts of their use, facilitate or present barriers to their use. METHODS: We interviewed 11 practicing GPs in London and South England using a semi-structured interview schedule and discussed a hypothetical CDSS that could detect early signs of dementia. We applied thematic analysis to the anonymised interview transcripts. RESULTS: We identified three overarching themes: trust in individual CDSSs; usability of individual CDSSs; and usability of CDSSs in the broader practice context, to which nine subthemes contributed. Trust was affected by CDSS provenance, perceived threat to autonomy and clear management guidance. Usability was influenced by sensitivity to the patient context, CDSS flexibility, ease of control, and non-intrusiveness. CDSSs were more likely to be used by GPs if they did not contribute to alert proliferation and subsequent fatigue, or if GPs were provided with training in their use. CONCLUSIONS: Building on these findings we make a number of recommendations for CDSS developers to consider when bringing a new CDSS into GP patient records systems. These include co-producing CDSS with GPs to improve fit within clinic workflow and wider practice systems, ensuring a high level of accuracy and a clear clinical pathway, and providing CDSS training for practice staff. These recommendations may reduce the proliferation of unhelpful alerts that can result in important decision-support being ignored.

Prevention of dementia using mobile phone applications (PRODEMOS): protocol for an international randomised controlled trial.

INTRODUCTION: Profiles of high risk for future dementia are well understood and are likely to concern mostly those in low-income and middle-income countries and people at greater disadvantage in high-income countries. Approximately 30%-40% of dementia cases have been estimated to be attributed to modifiable risk factors, including hypertension, smoking and sedentary lifestyle. Tailored interventions targeting these risk factors can potentially prevent or delay the onset of dementia. Mobile health (mHealth) improves accessibility of such prevention strategies in hard-to-reach populations while at the same time tailoring such approaches. In the current study, we will investigate the effectiveness and implementation of a coach-supported mHealth intervention, targeting dementia risk factors, to reduce dementia risk. METHODS AND ANALYSIS: The prevention of dementia using mobile phone applications (PRODEMOS) randomised controlled trial will follow an effectiveness-implementation hybrid design, taking place in the UK and China. People are eligible if they are 55-75 years old, of low socioeconomic status (UK) or from the general population (China); have ≥2 dementia risk factors; and own a smartphone. 2400 participants will be randomised to either a coach-supported, interactive mHealth platform, facilitating self-management of dementia risk factors, or a static control platform. The intervention and follow-up period will be 18 months. The primary effectiveness outcome is change in the previously validated Cardiovascular Risk Factors, Ageing and Incidence of Dementia dementia risk score. The main secondary outcomes include improvement of individual risk factors and cost-effectiveness. Implementation outcomes include acceptability, adoption, feasibility and sustainability of the intervention. ETHICS AND DISSEMINATION: The PRODEMOS trial is sponsored in the UK by the University of Cambridge and is granted ethical approval by the London-Brighton and Sussex Research Ethics Committee (reference: 20/LO/01440). In China, the trial is approved by the medical ethics committees of Capital Medical University, Beijing Tiantan Hospital, Beijing Geriatric Hospital, Chinese People's Liberation Army General Hospital, Taishan Medical University and Xuanwu Hospital. Results will be published in a peer-reviewed journal. TRIAL REGISTRATION NUMBER: ISRCTN15986016.

What is meant by "frailty" in undergraduate medical education? A national survey of UK medical schools.

PURPOSE: All UK medical schools are required to include frailty in their curriculum. The term is open to interpretation and associated with negative perceptions. Understanding and recognising frailty is a prerequisite for consideration of frailty in the treatment decision-making process across clinical specialities. The aim of this survey was to describe how frailty has been interpreted and approached in UK undergraduate medical education and provide examples of educational strategies employed. METHODS: All UK medical schools were invited to complete an electronic survey. Schools described educational strategies used to teach and assess frailty and provided frailty-related learning outcomes. Learning Outcomes were grouped into categories and mapped to the domains of Outcomes for Graduates (knowledge, skills and values). RESULTS: 25/34 Medical schools (74%) participated. The interpretation of what frailty is vary widely and the diversity of teaching strategies reflect this. The most common Learning outcomes included as "Frailty" are about the concept of frailty, Comprehensive Geriatric Assessments and Roles of the MDT. Frailty teaching is predominantly opportunistic and occurred within geriatric medicine rotations in all medical schools. Assessments focus on frailty syndromes such as falls and delirium. CONCLUSION: There is variation regarding how frailty has been interpreted and approached by medical schools. Frailty is represented in an array of teaching and assessment methods, with a lack of constructive alignment to related learning outcomes. Consensus should be agreed as to what frailty means in medical education. Further research is required to explore which frailty-specific educational strategies in undergraduate medical education enhance learning.

Design and Development of a Mobile Health (mHealth) Platform for Dementia Prevention in the Prevention of Dementia by Mobile Phone Applications (PRODEMOS) Project.

Background: Mobile health (mHealth) has the potential to bring preventive healthcare within reach of populations with limited access to preventive services, by delivering personalized support at low cost. Although numerous mHealth interventions are available, very few have been developed following an evidence-based rationale or have been tested for efficacy. This article describes the systematic development of a coach-supported mHealth application to improve healthy lifestyles for the prevention of dementia and cardiovascular disease in the United Kingdom (UK) and China. Methods: Development of the Prevention of Dementia by Mobile Phone applications (PRODEMOS) platform built upon the experiences with the Healthy Aging Through Internet Counseling in the Elderly (HATICE) eHealth platform. In the conceptualization phase, experiences from the HATICE trial and needs and wishes of the PRODEMOS target population were assessed through semi-structured interviews and focus group sessions. Initial technical development of the platform was based on these findings and took place in consecutive sprint sessions. Finally, during the evaluation and adaptation phase, functionality and usability of the platform were evaluated during pilot studies in UK and China. Results: The PRODEMOS mHealth platform facilitates self-management of a healthy lifestyle by goal setting, progress monitoring, and educational materials on healthy lifestyles. Participants receive remote coaching through a chat functionality. Based on lessons learned from the HATICE study and end-users, we made the intervention easy-to-use and included features to personalize the intervention. Following the pilot studies, in which in total 77 people used the mobile application for 6 weeks, the application was made more intuitive, and we improved its functionalities. Conclusion: Early involvement of end-users in the development process and during evaluation phases improved acceptability of the mHealth intervention. The actual use and usability of the PRODEMOS intervention will be assessed during the ongoing PRODEMOS randomized controlled trial, taking a dual focus on effectiveness and implementation outcomes.