Integration of primary care and palliative care services to improve equality and equity at the end-of-life: Findings from realist stakeholder workshops.

BACKGROUND: Inequalities in access to palliative and end of life care are longstanding. Integration of primary and palliative care has the potential to improve equity in the community. Evidence to inform integration is scarce as research that considers integration of primary care and palliative care services is rare. AIM: To address the questions: 'how can inequalities in access to community palliative and end of life care be improved through the integration of primary and palliative care, and what are the benefits?' DESIGN: A theory-driven realist inquiry with two stakeholder workshops to explore how, when and why inequalities can be improved through integration. Realist analysis leading to explanatory context(c)-mechanism(m)-outcome(o) configurations(c) (CMOCs). FINDINGS: A total of 27 participants attended online workshops (July and September 2022): patient and public members (n = 6), commissioners (n = 2), primary care (n = 5) and specialist palliative care professionals (n = 14). Most were White British (n = 22), other ethnicities were Asian (n = 3), Black African (n = 1) and British mixed race (n = 1). Power imbalances and racism hinder people from ethnic minority backgrounds accessing current services. Shared commitment to addressing these across palliative care and primary care is required in integrated partnerships. Partnership functioning depends on trusted relationships and effective communication, enabled by co-location and record sharing. Positive patient experiences provide affirmation for the multi-disciplinary team, grow confidence and drive improvements. CONCLUSIONS: Integration to address inequalities needs recognition of current barriers. Integration grounded in trust, faith and confidence can lead to a cycle of positive patient, carer and professional experience. Prioritising inequalities as whole system concern is required for future service delivery and research.

Understanding patient views and experiences of the IDENTIfication of PALLiative care needs (IDENTI-PALL): a qualitative interview study.

BACKGROUND: Palliative care improves quality of life for people with life-threatening illnesses. There are longstanding inequalities in access to palliative care, with many people never identified as having palliative care needs, particularly frail older people, those with non-malignant disease, and people from ethnic minority backgrounds. Little is known about the process of identification of palliative care needs from a patient perspective. AIM: To provide new understanding into patient views and experiences of the process of identification of palliative care needs, and to explore the impact of identification on health care, if any, from a patient perspective. DESIGN AND SETTING: A qualitative interview study undertaken with patients and family carers in a major UK city. METHOD: Semi-structured interviews were carried out with patients (and/or family carers) identified as being on general practice palliative care registers. An inductive thematic analysis was conducted to explore the data. RESULTS: Eleven participants were recruited: eight patients and three family carers. The following three interrelated themes were identified: 1) misconceptions about palliative care and unshared prognostic uncertainty hinder the identification of palliative care needs; 2) a compassionate, timely approach is required for identification of palliative care needs, with or without an identification tool; and 3) identification of palliative care needs is beneficial where it leads to proactive holistic care. CONCLUSION: A compassionate approach, sharing of prognostic uncertainty, and proactive primary care are key to timely, beneficial identification of palliative care needs. Future policy should ensure that identification is an adaptable, personalised process to meet the individual needs of people with advanced serious illnesses.

Ideas, concerns, expectations, and effects on life (ICEE) in GP consultations: an observational study using video-recorded UK consultations.

BACKGROUND: Eliciting patients' ideas, concerns, expectations, and whether a problem has an 'effect' on their life (ICEE), is a widely recommended communication technique. However, it is not known how frequently ICEE components are raised in UK GP consultations. AIM: To assess the frequency of ICEE in routine GP consultations with adult patients and explore variables associated with ICEE. DESIGN & SETTING: An observational study was undertaken. It involved secondary analysis of a pre-existing archive of video-recorded, face-to-face GP consultations in the UK. METHOD: Observational coding of 92 consultations took place. Associations were assessed using binomial and ordered logistic regression. RESULTS: Most consultations included at least one ICEE component (90.2%). The most common ICEE component per consultation was patient ideas (79.3%), followed by concerns (55.4%), expectations (51.1%), and then effects on life (42.4%). For all ICEE components patients more commonly initiated the ICEE dialogue, and in only three consultations (3.3%) did GPs directly ask patients about their expectations. Problems that were acute (odds ratio [OR] 2.98, 95% confidence interval [CI] = 1.36 to 6.53, P = 0.007) or assessed by GPs aged ≥50 years (OR 2.10, 95% CI = 1.07 to 4.13, P = 0.030) were associated with more ICEE components. Problems assessed later in the consultation (OR 0.60 per problem order increase, 95% CI = 0.41 to 0.87, P = 0.007) by patients aged ≥75 years (OR 0.40, 95% CI = 0.16 to 0.98, P = 0.046) and from the most deprived cohort (OR 0.39, 95% CI = 0.17 to 0.92, P = 0.032) were associated with fewer ICEE components. Patient ideas were associated with more patients being 'very satisfied' post-consultation (OR 10.74, 95% CI = 1.60 to 72.0, P = 0.014) and the opposite was true of concerns (OR 0.14, 95% CI = 0.02 to 0.86, P = 0.034). CONCLUSION: ICEE components were associated with patient satisfaction and demographic variables. Further research is required to assess if the way ICEE are communicated affects these associations and other potential confounders.

Understanding patient views and experiences of the IDENTIfication of PALLiative care needs (IDENTI-Pall): a qualitative interview study protocol.

INTRODUCTION: More people are living with multimorbidity, defined as two or more long-term physical or mental health conditions. Multimorbidity is associated with poor quality of life and high treatment burden. Palliative care identification tools have been developed for use in primary care to seek out patients who could benefit from a palliative approach to their care. There has been little evaluative research on such tools; patient perspectives on the process of identifying their palliative care needs is a significant gap. The aim of this research is to provide new understanding into patient perspectives of the experience of having their palliative care needs identified, and the impact on their healthcare. METHODS AND ANALYSIS: This qualitative study will employ semistructured interviews to elicit the views of participants. We will purposively sample 10-12 adults with advanced serious illness who have been identified by their primary care team as having palliative care needs, and/or are receiving care from specialist palliative care services. A family member or carer may be included in an interview at the participant's request. A descriptive, thematic analysis will be carried out using the data analysis software NVivo. ETHICS AND DISSEMINATION: Ethical approval has been granted by the North of Scotland Research Ethics Committee. Study findings will be disseminated in peer-reviewed journals and through conference presentations. Other activities include the development of patient-centred outcomes for clinical practice and policy in relation to the use of palliative care identification tools. TRIAL REGISTRATION NUMBER: National Institute for Health Research (NIHR) Clinical Studies Portfolio, UK Clinical Research Network (UKCRN) Study number 51296.

Stories of hope created together: A pilot, school-based workshop for sharing eco-emotions and creating an actively hopeful vision of the future.

The climate and ecological crises challenge all communities across the world, with the greatest impact upon the most vulnerable and the youngest. There are multiple impacts on mental health, including the psychological burdens that arise with increasing awareness of the loss, threat and injustice caused by these crises. Large numbers of young people globally are understandably concerned and distressed about these crises, whilst simultaneously reporting that their concerns are regularly dismissed and ignored, particularly by those in power. This can increase feelings of isolation and distress, particularly if they have no recourse to effect change. This pilot project sought to explore how a schools-based, co-created workshop for school pupils aged 16 to 18 years could use a community-oriented space to explore their eco-emotions, address feelings of isolation and engender a sense of realistic, active hope, using storytelling and images of possible futures. A 3-h workshop for delivery in schools was co-designed with young people, researchers, educators and clinicians, using principles of Youth Participatory Action Research (YPAR). Six school pupils aged 16-18 years consented and four completed the workshop, which involved a range of group-based activities to explore their understanding of the climate and ecological crises, support emotional expression related to these and engage in storytelling about hopeful and realistic futures. A live illustrator in attendance created shared images of the participants' fears and hopes. The workshop was recorded, transcribed and analysed using Thematic Analysis and sentiment analysis. Feedback was sought from participants at 1 and 4 weeks after completion and analysed using content analysis. Results indicated that participants reported a range of painful and positive emotions about the crises. They highly valued having space to express their experience alongside others. Storytelling and creativity appeared to help them articulate their feelings and hopes for the future, and gave them greater motivation and confidence in talking to others about these topics. This innovative pilot study suggests that a school-based youth participatory group could offer a novel way of helping young people to engage more with the climate and ecological crises in a way that supports their wellbeing. It provides strong support for future, larger-scale projects in this area.

Management of the Infected Total Hip Arthroplasty.

In the United Kingdom approximately 80,000 total hip arthroplasties are undertaken on an average each year. The popularity and demand for this operation are continually increasing. Our understanding of arthroplasty surgery and its complications has evolved greatly, and as a result infection rates are undeniably at an all-time low. The increasing volume of operations being performed does, however, mean that we still continue to see an increased number of cases of infection. There is no doubt that periprosthetic joint infection (PJI) poses a complex clinical and diagnostic predicament to clinicians. Delay in the diagnosis and treatment of PJI can not only be detrimental in terms of patient morbidity, but it also poses a significant financial burden to health care institutions. It is therefore in the best interest of the patient, surgeon, and institution to optimize the diagnosis and treatment of this devastating complication. There remains considerable variability in terms of approach to diagnosis and treatment of PJI among orthopedic surgeons. In this review, we will, therefore, examine in detail the current body of evidence available on PJI. We will discuss the most robust and up-to-date methods of diagnosis and offer a comparison of management strategies.