“We are not stray leaves blowing about in the wind”: exploring the impact of Family Wellbeing empowerment research, 1998–2021

Background An Aboriginal-developed empowerment and social and emotional wellbeing program, known as Family Wellbeing (FWB), has been found to strengthen the protective factors that help Indigenous Australians to deal with the legacy of colonisation and intergenerational trauma. This article reviews the research that has accompanied the implementation of the program, over a 23 year period. The aim is to assess the long-term impact of FWB research and identify the key enablers of research impact and the limitations of the impact assessment exercise. This will inform more comprehensive monitoring of research impact into the future. Methods To assess impact, the study took an implementation science approach, incorporating theory of change and service utilisation frameworks, to create a logic model underpinned by Indigenous research principles. A research impact narrative was developed based on mixed methods analysis of publicly available data on: 1) FWB program participation; 2) research program funding; 3) program outcome evaluation (nine studies); and 4) accounts of research utilisation (seven studies). Results Starting from a need for research on empowerment identified by research users, an investment of $2.3 million in research activities over 23 years produced a range of research outputs that evidenced social and emotional wellbeing benefits arising from participation in the FWB program. Accounts of research utilisation confirmed the role of research outputs in educating participants about the program, and thus, facilitating more demand (and funding acquisition) for FWB. Overall research contributed to 5,405 recorded participants accessing the intervention. The key enablers of research impact were; 1) the research was user- and community-driven; 2) a long-term mutually beneficial partnership between research users and researchers; 3) the creation of a body of knowledge that demonstrated the impact of the FWB intervention via different research methods; 4) the universality of the FWB approach which led to widespread application. Conclusions The FWB research impact exercise reinforced the view that assessing research impact is best approached as a “wicked problem” for which there are no easy fixes. It requires flexible, open-ended, collaborative learning-by-doing approaches to build the evidence base over time. Steps and approaches that research groups might take to build the research impact knowledge base within their disciplines are discussed.

Vertical integration of primary care practices with acute hospitals in England and Wales: why, how and so what? Findings from a qualitative, rapid evaluation

ObjectivesTo understand the rationale, implementation and early impact of vertical integration between primary care medical practices and the organisations running acute hospitals in the National Health Service in England and Wales.Design and settingA qualitative, cross-comparative case study evaluation at two sites in England and one in Wales, consisting of interviews with stakeholders at the sites, alongside observations of strategic meetings and analysis of key documents.ResultsWe interviewed 52 stakeholders across the three sites in the second half of 2019 and observed four meetings from late 2019 to early 2020 (further observation was prevented by the onset of the COVID-19 pandemic). The single most important driver of vertical integration was found to be to maintain primary care local to where patients live and thereby manage demand pressure on acute hospital services, especially emergency care. The opportunities created by maintaining local primary care providers—to develop patient services in primary care settings and better integrate them with secondary care—were exploited to differing degrees across the sites. There were notable differences between sites in operational and management arrangements, and in organisational and clinical integration. Closer organisational integration was attributed to previous good relationships between primary and secondary care locally, and to historical planning and preparation towards integrated working across the local health economy. The net impact of vertical integration on health system costs is argued by local stakeholders to be beneficial.ConclusionsVertical integration is a valuable option when primary care practices are at risk of closing, and may be a route to better integration of patient care. But it is not the only route and vertical integration is not attractive to all primary care physicians. A future evaluation of vertical integration is intended; of patients’ experience and of the impact on secondary care service utilisation.

Effects of whole-body MRI on outpatient health service costs: a general-population prospective cohort study in Mecklenburg-Vorpommern, Germany

ObjectiveWhole-body MRI (wb-MRI) is increasingly used in research and screening but little is known about the effects of incidental findings (IFs) on health service utilisation and costs. Such effects are particularly critical in an observational study. Our principal research question was therefore how participation in a wb-MRI examination with its resemblance to a population-based health screening is associated with outpatient service costs.DesignProspective cohort study.SettingGeneral population Mecklenburg-Vorpommern, Germany.ParticipantsAnalyses included 5019 participants of the Study of Health in Pomerania with statutory health insurance data. 2969 took part in a wb-MRI examination in addition to a clinical examination programme that was administered to all participants. MRI non-participants served as a quasi-experimental control group with propensity score weighting to account for baseline differences.Primary and secondary outcome measuresOutpatient costs (total healthcare usage, primary care, specialist care, laboratory tests, imaging) during 24 months after the examination were retrieved from claims data. Two-part models were used to compute treatment effects.ResultsIn total, 1366 potentially relevant IFs were disclosed to 948 MRI participants (32% of all participants); most concerned masses and lesions (769 participants, 81%). Costs for outpatient care during the 2-year observation period amounted to an average of €2547 (95% CI 2424 to 2671) for MRI non-participants and to €2839 (95% CI 2741 to 2936) for MRI participants, indicating an increase of €295 (95% CI 134 to 456) per participant which corresponds to 11.6% (95% CI 5.2% to 17.9%). The cost increase was sustained rather than being a short-term spike. Imaging and specialist care related costs were the main contributors to the increase in costs.ConclusionsCommunicated findings from population-based wb-MRI substantially impacted health service utilisation and costs. This introduced bias into the natural course of healthcare utilisation and should be taken care for in any longitudinal analyses.

The association of loneliness with health and social care utilisation in older adults in the general population: A systematic review

Background and Objectives Loneliness is proposed to be linked with increased service use. This review examined the association of loneliness and health and social care utilisation (HSCU) in older adults from the general population. Research Design and Methods Four databases were screened for studies that examined the association of loneliness (predictor) with HSCU (outcome) in older adults (defined as majority of sample 60 or older). Study quality was assessed with the NIH scale for observational cohorts and cross-sectional studies. Results We identified 32 studies, of which 9 prospective studies were evaluated as being good or good-fair quality. Two good-fair quality studies found loneliness at baseline was associated with subsequent admission to a residential care home. There was emerging evidence that loneliness was associated with emergency department use (n=1), and CVD-specific hospitalisation (n=1). Once adjusted for confounders the highest quality studies found no association of baseline loneliness with physician utilisation, outpatient service utilisation, skilled nursing facility use, and planned or unplanned hospital admissions. The remaining, studies were cross-sectional, or of fair to poor quality, and inadequate to reliably determine whether loneliness was associated with a subsequent change in HSCU. Discussion and implications There was heterogeneity in study design, measurement, and study quality. This generated an inconsistent evidence base where we cannot determine clear inferences about the relationship between loneliness and HSCU. Only one consistent finding was observed between two good-fair quality studies regarding care home admission. To determine clinical implications and make reliable inferences additional good quality longitudinal research is needed.

Burden and impact of chronic cough in UK primary care: a dataset analysis

ObjectiveChronic cough (CC) is a debilitating respiratory symptom, now increasingly recognised as a discrete disease entity. This study evaluated the burden of CC in a primary care setting.DesignCross-sectional, retrospective cohort study.SettingDiscover dataset from North West London, which links coded data from primary and secondary care. The index date depicted CC persisting for ≥8 weeks and was taken as a surrogate for date of CC diagnosis.ParticipantsData were extracted for individuals aged ≥18 years with a cough persisting ≥8 weeks or cough remedy prescription, between Jan 2015 and Sep 2019.Main outcome measuresDemographic characteristics, comorbidities and service utilisation cost, including investigations performed and treatments prescribed were determined.ResultsCC was identified in 43 453 patients from a total cohort of 2 109 430 (2%). Median (IQR) age was 64 years (41–87). Among the cohort, 31% had no recorded comorbidities, 26% had been given a diagnosis of asthma, 17% chronic obstructive pulmonary disease, 12% rhinitis and 15% reflux. Prevalence of CC was greater in women (57%) and highest in the 65–74 year age range. There was an increase in the number of all investigations performed in the 12 months before and after the index date of CC diagnosis, and in particular for primary care chest X-ray and spirometry which increased from 6535 to 12 880 and from 5791 to 8720, respectively. This was accompanied by an increase in CC-associated healthcare utilisation costs.ConclusionOne-third of individuals had CC in the absence of associated comorbidities, highlighting the importance of recognising CC as a condition in its own right. Overall outpatient costs increased in the year after the CC index date for all comorbidities, but varied significantly with age. Linked primary-care datasets may enable earlier detection of individuals with CC for specialist clinic referral and targeted treatment.

Resource use and costs associated with epilepsy in the Queensland hospital system: protocol for a population-based data linkage study

IntroductionEpilepsy places a large burden on health systems, with hospitalisations for seizures alone occurring more frequently than those related to diabetes. However, the cost of epilepsy to the Australian health system is not well understood. The primary aim of this study is to quantify the health service use and cost of epilepsy in Queensland, Australia. Secondary aims are to identify differences in health service use and cost across population and disease subgroups, and to explore the associations between health service use and common comorbidities.Methods and analysisThis project will use data linkage to identify the health service utilisation and costs associated with epilepsy. A base cohort of patients will be identified from the Queensland Hospital Admitted Patient Data Collection. We will select all patients admitted between 2014 and 2018 with a diagnosis classification related to epilepsy. Two comparison cohorts will also be identified. Retrospective hospital admissions data will be linked with emergency department presentations, clinical costing data, specialist outpatient and allied health occasions of service data and mortality data. The level of health service use in Queensland, and costs associated with this, will be quantified using descriptive statistics. Difference in health service costs between groups will be explored using logistic regression. Linear regression will be used to model the associations of interest. The analysis will adjust for confounders including age, sex, comorbidities, indigenous status, and remoteness.Ethics and disseminationEthical approval has been obtained through the QUT University Human Research Ethics Committee (1900000333). Permission to waive consent has been granted under the Public Health Act 2005, with approval provided by all relevant data custodians. Findings of the proposed research will be communicated through presentations at national and international conferences, presentations to key stakeholders and decision-makers, and publications in international peer-reviewed journals.

Barriers in Access to Healthcare for Kenyan Queer Womxn and Trans Men: Findings of a Cross-Sectional Online Survey and Interviews

BackgroundIn many African countries, including Kenya, sexual behaviour between consenting adults of the same sex/ gender is illegal, which results in limited availability and access to health services and information for sexual and gender minorities. This results in unmet health issues for sexual and gender minorities who have a higher burden of STD/STI and HIV, STI-related cancers, and mental ill-health and trauma.MethodsWe conducted an online survey among 335 Kenyan queer womxn and trans men over the age of 18 who had at least one self-identified female sexual partner, collecting data on health service utilisation and barriers to accessing healthcare. ResultsWe identified gaps in all four areas that comprise standard of health – availability, accessibility, acceptability, and quality of care, exacerbated by the restrictive law and policy landscape in Kenya. Queer womxn and trans men face multiple service-access barriers, many related to stigma and discrimination, as well as concerns around provider attitudes and knowledge. Violations of human rights and privacy are a concern for queer womxn and trans men patients. There are insufficient numbers of facilities, programmes, and information to meet the needs of queer womxn and trans men, which leads to a lack of holistic care or patients delaying care and preventative interventions. ConclusionMental health and trans health are areas that are particularly poorly equipped to serve the informants’ needs, highlighting the need to address the exclusion of sexual and gender minorities in the vulnerable groups of the National Mental Health Policy. Resources regarding the use of services need to be made available, and service providers need to be educated to provide non-judgmental, inclusive care for queer womxn and trans men in Kenya.

Population level impact of a pulse oximetry remote monitoring programme on mortality and healthcare utilisation in the people with covid-19 in England: a national analysis using a stepped wedge design

Objectives To identify the population level impact of a national pulse oximetry remote monitoring programme for covid-19 (COVID Oximetry @home; CO@h) in England on mortality and health service use. Design Retrospective cohort study using a stepped wedge pre- and post- implementation design. Setting All Clinical Commissioning Groups (CCGs) in England implementing a local CO@h programme. Participants 217,650 people with a positive covid-19 polymerase chain reaction test result and symptomatic, from 1st October 2020 to 3rd May 2021, aged ≥65 years or identified as clinically extremely vulnerable. Care home residents were excluded. Interventions A pre-intervention period before implementation of the CO@h programme in each CCG was compared to a post-intervention period after implementation. Main outcome measures Five outcome measures within 28 days of a positive covid-19 test: i) death from any cause; ii) any A&E attendance; iii) any emergency hospital admission; iv) critical care admission; and v) total length of hospital stay. Results Implementation of the programme was not associated with mortality or length of hospital stay. Implementation was associated with increased health service utilisation with a 12% increase in the odds of A&E attendance (95% CI: 6%-18%) and emergency hospital admission (95% CI: 5%-20%) and a 24% increase in the odds of critical care admission in those admitted (95% CI: 5%-47%). In a secondary analysis of CO@h sites with at least 10% or 20% of eligible people enrolled, there was no significant association with any outcome measure. However, uptake of the programme was low, with enrolment data received for only 5,527 (2.5%) of the eligible population. Conclusions At a population level, there was no association with mortality following implementation of the CO@h programme, and small increases in health service utilisation were observed. Low enrolment of eligible people may have diluted the effects of the programme at a population level.