The impact of comorbidities on referral to and outcomes of hip and knee replacement surgery

New CLAHRC research looks at how comorbidities – multiple conditions experienced by patients –  influence referrals to, and outcomes of hip and knee replacement surgery.

Taking a 360-degree view of the referral and treatment process our researchers, led by Bélène Podmore, investigated current evidence in this area for patients with multiple conditions undergoing surgery. We examined;

  • the short-term outcomes relating to the safety of the hip or knee replacement surgery
  • long-term outcomes relating to the benefits of undergoing hip and knee replacement surgery.

We found comorbidities predominantly impact the safety of hip and knee replacement surgery but have little impact on its effectiveness.

Bélène also interviewed a variety of health professionals and therapists for their take on referring and selecting patients with comorbidities for joint replacement surgery.  We found some disagreement among professionals – ranging from GPs to surgeons – on roles and responsibilities in the management of these patients.

The two pieces of research are presented in handy new “BITE-sized” summaries with links to full papers and further reading –

How do comorbidities impact on the referral pathway to access joint replacement surgery in the NHS? An interview study with healthcare professionals in the NHS

What is the impact of comorbidities on outcomes of hip and knee replacement surgery? A review of the evidence

Evaluation of heath impact of Low Emisison Zones makes the news

CLAHRC research investigating the impact of low emission zones on children’s physical activity and health has been featured on the BBC News

CLAHRC North Thames, in collaboration with three other CLAHRCs and a number of other research bodies, is evaluating the effects of London’s new Ultra Low Emission Zone (ULEZ) on children’s physical health and activity.

Our work is an offshoot of the CHILL (Children’s Health in London and Luton) study investigating the impact of pollution on children’s lungs.  We are using the data created by CHILL to focus specifically on the impacts on children’s physical activity and health. CHILL featured on BBC News on January 16th.

Watch a clip below to see how school children are recording the effects of pollution on their lungs. 

Professor Chris Griffiths, Chief Investigator for our work and part of the CHILL study is interviewed in the clip

 

Big role for research and inniovstion in the NHS Long-term plan

#NHSLongTermPlan 

https://www.longtermplan.nhs.uk/

The NHS Long-term plan published on Monday, January 7th includes extensive commitments to research.

The Plan sets out how the £20.5bn annual budget increase promised by prime minister Theresa May will be spent, and sets out priorities and targets for the service for the next ten years. A big focus will be on prevention and early detection of illness and disease with a view to taking pressure off hospital services.

Other big priorities for the Service include mental health and obesity, with GPs, mental health and community care receiving investment that will grow faster than the rest of the overall NHS budget.

The NHS Long Term Plan will also:

  • Open a digital ‘front door’ to the health service, allowing patients to be able to access health care at the touch of a button
  • Provide genetic testing for a quarter of people with dangerously high inherited cholesterol, reaching around 30,000 people
  • Give mental health help to 345,000 more children and young people through the expansion of community based services, including in schools
  • Use cutting edge scans and technology, including the potential use of artificial intelligence, to help provide the best stroke care in Europe with over 100,000 more people each year accessing new, better services
  • Invest in earlier detection and better treatment of respiratory conditions to prevent 80,000 hospital admissions and smart inhalers will be piloted so patients can easily monitor their condition, regardless of where they are
  • Ensure every hospital with a major A&E department has ‘same day emergency care’ in place so that patients can be treated and discharged with the right package of support, without needing an overnight stay.

It includes a section highlighting the role of research and innovation in enabling breakthroughs, prevention of illness, earlier diagnosis, more effective treatments, better outcomes and faster recovery. Some measures relating to research in the plan include:

  • NHS endorsement of recently announced Life Sciences Sector deal and recognition that research and innovation are important for patients and the UK economy
  • Increasing the number of people registering to participate in health research to one million by 2023/24
  • A commitment to innovation and ensuring it reaches patients faster with a simpler, clearer system for drugs, medtech and digital uptake

In an effort to strengthen the ability of patients, professionals and the public to contribute to improving the Service an NHS Assembly will be established in early 2019. The Assembly, consisting of national clinical, patient and staff organisations; the Voluntary, Community and Social Enterprise (VCSE) sector; the NHS Arm’s length bodies (ALBs); and frontline leaders from ICSs, STPs, trusts, CCGs and local authorities will advise the boards of NHS England and NHS Improvement as part of the ‘guiding coalition’ to implement this Long Term Plan.

Read reactions to, and summaries of the plan from vaious organisations

Healthy London Partnership; 
https://www.healthylondon.org/resource/the-nhs-long-term-plan-summary/

Association of Medical Research Charities
https://www.amrc.org.uk/research-and-innovation-in-nhs-englands-long-term-plan
KIng’s Fund
https://www.kingsfund.org.uk/press/press-releases/kings-fund-response-nhs-long-term-plan
Nuffield Trust:
https://www.nuffieldtrust.org.uk/event/learning-from-history

From theoretically informed to theoretically informative improvement research

A new BMJ Quality and Safety editorial by Dr Roman Kislov, Senior Research Fellow at the Alliance Manchester Business School, has highlighted CLAHRC work as an example of successful engagement with management theory by researchers.

Dr Kislov’s research focus is the processes and practices of knowledge mobilisation, and his editorial highlights our recent paper on how different NHS Boards implement a quality improvement intervention – the QUASER guide.

He cites the paper as “an example of successfully deployed theoretically informative approach, highlighting some practical tips for researchers who aspire to move from merely applying theory towards entering into dialogue with it and, through doing so, refining its assumptions.

Read the editorial

Engaging with theory: from theoretically informed to theoretically informative improvement research

Repeated calls have been made for the increased use of theory in designing and evaluating improvement and implementation interventions.1-4 The benefits are argued to include identifying contextual influences on quality improvement (QI), supporting the generalisability of findings and anticipating how future phenomena might unfold.2 5 Most importantly, the ability of

Read the iQUASER paper

Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service

Background Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis’ typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England.

Read our BITE sized summary of the iQUASER paper

Complications following hip or knee surgery are more likely for people with long-term illness, but benefits are still worthwhile

The work of CLAHRC researcher Dr Bélène Podmore has been highlighted as “high quality” by the National Institute for Health Research. Bélène’s work, recently published in BMJ Open investigated how having a long-term condition impacts access to and benefit from hip and knee surgery. The research was promoted by NIHR via their “Signals” service. NIHR Signals summarise the latest important research on health care, public health and social care, along with implications for practice.

Joint replacement benefits and harms for people with other illness

Why was this study needed? In the UK, over 210,000 hip and knee replacements were performed in 2017 at an average age of 68 for hips and 69 for knees. One in six of these people had an illness affecting their day to day life.

Read the paper

Podmore B, Hutchings A, van der Meulen J, et al
Impact of comorbid conditions on outcomes of hip and knee replacement surgery: a systematic review and meta-analysis
BMJ Open 2018;8:e021784. doi: 10.1136/bmjopen-2018-021784

 

Capturing the views of patients in emergency care

CLAHRC researchers highlight potential to use patient-reported outcomes for emergency admissions.

Patient-reported outcome measures or PROMs are a well-established method of capturing the views of NHS patients, allowing the service to assess the quality of care delivered, from the patient perspective.

PROMs use pre- and post-operative surveys completed by patients to calculate their health gains after surgical treatment.

While there is an extensive PROM programme across the English NHS, they have yet to be used in emergency admissions. These account for nearly 40% of all hospital admissions and are an area of increasing demand. However, this is also an area where the NHS knows least about;

  • the quality of patient outcomes,
  • whether resources are being used effectively,
  • and whether there are unexpected variation between different providers

CLAHRC researcher and PhD Dr Esther Kwong investigated how to use PROMs to evaluate the quality of acute and emergency hospital care in the NHS. Esther developed and tested PROMS with patients who underwent emergency admissions, establishing that it is feasible to use PROMS in this clinical area.

They are presented in four new CLAHRC BITEs – postcard summaries of Esther’s published academic papers.

Can Patient Reported Outcomes Measures (PROMs) be used in emergency admissions?

Feasibility of collecting retrospective patient reported outcome measures (PROMs) in emergency hospital admissions

Using patient-reported outcome measures (PROMs) for primary percutaneous coronary intervention

Assessing Patient Reported Outcomes (PROMS) for emergency admissions: laparotomy for gastrointestinal conditions

Introduction to Evaluation

Do you need to demonstrate the impact of projects in your organisation?

Do you want to improve the design and implementation of your programme?

Are you tasked with carrying out an evaluation, but don’t know where to start?

This one day, hands-on workshop, run by the NIHR CLAHRC NorthThames Academy, addresses these challenges.  It is aimed at staff from NHS Trusts, CCGs and Local Authorities, who have limited experience of conducting service evaluations.

After attending this workshop, you will have the skills and knowledge to undertake your own evaluation of a local programme or service.

The course covers:

  • Different types of evaluation, including their pros and cons
  • How to select suitable methods and approaches for evaluating a local programme or service
  • Practical skills and tips in using evaluation methods and approaches
  • Ways of sharing your evaluation findings to make an impact

This workshop is suitable for staff from NHS Trusts, Local Authorities and CCGs.  It is not aimed at academics and/or researchers.  Participants should attend the course with an evaluation in mind that they may need to carry out.  No previous experience of study design, statistics or evaluation is needed.

All participants will receive a certificate of attendance.

Cost – This course is free for staff working in NIHR CLAHRC North Thames partner organisations (please click here to see a list of our partners). There is adelegate fee of £250 for other attendees.

Registration – Please complete the registration form and email to clahrc.academy@ucl.ac.uk by 5pm, Friday 25th January 2019.

Please note, a cancellation fee of £100 will be charged to both partner and non-partner delegates in the event of non-attendance without notice after 5pm, Tuesday 26th March 2019

Requests for emergency contraception could be an important sign of abuse

Women who experience domestic violence and abuse (DVA) are more than twice as likely to seek emergency contraception as other women, according to a study by National Institute for Health Research (NIHR)-funded researchers at the University of Bristol and Queen Mary University of London, suggesting that requests for emergency contraception could be an important sign of abuse.

In the study, published in the British Journal of General Practice today, the researchers analysed medical records of over 200,000 women of reproductive age registered with a GP and found that those who had a record of DVA were 2.06 times more likely to have a consultation for emergency contraception compared to other women, rising to 2.8 times for women aged 25-39.

The researchers also found some evidence that abused women are more likely to seek emergency contraception repeatedly.

DVA is a major public health problem, with devastating consequences for the women who experience it and great financial cost to the NHS. It is known to have a significant impact on women’s reproductive health, including an increased risk of unintended pregnancy and abortion, as abusive and controlling partners coerce women to have unprotected sex or rape them.

Although emergency hormonal contraceptive, also known as the morning-after pill, is available from pharmacies, women can also get it from their GP. Up to a third of all emergency contraceptives are prescribed by GPs.

The researchers are calling for this new evidence to be included in existing DVA training programmes for GPs and sexual health practitioners, and for the training to be extended to community pharmacists, to help them identify and refer women who have experienced DVA on to specialist support services. Such programmes are recommended by the National Institute for Health and Care Excellence (NICE) and the World Health Organization (WHO) as part of a multi-sector response to DVA.

Joni Jackson, Research Associate from the NIHR Collaboration for Leadership in Applied Health Research (CLAHRC) West and co-lead author of the study, said:

We found a strong positive association between exposure to domestic violence and abuse and requests for emergency contraception. Our findings are in line with evidence from studies in other countries suggesting that women experiencing DVA use more emergency contraception than other women. GPs, pharmacists and sexual health practitioners are at the frontline responding to these requests, with community pharmacists dispensing 50% of all emergency contraceptive pills. This presents an important opportunity to identify women experiencing DVA, signpost them to appropriate support services, and potentially save lives.”

Dr Natalia Lewis, from the Centre for Academic Primary Care at the University of Bristol and co-lead author, said:

The negative impact of domestic violence and abuse on health results in higher use of healthcare services by abused women compared to the general population. This means that healthcare services are an important point of contact for DVA victims and survivors. We have already seen improvements in GPs’ ability to identify and refer women experiencing DVA through the success of the IRIS (Identification and Referral to Improve Safety) programme. IRIS has recently been adapted for sexual and reproductive health services. Our findings support the case for adapting the IRIS intervention to the community pharmacy setting, although more research is needed to explore if and how this could be done.”

The research was supported by NIHR CLAHRC West and CLAHRC North Thames.

Papers:

Exposure to domestic violence and abuse and consultations for emergency contraception: nested case-control study in a UK primary care dataset. Joni Jackson, Natalia V Lewis, Gene S Feder, Penny Whiting, Timothy Jones, John Macleod, Maria Theresa Redaniel. British Journal of General Practice. 4 December 2018.

Use of emergency contraception among women with experience of domestic violence and abuse: a systematic review. Natalia V Lewis, Theresa HM Moore, Gene S Feder, John Macleod, Penny Whiting. BMC Family Practice. 26 September 2018.

CLAHRC research has Europe-wide impact

Dr Werner Leber, an East London GP with a passion for driving earlier identification and diagnosis of HIV, has seen his work recognised by the European agency responsible for the continent’s defences against infectious disease – the European Centre for Disease Prevention and Control (ECDC).

Dr Leber (above) is a practising GP in Tower Hamlets as well as being an NIHR Clinical Lecturer in Primary Care. His work with the CLAHRC, based at the Queen Mary University of London, aims to improve the identification and management of people with HIV.

Werner’s research among East London’s GP practices will now have a Europe-wide impact after being highlighted as good practice by the ECDC in its first integrated European hepatitis B virus (HBV) hepatitis C virus (HCV) and HIV testing guidance. The trial is summarised on page 71 of the guidance.

“The results support the hypothesis that an education programme promoting rapid HIV testing in general practice leads to increased and earlier HIV diagnosis.”

Public health guidance on HIV, hepatitis B and C testing in the EU/EEA;
An integrated approach
European Centre for Disease Prevention and Control, 2018

The project consortium and a panel of experts highlighted work published by Dr Leber and his team – Promotion of rapid testing for HIV in primary care (RHIVA2): a cluster-randomised controlled trial as a case study to support the published evidence and advice for implementation for the new guidance.

Read the RHIVA2 case study as a stand-alone document.

In this trial in Hackney, general practices were randomly assigned to offer either opt-out rapid HIV testing to newly registering adults or continuing usual care. The study found that promotion of opt-out rapid testing in general practice led to an increased rate of diagnosis, and might increase early detection, of HIV.

In developing the guidance the ECDC looked for excellent examples of HBV, HCV and HIV testing services across EU/EEA Member States, reviewing the latest evidence and putting out two published calls for submissions of good practice.

Promotion of rapid testing for HIV in primary care (RHIVA2): a cluster-randomised controlled trial
Lancet HIV. 2015 Jun;2(6):e229-35. doi: 10.1016/S2352-3018(15)00059-4. Epub 2015 Apr 28.
Leber W, McMullen H, Anderson J, Marlin N, Santos AC, Bremner S, Boomla K, Kerry S, Millett D, Mguni S, Creighton S, Figueroa J, Ashcroft R, Hart G, Delpech V, Brown A,
Rooney G, Sampson M, Martineau A, Terris-Prestholt F, Griffiths C

What do hospitals need for a board-level quality improvement intervention to work?

Healthcare systems around the world are becoming more concerned with strengthening board level governance of quality. In England, national healthcare regulators are developing approaches, resources and interventions aimed at supporting senior hospital leaders in their role in the governance of quality.

New CLAHRC research investigates the organisational response to an improvement intervention in six hospital boards across England. The research, published in a new BMJ paper and BITE-sized summary shows the results a 30-month period of fieldwork, involving interviewing NHS board members, observing board meetings and analysing relevant documentation.

The findings will be relevant to NHS Boards, the staff and clinicians they lead and all those in the NHS working to improve the quality and safety of care.

As well as researchers, the results will be of interest to policymakers, regulators, knowledge mobilisation organisations and thinkers on boards and leadership across all sectors.

Read the iQUASER paper

Explaining organisational responses to a board-level quality improvement intervention: findings from an evaluation in six providers in the English National Health Service

Background Healthcare systems worldwide are concerned with strengthening board-level governance of quality. We applied Lozeau, Langley and Denis’ typology (transformation, customisation, loose coupling and corruption) to describe and explain the organisational response to an improvement intervention in six hospital boards in England.

Read a BMJ editorial highlighting the paper as “an example of an empirical study that successfully enters into dialogue with management theory

Engaging with theory: from theoretically informed to theoretically informative improvement research

Repeated calls have been made for the increased use of theory in designing and evaluating improvement and implementation interventions.1-4 The benefits are argued to include identifying contextual influences on quality improvement (QI), supporting the generalisability of findings and anticipating how future phenomena might unfold.2 5 Most importantly, the ability of

Read our “need to know” summary

What do hospitals need for a board-level quality improvement
intervention to work?