Search

Yuanyuan Liu,1,2 Terry Dickerson,2 Frances Early,3 Jonathan Fuld,3 Chen Jiang,4 P John Clarkson2 1Department of Industrial Design, School of Mechanical Engineering & Automation, Beihang University, 37 Xueyuan Road, Haidian District, Beijing, 100191, China; 2Engineering Design Centre, Department of Engineering, University of Cambridge, Cambridge, CB2 1PZ, UK; 3Centre for Self Management Support, Cambridge University Hospitals NHS Foundation Trust, Cambridge Biomedical Campus Department of Respiratory Medicine, Cambridge University Hospitals NHS Foundation Trust, Cambridge, CB2 0QQ, UK; 4Department of Clinical Neurosciences, University of Cambridge, Clifford Allbutt Building, Cambridge Biomedical Campus, Cambridge, CB2 0AH, UKCorrespondence: Yuanyuan LiuDepartment of Industrial Design, School of Mechanical Engineering & Automation, Beihang University, 37 Xueyuan Road, Haidian District, Beijing, 100191, ChinaEmail yuanyuanliu@buaa.edu.cnBackground: Pulmonary rehabilitation (PR) is recommended for patients with COPD to improve their symptoms and quality of life. However, in the UK, only one in ten of those who need PR receive it and this might be inaccessible to people with disabilities. This study aims to inform improvements to PR service by identifying barriers to the uptake of PR in the COPD care journey in relation to patients’ capabilities that can affect their access to PR.Methods: An Inclusive Design approach with mixed methods was undertaken. Firstly, patients and healthcare professionals were interviewed to gather insight into their experiences of COPD care and map patients’ care journey. Secondly, an Exclusion Calculator was used to estimate service demand on patients’ capability and the proportion of population excluded from the service. Thirdly, a framework analysis was applied to guide data analysis to identify the challenges of accessing PR. Finally, proposed recommendations were refined with patients and healthcare professionals.Results: The overall capability-related exclusion number was very high (62.5%), and exclusion caused by limited mobility was the highest (50%) among the interviewees and even higher based on the population database. This suggests the importance of considering COPD patients’ capability-related needs to improve their access to care. Capability-related challenges for patients accessing PR such as poor mobility to transport and low vision impairing ability to read inhaler instructions were identified, as well as non-capability-related challenges such as patients’ perception about COPD and inability to access proper information. Recommendations were proposed to help patients to self-manage their COPD and access to PR.Conclusion: Lack of attention to COPD patients’ capability level in the delivery of PR may affect its uptake. Considering the capability-related needs of COPD patients and providing patients with reassurance, information, and support on their care journey could improve the uptake of PR.Keywords: COPD, pulmonary rehabilitation, healthcare access, care journey, Inclusive Design, capability

Older children and teenagers with bilateral cochlear implants often have poor spatial hearing because they cannot fuse sounds from the two ears. This deficit jeopardizes speech and language development, education, and social well-being. The lack of protocols for fitting bilateral cochlear implants and resources for spatial-hearing training contribute to these difficulties. Spatial hearing develops with bilateral experience. A large body of research demonstrates that sound localisation can improve with training, underpinned by plasticity-driven changes in the auditory pathways. Generalizing training to non-trained auditory skills is best achieved by using a multi-modal (audio-visual) implementation and multi-domain training tasks (localisation, speech-in-noise, and spatial music). The goal of this work was to develop a package of virtual-reality games (BEARS, Both EARS) to train spatial hearing in young people (8–16 years) with bilateral cochlear implants using an action-research protocol. The action research protocol used formalized cycles for participants to trial aspects of the BEARS suite, reflect on their experiences, and in turn inform changes in the game implementations. This participatory design used the stakeholder participants as co-creators. The cycles for each of the three domains (localisation, spatial speech-in-noise, and spatial music) were customized to focus on the elements that the stakeholder participants considered important. The participants agreed that the final games were appropriate and ready to be used by patients. The main areas of modification were: the variety of immersive scenarios to cover age range and interests, the number of levels of complexity to ensure small improvements were measurable, feedback, and reward schemes to ensure positive reinforcement, and an additional implementation on an iPad for those who had difficulties with the headsets due to age or balance issues. The effectiveness of the BEARS training suite will be evaluated in a large-scale clinical trial to determine if using the games lead to improvements in speech-in-noise, quality of life, perceived benefit, and cost utility. Such interventions allow patients to take control of their own management reducing the reliance on outpatient-based rehabilitation. For young people, a virtual-reality implementation is more engaging than traditional rehabilitation methods, and the participatory design used here has ensured that the BEARS games are relevant.

Frances Early,1 Ian Wellwood,2 Isla Kuhn,3 Christi Deaton,2 Jonathan Fuld1 1Centre for Self-Management Support, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; 2Clinical Nursing Research Group, Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge School of Clinical Medicine, Cambridge, UK; 3Medical Library, University of Cambridge School of Clinical Medicine, Cambridge, UK Abstract: Pulmonary rehabilitation (PR) reduces the number and duration of hospital admissions and readmissions, and improves health-related quality of life in patients with COPD. Despite clinical guideline recommendations, under-referral and limited uptake to PR contribute to poor treatment access. We reviewed published literature on the effectiveness of interventions to improve referral to and uptake of PR in patients with COPD when compared to standard care, alternative interventions, or no intervention. The review followed recognized methods. Search terms included “pulmonary rehabilitation” AND “referral” OR “uptake” applied to MEDLINE, EMBASE, CINAHL, PsycINFO, ASSIA, BNI, Web of Science, and Cochrane Library up to January 2018. Titles, abstracts, and full papers were reviewed independently and quality appraised. The protocol was registered (PROSPERO # 2016:CRD42016043762). We screened 5,328 references. Fourteen papers met the inclusion criteria. Ten assessed referral and five assessed uptake (46,146 patients, 409 clinicians, 82 hospital departments, 122 general practices). One was a systematic review which assessed uptake. Designs, interventions, and scope of studies were diverse, often part of multifaceted evidence-based management of COPD. Examples included computer-based prompts at practice nurse review, patient information, clinician education, and financial incentives. Four studies reported statistically significant improvements in referral (range 3.5%–36%). Two studies reported statistically significant increases in uptake (range 18%–21.5%). Most studies had methodological and reporting limitations. Meta-analysis was not conducted due to heterogeneity of study designs. This review demonstrates the range of approaches aimed at increasing referral and uptake to PR but identifies limited evidence of effectiveness due to the heterogeneity and limitations of study designs. Research using robust methods with clear descriptions of intervention, setting, and target population is required to optimize access to PR across a range of settings. Keywords: health services research, service improvement, access to healthcare, evidence-based practice, long-term condition, supervised exercise&nbsp

Pulmonary rehabilitation (PR) for people with COPD leads to clinically significant improvements in quality of life and exercise capacity [1]. In England and Wales, UK, in 2013–2014, only 15% of eligible patients were referred (51% from primary care), of whom 31% did not attend assessment [2]. We aimed to generate a theory-informed understanding of enablers and barriers to PR referral and uptake from primary care., Healthcare service and patient barriers contribute to low referral to and uptake of pulmonary rehabilitation (PR). Solutions should support skilled clinician–patient conversations and span primary care–PR boundaries to prevent disjointed working. http://bit.ly/2PVKHZf

Introduction Pulmonary rehabilitation (PR) referral and uptake in the UK remains low despite being a high value treatment for COPD. The referral rate and uptake of PR in South Asian populations is known to be particularly reduced and reasons for this are poorly understood. This mixed methods study explored barriers and enablers for PR referral and uptake in a sub-group of South Asian (SA) patients and their clinicians. Methods Interviews were conducted with White British (n=35) and SA (n=7) patients with COPD and with Health Care Professionals (4/38) working with SA patients. A deductive coding framework informed by Normalisation Process theory and supplemented by inductive codes was used. Codes were applied across the whole study and grouped into categories for analysis and comparison. Results Six domains of enablers and barriers were identified; patient factors for accepting and declining, primary care and patient interface, factors within primary care, patient’s first interaction with PR and factors within PR course. Specific barriers and enablers emerged across all domains in the SA patient group: Perceived barriers for accepting PR referral included poor understanding of PR, unfamiliarity with healthcare models and physiotherapy as a treatment option, and guilt and shame related to smoking. A specific enabler of attendance was a strong belief in what doctors say. Within the primary care–patient interface, language and patient interactions via the family unit were perceived barriers. Within primary care, data was not specifically collected on SA referral/uptake of PR hence gaps would not be identified. Information on patient translator needs not being conveyed to PR services ahead of patient assessment was identified as a barrier. Within the PR course, both positive aspects and potential challenges of having a translator present in groups were reported. Conclusions Identification of specific factors that are perceived to influence PR referral and uptake for South Asian patients have important practical implications for increasing PR uptake and addressing this health inequality. Further research should seek to find effective ways of addressing the particular needs of this group.

Chronic obstructive pulmonary disease (COPD) has a negative impact on people’s quality of life affecting daily activities and mental and emotional well-being. Healthcare services need to understand what patients want and need. We used a co-production methodology, Working Together for Change, not previously used in a COPD setting to determine what matters to people with COPD. Forty patients took part in one-to-one discussions to identify what was working well, not working well and what was important for the future in terms of their COPD care. The responses were analysed in two one-day co-production workshops involving COPD patients, carers and professionals. The six highest priority themes around what’s not working well were: ‘I don’t think the right hand knows what the left hand is doing’, ‘I can’t get appointments when I want them’, ‘I’m not treated as a person’, ‘I can’t do what I want to do’, ‘I’m anxious and depressed’ and ‘I can’t eat well.’ Professionals gained powerful insights into the difficulties of COPD through their interactions with patients in the workshops. What mattered to patients encompassed meaning, purpose and relationships beyond immediate medical needs and underlines the need for patient-centred holistic approaches to COPD care and support., Chronic lung disease care: What matters most to patients Interviews and workshops exploring patient perceptions of chronic lung disease care suggest a need to incorporate psychological and practical support with clinical management. Patient psychology frequently affects COPD symptoms; for example, patients with similar levels of physical airflow obstruction experience varying levels of breathlessness and ability to function in day-to-day life. Frances Early at the UK’s Cambridge University Hospitals NHS Foundation Trust and co-workers used a discussion methodology called Working Together for Change to examine positive and negative themes in COPD care. They conducted one-to-one interviews with 40 patients from diverse backgrounds and followed up with workshop discussions involving health professionals and patients to explore emerging themes. Patients coveted a holistic, personalized approach to treatment, including practical support to manage relationships, maintain purpose and enhance emotional well-being.

IntroductionChronic obstructive pulmonary disease (COPD) is a progressive lung disease associated with breathlessness, inability to exercise, frequent infections, hospitalisation and reduced quality of life. Pulmonary rehabilitation (PR), providing supervised exercise and education, is an effective and cost-effective treatment for COPD but is significantly underused. Interventions to improve referral and uptake have been tested and some positive results reported. However, interventions are diverse and no clear recommendations for practice can be made. This study aims to understand the challenges to referral and uptake in primary care, where most referrals originate, and to develop a flexible toolkit of resources to support referral and uptake to PR in primary care in the UK.Methods and analysisThis is a mixed methods study informed by normalisation process theory and burden of treatment theory. In the first phase, general practitioners, practice nurses and PR providers will be invited to complete an online survey to inform a broad exploration of the topic areas. In phase 2 interviews and focus groups will be conducted with patients, healthcare professionals (HCP) in primary care, PR providers and commissioners to gain an in-depth understanding of the issues and needs. Toolkit development in phase 3 will draw together the learning from phases 1 and 2 and employ an iterative development process to build the toolkit jointly with patients and HCPs. It will be tested in primary care for usability and acceptability.Ethics and disseminationThe study has ethical and Health Research Authority approval (Research Ethics Committee reference number 17/EE/0136). It is registered with the International Standard Registered Clinical/Social Study Number (ISRCTN) registry (trial ID:ISRCTN20669629, assignment date 20 March 2018, trial start date 1 April 2016). Dissemination will be aimed at patients, carers/families, service providers, commissioners and national interest groups. Methods will include conferences, presentations, academic publications and plain English reports and will be supported by the British Lung Foundation.Trial registration numberISRCTN20669629; Pre-results.

Introduction and objectives Pulmonary rehabilitation (PR) is recommended for people with COPD who are limited by breathlessness yet in 2013/14 only 15% of eligible patients in England and Wales were referred and 10.5% attended assessment. With most PR referral occurring in primary care, we aimed to understand how referral is embedded in GPs’ and practice nurses’ normal practice and how it may be improved. Methods Mixed methods study utilising a 33-item online survey (scales, free text) based on Normalisation Process Theory in a purposive sample of 415 general practices in the East of England between August 2017 and January 2018. We present key findings from free text data, analysed using framework analysis. Results Response rate was 26.9% (112/415). Both GPs and nurses valued PR as beneficial for patients. Nurses were the main referrers as part of routine care; GPs referred at specific moments, e.g. post-discharge or opportunistically. Both wanted regular, prompt feedback from providers about the service and patient outcomes. Nurses valued feedback from service users. Reasons for poor uptake were attributed to patients’ lack of self-confidence and knowledge about PR, patients being unwell or not believing PR would help. Reasons for accepting a referral were attributed to recommendation from a trusted clinician, patients feeling unable to cope, desiring to improve their health and testimony from others who attended. Both GPs and nurses suggested referrals could be increased through improved information about referral criteria, prompts at diagnosis, easy, automated referral processes, better PR promotion and self-referral. GPs suggested prompts at annual reviews, PR as part of the standard approach to exacerbations, patient taster sessions and clinician education sessions. Nurses suggested more time in consultations would help. Both suggested that class times and locations were important and more publicity about classes and benefits might increase uptake. Conclusion While nurses were the main referrers to PR, there was overlap in GPs’ and nurses’ needs to support referral. These spanned knowledge and information to counter misconceptions, support for more effective and efficient referral processes and improved responsiveness from providers. Data suggest combined approaches for both groups to support referral practice could be feasible.

Introduction: Pulmonary rehabilitation (PR) is recommended for people with COPD limited by breathlessness. In 2013/14 only 15% of eligible UK patients were referred and 10.5% attended an assessment. Objectives: Most PR referral occurs in primary care. As part of a mixed methods study we surveyed GPs and practice nurses to understand how referral is embedded in normal practice. Methods: A 33 item online survey (scales, free text) based on Normalisation Process Theory was sent to 415 general practices in the East of England between August 2017 and January 2018. We present key quantitative results which were analysed descriptively. Chi square was used to compare GP and nurse responses. Results: Response rate was 26.9% (112/415). 96.4% (108/112) saw value in referring patients to PR. 72.3% (81/112) were highly confident that they understood the eligibility criteria for referral and 72.3% (81/112) could integrate it into their work. Only 38.4% (43/112) believed sufficient training for referral was provided. Nurses (n=68) compared to GPs (n=41) were highly confident in understanding referral criteria (94% v 37.5%, p Conclusion: Almost all clinicians responding saw value in making PR referrals. Nurses described greater understanding than GPs of the eligibility and process of PR referral. Results suggest a need for different strategies for different clinicians to address low PR utilisation.

Introduction and Objectives There is little qualitative research into what matters to people with COPD, in terms of managing their condition and supporting their wellbeing. We used a co-production methodology not previously applied in COPD, Working Together for Change (WTfC), to undertake a service evaluation. We aimed to identify what is important to people with COPD and what services would address these issues. Evaluation of the process has been described.1 Here we report the themes that emerged from WTfC that reflect what mattered to participants. Methods WTfC began with 45 structured one-to-one discussions between an evaluator and participants identified from a GP list. We asked three questions: “What is working well in terms of your COPD care?”, “What is not working well in terms of your COPD care?” and “What is important to you?” Responses were analysed using quality improvement methods in two co-production workshops involving COPD patients and carers (including some of the one-to-one participants), local health care professionals and voluntary sector organisations. Responses were themed by all participants working together with an expert facilitator. The group agreed a label for each theme and participants voted on the most important themes under the heading “What’s not working.” Results The themes in each category are presented in Table 1. The six most important themes for “What’s not working” were: “I don’t think the right hand knows what the left hand is doing”, “I can’t get appointments when I want them”, “I’m not treated as a person”, “I can’t do what I want to do”, “I’m anxious and depressed” and “I can’t eat well”. Conclusions What mattered to people with COPD encompassed not just health-related issues but also meaning, purpose and relationships. This underlines the importance of a patient-centred and holistic approach to delivering healthcare. This co-production process provided a non-clinical setting in which the patient voice could be heard and provide a meaningful input for health service planning. Reference Early F, Winders S-J, Reddy SM, Ralphs JE, Fuld JP. Co-production to inform clinical commissioning in COPD: An evaluation of working together for change. Eur J Pers Cent Healthc 2017;5(1):111–119.

Frances Early,1 Jane S Young,2 Elizabeth Robinshaw,3 Emma Z Mi,4 Ella Z Mi,4 Jonathan P Fuld1 1Centre for Self Management Support, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK; 2Faculty of Health, Social Care and Education, School of Nursing and Midwifery, Anglia Ruskin University, Cambridge, UK; 3Gloucestershire Hospitals NHS Foundation Trust, Gloucester, UK; 4School of Clinical Medicine, University of Cambridge, Cambridge, UK Background: COPD has significant psychosocial impact. Self-management support improves quality of life, but programs are not universally available. IT-based self-management interventions can provide home-based support, but have mixed results. We conducted a case series of an off-the-shelf Internet-based health-promotion program, The Preventive Plan (TPP), coupled with nurse-coach support, which aimed to increase patient activation and provide self-management benefits. Materials and methods: A total of 19 COPD patients were recruited, and 14 completed 3-month follow-up in two groups: groups 1 and 2 with more and less advanced COPD, respectively. Change in patient activation was determined with paired t-tests and Wilcoxon signed-rank tests. Benefits and user experience were explored in semistructured interviews, analyzed thematically. Results: Only group 1 improved significantly in activation, from a lower baseline than group2; group 1 also improved significantly in mastery and anxiety. Both groups felt significantly more informed about COPD and reported physical functioning improvements. Group 1 reported improvements in mood and confidence. Overall, group 2 reported fewer benefits than group 1. Both groups valued nurse-coach support; for group 1, it was more important than TPP in building confidence to self-manage. The design of TPP and lack of motivation to use IT were barriers to use, but disease severity and poor IT skills were not. Discussion: Our findings demonstrate the feasibility of combining nurse-coach support aligned to an Internet-based health resource, TPP, in COPD and provide learning about the challenges of such an approach and the importance of the nurse-coach role. Keywords: COPD, self-management, Internet, coaching, patient activation

Patients with chronic obstructive pulmonary disease (COPD) face challenges in managing the physical and psychological consequences of the condition. Systemic self-management interventions based on the Wagner chronic care model seek to facilitate change in patient, healthcare professional (HCP) and healthcare system in order to support patients to self-manage their condition. Few studies have investigated the interactional sphere between patients and HCPs in the context of a systemic self-management intervention. The aim of the present study was to evaluate such an intervention and explore the discursive implications for self-management in COPD. Data were collected via interviews with patients and HCPs, observations of patient-provider interaction and document analysis of documents given to the patients to support self-management. An illustrative analytical model was developed on the basis of Willig’s discourse analysis guidelines. The findings suggested two different ways of talking about self-management – biomedical and patient-centred – that seemed to have implications for what speakers drawing on these discursive repertoires could say, do and experience in relation to self-management support and practice. Whilst the analytical method does not pass judgement on which discourse is ‘best’, results of this study show how the two identified discourses are oriented to different actions and positions, and highlight their relative strengths and limitations. The findings of the present study are relevant to the issue of how the ‘healthcare institution’, and evidence-based medicine as we know it, should be manifested – empirically and practically – in the future.

Thoracic Society of Australia & New Zealand and the Australian & New Zealand Society of Respiratory Science, Annual Scientific Meeting

Background:Regular, moderate physical activity reduces the risk of mortality and morbidity; however increasing the physical activity levels of less active people is a public health challenge. This study explores the potential of mass participation physical activity events to engage less active people, through analyzing the accounts of participants in 2 events who identified themselves as low-active before entering.Methods:Seven participants in a sponsored run and 7 in a sponsored walk were interviewed and transcripts were analyzed using grounded theory techniques.Results:Participants had positive experiences encapsulated in 3 categories: Performing (physical completion of the event culminating in a sense of achievement); Relating (enjoying relationships); Soaking up the Atmosphere (enjoying the event ambience). The way in which these categories were manifested was affected by the event context.Conclusions:Mass participation events have potential to engage low-active people. The impact of participation resonated with factors that are positively associated with physical activity in other settings, and event characteristics matched key criteria for attracting low-active groups identified through social marketing research. Suggestions are given for how to capitalize on the findings for health promotion.

There is an urgent need for consensus on what defines a chronic obstructive pulmonary disease (COPD) self-management intervention. We aimed to obtain consensus regarding the conceptual definition of a COPD self-management intervention by engaging an international panel of COPD self-management experts using Delphi technique features and an additional group meeting.In each consensus round the experts were asked to provide feedback on the proposed definition and to score their level of agreement (1=totally disagree; 5=totally agree). The information provided was used to modify the definition for the next consensus round. Thematic analysis was used for free text responses and descriptive statistics were used for agreement scores.In total, 28 experts participated. The consensus round response rate varied randomly over the five rounds (ranging from 48% (n=13) to 85% (n=23)), and mean definition agreement scores increased from 3.8 (round 1) to 4.8 (round 5) with an increasing percentage of experts allocating the highest score of 5 (round 1: 14% (n=3); round 5: 83% (n=19)).In this study we reached consensus regarding a conceptual definition of what should be a COPD self-management intervention, clarifying the requisites for such an intervention. Operationalisation of this conceptual definition in the near future will be an essential next step.

Introduction 1.2 million people in the UK have chronic obstructive pulmonary disease (COPD) that causes breathlessness, difficulty with daily activities, infections and hospitalisation. Pulmonary rehabilitation (PR), a programme of supervised exercise and education, is recommended for patients with COPD. However, only 1 in 10 of those who need it receive PR. Also, the UK National COPD Audit Programme concluded that the COPD treatment might not be accessible to people with disabilities. This paper applies an Inclusive Design approach to community-based PR service provisions. It aims to inform improvements to the PR service by identifying barriers to the uptake of PR in the COPD care journey in relation to patients’ capabilities that can affect their access to PR. Methods and analysis The protocol includes four steps. Step 1 will involve interviews with healthcare professionals and patients to gather insight into their experiences and produce a hierarchical task analysis of the COPD care journeys. Step 2 will estimate the service exclusion: the demand of every task on patients’ capabilities will be rated by predefined scales, and the proportion of the population excluded from the service will be estimated by an exclusion calculator. Step 3 will identify the challenges of the PR service; a framework analysis will guide the data analysis of the interviews and care journey. Step 4 will propose recommendations to help patients manage their COPD care informed by the challenges identified in step 3 and refine recommendations through interviews and focus groups. Ethics and dissemination The Cambridge Central Research Ethics Committee gave the study protocol a positive ethical opinion (17/EE/0136). Study results will be disseminated through peer-reviewed journals, conferences and the British Lung Foundation networks. They will also be fed into a Research for Patient Benefit project on increasing the referral and uptake of PR.

Soliciting a patient’s agenda (the reason for their visit, concerns and expectations) is fundamental to health care but if not done effectively outcomes can be adversely affected. Forms to help patients consider important issues prior to a consultation have been tested with mixed results. We hypothesized that using an agenda form would impact the extent to which patients felt their doctor discussed the issues that were important to them. Patients were randomized to receive an agenda form to complete whilst waiting or usual care. The primary outcome measure was the proportion of patients agreeing with the statement ‘My doctor discussed the issues that were important to me’ rated on a four-point scale. Secondary outcomes included other experience and satisfaction measures, consultation duration and patient confidence. There was no significant effect of agenda form use on primary or secondary outcomes. Post hoc exploratory analyses suggested possible differential effects for new compared to follow-up patients. There was no overall benefit from the form and a risk of detrimental impact on patient experience for some patients. There is a need for greater understanding of what works for whom in supporting patients to get the most from their consultation.

A considerable proportion of patients with chronic obstructive pulmonary disease (COPD) entering pulmonary rehabilitation (PR) report psychological distress, which is often accompanied by poor physical health status. Mindfulness-based cognitive therapy (MBCT) has been shown to improve psychological and physical outcomes in other chronic diseases. We therefore evaluated the efficacy of MBCT as an add-on to a standard PR programme in COPD.COPD patients eligible for PR were cluster randomised to receive either an 8-week, group-based MBCT programme as an add-on to an 8-week PR programme (n=39), or PR alone (n=45). The primary outcomes of psychological distress and physical health status impairment were measured with the Hospital Anxiety and Depression Scale (HADS) and the COPD Assessment Test (CAT) before randomisation (T1), mid- (T2) and post-intervention (T3), and at 3 (T4) and 6 (T5) months’ follow-up .A statistically significant time×arm effect was found for the HADS (Cohen'sd=0.62, 95% CIs (d)=0.18–1.06, p=0.010). The treatment effect on the CAT failed to reach statistical significance (d=0.42, 95% CIs (d)=−0.06–0.90, p=0.061).MBCT showed a statistically significant and durable effect on psychological distress, indicating that MBCT may be an efficacious add-on to standard PR programmes in COPD.

The article examines the first known US antilynching play by a white woman, Tracy Mygatt's The Noose (1919). Early takes up the notion of the antilynching drama as a site of political struggle, exp...

Rationale, aims and objectives: Patient involvement in healthcare decision-making is often limited to consultation. Co-production is an approach that empowers patients to work collaboratively with providers as agents of change. The objective of this study was to explore participants’ experiences and satisfaction with a co-production process, Working Together for Change (WTfC), used to inform the commissioning of services for people living with Chronic Obstructive Pulmonary Disease (COPD). Method: Mixed methods developmental service evaluation drawing primarily on qualitative data from semi-structured interviews. Setting and participants: Community-based intervention with COPD patients, carers, commissioners and providers of COPD services. Intervention: One-to-one reviews with 45 patients identified what was working, not working and what was important for the future regarding COPD management. In 2 one-day workshops attended by 14 patients and carers and 17 professionals this information was analysed to inform commissioning priorities. Results: Participant satisfaction was high. Thematic analysis identified 3 themes: (1) an engaging experience, (2) a constructive process enabled by strong patient presence, real patient experiences, collaboration, sense of freedom, a range of contributions and commitment & (3) personal gains from the patient and carer voice being counted, mutual understanding, seeing the value of patient involvement and learning and sharing. Some concerns were raised about the process and suggestions made for improvement. Conclusions: WTfC was an acceptable process to inform COPD commissioning activity and resulted in an agreed and priorities action plan for COPD service commissioning. It supported collaborative working, egalitarian relationships and mutual learning between patients, carers and professionals. As a standalone activity it was not possible to evaluate the value of the outputs to commissioners or the objective impact but it provided a powerful introduction to co-production methods. WTfC can be an impactful starting point for embedding co-production into the commissioning process.

Introduction Patient involvement in population level health care decisions often involves consultation rather than interactive decision-making. Lack of insight into appropriate methods is a barrier to patient involvement. Working Together for Change (WTfC) is a person-centred process to inform service development. Information from person-centred reviews (PCRs) is themed in a two-day co-production workshop. It is effective in social care and mental health but has not been applied in physical health. We tested its feasibility to improve the quality of person-centred information for COPD commissioners and of patient involvement. Methods Forty COPD patients recruited from GP lists, secondary care and support groups participated in one-to-one PCRs. PCRs identified their priorities for what’s working in their life regarding COPD, what’s not working, what’s important to the future. These patients, health service professionals and third sector organisations involved in COPD support were then invited to attend the two one-day workshops. Patients’ priorities were themed collaboratively. Root cause analysis of what was not working was followed by statements of what success would look like if root causes were addressed. Action plans were created. Qualitative data from workshop observations and participant interviews were analysed using thematic analysis. Results Service priorities included information, holistic care, access, dietary support, access to patient information for HCPs. The improved quality of the person-centred information was evident in the ways in which professionals’ understanding of patient needs was enhanced through close, informal interaction with patients and carers, e.g. witnessing difficulties such as simultaneously eating and breathing and other physical limitations that prevent patients following healthcare advice (Table 1). Participation was positive for patients and professionals (Table 1) experiencing it as engaging and collaborative. Patients felt both heard and empowered and felt all the information they offered was precious. Discussion Patients found it a powerful experience and felt they made a contribution for the future. Professionals gained emotional and practical insights which inspired motivation for change in service delivery. The process tapped into strong motivations for mutual understanding. It is an effective element in developing person-centred COPD services and is transferable to other LTCs. Supported by grant from the Health Foundation

Introduction Pulmonary rehabilitation includes self-management support for COPD but is not suitable for or accessible to all. Web based approaches have potential to provide self-management support but effectiveness is not consistently demonstrated and issues of reach and adoption are relatively unstudied. We performed a mixed methods before-and-after study of an intervention comprising web-based health promotion for LTC self-management, The Prevention Plan TM (TPP), with integrated nurse coach support. This report describes the qualitative evaluation. The aim was to understand the benefits gained and the characteristics of patients most likely to benefit. Method Nineteen patients were recruited in two waves from May 2012–January 2013. Key selection criteria included for group 1 FEV 1 1 Semi-structured interviews were scheduled for one month and three months after recruitment and were focused around experiences of the programme, benefits and self-management behaviours. Qualitative data were imported into NVivo 10 and analysed through thematic content analysis. Two researchers discussed the themes and subthemes to ensure non-redundant categorization. Results Fifteen patients were interviewed. Key benefits: increased motivation for self-management, use of self-management skills, increased access to resources and enhanced understanding of lifestyle risk factors. Benefits were facilitated by use of action plans within TPP, nurse coach support to on-going motivation and completion of a health risk assessment by those with little awareness of lifestyle risks. Barriers to gaining benefit included preference for one-to-one contact, insufficient tailoring of website content and difficulties with website navigation. Patients most likely to benefit were those who: wanted to change but had no behavioural strategy; had little previous disease education; had an autonomous sense of self-determination. Conclusions The programme provided good support for the action phase of behaviour change, but less so for the motivational phase. Patients who were ready to change but did not have knowledge, skills or strategies benefited the most. When implementing a behaviour change programme providers should identify whether it addresses motivation and/or behaviour and assess potential participants accordingly. People who are not ready or able to change may derive little benefit from a behavioural programme.

Introduction Most patients have issues to raise in a consultation but may not actually raise them, adversely affecting the consultation outcome. Evidence suggests that methods to help patients consider their information needs before a consultation can increase satisfaction without increasing consultation length but there is a need to assess a wider range of outcome measures and to measure consultation length accurately. We studied the impact of a paper agenda form to prompt question asking in a respiratory outpatient clinic. The primary objective was to identify whether this increased agreement that “My doctor discussed the issues that were important to me”. Secondary endpoints included consultation length and post-consultation confidence to self-manage (0–10 scale). Method Patients were randomised to receive the agenda form or usual care by blocked randomization (block size 6), stratified by consultant. Patients receiving the form had a written brief inviting them to complete it in the waiting room. PROMs were collected post-consultation. Consultations were timed by an observer outside the room. As planned in the protocol, categorical data were analysed using Fisher’s exact test and continuous data were analysed using a t-test. Exploratory analyses to assess the effects of a number of factors used mixed model ANOVA. Results Groups were well matched at baseline for age, gender and respiratory diagnosis. There was no significant effect of agenda form use on the primary or secondary endpoints (Table 1). Exploratory analyses identified that in new patients (but not in follow-up patients) the form was associated with shorter consultation length (LS mean=15.2 mins) than usual care (LS mean=21.3 mins) (p = 0.017) and with lower confidence to self-manage (LS mean=6.6) than usual care (LS mean=9.2) (p = 0.001). Conclusion There was no overall benefit from the form and a risk of detrimental impact on patient experience for some patients. This resonates with reports from other more complex self-management interventions that have found unexpected detrimental effects in some patients. There is a need for greater understanding of what works for whom with regard to self-management support. It cannot be assumed that the impact will be universally beneficial at best or neutral at worst. Reference Trial reference: REC reference: 13/WA/0171

Recent studies have provided evidence that dyslexic children tend to show longer visual persistence than control children when presented with low-spatial-frequency grating stimuli. The possibility that this phenomenon might reflect an impairment of inhibitory Y-cell activity in the visual system of dyslexics has been investigated. A flicker masking technique was used to mask Y-cell activity selectively in a group of dyslexic boys and a group of age-matched controls. There were no overall differences in reaction times to the offsets of grating patterns of various spatial frequencies between the groups, and no differences between subgroups defined by age, degree of reading impairment, or any other criterion. The results show no evidence of abnormal Y-cell function in developmental dyslexia.