Seminar Details

Format: 10 minute presentaions with 5 minutes for questions.

 Date: Monday, 16th January 2012
 Time:  1 pm - 2.30 pm (12.45 for sandwiches)
 Venue:  Seminar Room 2, PCPH, Upper 3rd Floor, UCL (Royal Free Campus)
 Speakers:  
 1 pm  Elsa Gubert Clinician perspectives of a computer-based self-management programme for people with type 2 diabetes
 1.15 pm  Charlotte Dack Developing a computer-based self-management programme (SMP) for adults with type 2 diabetes: What did patients tell us?
 1.30 pm  Dev Chatterjee Benzodiazepine use in community-dwelling older adults in London- prevalence and characteristics associated with use
 1.45 pm  Melvyn Jones A systematic review of whether people with DM experience less chest pain when having a myocardial infarction
 2 pm  Nikita Thakrar Presentation of Myocardial Infarction in People with Diabetes: A Qualitative Study
 2.15 pm  Howell Jones Are GP Consortia Ready To Commission Services for Female Sex Workers?
Title:
Clinician perspectives of a computer-based self-management programme for people with type 2 diabetes
 - Elsa Gubert
Details:

Background:
With an ever increasing burden of chronic conditions, promoting self management has become an NHS priority. Currently only a minority of patients with type 2 diabetes access structured education programmes putting a lot of the educational burden on general practitioners and practice nurses. An online self-management programme (SMP) could provide a cost effective way of improving self-management. It might also help clinicians and patients make better use of time pressured consultations.

Aims:
We aimed to determine clinician perspectives of a computer-based intervention to assist us in developing a service which clinicians could use in partnership with their patients.

Methods:
Health professionals were interviewed either individually or within a focus group. The participants were multidisciplinary and both primary and secondary care were represented. The interviews and focus groups were taped and transcribed verbatim. Data were analysed using a thematic approach. An initial coding framework was reviewed in a multi-disciplinary data clinic including a sociologist, a psychologist, and three academic general practitioners.

Results:
17 health professionals were interviewed via three focus groups and four interviews. We sampled to saturation. Clinicians were concerned that the intervention should not add to their workload but ideally save time. It was felt that linking the intervention to aspects of patients' electronic medical records would be helpful with adequate safeguards in place.

Discussion:
The clinician perspectives in this study should help design web interventions which could support clinicians in promoting self management in their patients.

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Title:
Developing a computer-based self-management programme (SMP) for adults with type 2 diabetes: What did patients tell us?
 - Charlotte Dack

Details:

Background:
Diabetes affects over 200 million people worldwide causing substantial morbidity, premature mortality and costs the NHS about £9 billion per annum. Structured education reduces the incidence of complications and NICE guidelines advise that all people with type 2 diabetes (T2DM) should have structured education at diagnosis with annual reinforcement. However few people in the UK with T2DM receive such education. A computer-based self-management programme (SMP) could potentially address this unmet need.

Aims:
To explore patients’ perspectives of essential and desirable features of a computer-based SMP for adults with T2DM and how computers might improve their ability to self-manage.

Methods:
Focus groups and individual interviews were employed to find out patient’s views of computer-based SMPs and how they might improve self-management. Patients were purposively sampled to recruit a diverse population. Interviews and focus groups were taped and transcribed verbatim. Data was analysed thematically. Initial themes were reviewed in a multidisciplinary data clinic including a sociologist, a psychologist, and three academic GP’s.

Results:
Four focus groups and one interview were conducted (N = 20). Patients viewed computer-based SMPs as an alternative and acceptable means of education. They wanted an interactive programme with multiple tools to assist with learning, self-assessment, self-monitoring, emotional support, behaviour change and to enhance patient- practitioner communication. 

Discussion:
Improving self-management of diabetes using technology is a potential key tool in tackling the growing challenge of treating diabetes. Patients were supportive of a computer-based SMP. Working with potential users to develop interventions will ensure they fit the needs of people with T2DM.

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Title:
Benzodiazepine use in community-dwelling older adults in London- prevalence and characteristics associated with use
 - Dev Chatterjee
Details:

Background:
Benzodiazepine (BZ) consumption among older people has implications for mortality, morbidity and cost-effective prescribing. Many characteristics have been identified with BZ use, most suggesting that it reflects psychological states but some suggesting it reflects physical illness and disability.

Aims:
Determine the prevalence of BZ use in a cohort of individuals aged 65 and over and explore characteristics associated with their use.

Methods:
A cross-sectional study using the ‘ProAge’ health profile questionnaire completed by 1059 patients from three general practices in London.

Results:
The prevalence of benzodiazepine use was 3.3% (35/1059). Benzodiazepine use was associated with female gender, high consultation rates, low income, medication for arthritis or joint pain, polypharmacy, depression, difficulties in instrumental activities of daily living (IADL), poor self-perceived health, social isolation, recent pain, medications for anxiety and symptoms of anxiety or agitation. In binary logistic regression analysis only three factors retained statistically significant independent associations with benzodiazepine use: receiving more than state pension (OR = 0.24, 95% CI: 0.098, 0.598), pain in the past 4 weeks (OR = 4.35, 95% CI: 1.501, 12.579), and taking medication for anxiety (OR = 7.96, 95% CI: 2.185-28.965). In BZ users who complained of recent pain, binary logistic regression analysis showed only sadness and depression due to pain over the last 7 days had a statistically significant association with benzodiazepine use.

Conclusions:
Lower socioeconomic status, pain and medications for anxiety are associated with use of benzodiazepines in this sample of older people. The possible reasons for these associations, and their implications for practice, will be discussed.

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Title:
A systematic review of whether people with DM experience less chest pain when having a myocardial infarction
 - Melvyn Jones
Details:

Background:
People with diabetes mellitus (DM) are more likely to have a myocardial infarction (MI) compared to people without diabetes. DM autonomic neuropathy may lead to alteration and so under recognition of infarction pain. There is conflicting research on this subject

Methods:
Standard methods including searches of Pubmed / Embase using MOOSE criteria for meta analysis of observational data. Data was meta-analysed.

Results:
Searches identified 1566 abstracts,16 meeting our full criteria. Authors used a variety of classifications of symptoms such as absence of chest pain (CP), and typical /atypical (T/AT) classification. 16 papers identified patients with CP /no CP symptoms during an MI, those with DM having an odds ratio (OR) for CP during MI of 0.51 (0.51 to 0.52). (n=471723) However, one study dominates the review with 20 times the study size of all other studies. Conversely one study reported using T/AT showed a non significant increase in DM having typical symptoms OR 2.37 (0.84-6.67).

Seven papers identified other non pain symptoms such as increased breathlessness among DM (OR 1.46 (1.30-1.65 n=6069). For other symptoms such as sweating and extra cardiac pain (arm, neck pain) data is available but not yet analysed.

Conclusion:
Patients with DM experience less CP, and more non pain symptoms such as breathlessness during their MI. Limitations of the review include issues around recruiting on the basis of CP (selection bias), identifying patients who are admitted to hospital (survivor bias) and gender, age and morbidity disparity between groups.

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Title:
A Presentation of Myocardial Infarction in People with Diabetes: A Qualitative Study
 - Nikita Thakrar
Details:

Background:
There is conflicting research whether people with diabetes mellitus (DM) suffering a myocardial infarction (MI) experience symptoms of a different character and severity than non diabetics.

Methods:
Qualitative study using interview and medical record data to explore the presentation of MI in people with DM.

Results:
20 semi-structured, face to face interviews were conducted with English speaking people with DM and a diagnosis of MI who were admitted to the Coronary Care Unit (CCU) at 2 London teaching hospitals. Data has been analysed on 4 patients currently and I hope to complete the analysis on the larger sample by January 2012.

Three themes have been identified so far in the interim analysis: symptoms, help seeking process and knowledge of MI. what about the “inexpressibility of pain” idea?

The symptoms experienced in this study were of a wide range of both typical and atypical symptoms that varied in severity. An emotional aspect was also identified. Chest pain varied in nature and was absent in one person Only half the participants had typical chest pain that could be plausibly attributed to MI. Sweating and many other non-specific symptoms were present in this group. Breathlessness was a common feature in this group.

The participants attributed their symptoms to both minor illness and their DM, and yet often had a sense that there was something wrong. Participants used explanatory models to rationalise why they weren’t having MI and their knowledge of MI symptoms was limited. This is particularly striking considering several participants had previous MI or a family history of IHD. Lengths of delay before seeking help ranged from ten minutes to three weeks.

The preponderance of atypical symptoms, misattribution of symptoms and delay to presenting to health care would make diagnosis of MI challenging in other similar groups of people with DM.

Conclusion:
Interim analysis suggest Unexpected breathlessness may be a key indicator of MI in people with DM, Clinicians and the public being aware that a wide range of MI symptoms exist can lead to correct symptom attribution and prompt treatment seeking.

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Title:
Are GP Consortia Ready To Commission Services for Female Sex Workers?
  - Howell Jones
Details:

Introduction:
Female sex workers (FSWs) have complex health needs yet there are barriers to them accessing care. Recent governmental changes and publications from the Department of Health mean GPs will soon be able to commission services in their area and will have a responsibility to the unregistered people in their locale. However there is a paucity of literature examining FSWs opinions on health care services.

Method:
Aim: To obtain FSWs’ opinions on current health care services provided, and establish their uptake of them. Also, to acquire their views on the design of future services through discussion of their health needs, with the aim to educate GP consortia.

Design: A qualitative study using semi-structured interviews

Sample: Fourteen migrant FSWs at Central London Action on Street Health (CLASH), a specialist NHS clinic for FSWs in Piccadilly, London.

Analysis: Thematic framework analysis

Results:
There is great heterogeneity amongst FSWs not only on their experiences as FSWs but in their opinions on their health and health care services. Five main themes were established: ‘What Health Needs We Have’, ‘What Health Care Services We Want’, ‘When And Where We Want It’, ‘Who We Want’ and ‘We Are Not All The Same’. These themes has allowed recommendations for GP commissioners to be formulated.

Conclusions:
FSWs aren’t a homogenous group and their health needs aren’t restricted to sexual health, meaning services should be tailored to FSWs in individual areas. FSWs use of services is influenced heavily by their work and due to low usage of General Practice, specialist services should be more equipped to manage them. This pilot study has helped identify initial needs and wants of this population in order to help GPs commission effective services in the future and cemented the importance of specialist clinics.

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Page last modified on 11 jan 12 12:55 by Rushmi Pelpola