Jonathan Banks

Objectives Malignant upper urinary tract obstruction (MUUTO) is caused by advanced cancer. Developing MUUTO is often associated with approaching the end of life. Percutaneous nephrostomy (PCN) and retrograde ureteric stent insertion (RUS) are common interventions to treat patients with MUUTO, although neither intervention is likely to extend overall survival significantly. Little is known about patient, carer and healthcare professional (HCP) views of the MUUTO management pathway, the benefits and harms of the procedure and the treatment decision-making process. This study investigated the experiences, decision-making and priorities of patients admitted to hospital for MUUTO, and their carers, along with HCPs involved in providing care for this patient group. Design Qualitative, using semi-structured interviews. Setting This study was conducted across two NHS trusts in England. Participants 12 patients, 8 carers and 14 HCPs were interviewed. Patients were interviewed in hospital during their admission and, where possible, follow-up interviews took place 2–3 weeks later at their homes. In total, 18 patient interviews were conducted. Interviews were analysed thematically by cohort and systematically cross-referenced for areas of congruence and divergence of priorities and views. Ethical approval was obtained before study commencement. Results Most patients were admitted as emergencies and received PCNs to relieve severe pain and distress. Patients reported having little choice in the decision-making around intervention due to their symptoms and frequently described the PCN procedure as being painful. HCPs considered the availability of further cancer treatment options a rationale to support intervening for MUUTO. However, HCPs reported decision-making was often complicated by unclear prognosis and the need to address the emergency nature of patient circumstances. A lack of compassionate communication, disrespect and indignity, traumatic hospital admission and premature discharge, in addition to practical administrative difficulties caused patient and carer distress. Conclusions Emergency admissions for MUUTO are associated with significant patient and carer distress and are complex for HCPs to manage. MUUTO patients would benefit from a specific pathway to avoid emergency admissions and to facilitate timely advance care planning discussions so that patients’ wishes and HCP views can be shared and incorporated into decision-making about the appropriateness and value of PCN and RUS interventions.

Objectives: Identify and explore risk factors associated with COVID-19 infection and mortality rates in care homes in the West of England and gain an understanding of challenges faced during the pandemic, how they were addressed and how care homes can be better equipped for future pandemics. Methods: A mixed-methods study combined observational analysis of numbers of infections and deaths with potential risk factors supported by semi-structured interviews. Thirty-three care homes within a single local authority (LA) in the West of England were included in the quantitative analysis and, in the qualitative study, five care homes were included, including those located outside the participating LA. The quantitative analysis assessed two outcomes: number of weekly COVID-19 cases and deaths between 31/08/2020 and 21/02/2021. Associations with potential care risk factors were analysed using Poisson regression. 14 interviews were conducted with care home staff in various roles between November 2022 and September 2023. Data were analysed thematically. Results: Care home size was associated with higher COVID-19 infection (large compared with small care homes: incidence rate ratio (IRR) = 12.60, 95% confidence interval (CI) 2.54 to 62.51) and mortality rates (large compared with small care homes: IRR = 16.48, 95% CI 0.81 to 335.88). Qualitative data revealed that care home managers recognized these risks and were focussed on the challenges of implementing infection control within the limitations of their buildings. The primary challenge identified was staff shortages, requiring care home staff to assume expanded responsibilities. There was no evidence of association between hospital discharges and COVID-19 cases (IRR = 0.45, 95% CI 0.11 to 1.83) or deaths (IRR = 0.61, 0.11 to 3.22). The qualitative data highlighted care home staff had feelings of separation and felt under-valued in relation to the wider health care sector. There was also concern that COVID-19 prevention measures prioritised infection control over the psycho-social welfare of residents. Conclusion: Research on the risk factors for infection spread and associated mortality should be prioritised to better protect care homes in future pandemics. This requires making routine data in social care more readily available for research purposes. Proactive planning for future pandemics, by care homes and local authorities, should recognise the individual nature of buildings and the needs of residents.

Context: Patient‐reported experience measures (PREMs) provide important insights into the challenges experienced when living with a chronic condition. Although patient‐reported outcome measures (PROMs) exist in audiology, there are no validated PREMs to help clinicians understand patient perspectives and identify areas where patients may need additional support or interventions.Objective: The aim of this study was to develop and evaluate content for the new ‘My Hearing PREM’, which captures lived experiences of hearing loss from patients’ perspectives.Design: My Hearing PREM was developed and tested in two key phases. Phase 1 involved generating the PREM prototype in accordance with our conceptual model of the lived experience of hearing loss. In Phase 2, cognitive interviews were conducted with adults with hearing loss to appraise the content of the PREM (relevance, clarity, acceptability and comprehensiveness) and assess its respondent burden. Key stakeholders (e.g., adults with hearing loss, patient and public representatives, clinicians and researchers) were consulted throughout Phases 1 and 2 to review and refine the PREM. Interview data were analysed using thematic analysis.Setting and Participants: Sixteen participants (aged 16 years and over) with hearing loss took part in cognitive interviews, recruited from UK audiology departments and non‐clinical settings (e.g., lip‐reading classes, national charity links and social media).Results: Most PREM items were found to be relevant, clear, acceptable and comprehensive. Several problems were identified, including items not working well with the response scale options, irrelevant questions and a lack of clarity about terms (e.g., healthcare professionals) and whether questions should be answered based on the use of hearing aids (or not). The PREM was amended accordingly.Conclusions: Currently, no hearing loss‐specific PREMs exist in audiology. Involving multiple stakeholders in the development of the PREM helped to ensure that the items were relevant, clear, acceptable and comprehensive. The PREM is undergoing further evaluation and refinement in preparation for investigating the feasibility of implementing it into clinical practice.Patient or Public Contribution: Ongoing Patient and Public Involvement and Engagement (PPIE) with key groups (South Asian Women's groups, young people's groups, learning disability networks and student populations) was integral to the study. PPIE members reviewed patient information sheets and consent forms, advised on recruitment, reviewed the interview schedule and checked coding and analysis procedures. PPIE members provided feedback on the PREM's comprehensibility. Members of the public, including adults attending lip‐reading classes and hearing aid users from the South Asian community, provided feedback on iterative PREM drafts.

Background: Deep vein thrombosis (DVT), a formation of blood clots within deep veins, mostly of the proximal lower limb, has an annual incidence of 1–2 per 1000. Patients who are affected by multiple chronic health conditions and who experience limited mobility are at high risk of developing DVT. Traditional DVT diagnosis involves probabilistic assessment in primary care, followed by specialised ultrasound scans (USS), mainly conducted in hospitals. The emergence of point-of-care ultrasound (POCUS), coupled with artificial intelligence (AI) applications, has the potential to expand primary care diagnostic capabilities. Aim: To assess the accuracy and acceptability of AI-guided POCUS for DVT diagnosis when performed by non-specialists in primary care. Design & setting: Diagnostic cross-sectional study coupled with a qualitative evaluation conducted at primary care DVT clinics. Method: First, a diagnostic test accuracy (DTA) study will investigate the accuracy of AI-guided POCUS in 500 individuals with suspected DVT, performed by healthcare assistants (HCAs). The reference standard is the standard of care of USS conducted by sonographers. Second, after receiving both scans, participants will be invited to complete a patient satisfaction survey (PSS). Finally, semi-structured interviews with 20 participants and four HCAs, and three sonographers will explore the acceptability of AI-guided POCUS DVT diagnosis. Conclusion: This study will rigorously evaluate the accuracy and acceptability of AI-guided POCUS DVT diagnosis conducted by non-specialists in primary care.

Background: Housing is an important wider determinant of health. Private Rented Sector (PRS) housing is generally the worst quality of housing stock across tenures. Although a wide range of interventions are available to local governments to manage and improve the quality of PRS housing and therefore the health of tenants, there is limited evidence about the extent to which these are used. This study aims to explore what drives the use of different interventions in different local governments, to better understand and inform local strategies. Methods: As the first realist evaluation on this topic, the range of available interventions was informed by a Local Government Association toolkit. Consistent with realist approaches, retroductive analysis of intervention-context-mechanism-outcome configurations helped to develop and refine Initial Programme Theories (IPTs). Data sources included local government housing documents, a survey and eleven semi-structured interviews with housing officers. Results: Using data for 22 out of the 30 local governments in the South West region of the United Kingdom, eight IPTs were developed which act on different levels from individual PRS team leaders to system wide. The IPTs include a belief in market forces, risk adverse to legal challenge, attitude to enforcement, relational approaches to partnership working, job security and renumeration, financial incentives drive action, and system-level understanding of the drivers of poor health, inequalities and opportunities for cost-savings. The findings suggest that limited objective health outcomes are being used to understand impact, which hinders interpretation of the effectiveness of all mechanisms. Conclusion: Interventions that bring about positive outcomes in managing PRS housing are unlikely to be universal; they depend on the context which differs across place and over time. The proposed IPTs highlight the need for strategies to be tailored considering the local context and should be evaluated in subsequent phases of study.

Background: Shingles (herpes zoster), caused by reactivation of the varicella-zoster virus, is usually diagnosed and managed in primary care. The lifetime risk of shingles in the general population is approximately 30%, and it can have a detrimental effect on quality of life. There has been little qualitative research about patient experience and understanding of shingles. Aim: To explore patient experiences and understanding of shingles. Design and setting: Qualitative interviews with people with shingles recruited from primary care in England. Method: Qualitative semi-structured remote interviews were undertaken with 29 participants in a randomised controlled trial in primary care in England (ATHENA, ISRCTN14490832 ). Participants were aged >49 years and were diagnosed within 6 days of shingles rash onset. Interviewees were sampled for diversity in terms of pain, intervention adherence, age, gender, and ethnicity. Data were analysed using reflexive thematic analysis. Results: Interviews took place in November 2022 to April 2023. Participants’ understanding of shingles was limited, particularly pre-diagnosis. A common theme was that ‘everyone has heard of it, but no one knows what it is’. Television campaigns about the shingles vaccination programme helped some to recognise the rash. Shingles was understood as a disease with a variable prognosis, resulting in a sense of uncertainty about the significance when diagnosed. Participants reported a range of symptoms, which impacted on everyday life. Some people thought their diagnosis was caused by poor mental health or challenging life circumstances, a perception sometimes reinforced by healthcare professionals. Many participants sought meaning in their diagnosis, reflecting on, and sometimes changing, their life and circumstances. Conclusion: Primary care practitioners should be aware of the broad spectrum of patient knowledge, and the potential for better understanding to promote early attendance and treatment to reduce the impact of shingles.

Introduction Traumatic pneumothoraces are present in one of five victims of severe trauma. Current guidelines advise chest drain insertion for most traumatic pneumothoraces, although very small pneumothoraces can be managed with observation at the treating clinician’s discretion. There remains a large proportion of patients in whom there is clinical uncertainty as to whether an immediate chest drain is required, with no robust evidence to inform practice. Chest drains carry a high risk of complications such as bleeding and infection. The default to invasive treatment may be causing potentially avoidable pain, distress and complications. We are evaluating the clinical and cost-effectiveness of an initial conservative approach to the management of patients with traumatic pneumothoraces. Methods and analysis The CoMiTED (Conservative Management in Traumatic Pneumothoraces in the Emergency Department) trial is a multicentre, pragmatic parallel group, individually randomised controlled non-inferiority trial to establish whether initial conservative management of significant traumatic pneumothoraces is non-inferior to invasive management in terms of subsequent emergency pleural interventions, complications, pain, breathlessness and quality of life. We aim to recruit 750 patients from at least 40 UK National Health Service hospitals. Patients allocated to the control (invasive management) group will have a chest drain inserted in the emergency department. For those in the intervention (initial conservative management) group, the treating clinician will be advised to manage the participant without chest drain insertion and undertake observation. The primary outcome is a binary measure of the need for one or more subsequent emergency pleural interventions within 30 days of randomisation. Secondary outcomes include complications, cost-effectiveness, patient-reported quality of life and patient and clinician views of the two treatment options; participants are followed up for 6 months. Ethics and dissemination This trial received approval from the Wales Research Ethics Committee 4 (reference: 22/WA/0118) and the Health Research Authority. Results will be submitted for publication in a peer-reviewed journal. Trial registration number ISRCTN35574247.

Background: Herpes zoster (shingles) is normally diagnosed clinically. Timely diagnosis is important so that antiviral treatment can be started soon after rash onset.Aim: To assess whether a practice-level educational intervention, aimed at non-clinical patient-facing staff, improves the timely assessment of patients with shingles.Design and setting: This was a cluster randomised study within a trial (SWAT) with nested qualitative study in general practices in England.Method: Practices were cluster randomised 1:1, stratified by centre and minimised by practice list size and Index of Multiple Deprivation score. Intervention practices were sent educational materials, highlighting the common presenting features of shingles and what action to take if suspected. The primary and secondary outcomes were the mean proportion of patients per practice seen within 72 and 144 h of rash onset, respectively. Comparison between groups was conducted using linear regression, adjusting for randomisation variables. Semi-structured interviews with practice staff in intervention practices explored views and opinions about the intervention.Results: In total, 67 practices were enrolled; 34 randomised to the intervention and 33 to the control. The mean difference in proportion of patients seen within 72 and 144 h was −0.132 (95% confidence interval [CI] = −0.308 to 0.043) and −0.039 (95% CI = −0.158 to 0.080), respectively. In intervention practices, 90.9% reported distributing the educational materials; however, engagement with these was suboptimal. Twelve participants were interviewed, and the poster component of the intervention was said to be easiest to implement.Conclusion: Our educational intervention did not improve the timely assessment of patients with shingles. This may be the result of poor intervention engagement.

Coeliac disease (CD) is a common autoimmune condition that affects approximately 1% of the population worldwide.¹ However, it is estimated that two thirds of patients with CD in the UK remain undiagnosed.² CD can present at any age with a wide range of symptoms and signs, making recognition challenging.³ Traditionally, the diagnosis of CD requires serological testing followed by endoscopic biopsy while consuming a gluten-containing diet, as outlined in guidelines produced by the British Society of Gastroenterology (BSG) in 2014 and the National Institute for Health and Care Excellence (NICE) in 2015.^4,5 There is variability in adherence to these guidelines in practice and clinical pathways are evolving.⁶

Introduction Hearing loss is a common chronic health condition and adversely affects communication and social function resulting in loneliness, social isolation and depression. We know little about the patient experience of living with hearing loss and their views on the quality of the audiology service. In this study, we will develop and validate the first patient-reported experience measure (PREM) to understand patients’ experiences of living with hearing loss and their healthcare interactions with audiology services. Methods and analysis We will develop the PREM in three phases: (1) development of PREM prototype (items/statements) derived from previous qualitative work and narrative review, (2) cognitive interview testing of the PREM prototype using a ‘think aloud’ technique to examine the acceptability and comprehensibility of the tool and refine accordingly and (3) psychometric testing of the modified PREM with 300 participants to assess the reliability and validity of the tool using Rasch analyses with sequential item reduction. Eligible participants will be young people and adults aged 16 years and over who have hearing loss. Participants will be recruited from three clinical sites located in England (Bath, Bristol) and Scotland (Tayside) and non-clinical settings (eg, lip-reading classes, residential care settings, national charity links, social media). Ethics and dissemination The study was approved by the West of Scotland Research Ethics Service (approval date: 6 May 2022; ref: 22/WS/0057) and the Health Research Authority and Health and Care Research Wales (HCRW) Approval (approval date: 14 June 2022; IRAS project ID: 308816). Findings will be shared with our patient and public involvement groups, academics, audiology communities and services and local commissioners via publications and presentations. The PREM will be made available to clinicians and researchers without charge.