NIHR CLAHRC e-newsletter Technologies edition www.clahrcpp.co.uk

Technologies Edition

Welcome to the community e-newsletter for the National Institute for Health Research (NIHR) Collaborations for Leadership in Applied Health Research and Care (CLAHRCs) bringing you the latest news and interesting developments from across the thirteen collaborations and the health service research community. The NIHR CLAHRCs are funded by the NIHR and form part of the NIHR infrastructure. This newsletter looks at the work NIHR CLAHRCs are doing on technologies.

Find out more about the CLAHRC Partnership Programme at www.clahrcpp.co.uk.

Helping patients at risk of developing type 2 diabetes
NIHR CLAHRC Greater Manchester is working with Hitachi, Salford Royal NHS Foundation Trust, NHS Salford Clinical Commissioning Group and NorthWest EHealth to prevent type 2 diabetes. The Comparison of Active Treatments for Impaired Glucose Regulation (CATFISH) trial will compare an enhanced technology-enabled lifestyle intervention service against an existing telephone-based service to establish the acceptability, effectiveness and efficiency of the enhanced service. Read more.

Telehealth for depression & self-harm and health anxiety
A number of NIHR CLAHRC East Midlands projects are exploring the area of telehealth, which involves the remote exchange of data between a patient at home and their clinician to assist in diagnosis, monitoring and symptom reduction, typically for Long Term Conditions.Within their Enhancing Mental Health (EMH) Theme an  E-Dash study is investigating whether a problem solving-based Cognitive Behavioural Therapy (CBT) – a type of talking therapy – can help adolescents and young adults with depression who have self-harmed. The aim is to find ways to get those aged 16-30 involved in, and to stay with, talking therapy delivered remotely via video calling. Also within the EMH Theme, the Health Anxiety study is seeking to understand the needs of unscheduled care users, and to find out whether CBT over the phone, or via video calling, will improve their physical and emotional health. Both projects are finding out if talking therapy given remotely is clinically and cost effective compared to usual care.NIHR CLAHRC East Midlands is working with clinicians, commissioners and service users to determine the barriers and facilitators to implementing this approach in practice.  If it is clinically and cost effective, it will be rolled out across the East Midlands, which will improve health outcomes, quality of life and reduce use of NHS resources.

Using video calls to reduce loneliness and the impact of dementia
A team from Plymouth University supported by NIHR CLAHRC South West Peninsula  is exploring the potential of using video call technology such as Skype to prevent loneliness and reduce the impact or risk of dementia. For more information visit NIHR CLAHRC South West Peninsula’s website

E-solution helps match patients with back pain to appropriate care pathways
Over 70% of the population will experience a significant episode of back pain at some point during their life. Back pain is the most common reason middle-aged people visit their GP and is the second most common reason for sickness absence from work. A review of current practice suggests that a significant majority of back pain patients are over-treated in the NHS; while a significant number go on to suffer long-term pain and disability.  Researchers from Keele University, partners in the NIHR CLAHRC West Midlands leading the chronic disease programme, have developed the STarT Back tool, whereby patients are screened for risk of chronicity and matched pathways are put in place to target the right treatment to the right patient. STarT Back has been shown to be clinically and cost effective – reducing over-treatment of low-risk groups, by ensuring their management is maintained in primary care, with more effective matched and targeted treatment for medium- and high-risk groups provided by physiotherapists in community and secondary care settings. A linked study demonstrated that the application of the STarT Back approach provided a 40% reduction in referral of low-risk groups, while medium- and high-risk groups gained earlier access to therapy, with improved outcomes and significant reduction in time lost from work.

As part of NIHR CLAHRC West Midlands  programme to support the NHS to take research into practice NIHR CLAHRC West Midlands  colleagues from Keele University, with West Midlands  Academic Heath Science Network (AHSN) funding in 2014, identified the barriers to implementing this approach in practice and have supported an extensive programme of training and pathway development . In addition, Keele have worked with industry partners (EMIS and www.patient.co.uk) to integrate the STarT Back tool into the GP clinical system (EMIS) allowing automated completion of the tool and access to high quality patient information and auto-referral to appropriate matched treatments.  Piloted with five practices in North Staffordshire CCG in 2014, this system will be rolled out across the West Midlands as part of the ongoing implementation activities supported by the West Midlands AHSN during 2015. For more information  visit NIHR CLAHRC West Midland’s  website..

WISH for better healthcare
The Web Improvement Support for Healthcare (WISH) is NIHR CLAHRC North West London’s online software giving informatics support for improvement projects.

WISH can be accessed by all NIHRC CLARCH North West London members and gives a structured way to integrate numerical measurement, descriptions, and observations about change. It provides automated analysis of customised measure and annotations to all users wherever they can access the internet. It also allows all members of an improvement project to freely access, contribute to, and analyse data for that initiative; as a result everyone can see what effect the initiatives are having on healthcare provision. This structured way to handle data about change gives information that project teams can use to take actions to benefit patient care. WISH provides a valuable resource to communicate success to patients, peers, the press, and publication, as it houses projects’ evidence of changes.

NIHR CLAHRC North West London developed WISH in collaboration with Imperial College London Departments of Medicine and Computing, building on feedback from users. It was designed to be used by members of the NIHR CLAHRC North West London improvement projects, and it now has over 700 users.  More information about the technical development and purposes of WISH has been published here

Maternal Obesity Management Using Mobile Technology (MOMTech)
Maternal obesity and excessive gestational weight gain (GWG) is on the rise with a negative impact on pregnancy outcomes and significant demands on NHS resources. Research into managing GWG using accessible technology is limited. The MOMTech project was designed to develop a text messaging based complex intervention to support obese women (BMI≥30) to develop healthier lifestyles and limit GWG, and evaluate its feasibility. An interdisciplinary team of researchers in collaboration with Doncaster and Bassetlaw Hospitals NHS Foundation Trust (DBNHSTF) staff and maternity user representatives developed prototype resources including consultation templates, diaries, text messages and the platform to send the messages. In the feasibility study, participants received two daily text messages, supported by four appointments with a healthy lifestyle midwife, diet and activity goal setting, and self-monitoring diaries. The comparison group were obese mothers who declined to participate but consented for their routinely collected data to be used for comparison. Postnatal interviews and focus groups with participants and the comparison group explored the intervention’s acceptability and suggested improvements.

This small feasibility study on 14 women showed a reduction in mean GWG in the intervention group compared to the comparison group (6.65 kg versus 9.74 kg) and few (28% versus 50%) exceeded the Institute of Medicine’s upper limit of 9 kg GWG for obese women.  Qualitative results also showed women’s satisfaction with such supporting services to enhance continuity of care and support between antenatal appointments. This suggested that MOMTech was feasible within clinical setting and acceptable to support women in limiting GWG.  More information is here.

Computerised test for ADHD
The NIHR CLAHRC East Midland’s AQUA-Trial is investigating whether an objective test of activity and attention (called QbTest) leads to an earlier correct diagnosis of Attention Deficit/Hyperactivity Disorder (ADHD). The study will also determine whether the QbTest leads to better treatment and improved patient outcomes for ADHD, as well as its clinical and cost effectiveness in the NHS.

ADHD is a neuro-developmental disorder that affects 3-5 in 100 children. In the last 30 years the number of children recognised and treated for ADHD in the UK increased almost 10 fold. However, clinical methods for assessing and treating ADHD have hardly changed over the past 30 years. Current best practice relies on lengthy clinical interviews and observations or questionnaires. However, in real-world NHS practice it is generally not possible to provide this to all referrals with the result that patients often have to wait a long time until an ADHD diagnosis is confirmed.

QbTest uses a computerised measure of attention and impulsivity with a motion tracking system that records the amount of movement the patient makes when performing the task. Objective measures of activity and attention have the potential to shorten assessment time, increase diagnostic accuracy, reduce delays in treatment, and improve treatment response. Read more.

NIHR CLAHRC West collaboration with SPHERE to develop health monitoring sensors
A new collaboration between NIHR CLAHRC West and the SPHERE Interdisciplinary Research Collaboration (IRC) will help SPHERE’s platform of health sensors meet user requirements.

SPHERE is developing a platform of sensors to monitor the health and wellbeing of people at home, while also enabling clinical care. SPHERE is an early warning system to detect and prevent long-term medical conditions including obesity, depression, stroke, falls, cardiovascular and musculoskeletal diseases. The collaboration between SPHERE and NIHR CLAHRC West will give even more emphasis to the requirements of patients and healthcare professionals.

Working between NIHR CLAHRC West and SPHERE, Dr Patrick Kierkegaard is developing mixed-methods studies focusing on user requirements, implementation and evaluation of SPHERE technology.  These include what healthcare professionals and members of the public want from in-home technology and how best to implement it in clinical care. The work will include collaboration with stakeholders across the region and will form the basis of new work into translation.
The SPHERE-IRC project is led by the University of Bristol together with the Universities of Southampton and Reading, and is supported by the Engineering and Physical Sciences Research Council (EPSRC). For more information visit SPHERE’S website.

Group-based self-management for COPD
People with chronic obstructive pulmonary disease (COPD) face many challenges with managing the symptoms of their condition. New skills such as how to exercise and how to manage their stress and breathing are important to learn. SPACE for COPD is a manual which aims to teach people these skills, and provides them with information about their condition and how best to manage it. NIHR CLAHRC East Midlands SPACE for COPD study is looking to investigate the short and long term effects of delivering this manual over a period of 6 months in a group-based, community setting. During assessments participant demographics and healthcare utilisation are recorded, and questionnaires are completed. In addition patients are asked to wear an activity monitor for 7 days at each assessment point. There is also a web-based version of the manual available which is being studied as a separate research project. The aim of this project is to increase the provision of Pulmonary Rehabilitation (PR) while also offering an alternative and novel approach to delivering this service. Furthermore, an additional study, interSPACE, is looking to provide a tablet preloaded with the SPACE for COPD content to patients upon their discharge post hospitalisation for an exacerbation of their disease. For more information visit the SPACE for COPD  website

App to support recovery in Early Intervention Services (the ARIES study)
Despite improved outcomes associated with Early Intervention Services (EIS) many young people do not attain functional recovery after first episode psychosis (FEP) and relapse rates remain high. Smartphone apps may be particularly suited to deliver time-unlimited, just-in-time, interactive support to EIS service users. A NIHR CLAHRC North Thames project involving researchers and clinicians across UCL and Surrey and Borders NHS Foundation trust is further developing and testing the My Journey EIIP app as a supported self-management intervention for EIS.  In consultation with EIS service users, clinicians, and carers, NIHR CLAHRC North Thames is adding interactive, individualised recovery and relapse prevention planning tools to My Journey. A small sample of service users will test a prototype first in the lab and then in their everyday lives. Their feedback will inform the final version of the app. The app will be tested in a pilot randomised controlled trial to evaluate whether the intervention and trial methods are feasible. Longer term,  a larger trial will be initiated to test its impact on recovery and relapse rates, and  widespread implementation in EISs will be supported by NIHR CLAHRC  North Thames.

The Intelligent Shoe
In 2010 the SMART consortium gained funding from the NIHR CLAHRC Yorkshire and Humber to continue an extensive programme of research to develop and evaluate an Information Communication Technologies (ICT) enhanced Personalised Self-Management System with a specific focus on stroke rehabilitation. One of the key components of this work is an ‘intelligent shoe’ comprising a multi-sensored insole placed into the user’s shoes to measure and record an individual’s walking speed, distance, steps, symmetry and time spent walking with specifically adapted feedback screens for a mobile phone or tablet to motivate stroke survivors to self-manage their rehabilitation. NIHR CLAHRC Yorkshire and Humber developed a collaborative agreement and non-disclosure document with a SME called Kinematix with whom the SMART consortium had worked on the development of the new prototype for stroke survivors. This programme of research also includes exploring how the Intelligent Shoe can be used in other areas of rehabilitation including Muskuloskeletal and Paediatric populations as well as working with in partnership with Dr Chris McDermott at SiTraN to develop a hybrid prototype for Peripheral Neuropathy.

Smartphones to be used in arthritis study
Arthritis Research UK and the NIHR CLAHRC Greater Manchester will be working with the rheumatology department at Salford Royal NHS Foundation Trust to improve care for rheumatoid arthritis (RA) patients – by collecting patient data in between visits so that patients can view and discuss the data with the clinician at their next appointment.  The study will design, implement and evaluate a system for remote data collection from patients, with the key outcome of the project being the information to inform investment in a sustainable system for remote monitoring, integrated into both clinical and research systems, to improve care for patients. The project is novel because it will collect regular information from patients with RA between clinic visits using smartphones, and will securely transfer this patient data into a hospital electronic patient record and a research database. The new system will be evaluated with a view to wider roll-out. Read more.

NIHR CLAHRC North West London Quality Improvement eLearning modules:
Funded by Health Education Northwest London and in collaboration with an industry partner (OCB Media), NIHR CLAHRC North West London is developing a significant eLearning package with a novel blended learning approach that will support training in Quality Improvement. The ten modules will be eligible for CPD points and will be available from summer 2015, to all NHS staff through the national eLearning platform.

Planned modules include Action Effect Method, Patient and Public Engagement and Involvement, Long term success, Measurement for Improvement, Stakeholder Engagement, Plan-Do-Study-Act cycles, Process Mapping and Mental and Physical Wellbeing.

The NIHR CLAHRC North West London team will offer support, host webinars and provide access to our collaborative learning events for learners to take full advantage of the blended learning. Learners will also be able to take their learning further by completing the MSc. in Improvement Science at the University of West London.

For the eLearning modules, a modified Fitzpatrick model will be used to capture confidence, experience and knowledge in using Quality Improvement methods and assess the use of blended learning approaches to QI. This evaluation will also measure impact of the eLearning package in capacity building within health services. We will also measure learners’ experience in using this fresh approach to QI learning. For more Information, registration links and updates on the modules visit  NIHR CLAHRC North West London’s  website.

Enhanced Community Palliative Support Services
Most people would prefer to die at home but a lack of community-based palliative care resources often results in individuals being transferred to hospital when their symptoms become difficult to manage. In Canada a new approach is being used to deliver specialist care in the homes of palliative patients. Trained care assistants observe and report signs and symptoms, and use innovative technology to collect patient data and to communicate with specialist palliative nurses, providing them with information the nurse would normally collect during a visit, and delivering the care plan developed and managed by the nurse. The nurse monitors and delegates appropriate interventions in real time to the care assistant or to a district nurse where appropriate. This approach leverages the skills of the palliative specialist enabling them to care for four patients simultaneously when traditionally they could only care for one.  Initially funded by an award of £250,000 from the NHS England Nursing Technology Fund, NIHR CLAHRC Yorkshire and Humber will test this approach in a number of community settings within the Yorkshire and Humber region. For further information visit the NIHR CLAHRC Yorkshire and Humber website.

Working with opticians to detect diabetic neuropathy earlier
The NIHR CLAHRC Greater Manchester, working with industry partners Heidelberg Engineering, is giving optometrists practical experience of performing the corneal confocal microscopy (CCM) procedure, a new, quick, non-invasive eye test which can detect diabetic neuropathy in limbs in its earliest stages.

Around 1 in 5 diabetic patients develop diabetic neuropathy (the most common complication in diabetes that results in damage to the nerves in the limbs, particularly the feet and legs) and it can lead to numbness, pain, loss of sensation, foot ulceration and, potentially, amputation. Early identification of neuropathy enables earlier treatment to control progression of this serious condition.

In April 2015, the project started recruiting patients in optometry practices in Urmston, Harpurhey and Moss Side, with a fourth practice in Irlam beginning recruitment in June. Many patients that access these practices for their diabetic screening appointment are taking part in this study, giving patients a longer appointment time with their optometrist and a chance to input their views on this potential new national diabetes assessment method. Recruitment is due to end in September 2015 with 400-500 patients involved in the study. Results will be available by the end of 2015. Read more.

Text service designed for youngsters who self-harm
A team from NIHR CLAHRC South West Peninsula has explored the potential of text messaging as a way to deter children and young adults from repeat self-harming. TeenTEXT built on previous research which showed that regular contact with those at risk of self-harm reduces repetition. The previous research considered ‘traditional’ means of communication such as letters, postcards and phone calls: TeenTEXT explored the potential of a newer means of communication more popular with the target age group. The project designed and secured funding for a randomised control trial to determine the effectiveness and benefit to children and young adults who self-harm.  For more information visit NIHR CLAHRC South West Peninsula’s  website.

The Geography of Health
As part of NIHR CLAHRC North West London’s ongoing commitment to apply quality improvement learning to healthcare services it has been incorporating geographical analysis into its remit. This has come in the form of Geographical Information Systems (GIS) that allows project teams to visualise and analyse the spatial and spatiotemporal trends of their data.

The maps produced from a GIS offer an additional method in the way data measures can be visualised; demonstrating the location of services or patients, staff or patient flow through a hospital and the geographic spread of service need over time. This type of analysis is slowly becoming more commonplace in frontline service improvement, but it is by supplying these visualisations together with more traditional methods that we can see the full picture. An example of such a tool is an online dashboard produced by Public Health England, which demonstrates an easy to use tool that allows the user to delve into multiple data subjects and varying visualisation techniques.

NIHR CLAHRC North West London has also been undertaking research into improving the effectiveness of GIS communication. Through the combined application of well-known and well used techniques already used in other fields of geographical analysis we have devised a method that is aimed at identifying areas of high need for patients in areas of varied population density. More information is here.

Development of technology to assess dementia
NeuroCore is a team carrying out a number of research studies using apps and other new technologies for the assessment of dementia and other neuro-degenerative conditions. One such project is ACEmobile, supported by NIHR CLAHRC South West Peninsula, is the first of its kind; an iPad-based tool that supports the assessment of dementia. The tool provides support through the whole process, meaning more members of the clinical team can feel confident carrying out this type of assessment. Designed by clinicians for clinicians, ACEmobile also collects secure and anonymised data to allow the team to improve our understanding of dementia and ability to detect it earlier. ACEmobile is currently an iPad-based tool that guides the user through the Addenbrooke’s Cognitive Examination (ACE-III). ACE-III is one of the most popular and commonly-used paper and pencil screening tools for dementia. The app removes the need for clinicians to learn the ACE-III manual and it also automatically calculates patients’ scores and creates a report to go into their medical records.  The creators have designed the app to make dementia assessment easier and more reliable for NHS staff and health professionals around the world. For more information visit NIHR South West Peninsula’s website

Prescribing systems could save hospitals money
Mistakes can be made in the prescribing and dispensing of medications in hospital. One solution to prevent many of these errors is an electronic prescribing system. This system computerises the process so that prescriptions are entered onto a computer, which transmits them to the pharmacy, which then prompts nurses when certain drugs should be given. Warnings also pop up to remind clinical staff if there is an opportunity for patient harm to arise. Electronic prescribing systems are expensive, however. The question NIHR CLAHRC West Midlands researchers are tackling is whether an electronic prescribing system is good value for money.

When patient experiences harm from a medication error, which may be anything from an allergic rash to a life-threatening complication, they suffer a loss of health and their period in hospital is extended. So preventing errors reduces both excess costs and improves patient health. To measure the benefits, NIH CLAHRC West Midlands Research Methods Theme (6) has therefore collected information on excess length of stay and patient harms and, using information on the effectiveness of electronic prescribing systems, estimated the resulting benefits. Health gains can be converted into a monetary value using the cost-effectiveness threshold the NHS specifies that all new technologies must meet.

Preliminary results suggest that the gains from an electronic prescribing system are greater than the costs of implementing it. So these systems may actually save hospitals money despite their high costs. For more information visit NIHR CLAHRC West Midlands

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