Key findings of the national evaluation of Keep Well Wave 1. C O Donnell. On behalf of the National Evaluation Team, Universities of Glasgow & Edinburgh.
Delivering for Health. Current view Geared towards acute conditions Hospital centred Doctor dependent Episodic care Disjointed care Reactive care Patient as passive recipient Self care infrequent Carers undervalued Low tech Evolving model of care Geared towards long-term conditions Embedded in communities Team based Continuous care Integrated care Preventive care Patient as partner Self care encouraged and facilitated Carers supported as partners High tech
Focus on hard-toreach/hard-toengage. Targeting through practices and/or individuals. Main delivery mechanism general practice. Health checks. Referral on to appropriate services health and social.
Keep Well logic model.
Structure of the evaluation. Phase 1 (2007-10) Informed by Theory of Change Understanding the process of implementation of Keep Well Phase 2 (2009-10) Informed by Realistic Evaluation Deeper understanding of certain facets through use of case studies Patient and practice experiences (2009-10) Work Package 1: Tracking national and pilot theories of change. Work Package 2: Tracking the progress of Keep Well through secondary data. Practice level case studies to assess the impact of aspects of Keep Well (informed by Phase 1 findings) Collection of quantitative and qualitative data at practice level, and patient level including patients recruited via Keep Well practices and community-based venues.
Key stakeholder interviews. Interviews conducted annually in three rounds, from late 2007-2009. 74 interviews. National, local and general/family practice level. Strategic and operational personnel: Directors & civil servants in Scottish Government. Programme leads. Directors of Public Health. Pilot level managers. Staff involved in service delivery. Staff in participating general practices.
Aim of today s talk. To report on reach and engagement data across the Wave 1 pilots. To consider the impact of multiple contacts on patients. To consider the impact of different approaches to reach on patient engagement with Keep Well. To describe the baseline characteristics of patients attending a Keep Well health check. To consider the impact of context on Keep Well.
Reach of the Keep Well programme. Reach of KW was high across the 3 sites who provided data, but there was variation: Glasgow 97.5%. Dundee 76.2%. Lanarkshire 98.0%. Engagement (i.e. attendance at a health check) varied across sites: Glasgow 70.4%. Dundee 52.0%. Lanarkshire 54.8%. Attendance: Increased with age. Generally decreased with increasing deprivation.
Approach as a context. Glasgow: Covered 98% of target population, of whom 73% lived in the most deprived areas. 70% attended for a health check, with 78% of them living in the most deprived areas. Blanket approach Lanarkshire: Covered 98% of target population, 37% of whom lived in the most deprived areas. 55% attended for a health check, with 35% living in most deprived areas. Dundee: Covered 76% of target population, of whom 53% lived in the most deprived areas. 52% attended for a health check, with 53% of them living in most deprived areas. Pocket approach
Types Number Attendance by number and type of contacts. Same type Mixed type 2 3 4 5 Glasgow 1 contact 80.5 (%) 2 contacts 72.4 83.4 3 contacts 53.0 79.9 90.5 4+ contacts 31.3 66.0 61.4 42.2 60.0 Dundee 1 61.6 2 41.3 71.8 3 21.4 51.3 72.7 4+ 20.4 31.6 40.4 - -
Glasgow Dundee Odds ratio (95% CI) P-value Odds ratio (95% CI) P- value No. contacts Type contacts Adjusted of of 0.81 (0.79-0.82) 0.90 (0.87-0.94) <0.001 0.58 (0.55-0.60) <0.001 1.17 (1.07-1.29) <0.001 <0.001 No. of 0.71 contacts 1 (0.69-0.72) Type of 1.74 contacts 2 (1.64-1.85) <0.001 0.45 (0.43-0.48) <0.001 3.41 (3.02-3.84) <0.001 <0.001
Understanding engagement from practices perspective. No clear guidance on how to implement Keep Well. Often targeted patients on basis of target age range. Difficult to conceptualise who were hard-to-reach. Re-deployment of existing staff and increased work hours. Employment of new staff. Most common mechanism of delivery was practice nurse (9/25; 36%); external KW nurse (6/25; 24%); or health care assistant followed by practice nurse (4/25; 16%). Strategy tended to be open invitation letter, followed by telephone contact, then opportunistic contact. More targeted approaches started with telephone contacts.
Risk profile of patients. Glasgow (n=9213) Dundee (n=5423) Lanarkshire (n=8814) Aged 60+ 23.6 33.2 38.2 Family history IHD <60y 24.8 8.4 - Family history of diabetes 18.6 21.0 - Cholesterol >5.0mmol/l >6.0mmol/l HDL cholesterol <1.5 mmol/l <1.0 mmol/l SBP >140 mmhg >160 mmhg 64.5 28.4 75.3 21.4 67.2 28.9 56.0 10.2 56.6 23.3 27.4 31.1 34.7 3.8 4.3 10.2 Current smoker 40.9 30.1 27.5 Heavy smoker (20-39 7.7 5.4 9.0 cigs/day) BMI >25 kg/m 2 >30 kg/m 2 59.9 27.4 66.3 28.0 70.5 30.4 -
Ten year risk of CVD event. Glasgow (n=9213) Dundee (n=5423) Lanarkshire (n=8814) % CVD risk (Mean, (95% CI)) 14.1 (13.8-14.2) 13.6 (13.4-13.9) 14.8 (14.6-15.0) CVD risk 20% (Number (%)) 1975 (21.4) 1021 (20.7) 1839 (20.9)
Attendance across the socioeconomic spectrum. 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 5 Deprivation quintile Glasgow Dundee Lanarkshire
Ten year risk by deprivation quintile. 18% 16% 14% 12% 10% 8% 6% 4% 2% 0% 1 2 3 4 5 Deprivation quintile Glasgow Dundee Lanarkshire
Impact of deprivation on reach and engagement. Quartiles Range of practice population living in 15% most deprived datazone No. of practices Reach Rate ratio (95% CI) Engagement Rate ratio (95% CI) 1 2.75-28.97 7 1.00 1.00 2 31.16-68.15 9 1.14 (1.10-1.18) p<0.001 3 68.56-76.53 8 1.19 (1.15-1.23) p<0.001 4 76.60-91.39 7 0.89 (0.86-0.92) p<0.001 1.17 (1.13-.123) p<0.001 1.40 (1.34-1.45) p<0.001 1.06 (1.02-1.11) p=0.005
Lessons learned. Availability of data. Delays in provision of data. Access to patient-level data. For practices shifting goalposts. Ethics and research governance. Delays. Different requirements in each area. Context. Context is all important. Depth and concentration of deprivation. Practice context. Shared understandings of key concepts.
My colleagues. Mhairi Mackenzie, Maggie Reid, Urban Studies, University of Glasgow. Fiona Turner, Yinging Wang, Julia Clark. General Practice & Primary Care, University of Glasgow. Sanjeev Sridharan, University of Toronto. Steve Platt, University of Edinburgh.