A qualitative study of patient choices in using emergency health care for long-term conditions: The importance of candidacy and recursivity

Objective

We aimed to explore how patients with long-term conditions choose between available healthcare options during a health crisis.

Methods

Patients in North-West England with one or more of four long-term conditions were invited to take part in a questionnaire cohort study of healthcare use. Semi-structured interviews were conducted with a sub-sample of fifty consenting patients. Data were analysed qualitatively, using a framework approach.

Results

Patients described using emergency care only in response to perceived urgent need. Their judgements about urgency of need, and their choices about what services to use were guided by previous experiences of care, particularly how accessible services were and the perceived expertise of practitioners.

Conclusion

Recursivity and candidacy provide a framework for understanding patient decision-making around emergency care use. Patients were knowledgeable and discriminating users of services, drawing on experiential knowledge of healthcare to choose between services. Their sense of ‘candidacy’ for specific emergency care services, was recursively shaped by previous experiences.

Practice implications

Strategies that emphasise the need to educate patients about healthcare services use alone are unlikely to change care-seeking behaviour. Practitioners need to modify care experiences that recursively shape patients’ judgements of candidacy and their perceptions of accessible expertise in alternative services.     

Speech perception scores in cochlear implant recipients: An analysis of ceiling effects in the CUNY sentence test (Quiet) in post-lingually deafened cochlear implant recipients

Objectives: To evaluate the clinical utility of the City University of New York sentence test in a cohort of post-lingually deafened cochlear implants recipients over time.

Methods: 117 post-lingually deafened, Australian English-speaking CI recipients aged between 23 and 98 years (M?=?66 years; SD?=?15.09) were recruited. CUNY sentence test scores in quiet were collated and analysed at two cut-offs, 95% and 100%, as ceiling scores.

Results: CUNY sentence scores ranged from 4% to 100% (M?=?86.75; SD?=?20.65), with 38.8% of participants scoring 95% and 16.5% of participants reaching the 100% scores. The percentage of participants reaching the 95% and 100% ceiling scores increased over time (6 and 12 months post-implantation).

The distribution of all post-operative CUNY test scores skewed to the right with 82% of test scores reaching above 90%.

Discussion: This study demonstrates that the CUNY test cannot be used as a valid tool to measure the speech perception skills of post-lingually deafened CI recipients over time. This may be overcome by using adaptive test protocols or linguistically, cognitively or contextually demanding test materials.

Conclusion: The high percentage of CI recipients achieving ceiling scores for the CUNY sentence test in quiet at 3 months post-implantation, questions the validity of using CUNY in CI assessment test battery and limits its application for use in longitudinal studies evaluating CI outcomes. Further studies are required to examine different methods to overcome this problem.     

Bone-anchored hearing aid: Why do some patients refuse it?

Objective

Bone-anchored hearing aid (BAHA™) is a proven tool to improve hearing. Nevertheless, there are patients who are candidates for BAHA™ implants that end up refusing the surgery. The objective of this study is to review our BAHA™ experience with particular emphasis on reasons behind the refusal of some candidates.

Methods

A prospective cohort of 100 consecutive new candidates referred to The BAHA™ program in a tertiary health care center. Candidates’ demographics, hearing status, Co-morbidities and audiometeric tests were all recorded. Patients’ acceptance or refusal was noted alongside the reasons to refuse BAHA™.

Results

100 new candidates were seen for BAHA™ assessment, 10 patients were excluded due to incomplete data. There were 68 children and 22 adults. Unilateral Conductive Hearing Loss was the most common reason for consultation (40%), followed by unilateral SNHL (23.3%). Aural Atresia was the commonest clinical finding (36.6%). The commonest reason for refusal was social acceptance by the parents due to concern with cosmesis.

Conclusion

The main reason of BAHA™ surgery refusal, in otherwise eligible candidates, is related to cosmesis. Patients with congenital anomalies were the most likely candidates to accept BAHA™ implants.     

How is the Children's Implant Profile used in the Cochlear Implant Candidacy Process?

Objective

The complex process of cochlear implant candidacy assessment at The Children's Hospital of Philadelphia (CHOP) is guided by a modified version of the Children's Implant Profile (ChIP) that has been used world wide over the past 18 years. The aim of this study is to analyze the use of the modified ChIP (mChIP) in the candidacy process by the CHOP Cochlear Implant Program. Of special interest were those cases in which the recommendation regarding implantation appeared inconsistent with the mChIP score. These were further analyzed to understand the real-life decision processes.

Methods

This retrospective study involved 121 children assessed for cochlear implant candidacy at CHOP over a 2-year period. The mChIP ratings of No Concern, Some Concern and Great Concern were assigned values of 1, 2 and 3, respectively. Values of 1.5 and 2.5 were used when the check mark was on the boundary between two categories. An average score was calculated and the relationships between mChIP scores and the recommendation regarding implantation were examined.

Results

Eighty-seven children were considered suitable for cochlear implantation; implantation was not recommended for 20. Another 14 cases in which one or more areas of the mChIP had not been completed were excluded. Using a criterion based solely on the mean score would correctly predict 75% of the team's recommendations to implant and 75% of recommendations not to implant. Examination of the cases where implantation was not recommended illuminated the decision-making process.

Conclusions

A statistical analysis of the mChIP fails to capture the complexity of the decision-making process. Most important, it appears that the team's practice is generally to recommend implantation when there is at least a modest prospect of benefit, unless there are absolute contraindications or many areas of Great Concern.     

Unicondylar knee arthroplasty in the UK National Health Service: An analysis of candidacy, outcome and cost efficacy

The viability of unicondylar knee arthroplasty (UKA) as a stand-alone or temporising option for the management of gonarthrosis is a topic of considerable contention. Despite recent advances in prosthesis design and surgical technique, as well as mounting evidence of long-term survivorship, UKA remains infrequently used, accounting for just 8–15% of all knee arthroplasties. Instead this group is more typically managed using total knee arthroplasty (TKA). For UKA to warrant increased usage the candidacy for UKA must be prevalent, the outcome must be equivalent or superior to that of TKA, and the costs should be comparatively low. Here we address three issues regarding UKA: 1) a prospective assessment of the proportion of knees needing arthroplasty that are candidates for UKA; 2) retrospective outcome measures comparing TKA, UKA and controls; and 3) an estimation of the difference in costs between TKA and UKA from a hospital perspective. We show in a series of 200 knees that candidacy for UKA is widespread; representing 47.6% of knees. Furthermore, we also show for the first time, that not only is UKA functionally superior to TKA (based on Total Knee Questionnaire (TKQ) scores), but scores in medial and lateral UKA knees do not differ significantly from normal, non-operative age- and sex-matched knees (t = 1.14 [38], p = 0.163; and t = 1.16 [38], p = 0.255 respectively). Finally, we report that UKA offers a substantial cost saving over TKA (£1761 per knee) indicating that UKA should be considered the primary treatment option for unicompartmental knee arthritis.     

Expert opinion: Can different assessments be used to overcome current candidacy issues?

Since the National Institute of Health and Care Excellence (NICE) review of cochlear implantation in 2009, (NICE, 2009) there have been a number of significant changes to our understanding of the impact of severe-to-profound hearing loss on quality of life and comorbidity with life limiting illness. There have been questions about the validity of current methods of assessing candidacy for cochlear implants. There have also been significant improvements in the effectiveness of implants, the age of successful implantation and a reduction in costs. Additionally, the costs to the health and welfare system of not addressing severe-to-profound hearing loss are often not considered when assessing costs and benefits of this technology and when assessing candidacy criteria. Consideration of these changes since the NICE review suggests the need for an urgent review of the current guidance.     

使用人工耳蜗和助听器的语前聋儿童言语识别能力的研究

目的 通过对使用人工耳蜗和助听器的语前聋儿童的言语识别能力的比较研究,为人工耳蜗植入适应证提供参考.方法实验对象包括18例人工耳蜗植入和40例配戴助听器的先天性语前聋儿童,先在自由声场测试双耳裸耳听阈,根据装置使用时间和平均裸耳听阈值分组,测试并比较使用人工耳蜗和助听器的语前聋儿童封闭项的声母、韵母、单音节词识别率.结果人工耳蜗植入时间≥2年组儿童的韵母、声母和单音节词识别率明显高于＜2年组患者.助听器使用时间≥2年组的各测试项识别率与＜2年组差异无统计学意义.装置使用时间＜2年的语前聋儿童,人工耳蜗植入者的各测试项识别率均明显高于平均裸耳听阈＞100 dB HL的助听器使用者,与平均裸耳听阈≤100 dB HL的助听器使用者的各测试项识别率差异均无统计学意义.装置使用时间≥2年的语前聋儿童,人工耳蜗植入者的各测试项识别率均明显高于平均裸耳听阈＞90 dB HL的助听器使用者,但与平均裸耳听阈＞70 dB HL但≤90 dB HL的助听器使用者差异无统计学意义.结论极重度语前聋儿童人工耳蜗植入后能获得比助听器使用者更好的言语识别能力.     

Candidacy and the Children's Implant Profile: Is our selection appropriate?: Candidatura y el Perfil Infantil para Implante; ¿es apropiada nuestra selección?

This study has two aims: first, to determine whether our paediatric Cochiear Implant Programme uses a modified version of the Children's Implant Profile (CHIP) in a consistent manner to inform candidacy decisions; and second, to establish whether our ratings of concern on the ChIP are predictive of speech discrimination, speech production and language outcomes. Retrospective data were collated over a 6-year period. For each ChIP category, ratings of ‘no concern’, ‘mild-moderate concern’ or ‘great concern’ were agreed for each child, and scores of 0, 1 or 2 were assigned respectively. During the period of study, of 147 children assessed, 63% were considered to be suitable for cochlear implantation. A forward stepwise logistic regression showed that degree of concern on five of the ChIP factors significantly predicted the decision to implant. At 1 year and 3 years after switch-on, the total ChIP score significantly predicted some speech perception outcomes, as did the degree of concern preimplant regarding speech and language abilities and functional hearing. These concerns were also significantly predictive of receptive language ability and speech intelligibility ratings 3 years after implantation.     

Perceived colorectal cancer candidacy and the role of candidacy in colorectal cancer screening

Screening is a well-established tool to advance earlier cancer diagnosis. We used Davison’s concept of ‘candidacy’ to explore how individuals draw on collectively constructed images of ‘typical’ colorectal cancer (CRC) sufferers, or ‘candidates’, in order to evaluate their own risk and to ascertain the impact of candidacy on screening participation in CRC. We interviewed 61 individuals who were invited to participate in the Scottish Bowel Screening Programme. Of these, 37 were screeners (17 men and 20 women) and 24 non-screeners (13 men and 11 women). To analyse these data we used a coding frame that drew on: symptoms, risk factors, and retrospective and prospective candidacy. Few participants could identify a definite bowel cancer candidate and notions of candidacy were largely predicated on luck in the sense that anyone could be a candidate for CRC and there was little evidence to support a linear relationship between feelings of risk and screening decisions. Often participants described screening as part of a wider portfolio of being healthy and referred to feeling obliged to look after themselves. Our study suggests that rather than candidates for bowel cancer, screeners viewed themselves as candidates for screening by which screening decisions pointed towards the acceptance and normalisation of the rhetoric of personal responsibility for health. These findings have related theoretical and practical implications; the moral structure that underpins the new public health can be witnessed practically in the narratives by which those who see themselves as candidates for screening embrace wider positive health practices.     

Assessing candidacy for bilateral cochlear implants: A survey of practices in the United States and Canada

Abstract

Objectives

There are currently no agreed-upon criteria to establish candidacy for bilateral cochlear implants (CIs). This study categorized practice patterns for establishing bilateral CI candidacy.

Methods

A postal survey was sent to all practices performing CIs in the United States and Canada. The survey queried centers regarding candidacy criteria for bilateral implantation, testing parameters, definition of ‘best aided condition’, use of testing in noise, localization, and quality-of-life questionnaires. The survey was resent to non-responding centers 4 weeks after the initial mailing.

Results

The overall response rate was 40%. ‘Best aided condition’ (70%) and hearing in noise (52%) were used to establish bilateral candidacy, while 45% of centers offered bilateral implants to all candidates. The majority of respondents defined ‘best aided’ as hearing aids only (57% non-exclusive) or CI and hearing aid together (57%). Only 25% considered a CI alone as best aided. Nearly 5% considered no aiding to be the best aided. Sound localization was used by 8% of respondents for candidacy assessment. Reimbursement affected candidacy decision for 45%. There was variability in stimulus levels (60, 50, 45, and 55 dB), signal-to-noise ratios, and speaker orientations used.

Discussion

There are no consistent criteria to assess patients for bilateral CIs. This practice variation makes comparing outcomes across centers challenging and leaves open the possibility of having external standards imposed by regulators or payors. Standardization of candidacy assessment is necessary to develop best practices for bilateral cochlear implantation both to optimize patient outcomes and to ensure the continuity of coverage for these services.