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PURPOSE To appraise the aftereffect of a primary care–based community-links practitioner (CLP) action on patients’ affection of activity and well-being.



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METHODS Quasi-experimental cluster-randomized controlled balloon in socioeconomically beggared areas of Glasgow, Scotland. Developed patients (aged 18 years or older) referred to CLPs in 7 action practices were compared with a accidental sample of developed patients from 8 allegory practices at baseline and 9 months. Primary outcome: health-related affection of activity (EQ-5D-5L, a connected admeasurement of self-reported health-related affection of activity that assesses 5 ambit at 5 levels of severity). Secondary outcomes: abundance (Investigating Choice Experiments for the Preferences of Earlier Bodies Capability Admeasurement for Adults [ICECAP-A]), abasement (Hospital All-overs and Abasement Scale, Abasement [HADS-D]), all-overs (Hospital All-overs and Abasement Scale, All-overs [HADS-A]), and self-reported exercise. Multilevel, multiregression analyses adapted for baseline differences. Patients were not addled to the intervention, but aftereffect assay was masked.

RESULTS Abstracts were calm on 288 and 214 (74.3%) patients in the action practices at baseline and follow-up, respectively, and on 612 and 561 (92%) patients in the allegory practices. Intention-to-treat assay begin no differences amid the 2 groups for any outcome. In subgroup analyses, patients who saw the CLP on 3 or added occasions (45% of those referred) had cogent improvements in EQ-5D-5L, HADS-D, HADS-A, and exercise levels. There was a aerial absolute alternation amid CLP arrangement ante and accommodating uptake of adapted association resources.



CONCLUSIONS We were clumsy to prove the capability of barometer to CLPs based in primary affliction in beggared areas for convalescent accommodating outcomes. Future efforts to accession uptake and assurance could beforehand all-embracing outcomes, although the credible improvements in those who consistently saw the CLPs may be due to about-face causality. Added assay is bare afore wide-scale deployment of this approach.

Health inequalities are a all-around problem, consistent from a axiological bigotry in the administration of income, power, and wealth. This bigotry banned opportunities above the activity course, including admission to education, housing, jobs, and bloom care.1,2 In addition, bodies of low socioeconomic cachet acquaintance assorted bloom problems and a absorption of accident factors,3 affronted by poor admission to assets to administer them.4



A accepted action acknowledgment to bloom inequalities in contempo years has been the accession of assorted amusing prescribing programs. Amusing prescribing aims to articulation patients to nonmedical sources of abutment aural a community, appropriately accretion options and assets above those commonly provided in primary bloom care.5 In principle, amusing prescribing interventions should accredit a added holistic acknowledgment to patients’ needs. By accouterment admission to community-based casework and support, they can abate amusing isolation, beforehand behavior change (such as abutting a walking group), and abate some of the furnishings of abjection through abundance admonition or application opportunities, for example.6 The affirmation abject for the capability of amusing prescribing is acutely limited, however.7–9

The Scottish government has afresh accurate amusing prescribing in areas of aerial socioeconomic deprivation. The Glasgow Deep End Links Worker Programme (LWP) aims to advice bodies in areas of denial to “live well” in their communities by accouterment an absorbed community-links practitioner (CLP) to accepted practices.10 Here, we address the quantitative allegation on accommodating outcomes of this program. Our aim was to assay the antecedent that the action would beforehand to improvements in patients’ affection of activity and added aspects of well-being.

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We conducted a quasi-experimental cluster-randomized controlled balloon (RCT) of the Glasgow Deep End LWP.11 Practices were acceptable for the affairs if they were amid in Glasgow and in the 100 practices in Scotland (which has about 1,000 practices) confined the most-deprived patients (based on the allotment of registered patients in practices active in the 15% most-deprived postcodes in Scotland). Fifteen accepted practices confined patients active in actual beggared areas (out of 76 acceptable practices in Glasgow) took part. Funding from the Scottish government financed 7 practices to apparatus the intervention. The actual 8 practices acted as a allegory group. Patients who alternate in the appraisal provided accounting abreast consent. The abstraction was accustomed by the University of Glasgow College of Medical Veterinary and Activity Sciences Ethics Committee (200140077) and registered prospectively with International Accepted Randomized Controlled Trials (ISRCTN80842457), and the agreement was published.11

Fourteen practices bidding an absorption in abutting the LWP, in accession to the convenance of the program’s analytic lead. Of these, 6 were about called to accompany the action arm of the trial, forth with the analytic lead’s practice. The actual 8 were appointed comparator practices.11

Adult patients who were registered with an action convenance and were referred to a CLP during the abstraction application aeon were eligible. Full capacity of the application action accept been published.11 In brief, the bloom affliction clinicians—general practitioners (GPs) and convenance nurses (PNs)—were abreast to accord developed patients (aged 18 years or older) the abstraction advice and to seek permission to canyon on their acquaintance capacity to the assay aggregation at the time of barometer to a CLP. Back this permission was received, a affiliate of the assay aggregation contacted patients to explain the abstraction and, if patients bidding absorption in demography part, mailed them the abstraction accord anatomy and baseline check to complete and acknowledgment to the abstraction office. If there was no acknowledgment aural 10 days, patients were telephoned and accustomed added options for commutual the questionnaire, either during a contiguous affair or over the blast with the abstraction researcher. We aimed to aggregate baseline abstracts afore the alpha of the CLP action whenever possible, although the advisers had no ascendancy over back the CLP would align to see the patient.

Because the characteristics of patients apparent by a CLP were alien in beforehand (any accommodating accounted acceptable for barometer to the CLP by the convenance was eligible), it was not accessible to baddest akin ascendancy patients from the comparator practices at the time of application and baseline abstracts collection. Therefore, 1,000 developed patients (aged 18 years or older) registered with a comparator convenance were about called for allurement to participate in the evaluation. A chief GP in anniversary convenance advised the account to abolish patients they advised inappropriate for bloom or amusing affidavit (such as terminal affliction or ancestors or added amusing crisis).11 The convenance again mailed the abstraction allurement backpack to the patients included.

The practice-level action had 2 key components: a adjourned full-time CLP in anniversary convenance and a convenance development fund. Table 1 describes the key appearance of the program. Its amount functions were as follows:

CLPs accustomed links amid the convenance and bounded association organizations, helped by the convenance development armamentarium acclimated to “buy out” convenance agents time to absorb convalescent systems and architecture relationships.

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General practices developed barometer systems through which GPs and PNs referred patients they believed acceptable to account from seeing a CLP.

Description of the Glasgow Deep End Links Worker Affairs Application the TIDieR Framework12

Each CLP met the referred accommodating as abounding times as both anticipation appropriate, articular the patient’s best acute problems, and accurate barometer to and advancing acquaintance with bounded association resources. The “theory of change” that underpinned the appraisal is apparent in Supplemental Table 1, accessible at Media Allegory practices were not allocated a CLP or a convenance development fund.

The primary accommodating aftereffect was health-related affection of life, abstinent at baseline and at 9 months’ aftereffect by the EQ-5D-5L, a connected admeasurement of self-reported health-related affection of activity that assesses 5 ambit at 5 levels of severity.15

Secondary accommodating aftereffect measures at baseline and aftereffect at 9 months included the Investigating Choice Experiments for the Preferences of Earlier Bodies Capability Admeasurement for Adults (ICECAP-A,16 a capability-based admeasurement of abundance in adults), the Hospital All-overs and Abasement Scale (HADS),17 the Assignment and Amusing Adjustment Scale,18 accountability of multimorbidity,19 and self-reported affairs activities (smoking, alcohol, exercise). At baseline, abstracts were calm on sociodemographic measures (age, sex, education, ethnicity, and assignment status) and denial cachet based on postcode by application the Scottish Base of Assorted Denial (the Scottish government’s small-area index, which integrates 7 domains of denial to accord an all-embracing score).20

It was not accessible to affectation participants or bloom affliction professionals to the accumulation allocation of their practice. It was additionally not achievable to dark associates of the amount abstraction aggregation accession the abstracts (B.F., L.G.), but the statisticians accustomed out the primary analyses (A.M., A.B., G.J.-R.) and all added coauthors were addled to the allocation. The statistical assay plan was accounting afore unblinded abstracts analysis.

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The minimum ambition sample sizes of 286 patients for action and 484 patients for comparator practices was affected to accept 80% ability to ascertain a minimally important aftereffect admeasurement of 0.274 accepted deviations (SDs) in the EQ-5D-5L with a 95% amount of confidence, bold an intraclass alternation of 0.01 and a 50% aftereffect rate. This sample admeasurement would accommodate 90% ability to ascertain an aftereffect admeasurement of 0.316 SDs beneath the aforementioned assumptions.

Primary assay was on an intention-to-treat base (all patients referred to a CLP) application all accessible data. Subgroup assay was conducted on patients who absolutely abounding a CLP contiguous consultation. Differences amid groups were activated with adapted mixed-effects beeline or ambiguous beeline corruption models, acceptance absorption by practice. Because the comparator patients were respondents from a about called sample, it was accepted that there would be differences in accommodating characteristics and aftereffect measures at baseline compared with the action patients. The statistical archetypal acclimated retained the accepted adjustments (baseline aftereffect value, age, sex, deprivation, and multimorbidity) additional any added variables that differed at baseline and were cogent predictors of aftereffect in the corruption model.

Of 980 developed patients referred to a CLP during the abstraction aeon (March-December 2015), 559 (57%) were referred to the assay aggregation for abeyant application to the study. Of these, 288 (52%) were recruited (Supplemental Figure 1a, accessible at Media Patients recruited into the abstraction were adumbrative of all CLP accommodating referrals in agreement of sex, cardinal and blazon of barometer problems, and denial akin but were hardly earlier (mean 46.4 years vs 48.3 years for all CLP referrals vs CLP abstraction recruits, respectively, P = 0.018). (Supplemental Table 1, accessible at Media In allegory practices, a accidental sample of 7,942 yielded 612 (8%) alternate completed baseline questionnaires (Supplemental Figure 1b, accessible at Media

Of the 288 patients recruited to the abstraction in the action group, 214 (74.3%) completed the aftereffect check 9 months later. Of the 612 patients recruited into the abstraction in the allegory group, 561 (92%) completed the aftereffect questionnaire.

In both the action and allegory groups, English was the absolute aboriginal accent (98%), and 60% of participants were changeable (Table 2). Patients in the action accumulation were younger, of lower socioeconomic status, and added acceptable to be active abandoned than patients in the allegory group. They additionally had added medical and amusing problems, poorer affection of life, and poorer brainy bloom (Table 2). The prevalence of alone medical altitude and amusing problems is apparent in the added book (Supplemental Tables 2 and 3, accessible at Media Almost one-half (45%) of the action accumulation smoked, and 58% appear that they did not exercise regularly.

Patient Characteristics at Baseline

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Although we endeavored to aggregate baseline accommodating questionnaires afore the accommodating aboriginal consulted with the CLP, this was accessible in alone 159/288 (55%) of patients. However, the baseline aftereffect and demographic measures of patients who completed the check afore or afterwards the aboriginal CLP arrangement did not alter decidedly (Supplemental Tables 4 and 5, accessible at Media This award suggests that seeing the CLP already afore commutual the baseline check did not affect the baseline aftereffect array (further accurate by our allegation below).

Of the 288 patients in the abstraction who were referred to the CLP, 26 (9.0%) did not appoint at all. Of the 262 who engaged, 41.4% had 1 face-to face arrangement with the CLP, 13.4% had 2, 12.1% had 3, and 33.5% had 4 or more, with the beggarly cardinal actuality 3.1 (SD 4.59). Uptake of association assets by patients added with accretion cardinal of CLP contacts (Spearman’s ρ = 0.684, P

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