Clinical Handover and Chronic Non-Communicable Diseases (NCDs)

This is a comprehensive scoping systematic review utilising a narrative synthesis approach to summarise the literature focussing on the quality of handover communication and associated interventions in low and middle-income countries across all dimensions of handover. The protocol for the review, registered with PROSPRO.

Research Team and Project Partners

• Dr Semira Manaseki-Holland, Reader in Public Health, University of Birmingham, UK.  
• Dr Jeemon Panniyammakal, Associate Professor, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
• Professor Sheila Greenfield, Professor of Medical Sociology, University of Birmingham,  UK and qualitative expert providing data collection and analysis advice.

Two systematic reviews summarising the evidence on patient-held records in LMIC have been planned. The first systematic review investigates the evidence for patient-held records for clinical information handover and patient’s information to enable self-management in low and middle income countries. Patient-held records are primarily developed as a copy of the medical record for patients to keep, consult and to take with them during healthcare visits, to help manage communication and to improve the continuity and quality of care.

The second review specifically looks at maternal and child health records also known as home-based records. Home-based records are a type of condition specific patient-held record used widely in LMIC. This systematic review investigates the evidence of home-based records in improving informational continuity of care, health outcomes and perceived usefulness in LMICs. The protocol for the review, registered with PROSPERO

Outputs

Publications

• Systematic review on the use of patient-held health records in low-income and middle-income countries. Joseph L, Lavis A, Greenfield S, Boban D, Humphries C, Jose P, Jeemon P, Manaseki-Holland S.BMJ Open. 2021 Sep 2;11(9):e046965. doi: 10.1136/bmjopen-2020-046965.PMID: 34475153

• Joseph L, Lavis A, Greenfield S, Boban D, Jose P, Jeemon P, Manaseki-Holland S. A systematic review of home-based records in maternal and child health for improving informational continuity, health outcomes, and perceived usefulness in low and middle-income countries. PLoS One. 2022 Aug 4;17(8):e0267192. doi: 10.1371/journal.pone.0267192. PMID: 35925923; PMCID: PMC9352021.

Research Team and Project Partners

• Dr Semira Manaseki-Holland,  Reader in Public Health, University of Birmingham, UK.  
• Dr Jeemon Panniyammakal, Associate Professor, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India.
• Professor Sheila Greenfield, Professor of Medical Sociology, University of Birmingham,  UK and qualitative expert providing data collection and analysis advice.
• Dr Anna Lavis, Lecturer in Medical Sociology and Qualitative Methods, University of Birmingham, UK
• Linju Joseph, PhD student, University of Birmingham, UK
• Claire Humphries, PhD student, University of Birmingham, UK
• Dr Dona Boban, Research Associate at Amrita Vishwa Vidyapeetham, Kochi, India
• Ms. Prinu Jose, PhD student, Manipal University, Manipal, India

HANDOVER Project, initiated in 2008, was the first multi-year, multi-million-euro effort to improve handovers at the interface between the hospital and the home in Europe. Six European nations (Italy, the Netherlands, Poland, UK, Spain, and Sweden) participated in the Project, along with researchers from the United States and Australia. The aims entailed optimising the continuum of clinical care between primary care and the hospital to reduce unnecessary treatment, medical errors, and avoidable harm. Specific objectives included identifying and studying best practices, creating standardised approaches to handover communication, and measuring their effectiveness in terms of impacts on patients and health care costs. The Project was initiated by a group of health services researchers and clinicians from the six participating nations, in the UK led by University of Birmingham, Professor Richard Lilford. Countries were specifically selected to represent different European systems for the organisation and funding of healthcare. The HANDOVER Project was funded by the European Union's (EU's) Seventh Framework Programme (FP7), which brought EU research initiatives under a common roof to foster growth in research and innovation through competitiveness, training programmes, and funding to support regional and cross-national collaborations. 

Outputs

Publications:

• A large number of publications and new projects stemmed from this consortium. A volume of the BMJ Quality and Safety was dedicated to some of the work of this group.
• https://cordis.europa.eu/project/id/223409

Research Team and Project Partners

• https://cordis.europa.eu/project/id/223409

Project Objectives:

1. To describe the existing situation in two States of India for exchanging patient information (clinical handover) between providers and between providers and patients for patients with chronic NCDs in terms of:

• Handover practices and activities (what happens at hospital outpatient, and stages of referral for inpatients or discharge)
• Training for healthcare providers
• Policies (documented policies and guidelines for healthcare providers from any level of healthcare system)
• Opinion of patients and healthcare provides about information exchange between visits to healthcare providers and its importance

2. To identify factors that may be facilitators or barriers to good handover between healthcare providers and identify motivators and processes which may improve this communication.

3. To develop ideas and interventions that will improve the situation of information exchange between primary and secondary care (clinical handover) in India. These could in turn improve the continuity of care and integration of primary and secondary care health services for chronic non-communicable disease patients.

Project Setting:

Himachal Pradesh

Himachal Pradesh, a northern Indian State in the Himalayas, is spread over 55673 km2 with a population of approximately 6.8 Million, with 90% living in rural areas and 10% in urban areas as per Census 2011. There are 83 hospitals and 485 primary health centres in the state. Private healthcare providers are less prevalent in Himachal Pradesh compared to many other states and utilisation of public healthcare remains relatively high. The number of primary and community health centres across the state are in line with what is required by the government, however they are often significantly understaffed with a particular lack of specialty practitioners.

One primary health centre (PHC), one community health centre (CHC) and one tertiary-care hospital in Himachal Pradesh state were engaged in our project in Himachal Pradesh .

Kerala

Kerala, a southern Indian State situated on the south west corner of the country, is spread over 38,863 km2 with a population of 33.4 Million distributed equally between urban and rural living as per Census 2011. There are 125 hospitals and 660 Primary health Centres in the state. The healthcare environment in Kerala has become increasingly complex in recent years due to low staffing at peripheral centres, public disenchantment with government facilities and a subsequent growth in popularity and presence of private healthcare providers. A 2008 government development report estimated that when taking both public and private facilities into account, there is (approximately) 1 medical institution per 2000 population and 1 hospital bed per 250 population.

One urban tertiary-care hospital in Cochin plus two PHCs and one secondary-care peri-urban hospital in a near-by district were engaged in our project in Kerala state.

Research Methods

A situational analysis of clinical handover in Himachal Pradesh and Kerala was done using a mixed-methods approach. A successful and pivotal Experts meeting held in October 2015 in New Delhi, was attended by national, state level and international policy makers, academics, private and public hospital representatives and patient groups. The initial findings from the patients and healthcare providers were discussed and options were explored for potential evidence based interventions to improve clinical handover in India for a future implementation research study.

Consultation and the National Expert Meeting 2015

The meeting was chaired by the Deputy Commissioner for Non-Communicable Diseases from the Ministry of Health and Family Welfare and senior UN, NGO and hospital collaborators attended from the following Organisations: 

Outputs

Publications:

• Humphries C, Jaganathan S, Panniyammakal J, Singh S, Goenka S, Dorairaj P, Gill P, Greenfield S, Lilford R and Manaseki-Holland S. (2018) Investigating clinical handover and healthcare communication for outpatients with chronic disease in India: A mixed-methods study. PLOS ONE, 3(12). pp. e0207511.
• Humphries C, Jaganathan S, Panniyammakal J, Singh S, Goenka S, Dorairaj P, Gill P, Greenfield S, Lilford R and Manaseki-Holland S. (2019) Patient and healthcare provider knowledge, attitudes and barriers to handover and healthcare communication during chronic disease inpatient care in India: a qualitative exploratory study. BMJ Open, 9(11). pp. e028199
• Humphries C, Jaganathan S, Panniyammakal J, Singh S, Dorairaj P, Gill P, Greenfield S, Lilford R, Manaseki-Holland S. (2020) Investigating discharge communication for chronic disease patients in three hospitals in India. PLOS ONE 15(4): e0230438. https://doi.org/10.1371/journal.pone.0230438

PhD studentships: 

• Dr Claire Humphries received the University of Birmingham Medical and Dental School PhD Scholarship in order to analyse the vast pool of mixed-method data derived from the ‘Clinical Handover in India’ project. Claire successfully completed her in 2020.

Conference presentations:

• Humphries C, Jaganathan S, Panniyammakal J, Singh SK, Goenka S, Dorairaj P, Gill P, Greenfield S, Lilford R, Manaseki-Holland S. (2017). An investigation into clinical handover practices for chronic disease patients at the point of hospital admission and discharge in two states of India. World NCD Congress, Chandigarh, India. November 2017
• Humphries C, Jaganathan S, Panniyammakal J, Singh SK, Goenka S, Dorairaj P, Gill P, Greenfield S, Lilford R, Manaseki-Holland S. Clinical handover communication for outpatients with chronic conditions in India: A mixed-methods exploratory study. Fourth Global Symposium on Health Systems Research. Vancouver, Canada. November 14-18 2018.

• Humphries C, Jaganathan S, Panniyammakal J, Singh SK, Goenka S, Dorairaj P, Gill P, Greenfield S, Lilford R, Manaseki-Holland S. (2018). Investigating the relationship between quality of discharge and health outcomes for chronic disease patients in three hospitals in India. Fifth Global Symposium on Health Systems Research. Liverpool, UK. October 8-12 2018. 

Research Team and Project Partners

• Dr Semira Manaseki-Holland,  Reader in Public Health, Institute of Applied Health Research, University of Birmingham, UK
• Professor Prabhakaran Dorairaj, Vice President (Research and Policy), Public Health Foundation of India (PHFI) and Director, Centre for Control of Chronic Conditions (CCDC)
• Dr. Sanjeev K. Singh, Medical Superintendent, Amrita School of Medicine, Kochi 
• Professor Richard Lilford, Director of National Institute for Health Research (NIHR) Applied Research Centre West Midlands (ARC WM), University of Birmingham, UK
• Professor Paramjit Gill, Professor of Primary Care, University of Warwick, UK
• Professor Sheila Greenfield, Professor of Medical Sociology, University of Birmingham, UK
• Dr Jeemon Panniyammakal, Associate Professor, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India

Funders: 

• MRC HSRI Joint funding – jointly funded by the Department of International Development (DFID), the Economic and Social Research Council (ESRC), the MRC and Wellcome Trust
• NIHR CLAHRC for Richard Lilford and Sheila Greenfield
• University of Birmingham MDS Studentship (Claire Humphries)

Photo of field research team in Cochin and project manager Ms Suganthi and PI, Dr Semira Manaseki-Holland, 2014

This project is managed by Linju Joseph based in Kerala at the Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, Kerala, and affiliated to the Centre for Chronic Disease Control (CCDC), New Delhi. This project involves a multi-methods study, which includes qualitative research and the development of approaches for a patient-held health intervention tool for non-communicable disease in Kerala, India. The project aims to understand how patient-held records can be used for improving handover communication, informational continuity of care and self-management for patients with diabetes and hypertension.

Outputs:

PhD studentships: 

• Ms Linju Joseph is a Global Challenges Scholar and is conducting her PhD research on understanding user experience of current patient-held records for improving handover, informational continuity of care and self-management in patients with diabetes and hypertension in Kerala, India.  

Research Team and Project Partners

• Dr Semira Manaseki-Holland, Reader in Public Health, University of Birmingham, UK and Lead Investigator on 'Clinical Handover in India'
• Dr Jeemon Panniyammakal, Additional Professor, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum
• Dr Pratap Kumar, Senior Lecturer, Strathmore University Business School, Founder and CEO-Health-E-Net, Kenya 
• Professor Sheila Greenfield, Professor of Medical Sociology, University of Birmingham,  UK and qualitative expert providing data collection and analysis advice
• Dr Anna Lavis, Lecturer in Medical Sociology and Qualitative Methods, University of Birmingham, UK
• Dr Lekha T R, Research Assistant, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India

A patient-held record for patients with diabetes and hypertension from Kerala

Outputs

Publications:

Joseph L, Greenfield S, Manaseki-Holland S, T R L, S S, Panniyammakal J, Lavis A. Patients', carers' and healthcare providers' views of patient-held health records in Kerala, India: A qualitative exploratory study. Health Expect. 2023 Jun;26(3):1081-1095. doi: 10.1111/hex.13721. Epub 2023 Feb 13. PMID: 36782391; PMCID: PMC10154823.

Joseph L, Greenfield S, Lavis A, Lekha TR, Panniyammakal J, Manaseki-Holland S. Exploring Factors Affecting Health Care Providers' Behaviors for Maintaining Continuity of Care in Kerala, India; A Qualitative Analysis Using the Theoretical Domains Framework. Front Public Health. 2022 Jul 8;10:891103. doi: 10.3389/fpubh.2022.891103. PMID: 35875019; PMCID: PMC9304901.

Funders: 

• NIHR Global Health Groups

A nested study within the NIHR Global Health Research Group on Atrial Fibrillation management (Global AF Reach) 2018-22

As a part of Global AF Reach, two studies have been included across the three countries to investigate the current clinical pathways and handover practices for AF patients (incident and prevalent cases) in Brazil, China, and Sri Lanka.The first study is a pilot study investigating AF patient care seeking pathways and loss to follow-up after diagnosis during an admission, or a visit to primary care or A&E (incident cases)

The second study is investigating AF patient management, clinical pathways, care-seeking behaviours, and loss to follow-up once seen at tertiary centres (prevalent cases)

Outputs

Publications:

Goulart AC, Varella AC, Gooden T, Lip G, Jolly K, Thomas GN, Lotufo PA, Greenfield S, Olmos RD, Bensenor IM, Manaseki-Holland S. Identifying and understanding the care pathway of patients with atrial fibrillation in Brazil and the impact of the COVID-19 pandemic: A mixed-methods study. PLOS One. 2023 Sep 22.

Gooden TE, Wang J, Carvalho Goulart A, Varella AC, Tai M, Sheron VA, Wang H, Zhang H, Zhong J, Kumarendran B, Nirantharakumar K. Generalisability of and lessons learned from a mixed-methods study conducted in three low-and middle-income countries to identify care pathways for atrial fibrillation. Global Health Action. 2023 Dec 31;16(1):2231763.

Sheron VA, Shanmugathas S, Gooden TE, Guruparan M, Kumarendran B, Lip GY, Manaseki-Holland S, Nirantharakumar K, Shribavan K, Subaschandren K, Haniffa R. Healthcare provider and patient perspectives on access to and management of atrial fibrillation in the Northern Province, Sri Lanka: a rapid evaluation of barriers and facilitators to care. BMC health services research. 2022 Aug 23;22(1):1078.

Paschoal E, Gooden TE, Olmos RD, Lotufo PA, Benseñor IM, Manaseki-Holland S, Lip GY, Thomas GN, Jolly K, Lancashire E, Lane DA. Health care professionals’ perceptions about atrial fibrillation care in the Brazilian public primary care system: a mixed-methods study. BMC Cardiovascular Disorders. 2022 Dec 22;22(1):559.

Research Team and Project Partners

September 2022 Barcelona at the end-of-grant Global AF Reach meeting

• Dr Semira Manaseki-Holland, Reader in Public Health, University of Birmingham, UK
• Professor Neil Thomas, Professor in Epidemiology and Research Methods, Institute Director of Research Knowledge and Transfer, University of Birmingham, UK
• Professor Sheila Greenfield, Professor of Medical Sociology, University of Birmingham, UK
• Professor Kate Jolly, Professor of Public Health and Primary Care, Deputy Director of the Institute of Applied Health Research, University of Birmingham, UK
• Dr Krishnarajah Nirantharakumar, UKRI Innovation Clinical Fellow, Honorary Consultant in Public Health Medicine, University of Birmingham, UK
• Professor Greg Lip, Price-Evans Chair of Cardiovascular Medicine, University of Liverpool, UK Distinguished Professor, Aalborg University, Denmark
• Dr Deirdre Lane, Reader in Cardiovascular Health, University of Liverpool, UK; Adjunct Professor, Aalborg University, Denmark
• Associate Professor Yutao Guo, Chinese People’s Liberation Army General Hospital, Beijing, China
• Professor Feng Mei, Director of General Practice and Vice President of Shanxi Provincial GP Training and Research Center, Shanxi DaYi Hospital, Shanxi, China
• Professor. Li Xuewen, Vice-president and Director of Cardiology , Shanxi DaYi Hospital, China
• Professor Paulo A. Lotufo, Professor & Director, University of São Paulo, Brazil
• Dr Isabela M. Benseñor, Associate Professor, Faculdade de Medicina da Universidade de São Paulo, Brazil
• Dr Rodrigo Olmos, Assistant Professor, University of São Paulo, Brazil
• Dr Gustavo Gusso, Assistant Professor, University of São Paulo, Brazil
• Dr Alessandra Goulart, Associate Professor, Faculdade de Medicina da Universidade de São Paulo, Brazil
• Dr Rajendra Surenthirakumaran, Senior Lecturer & Consultant Community Physician, University of Jaffna, Sri Lanka
• Dr Ajini Arasalingam, Senior Lecturer in Medicine & Honorary Consultant Neurologist, University of Jaffna, Sri Lanka
• Dr Subaschandren Kumaran, Senior Lecturer & Consultant Family Physician, University of Jaffna, Sri Lanka
• Dr Balachandran Kumarendran, Senior Lecturer & Consultant Community Physician, University of Jaffna, Sri Lanka
• Dr Mahesan Guruparan, Consultant Cardiologist, Teaching Hospital Jaffna, Sri Lanka

Funders:

• NIHR Funding and Awards 

In 2016 based on the experience and tools developed during the Clinical Handover in India project, we began a programme of work looking at clinical handover between primary and secondary care for NCD chronic diseases. The Mongolia project protocol is available from the lead investigator.

Outputs

Publications:

• Ibrahim H, Munkhbayar U, Toivgoo A, Humphries C, Ochir C, Narula I, Lilford R, Manaseki-Holland S.  2018.  Can universal patient-held health booklets promote continuity of care and patient-centred care in low-resource countries? The case of Mongolia. BMJ Qual Saf. 2019;28(9):729-740. doi:10.1136/bmjqs-2018-008941

Research Team and Project Partners

• Dr Semira Manaseki-Holland, Reader in Public Health, University of Birmingham, UK
• Professor Richard Lilford, Director of National Institute for Health Research (NIHR) Applied Research Centre West Midlands (ARC WM), University of Birmingham, UK
• Dr Aira Toivgoo, Managing Director at Wellspring NGO, Mongolia
• Dr Indermohan S Narula, Group Leader at The Global Fund to Fight AIDS, Tuberculosis and Malaria, Mongolia 
• Professor Chimedsuren Ochir, Professor at Mongolian National University of Medical Sciences, Mongolia 
• Dr Uyanga Munkhbayar, Mongolian National University of Medical Sciences, Mongolia
• Dr Claire Humphries, PhD student, University of Birmingham, UK at the time of the project
• Dr Hussein Ibrahim, BMedSci 3rd year medical student, University of Birmingham, UK at the time of the project

Funders:

The School of Population Sciences and Humanities, College of Medical and Dental Sciences, University of Birmingham, UK, BMedSci Research Budget helped cover some of the costs of this study.