Health Services and Delivery Research最新文献

{"title":"Measuring and optimising the efficiency of community hospital inpatient care for older people: the MoCHA mixed-methods study","authors":"John B. Young, C. Hulme, Andrew Smith, J. Buckell, M. Godfrey, Claire Holditch, Jessica Grantham, H. Tucker, P. Enderby, J. Gladman, E. Teale, Jean-Christophe Thiebaud","doi":"10.3310/hsdr08010","DOIUrl":"https://doi.org/10.3310/hsdr08010","url":null,"abstract":"Background: \u0000Community hospitals are small hospitals providing local inpatient and outpatient services. National surveys report that inpatient rehabilitation for older people is a core function but there are large differences in key performance measures. We have investigated these variations in community hospital \u0000ward performance. \u0000 \u0000Objectives: \u0000(1) To measure the relative performance of community hospital wards (studies 1 and 2); \u0000(2) to identify characteristics of community hospital wards that optimise performance (studies 1 and 3); \u0000(3) to develop a web-based interactive toolkit that supports operational changes to optimise ward performance (study 4); \u0000(4) to investigate the impact of community hospital wards on secondary care use (study 5); and \u0000(5) to investigate associations between short-term community (intermediate care) services and secondary care utilisation (study 5). \u0000 \u0000Methods: \u0000 \u0000Study 1 – we used national data to conduct econometric estimations using stochastic frontier analysis in which a cost function was modelled using significant predictors of community hospital ward \u0000costs. \u0000Study 2 – a national postal survey was developed to collect data from a larger sample of community \u0000hospitals. \u0000Study 3 – three ethnographic case studies were performed to provide insight into less tangible aspects of community hospital ward care. \u0000Study 4 – a web-based interactive toolkit was developed by \u0000integrating the econometrics (study 1) and case study (study 3) findings. \u0000Study 5 – regression analyses were conducted using data from the Atlas of Variation Map 61 (rate of emergency admissions to hospital for people aged ≥ 75 years with a length of stay of < 24 hours) and the National Audit of Intermediate Care. \u0000 \u0000Results: \u0000Community hospital ward efficiency is comparable with the NHS acute hospital sector (mean cost efficiency 0.83, range 0.72–0.92). The rank order of community hospital ward efficiencies was \u0000distinguished to facilitate learning across the sector. On average, if all community hospital wards were operating in line with the highest cost efficiency, savings of 17% (or £47M per year) could be achieved \u0000(price year 2013/14) for our sample of 101 wards. Significant economies of scale were found: a 1% rise in output was associated with an average 0.85% increase in costs. We were unable to obtain a larger community hospital sample because of the low response rate to our national survey. The case studies identified how rehabilitation was delivered through collaborative, interdisciplinary working; interprofessional communication; and meaningful patient and family engagement. We also developed insight into patients’ \u0000recovery trajectories and care transitions. The web-based interactive toolkit was established [http://mocha.nhsbenchmarking.nhs.uk/ (accessed 9 September 2019)]. The crisis response team type of intermediate care, but not community hospitals, had a statistically significant negative association with emergency admissions. \u0000Limit","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"8 1","pages":"1-100"},"PeriodicalIF":0.0,"publicationDate":"2020-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42127418","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Implementation of interventions to reduce preventable hospital admissions for cardiovascular or respiratory conditions: an evidence map and realist synthesis","authors":"D. Chambers, A. Cantrell, A. Booth","doi":"10.3310/hsdr08020","DOIUrl":"https://doi.org/10.3310/hsdr08020","url":null,"abstract":"Background \u0000 \u0000In 2012, a series of systematic reviews summarised the evidence regarding interventions to reduce preventable hospital admissions. Although intervention effects were dependent on context, the reviews revealed a consistent picture of reduction across different interventions targeting cardiovascular and respiratory conditions. The research reported here sought to provide an in-depth understanding of how interventions that have been shown to reduce admissions for these conditions may work, with a view to supporting their effective implementation in practice. \u0000 \u0000 \u0000 \u0000Objectives \u0000 \u0000To map the available evidence on interventions used in the UK NHS to reduce preventable admissions for cardiovascular and respiratory conditions and to conduct a realist synthesis of implementation evidence related to these interventions. \u0000 \u0000 \u0000 \u0000Methods \u0000 \u0000For the mapping review, six databases were searched for studies published between 2010 and October 2017. Studies were included if they were conducted in the UK, the USA, Canada, Australia or New Zealand; recruited adults with a cardiovascular or respiratory condition; and evaluated or described an intervention that could reduce preventable admissions or re-admissions. A descriptive summary of key characteristics of the included studies was produced. The studies included in the mapping review helped to inform the sampling frame for the subsequent realist synthesis. The wider evidence base was also engaged through supplementary searching. Data extraction forms were developed using appropriate frameworks (an implementation framework, an intervention template and a realist logic template). Following identification of initial programme theories (from the theoretical literature, empirical studies and insights from the patient and public involvement group), the review team extracted data into evidence tables. Programme theories were examined against the individual intervention types and collectively as a set. The resultant hypotheses functioned as synthesised statements around which an explanatory narrative referenced to the underpinning evidence base was developed. Additional searches for mid-range and overarching theories were carried out using Google Scholar (Google Inc., Mountain View, CA, USA). \u0000 \u0000 \u0000 \u0000Results \u0000 \u0000A total of 569 publications were included in the mapping review. The largest group originated from the USA. The included studies from the UK showed a similar distribution to that of the map as a whole, but there was evidence of some country-specific features, such as the prominence of studies of telehealth. In the realist synthesis, it was found that interventions with strong evidence of effectiveness overall had not necessarily demonstrated effectiveness in UK settings. This could be a barrier to using these interventions in the NHS. Facilitation of the implementation of interventions was often not reported or inadequately reported. Many of the interventions were diverse in the ways in which they were ","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"8 1","pages":"1-148"},"PeriodicalIF":0.0,"publicationDate":"2020-01-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"47593953","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review","authors":"Michael Nunns, Liz Shaw, S. Briscoe, J. Thompson Coon, A. Hemsley, J. McGrath, C. Lovegrove, David Thomas, R. Anderson","doi":"10.3310/hsdr07400","DOIUrl":"https://doi.org/10.3310/hsdr07400","url":null,"abstract":"Multicomponent hospital-led interventions to reduce hospital stay for older adults following elective surgery: a systematic review Michael Nunnso ,1* Liz Shawo ,1 Simon Briscoeo ,1 Jo Thompson Coono ,1 Anthony Hemsleyo ,2 John S McGratho ,1,3 Christopher J Lovegroveo ,3,4 David Thomaso 3 and Rob Andersono 1 1Exeter Health Services and Delivery Research Evidence Synthesis Centre, Institute of Health Research, University of Exeter Medical School, University of Exeter, Exeter, UK 2Department of Healthcare for Older People, Royal Devon & Exeter NHS Foundation Trust, Exeter, UK 3Royal Devon & Exeter NHS Foundation Trust, Exeter, UK 4School of Health Professions, Faculty of Health & Human Sciences, University of Plymouth, Plymouth, UK *Corresponding author m.p.nunns@exeter.ac.uk Background: Elective older adult inpatient admissions are increasingly common. Older adults are at an elevated risk of adverse events in hospital, potentially increasing with lengthier hospital stay. Hospital-led organisational strategies may optimise hospital stay for elective older adult inpatients. Objectives: To evaluate the effectiveness and cost-effectiveness of hospital-led multicomponent interventions to reduce hospital stay for older adults undergoing elective hospital admissions. Data sources: Seven bibliographic databases (MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, EMBASE, Health Management Information Consortium, Cochrane Central Register of Controlled Trials, Cumulative Index to Nursing and Allied Health Literature and Allied and Complementary Medicine Database) were searched from inception to date of search (August 2017), alongside carrying out of web searches, citation searching, inspecting relevant reviews, consulting stakeholders and contacting authors. This search was duplicated, with an additional cost-filter, to identify cost-effectiveness evidence. Review methods: Comparative studies were sought that evaluated the effectiveness or cost-effectiveness of relevant interventions in elective inpatients with a mean or median age of ≥ 60 years. Study selection, data extraction and quality assessment were completed independently by two reviewers. The main outcome was length of stay, but all outcomes were considered. Studies were sorted by procedure, intervention and outcome categories. Where possible, standardised mean differences or odds ratios were calculated. Meta-analysis was performed when multiple randomised controlled trials had the same intervention, treatment procedure, comparator and outcome. Findings were explored using narrative synthesis. Findings: A total of 218 articles were included, with 80 articles from 73 effectiveness studies (n = 26,365 patients) prioritised for synthesis, including 34 randomised controlled trials conducted outside the UK and 39 studies from the UK, of which 12 were randomised controlled trials. Fifteen studies included cost-effectiveness data. The evidence was dominated by enhanced recovery protocols and prehab","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"7 1","pages":"1-178"},"PeriodicalIF":0.0,"publicationDate":"2019-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42768471","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Informing NHS policy in ‘digital-first primary care’: a rapid evidence synthesis","authors":"M. Rodgers, G. Raine, Siân Thomas, M. Harden, A. Eastwood","doi":"10.3310/hsdr07410","DOIUrl":"https://doi.org/10.3310/hsdr07410","url":null,"abstract":"Informing NHS policy in ‘digital-first primary care’: a rapid evidence synthesis Mark Rodgerso ,* Gary Raineo , Sian Thomaso , Melissa Hardeno and Alison Eastwoodo Centre for Reviews and Dissemination, University of York, York, UK *Corresponding author mark.rodgers@york.ac.uk Background: In ‘digital-first primary care’ models of health-care delivery, a patient’s first point of contact with a general practitioner or other health professional is through a digital channel, rather than a face-to-face consultation. Patients are able to access advice and treatment remotely from their home or workplace via a number of different technologies. Objectives: This rapid responsive evidence synthesis was undertaken to inform NHS England policy in ‘digital-first primary care’. It was conducted in two stages: (1) scoping the published evidence and (2) addressing a refined set of questions produced by NHS England from the evidence retrieved during","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":"7 1","pages":"1-124"},"PeriodicalIF":0.0,"publicationDate":"2019-12-20","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45171985","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Developing an intervention around referral and admissions to intensive care: a mixed-methods study","authors":"C. Bassford, F. Griffiths, M. Svantesson, M. Ryan, N. Krucien, J. Dale, S. Rees, K. Rees, A. Ignatowicz, H. Parsons, N. Flowers, Z. Fritz, G. Perkins, Sarah Quinton, Sarah Symons, C. White, Huayi Huang, J. Turner, M. Brooke, Aimee McCreedy, C. Blake, A. Slowther","doi":"10.3310/hsdr07390","DOIUrl":"https://doi.org/10.3310/hsdr07390","url":null,"abstract":"Intensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.To explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.A mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.Influences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.Limitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.Decision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resource","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-11-22","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45886532","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Using online patient feedback to improve NHS services: the INQUIRE multimethod study","authors":"J. Powell, H. Atherton, V. Williams, Fadhila Mazanderani, Farzana Dudhwala, S. Woolgar, A. Boylan, J. Fleming, S. Kirkpatrick, Angela Martin, M. V. van Velthoven, A. de Iongh, Douglas Findlay, L. Locock, S. Ziebland","doi":"10.3310/hsdr07380","DOIUrl":"https://doi.org/10.3310/hsdr07380","url":null,"abstract":"\u0000 \u0000 Online customer feedback has become routine in many industries, but it has yet to be harnessed for service improvement in health care.\u0000 \u0000 \u0000 \u0000 To identify the current evidence on online patient feedback; to identify public and health professional attitudes and behaviour in relation to online patient feedback; to explore the experiences of patients in providing online feedback to the NHS; and to examine the practices and processes of online patient feedback within NHS trusts.\u0000 \u0000 \u0000 \u0000 A multimethod programme of five studies: (1) evidence synthesis and stakeholder consultation; (2) questionnaire survey of the public; (3) qualitative study of patients’ and carers’ experiences of creating and using online comment; (4) questionnaire surveys and a focus group of health-care professionals; and (5) ethnographic organisational case studies with four NHS secondary care provider organisations.\u0000 \u0000 \u0000 \u0000 The UK.\u0000 \u0000 \u0000 \u0000 We searched bibliographic databases and conducted hand-searches to January 2018. Synthesis was guided by themes arising from consultation with 15 stakeholders. We conducted a face-to-face survey of a representative sample of the UK population (n = 2036) and 37 purposively sampled qualitative semistructured interviews with people with experience of online feedback. We conducted online surveys of 1001 quota-sampled doctors and 749 nurses or midwives, and a focus group with five allied health professionals. We conducted ethnographic case studies at four NHS trusts, with a researcher spending 6–10 weeks at each site.\u0000 \u0000 \u0000 \u0000 Many people (42% of internet users in the general population) read online feedback from other patients. Fewer people (8%) write online feedback, but when they do one of their main reasons is to give praise. Most online feedback is positive in its tone and people describe caring about the NHS and wanting to help it (‘caring for care’). They also want their feedback to elicit a response as part of a conversation. Many professionals, especially doctors, are cautious about online feedback, believing it to be mainly critical and unrepresentative, and rarely encourage it. From a NHS trust perspective, online patient feedback is creating new forms of response-ability (organisations needing the infrastructure to address multiple channels and increasing amounts of online feedback) and responsivity (ensuring responses are swift and publicly visible).\u0000 \u0000 \u0000 \u0000 This work provides only a cross-sectional snapshot of a fast-emerging phenomenon. Questionnaire surveys can be limited by response bias. The quota sample of doctors and volunteer sample of nurses may not be representative. The ethnographic work was limited in its interrogation of differences between sites.\u0000 \u0000 \u0000 \u0000 Providing and using online feedback are becoming more common for patients who are often motivated to give praise and to help the NHS improve, but health organisations and professionals are cautious and not fully prepared to use online feedback for service improvement. We identi","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43929627","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Alternative community-based models of care for young people with anorexia nervosa: the CostED national surveillance study","authors":"S. Byford, H. Petkova, R. Stuart, D. Nicholls, M. Simic, T. Ford, G. Macdonald, S. Gowers, S. Roberts, B. Barrett, J. Kelly, G. Kelly, Nuala Livingstone, K. Joshi, Helen Smith, I. Eisler","doi":"10.3310/hsdr07370","DOIUrl":"https://doi.org/10.3310/hsdr07370","url":null,"abstract":"\u0000 \u0000 Evidence suggests that investing in specialist eating disorders services for young people with anorexia nervosa could have important implications for the NHS, with the potential to improve health outcomes and reduce costs through reductions in the number and length of hospital admissions.\u0000 \u0000 \u0000 \u0000 The primary objectives were to evaluate the costs and cost-effectiveness of alternative community-based models of service provision for young people with anorexia nervosa and to model the impact of potential changes to the provision of specialist services.\u0000 \u0000 \u0000 \u0000 Observational surveillance study using the Child and Adolescent Psychiatry Surveillance System.\u0000 \u0000 \u0000 \u0000 Community-based secondary or tertiary child and adolescent mental health services (CAMHS) in the UK and the Republic of Ireland.\u0000 \u0000 \u0000 \u0000 A total of 298 young people aged 8–17 years in contact with CAMHS for a first episode of anorexia nervosa in accordance with Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, diagnostic criteria.\u0000 \u0000 \u0000 \u0000 Community-based specialist eating disorders services and generic CAMHS.\u0000 \u0000 \u0000 \u0000 Children’s Global Assessment Scale (CGAS) score (primary outcome) and percentage of median expected body mass index (BMI) for age and sex (%mBMI) (secondary outcome) were assessed at baseline and at 6 and 12 months.\u0000 \u0000 \u0000 \u0000 Data were collected by clinicians from clinical records.\u0000 \u0000 \u0000 \u0000 Total costs incurred by young people initially assessed in specialist eating disorders services were not significantly different from those incurred by young people initially assessed in generic CAMHS. However, adjustment for baseline covariates resulted in observed differences favouring specialist services (costs were lower, on average) because of the significantly poorer clinical status of the specialist group at baseline. At the 6-month follow-up, mean %mBMI was significantly higher in the specialist group, but no other significant differences in outcomes were evident. Cost-effectiveness analyses suggest that initial assessment in a specialist service has a higher probability of being cost-effective than initial assessment in generic CAMHS, as determined by CGAS score and %mBMI. However, no firm conclusion can be drawn without knowledge of society’s willingness to pay for improvements in these outcomes. Decision modelling did not support the hypothesis that changes to the provision of specialist services would generate savings for the NHS, with results suggesting that cost per 10-point improvement in CGAS score (improvement from one CGAS category to the next) varies little as the percentage of participants taking the specialist or generic pathway is varied.\u0000 \u0000 \u0000 \u0000 Follow-up rates were lower than expected, but the sample was still larger than has been achieved to date in RCTs carried out in this population in the UK, and an exploration of the impact of missing cost and outcome data produced very similar results to those of the main analyses.\u0000 \u0000 \u0000 \u0000 The results of this study sugg","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-29","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"45316884","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Using patient experience data to develop a patient experience toolkit to improve hospital care: a mixed-methods study","authors":"L. Sheard, C. Marsh, T. Mills, Rosemary Peacock, Joe Langley, R. Partridge, I. Gwilt, R. Lawton","doi":"10.3310/hsdr07360","DOIUrl":"https://doi.org/10.3310/hsdr07360","url":null,"abstract":"\u0000 \u0000 Patients are increasingly being asked to provide feedback about their experience of health-care services. Within the NHS, a significant level of resource is now allocated to the collection of this feedback. However, it is not well understood whether or not, or how, health-care staff are able to use these data to make improvements to future care delivery.\u0000 \u0000 \u0000 \u0000 To understand and enhance how hospital staff learn from and act on patient experience (PE) feedback in order to co-design, test, refine and evaluate a Patient Experience Toolkit (PET).\u0000 \u0000 \u0000 \u0000 A predominantly qualitative study with four interlinking work packages.\u0000 \u0000 \u0000 \u0000 Three NHS trusts in the north of England, focusing on six ward-based clinical teams (two at each trust).\u0000 \u0000 \u0000 \u0000 A scoping review and qualitative exploratory study were conducted between November 2015 and August 2016. The findings of this work fed into a participatory co-design process with ward staff and patient representatives, which led to the production of the PET. This was primarily based on activities undertaken in three workshops (over the winter of 2016/17). Then, the facilitated use of the PET took place across the six wards over a 12-month period (February 2017 to February 2018). This involved testing and refinement through an action research (AR) methodology. A large, mixed-methods, independent process evaluation was conducted over the same 12-month period.\u0000 \u0000 \u0000 \u0000 The testing and refinement of the PET during the AR phase, with the mixed-methods evaluation running alongside it, produced noteworthy findings. The idea that current PE data can be effectively triangulated for the purpose of improvement is largely a fallacy. Rather, additional but more relational feedback had to be collected by patient representatives, an unanticipated element of the study, to provide health-care staff with data that they could work with more easily. Multidisciplinary involvement in PE initiatives is difficult to establish unless teams already work in this way. Regardless, there is merit in involving different levels of the nursing hierarchy. Consideration of patient feedback by health-care staff can be an emotive process that may be difficult initially and that needs dedicated time and sensitive management. The six ward teams engaged variably with the AR process over a 12-month period. Some teams implemented far-reaching plans, whereas other teams focused on time-minimising ‘quick wins’. The evaluation found that facilitation of the toolkit was central to its implementation. The most important factors here were the development of relationships between people and the facilitator’s ability to navigate organisational complexity.\u0000 \u0000 \u0000 \u0000 The settings in which the PET was tested were extremely diverse, so the influence of variable context limits hard conclusions about its success.\u0000 \u0000 \u0000 \u0000 The current manner in which PE feedback is collected and used is generally not fit for the purpose of enabling health-care staff to make meaningful loca","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-17","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"48093435","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"Intentional rounding in hospital wards to improve regular interaction and engagement between nurses and patients: a realist evaluation","authors":"Ruth Harris, S. Sims, M. Leamy, R. Levenson, N. Davies, S. Brearley, R. Grant, Stephen Gourlay, G. Favato, F. Ross","doi":"10.3310/hsdr07350","DOIUrl":"https://doi.org/10.3310/hsdr07350","url":null,"abstract":"© Crown copyright 2013. Contains public sector information licensed under the Open Government Licence v3.0© Queen’s Printer and Controller of HMSO 2019. This work was produced by Harriset al.under the terms of a commissioning contract issued by the Secretary of State for Health and Social Care. This issue may be freely reproduced for the purposes of private research and study and extracts (or indeed, the full report) may be included in professional journals provided that suitable acknowledgement is made and the reproduction is not associated with any form of advertising. Applications for commercial reproduction should be addressed to: NIHR Journals Library, National Institute for Health Research, Evaluation, Trials and Studies Coordinating Centre, Alpha House, University of Southampton Science Park, Southampton SO16 7NS, UK.20132019Crown copyrightQueen’s Printer and Controller of HMSOThe government response to the care failures at the Mid Staffordshire NHS Foundation Trust led to the policy imperative of ‘regular interaction and engagement between nurses and patients’ (Francis R.Report of the Mid Staffordshire NHS Foundation Trust Public Inquiry. London: The Stationery Office; 2013. © Crown copyright 2013. Contains public sector information licensed under the Open Government Licence v3.0) in the NHS. The pressure on nursing to act resulted in the introduction of the US model, known as ‘intentional rounding’, into nursing practice. This is a timed, planned intervention that sets out to address fundamental elements of nursing care by means of a regular bedside ward round.The study aims were to examine what it is about intentional rounding in hospital wards that works, for whom and in what circumstances.A multimethod study design was undertaken using realist evaluation methodology. The study was conducted in four phases: (1) theory development; (2) a national survey of all NHS acute trusts in England; (3) in-depth case studies of six wards, involving individual interviews, observations, retrieval of routinely collected ward outcome data and analysis of costs; and (4) synthesis of the study findings.The study was conducted in acute NHS trusts in England.A total of 108 acute NHS trusts participated in the survey. Seventeen senior managers, 33 front-line nurses, 28 non-nursing professionals, 34 patients and 28 carers participated in individual interviews. Thirty-nine members of nursing staff were shadowed during their delivery of intentional rounding and the direct care received by 28 patients was observed.A realist synthesis was undertaken to identify eight context–mechanism–outcome configurations, which were tested and refined using evidence collected in subsequent research phases.The national survey showed that 97% of NHS trusts had implemented intentional rounding in some way. Data synthesis from survey, observation and interview findings showed that only two of the original eight mechanisms were partially activated (consistency and comprehensivene","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-10-09","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"43573995","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}

{"title":"A national quality improvement programme to improve survival after emergency abdominal surgery: the EPOCH stepped-wedge cluster RCT","authors":"C. Peden, T. Stephens, Graham Martin, B. Kahan, Ann Thomson, K. Everingham, D. Kocman, J. Lourtie, S. Drake, A. Girling, R. Lilford, K. Rivett, Duncan Wells, R. Mahajan, P. Holt, Fan Yang, S. Walker, G. Richardson, S. Kerry, I. Anderson, D. Murray, D. Cromwell, M. Phull, M. Grocott, J. Bion, R. Pearse","doi":"10.3310/hsdr07320","DOIUrl":"https://doi.org/10.3310/hsdr07320","url":null,"abstract":"\u0000 \u0000 Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients.\u0000 \u0000 \u0000 \u0000 The objectives were to assess whether or not the QI programme improves 90-day survival after emergency abdominal surgery; to assess effects on 180-day survival, hospital stay and hospital readmission; and to better understand these findings through an integrated process evaluation, ethnographic study and cost-effectiveness analysis.\u0000 \u0000 \u0000 \u0000 This was a stepped-wedge cluster randomised trial. Hospitals were organised into 15 geographical clusters, and commenced the QI programme in random order over 85 weeks. Analyses were performed on an intention-to-treat basis. The primary outcome was analysed using a mixed-effects parametric survival model, adjusting for time-related effects. Ethnographic and economics data were collected in six hospitals. The process evaluation included all hospitals.\u0000 \u0000 \u0000 \u0000 The trial was set in acute surgical services of 93 NHS hospitals.\u0000 \u0000 \u0000 \u0000 Patients aged ≥ 40 years who were undergoing emergency abdominal surgery were eligible.\u0000 \u0000 \u0000 \u0000 The intervention was a QI programme to implement an evidence-based care pathway.\u0000 \u0000 \u0000 \u0000 The primary outcome measure was mortality within 90 days of surgery. Secondary outcomes were mortality within 180 days, length of hospital stay and hospital readmission within 180 days. The main economic measure was the quality-adjusted life-years.\u0000 \u0000 \u0000 \u0000 Data were obtained from the National Emergency Laparotomy Audit database; qualitative interviews and ethnographic observations; quality-of-life and NHS resource use data were collected via questionnaires.\u0000 \u0000 \u0000 \u0000 Of 15,873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 participants in the usual care group and 7374 in the QI group. The primary outcome occurred in 1393 participants in the usual care group (16%), compared with 1210 patients in the QI group (16%) [QI vs. usual care hazard ratio (HR) 1.11, 95% confidence interval (CI) 0.96 to 1.28]. No differences were found in mortality at 180 days or hospital readmission; there was a small increase in hospital stay in the QI group (HR for discharge 0.90, 95% CI 0.83 to 0.97). There were only modest improvements in care processes following QI implementation. The ethnographic study revealed good QI engagement, but limited time and resources to implement change, affecting which processes teams addressed, the rate of change and eventual success. In some sites, there were challenges around prioritising the intervention in busy environments and in obtaining senior engagement. The intervention is unlikely to be cost-effective at standard cost-effectiveness thresholds, but may be cost-effective over the lifetime horizon.\u0000 \u0000 \u0000 \u0000 Substantial delays were encountered in securing data access to national registries. Fewer patients than expected underwent surgery a","PeriodicalId":12880,"journal":{"name":"Health Services and Delivery Research","volume":" ","pages":""},"PeriodicalIF":0.0,"publicationDate":"2019-09-25","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"42103921","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":0,"RegionCategory":"","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}