质量改进和研究:它们能协同工作吗?

IF 1.9 3区 医学 Q2 DENTISTRY, ORAL SURGERY & MEDICINE
G. D. Taylor
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Incorrectly labelling a research project as a QI initative runs the risk of ethical breaches, especially if patient data is used without appropriate consent. Similarly, findings may be invalid as the methods employed are likely not to be as robust and rigorous as they should be. In contrast, research can be labelled incorrectly, when in fact it is QI. In these cases, it is often a mistake; however, it could be that clinical teams wish to promote the project as research, instead of QI, as it seems more prestigious or publishable [<span>5</span>]. Misinterpreting QI as research is of less concern than the converse. However, in doing so, the iterative nature of QI approaches might be lost or unnecessary delays are result from the often protracted ethical review and regulatory approval processes [<span>3</span>].</p><p>There are some simple ways to avoid misinterpretation. The easiest method is to use established decisions tools. 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The results of these QI initiatives highlighted the commonly reported impacts (pain, eating, sleep loss and daily activities) were mostly being recorded [<span>9</span>]; however, there was variation and lack of consensus in the management options being used in the local context. While useful, the QI approaches highlighted unresolved clinical questions. Following the translational loop, shown in Figure 1, a follow-on research study was designed and undertaken to ascertain how cFPM were being managed across the United Kingdom by general dentists and specialists in paediatric dentistry. The findings identified substantial differences between, and within, these professional groups [<span>10</span>]. The findings from this research were unable, in isolation, to inform a change in clinical practice. 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Despite disseminating this message through publications [<span>13-15</span>] and regional and international presentations, it was felt at a local departmental meeting that shared decision making was not routinely being undertaken for cFPM. As part of a QIP, following PDSA principles, ‘planned’ baseline data showed that shared-decision making was not common practice. For the ‘Do’ stage, age-appropriate information is currently being developed by colleagues at Newcastle Dental Hospital for both children and parents to help facilitate this process. Data will be collected to ‘study’ whether the intervention was effective, before ‘acting’ on what to do next. 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引用次数: 0

摘要

质量改进(QI)和研究对于提高患者护理水平是必不可少的。不幸的是,它们经常被误解为彼此,这可能导致道德、实践和监管方面的挑战。尽管这两项活动具有不同的目的,但它们可以协同工作,并构成循证实践和创新bb10的转化连续体的一部分。QI揭示值得正式研究的问题并不罕见。本文将探讨什么是QI和research,以及它们如何被误解。随后将简要讨论它们如何共存,并使用一个关注受损第一恒磨牙(cFPM)管理的案例研究来证明这一点。质量改进是一个总体术语,用于描述改善医疗保健结果的系统持续方法。一旦确定了问题,QI过程就会致力于发现解决方案,旨在改善服务提供,并最终改善患者预后。QI方法包括审计、服务评价和质量改进项目(QIP),而不是单一的方法。相比之下,研究是假设驱动的,方法严谨,旨在产生超越当地背景的可推广的发现。研究需要伦理批准(而不是QI的地方监督),并由严格的标准管理,以确保其可靠性和有效性。现在将更详细地讨论这三种QI方法和研究。研究和QI方法经常被混为一谈。考虑到两者在道德和法律要求上的差异,这可能会产生重大后果。如上所述,研究测试了一个新的想法,旨在产生可推广的证据[3,5]。任何符合这些标准的项目都是研究。将研究错误地标记为“QI”是相对常见的[2,5]。很可能是天真;然而,它可以故意避免研究中需要的伦理和监管审查。任何测试一种新的干预措施(例如,修复材料的成功与否)或从患者那里收集新知识(例如,关于放置氟化二胺银后变色的意见)的项目都是研究,应被视为研究。错误地将一个研究项目标记为QI倡议存在违反伦理的风险,特别是在未经适当同意使用患者数据的情况下。同样,研究结果可能是无效的,因为所采用的方法可能不像它们应该的那样健壮和严格。相比之下,研究可能被错误地贴上标签,而实际上它是QI。在这些情况下,这往往是一个错误;然而,可能是临床团队希望将该项目作为研究来推广,而不是QI,因为它看起来更有声望或更容易发表。将QI误解为研究更值得关注。然而,在这样做的过程中,QI方法的迭代性质可能会丢失,或者由于经常旷日持久的伦理审查和监管批准过程而导致不必要的延迟。有一些简单的方法可以避免误解。最简单的方法是使用已建立的决策工具。英国卫生研究管理局提供了一个在线决策辅助工具,以确定一个项目是研究、审计还是服务评估bb0。或者,团队可以寻求当地研发部门的早期建议,以帮助确定正确的分类。在现实中,QI和研究经常共存,经常在一个转化循环中相互补充(见图1)[2,4,5]。QI计划有助于确定有研究价值的问题和/或提供基于临床相关性的见解,从而有助于塑造研究的设计。相反,导致实践[7]循证变化的研究结果可以通过QI方法在当地进行调整和测试,从而确保吸收和可持续性[2,7]。在实践中,在牙科中翻译证据是具有挑战性的,因为各种复杂的健康状况和实践环境的多样性被认为是实施bbb的主要障碍。尽管如此,如果做得好,共存可以促进证据更快地转化为实践,支持整个医疗保健系统的持续改进和创新[1,2,7]。如何最好地管理cfpm的问题-是恢复还是提取-被认为是一个关键的临床挑战,导致了决定项目的启动。采用了QI方法的组合,以(A)确定是否作为患者评估过程的一部分讨论了与儿童cFPM相关的公认的直接影响[9],以及(b)讨论和提供了哪些治疗方案。 这些QI倡议的结果强调了通常报告的影响(疼痛、饮食、睡眠不足和日常活动)大多被记录在2010年;但是,在当地情况下使用的管理办法存在差异,缺乏共识。QI方法虽然有用,但突出了尚未解决的临床问题。在图1所示的转化循环之后,设计并开展了一项后续研究,以确定英国普通牙医和儿科牙科专家如何管理cFPM。研究结果表明,这些专业群体之间和内部存在巨大差异。这项研究的结果,孤立地,不能告知临床实践的变化。因此,开展了一项更广泛的研究计划(作为NIHR博士研究奖学金的一部分资助),以(a)通过半结构化访谈建立青少年和成年人对管理cFPM的看法和经验,(b)引出公众对管理cFPM的偏好,包括确定社会支付意愿(WTP)。使用离散选择实验和(c)使用数学模型[11]确定在患者一生中管理cFPM的最有效方法。这些研究的结果在其他地方也有报道[12-14];然而,很明显,做出恢复或提取的决定并不是二元的。相反,对于cFPM,患者、家长和医疗保健专业人员共同做出共同决策的必要性变得非常明确[13-15]。尽管通过出版物[13-15]以及区域和国际演讲传播了这一信息,但在当地的部门会议上,人们认为cFPM并没有常规地进行共同决策。作为QIP的一部分,遵循PDSA原则,“计划的”基线数据显示共同决策并不常见。在“做”阶段,纽卡斯尔牙科医院的同事目前正在为儿童和家长开发适合年龄的信息,以帮助促进这一过程。在采取下一步行动之前,将收集数据以“研究”干预措施是否有效。该QIP将继续进行,同时将进行进一步的研究,探索如何将这些干预措施嵌入决策辅助系统,以支持cFPM在多种环境下的决策。这个孤立的案例研究显示了QI和研究之间复杂而密切的关系。尽管QI和研究经常被误解为彼此,但它们可以而且应该共存,作为循证实践的转化连续体的一部分。作者声明无利益冲突。
本文章由计算机程序翻译,如有差异,请以英文原文为准。

Quality Improvement and Research: Can They Work Synergistically?

Quality Improvement and Research: Can They Work Synergistically?

Quality improvement (QI) and research are both essential and necessary for advancing patient care. Unfortunately, they are often misinterpreted for one another, which can lead to ethical, practical, and regulatory challenges [1]. Despite these two activities serving distinct purposes, they can work synergistically and form part of a translational continuum of evidence-informed practice and innovation [2]. It is not uncommon that QI reveals questions that are worthy of formally researching.

This article will explore what QI and research are, and how they can be misinterpreted. This will be followed by a brief discussion on how they can co-exist, using a case study focusing on the management of compromised first permanent molars (cFPM), to demonstrate this.

Quality improvement is an overarching term used to describe a systematic continuous approach to improving healthcare outcomes. Once a problem is identified, QI processes work towards findings solutions that aim to improve service provision, and ultimately patient outcomes [2]. Rather than a single method, QI methods include audit, service evaluation and quality improvement project (QIP). Research, in contrast, is hypothesis-driven, methodologically rigorous, and designed to generate findings that are generalisable beyond the local context [3]. Research requires ethical approval (rather than local oversight in QI) and is governed by strict standards to ensure their reliability and validity. The three QI approaches and research will now be discussed in more detail.

Research and QI approaches are frequently conflated. This could have significant ramifications given the ethical and legal requirement differences between the two.

As described above, research tests a new idea and aims to generate generalisable evidence [3, 5]. Any project that meets these criteria is research. Labelling research as ‘QI’ incorrectly is relatively common [2, 5]. It is likely to be naivety; however, it can be deliberate to avoid the ethical and regulatory scrutiny required in research studies [5]. Any project that tests a novel intervention (e.g., success of restorative material) or collects new knowledge from patients (e.g., opinions on discolouration following placement of silver diamine fluoride) is research, and should be treated as such. Incorrectly labelling a research project as a QI initative runs the risk of ethical breaches, especially if patient data is used without appropriate consent. Similarly, findings may be invalid as the methods employed are likely not to be as robust and rigorous as they should be. In contrast, research can be labelled incorrectly, when in fact it is QI. In these cases, it is often a mistake; however, it could be that clinical teams wish to promote the project as research, instead of QI, as it seems more prestigious or publishable [5]. Misinterpreting QI as research is of less concern than the converse. However, in doing so, the iterative nature of QI approaches might be lost or unnecessary delays are result from the often protracted ethical review and regulatory approval processes [3].

There are some simple ways to avoid misinterpretation. The easiest method is to use established decisions tools. The UK's Health Research Authority provides an online decision aid to determine if a project is research, audit, or service evaluation [8]. Alternatively, teams can seek early advice from local research and development departments to help determine the correct classification.

In reality, QI and research regularly co-exist, often complementing one another in a translational loop (see Figure 1) [2, 4, 5]. QI initiatives help identify research-worthy questions and/or provide insights, grounded in clinical relevance, that help shape the design of the research study. In converse, research findings which lead to evidence-based changes of practice [7] can then be adapted and tested locally through QI approaches, ensuring uptake and sustainability [2, 7]. In practice, translating evidence is challenging in dentistry with variable and complex health conditions and diversity of practice settings being cited as the main obstacles to implementation [7]. Despite this, when done well, the co-existence can promote faster translation of evidence into practice, supporting the continuous improvement and innovation across healthcare systems [1, 2, 7].

The question of how best to manage cFPM—whether to restore or extract—was identified as a key clinical challenge, leading to the initiation of the DECIDE project. A combination of QI approaches were undertaken to (a) establish whether the acknowledged direct impacts associated with cFPM in children were being discussed as part of the patient assessment process [9], and (b) what treatment options were being discussed and offered. The results of these QI initiatives highlighted the commonly reported impacts (pain, eating, sleep loss and daily activities) were mostly being recorded [9]; however, there was variation and lack of consensus in the management options being used in the local context. While useful, the QI approaches highlighted unresolved clinical questions. Following the translational loop, shown in Figure 1, a follow-on research study was designed and undertaken to ascertain how cFPM were being managed across the United Kingdom by general dentists and specialists in paediatric dentistry. The findings identified substantial differences between, and within, these professional groups [10]. The findings from this research were unable, in isolation, to inform a change in clinical practice. As a result, a wider programme of research (funded as part of an NIHR doctoral research fellowship) was undertaken to (a) establish adolescents' and adults' views and experiences around managing cFPM using semi-structured interviews, (b) elicit the public's preferences for managing cFPM, including determining societal willingness to pay (WTP), using a discrete choice experiment and (c) determine the most efficient way of managing cFPM over the lifetime of a patient using mathematical modelling [11]. The findings of these studies are reported elsewhere [12-14]; however, it was clear that making the decision to restore or extract is not binary. Instead, the need to make shared decisions jointly between the patient, parent and healthcare professional for cFPM became abundantly clear [13-15]. Despite disseminating this message through publications [13-15] and regional and international presentations, it was felt at a local departmental meeting that shared decision making was not routinely being undertaken for cFPM. As part of a QIP, following PDSA principles, ‘planned’ baseline data showed that shared-decision making was not common practice. For the ‘Do’ stage, age-appropriate information is currently being developed by colleagues at Newcastle Dental Hospital for both children and parents to help facilitate this process. Data will be collected to ‘study’ whether the intervention was effective, before ‘acting’ on what to do next. This QIP will continue whilst a further research study looking to explore how these interventions can be embedded into a decision-aid to support decision-making of cFPM across multiple settings will then follow.

The isolated case study demonstrates the intricate and intimate relationship QI and research can have.

Despite QI and research often being misinterpreted for one another, they can and should co-exist as part of translational continuum of evidence-informed practice.

The author declares no conflicts of interest.

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来源期刊
CiteScore
5.50
自引率
2.60%
发文量
82
审稿时长
6-12 weeks
期刊介绍: The International Journal of Paediatric Dentistry was formed in 1991 by the merger of the Journals of the International Association of Paediatric Dentistry and the British Society of Paediatric Dentistry and is published bi-monthly. It has true international scope and aims to promote the highest standard of education, practice and research in paediatric dentistry world-wide. International Journal of Paediatric Dentistry publishes papers on all aspects of paediatric dentistry including: growth and development, behaviour management, diagnosis, prevention, restorative treatment and issue relating to medically compromised children or those with disabilities. This peer-reviewed journal features scientific articles, reviews, case reports, clinical techniques, short communications and abstracts of current paediatric dental research. Analytical studies with a scientific novelty value are preferred to descriptive studies. Case reports illustrating unusual conditions and clinically relevant observations are acceptable but must be of sufficiently high quality to be considered for publication; particularly the illustrative material must be of the highest quality.
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