Publications by authors named "Joanne Greenhalgh"

57 Publications

Routine provision of feedback from patient-reported outcome measurements to healthcare providers and patients in clinical practice.

Cochrane Database Syst Rev 2021 Oct 12;10:CD011589. Epub 2021 Oct 12.

Health Services & Policy Research, Exeter Collaboration for Academic Primary Care (APEx), NIHR School for Primary Care Research, NIHR ARC South West Peninsula (PenARC), University of Exeter, Exeter, UK.

Background: Patient-reported outcomes measures (PROMs) assess a patient's subjective appraisal of health outcomes from their own perspective. Despite hypothesised benefits that feedback  on PROMs can support decision-making in clinical practice and improve outcomes, there is uncertainty surrounding the effectiveness of PROMs feedback.

Objectives: To assess the effects of PROMs feedback to patients, or healthcare workers, or both on patient-reported health outcomes and processes of care.

Search Methods: We searched MEDLINE, Embase, CENTRAL, two other databases and two clinical trial registries on 5 October 2020. We searched grey literature and consulted experts in the field.

Selection Criteria: Two review authors independently screened and selected studies for inclusion. We included randomised trials directly comparing the effects on outcomes and processes of care of PROMs feedback to healthcare professionals and patients, or both with the impact of not providing such information.

Data Collection And Analysis: Two groups of two authors independently extracted data from the included studies and evaluated study quality. We followed standard methodological procedures expected by Cochrane and EPOC. We used the GRADE approach to assess the certainty of the evidence. We conducted meta-analyses of the results where possible.

Main Results: We identified 116 randomised trials which assessed the effectiveness of PROMs feedback in improving processes or outcomes of care, or both in a broad range of disciplines including psychiatry, primary care, and oncology. Studies were conducted across diverse ambulatory primary and secondary care settings in North America, Europe and Australasia. A total of 49,785 patients were included across all the studies. The certainty of the evidence varied between very low and moderate. Many of the studies included in the review were at risk of performance and detection bias. The evidence suggests moderate certainty that PROMs feedback probably improves quality of life (standardised mean difference (SMD) 0.15, 95% confidence interval (CI) 0.05 to 0.26; 11 studies; 2687 participants), and leads to an increase in patient-physician communication (SMD 0.36, 95% CI 0.21 to 0.52; 5 studies; 658 participants), diagnosis and notation (risk ratio (RR) 1.73, 95% CI 1.44 to 2.08; 21 studies; 7223 participants), and disease control (RR 1.25, 95% CI 1.10 to 1.41; 14 studies; 2806 participants). The intervention probably makes little or no difference for general health perceptions (SMD 0.04, 95% CI -0.17 to 0.24; 2 studies, 552 participants; low-certainty evidence), social functioning (SMD 0.02, 95% CI -0.06 to 0.09; 15 studies; 2632 participants; moderate-certainty evidence), and pain (SMD 0.00, 95% CI -0.09 to 0.08; 9 studies; 2386 participants; moderate-certainty evidence). We are uncertain about the effect of PROMs feedback on physical functioning (14 studies; 2788 participants) and mental functioning (34 studies; 7782 participants), as well as fatigue (4 studies; 741 participants), as the certainty of the evidence was very low. We did not find studies reporting on adverse effects defined as distress following or related to PROM completion.

Authors' Conclusions: PROM feedback probably produces moderate improvements in communication between healthcare professionals and patients as well as in diagnosis and notation, and disease control, and small improvements to quality of life. Our confidence in the effects is limited by the risk of bias, heterogeneity and small number of trials conducted to assess outcomes of interest. It is unclear whether   many of these improvements are clinically meaningful or sustainable in the long term. There is a need for more high-quality studies in this area, particularly studies which employ cluster designs and utilise techniques to maintain allocation concealment.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1002/14651858.CD011589.pub2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8509115PMC
October 2021

Understanding the complexities of collecting and using PRO data in a primary care context.

BMJ Qual Saf 2021 Sep 11. Epub 2021 Sep 11.

School of Sociology and Social Policy, University of Leeds, Leeds, UK

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjqs-2021-013315DOI Listing
September 2021

Hidden labour: the skilful work of clinical audit data collection and its implications for secondary use of data via integrated health IT.

BMC Health Serv Res 2021 Jul 16;21(1):702. Epub 2021 Jul 16.

Faculty of Health Studies, University of Bradford, Bradford, UK.

Background: Secondary use of data via integrated health information technology is fundamental to many healthcare policies and processes worldwide. However, repurposing data can be problematic and little research has been undertaken into the everyday practicalities of inter-system data sharing that helps explain why this is so, especially within (as opposed to between) organisations. In response, this article reports one of the most detailed empirical examinations undertaken to date of the work involved in repurposing healthcare data for National Clinical Audits.

Methods: Fifty-four semi-structured, qualitative interviews were carried out with staff in five English National Health Service hospitals about their audit work, including 20 staff involved substantively with audit data collection. In addition, ethnographic observations took place on wards, in 'back offices' and meetings (102 h). Findings were analysed thematically and synthesised in narratives.

Results: Although data were available within hospital applications for secondary use in some audit fields, which could, in theory, have been auto-populated, in practice staff regularly negotiated multiple, unintegrated systems to generate audit records. This work was complex and skilful, and involved cross-checking and double data entry, often using paper forms, to assure data quality and inform quality improvements.

Conclusions: If technology is to facilitate the secondary use of healthcare data, the skilled but largely hidden labour of those who collect and recontextualise those data must be recognised. Their detailed understandings of what it takes to produce high quality data in specific contexts should inform the further development of integrated systems within organisations.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12913-021-06657-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8284699PMC
July 2021

When trust, confidence, and faith collide: refining a realist theory of how and why inter-organisational collaborations in healthcare work.

BMC Health Serv Res 2021 Jun 26;21(1):602. Epub 2021 Jun 26.

Sociology and Social Policy Department, University of Leeds, Leeds, LS2 9JT, UK.

Background: Health systems are facing unprecedented socioeconomic pressures as well as the need to cope with the ongoing strain brought about by the COVID-19 pandemic. In response, the reconfiguration of health systems to encourage greater collaboration and integration has been promoted with a variety of collaborative shapes and forms being encouraged and developed. Despite this continued interest, evidence for success of these various arrangements is lacking, with the links between collaboration and improved performance often remaining uncertain. To date, many examinations of collaborations have been undertaken, but use of realist methodology may shed additional light on how and why collaboration works, and whom it benefits.

Methods: This paper seeks to test initial context-mechanism-outcome configurations (CMOCs) of interorganisational collaboration with the view to producing a refined realist theory. This phase of the realist synthesis used case study and evaluation literature; combined with supplementary systematic searches. These searches were screened for rigour and relevance, after which CMOCs were extracted from included literature and compared against existing ones for refinement, refutation, or affirmation. We also identified demi-regularities to better explain how these CMOCs were interlinked.

Results: Fifty-one papers were included, from which 338 CMOCs were identified, where many were analogous. This resulted in new mechanisms such as 'risk threshold' and refinement of many others, including trust, confidence, and faith, into more well-defined constructs. Refinement and addition of CMOCs enabled the creation of a 'web of causality' depicting how contextual factors form CMOC chains which generate outputs of collaborative behaviour. Core characteristics of collaborations, such as whether they were mandated or cross-sector, were explored for their proposed impact according to the theory.

Conclusion: The formulation of this refined realist theory allows for greater understanding of how and why collaborations work and can serve to inform both future work in this area and the implementation of these arrangements. Future work should delve deeper into collaborative subtypes and the underlying drivers of collaborative performance.

Review Registration: This review is part of a larger realist synthesis, registered at PROSPERO with ID CRD42019149009 .
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12913-021-06630-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8235919PMC
June 2021

An Evidence-Based Theory About PRO Use in Kidney Care: A Realist Synthesis.

Patient 2021 Jun 10. Epub 2021 Jun 10.

Sociology and Social Policy, University of Leeds, Leeds, UK.

Background: There is international interest on the use of patient-reported outcomes (PROs) in nephrology.

Objectives: Our objectives were to develop a kidney-specific program theory about use of PROs in nephrology that may enhance person-centered care, both at individual and aggregated levels of care, and to test and refine this theory through a systematic review of the empirical literature. Together, these objectives articulate what works or does not work, for whom, and why.

Methods: Realist synthesis methodology guided the electronic database and gray literature searches (in January 2017 and October 2018), screening, and extraction conducted independently by three reviewers. Sources included all nephrology patients and/or practitioners. Through a process of extraction and synthesis, each included source was examined to assess how contexts may trigger mechanisms to influence specific outcomes.

Results: After screening 19,961 references, 84 theoretical and 34 empirical sources were used. PROs are proposed to be useful for providing nephrology care through three types of use. The first type is use of individual-level PRO data at point of care, receiving the majority of theoretical and empirical explorations. Clinician use to support person-centered care, and patient use to support patient engagement, are purported to improve satisfaction, health, and quality of life. Contextual factors specific to the kidney care setting that may influence the use of PRO data include the complexity of kidney disease symptom burden, symptoms that may be stigmatized, comorbidities, and time or administrative constraints in dialysis settings. Electronic collection of PROs may facilitate PRO use given these contexts. The second type is use of aggregated PRO data at point of care, including public reporting of PROs to inform decisions at point of care and improve quality of care, and use of PROs for treatment decisions. The third type is use of aggregated PRO data by organizations, including publicly available PRO data to compare centers. In single-payer systems, regular collection of PROs by dialysis centers can be achieved through economic incentives. Both the second and third types of PRO use include pressures that may trigger quality improvement processes.

Conclusion: The current state of the evidence is primarily theoretical. There is pressing need for empirical research to improve the evidence-base of PRO use at individual and aggregated levels of nephrology care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s40271-021-00530-2DOI Listing
June 2021

Why do some inter-organisational collaborations in healthcare work when others do not? A realist review.

Syst Rev 2021 03 22;10(1):82. Epub 2021 Mar 22.

Population Health Sciences, University of Bristol & NIHR Applied Research Collaboration West, 9th Floor, Whitefriars, Lewins Mead, Bristol, BS1 2NT, UK.

Background: Inter-organisational collaboration is increasingly prominent within contemporary healthcare systems. A range of collaboration types such as alliances, networks, and mergers have been proposed as a means to turnaround organisations, by reducing duplication of effort, enabling resource sharing, and promoting innovations. However, in practice, due to the complexity of the process, such efforts are often rife with difficulty. Notable contributions have sought to make sense of this area; however, further understanding is needed in order to gain a better understanding of why some inter-organisational collaborations work when others do not, to be able to more effectively implement collaborations in the future.

Methods: Realist review methodology was used with the intention of formulating context-mechanism-outcome configurations (CMOCs) to explain how inter-organisational collaborations work and why, combining systematic and purposive literature search techniques. The systematic review encompassed searches for reviews, commentaries, opinion pieces, and case studies on HMIC, MEDLINE, PsycINFO, and Social Policy and Practice databases, and further searches were conducted using Google Scholar. Data were extracted from included studies according to relevance to the realist review.

Results: Fifty-three papers were included, informing the development of programme theories of how, why, and when inter-organisational collaborations in healthcare work. Formulation of our programme theories incorporated the concepts of partnership synergy and collaborative inertia and found that it was essential to consider mechanisms underlying partnership functioning, such as building trust and faith in the collaboration to maximise synergy and thus collaborative performance. More integrative or mandated collaboration may lean more heavily on contract to drive collaborative behaviour.

Conclusion: As the first realist review of inter-organisational collaborations in healthcare as an intervention for improvement, this review provides actionable evidence for policymakers and implementers, enhancing understanding of mechanisms underlying the functioning and performing of inter-organisational collaborations, as well as how to configure the context to aid success. Next steps in this research will test the results against further case studies and primary data to produce a further refined theory.

Systematic Review Registration: PROSPERO CRD42019149009.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13643-021-01630-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7984506PMC
March 2021

Effects of interorganisational information technology networks on patient safety: a realist synthesis.

BMJ Open 2020 10 10;10(10):e036608. Epub 2020 Oct 10.

Sociology and Social Policy, University of Leeds, Leeds, UK.

Objective: Health services in many countries are investing in interorganisational networks, linking patients' records held in different organisations across a city or region. The aim of the systematic review was to establish how, why and in what circumstances these networks improve patient safety, fail to do so, or increase safety risks, for people living at home.

Design: Realist synthesis, drawing on both quantitative and qualitative evidence, and including consultation with stakeholders in nominal groups and semistructured interviews.

Eligibility Criteria: The coordination of services for older people living at home, and medicine reconciliation for older patients returning home from hospital.

Information Sources: 17 sources including Medline, Embase, CINAHL, Cochrane Library, Web of Science, ACM Digital Library, and Applied Social Sciences Index and Abstracts.

Outcomes: Changes in patients' clinical risks.

Results: We did not find any detailed accounts of the sequences of events that policymakers and others believe will lead from the deployment of interoperable networks to improved patient safety. We were, though, able to identify a substantial number of theory fragments, and these were used to develop programme theories.There is good evidence that there are problems with the coordination of services in general, and the reconciliation of medication lists in particular, and it indicates that most problems are social and organisational in nature. There is also good evidence that doctors and other professionals find interoperable networks difficult to use. There was limited high-quality evidence about safety-related outcomes associated with the deployment of interoperable networks.

Conclusions: Empirical evidence does not currently justify claims about the beneficial effects of interoperable networks on patient safety. There appears to be a mismatch between technology-driven assumptions about the effects of networks and the sociotechnical nature of coordination problems.

Prospero Registration Number: CRD42017073004.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2019-036608DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7552839PMC
October 2020

Exploring variation in the use of feedback from national clinical audits: a realist investigation.

BMC Health Serv Res 2020 Sep 11;20(1):859. Epub 2020 Sep 11.

Faculty of Health Studies and the Wolfson Centre for Applied Health Research University of Bradford, Bradford, England.

Background: National Clinical Audits (NCAs) are a well-established quality improvement strategy used in healthcare settings. Significant resources, including clinicians' time, are invested in participating in NCAs, yet there is variation in the extent to which the resulting feedback stimulates quality improvement. The aim of this study was to explore the reasons behind this variation.

Methods: We used realist evaluation to interrogate how context shapes the mechanisms through which NCAs work (or not) to stimulate quality improvement. Fifty-four interviews were conducted with doctors, nurses, audit clerks and other staff working with NCAs across five healthcare providers in England. In line with realist principles we scrutinised the data to identify how and why providers responded to NCA feedback (mechanisms), the circumstances that supported or constrained provider responses (context), and what happened as a result of the interactions between mechanisms and context (outcomes). We summarised our findings as Context+Mechanism = Outcome configurations.

Results: We identified five mechanisms that explained provider interactions with NCA feedback: reputation, professionalism, competition, incentives, and professional development. Professionalism and incentives underpinned most frequent interaction with feedback, providing opportunities to stimulate quality improvement. Feedback was used routinely in these ways where it was generated from data stored in local databases before upload to NCA suppliers. Local databases enabled staff to access data easily, customise feedback and, importantly, the data were trusted as accurate, due to the skills and experience of staff supporting audit participation. Feedback produced by NCA suppliers, which included national comparator data, was used in a more limited capacity across providers. Challenges accessing supplier data in a timely way and concerns about the quality of data submitted across providers were reported to constrain use of this mode of feedback.

Conclusion: The findings suggest that there are a number of mechanisms that underpin healthcare providers' interactions with NCA feedback. However, there is variation in the mode, frequency and impact of these interactions. Feedback was used most routinely, providing opportunities to stimulate quality improvement, within clinical services resourced to collect accurate data and to maintain local databases from which feedback could be customised for the needs of the service.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12913-020-05661-0DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7488667PMC
September 2020

Searching for Programme theories for a realist evaluation: a case study comparing an academic database search and a simple Google search.

BMC Med Res Methodol 2020 08 26;20(1):217. Epub 2020 Aug 26.

Department of Sociology and Social Policy, University of Leeds, Leeds, LS2 9JT, UK.

Background: Realist methodologies are increasingly being used to evaluate complex interventions in health and social care. Programme theory (ideas and assumptions of how a particular intervention works) development is the first step in a realist evaluation or a realist synthesis, with literature reviews providing important evidence to support this. Deciding how to search for programme theories is challenging and there is limited guidance available. Using an example of identifying programme theories for a realist evaluation of Pressure Ulcer Risk Assessment Instruments in clinical practice, the authors explore and compare several different approaches to literature searching and highlight important methodological considerations for those embarking on a programme theory review.

Methods: We compared the performance of an academic database search with a simple Google search and developed an optimised search strategy for the identification primary references (i.e. documents providing the clearest examples of programme theories) associated with the use of Pressure Ulcer Risk Assessment Instruments (PU-RAIs). We identified the number of primary references and the total number of references retrieved per source. We then calculated the number needed to read (NNR) expressed as the total number of titles and abstracts screened to identify one relevant reference from each source.

Results: The academic database search (comprising CINAHL, The Cochrane Library, EMBASE, HMIC, Medline) identified 2 /10 primary references with a NNR of 1395.The Google search identified 7/10 primary references with a NNR of 10.1. The combined NNR was 286.3. The optimised search combining Google and CINAHL identified 10/10 primary references with a NNR of 40.2.

Conclusion: The striking difference between the efficiency of the review's academic database and Google searches in finding relevant references prompted an in-depth comparison of the two types of search. The findings indicate the importance of including grey literature sources such as Google in this particular programme theory search, while acknowledging the need for transparency of methods. Further research is needed to facilitate improved guidance for programme theory searches to enhance practice in the realist field and to save researcher time and therefore resource.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s12874-020-01084-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7450563PMC
August 2020

Using an implementation science approach to implement and evaluate patient-reported outcome measures (PROM) initiatives in routine care settings.

Qual Life Res 2021 Nov 10;30(11):3015-3033. Epub 2020 Jul 10.

Nuffield Department of Population Health, University of Oxford, Oxford, UK.

Purpose: Patient-reported outcome and experience measures (PROMs/PREMs) are well established in research for many health conditions, but barriers persist for implementing them in routine care. Implementation science (IS) offers a potential way forward, but its application has been limited for PROMs/PREMs.

Methods: We compare similarities and differences for widely used IS frameworks and their applicability for implementing PROMs/PREMs through case studies. Three case studies implemented PROMs: (1) pain clinics in Canada; (2) oncology clinics in Australia; and (3) pediatric/adult clinics for chronic conditions in the Netherlands. The fourth case study is planning PREMs implementation in Canadian primary care clinics. We compare case studies on barriers, enablers, implementation strategies, and evaluation.

Results: Case studies used IS frameworks to systematize barriers, to develop implementation strategies for clinics, and to evaluate implementation effectiveness. Across case studies, consistent PROM/PREM implementation barriers were technology, uncertainty about how or why to use PROMs/PREMs, and competing demands from established clinical workflows. Enabling factors in clinics were context specific. Implementation support strategies changed during pre-implementation, implementation, and post-implementation stages. Evaluation approaches were inconsistent across case studies, and thus, we present example evaluation metrics specific to PROMs/PREMs.

Conclusion: Multilevel IS frameworks are necessary for PROM/PREM implementation given the complexity. In cross-study comparisons, barriers to PROM/PREM implementation were consistent across patient populations and care settings, but enablers were context specific, suggesting the need for tailored implementation strategies based on clinic resources. Theoretically guided studies are needed to clarify how, why, and in what circumstances IS principles lead to successful PROM/PREM integration and sustainability.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1007/s11136-020-02564-9DOI Listing
November 2021

Institutional use of National Clinical Audits by healthcare providers.

J Eval Clin Pract 2021 Feb 20;27(1):143-150. Epub 2020 Apr 20.

Faculty of Health Studies, University of Bradford, Bradford, UK.

Rationale, Aims, And Objectives: Healthcare systems worldwide devote significant resources towards collecting data to support care quality assurance and improvement. In the United Kingdom, National Clinical Audits are intended to contribute to these objectives by providing public reports of data on healthcare treatment and outcomes, but their potential for quality improvement in particular is not realized fully among healthcare providers. Here, we aim to explore this outcome from the perspective of hospital boards and their quality committees: an under-studied area, given the emphasis in previous research on the audits' use by clinical teams.

Methods: We carried out semi-structured, qualitative interviews with 54 staff in different clinical and management settings in five English National Health Service hospitals about their use of NCA data, and the circumstances that supported or constrained such use. We used Framework Analysis to identify themes within their responses.

Results: We found that members and officers of hospitals' governing bodies perceived an imbalance between the benefits to their institutions from National Clinical Audits and the substantial resources consumed by participating in them. This led some to question the audits' legitimacy, which could limit scope for improvements based on audit data, proposed by clinical teams.

Conclusions: Measures to enhance the audits' perceived legitimacy could help address these limitations. These include audit suppliers moving from an emphasis on cumulative, retrospective reports to real-time reporting, clearly presenting the "headline" outcomes important to institutional bodies and staff. Measures may also include further negotiation between hospitals, suppliers and their commissioners about the nature and volume of data the latter are expected to collect; wider use by hospitals of routine clinical data to populate audit data fields; and further development of interactive digital technologies to help staff explore and report audit data in meaningful ways.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jep.13403DOI Listing
February 2021

How, in what contexts, and why do quality dashboards lead to improvements in care quality in acute hospitals? Protocol for a realist feasibility evaluation.

BMJ Open 2020 02 25;10(2):e033208. Epub 2020 Feb 25.

School of Health Sciences, University of Manchester, Manchester, Greater Manchester, UK.

Introduction: National audits are used to monitor care quality and safety and are anticipated to reduce unexplained variations in quality by stimulating quality improvement (QI). However, variation within and between providers in the extent of engagement with national audits means that the potential for national audit data to inform QI is not being realised. This study will undertake a feasibility evaluation of QualDash, a quality dashboard designed to support clinical teams and managers to explore data from two national audits, the Myocardial Ischaemia National Audit Project (MINAP) and the Paediatric Intensive Care Audit Network (PICANet).

Methods And Analysis: Realist evaluation, which involves building, testing and refining theories of how an intervention works, provides an overall framework for this feasibility study. Realist hypotheses that describe how, in what contexts, and why QualDash is expected to provide benefit will be tested across five hospitals. A controlled interrupted time series analysis, using key MINAP and PICANet measures, will provide preliminary evidence of the impact of QualDash, while ethnographic observations and interviews over 12 months will provide initial insight into contexts and mechanisms that lead to those impacts. Feasibility outcomes include the extent to which MINAP and PICANet data are used, data completeness in the audits, and the extent to which participants perceive QualDash to be useful and express the intention to continue using it after the study period.

Ethics And Dissemination: The study has been approved by the University of Leeds School of Healthcare Research Ethics Committee. Study results will provide an initial understanding of how, in what contexts, and why quality dashboards lead to improvements in care quality. These will be disseminated to academic audiences, study participants, hospital IT departments and national audits. If the results show a trial is feasible, we will disseminate the QualDash software through a stepped wedge cluster randomised trial.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2019-033208DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044920PMC
February 2020

Networked information technologies and patient safety: a protocol for a realist synthesis.

Syst Rev 2019 12 5;8(1):307. Epub 2019 Dec 5.

Leeds Institute of Health Sciences, University of Leeds, Worsley Building, Clarendon Way, Leeds, LS2 9NL, England.

Background: There is a widespread belief that information technologies will improve diagnosis, treatment and care. Evidence about their effectiveness in health care is, however, mixed. It is not clear why this is the case, given the remarkable advances in hardware and software over the last 20 years. This review focuses on interoperable information technologies, which governments are currently advocating and funding. These link organisations across a health economy, with a view to enabling health and care professionals to coordinate their work with one another and to access patient data wherever it is stored. Given the mixed evidence about information technologies in general, and current policies and funding, there is a need to establish the value of investments in this class of system. The aim of this review is to establish how, why and in what circumstances interoperable systems affect patient safety.

Methods: A realist synthesis will be undertaken, to understand how and why inter-organisational systems reduce patients' clinical risks, or fail to do so. The review will follow the steps in most published realist syntheses, including (1) clarifying the scope of the review and identifying candidate programme and mid-range theories to evaluate, (2) searching for evidence, (3) appraising primary studies in terms of their rigour and relevance and extracting evidence, (4) synthesising evidence, (5) identifying recommendations, based on assessment of the extent to which findings can be generalised to other settings.

Discussion: The findings of this realist synthesis will shed light on how and why an important class of systems, that span organisations in a health economy, will contribute to changes in patients' clinical risks. We anticipate that the findings will be generalizable, in two ways. First, a refined mid-range theory will contribute to our understanding of the underlying mechanisms that, for a range of information technologies, lead to changes in clinical practices and hence patients' risks (or not). Second, many governments are funding and implementing cross-organisational IT networks. The findings can inform policies on their design and implementation.

Systematic Review Registration: PROSPERO CRD42017073004.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13643-019-1223-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6896666PMC
December 2019

Problem-solving training: assessing the feasibility and acceptability of delivering and evaluating a problem-solving training model for front-line prison staff and prisoners who self-harm.

BMJ Open 2019 10 3;9(10):e026095. Epub 2019 Oct 3.

Spectrum Community Health CIC, Wakefield, UK.

Objectives: Problem-solving skills training is adaptable, inexpensive and simple to deliver. However, its application with prisoners who self-harm is unknown. The study assessed the feasibility and acceptability of a problem-solving training (PST) intervention for prison staff and prisoners who self-harm, to inform the design of a large-scale study.

Design And Setting: A mixed-methods design used routinely collected data, individual outcome measures, an economic protocol and qualitative interviews at four prisons in Yorkshire and Humber, UK.

Participants: (i) Front-line prison staff, (ii) male and female prisoners with an episode of self-harm in the previous 2 weeks.

Intervention: The intervention comprised a 1 hour staff training session and a 30 min prisoner session using adapted workbooks and case studies.

Outcomes: We assessed the study processes-coverage of training; recruitment and retention rates and adequacy of intervention delivery-and available data (completeness of outcome data, integrity of routinely collected data and access to the National Health Service (NHS) resource information). Prisoner outcomes assessed incidence of self-harm, quality of life and depression at baseline and at follow-up. Qualitative findings are presented elsewhere.

Results: Recruitment was higher than anticipated for staff n=280, but lower for prisoners, n=48. Retention was good with 43/48 (89%) prisoners completing the intervention, at follow-up we collected individual outcome data for 34/48 (71%) of prisoners. Access to routinely collected data was inconsistent. Prisoners were frequent users of NHS healthcare. The additional cost of training and intervention delivery was deemed minimal in comparison to 'treatment as usual'. Outcome measures of self-harm, quality of life and depression were found to be acceptable.

Conclusions: The intervention proved feasible to adapt. Staff training was delivered but on the whole it was not deemed feasible for staff to deliver the intervention. A large-scale study is warranted, but modifications to the implementation of the intervention are required.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2018-026095DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6797432PMC
October 2019

How do team experience and relationships shape new divisions of labour in robot-assisted surgery? A realist investigation.

Health (London) 2021 03 14;25(2):250-268. Epub 2019 Sep 14.

University of Manchester, UK.

Safe and successful surgery depends on effective teamwork between professional groups, each playing their part in a complex division of labour. This article reports the first empirical examination of how introduction of robot-assisted surgery changes the division of labour within surgical teams and impacts teamwork and patient safety. Data collection and analysis was informed by realist principles. Interviews were conducted with surgical teams across nine UK hospitals and, in a multi-site case study across four hospitals, data were collected using a range of methods, including ethnographic observation, video recording and semi-structured interviews. Our findings reveal that as the robot enables the surgeon to do more, the surgical assistant's role becomes less clearly defined. Robot-assisted surgery also introduces new tasks for the surgical assistant and scrub practitioner, in terms of communicating information to the surgeon. However, the use of robot-assisted surgery does not redistribute work in a uniform way; contextual factors of individual experience and team relationships shape changes to the division of labour. For instance, in some situations, scrub practitioners take on the role of supporting inexperienced surgical assistants. These changes in the division of labour do not persist when team members return to operations that are not robot-assisted. This study contributes to wider literature on divisions of labour in healthcare and how this is impacted by the introduction of new technologies. In particular, we emphasise the need to pay attention to often neglected micro-level contextual factors. This can highlight behaviours that can be promoted to benefit patient care.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1363459319874115DOI Listing
March 2021

How and in what Contexts Does Networked Health IT Improve Patient Safety? Elicitation of Theories from the Literature.

Stud Health Technol Inform 2019 Aug;264:753-757

Leeds Institute of Health Sciences, University of Leeds, Leeds, UK.

Healthcare systems worldwide are investing in networked health IT systems that link healthcare providers across multiple organisations. Much of the policy arguments in favour of such investment rely on the assumption that networked health IT will lead to improved patient safety. As part of the first stage of a realist review to determine how and in what contexts networked, inter-organisational health IT does lead to improved patient safety, we elicited stakeholders' theories from the literature that reveal possible answers to this question. A key mechanism appears to be that the information provided supports improved decision making. Greatest benefits are likely to be found in relation to medication information, in scenarios where the patient is less able to provide accurate information about their medications themselves. However, access and use of this information depends on ease of access, clinicians' perception of the likelihood that the desired information will be available, and clinicians' trust in the information.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3233/SHTI190324DOI Listing
August 2019

Sustainable Information Infrastructures: Insights from a Realist Synthesis.

Stud Health Technol Inform 2019 Aug;265:63-68

University of Leeds, England.

Policy makers and health system managers in many countries are advocating the deployment of inter-operable health information technology systems, spanning organisations in a health economy, believing that they will be clinically effective. The case for investments has not, however, been made to date. This paper presents early results from a systematic review of the effects of inter-operable systems on patient safety. The review uses the realist synthesis method, which focuses on evidence about the decisions and actions that link interventions and outcomes, as well as the evidence about those outcomes. The evidence base is sufficient to identify plausible arguments for investments in inter-operable systems. This said, there is limited empirical evidence about each of the steps in the sequences of events. We comment on implications for the design of sustainable socio-technical solutions. We suggest that current gaps in the evidence base are in areas where informatics field methods can make a valuable contribution to our understanding of the role of inter-operable systems in patient safety.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.3233/SHTI190139DOI Listing
August 2019

Implementation of a problem-solving training initiative to reduce self-harm in prisons: a qualitative perspective of prison staff, field researchers and prisoners at risk of self-harm.

Health Justice 2019 Jul 31;7(1):14. Epub 2019 Jul 31.

Sociology and Social Policy, Faculty of Education and Social Science and Law, University of Leeds, Leeds, LS2 9JT, UK.

Background: Social problem-solving is one technique used to help reduce incidence of self-harm. Our study evaluated the feasibility and acceptability of the adaptation and implementation of a brief Problem-Solving Training (PST) intervention to reduce self-harm in prisons.

Methods: The process involved i) adaptation of the training materials using focus groups with prison staff and prisoners, ii) training frontline prison staff to use the skills, and iii) implementation of the skills with prisoners at risk of self-harm. Qualitative interviews were conducted with prison staff, prisoners and field researchers and were analysed using a thematic framework to produce a model of the barriers and facilitators to the process.

Results: We conducted 43 interviews across three prison sites. The interviews included 19 prison staff, 18 prisoners and six field researcher meetings. The adaptation to the training and intervention materials were well received. The findings identified the need to support training using a collaborative and flexible approach. Prisoner engagement was affected by their own personal circumstances and by a range of contextual issues relating to the prison environment. Implementation of the skills by prison staff were hindered by resource constraints, the prison environment and staff attitudes.

Conclusions: We found that it was feasible to adapt an existing intervention and contextualise it within the prison environment. Although we could train large numbers of staff it was deemed unfeasible for staff to implement the problem-solving skills to prisoners at risk of self-harm. Prisoners who engaged with the intervention reported a range of benefits. Alternative implementation mechanisms to tackle the contextual barriers proposed by staff and prisoners included delivery of the intervention using an educational setting and/or use of a prisoner peer-led scheme.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s40352-019-0094-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6717963PMC
July 2019

Factors supporting and constraining the implementation of robot-assisted surgery: a realist interview study.

BMJ Open 2019 06 14;9(6):e028635. Epub 2019 Jun 14.

School of Health Sciences, University of Manchester, Manchester, UK.

Objective: To capture stakeholders' theories concerning how and in what contexts robot-assisted surgery becomes integrated into routine practice.

Design: A literature review provided tentative theories that were revised through a realist interview study. Literature-based theories were presented to the interviewees, who were asked to describe to what extent and in what ways those theories reflected their experience. Analysis focused on identifying mechanisms through which robot-assisted surgery becomes integrated into practice and contexts in which those mechanisms are triggered.

Setting: Nine hospitals in England where robot-assisted surgery is used for colorectal operations.

Participants: Forty-four theatre staff with experience of robot-assisted colorectal surgery, including surgeons, surgical trainees, theatre nurses, operating department practitioners and anaesthetists.

Results: Interviewees emphasised the importance of support from hospital management, team leaders and surgical colleagues. Training together as a team was seen as beneficial, increasing trust in each other's knowledge and supporting team bonding, in turn leading to improved teamwork. When first introducing robot-assisted surgery, it is beneficial to have a handpicked dedicated robotic team who are able to quickly gain experience and confidence. A suitably sized operating theatre can reduce operation duration and the risk of de-sterilisation. Motivation among team members to persist with robot-assisted surgery can be achieved without involvement in the initial decision to purchase a robot, but training that enables team members to feel confident as they take on the new tasks is essential.

Conclusions: We captured accounts of how robot-assisted surgery has been introduced into a range of hospitals. Using a realist approach, we were also able to capture perceptions of the factors that support and constrain the integration of robot-assisted surgery into routine practice. We have translated these into recommendations that can inform future implementations of robot-assisted surgery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2018-028635DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6589012PMC
June 2019

A realist analysis of treatment programmes for sex offenders with intellectual disabilities.

J Appl Res Intellect Disabil 2020 Jul 13;33(4):729-738. Epub 2019 May 13.

Sociology & Social Policy, University of Leeds, Leeds, UK.

Background: The resources used in treatment for sex offenders with intellectual disabilities have had much research attention, but less has been written about how participants are expected to respond (programme mechanisms).

Methods: A realist evaluation of seven programmes from the UK, Canada, USA, Switzerland and Germany was conducted. In semi-structured interviews, programme designers elucidated how they are intended to work. The data analysis was driven by the realist concern to expose programme mechanisms and intended outcomes.

Results: Two main outcomes are increasing risk management capacities and cultivating prosocial identities. These are achieved through developing insights into a person's risks, work on (sexual) self-regulation skills, sexual boundaries and personal values and by developing meaningful social roles and positive relationships.

Conclusions: Over time, there have been changes to some of the treatment resources used. However, there were little differences in terms of the intended programme mechanisms and outcomes, which remained surprisingly consistent.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jar.12618DOI Listing
July 2020

Strategies for incorporating patient-reported outcomes in the care of people with chronic kidney disease (PRO kidney): a protocol for a realist synthesis.

Syst Rev 2019 01 12;8(1):20. Epub 2019 Jan 12.

Sociology and Social Policy, University of Leeds, 11.21, Social Sciences Building, Leeds, LS2 9JT, UK.

Background: Patient-reported outcomes and experience measures (jointly referred to here as PROs) are internationally recognized as a means for patients to provide information about their quality of life, symptoms, and experiences with care. Although increasingly recognized as key to improving the quality of healthcare at individual (e.g., patients, caregivers, and providers) and aggregate (e.g., government, policy/system-wide decision-making) levels, there are important knowledge gaps in our understanding of how PROs are, and can be, used across different settings, particularly in nephrology to enhance person-centered care. This knowledge is needed for developing strategies to guide optimal use of PROs in nephrology care. Currently, no strategies exist. The purpose of this review is to address this knowledge gap by answering the following realist question: How can PROs be used to enhance person-centered nephrology care, both at individual and aggregate levels?

Methodology: Realist synthesis is an explanatory approach to data synthesis that aims to explain how context and mechanisms influence the outcome of an intervention. An initial program theory will be developed through the systematic search of the published literature in bibliographic databases (Ovid MEDLINE, Ovid Embase, EBSCOhost CINAHL, Web of Science, and Scopus) on existing theories explaining how PROs are used in healthcare settings. This initial program theory will then be tested and refined through the process of realist synthesis, using context-mechanism-outcome configurations. A kidney-specific program theory will then be created to address the utilization of PROs in nephrology across individual and aggregate levels to augment person-centered care. Searching will be iterative and refined as data is extracted and analyzed using a pilot-tested context + mechanism = outcome heuristic. Throughout, we will consult methodological experts, research team practitioners, and the Patient Advisory Committee to help refine the theories. Last, we will develop and disseminate knowledge translation products widely to knowledge user groups.

Discussion: The utilization of PROs remains a challenge in nephrology. The findings from this synthesis will provide a framework to guide both policy makers and practitioners on how to enhance person-centered care through successful utilization of PROs across individual and aggregate levels in nephrology.

Systematic Review Registration: PROSPERO CRD42017056063.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s13643-018-0911-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6330465PMC
January 2019

'The harmony of social theory in evaluation' - commentary on 'The art and science of non-evaluation evaluation'.

J Health Serv Res Policy 2018 10;23(4):270-271

2 Senior Lecturer, School of Sociology and Social Policy, University of Leeds, UK.

View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1355819618790991DOI Listing
October 2018

How do patient reported outcome measures (PROMs) support clinician-patient communication and patient care? A realist synthesis.

J Patient Rep Outcomes 2018 Dec 15;2:42. Epub 2018 Sep 15.

7Health Services Research, London School of Hygiene and Tropical Medicine, 15-17 Tavistock Place, London, WC1H 9SH England.

Background: In this paper, we report the findings of a realist synthesis that aimed to understand how and in what circumstances patient reported outcome measures (PROMs) support patient-clinician communication and subsequent care processes and outcomes in clinical care. We tested two overarching programme theories: (1) PROMs completion prompts a process of self-reflection and supports patients to raise issues with clinicians and (2) PROMs scores raise clinicians' awareness of patients' problems and prompts discussion and action. We examined how the structure of the PROM and care context shaped the ways in which PROMs support clinician-patient communication and subsequent care processes.

Results: PROMs completion prompts patients to reflect on their health and gives them permission to raise issues with clinicians. However, clinicians found standardised PROMs completion during patient assessments sometimes constrained rather than supported communication. In response, clinicians adapted their use of PROMs to render them compatible with the ongoing management of patient relationships. Individualised PROMs supported dialogue by enabling the patient to tell their story. In oncology, PROMs completion outside of the consultation enabled clinicians to identify problematic symptoms when the PROM acted as a substitute rather than addition to the clinical encounter and when the PROM focused on symptoms and side effects, rather than health related quality of life (HRQoL). Patients did not always feel it was appropriate to discuss emotional, functional or HRQoL issues with doctors and doctors did not perceive this was within their remit.

Conclusions: This paper makes two important contributions to the literature. First, our findings show that PROMs completion is not a neutral act of information retrieval but can change how patients think about their condition. Second, our findings reveal that the ways in which clinicians use PROMs is shaped by their relationships with patients and professional roles and boundaries. Future research should examine how PROMs completion and feedback shapes and is influenced by the process of building relationships with patients, rather than just their impact on information exchange and decision making.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1186/s41687-018-0061-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153194PMC
December 2018

How do aggregated patient-reported outcome measures data stimulate health care improvement? A realist synthesis.

J Health Serv Res Policy 2018 01 20;23(1):57-65. Epub 2017 Dec 20.

7 Professor of Health Services Research, London School of Hygiene and Tropical Medicine, UK.

Objectives Internationally, there has been considerable debate about the role of data in supporting quality improvement in health care. Our objective was to understand how, why and in what circumstances the feedback of aggregated patient-reported outcome measures data improved patient care. Methods We conducted a realist synthesis. We identified three main programme theories underlying the use of patient-reported outcome measures as a quality improvement strategy and expressed them as nine 'if then' propositions. We identified international evidence to test these propositions through searches of electronic databases and citation tracking, and supplemented our synthesis with evidence from similar forms of performance data. We synthesized this evidence through comparing the mechanisms and impact of patient-reported outcome measures and other performance data on quality improvement in different contexts. Results Three programme theories were identified: supporting patient choice, improving accountability and enabling providers to compare their performance with others. Relevant contextual factors were extent of public disclosure, use of financial incentives, perceived credibility of the data and the practicality of the results. Available evidence suggests that patients or their agents rarely use any published performance data when selecting a provider. The perceived motivation behind public reporting is an important determinant of how providers respond. When clinicians perceived that performance indicators were not credible but were incentivized to collect them, gaming or manipulation of data occurred. Outcome data do not provide information on the cause of poor care: providers needed to integrate and interpret patient-reported outcome measures and other outcome data in the context of other data. Lack of timeliness of performance data constrains their impact. Conclusions Although there is only limited research evidence to support some widely held theories of how aggregated patient-reported outcome measures data stimulate quality improvement, several lessons emerge from interventions sharing the same programme theories to help guide the increasing use of these measures.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1177/1355819617740925DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5768260PMC
January 2018

Percutaneous coronary intervention patients' and cardiologists' experiences of the informed consent process in Northern England: a qualitative study.

BMJ Open 2017 06 24;7(6):e015127. Epub 2017 Jun 24.

Centre for Applied Research in Health, School of Human and Health Sciences, University of Huddersfield, Huddersfield, UK.

Objective: Informed consent is central to ethical medical practice, but little is known about how the process takes place in clinical practice. Percutaneous coronary intervention (PCI) is a common revascularisation procedure. Studies report that patients overestimate benefits, forget the risks and are unaware of alternative treatments. The aim of this study was to describe PCI patients' and cardiologists' experiences of the informed consent process in acute care settings.

Design/setting/participants: A qualitative study with a maximum variation sample of elective and acute PCI patients and cardiologists taking their consent, recruited from a district general hospital and tertiary centre. In-depth interviews were conducted, and consent discussions were audio recorded. Data collection, coding and theorising occurred simultaneously.

Findings: Forty-one (26 male) patients scheduled for elective (20) or urgent (21) PCI and 19 cardiologists (5 female) participated. Despite diversity in patients' experiences of informed consent, elective and acute patients experienced a common four-stage process of consent. Most patients made the decision to have treatment at PCI referral and took a passive role in the discussions we recorded. They recognised cardiologists as experts, trusted the medical system to 'fix' their health problem and were unaware of their role in the informed consent process. Informed consent discussions functioned as a formal 'event',enabling cardiologists to check patients' understanding and enabling patients to access treatment.

Conclusions: The configuration of services and patients' perceptions of their role in informed consent underpin a mismatch between legal and ethical principles of informed consent and current practice. The variation in patients' experiences of the current place of informed consent in service delivery represents a missed opportunity for cardiologists to work in decision-making partnerships with patients. In light of recent changes in the law, a new approach to informed consent is required.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1136/bmjopen-2016-015127DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5541457PMC
June 2017

Guidance on guidelines: Understanding the evidence on the uptake of health care guidelines.

J Eval Clin Pract 2018 02 29;24(1):105-116. Epub 2017 Mar 29.

School of Sociology and Social Policy, University of Leeds, Leeds, UK.

Rationale: Regardless of health issue, health sector, patient condition, or treatment modality, the chances are that provision is supported by "a guideline" making professionally endorsed recommendations on best practice. Against this background, research has proliferated seeking to evaluate how effectively such guidance is followed. These investigations paint a gloomy picture with many a guideline prompting lip service, inattention, and even opposition. This predicament has prompted a further literature on how to improve the uptake of guidelines, and this paper considers how to draw together lessons from these inquiries.

Methods: This huge body of material presents a considerable challenge for research synthesis, and this paper produces a critical, methodological comparison of 2 types of review attempting to meet that task. Firstly, it provides an overview of the current orthodoxy, namely, "thematic reviews," which aggregate and enumerate the "barriers and facilitators" to guideline implementation. It then outlines a "realist synthesis," focussing on testing the "programme theories" that practitioners have devised to improve guideline uptake.

Results: Thematic reviews aim to provide a definitive, comprehensive catalogue of the facilitators and barriers to guideline implementation. As such, they present a restatement of the underlying problems rather than an improvement strategy. The realist approach assumes that the incorporation of any guideline into current practice will produce unintended system strains as different stakeholders wrestle over responsibilities. These distortions will prompt supplementary revisions to guidelines, which in turn beget further strains. Realist reviews follow this dynamic understanding of organisational change.

Conclusions: Health care decision makers operate in systems that are awash with guidelines. But guidelines only have paper authority. Managers do not need a checklist of their pros and cons, because the fate of guidelines depends on their reception rather than their production. They do need decision support on how to engineer and reengineer guidelines so they dovetail with evolving systems of health care delivery.
View Article and Find Full Text PDF

Download full-text PDF

Source
http://dx.doi.org/10.1111/jep.12734DOI Listing
February 2018
-->