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  • Systematic review of acute physically active learning and classroom movement breaks on children's physical activity, cognition, academic performance and classroom behaviour: understanding critical design features.

    Daly-Smith, Andrew; Zwolinsky, S; McKenna, J.; Tomporowski, P.D.; Defeyter, M.A.; Manley, A. (2018)
    To examine the impact of acute classroom movement break (CMB) and physically active learning (PAL) interventions on physical activity (PA), cognition, academic performance and classroom behaviour. Systematic review. PubMed, EBSCO, Academic Search Complete, Education Resources Information Center, PsycINFO, SPORTDiscus, SCOPUS and Web of Science. Studies investigating school-based acute bouts of CMB or PAL on (PA), cognition, academic performance and classroom behaviour. The Downs and Black checklist assessed risk of bias. Ten PAL and eight CMB studies were identified from 2929 potentially relevant articles. Risk of bias scores ranged from 33% to 64.3%. Variation in study designs drove specific, but differing, outcomes. Three studies assessed PA using objective measures. Interventions replaced sedentary time with either light PA or moderate-to-vigorous PA dependent on design characteristics (mode, duration and intensity). Only one study factored individual PA outcomes into analyses. Classroom behaviour improved after longer moderate-to-vigorous (>10 min), or shorter more intense (5 min), CMB/PAL bouts (9 out of 11 interventions). There was no support for enhanced cognition or academic performance due to limited repeated studies. Low-to-medium quality designs predominate in investigations of the acute impacts of CMB and PAL on PA, cognition, academic performance and classroom behaviour. Variable quality in experimental designs, outcome measures and intervention characteristics impact outcomes making conclusions problematic. CMB and PAL increased PA and enhanced time on task. To improve confidence in study outcomes, future investigations should combine examples of good practice observed in current studies. CRD42017070981.
  • Implementing physically active learning: Future directions for research, policy, and practice

    Daly-Smith, Andrew; Quarmby, T.; Archbold, V.S.J.; Routen, A.C.; Morris, J.L.; Gammon, C.; Bartholomew, J.B.; Resaland, G.K.; Llewellyn, B.; Allman, R.; et al. (2020-01)
    To identify co-produced multi-stakeholder perspectives important for successful widespread physically active learning (PAL) adoption and implementation. A total of 35 stakeholders (policymakers n = 9; commercial education sector, n = 8; teachers, n = 3; researchers, n = 15) attended a design thinking PAL workshop. Participants formed 5 multi-disciplinary groups with at least 1 representative from each stakeholder group. Each group, facilitated by a researcher, undertook 2 tasks: (1) using Post-it Notes, the following question was answered: within the school day, what are the opportunities for learning combined with movement? and (2) structured as a washing-line task, the following question was answered: how can we establish PAL as the norm? All discussions were audio-recorded and transcribed. Inductive analyses were conducted by 4 authors. After the analyses were complete, the main themes and subthemes were assigned to 4 predetermined categories: (1) PAL design and implementation, (2) priorities for practice, (3) priorities for policy, and (4) priorities for research. The following were the main themes for PAL implementation: opportunities for PAL within the school day, delivery environments, learning approaches, and the intensity of PAL. The main themes for the priorities for practice included teacher confidence and competence, resources to support delivery, and community of practice. The main themes for the policy for priorities included self-governance, the Office for Standards in Education, Children's Services, and Skill, policy investment in initial teacher training, and curriculum reform. The main themes for the research priorities included establishing a strong evidence base, school-based PAL implementation, and a whole-systems approach. The present study is the first to identify PAL implementation factors using a combined multi-stakeholder perspective. To achieve wider PAL adoption and implementation, future interventions should be evidence based and address implementation factors at the classroom level (e.g., approaches and delivery environments), school level (e.g., communities of practice), and policy level (e.g., initial teacher training).
  • ‘You get some very archaic ideas of what teaching is … ’: primary school teachers’ perceptions of the barriers to physically active lessons

    Quarmby, T.; Daly-Smith, Andrew; Kime, N. (2019-04)
    Physically active lessons present a key paradigm shift in educational practice. However, little is known about the barriers to implementing physically active lessons. To address this, 31 practising primary teachers (23 = female) from 9 primary schools across West Yorkshire, England, were engaged in focus group interviews. Drawing on the socio-ecological model, findings revealed that barriers influencing the implementation of physically active lessons are multifaceted. Teacher’s confidence and competence, concerns over classroom space, preparation time and resources, coupled with the wider school culture that is influenced by governors and parents, reinforce a didactic approach and act as barriers to physically active lessons.
  • Using a multi-stakeholder experience-based design process to co-develop the Creating Active Schools Framework

    Daly-Smith, Andrew; Quarmby, T.; Archbold, V.S.J.; Corrigan, N.; Wilson, D.; Resaland, G.K.; Bartholomew, J.B.; Singh, A.; Tjomsland, H.E.; Sherar, L.B.; et al. (2020-02)
    UK and global policies recommend whole-school approaches to improve childrens' inadequate physical activity (PA) levels. Yet, recent meta-analyses establish current interventions as ineffective due to suboptimal implementation rates and poor sustainability. To create effective interventions, which recognise schools as complex adaptive sub-systems, multi-stakeholder input is necessary. Further, to ensure 'systems' change, a framework is required that identifies all components of a whole-school PA approach. The study's aim was to co-develop a whole-school PA framework using the double diamond design approach (DDDA). Fifty stakeholders engaged in a six-phase DDDA workshop undertaking tasks within same stakeholder (n = 9; UK researchers, public health specialists, active schools coordinators, headteachers, teachers, active partner schools specialists, national organisations, Sport England local delivery pilot representatives and international researchers) and mixed (n = 6) stakeholder groupings. Six draft frameworks were created before stakeholders voted for one 'initial' framework. Next, stakeholders reviewed the 'initial' framework, proposing modifications. Following the workshop, stakeholders voted on eight modifications using an online questionnaire. Following voting, the Creating Active Schools Framework (CAS) was designed. At the centre, ethos and practice drive school policy and vision, creating the physical and social environments in which five key stakeholder groups operate to deliver PA through seven opportunities both within and beyond school. At the top of the model, initial and in-service teacher training foster teachers' capability, opportunity and motivation (COM-B) to deliver whole-school PA. National policy and organisations drive top-down initiatives that support or hinder whole-school PA. To the authors' knowledge, this is the first time practitioners, policymakers and researchers have co-designed a whole-school PA framework from initial conception. The novelty of CAS resides in identifying the multitude of interconnecting components of a whole-school adaptive sub-system; exposing the complexity required to create systems change. The framework can be used to shape future policy, research and practice to embed sustainable PA interventions within schools. To enact such change, CAS presents a potential paradigm shift, providing a map and method to guide future co-production by multiple experts of PA initiatives 'with' schools, while abandoning outdated traditional approaches of implementing interventions 'on' schools.
  • QualDash: Adaptable Generation of Visualisation Dashboards for Healthcare Quality Improvement

    Elshehaly, Mai; Randell, Rebecca; Brehmer, M.; McVey, L.; Alvarado, Natasha; Gale, C.P.; Ruddle, R.A. (2021-02)
    Adapting dashboard design to different contexts of use is an open question in visualisation research. Dashboard designers often seek to strike a balance between dashboard adaptability and ease-of-use, and in hospitals challenges arise from the vast diversity of key metrics, data models and users involved at different organizational levels. In this design study, we present QualDash, a dashboard generation engine that allows for the dynamic configuration and deployment of visualisation dashboards for healthcare quality improvement (QI). We present a rigorous task analysis based on interviews with healthcare professionals, a co-design workshop and a series of one-on-one meetings with front line analysts. From these activities we define a metric card metaphor as a unit of visual analysis in healthcare QI, using this concept as a building block for generating highly adaptable dashboards, and leading to the design of a Metric Specification Structure (MSS). Each MSS is a JSON structure which enables dashboard authors to concisely configure unit-specific variants of a metric card, while offloading common patterns that are shared across cards to be preset by the engine. We reflect on deploying and iterating the design of QualDash in cardiology wards and pediatric intensive care units of five NHS hospitals. Finally, we report evaluation results that demonstrate the adaptability, ease-of-use and usefulness of QualDash in a real-world scenario.
  • The effects of inter-organisational information technology networks on patient safety: a realist synthesis

    Keen, J.; Abdulwahid, M.; King, N.; Wright, J.; Randell, Rebecca; Gardner, P.; Waring, J.; Longo, R.; Nikolova, S.; Sloan, C.; et al. (2020)
    Health services in many countries are investing in inter-organisational 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 semi-structured interviews. Eligibility criteria The co-ordination 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 (ASSIA). Outcomes Changes in patients’ clinical risks. Results We did not find any detailed accounts of the sequences of events that policy makers 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 co-ordination 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 socio-technical nature of co-ordination problems. Review registration: PROSPERO CRD42017073004
  • The association between the nationality of nurses and safety culture in maternity care units of Oman

    Al Nadabi, Waleed; Faisal, Muhammad; Muhammed, Muhammed A. (2020)
    Background: Patient safety culture/climate in maternity units has been linked to better safety outcomes. Nurses have a crucial role in patient safety and represent the majority of staff in maternity units. In many countries, nurses are recruited from abroad, bringing their own perceptions of patient safety culture. Nonetheless, little is known about the relationship between perceptions of patient safety culture and nurses’ nationality. Understanding this relationship will assist stakeholders in designing a responsive programme to improve patient safety culture. Aims: To investigate the association between nurses’ nationality and their perceptions about patient safety culture in maternity units in Ministry of Health hospitals in Oman. Methods: In 2017, the Safety Attitude Questionnaire (SAQ) was distributed to all staff (892 distributed, 735 returned) in 10 maternity units. Results: About three-quarters (74%, 541/735) of the returned SAQs were completed by nurses, of whom 34% were non-Omani, 21.8% were Omani and 44.7% did not report their nationality (missing). Overall, the mean safety score for non-Omani nurses was significantly higher than for the Omani nurses: 3.9 (SD 1.3) vs 3.6 (SD 1.2) (P < 0.001). The mean safety score for stress recognition was significantly lower for non-Omani nurses: 2.8 (SD 1.5) vs 3.2 (SD 1.3) (P < 0.001). Conclusion: Non-Omani nurses have a more positive perception of patient safety culture than Omani nurses except in respect of stress recognition. Decision-makers, directors, and clinicians should consider these differences when designing interventions to improve patient safety culture.
  • Patient safety culture in Oman: A national study

    Al Nadabi, Waleed; Faisal, Muhammad; Mohammed, Mohammed A. (2020)
    Rational, aim, and objectives: A positive patient safety culture in maternity units is linked to higher quality of care and better outcomes for mothers. However, safety culture varies across maternity units. Analyses of variation in safety culture using statistical process control (SPC) methods may help provider units to learn from each other's performance. This study aims to measure patient safety culture across maternity units in Oman using SPC methods. Methods: The 36-item Safety Attitude Questionnaire (SAQ) was distributed to all doctors, nurses, and midwifes working in ten maternity care units in Oman's hospitals and analysed using SPC methods. The SAQ considers six domains: job satisfaction, perception of management, safety climate, stress recognition, teamwork, and work condition. Results: Of the 892 targeted participants, 735 (82%) questionnaires were returned. The overall percentage of positive safety responses in all hospitals ranged from 53% to 66%, but no hospital had the targeted response of above 75%. Job satisfaction had the highest safety score (4.10) while stress recognition was the lowest (3.17). SPC charts showed that the overall percentage of positive responses in three maternity units (H1, H7, and H10) was above and one (H4) was below the control limits that represent special cause variation that merits further investigation. Conclusion: Generally, the safety culture in maternity units in Oman is below target and suggests that considerable work is required to enhance safety culture. Several maternity units showed evidence of high/low special cause variation that may offer a useful starting point for understanding and enhancing safety culture.
  • The value of a Patient Access Portal in primary care: a cross-sectional survey of 62,486 registered users in the UK

    Mohammed, Mohammed A.; Montague, Jane; Faisal, Muhammad; Lamming, Laura (2020)
    In England, primary care patients have access to Patient Access Portals (PAPs), enabling them to book appointments, request repeat medication prescriptions, send/receive messages and review their medical records. Few studies have elicited user views and value of PAPs, especially in a publicly funded primary care setting. This study aimed to elicit the value users of PAPs place on online access to medical records and linked services. Secondary data analysis of the completed electronic survey (available 2 May 2015–27 June 2015) distributed via the EMIS PAP to all its registered users. EMIS designed the survey; responses were voluntary. There were 62,486 responders (95.7% self-completed). The PAP was mainly used for medication requests (86.3%) and online appointment bookings (78.4%), and, to a lesser extent, medical record viewing (18.3%) and messaging (9.5%). The majority (70%) reported a positive impact from using it. One in five rated it as their favourite online service second only to online banking. Almost three out of four responders stated that availability of online access would influence their move to another practice. Nonetheless, responders were reluctant to award a high monetary value to it. These findings correlated with the number of long-term conditions. The majority of users place a relatively high value, but not monetary value, on the PAP and report a positive impact from using it. The potential for PAPs to enhance patient experience, especially for those with long-term conditions, appears to be largely untapped. Research exploring the reasons for non-use is also required.
  • Factors associated with accelerometer measured movement behaviours among White British and South Asian children aged 6-8 years during school terms and school holidays.

    Nagy, Liana C.; Faisal, Muhammad; Horne, M.; Collins, P.; Barber, S.; Mohammed, Mohammed A. (2019-08)
    To investigate factors associated with movement behaviours among White British (WB) and South Asian (SA) children aged 6-8 years during school terms and holidays. Cross-sectional. Three primary schools from the Bradford area, UK. One hundred and sixty WB and SA children aged 6-8 years. Sedentary behaviour (SB), light physical activity (LPA) and moderate-to-vigorous physical activity (MVPA) measured by accelerometry during summer, winter and spring and during school terms and school holidays. Data were analysed using multivariate mixed-effects multilevel modelling with robust SEs. Factors of interest were ethnicity, holiday/term, sex, socioeconomic status (SES), weight status, weekend/weekday and season. One hundred and eight children (67.5%) provided 1157 valid days of data. Fifty-nine per cent of children were WB (n=64) and 41% (n=44) were SA. Boys spent more time in MVPA (11 min/day, p=0.013) compared with girls and SA children spent more time in SB (39 min, p=0.017) compared with WB children in adjusted models. Children living in higher SES areas were more sedentary (43 min, p=0.006) than children living in low SES areas. Children were more active during summer (15 min MVPA, p<0.001; 27 LPA, p<0.001) and spring (15 min MVPA, p=0.005; 38 min LPA, p<0.001) and less sedentary (−42 min and −53 min, p<0.001) compared with winter. Less time (8 min, p=0.012) was spent in LPA during school terms compared with school holidays. Children spent more time in MVPA (5 min, p=0.036) during weekend compared with weekdays. Overweight and obese children spent more time in LPA (21 min, p=0.021) than normal-weight children. The results of our study suggest that significant child level factors associated with movement behaviours are ethnicity, sex, weight-status and area SES. Significant temporal factors are weekends, school holidays and seasonality. Interventions to support health enhancing movement behaviours may need to be tailored around these factors.
  • Ethnic differences in sedentary behaviour in 6-8-year-old children during school terms and school holidays: a mixed methods study

    Nagy, Liana C.; Horne, M.; Faisal, Muhammad; Mohammed, Mohammed A.; Barber, Sally E. (2019-02)
    Sedentary behaviour (SB) in childhood is a major public health concern. Little is known about ethnic differences in SB during school and holiday weeks among White British (WB) and South Asian (SA) children, which this study aims to address through investigating inclinometer measured SB and exploring reasons for child engagement in SB. A mixed methods study, comprising of a quantitative investigation with 160, 6-8 years old children and a qualitative study with a subsample of 18 children, six parents and eight teachers was undertaken. Children of WB and SA ethnicity in three schools were invited to wear inclinometers for seven school terms (summer/winter/spring) and seven holidays (winter/spring) days during July 2016-May 2017. Total SB, SB accumulated in bouts > 30 min and breaks in SB were explored using multivariate linear mixed effects models which adjusted for wear time, sex, deprivation, overweight status, season, term, weekday and school. Nine focus groups and two interviews were carried out using the Theoretical Domains Framework to explore SB perceptions among parents, teachers and children. Data were analysed using the Framework Approach. 104/160 children provided 836 valid days of data. Children spent on average eight hours of SB/day during term time and holidays, equating to 60% of their awake time, and had on average 111 SB breaks /day. SA children had 25 fewer SB breaks/ day when compared to WB (p 
  • Impact of the level of sickness on higher mortality in emergency medical admissions to hospital at weekends

    Mohammed, Mohammed A.; Faisal, Muhammad; Richardson, D.; Howes, R.; Beatson, K.; Wright, J.; Speed, K. (2017-10-01)
    Routine administrative data have been used to show that patients admitted to hospitals over the weekend appear to have a higher mortality compared to weekday admissions. Such data do not take the severity of sickness of a patient on admission into account. Our aim was to incorporate a standardized vital signs physiological-based measure of sickness known as the National Early Warning Score to investigate if weekend admissions are: sicker as measured by their index National Early Warning Score; have an increased mortality; and experience longer delays in the recording of their index National Early Warning Score. Methods: We extracted details of all adult emergency medical admissions during 2014 from hospital databases and linked these with electronic National Early Warning Score data in four acute hospitals. We analysed 47,117 emergency admissions after excluding 1657 records, where National Early Warning Score was missing or the first (index) National Early Warning Score was recorded outside ±24 h of the admission time. Results: Emergency medical admissions at the weekend had higher index National Early Warning Score (weekend: 2.53 vs. weekday: 2.30, p
  • A prospective study of consecutive emergency medical admissions to compare a novel automated computer-aided mortality risk score and clinical judgement of patient mortality risk

    Faisal, Muhammad; Khatoon, Binish; Scally, Andy J.; Richardson, D.; Irwin, S.; Davidson, R.; Heseltine, D.; Corlett, A.; Ali, J.; Hampson, R.; et al. (2019-06)
    Objectives: To compare the performance of a validated automatic computer-aided risk of mortality (CARM) score versus medical judgement in predicting the risk of in-hospital mortality for patients following emergency medical admission. Design: A prospective study. Setting: Consecutive emergency medical admissions in York hospital. Participants: Elderly medical admissions in one ward were assigned a risk of death at the first post-take ward round by consultant staff over a 2-week period. The consultant medical staff used the same variables to assign a risk of death to the patient as the CARM (age, sex, National Early Warning Score and blood test results) but also had access to the clinical history, examination findings and any immediately available investigations such as ECGs. The performance of the CARM versus consultant medical judgement was compared using the c-statistic and the positive predictive value (PPV). Results: The in-hospital mortality was 31.8% (130/409). For patients with complete blood test results, the c-statistic for CARM was 0.75 (95% CI: 0.69 to 0.81) versus 0.72 (95% CI: 0.66 to 0.78) for medical judgements (p=0.28). For patients with at least one missing blood test result, the c-statistics were similar (medical judgements 0.70 (95% CI: 0.60 to 0.81) vs CARM 0.70 (95% CI: 0.59 to 0.80)). At a 10% mortality risk, the PPV for CARM was higher than medical judgements in patients with complete blood test results, 62.0% (95% CI: 51.2 to 71.9) versus 49.2% (95% CI: 39.8 to 58.5) but not when blood test results were missing, 50.0% (95% CI: 24.7 to 75.3) versus 53.3% (95% CI: 34.3 to 71.7). Conclusions: CARM is comparable with medical judgements in discriminating in-hospital mortality following emergency admission to an elderly care ward. CARM may have a promising role in supporting medical judgements in determining the patient's risk of death in hospital. Further evaluation of CARM in routine practice is required.
  • Performance of externally validated enhanced computer-aided versions of the National Early Warning Score in predicting mortality following an emergency admission to hospital in England: a cross-sectional study

    Faisal, Muhammad; Richardson, D.; Scally, Andy J.; Howes, R.; Beatson, K.; Mohammed, Mohammed A. (2019-11)
    OBJECTIVES: In the English National Health Service, the patient's vital signs are monitored and summarised into a National Early Warning Score (NEWS) to support clinical decision making, but it does not provide an estimate of the patient's risk of death. We examine the extent to which the accuracy of NEWS for predicting mortality could be improved by enhanced computer versions of NEWS (cNEWS). DESIGN: Logistic regression model development and external validation study. SETTING: Two acute hospitals (YH-York Hospital for model development; NH-Northern Lincolnshire and Goole Hospital for external model validation). PARTICIPANTS: Adult (≥16 years) medical admissions discharged over a 24-month period with electronic NEWS (eNEWS) recorded on admission are used to predict mortality at four time points (in-hospital, 24 hours, 48 hours and 72 hours) using the first electronically recorded NEWS (model M0) versus a cNEWS model which included age+sex (model M1) +subcomponents of NEWS (including diastolic blood pressure) (model M2). RESULTS: The risk of dying in-hospital following emergency medical admission was 5.8% (YH: 2080/35 807) and 5.4% (NH: 1900/35 161). The c-statistics for model M2 in YH for predicting mortality (in-hospital=0.82, 24 hours=0.91, 48 hours=0.88 and 72 hours=0.88) was higher than model M0 (in-hospital=0.74, 24 hours=0.89, 48 hours=0.86 and 72 hours=0.85) with higher Positive Predictive Value (PPVs) for in-hospital mortality (M2 19.3% and M0 16.6%). Similar findings were seen in NH. Model M2 performed better than M0 in almost all major disease subgroups. CONCLUSIONS: An externally validated enhanced computer-aided NEWS model (cNEWS) incrementally improves on the performance of a NEWS only model. Since cNEWS places no additional data collection burden on clinicians and is readily automated, it may now be carefully introduced and evaluated to determine if it can improve care in hospitals that have eNEWS systems.
  • Exploring variation in the use of feedback from national clinical audits: a realist investigation

    Alvarado, N.; McVey, L.; Greenhalgh, J.; Dowding, D.; Mamas, M.; Gale, C.; Doherty, P.; Randell, Rebecca (2020)
    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 interactions between providers and NCA feedback: reputation, professionalism, competition, incentives, and professional development. Underpinned by the mechanisms professionalism and incentives, feedback was used most routinely within clinical services resourced to maintain local databases, where data were stored before upload to NCA suppliers. Local databases enabled staff to access data easily, customise reports and integrate them within governance processes. Use of feedback generated in this way was further supported where staff supporting audit participation were trusted to collect timely and accurate data. Feedback produced by NCA suppliers, which included national comparator data, was used in a more limited capacity. Challenges accessing data from NCA supplier databases, concerns about the quality of data across participating organisations and timeliness were reported to constrain the perceived usefulness of this type of feedback as a tool for stimulating quality improvement. Conclusion The findings suggest that there are a number of mechanisms through which healthcare providers, in particular staff within clinical services, engage with NCA feedback, but that there is variation in the mode, frequency and impact of these interactions. Feedback was used most routinely within clinical services resourced to maintain local databases, where data were considered timely, trusted as accurate and could be easily accessed to customise reports for the needs of the service.
  • Eliciting Context-Mechanism-Outcome configurations: Experiences from a realist evaluation investigating the impact of robotic surgery on teamwork in the operating theatre

    Alvarado, N.; Honey, S.; Greenhalgh, J.; Pearman, A.; Dowding, D.; Cope, A.; Long, A.; Jayne, D.; Gill, A.; Kotze, A.; et al. (2017-10-01)
    This article recounts our experience of eliciting, cataloguing and prioritizing conjectured Context-Mechanism-Outcome configurations at the outset of a realist evaluation, to provide new insight into how Context-Mechanism-Outcome configurations can be generated and theorized. Our construction of Context-Mechanism-Outcome configurations centred on how, why and in what circumstances teamwork was impacted by robotic surgery, rather than how and why this technology improved surgical outcomes as intended. We found that, as well as offering resources, robotic surgery took away resources from the theatre team, by physically reconfiguring the operating theatre and redistributing the surgical task load, essentially changing the context in which teamwork was performed. We constructed Context-Mechanism-Outcome configurations that explain how teamwork mechanisms were both constrained by the contextual changes, and triggered in the new context through the use of informal strategies. We conclude by reflecting on our application of realist evaluation to understand the potential impacts of robotic surgery on teamwork.
  • Institutional use of National Clinical Audits by healthcare providers

    McVey, L.; Alvarado, N.; Keen, J.; Greenhalgh, J.; Mamas, M.; Gale, C.; Doherty, P.; Feltbower, R.; Elshehaly, Mai; Dowding, D.; et al. (2020-01)
    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.
  • The learning curve to achieve satisfactory completion rates in upper GI endoscopy: an analysis of a national training database

    Ward, S.T.; Hancox, A.; Mohammed, Mohammed A.; Ismail, T.; Griffiths, E.A.; Valori, R.; Dunckley, P. (2017-06)
    Objective: The aim of this study was to determine the number of OGDs (oesophago-gastro-duodenoscopies) trainees need to perform to acquire competency in terms of successful unassisted completion to the second part of the duodenum 95% of the time. Design: OGD data were retrieved from the trainee e-portfolio developed by the Joint Advisory Group on GI Endoscopy ( JAG) in the UK. All trainees were included unless they were known to have a baseline experience of >20 procedures or had submitted data for <20 procedures. The primary outcome measure was OGD completion, defined as passage of the endoscope to the second part of the duodenum without physical assistance. The number of OGDs required to achieve a 95% completion rate was calculated by the moving average method and learning curve cumulative summation (LC-Cusum) analysis. To determine which factors were independently associated with OGD completion, a mixed effects logistic regression model was constructed with OGD completion as the outcome variable. Results: Data were analysed for 1255 trainees over 288 centres, representing 243 555 OGDs. By moving average method, trainees attained a 95% completion rate at 187 procedures. By LC-Cusum analysis, after 200 procedures, >90% trainees had attained a 95% completion rate. Total number of OGDs performed, trainee age and experience in lower GI endoscopy were factors independently associated with OGD completion. Conclusions: There are limited published data on the OGD learning curve. This is the largest study to date analysing the learning curve for competency acquisition. The JAG competency requirement for 200 procedures appears appropriate
  • Improving wrist imaging through a multicentre educational intervention: The challenge of orthogonal projections

    Snaith, Beverly; Raine, S.; Fowler, L.; Osborne, C.; House, S.; Holmes, R.; Tattersall, E.; Pierce, E.; Dobson, M.; Harcus, J.W. (2020-09-01)
    In relation to wrist imaging, the accepted requirement is two orthogonal projections obtained at 90°, each with the wrist in neutral position. However, the literature and anecdotal experience suggests that this principle is not universally applied. Method: This multiphase study was undertaken across eight different hospitals sites. Compliance with standard UK technique was confirmed if there was a change in ulna orientation between the dorsi-palmar (DP) and lateral wrist projections. A baseline evaluation for three days was randomly identified from the preceding three months. An educational intervention was implemented using a poster to demonstrate standard positioning. To measure the impact of the intervention, further evaluation took place at two weeks (early) and three months (late). Results: Across the study phases, only a minority of radiographs demonstrated compliance with the standard technique, with an identical anatomical appearance of the distal ulna across the projections. Initial compliance was 16.8% (n = 40/238), and this improved to 47.8% (n = 77/161) post-intervention, but declined to 32.8% (n = 41/125) within three months. The presence of pathology appeared to influence practice, with a greater proportion of those with an abnormal radiographic examination demonstrating a change in ulna appearances in the baseline cohort (p
  • Patients treated for hyperthyroidism are at increased risk of becoming obese: findings from a large prospective secondary care cohort

    Torlinska, B.; Nichols, L.; Mohammed, Mohammed A.; McCabe, C.; Boelaert, K. (2019-10-15)
    Background: The most commonly reported symptom of hyperthyroidism is weight loss; successful treatment increases weight. Weight gain faced by patients with hyperthyroidism is widely considered a simple reaccumulation of premorbid weight, whereas many patients feel there is a significant weight “overshoot” attributable to the treatment. We aimed to establish if weight gain seen following treatment for hyperthyroidism represents replenishment of premorbid weight or “overshoot” beyond expected regain and, if there is excessive weight gain, whether this is associated with the applied treatment modality. Methods: We calculated the risk of becoming obese (body mass index [BMI] >30 kg/m2) following treatment for hyperthyroidism by comparing BMI of 1373 patients with overt hyperthyroidism seen in a secondary care setting with the age- and sex-matched background population (Health Survey for England, 2007–2009). Next, we investigated the effect of treatment with an antithyroid drug (ATD) alone in regard to ATD with radioactive iodine (131I) therapy. We modeled the longitudinal weight data in relation to the treatment pathway to thyroid function and the need for long-term thyroxine replacement. Results: During treatment of hyperthyroidism, men gained 8.0 kg (standard deviation ±7.5) and women 5.5 kg (±6.8). At discharge, there was a significantly increased risk of obesity in male (odds ratio = 1.7 [95% confidence interval 1.3–2.2], p < 0.001) and female (1.3, 1.2–1.5, p < 0.001) patients with hyperthyroidism compared with the background population. Treatment with 131I was associated with additional weight gain (0.6 kg, 0.4–0.8, p < 0.001), compared with ATD treatment alone. More weight gain was seen if serum thyrotropin (TSH) was markedly increased (TSH >10 mIU/L; 0.5 kg, 0.3–0.7, p < 0.001) or free thyroxine (fT4) was reduced (fT4 ≤ 10 pmol/L (0.8 ng/dL); 0.3 kg, 0.1–0.4, p < 0.001) during follow-up. Initiation of levothyroxine was associated with further weight gain (0.4 kg, 0.2–0.6, p < 0.001) and the predicted excess weight gain in 131I-induced hypothyroidism was 1.8 kg. Conclusions: Treatment for hyperthyroidism is associated with significant risks of becoming obese. 131I treatment and subsequent development of hypothyroidism were associated with small but significant amounts of excess weight gain compared with ATD alone. We advocate that the discussion over the weight “overshoot” risk forms part of the individualized treatment decision-making process.

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