Measuring quality in the therapeutic relationship-Part 2: subjective approaches

Publisher version: http://qualitysafety.bmj.com/content/19/6/479.ful

Hands-on guide to questionnaire research: reaching beyond the white middle classes

Apparently simple questions can easily be misunderstood or cause offence in disadvantaged groups. But such problems can be avoided by careful design, piloting, and administration

A meta-narrative review of electronic patient records

This session comprises four papers that consider how systematic review methods may be developed in order to make the best use of complex evidence in education and health. The methods and approaches reflected upon in these papers are not drawn from a single research tradition, but share a common goal of broadening the methodological scope of systematic reviews and better understanding the utilisation of knowledge produced in this way. The first paper (Henry Potts) reports an ongoing review using a meta-narrative approach to make sense of the diverse sources of knowledge regarding electronic patient records. The review method has stressed the importance of understanding knowledge from within the research tradition in which it was produced; it is argued that this has important implications for the way that evidence is utilised in the policy making process. The second paper (Geoff Wong) reflects upon the experience of using an explicit realist approach in the synthesis of the evidence in Internet based learning. This realist synthesis offers a method of making sense of the highly heterogeneous and context dependent evidence which exists in this field thus enabling greater insights into what makes such educational interventions ‘work’. The third paper (Rod Sheaff) reports a review of the predominantly qualitative research literature on organisational structures and their impacts upon policy outcomes in health systems. A scoping study found 14389 relevant papers of which 1568 were selected for review. These studies were very variable in the amount and quality of the qualitative data, hence 'evidence', which they reported. The paper describes an attempt to adapt realist methods so as to synthesise such bodies of research in ways which take account of this variation in the strength of qualitative evidence. The fourth paper (Mark Pearson) draws upon the work of Donald Campbell and colleagues in order to gain a fuller understanding of how systematic reviews are utilised in the policy making process. It is argued that interpretive approaches to understanding policy making (such as rhetorical analysis) need to be tempered with a more nuanced understanding of research validity. The case is made that interpretive approaches not only can, but should, be melded with research validity to increase understanding of the policy making process

Risk models and scores for type 2 diabetes: Systematic review

This article is published under a Creative Commons Attribution Non Commercial (CC BY-NC 3.0) licence that allows reuse subject only to the use being non-commercial and to the article being fully attributed (http://creativecommons.org/licenses/by-nc/3.0).Objective - To evaluate current risk models and scores for type 2 diabetes and inform selection and implementation of these in practice. Design - Systematic review using standard (quantitative) and realist (mainly qualitative) methodology. Inclusion - criteria Papers in any language describing the development or external validation, or both, of models and scores to predict the risk of an adult developing type 2 diabetes. Data sources - Medline, PreMedline, Embase, and Cochrane databases were searched. Included studies were citation tracked in Google Scholar to identify follow-on studies of usability or impact. Data extraction - Data were extracted on statistical properties of models, details of internal or external validation, and use of risk scores beyond the studies that developed them. Quantitative data were tabulated to compare model components and statistical properties. Qualitative data were analysed thematically to identify mechanisms by which use of the risk model or score might improve patient outcomes. Results - 8864 titles were scanned, 115 full text papers considered, and 43 papers included in the final sample. These described the prospective development or validation, or both, of 145 risk prediction models and scores, 94 of which were studied in detail here. They had been tested on 6.88 million participants followed for up to 28 years. Heterogeneity of primary studies precluded meta-analysis. Some but not all risk models or scores had robust statistical properties (for example, good discrimination and calibration) and had been externally validated on a different population. Genetic markers added nothing to models over clinical and sociodemographic factors. Most authors described their score as “simple” or “easily implemented,” although few were specific about the intended users and under what circumstances. Ten mechanisms were identified by which measuring diabetes risk might improve outcomes. Follow-on studies that applied a risk score as part of an intervention aimed at reducing actual risk in people were sparse. Conclusion - Much work has been done to develop diabetes risk models and scores, but most are rarely used because they require tests not routinely available or they were developed without a specific user or clear use in mind. Encouragingly, recent research has begun to tackle usability and the impact of diabetes risk scores. Two promising areas for further research are interventions that prompt lay people to check their own diabetes risk and use of risk scores on population datasets to identify high risk “hotspots” for targeted public health interventions.Tower Hamlets, Newham, and City and Hackney primary care trusts and National Institute of Health Research

Electric Potential and Fréchet Derivatives for a Uniform Anisotropic Medium with a Tilted Axis of Symmetry

In this paper we develop analytic solutions for the electric potential, current density and Fréchet derivatives at any interior point within a 3-D transversely isotropic medium having a tilted axis of symmetry. The current electrode is assumed to be on the surface of the Earth and the plane of stratification given arbitrary strike and dip. Profiles can be computed for any azimuth. The equipotentials exhibit an elliptical pattern and are not orthogonal to the current density vectors, which are strongly angle dependent. Current density reaches its maximum value in a direction parallel to the longitudinal conductivity direction. Illustrative examples of the Fréchet derivatives are given for the 2.5-D problem, in which the profile is taken perpendicular to strike. All three derivatives of the Green's function with respect to longitudinal conductivity, transverse resistivity and dip angle of the symmetry axis (dG/dσl, dG/dσt, dG/dθ0) show a strongly asymmetric pattern compared to the isotropic case. The patterns are aligned in the direction of the tilt angle. Such sensitivity patterns are useful in real-time experimental design as well as in the fast inversion of resistivity data collected over an anisotropic eart

Summary care record early adopter programme: an independent evaluation by University College London.

Benefits The main potential benefit of the SCR is considered to be in emergency and unscheduled care settings, especially for people who are unconscious, confused, unsure of their medical details, or unable to communicate effectively in English. Other benefits may include improved efficiency of care and avoidance of hospital admission, but it is too early for potential benefits to be verified or quantified. Progress As of end April 2008, the SCR of 153,188 patients in the first two Early Adopter sites (Bolton and Bury) had been created. A total of 614,052 patients in four Early Adopter sites had been sent a letter informing them of the programme and their choices for opting out of having a SCR. Staff attitudes and usage The evaluation found that many NHS staff in Early Adopter sites (which had been selected partly for their keenness to innovate in ICT) were enthusiastic about the SCR and keen to see it up and running, but a significant minority of GPs had chosen not to participate in the programme and others had deferred participation until data quality improvement work was completed. Whilst 80 per cent of patients interviewed were either positive about the idea of having a SCR or ?did not mind?, others were strongly opposed ?on principle?. Staff who had attempted to use the SCR when caring for patients felt that the current version was technically immature (describing it as ?clunky? and ?complicated?), and were looking forward to a more definitive version of the technology. A comparable technology (the Emergency Care Summary) introduced in Scotland two years ago is now working well, and over a million records have been accessed in emergency and out-of-hours care. Patient attitudes and awareness Having a SCR is optional (people may opt out if they wish, though fewer than one per cent of people in Early Adopter sites have done so) and technical security is said to be high via a system of password protection and strict access controls. Nevertheless, the evaluation showed that recent stories about data loss by government and NHS organisations had raised concerns amongst both staff and patients that human fallibility could potentially jeopardise the operational security of the system. Despite an extensive information programme to inform the public in Early Adopter sites about the SCR, many patients interviewed by the UCL team were not aware of the programme at all. This raises important questions about the ethics of an ?implied consent? model for creating the SCR. The evaluation recommended that the developers of the SCR should consider a model in which the patient is asked for ?consent to view? whenever a member of staff wishes to access their record. Not a single patient interviewed in the evaluation was confident that the SCR would be 100 per cent secure, but they were philosophical about the risks of security breaches. Typically, people said that the potential benefit of a doctor having access to key medical details in an emergency outweighed the small but real risk of data loss due to human or technical error. Even patients whose medical record contained potentially sensitive data such as mental health problems, HIV or drug use were often (though not always) keen to have a SCR and generally trusted NHS staff to treat sensitive data appropriately. However, they and many other NHS patients wanted to be able to control which staff members were allowed to access their record at the point of care. Some doctors, nurses and receptionists, it seems, are trusted to view a person?s SCR, whereas others are not, and this is a decision which patients would like to make in real time

"We were treated like adults" - development of a pre-medicine summer school for 16 year olds from deprived socioeconomic backgrounds: action research study

Objective To develop a one week widening access summer school for 16 year old pupils from, non-traditional backgrounds who are considering applying to medical school, and to identify its short term impact and key success factors.Design Action research with partnership schools tit deprived inner-city areas in five overlapping phases: schools liaison, recruitment of pupils and assessment of needs, programme design, programme delivery, and evaluation. The design phase incorporated findings from one-to-one interviews with every pupil, and workshops and focus groups for pupils, Parents, teachers, medical student assistants, NHS staff, and other stakeholders. An in-depth process evaluation of the summer School was undertaken from the perspective of multiple stakeholders using questionnaires, interviews, focus groups, and observation.Participants 40 pupils aged 16 years from socioeconomically deprived and under-represented ethnic Minority groups.Results The summer school was popular with pupils, parents, teachers, and staff. It substantially raised pupils' confidence and motivation to apply to medical school. Critical success factors were identified as an atmosphere of "respect"; a focus on hands-on work in small groups; the input. of medical students as role models; and vision and leadership from senior staff. A particularly popular and effective aspect Of the course was a grand round held Oil the last clay, in which pupils gave group presentations of real cases.Conclusion An action research format allowed us to draw the different stakeholders into a collaborative endeavour characterised by enthusiasm, interpersonal support, and mutual respect. The input from pupils to the programme design ensured high engagement and low drop-out rates. Hands-on activities in small groups and social drama of preparing and giving a grand round presentation were particularly important

Soft networks for bridging the gap between research and practice: illuminative evaluation of CHAIN

Objectives To explore the process of knowledge exchange in an informal email network for evidence based health care, to illuminate the value of the service and its critical success factors, and to identify areas for improvement.Design Illuminative evaluationSetting Targeted email and networking service for UK healthcare practitioners and researchers.Participants 2800 members of a networking service.Main outcome measures Tracking of email messages, interviews with core staff, and a qualitative analysis of messages, postings from focus groups, and invited and unsolicited feedback to the service.Results The informal email network helped to bridge the gap between research and practice by serving as a rich source of information, providing access to members' experiences, suggestions, and ideas, facilitating cross boundary collaboration, and enabling participation in networking at a variety of levels. Ad hoc groupings and communities of practice emerged spontaneously as members discovered common areas of interest.Conclusion This study illuminated how knowledge for evidence based health care can be targeted, personalised, and made meaningful through informal social processes. Critical success factors include a broad based membership from both the research and service communities; a loose and fluid network structure; fight targeting of messages based on members' interests; the presence of a strong network identity and culture of reciprocity; and the opportunity for new members to learn through passive participation