Conflict of interest disclosure by US cardiothoracic surgeons.

BACKGROUND: Surgeon-industry collaboration is a key driver of advancement in surgical technology and practice. Disclosures of financial relationships between investigators and industries are important to ensure transparent and critical evaluation of literature. METHODS: All American cardiothoracic (CT) surgeons who published in three major CT surgery journals in 2019 were identified. Whether these surgeons disclosed any conflicts of interest was recorded and compared to actual payments received within 5 years of publication as reported by the Centers for Medicare and Medicaid Services data. RESULTS: In the study period, there were 1079 unique manuscripts involving 885 American CT surgeons as authors, which combined for 2719 author instances. Of these, 96.2% of authors (851 of 885) received payments from companies. The authors who received payments produced 2651 author instances (97.4%). Financial disclosure was reported in only 11.4% (301 of 2651) of these instances. In total, 851 surgeons received more than $187 million over 5 years, with the highest-paid surgeon receiving an average of over $5.9 million per year. The largest individual payments were from "Associated Research Funding," with over $115 million being paid to 277 surgeons over 5 years. The top paying company issued over $96.5 million to American CT surgeons over 5 years. CONCLUSIONS: Nearly all the reviewed publications in three top CT surgery journals were by surgeons who received payments from companies, but very few of these payments were recorded as potential conflicts of interest. A more consistent and robust policy of COI disclosure is needed to reduce perceptions of bias.

Validity Evidence for Procedure-specific Competence Assessment Tools in Orthopaedic Surgery: A Scoping Review.

INTRODUCTION: Competency-based training requires frequent assessment of residents' skills to determine clinical competence. This study reviews existing literature on procedure-specific competence assessment tools in orthopaedic surgery. METHODS: A systematic search of eight databases up to May 2023 was conducted. Two reviewers independently assessed validity evidence and educational utility of each assessment tool and evaluated studies' methodological quality. RESULTS: Database searching identified 2,556 unique studies for title and abstract screening. Full texts of 290 studies were reviewed; 17 studies met the inclusion criteria. Bibliography review identified another five studies, totaling 22 studies examining 24 assessment tools included in the analysis. These tools assessed various orthopaedic surgery procedures within trauma, sports medicine, spine, and upper extremity. Overall validity evidence was low across all studies, and was lowest for consequences and highest for content. Methodological quality of studies was moderate. Educational utility assessment was not explicitly done for most tools. DISCUSSION: The paucity of current procedure-specific assessment tools in orthopaedic surgery lacks the validity evidence required to be used reliably in high-stake summative assessments. Study strengths include robust methodology and use of an evidence-based validity evidence framework. Poor-quality existing evidence is a limitation and highlights the need for evidence-based tools across more subspecialties.

Assessment of a Novel, Adjustable Task Trainer for Cardiac Surgical Skills.

INTRODUCTION: A recent needs assessment in Canadian cardiac surgery programs identified the desire for a coronary artery bypass (CABG) and aortic valve replacement (AVR) simulation model for home practice. We aimed to develop and assess a portable, adjustable task trainer for cardiac surgical skills with high functional task alignment. METHODS: Intraoperative measurements were taken from patients undergoing elective CABG and AVR (N = 30). Measurements were taken in 3 axes and used to create a chest cavity that resembles the mediastinal constraints of a patient undergoing CABG and AVR. The task trainer is adjustable on the following 3 levels: (1) size of the incision, (2) depth of the chest, and (3) relative position of coronary artery or aortic valve model within the chest. Three groups (novices, intermediates, and experts) of cardiac surgery members evaluated the task trainer for functional task alignment and construct validity. RESULTS: The CABG and AVR model had high functional task alignment. There was a high satisfaction for both models and all participants would recommend the AVR and CABG model as an educational tool. Performance time significantly differed between the groups for both models (CABG: P = 0.032 and AVR: P = 0.001), as well as number of errors (CABG: P = 0.04 and AVR: P = 0.043). CONCLUSIONS: Using real patient data, we were able to develop an adjustable task trainer for training principles of CABG and AVR. Our pilot study provides preliminary sources of evidence for validity and future study will look to assess transferability of skill to the operating room.

Oral care reduces incidence of pneumonia after esophagectomy: systematic review and meta-analysis.

PURPOSE: Post-operative pneumonia after esophagectomy is a major contributor to morbidity and mortality. Prior studies have demonstrated a link between the presence of pathologic oral flora and the development of aspiration pneumonia. The objective of this systematic review and meta-analysis was to evaluate the effect of pre-operative oral care on the incidence of post-operative pneumonia after esophagectomy. METHODS: A systematic search of the literature was performed on September 2, 2022. Screening of titles and abstracts, full-text articles, and evaluation of methodological quality was performed by two authors. Case reports, conference proceedings, and animal studies were excluded. A meta-analysis of peri-operative oral care on the odds of post-operative pneumonia after esophagectomy was performed using Revman 5.4.1 with a Mantel-Haenszel, random-effects model. RESULTS: A total of 736 records underwent title and abstract screening, leading to 28 full-text studies evaluated for eligibility. A total of nine studies met the inclusion criteria and underwent meta-analysis. Meta-analysis revealed a significant reduction in post-operative pneumonia among patients undergoing pre-operative oral care intervention compared to those without an oral care intervention (OR 0.57, 95% CI 0.43-0.74, p < 0.0001; I2 = 49%). CONCLUSION: Pre-operative oral care interventions have significant potential in the reduction of post-operative pneumonia after esophagectomy. North American prospective studies, as well as studies on the cost-benefit analysis, are required.

Validity Evidence for Procedure-Specific Competency Assessment Tools in Cardiovascular and Thoracic Surgery: A Scoping Review.

OBJECTIVE: Surgical education has shifted from a time-based approach to the achievement and demonstration of procedural competency. High quality, objective assessment instruments are required to support this new approach. This study comprehensively reviewed the literature to identify and evaluate available procedure-specific assessment instruments in cardiothoracic and vascular surgery. DESIGN: A systematic search of 8 databases identified studies containing procedure-specific operative assessment instruments in cardiothoracic and vascular surgery. Generic global rating scales were excluded, unless modified to be procedure-specific. Two reviewers independently evaluated the validity evidence, methodological rigour and educational utility of each instrument using objective scoring criteria. Validity evidence was evaluated with a scoring tool aligned with the contemporary framework of validity. Methodological rigour was evaluated using the Medical Education Research Study Quality Instrument. Educational utility was evaluated according to the Accreditation Council for Graduate Medical Education (ACGME) framework. RESULTS: There were 2130 unique studies describing procedure-specific assessment in surgery. Of these, 9 studies evaluating 8 procedure-specific assessment instruments met inclusion criteria for cardiothoracic and vascular surgery. Four instruments were identified in thoracic surgery, 2 in cardiac surgery, and 2 in vascular surgery. Only 1 instrument was designed to evaluate surgeon performance, with the remainder designed to evaluate residents. No single instrument scored the maximum score of 15 for validity evidence. The highest score was 11, with 62.5% (n = 5) of instruments scoring greater than 10. All tools attained high scores in content validity, with minimal evidence generally presented regarding the consequences of assessment using a particular instrument. All but 1 instrument scored greater than 11 out of a maximum 16.5 points for methodological rigour. Very few studies reported on the ACGME domains of educational utility. CONCLUSIONS: In an era where surgical education is shifting towards the demonstration of procedural competency, objective procedure-specific assessment is critical. This review identified that few procedure-specific assessment instruments in cardiothoracic and vascular surgery exist, emphasizing the need for such instruments to ensure the success of competency-based education models.

Sexual dimorphism in ritualized agonistic behaviour, fighting ability and contest costs of Sus scrofa.

BACKGROUND: Sexual selection has driven sexual dimorphism in agonistic behaviour in many species. Agonistic behaviour is fundamentally altered by domestication and captivity, but it is unclear whether ancestral sex differences remain. We aimed to evaluate the effect of sex on agonistic behaviour, fighting ability and contest costs. We studied this in domestic pigs (Sus scrofa) where aggression compromises welfare, and sexual dimorphism in aggression has been inconclusively demonstrated. Behaviour and physiology of 827 male and female juvenile pigs were studied during resident-intruder tests and dyadic contests at various ages, while accounting for the relative body weight difference between the opponents. RESULTS: Males won in 79% of contests against females, even when at a large weight disadvantage. The effect of sex increased with age, with males having a 138 times higher likelihood of winning than females when 13 weeks old. In dyadic contests, males invested more time in non-damaging agonistic display behaviour and took longer before escalating into damaging aggression. Males showed ritualized display that included foaming from the mouth and piloerection of the neck hair, which was nearly always absent in females. Contest costs in terms of contest duration, blood lactate and skin lesions where higher for males, especially when fighting another male. CONCLUSIONS: Profound sex differences were present for agonistic behaviour, fighting ability and contest costs, and became more pronounced as animals got older. Males invested more in ritualized display before escalating into costly fights, whereas females attacked sooner but also terminated contests more rapidly and with fewer costs. The sexual dimorphism in agonistic behaviour in juvenile domestic pigs is in line with the evolutionary relevance for females' maternal defence and males' competition for females.

Validity Evidence for Procedure-specific Competence Assessment Tools in General Surgery: A Scoping Review.

OBJECTIVE: This study aims to provide a focused and detailed assessment of the validity evidence supporting procedure-specific operative assessment tools in general surgery. SUMMARY OF BACKGROUND DATA: Competency-based assessment tools should be supported by robust validity evidence to be used reliably for evaluation of operative skills. The contemporary framework of validity relies on five sources of evidence: content, response process, internal structure, relation to other variables, and consequences. METHODS: A systematic search of 8 databases was conducted for studies containing procedure-specific operative assessment tools in general surgery. The validity evidence supporting each tool was assessed and scored in alignment with the contemporary framework of validity. Methodological rigour of studies was assessed with the Medical Education Research Study Quality Instrument. The educational utility of each tool was assessed with the Accreditation Council for Graduate Medical Education framework. RESULTS: There were 28 studies meeting inclusion criteria and 23 unique tools were assessed. Scores for validity evidence varied widely between tools, ranging from 3 - 14 (maximum 15). Medical Education Research Study Quality Instrument scores assessing the quality of study methodology were also variable (8.5-15.5, maximum 16.5). Direct reporting of educational utility criteria was limited. CONCLUSIONS: This study has identified a small group of procedure-specific operative assessment tools in general surgery. Many of these tools have limited validity evidence and have not been studied sufficiently to be used reliably in high-stakes summative assessments. As general surgery transitions to competency-based training, a more robust library of operative assessment tools will be required to support resident education and evaluation.

An estimation of the financial consequences of reducing pig aggression.

Animal welfare scientists have accumulated knowledge and developed interventions to improve livestock welfare, but these are poorly adopted in commercial practice. Animal welfare interventions are rarely tested for economic viability and this limits their uptake. This study employs Stochastic Partial Budgeting (SPB) to determine the viability of animal welfare improvements. Aggression between pigs is used as an example because there is a large literature base from which to draw interventions, and the problem has persisted for decades without resolution. Costs and benefits of three interventions to control aggression (pre-weaning socialisation, synthetic maternal pheromones and large social groups) were estimated by reviewing the academic and industry literature and by conducting a survey of sixteen pig farmers. The net effects were compared to farmers' willingness to pay (WTP) for interventions to reduce aggression as identified by recent research. Results are consistent with prior research which indicates that improving animal welfare generally comes at a cost to producers. Nevertheless, pre-weaning socialisation resulted in a neutral or positive net effect 38% of the time and should be central to campaigns promoting the control of aggression in the industry. Exposing pigs to synthetic maternal pheromones did not improve profitability but the net costs were small and within the realms of WTP for a sub-group of farmers with animal welfare goals. The net costs of converting existing buildings in order to house pigs in large social groups were beyond the realms of farmers' WTP. The approach adopted in this study, of combining SPB with WTP from the sector, should be extended to other animal welfare issues.

Qualitative analysis of the coordination of major system change within the Colombian health system in response to COVID-19: study protocol.

BACKGROUND: Coronavirus (COVID-19) is posing a major and unprecedented challenge to health service planning and delivery across health systems internationally. This nationally funded study is analysing the response of the Colombian health system to the COVID-19 pandemic, drawing on qualitative case studies of three local health systems within the country. The approach will be informed by the concept of 'major system change'-or coordinated change among a variety of healthcare organizations and other relevant stakeholders- to identify processes that both enable and inhibit adaptation of health services to the challenges presented by COVID-19. The study will collect information on capacity 'bottlenecks' as well as successful practices and forms of innovation that have emerged locally, which have the potential for being 'scaled up' across Colombia's health services. METHODS/DESIGN: This qualitative study will be undertaken in two phases. In the first, up to 30 stakeholder interviews will be conducted to ascertain immediate challenges and opportunities for improvement in response to COVID-19 that can be shared in a timely way with health service leaders to inform health service planning. The stakeholders will include planning, provider and intermediary organizations within the health system at the national level. In the second, up to 60 further interviews will be conducted to develop in-depth case studies of three local health systems at the metropolitan area level within Colombia. The interview data will be supplemented with documentary analysis and, where feasible, non-participant observation of planning meetings. DISCUSSION: The study's findings will aid evaluation of the relevance of the concept of major system change in a context of 'crisis' decision-making and contribute to international lessons on improving health systems' capacity to respond to COVID-19 and future pandemics. Study findings will be shared among various stakeholders in the Colombian healthcare system in a formative and timely way in order to inform healthcare planning in response to COVID-19 and future pandemics. Conducting the study at a time of COVID-19 raises a number of practical issues (including physical distancing and pressure on health services) which have been anticipated in the study design and research team's ways of working.

Competency Assessment for Mediastinal Mass Resection and Thymectomy: Design and Delphi Review Process.

OBJECTIVES: Mediastinal mass resection and thymectomy are complex and related operations that are core components of competency for a general thoracic surgeon and an important learning objective for thoracic surgery trainees. This study aimed to design a combined competency assessment instrument for mediastinal mass resection and thymectomy. DESIGN: A comprehensive competency assessment instrument was designed by a process of logical analysis by 3 expert thoracic surgeons with an interest in mediastinal surgery. The instrument was then assessed and refined using a modified Delphi process. SETTING: The Delphi questionnaire was distributed to all members of the Canadian Association of Thoracic Surgeons in 2018 to 2019. PARTICIPANTS: The first round of the Delphi review was completed by 58 respondents (response rate 43.9%). Respondents represented all Canadian provinces with a wide range of clinical experience and a high rate of involvement in resident education. RESULTS: A first draft of the competency assessment instrument included 42 steps in 6 categories. A total of 3 rounds of Delphi review were performed. Cronbach's alpha for the final round was 0.83. Ultimately, 29 items were retained from the original instrument and two modified and three new items were added. The final instrument has 34 steps in 5 categories. CONCLUSIONS: A nationwide consensus was established on the key components of assessing competence to perform mediastinal mass resection and thymectomy. The resulting instrument could be used to guide competency based assessments of thoracic surgeons and trainees.

Development and Pilot Testing of an Assessment Tool for Performance of Anatomic Lung Resection.

BACKGROUND: To meet the need for competency assessment in thoracic surgery education, we developed and tested an instrument to assess trainees' ability to perform anatomic lung resection for cancer. METHODS: The Thoracic Competency Assessment Tool-Anatomic Resection for Lung Cancer (TCAT-ARC) was developed through a multistep process involving logical analysis, expert review, and simulation-based and clinical pilot testing. Validity evidence was gathered during a 6-month clinical study of trainees performing anatomic lung resections and assessments of practicing surgeons. Feedback was gathered via post-encounter questionnaires. RESULTS: A 35-item instrument was developed and was tested in the clinical validation study. Seven trainees in 4 North American institutions participated and completed 64 anatomic lung resections. Reliability was high (α = 0.93). Interobserver reliability (k = 0.73) and correlation with an existing global competency scale (k = 0.68) were moderately high. Item analysis revealed the most difficult and discriminatory items, which matched well with a conceptual understanding of lung resection. Both trainees and assessors viewed the instrument as highly educationally effective and user-friendly. Practicing surgeons outperformed trainees. CONCLUSIONS: The TCAT-ARC demonstrated early evidence of validity and reliability in assessing performance of anatomic lung resection. The instrument may be most useful early in training and as a means for providing fine-grained formative feedback about which steps have been mastered and which still require improvement. The TCAT-ARC may be used in training programs to aid in the development of trainees' competency and as a part of an aggregate assessment of trainees' overall mastery of the procedure and readiness for independent practice.

Mixed methods evaluation of a hospital group model using an embedded research approach: study protocol.

INTRODUCTION: Hospital group models represent an organisational form that aims to bring together multiple provider organisations with a central headquarters and unified leadership responsible for locally managed operating units, standardised systems and a value-set shared across the group. These models seek to improve outcomes by reducing unwarranted variations in care provision and reducing costs through economies of scale. There is limited evidence on the impact and processes of implementing these models, so this study aims to evaluate one case study of a hospital group model. METHODS AND ANALYSIS: We will conduct a formative, mixed-methods evaluation using an embedded research approach to analyse the implementation of the model and its impact on outcomes and costs. We will carry out a multisited ethnography to analyse the programme theory for model design and implementation, the barriers and facilitators in the implementation; and wider contextual issues that influence implementation using semi-structured interviews (n=80), non-participant observations (n=80 hours), 'shadowing' (n=20 hours) and documentary analysis. We will also carry out an economic evaluation composed of a cost-consequence analysis and a return on investment analysis to evaluate the costs of creating and running the model and balance these against the potential cost-savings. ETHICS AND DISSEMINATION: The study protocol was reviewed by the local R&D Office and University College London Ethics Committee and classified as a service evaluation, not requiring approval by a research ethics committee. We will follow guidelines for informed consent, confidentiality and information governance, and address issues of critical distance prevalent in embedded research. Findings will be shared at regular time points to inform the implementation of the model. The evaluation will also generate: an evaluation framework to evaluate future changes; recommendations for meaningful baseline data and measuring improvement; identification of implementation costs and potential cost-savings; and lessons for the National Health Service on implementing these models.

Development and Pilot Testing of an Assessment Tool for Performance of Invasive Mediastinal Staging.

BACKGROUND: To develop and evaluate a surgical trainee competency assessment instrument for invasive mediastinal staging, including cervical mediastinoscopy and endobronchial ultrasound (EBUS), a comprehensive instrument was developed, the Thoracic Competency Assessment Tool-Invasive Staging (TCAT-IS), using expert review and simulated and clinical pilot-testing. METHODS: Validity and reliability evidence were collected, and item analysis was performed. Initially, a 27-item instrument was developed, which underwent expert review with members of the Canadian Association of Thoracic Surgeons (n = 86) in 2014 to 2015 (response rate, 57%). TCAT-IS was refined to 29 items in 4 competency areas: preoperative, general operative, mediastinoscopy, and EBUS. Further refinements were made based on simulated use. The final version was then used to assess competency of 5 thoracic trainees performing invasive mediastinal staging in live patients. RESULTS: Participants were assessed during 20 mediastinoscopy and 8 EBUS procedures, with 47 total assessments completed. Reliability (Cronbach's alpha = 0.94), interrater reliability (κ = 0.80), and correlation with an established global competency scale (κ = 0.75) were high. The most difficult items were "set up and adjust EBUS equipment" and "identify vascular anatomy (EBUS)." Feedback questionnaires from trainees (response rate, 80%) and surgeons (response rate, 100%) were consistently positive regarding user friendliness, utility as an assessment tool, and educational benefit. Participants believed the tool "facilitated communicating feedback to the trainee with specific areas to work on." CONCLUSIONS: TCAT-IS is an effective tool for assessing competence in invasive staging and may enhance instruction. This initial test establishes early validity and reliability evidence, supporting the use of TCAT-IS in providing structured, specific, formative assessments of competency.

Impact and sustainability of centralising acute stroke services in English metropolitan areas: retrospective analysis of hospital episode statistics and stroke national audit data.

OBJECTIVES: To investigate whether further centralisation of acute stroke services in Greater Manchester in 2015 was associated with changes in outcomes and whether the effects of centralisation of acute stroke services in London in 2010 were sustained. DESIGN: Retrospective analyses of patient level data from the Hospital Episode Statistics (HES) database linked to mortality data from the Office for National Statistics, and the Sentinel Stroke National Audit Programme (SSNAP). SETTING: Acute stroke services in Greater Manchester and London, England. PARTICIPANTS: 509 182 stroke patients in HES living in urban areas admitted between January 2008 and March 2016; 218 120 stroke patients in SSNAP between April 2013 and March 2016. INTERVENTIONS: Hub and spoke models for acute stroke care. MAIN OUTCOME MEASURES: Mortality at 90 days after hospital admission; length of acute hospital stay; treatment in a hyperacute stroke unit; 19 evidence based clinical interventions. RESULTS: In Greater Manchester, borderline evidence suggested that risk adjusted mortality at 90 days declined overall; a significant decline in mortality was seen among patients treated at a hyperacute stroke unit (difference-in-differences -1.8% (95% confidence interval -3.4 to -0.2)), indicating 69 fewer deaths per year. A significant decline was seen in risk adjusted length of acute hospital stay overall (-1.5 (-2.5 to -0.4) days; P<0.01), indicating 6750 fewer bed days a year. The number of patients treated in a hyperacute stroke unit increased from 39% in 2010-12 to 86% in 2015/16. In London, the 90 day mortality rate was sustained (P>0.05), length of hospital stay declined (P<0.01), and more than 90% of patients were treated in a hyperacute stroke unit. Achievement of evidence based clinical interventions generally remained constant or improved in both areas. CONCLUSIONS: Centralised models of acute stroke care, in which all stroke patients receive hyperacute care, can reduce mortality and length of acute hospital stay and improve provision of evidence based clinical interventions. Effects can be sustained over time.

Economic evaluation of the NET intervention versus guideline dissemination for management of mild head injury in hospital emergency departments.

BACKGROUND: Evidence-based guidelines for the management of mild traumatic brain injury (mTBI) in the emergency department (ED) are now widely available, and yet, clinical practice remains inconsistent with the guidelines. The Neurotrauma Evidence Translation (NET) intervention was developed to increase the uptake of guideline recommendations and improve the management of minor head injury in Australian emergency departments (EDs). However, the adoption of this type of intervention typically entails an upfront investment that may or may not be fully offset by improvements in clinical practice, health outcomes and/or reductions in health service utilisation. The present study estimates the cost and cost-effectiveness of the NET intervention, as compared to the passive dissemination of the guideline, to evaluate whether any improvements in clinical practice or health outcomes due to the NET intervention can be obtained at an acceptable cost. METHODS AND FINDINGS: Study setting: The NET cluster randomised controlled trial [ACTRN12612001286831]. STUDY SAMPLE: Seventeen EDs were randomised to the control condition and 14 to the intervention. One thousand nine hundred forty-three patients were included in the analysis of clinical practice outcomes (NET sample). A total of 343 patients from 14 control and 10 intervention EDs participated in follow-up interviews and were included in the analysis of patient-reported health outcomes (NET-Plus sample). OUTCOME MEASURES: Appropriate post-traumatic amnesia (PTA) screening in the ED (primary outcome). Secondary clinical practice outcomes: provision of written information on discharge (INFO) and safe discharge (defined as CT scan appropriately provided plus PTA plus INFO). Secondary patient-reported, post-discharge health outcomes: anxiety (Hospital Anxiety and Depression Scale), post-concussive symptoms (Rivermead), and preference-based health-related quality of life (SF6D). METHODS: Trial-based economic evaluations from a health sector perspective, with time horizons set to coincide with the final follow-up for the NET sample (2 months post-intervention) and to 1-month post-discharge for the NET-Plus sample. RESULTS: Intervention and control groups were not significantly different in health service utilisation received in the ED/inpatient ward following the initial mTBI presentation (adjusted mean difference $23.86 per patient; 95%CI - $106, $153; p = 0.719) or over the longer follow-up in the NET-plus sample (adjusted mean difference $341.78 per patient; 95%CI - $58, $742; p = 0.094). Savings from lower health service utilisation are therefore unlikely to offset the significantly higher upfront cost of the intervention (mean difference $138.20 per patient; 95%CI $135, $141; p < 0.000). Estimates of the net effect of the intervention on total cost (intervention cost net of health service utilisation) suggest that the intervention entails significantly higher costs than the control condition (adjusted mean difference $169.89 per patient; 95%CI $43, $297, p = 0.009). This effect is larger in absolute magnitude over the longer follow-up in the NET-plus sample (adjusted mean difference $505.06; 95%CI $96, $915; p = 0.016), mostly due to additional health service utilisation. For the primary outcome, the NET intervention is more costly and more effective than passive dissemination; entailing an additional cost of $1246 per additional patient appropriately screened for PTA ($169.89/0.1363; Fieller's 95%CI $525, $2055). For NET to be considered cost-effective with 95% confidence, decision-makers would need to be willing to trade one quality-adjusted life year (QALY) for 25 additional patients appropriately screened for PTA. While these results reflect our best estimate of cost-effectiveness given the data, it is possible that a NET intervention that has been scaled and streamlined ready for wider roll-out may be more or less cost-effective than the NET intervention as delivered in the trial. CONCLUSIONS: While the NET intervention does improve the management of mTBI in the ED, it also entails a significant increase in cost and-as delivered in the trial-is unlikely to be cost-effective at currently accepted funding thresholds. There may be a scope for a scaled-up and streamlined NET intervention to achieve a better balance between costs and outcomes. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12612001286831 , date registered 12 December 2012.

The potential role of cost-utility analysis in the decision to implement major system change in acute stroke services in metropolitan areas in England.

BACKGROUND: The economic implications of major system change are an important component of the decision to implement health service reconfigurations. Little is known about how best to report the results of economic evaluations of major system change to inform decision-makers. Reconfiguration of acute stroke care in two metropolitan areas in England, namely London and Greater Manchester (GM), was used to analyse the economic implications of two different implementation strategies for major system change. METHODS: A decision analytic model was used to calculate difference-in-differences in costs and outcomes before and after the implementation of two major system change strategies in stroke care in London and GM. Values in the model were based on patient level data from Hospital Episode Statistics, linked mortality data from the Office of National Statistics and data from two national stroke audits. Results were presented as net monetary benefit (NMB) and using Programme Budgeting and Marginal Analysis (PBMA) to assess the costs and benefits of a hypothetical typical region in England with approximately 4000 strokes a year. RESULTS: In London, after 90 days, there were nine fewer deaths per 1000 patients compared to the rest of England (95% CI -24 to 6) at an additional cost of £770,027 per 1000 stroke patients admitted. There were two additional deaths (95% CI -19 to 23) in GM, with a total costs saving of £156,118 per 1000 patients compared to the rest of England. At a £30,000 willingness to pay the NMB was higher in London and GM than the rest of England over the same time period. The results of the PBMA suggest that a GM style reconfiguration could result in a total greater health benefit to a region. Implementation costs were £136 per patient in London and £75 in GM. CONCLUSIONS: The implementation of major system change in acute stroke care may result in a net health benefit to a region, even one functioning within a fixed budget. The choice of what model of stroke reconfiguration to implement may depend on the relative importance of clinical versus cost outcomes.

Analysing barriers to service improvement using a multi-level theory of innovation: the case of glaucoma outpatient clinics.

The development and implementation of innovation by healthcare providers is understood as a multi-determinant and multi-level process. Theories at different analytical levels (i.e. micro and organisational) are needed to capture the processes that influence innovation by providers. This article combines a micro theory of innovation, actor-network theory, with organisational level processes using the 'resource based view of the firm'. It examines the influence of, and interplay between, innovation-seeking teams (micro) and underlying organisational capabilities (meso) during innovation processes. We used ethnographic methods to study service innovations in relation to ophthalmology services run by a specialist English NHS Trust at multiple locations. Operational research techniques were used to support the ethnographic methods by mapping the care process in the existing and redesigned clinics. Deficiencies in organisational capabilities for supporting innovation were identified, including manager-clinician relations and organisation-wide resources. The article concludes that actor-network theory can be combined with the resource-based view to highlight the influence of organisational capabilities on the management of innovation. Equally, actor-network theory helps to address the lack of theory in the resource-based view on the micro practices of implementing change.

Impact and experiences of delayed discharge: A mixed-studies systematic review.

BACKGROUND: The impact of delayed discharge on patients, health-care staff and hospital costs has been incompletely characterized. AIM: To systematically review experiences of delay from the perspectives of patients, health professionals and hospitals, and its impact on patients' outcomes and costs. METHODS: Four of the main biomedical databases were searched for the period 2000-2016 (February). Quantitative, qualitative and health economic studies conducted in OECD countries were included. RESULTS: Thirty-seven papers reporting data on 35 studies were identified: 10 quantitative, 8 qualitative and 19 exploring costs. Seven of ten quantitative studies were at moderate/low methodological quality; 6 qualitative studies were deemed reliable; and the 19 studies on costs were of moderate quality. Delayed discharge was associated with mortality, infections, depression, reductions in patients' mobility and their daily activities. The qualitative studies highlighted the pressure to reduce discharge delays on staff stress and interprofessional relationships, with implications for patient care and well-being. Extra bed-days could account for up to 30.7% of total costs and cause cancellations of elective operations, treatment delay and repercussions for subsequent services, especially for elderly patients. CONCLUSIONS: The poor quality of the majority of the research means that implications for practice should be cautiously made. However, the results suggest that the adverse effects of delayed discharge are both direct (through increased opportunities for patients to acquire avoidable ill health) and indirect, secondary to the pressures placed on staff. These findings provide impetus to take a more holistic perspective to addressing delayed discharge.

The influence of experience on contest assessment strategies.

Animal contest behaviour has been widely studied, yet major knowledge gaps remain concerning the information-gathering and decision-making processes used during encounters. The mutual assessment strategy, where the individual assesses its own fighting ability (Resource Holding Potential, RHP) and compares it to that of its opponent, is least understood. We hypothesise that individuals need experience of agonistic encounters to become proficient at mutual assessment. Pigs (Sus scrofa, n = 316) were contested twice. In between contests, animals did or did not (control) receive intense fighting experience. A substantial proportion of the contests reached an outcome with a clear winner without fighting. Non-escalation was highest in RHP asymmetric dyads of the second contest, irrespective of experience. In contest 1 (no experience) and in contest 2 for the experienced animals, costs increased with loser RHP and where unaffected by winner RHP, suggesting a self-assessment strategy. In contest 2 control dyads, which only had experience of one prior contest, a negative relation between winner RHP and costs suggested mutual assessment during the pre-escalation phase but not during escalated aggression. This reveals that a brief and relatively mild experience can be beneficial in the development of mutual assessment whereas profound experience may result in adoption of a self-assessment strategy.

Mixed methods evaluation of the Getting it Right First Time programme - improvements to NHS orthopaedic care in England: study protocol.

BACKGROUND: Orthopaedic procedures, such as total hip replacement and total knee replacement, are among the commonest surgical procedures in England. The Getting it Right First Time project (GIRFT) aims to deliver improvements in quality and reductions in the cost of NHS orthopaedic care across the country. We will examine whether the planned changes have delivered improvements in the quality of care and patient outcomes. We will also study the processes involved in developing and implementing changes to care, and professional and organisational factors influencing these processes. In doing so, we will identify lessons to guide future improvement work in other services. METHODS/DESIGN: We will evaluate the implementation of the GIRFT programme, and its impact on outcomes and cost, using a mixed methods design. Qualitative methods will be used to understand the programme theory underlying the approach and study the effect of the intervention on practice, using a case study approach. This will include an analysis of the central GIRFT programme and local provider responses. Data will be collected via semi-structured interviews, non-participant observation, and documentary analysis. Quantitative methods will be used to examine 'what works and at what cost?' We will also conduct focus groups with patients and members of the public to explore their perceptions of the GIRFT programme. The research will draw on theories of adoption, diffusion, and sustainability of innovation; its characteristics; and contextual factors at provider-level that influence implementation. DISCUSSION: We will identify generalisable lessons to inform the organisation and delivery of future improvement programmes, to optimise their implementation and impact, both within the UK and internationally. Potential challenges involved in conducting the evaluation include the phased implementation of the intervention in different provider organisations; the inclusion of both retrospective and prospective components; and the effects of ongoing organisational turbulence in the English NHS. However, these issues reflect the realities of service change and its evaluation.