A prospective study evaluating patient reported outcome measures in patients who have undergone chest wall perforator flaps.

AIMS: To evaluate Patient Reported Outcome Measures (PROMs) and surgical outcomes in patients undergoing Chest Wall Perforator Flaps (CWPFs). METHODS: This was an observational single cohort study using an audit approach and a survey instrument. 84 patients who had undergone CWPFs in the last 5 years at the Department of Breast Surgery, City Hospital Birmingham, were identified from a pre-existing database. Surgical outcomes were recorded. Patients were contacted telephonically or in person at the time of follow-up and were asked to fill up a PROMs questionnaire. RESULTS: Out of 84 patients, 58 patients chose to respond. The average age of the patients was 51.3 years (±8.2 years). The average follow-up was 15.4 months (±9.9 months). The most common histological subtype was Infiltrating ductal carcinoma (IDC)-Not otherwise specified 34/58 (58.6%). Majority of the patients had T2 cancers-28/58 (48.3%). 26/58 (44.8%) were node negative. Eight patients (13.7%) had post-operative complications. No patient had total/partial flap loss. Nine patients (15.5%) had margin re-excision. One patient developed distant metastasis while 1 patient developed a second primary. Fifty-one patients (88%) were either satisfied or very satisfied with the post-operative appearance of the breasts. Thirty-six patients (62%) had no/little persistent pain or tenderness post-surgery. Eighty-six per cent (38/44) of the patients undergoing Lateral Intercostal Artery Perforator (LICAP) Flap and 16/18 (89%) of patients undergoing Anterior Intercostal Artery Perforator (AICAP) flap had no/little difficulty in carrying out normal activities at follow up. CONCLUSION: CWPFs are associated with a low complication rate and a high patient satisfaction rate.

Developing a strategy to scale up place-based arts initiatives that support mental health and wellbeing: A realist evaluation of 'Arts for the Blues'.

Place-based arts initiatives are regarded as rooted in local need and as having capacity to engage local assets. However, many place-based arts initiatives remain poorly funded and short-lived, receiving little attention on how to scale up and sustain their activities. In this study we make a unique contribution to knowledge about scaling up place-based arts initiatives that support mental health and wellbeing through focusing on the example of 'Arts for the Blues', an arts-based psychological group intervention designed to reduce depression and improve wellbeing amongst primary care mental health service users in deprived communities. Methodologically, we used realist evaluation to refine the study's theoretical assumptions about scaling up, drawing on the lived and professional experiences of 225 diverse stakeholders' and frontline staff through a series of focus groups and evaluation questions at two stakeholders' events and four training days. Based on our findings, we recommend that to scale up place-based arts initiatives which support mental health and wellbeing: (i) the initiative needs to be adaptable, clear, collaborative, evidence-based, personalised and transformative; (ii) the organisation has to have a relevant need, have an understanding of the arts, has to have resources, inspiration and commitment from staff members, relevant skillsets and help from outside the organisation; (iii) at a policy level it is important to pay attention to attitude shifts towards the arts, meet rules, guidelines and standards expected from services, highlight gaps in provision, seek out early intervention and treatment options, and consider service delivery changes. The presence of champions at a local level and buy-in from managers, local leaders and policy makers are also needed alongside actively seeking to implement arts initiatives in different settings across geographical spread. Our theoretically-based and experientially-refined study provides the first ever scaling up framework developed for place-based arts initiatives that support the mental health and wellbeing, offering opportunities for spread and adoption of such projects in different organisational contexts, locally, nationally and internationally.

Evaluating the implementation of a person-centred transition programme for adolescents and young adults with long-term conditions: the role of context and organisational behaviour.

PURPOSE: Drawing on the experiences of healthcare professionals in one paediatric hospital, this paper explores the influence of context and organisational behaviour on the implementation of a person-centred transition programme for adolescents and young adults (AYA) with long-term conditions. DESIGN/METHODOLOGY/APPROACH: A single embedded qualitative case study design informed by a realist evaluation framework, was used. Participants who had experience of implementing the transition programme were recruited from across seven individual services within the healthcare organisation. The data were gathered through semi-structured interviews (n = 20) and analysed using thematic analysis. FINDINGS: Implementation of the transition programme was influenced by the complex interaction of macro, meso and micro processes and contexts. Features of organisational behaviour including routines and habits, culture, organisational readiness for change and professional relationships shaped professional decision-making around programme implementation. ORIGINALITY/VALUE: There exists a significant body of research relating to the role of context and its influence on the successful implementation of complex healthcare interventions. However, within the area of healthcare transition there is little published evidence on the role that organisational behaviour and contextual factors play in influencing transition programme implementation. This paper provides an in-depth understanding of how organisational behaviour and contextual factors affect transition programme implementation.

Systematic review of cochlear implantation in adults with asymmetrical hearing loss.

BACKGROUND: Rapid advances in cochlear implantation has witnessed an expanding spectrum for candidacy worldwide. This includes a subgroup of adults with asymmetrical hearing loss who have a wide range in their hearing capacity between the two ears. As per guidelines they are not included in mainstream candidacy for CI across the world. Evidence is now emerging to support the benefits of CI in AHL. METHODS: This review analyzed literature regarding the outcomes of CI in AHL. Primary outcome measure was to assess audiological benefits and secondary outcome measure was to assess hearing related quality of life. 15 relevant articles, published worldwide between 2009 and 2019 were chosen. CASP checklist for systematic reviews was used to ascertain the quality of literature. The strength of recommendations from each study was analyzed and classified as strong, moderate, weak or none based on GRADE guidelines. RESULTS: Heterogeneity in samples was obvious and samples varied largely between the studies. The levels of evidence ranged from systematic review to expert opinion, but overall they reflected positively on both audiological and QOL benefits. CONCLUSION: CI provides important auditory and QOL benefits in AHL, but there is no high level evidence as yet to strongly support CI for AHL. A long term multi-centric study is necessary to influence a change in practice for a growing population of AHL.Trial registration: ClinicalTrials.gov identifier: NCT03052920.

Measuring the impact of an acute visiting scheme on emergency department attendances - a pre-post cohort design.

BACKGROUND: Emergency department (ED) attendances are contributing to rising costs of the National Health Service (NHS) in England. Critically assessing the impact of new services to reduce emergency department use can be difficult as new services may create additional access points, unlocking latent demand. The study evaluated an Acute Visiting Scheme (AVS) in a primary care context. We asked if AVS reduces overall ED demand and whether or not it changed utilisation patterns for frequent attenders. METHOD: The study used a pre post single cohort design. The impact of AVS on all-cause ED attendances was hypothesised as a substitution effect, where AVS duty doctor visits would replace emergency department visits. Primary outcome was frequency of ED attendances. End points were reduction of frequency of service use and increase of intervals between attendances by frequent attenders. RESULTS: ED attendances for AVS users rose by 47.6%. If AVS use was included, there was a more than fourfold increase of total service utilisation, amounting to 438.3%. It shows that AVS unlocked significant latent demand. However, there was some reduction in the frequency of ED attendances for some patients and an increase in time intervals between ED attendances for others. CONCLUSION: The study demonstrates that careful analysis of patient utilisation can detect a differential impact of AVS on the use of ED. As the new service created additional access points for patients and hence introduces an element of choice, the new service is likely to unlock latent demand. This study illustrates that AVS may be most useful if targeted at specific patient groups who are most likely to benefit from the new service.

The implementation of a Technician Enhanced Administration of Medications [TEAM] model: An evaluative study of impact on working practices in a children's hospital.

BACKGROUND: Children are frequently prescribed unlicensed and off-label medicines meaning dosing and administration of medicines to children is often based on poor quality guidance. In UK hospitals, nursing staff are often responsible for administering medications. Medication Errors [MEs] are problematic for health services, though are poorly reported and therefore difficult to quantify with confidence. In the UK, children's medicines require administration by at least two members of ward staff, known as a 'second check' system, thought to reduce Medication Administration Errors [MAEs]. OBJECTIVES: To assess the impact on working practices of the introduction of a new way of working, using Technician Enhanced Administration of Medications [TEAM] on two specialist wards within a children's' hospital. To evidence any potential impact of a TEAM ward-based pharmacy technician [PhT] on the reporting of MEs. METHODS: A TEAM PhT was employed on two wards within the children's hospital and trained in medicines administration. Firstly, an observational pre-and-post cohort design was used to identify the effect of TEAM on MEs. We analysed the hospital's official reporting system for incidents and 'near misses', as well as the personal incident log of the TEAM PhT. Secondly, after implementation, we interviewed staff about their perceptions of TEAM and its impact on working practices. RESULTS: We affirm MEs are considerably under-reported in hospital settings, but TEAM PhTs can readily identify them. Further, placing TEAM PhTs on wards may create opportunities for inter-professional knowledge exchange and increase nurses' awareness of potential MAEs, although this requires facilitation. CONCLUSIONS: TEAM PhT roles may be beneficial for pharmacy technicians' motivation, job satisfaction, and career development. Hospitals will need to consider the balance between resources invested in TEAM PhTs and the level of impact on reporting MEs. Health economic analyses could provide evidence to fully endorse integration of TEAM PhTs for all hospital settings.

The challenge of conducting qualitative research to understand the factors that influence equity in medical education: A scoping review.

This article was migrated. The article was marked as recommended. Introduction There are national and international concerns about equity in basic and postgraduate medical education, especially about differential rates of access and attainment across groups of learners. Qualitative research has been increasingly used to understand the factors that influence equity but there are potential limitations to this understanding related to how the research has been conducted. The aim of the scoping review was to identify how qualitative research exploring the factors that influence equity in basic and postgraduate medical education has been conducted. The intention was to inform future research. Methods The electronic databases British Education Index, Campbell Library, CINAHL, Cochrane Library, EMBASE, ERIC, Google Scholar, Health Management Information Consortium (HMIC), MEDLINE, PsycINFO, Web of Science and medical education journals were searched to identify relevant published articles between 2008 and April 2019. Results Among 19,523 articles identified from the literature search, 72 full text articles were included in the review. Most studies had a focus on only one background characteristic and only two studies had a strengths-based focus on individuals. Recommendations for change was at the 'policy level' in ten studies and four studies had learner recommendations for change. No studies with a participatory approach were identified. Conclusion The approach to conducting previous qualitative research appears to limit greater understanding of the complexity of factors that influence equity. In response to this challenge, we recommend that future research widen the focus to consider the experiences and strengths of individual learners in addition to those identified by background characteristics. Future qualitative research is recommended to have a broad focus on both the 'policy level' and 'local level', especially from multiple perspectives. We also recommend greater collaboration of participants with researchers throughout the research process.

Sharing a vision. Do participants in integrated care programmes have the same goals and objectives?

Integrating health and social care services remains one of the most difficult undertakings in the field of care delivery. One of the key requirements for success in integration programmes is a shared vision amongst care providers. Shared visions may contain views as to what the new services should look like, how it should operate and what it should be able to achieve. The paper reports findings of an evaluation of a service integration programme in the North of England. It confirms that a programme consensus on issues such as aims and objectives and programme logics is seen by participants as a key to success. Yet, the study also found that there is a specific window of opportunity in integration programmes when participating organisations start on relatively high levels of commitment and enthusiasm which tend to tail off relatively quickly. The paper closes with a discussion about the implications of the findings for programme designers and service planners.

Systematic review of study designs and methods in health transition research for young people with intellectual disabilities.

BACKGROUND: Transition for young people with intellectual disabilities from paediatric or adolescent services into adult health care services remains a difficult process for all stakeholders. The study assessed the type of interventions, the methodological approaches, study designs and location of existing published evidence in health care transitions. METHODS: A systematic review utilising the PRISMA protocol with an amended quality appraisal tool to explore the nature of published evidence on health care transitions for young people. RESULTS: Findings demonstrate that health transition research for this population lacks a robust evidence base and researchers favour exploratory studies investigating the experiential dimension of transition. The lack of involvement of young people in the studies indicates a problematic absence of genuinely participatory research. CONCLUSION: The study is the first systematic review of empirical studies in health transition of young people with intellectual disabilities exploring the nature of existing evidence. The results will support setting priorities for future research.

Evaluation of wrist and hip sedentary behaviour and moderate-to-vigorous physical activity raw acceleration cutpoints in older adults.

Wrist-based accelerometers are now common in assessing physical activity (PA) and sedentary behaviour (SB) in population-based studies, but there is a scarcity of raw acceleration cutpoints in older adults. The study aimed to determine and evaluate wrist-based GENEActiv (GA) and hip-based ActiGraph GT3X+ (AG) raw acceleration cutpoints for SB and moderate-to-vigorous PA (MVPA) in older adults ≥60 years of age. A laboratory-based calibration analyses of 34 healthy older adults involved receiver operator characteristic (ROC) curves to determine raw acceleration cutpoints for SB and MVPA. ROC analysis revealed an area under the curve (AUC) of 0.88 for GA SB and MVPA, and 0.90 for AG SB and 0.94 for AG MVPA. Sensitivity optimised SB and specificity optimised MVPA GA cutpoints of 57 mg and 104 mg, and AG cutpoints of 15 mg and 69 mg were also generated, respectively. Cross-validation analysis revealed moderate agreement for GA and AG SB cutpoints, and fair to substantial agreement for GA and AG MVPA cutpoints, respectively. The resultant cutpoints can classify older adults as engaging in SB or not engaging in MVPA but the sensitivity optimised SB cutpoints should be interpreted with a degree of caution due to their modest cross-validation results.

Care Integration - From "One Size Fits All" to Person Centred Care Comment on "Achieving Integrated Care for Older People: Shuffling the Deckchairs or Making the System Watertight for the Future?"

Integrating services is a hot topic amongst health system policy-makers and healthcare managers. There is some evidence that integrated services deliver efficiencies and reduce service utilisation rates for some patient populations. In their article on Achieving Integrated Care for Older People, Gillian Harvey and her colleagues formulate some critical insights from practice and research around integrated care. However, the real challenge is to reconcile service integration with patient experiences. This paper argues that unless we think service integration from the patient's perspective we will continue to fail to produce the evidence we need to support integrated care solutions to the current health system challenges.

Head-to-head trials of antibiotics for bronchiectasis.

BACKGROUND: The diagnosis of bronchiectasis is defined by abnormal dilation of the airways related to a pathological mechanism of progressive airway destruction that is due to a 'vicious cycle' of recurrent bacterial infection, inflammatory mediator release, airway damage, and subsequent further infection. Antibiotics are the main treatment option for reducing bacterial burden in people with exacerbations of bronchiectasis and for longer-term eradication, but their use is tempered against potential adverse effects and concerns regarding antibiotic resistance. The comparative effectiveness, cost-effectiveness, and safety of different antibiotics have been highlighted as important issues, but currently little evidence is available to help resolve uncertainty on these questions. OBJECTIVES: To evaluate the comparative effects of different antibiotics in the treatment of adults and children with bronchiectasis. SEARCH METHODS: We identified randomised controlled trials (RCTs) through searches of the Cochrane Airways Group Register of trials and online trials registries, run 30 April 2018. We augmented these with searches of the reference lists of published studies. SELECTION CRITERIA: We included RCTs reported as full-text articles, those published as abstracts only, and unpublished data. We included adults and children (younger than 18 years) with a diagnosis of bronchiectasis by bronchography or high-resolution computed tomography who reported daily signs and symptoms, such as cough, sputum production, or haemoptysis, and those with recurrent episodes of chest infection; we included studies that compared one antibiotic versus another when they were administered by the same delivery method. DATA COLLECTION AND ANALYSIS: Two review authors independently assessed trial selection, data extraction, and risk of bias. We assessed overall quality of the evidence using GRADE criteria. We made efforts to collect missing data from trial authors. We have presented results with their 95% confidence intervals (CIs) as mean differences (MDs) or odds ratios (ORs). MAIN RESULTS: Four randomised trials were eligible for inclusion in this systematic review - two studies with 83 adults comparing fluoroquinolones with ß-lactams and two studies with 55 adults comparing aminoglycosides with polymyxins.None of the included studies reported information on exacerbations - one of our primary outcomes. Included studies reported no serious adverse events - another of our primary outcomes - and no deaths. We graded this evidence as low or very low quality. Included studies did not report quality of life. Comparison between fluoroquinolones and ß-lactams (amoxicillin) showed fewer treatment failures in the fluoroquinolone group than in the amoxicillin group (OR 0.07, 95% CI 0.01 to 0.32; low-quality evidence) after 7 to 10 days of therapy. Researchers reported that Pseudomonas aeruginosa infection was eradicated in more participants treated with fluoroquinolones (Peto OR 20.09, 95% CI 2.83 to 142.59; low-quality evidence) but provided no evidence of differences in the numbers of participants showing improvement in sputum purulence (OR 2.35, 95% CI 0.96 to 5.72; very low-quality evidence). Study authors presented no evidence of benefit in relation to forced expiratory volume in one second (FEV1). The two studies that compared polymyxins versus aminoglycosides described no clear differences between groups in the proportion of participants with P aeruginosa eradication (OR 1.40. 95% CI 0.36 to 5.35; very low-quality evidence) or improvement in sputum purulence (OR 0.16, 95% CI 0.01 to 3.85; very low-quality evidence). The evidence for changes in FEV1 was inconclusive. Two of three trials reported adverse events but did not report the proportion of participants experiencing one or more adverse events, so we were unable to interpret the information. AUTHORS' CONCLUSIONS: Limited low-quality evidence favours short-term oral fluoroquinolones over beta-lactam antibiotics for patients hospitalised with exacerbations. Very low-quality evidence suggests no benefit from inhaled aminoglycosides verus polymyxins. RCTs have presented no evidence comparing other modes of delivery for each of these comparisons, and no RCTs have included children. Overall, current evidence from a limited number of head-to-head trials in adults or children with bronchiectasis is insufficient to guide the selection of antibiotics for short-term or long-term therapy. More research on this topic is needed.

A process evaluation of the first year of Leading Change, Adding Value.

BACKGROUND: Leading Change, Adding Value (LCAV) is a national framework to support transformational change across health and social care. DESIGN: a qualitative approach of semi-structured interviews was used to capture information on how LCAV has been disseminated in its early stages from the perspective of key stakeholders and partners. This also included looking at how it might be embedded into everyday practice. METHODS: data collection took place over a 3-month period between January and March 2017. Twenty semi-structured telephone interviews were conducted with key LCAV partners and stakeholders from across health and social care. Perceptions were sought as to how LCAV has been, and may be, used by frontline staff following initial dissemination and any potential barriers and enablers to taking the framework forward. RESULTS: a thematic framework analysis of data identified a three-theme paradigm to evaluate LCAV: past-where has this come from? Present-where is it now? Future-where is this going?. CONCLUSION: a programme of dissemination events and examples of good practice in the form of case studies have been valuable tools to engage nursing, midwifery and care staff across health and social care. Continuing to establish networks of frontline staff engaging with LCAV and supporting each other will help facilitate best practice sharing, and multi-professional and cross-boundary working.

Using formative research with older adults to inform a community physical activity programme: Get Healthy, Get Active.

AIM: The purpose of this formative study was to explore current knowledge and attitudes towards physical activity, as well as perceived barriers, facilitators and opportunities for physical activity participation among older adults living in the community. The findings have subsequently informed the design, delivery and recruitment strategies of a local community physical activity intervention programme which forms part of Sport England's national Get Healthy, Get Active initiative. BACKGROUND: There is a growing public health concern regarding the amount of time spent in sedentary and physical activity behaviours within the older adult population. METHODS: Between March and June 2016, 34 participants took part in one of six focus groups as part of a descriptive formative study. A homogenous purposive sample of 28 community dwelling white, British older adults (six male), aged 65-90 years (M=78, SD=7 years) participated in one of five focus group sessions. An additional convenience pragmatic sub-sample of six participants (three male), aged 65-90 years (M=75, SD=4 years), recruited from an assisted living retirement home participated in a sixth focus group. Questions for focus groups were structured around the PRECEDE stage of the PRECEDE-PROCEDE model of health programme design, implementation and evaluation. Questions addressed knowledge, attitudes and beliefs towards physical activity, as well as views on barriers and opportunities for physical activity participation. All data were transcribed verbatim. Thematic analysis was then conducted with outcomes represented as pen profiles. FINDINGS: Consistent views regarding both the potential physical and psychosocial benefits of physical activity were noted regardless of living status. The themes of, opportunities and awareness for physical activity participation, cost, transport, location and season/weather varied between participants living in an assisted living retirement home and community dwelling older adults. Further comparative research on the physical activity requirements of older adults living in assisted living versus community settings are warranted.

An evaluation of the Open and Honest Care Programme in acute NHS trusts in Northern England.

AIM: To explore the impact of the National Health Service England's Open and Honest Care Programme on patient safety, patient and staff experience and improvement practices within acute National Health Service settings. BACKGROUND: The Open and Honest Care Programme forms a key tenet of the Nursing Midwifery and Care Staff Strategy launched by the Department of Health in England and Wales in 2012. METHODS: An electronic survey (n = 387) was administered to National Health Service staff. Semi-structured telephone interviews (n = 13) were conducted with senior nurses and ward managers. RESULTS: Over 70% of the survey respondents agreed that the programme increased transparency with the public about the quality of care, helped the working experience of National Health Service staff and improved patient safety respectively. Interviews revealed the Open and Honest Care Programme had enabled National Health Service staff to appraise the effectiveness of their improvement efforts. CONCLUSION: The Open and Honest Care Programme could be an important part of the National Health Service Improvement Strategy. The collection of metric and narrative information highlighted where patient-centred improvements were required, facilitating the targeting and development of specific interventions or resources. IMPLICATIONS FOR NURSING MANAGEMENT: The results indicate that the programme may assist managers to identify areas for improvement and that programmes such as this deserve consideration by health-care management globally.

Project SEARCH UK - Evaluating Its Employment Outcomes.

BACKGROUND: The study reports the findings of an evaluation of Project SEARCH UK. The programme develops internships for young people with intellectual disabilities who are about to leave school or college. The aim of the evaluation was to investigate at what rate Project SEARCH provided employment opportunities to participants. METHODS: The evaluation obtained data from all sites operational in the UK at the time of evaluation (n = 17) and analysed employment outcomes. RESULTS: Data were available for 315 young people (n = 315) in the programme and pay and other employment related data were available for a subsample. The results of the analysis suggest that Project SEARCH achieves on average employment rates of around 50 per cent. CONCLUSION: Project SEARCH UK represents a valuable addition to the supported employment provision in the UK. Its unique model should inform discussions around best practice in supported employment. Implications for other supported employment programmes are discussed.

User involvement in service integration and carers' views of co-locating children's services.

PURPOSE: There has been considerable discussion about the benefits of health and social care integration over the last decade but less research on the purpose and effectiveness of carer and user involvement in service changes and service evaluation. The paper aims to report the findings of a study of two learning disabilities services in Wales that undertook co-location in a children development centre. DESIGN/METHODOLOGY/APPROACH: The study investigated whether carers of children with learning disabilities had any knowledge of organisational changes that occurred as a result of co-locating services. The study used a mixed method approach. The authors conducted semi-structured interviews with all parental representatives on the service planning groups and then asked local staff to facilitate a survey to parents of children with learning disabilities in their area. FINDINGS: Carers in both locations were mainly unaware of any changes, unless they were personally involved in service changes through advocacy or parental support groups. Carer responses mainly reflected national debates, such as service cuts, rather than the local context. Whilst there was significant support for co-location in general, parental views differed considerably on the merits of service changes depending on the needs of their own child. ORIGINALITY/VALUE: These results caution against assuming a simple pathway from parental views of local services to defining service needs to plan new services. The authors argue that parents lack sufficient knowledge of organisational changes to make an informed decision on whether these changes would bring about service improvements. Implications for research and professional practice are spelled out.

Supported employment for young people with intellectual disabilities facilitated through peer support: a pilot study.

The article reports the evaluation of a small-scale-supported employment project in a local authority in England. The study examined whether or not the peer support model could be used to deliver supported employment to a group of young people with intellectual disabilities. We utilised a mixed-method approach involving activity data, family interviews and a postal survey with participating employers. Five families took part in the study. Our findings show that families viewed the project positively, although it was insufficiently embedded in the wider transition planning. The study indicates that the peer support model may represent a useful addition to the conventional supported employment efforts for this population. However, more research is needed to demonstrate the benefits of peer support over and above the benefits of conventional supported employment for young people in post-school transition. In particular, producing a better evidence base on the exact impact of peer support on service users' experiences is recommended.