Mobilizing pilot-based evidence for the spread and sustainability of innovations in healthcare: The role of innovation intermediaries.

An endemic challenge facing healthcare systems around the world is how to spread innovation more widely and sustainably. A common response to this challenge involves conducting pilot implementation studies to generate evidence of the innovation's benefits. However, despite the key role that such studies play in the local adoption of innovation, their contribution to the wider spread and sustainability of innovation is relatively under-researched and under-theorized. In this paper we examine this contribution through an empirical examination of the experiences of an innovation intermediary organization in the English NHS (National Health Service). We find that their work in mobilizing pilot-based evidence involves three main strands; configuring to context; transitioning evidence; and managing the transition. Through this analysis we contribute to theory by showing how the agency afforded by intermediary roles can support the effective transitioning of pilot-based evidence across different phases in the innovation journey, and across different occupational groups, and can thus help to create a positive feedback loop from localized early implementers of an innovation to later more widespread adoption and sustainability. Based on these findings, we develop insights on the reasons for the unnecessary repetition of pilots - so-called 'pilotitis'- and offer policy recommendations on how to enhance the role of pilots in the wider spread and sustainability of innovation.

Centering Public Perceptions on Translating AI Into Clinical Practice: Patient and Public Involvement and Engagement Consultation Focus Group Study.

BACKGROUND: Artificial intelligence (AI) is widely considered to be the new technical advancement capable of a large-scale modernization of health care. Considering AI's potential impact on the clinician-patient relationship, health care provision, and health care systems more widely, patients and the wider public should be a part of the development, implementation, and embedding of AI applications in health care. Failing to establish patient and public engagement and involvement (PPIE) can limit AI's impact. OBJECTIVE: This study aims to (1) understand patients' and the public's perceived benefits and challenges for AI and (2) clarify how to best conduct PPIE in projects on translating AI into clinical practice, given public perceptions of AI. METHODS: We conducted this qualitative PPIE focus-group consultation in the United Kingdom. A total of 17 public collaborators representing 7 National Institute of Health and Care Research Applied Research Collaborations across England participated in 1 of 3 web-based semistructured focus group discussions. We explored public collaborators' understandings, experiences, and perceptions of AI applications in health care. Transcripts were coanalyzed iteratively with 2 public coauthors using thematic analysis. RESULTS: We identified 3 primary deductive themes with 7 corresponding inductive subthemes. Primary theme 1, advantages of implementing AI in health care, had 2 subthemes: system improvements and improve quality of patient care and shared decision-making. Primary theme 2, challenges of implementing AI in health care, had 3 subthemes: challenges with security, bias, and access; public misunderstanding of AI; and lack of human touch in care and decision-making. Primary theme 3, recommendations on PPIE for AI in health care, had 2 subthemes: experience, empowerment, and raising awareness; and acknowledging and supporting diversity in PPIE. CONCLUSIONS: Patients and the public can bring unique perspectives on the development, implementation, and embedding of AI in health care. Early PPIE is therefore crucial not only to safeguard patients but also to increase the chances of acceptance of AI by the public and the impact AI can make in terms of outcomes.

Excess deaths by cause and place of death in England and Wales during the first year of COVID-19.

Using officially registered weekly mortality data, we estimate a counterfactual death count in the absence of the pandemic and we calculate the number of excess deaths in England and Wales during 2020 after the pandemic onset. We also break down those figures by region, age, gender, place of death, and cause of death. Our results suggest that there were 82,428 (95% Confidence interval [CI]: 78,402 to 86,415) excess deaths, and 88.9% (95% CI: 84.8%-93.5%) of them was due to COVID-19, suggesting that non-COVID-19 excess mortality may have been slightly higher that what has been previously estimated. Regarding deaths not due to COVID-19, persons older than 45 years old who died at their homes, mainly from heart diseases and cancer, were the most affected group. Across all causes of death, there was increased excess mortality from dementia and Alzheimer's disease, diabetes, Parkinson's disease and heart-related disease, while at the same period there was a reduction in deaths from pneumonia and influenza, stroke as well as infectious diseases and accidents. Supported by regional panel event estimates, our results highlight how measures to mitigate the pandemic spread and ease the pressure on healthcare service systems may adversely affect out-of-hospital mortality from other causes.

Retirement and Household Expenditure in Turbulent Times.

We examine how expenditure changes at retirement during an institutionally and economically uncertain period when a series of pension reforms and cuts were implemented. Overall, we fail to confirm that consumption declines at retirement using data from Greece (2008-2018). Any estimated declines come from turbulent years when major pension cuts were applied. Expenditure drops at retirement were due to pension income shocks, especially for those who were particularly dependent on pension income. Further checks support the presence of an income shock mechanism for retirees who are relatively more treated during the crisis sub-period. Given an aging population and the ongoing global turbulence, our results offer valuable insights.

Mapping the role of patient and public involvement during the different stages of healthcare innovation: A scoping review.

BACKGROUND: Patient and public involvement (PPI) has become increasingly important in the development, delivery and improvement of healthcare. PPI is used in healthcare innovation; yet, how it is used has been under-reported. The aim of this scoping review is to identify and map the current available empirical evidence on the role of PPI during different stages of healthcare innovation. METHODS: The scoping review was conducted in accordance with PRISMAScR and included any study published in a peer-reviewed journal between 2004 and 2021 that reported on PPI in healthcare innovation within any healthcare setting or context in any country. The following databases were searched: Medline, EMBASE, CINAHL, PsycInfo, HMIC and Google Scholar. We included any study type, including quantitative, qualitative and mixed-method studies. We excluded theoretical frameworks, conceptual, scientific or grey literature as well as discussion and opinion papers. RESULTS: Of the 87 included studies, 81 (93%) focused on or were conducted by authors in developed countries. A wide range of conditions were considered, with more studies focusing on mental health (n = 18, 21%) and cancer care (n = 8, 9%). The vast majority of the studies focused on process and service innovations (n = 62, 71%). Seven studies focused on technological and clinical innovations (8%), while 12 looked at both technological and service innovations (14%). Only five studies examined systems innovation (5%) and one study looked across all types of innovations (1%). PPI is more common in the earlier stages of innovation, particularly problem identification and invention, in comparison to adoption and diffusion. CONCLUSION: Healthcare innovation tends to be a lengthy process. Yet, our study highlights that PPI is more common across earlier stages of innovation and focuses mostly on service innovation. Stronger PPI in later stages could support the adoption and diffusion of innovation. PATIENT OR PUBLIC CONTRIBUTION: One of the coauthors of the paper (S. S.) is a service user with extensive experience in PPI research. S. S. supported the analysis and writing up of the paper.

Studying the post-COVID-19 condition: research challenges, strategies, and importance of Core Outcome Set development.

BACKGROUND: A substantial portion of people with COVID-19 subsequently experience lasting symptoms including fatigue, shortness of breath, and neurological complaints such as cognitive dysfunction many months after acute infection. Emerging evidence suggests that this condition, commonly referred to as long COVID but also known as post-acute sequelae of SARS-CoV-2 infection (PASC) or post-COVID-19 condition, could become a significant global health burden. MAIN TEXT: While the number of studies investigating the post-COVID-19 condition is increasing, there is no agreement on how this new disease should be defined and diagnosed in clinical practice and what relevant outcomes to measure. There is an urgent need to optimise and standardise outcome measures for this important patient group both for clinical services and for research and to allow comparing and pooling of data. CONCLUSIONS: A Core Outcome Set for post-COVID-19 condition should be developed in the shortest time frame possible, for improvement in data quality, harmonisation, and comparability between different geographical locations. We call for a global initiative, involving all relevant partners, including, but not limited to, healthcare professionals, researchers, methodologists, patients, and caregivers. We urge coordinated actions aiming to develop a Core Outcome Set (COS) for post-COVID-19 condition in both the adult and paediatric populations.

The Effect of Health Care Professional Disruptive Behavior on Patient Care: A Systematic Review.

BACKGROUND: Disruptive behavior among health care professionals can adversely affect patient care. These behaviors undermine cultures of safety, exposing patients to preventable risk. Existing evidence associates disruptive behaviors with a negative effect at the organizational level and on the health care professional, but the effect on patient care has been less well documented. OBJECTIVES: This study aimed to identify and synthesize the empirical evidence of health care professional disruptive behaviors on the following outcome measures of patient care: clinical outcomes, patient safety, patient satisfaction, or quality of care. METHODS: A systematic literature review was conducted. Between June 6 and July 23, 2019, 6 databases were searched for published empirical studies that examined disruptive behaviors and patient outcomes. Excluded from this pool were studies that did not make associations with patient care. Studies were analyzed using thematic analysis. RESULTS: Twenty-five studies met the inclusion criteria and were included in the review. The prevalence and type of disruptive behavior varied, but it consistently contributed to a reduction in the quality and safety of patient care. The effects on patient care was manifested through adverse incidents, neglect of care needs, never events, and complaints. Disruptive behaviors significantly impaired the safety culture leading to reduced patient safety, evidenced by worse clinical outcomes. CONCLUSIONS: Disruptive behaviors among health care professionals are a significant threat to patient safety and quality of care. Organizations must harness the benefits of awareness programs, policy, and interventions to generate a culture change where these behaviors are not accepted, thereby protecting patients from preventable harm.

Characterising long COVID: a living systematic review.

BACKGROUND: While it is now apparent clinical sequelae (long COVID) may persist after acute COVID-19, their nature, frequency and aetiology are poorly characterised. This study aims to regularly synthesise evidence on long COVID characteristics, to help inform clinical management, rehabilitation strategies and interventional studies to improve long-term outcomes. METHODS: A living systematic review. Medline, CINAHL (EBSCO), Global Health (Ovid), WHO Global Research on COVID-19 database, LitCovid and Google Scholar were searched till 17 March 2021. Studies including at least 100 people with confirmed or clinically suspected COVID-19 at 12 weeks or more post onset were included. Risk of bias was assessed using the tool produced by Hoy et al. Results were analysed using descriptive statistics and meta-analyses to estimate prevalence. RESULTS: A total of 39 studies were included: 32 cohort, 6 cross-sectional and 1 case-control. Most showed high or moderate risk of bias. None were set in low-income countries and few included children. Studies reported on 10 951 people (48% female) in 12 countries. Most included previously hospitalised people (78%, 8520/10 951). The longest mean follow-up time was 221.7 (SD: 10.9) days post COVID-19 onset. Over 60 physical and psychological signs and symptoms with wide prevalence were reported, most commonly weakness (41%; 95% CI 25% to 59%), general malaise (33%; 95% CI 15% to 57%), fatigue (31%; 95% CI 24% to 39%), concentration impairment (26%; 95% CI 21% to 32%) and breathlessness (25%; 95% CI 18% to 34%). 37% (95% CI 18% to 60%) of patients reported reduced quality of life; 26% (10/39) of studies presented evidence of reduced pulmonary function. CONCLUSION: Long COVID is a complex condition with prolonged heterogeneous symptoms. The nature of studies precludes a precise case definition or risk evaluation. There is an urgent need for prospective, robust, standardised, controlled studies into aetiology, risk factors and biomarkers to characterise long COVID in different at-risk populations and settings. PROSPERO REGISTRATION NUMBER: CRD42020211131.

Professionals' responses to the introduction of AI innovations in radiology and their implications for future adoption: a qualitative study.

BACKGROUND: Artificial Intelligence (AI) innovations in radiology offer a potential solution to the increasing demand for imaging tests and the ongoing workforce crisis. Crucial to their adoption is the involvement of different professional groups, namely radiologists and radiographers, who work interdependently but whose perceptions and responses towards AI may differ. We aim to explore the knowledge, awareness and attitudes towards AI amongst professional groups in radiology, and to analyse the implications for the future adoption of these technologies into practice. METHODS: We conducted 18 semi-structured interviews with 12 radiologists and 6 radiographers from four breast units in National Health Services (NHS) organisations and one focus group with 8 radiographers from a fifth NHS breast unit, between 2018 and 2020. RESULTS: We found that radiographers and radiologists vary with respect to their awareness and knowledge around AI. Through their professional networks, conference attendance, and contacts with industry developers, radiologists receive more information and acquire more knowledge of the potential applications of AI. Radiographers instead rely more on localized personal networks for information. Our results also show that although both groups believe AI innovations offer a potential solution to workforce shortages, they differ significantly regarding the impact they believe it will have on their professional roles. Radiologists believe AI has the potential to take on more repetitive tasks and allow them to focus on more interesting and challenging work. They are less concerned that AI technology might constrain their professional role and autonomy. Radiographers showed greater concern about the potential impact that AI technology could have on their roles and skills development. They were less confident of their ability to respond positively to the potential risks and opportunities posed by AI technology. CONCLUSIONS: In summary, our findings suggest that professional responses to AI are linked to existing work roles, but are also mediated by differences in knowledge and attitudes attributable to inter-professional differences in status and identity. These findings question broad-brush assertions about the future deskilling impact of AI which neglect the need for AI innovations in healthcare to be integrated into existing work processes subject to high levels of professional autonomy.

Acceptability and Feasibility of an Isometric Resistance Exercise Program for Abdominal Cancer Surgery: An Embedded Qualitative Study.

Although it is recognized in the early stages of cancer recovery that changes in lifestyle including increases in physical activity improves physical function, there are no clear findings whether low versus moderate intensity activity or home or gym exercise offer optimal benefit. Isometric-resistance exercises can be carried out with very little equipment and space and can be performed while patients are bed-bound in hospital or at home. This embedded qualitative study, based in an English hospital trust providing specialist cancer care, was undertaken as a component of a feasibility trial to evaluate the acceptability and feasibility of an isometric-resistance exercise program and explore the suitability of functional assessments by drawing from the experiences of abdominal cancer patients following surgery. Telephone interviews were undertaken with 7 participants in the intervention group, and 8 interviews with the usual care group (n = 15). The gender composition consisted of 11 females and 4 males. Participants' ages ranged from 27 to 84 (M = 60.07, SD = 15.40). Interviews were conducted between August 2017 and May 2018, with audio files digitally recorded and data coded using thematic framework analysis. Our results show that blinding to intervention or usual care was a challenge, participants felt the intervention was safe and suitable aided by the assistance of a research nurse, yet, found the self-completion questionnaire tools hard to complete. Our study provides an insight of trial processes, participants' adherence and completion of exercise interventions, and informs the design and conduct of larger RCTs based on the experiences of abdominal cancer surgery patients.

What are the long-term symptoms and complications of COVID-19: a protocol for a living systematic review.

Although the majority of patients with COVID-19 will experience mild to moderate symptoms and will recover fully, there is now increasing evidence that a significant proportion will experience persistent symptoms for weeks or months after the acute phase of the illness. These symptoms include, among others, fatigue, problems in breathing, lack of smell and taste, headaches, and also depression and anxiety. It has also become clear that the virus has lasting effects not only on the respiratory system but also on other parts of the body, including the heart, liver, and the nervous system. In this paper we present a protocol for a living systematic review that aims to synthesize the evidence on the prevalence and duration of symptoms and clinical features of post-acute COVID-19 and its long-term complications. The living systematic review will be updated regularly, initially monthly with update cycles under continuous review as the pace of new evidence generated develops through the pandemic. We will include studies that follow up with COVID-19 patients who have experienced persistent mild, moderate or severe symptoms, with no restrictions regarding country, setting, or language. We will use descriptive statistics to analyse the data and our findings will be presented as infographics to facilitate transcription to lay audiences. Ultimately, we aim to support the work of policy makers, practitioners, and patients when planning rehabilitation for those recovering from COVID-19. The protocol has been registered with PROSPERO ( CRD42020211131, 25/09/2020).

Incentives and gender in a multi-task setting: An experimental study with real-effort tasks.

This paper investigates the behavioural effects of competitive, social-value and social-image incentives on men's and women's allocation of effort in a multi-task environment. Specifically, using two real-effort laboratory tasks, we investigate how competitive prizes, social-value generation and public awards affect effort allocation decisions between the tasks. We find that all three types of incentives significantly focus effort allocation towards the task they are applied in, but the effect varies significantly between men and women. The highest effort distortion lies with competitive incentives, which is due to the effort allocation decision of men. Women exert similar amount of effort across the three incentive conditions, with slightly lower effort levels in the social-image incentivized tasks. Our results inform how and why genders differences may persist in competitive workplaces.

The impact generated by publicly and charity-funded research in the United Kingdom: a systematic literature review.

OBJECTIVE: To identify, synthesise and critically assess the empirical evidence of the impact generated by publicly and charity-funded health research in the United Kingdom. METHODS: We conducted a systematic literature review of the empirical evidence published in English in peer-reviewed journals between 2006 and 2017. Studies meeting the inclusion criteria were selected and their findings were analysed using the Payback Framework and categorised into five main dimensions, namely knowledge, benefits to future research and research use, benefits from informing policy and product development, health and health sector benefits, and broader economic benefits. We assessed the studies for risk of selection, reporting and funding bias. RESULTS: Thirteen studies met the inclusion criteria. The majority of the studies (10 out of 13) assessed impact at multiple domains including the main five key themes of the Payback Framework. All of them showed a positive impact of funded research on outcomes. Of those studies, one (8%), six (46%) and six (46%) presented a low, moderate and high risk of bias, respectively. CONCLUSIONS: Empirical evidence on the impact of publicly and charity-funded research is still limited and subject to funding and selection bias. More work is needed to establish the causal effects of funded research on academic outcomes, policy, practice and the broader economy.

Most UK scientists who publish extremely highly-cited papers do not secure funding from major public and charity funders: A descriptive analysis.

The UK is one of the largest funders of health research in the world, but little is known about how health funding is spent. Our study explores whether major UK public and charitable health research funders support the research of UK-based scientists producing the most highly-cited research. To address this question, we searched for UK-based authors of peer-reviewed papers that were published between January 2006 and February 2018 and received over 1000 citations in Scopus. We explored whether these authors have held a grant from the National Institute for Health Research (NIHR), the Medical Research Council (MRC) and the Wellcome Trust and compared the results with UK-based researchers who serve currently on the boards of these bodies. From the 1,370 papers relevant to medical, biomedical, life and health sciences with more than 1000 citations in the period examined, we identified 223 individuals from a UK institution at the time of publication who were either first/last or single authors. Of those, 164 are still in UK academic institutions, while 59 are not currently in UK academia (have left the country, are retired, or work in other sectors). Of the 164 individuals, only 59 (36%; 95% CI: 29-43%) currently hold an active grant from one of the three funders. Only 79 (48%; 95% CI: 41-56%) have held an active grant from any of the three funders between 2006-2017. Conversely, 457 of the 664 board members of MRC, Wellcome Trust, and NIHR (69%; 95% CI: 65-72%) have held an active grant in the same period by any of these funders. Only 7 out of 655 board members (1.1%) were first, last or single authors of an extremely highly-cited paper. There are many reasons why the majority of the most influential UK authors do not hold a grant from the country's major public and charitable funding bodies. Nevertheless, the results are worrisome and subscribe to similar patterns shown in the US. We discuss possible implications and suggest ways forward.

Crises and mortality: Does the level of unemployment matter?

The relationship between mortality and economic fluctuations has been a topic of long interest, which intensified following the 2008 global financial crisis. We study whether mortality responds non-linearly and asymmetrically to unemployment in the context of national economic crises. Although these assumptions have been challenged in other domains, they have been neglected in the mortality literature. Greece offers an ideal setting as unemployment was decreasing until mid-2008, but then it was sharply increased as a result of a severe economic crisis. We use quarterly data on regional unemployment and mortality from 1999 to 2013, giving a balanced panel of 780 observations. We find evidence of a countercyclical total mortality, especially for the older groups, and a further deteriorating crisis effect. We provide evidence that the relationship is non-linear and asymmetric, suggesting that the effect on death rates changes for very high values of unemployment and depends on its direction. Both non-linearity and asymmetry are mainly driven by those above 65 years old. The results suggest that the mechanisms explaining these effects are likely to vary across age groups. Our findings have important methodological implications and suggest that empirical investigations on fluctuations, recessions and mortality should not ignore possible non-linear and asymmetric behaviours, especially during turbulent times.

Effects of preoperative and postoperative resistance exercise interventions on recovery of physical function in patients undergoing abdominal surgery for cancer: a systematic review of randomised controlled trials.

OBJECTIVE: To systematically review the effects of preoperative and postoperative resistance exercise training on the recovery of physical function in patients undergoing abdominal surgery for cancer. DATA SOURCES: A systematic review of English articles using Medline, Physiotherapy Evidence Database, CINAHL and the Cochrane Library electronic databases was undertaken. ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies were included if they used a randomised, quasi-randomised or controlled trial study design and compared the effects of a muscle-strengthening exercise intervention (±other therapy) with a comparative non-exercise group; involved adult participants (≥18 years) who had elected to undergo abdominal surgery for cancer; and used muscle strength, physical function, self-reported functional ability, range of motion and/or a performance-based test as an outcome measure. RESULTS: Following screening of titles and abstracts of the 588 publications retrieved from the initial search, 24 studies met the inclusion criteria and were accessed for review of the full-text version of the article, and 2 eligible studies met the inclusion criteria and were included in the review. One exercise programme was undertaken preoperatively and the other postoperatively, until discharge from hospital. The exercise interventions of the included studies were performed for five and eight sessions, respectively. There were no differences between groups in either study. CONCLUSION: The only two studies designed to determine whether preoperative or postoperative resistance muscle-strengthening exercise programmes improved or negatively affected physical function outcomes in patients undergoing abdominal surgery for cancer provide inconclusive results.

Enhancing clinical communication in dermatologists: a personalized educational intervention.

OBJECTIVES: Effective communication is a vital component of patient-centered consultations with favorable treatment outcomes. This study aimed in testing the effectiveness of a personalized, communication training program for dermatologists in their practices. METHODS: Fifteen dermatologists were offered the educational intervention NO.TE.S. (Non-Technical Skills). Depending on the dermatologists' needs, seven to nine sessions with a 60-min duration were performed, focusing on: patient-centered care, principles of Neurolinguistic Programming, a guide to the medical interview, principles of motivational interviewing and self-care. After the program's completion, participants completed anonymously an 18-item evaluation questionnaire. RESULTS: All 14 participants would suggest NO.TE.S to a colleague. According to the main themes identified, their participation led to (i) re-consideration of the physician-patient relationship, (ii) more conscious application of the patient-centered model, (iii) improvement in communication skills, (iv) awareness of medical interview guides, (v) increase in self-confidence, and (vi) techniques of self-care. Eleven physicians (78.6%) declared improvement in patients' satisfaction, 14 (100%) in their own satisfaction, seven (50%) in adherence to therapeutic plan and seven (50%) in treatment outcomes. CONCLUSION: The one-to-one coaching is a convenient and well-received personalized means of enhancing clinical communication in dermatologists, leading to more patient-centered medical encounters with better treatment outcomes.

The consent process: Enabling or disabling patients' active participation?

Standards expected by doctors' regulatory bodies in respect of the process of consent to treatment have arguably sought to restructure the nature of the doctor-patient relationship from one of the paternalism to that of shared decision-making. Yet, few studies have explored empirically, from patients' perspectives, the extent to which the process of consent to treatment enables or disables patients' participation in medical decision-making. Our article examines patients' attitudes towards the consent process, exploring how and why these attitudes influence patients' active participation in decision-making and considering possible consequent medico-legal issues. Data were collected longitudinally using semi-structured interviews and field observations involving 35 patients and 19 of their caregivers, in an English hospital between February and November 2014. These indicate that generally patients defer to the doctor in respect of treatment decision-making. Although most patients and their caregivers wanted detailed information and discussion, they did not necessarily expect that this would be provided. Furthermore, patients perceived that signing the consent form was an obligatory routine principally to protect doctors from legal action should something go wrong. Our study suggests that patients' predominantly paternalistic perceptions of the consent process can not only undermine attempts by doctors to involve them in decision-making but, as patients are now considered in law as informed actors, their perceptions of the consent form as not being in their interests could be a self-fulfilling prophecy if signing is undertaken without due consideration to the content.

Doctor-patient differences in risk and time preferences: A field experiment.

We conduct a framed field experiment among patients and doctors to test whether the two groups have similar risk and time preferences. We elicit risk and time preferences using multiple price list tests and their adaptations to the healthcare context. Risk and time preferences are compared in terms of switching points in the tests and the structurally estimated behavioural parameters. We find that doctors and patients significantly differ in their time preferences: doctors discount future outcomes less heavily than patients. We find no evidence that doctors and patients systematically differ in their risk preferences in the healthcare domain.