'For Want of a Nail': developing a transparent approach to retroduction and early initial programme theory development in a realist evaluation of community end of life care services.

A crucial part of theory-driven realist thinking is retroduction, the process of looking backwards for explanation of how and why things may be. Conducted early in the realist evaluation process, it provides a foundation for evidenced 'theory gleaning'. Despite retroduction being an inherent part of the realist process, it is often 'hidden' in realist reports. This paper explains the thinking behind, alongside an example of, a framework created by the authors to make transparent the retroductive process as used in a realist evaluation of two community End of Life Care services. The approach makes visible the application of the 'sociological imagination' and lends robustness to hypotheses by establishing how the authors utilised: wide-ranging potential generative causation; stakeholder and Patient and Public Involvement feedback; literature scoping; and substantive theories at the middle range, specifically Transitions Theory. These stages led to the development of Initial Programme Theories, with a clear history of genesis.

Factors that influence paramedic decision-making about resuscitation for treatment of out of hospital cardiac arrest: Results of a discrete choice experiment in National Health Service ambulance trusts in England and Wales.

Background: During out of hospital cardiac arrest (OHCA) paramedics must make decisions to commence, continue, terminate or withhold resuscitation. These decisions are known to be complex, subject to variability and often dependent on provider preference. This study aimed to understand paramedic decision-making regarding the commencement of resuscitation using a discrete choice experiment. Methods: A discrete choice experiment between October-December 2022 surveying paramedics from ten National Health Service ambulance trusts in England and Wales. Respondents were presented with fourteen vignettes, each comprising thirteen attributes, and asked to decide if they would provide resuscitation or not. Results: Eight hundred and sixty-four paramedics completed the survey (61.8% male, median age 36 years (IQR 17.1)) and half had < 5 years clinical experience (n = 443 (51.2%). Respondents expressed a general preference to offer resuscitation (p = <0.01). All attributes except patient gender were statistically significant and important regarding an offer of resuscitation. Cut-offs where an offer of resuscitation was less likely were patient age of 73 years (p=>0.05), mild dementia (p = >0.05) and moderate frailty (p = <0.01). Paramedic characteristics of female gender, longest (>10 years) and shortest (<5 years) period qualified, lower academic qualification, lower skill level and attending fewer OHCA's were more likely to result in an offer of resuscitation. Conclusion: During OHCA paramedics use objective and non-objective factors to make pragmatic decisions regarding an offer of resuscitation. Future research should focus on how best to support paramedics to make decisions during OHCA, how variability in decision-making impacts patient outcomes and how this relates to patient and public expectations.

Achieving integrated treatment: a realist synthesis of service models and systems for co-existing serious mental health and substance use conditions.

Approximately 30-50% of people with serious mental illness have co-existing drug or alcohol problems (COSMHAD), associated with adverse health and social care outcomes. UK guidelines advocate both co-occurring needs being met within mental health services, but uncertainty remains about how to operationalise this to improve outcomes. Various unevaluated service configurations exist in the UK. A realist synthesis was done to identify, test, and refine programme theories of how context shapes the mechanisms through which UK service models for COSMHAD work, for whom, and in what circumstances. Structured and iterative realist searches of seven databases identified 5099 records. A two-stage screening process identified 132 papers. Three broad contextual factors shaped COSMHAD services across 11 programme theories: committed leadership, clear expectations regarding COSMHAD from mental health and substance use workforces, and clear care-coordination processes. These contextual factors led to increased staff empathy, confidence, legitimisation, and multidisciplinary ethos, which improved care coordination and increased the motivation of people with COSMHAD to work towards their goals. Our synthesis highlights that integrating COSMHAD care is complex, and both individual and cultural behavioural shifts in leadership, workforce, and service delivery are essential to ensure people with COSMHAD receive compassionate, trauma-informed care that meets their needs.

Longitudinal realist evaluation of the Dementia PersonAlised Care Team (D-PACT) intervention: protocol.

BACKGROUND: Different dementia support roles exist but evidence is lacking on which aspects are best, for whom, and in what circumstances, and on their associated costs and benefits. Phase 1 of the Dementia PersonAlised Care Team programme (D-PACT) developed a post-diagnostic primary care-based intervention for people with dementia and their carers and assessed the feasibility of a trial. AIM: Phase 2 of the programme aims to 1) refine the programme theory on how, when, and for whom the intervention works; and 2) evaluate its value and impact. DESIGN & SETTING: A realist longitudinal mixed-methods evaluation will be conducted in urban, rural, and coastal areas across South West and North West England where low-income or ethnic minority populations (for example, South Asian) are represented. Design was informed by patient, public, and professional stakeholder input and phase 1 findings. METHOD: High-volume qualitative and quantitative data will be collected longitudinally from people with dementia, carers, and practitioners. Analyses will comprise the following: 1) realist longitudinal case studies; 2) conversation analysis of recorded interactions; 3) statistical analyses of outcome and experience questionnaires; 4a) health economic analysis examining costs of delivery; and 4b) realist economic analysis of high-cost events and 'near misses'. All findings will be synthesised using a joint display table, evidence appraisal tool, triangulation, and stakeholder co-analysis. CONCLUSION: The realist evaluation will describe how, why, and for whom the intervention does or does not lead to change over time. It will also demonstrate how a non-randomised design can be more appropriate for complex interventions with similar questions or populations.

A Qualitative Exploration of Stakeholder Involvement in Decision-Making for Alcohol Treatment and Prevention Services.

The concept of providing individuals with a 'voice' via stakeholder involvement has been advocated within English health care policy for several decades. Stakeholder involvement encourages people affected by an issue to contribute to planning and decision making regarding treatment and care, inclusive of providers and recipients of care. This paper explores stakeholder involvement in the design and delivery of public health alcohol services. A qualitative case study approach was adopted, including in-depth interviews with 11 alcohol commissioners, 10 alcohol service providers and 6 general practitioners plus three facilitated focus groups with 31 alcohol service users. Findings show that most participants were aware of, and could name, various methods of stakeholder involvement that they had engaged with; however, the extent and impact of stakeholder involvement in decision making are not transparent. It is essential that a deeper understanding is generated of the different roles that stakeholders can play within the entire decision-making process to maximise its utility.

Systematic Review of Studies Using Conjoint Analysis Techniques to Investigate Patients' Preferences Regarding Osteoarthritis Treatment.

BACKGROUND: The use of conjoint analysis (CA) to elicit patients' preferences for osteoarthritis (OA) treatment has the potential to contribute to tailoring treatments and enhancing patients' compliance and adherence. This review's main aim was to identify and summarise the evidence that used conjoint analysis techniques to quantify patient preferences for OA treatments. METHODS: A comprehensive search strategy was conducted using electronic databases and hand reference checks. Databases were searched from their inception until 10th June 2019. All OA and CA related terms were used to conduct the search. The authors reviewed the papers and used the International Society of Pharmacoeconomics and Outcomes Research (ISPOR) checklist to assess the quality of the included studies. RESULTS: The search identified 534 records. Sixteen records were selected for full-text review and quality assessment and all were included in the narrative data synthesis. All included studies suggested that the severity of symptoms influenced the patients' preference for OA treatment. All included studies recognised CA as a useful method to investigate patients' preferences concerning OA treatment. CONCLUSION: Patients preference for OA treatment is driven by the severity of patients' symptoms and the desire to avoid treatment side effects and CA is a useful tool to investigate patients' preferences for OA treatment.

Attracting, recruiting and retaining nurses and care workers working in care homes: the need for a nuanced understanding informed by evidence and theory.

The care home sector relies on nurses and care workers to deliver care to residents living with frailty and complex needs. However, attracting, recruiting and retaining staff is one of the biggest challenges facing this sector. There is evidence available that describes factors that influence staff decisions to join and/or remain in the care home workforce, for example, individual rewards (such as feeling valued at work or training opportunities), relationships with colleagues and residents, supportive management or working arrangements (including flexible hours). However, it is less clear how different strategies are informed by evidence to improve recruitment and retention. Care homes are heterogeneous in terms of their size, staffing levels and mix, staff age groups, geographical location and working conditions. What matters to different members of the care home workforce will vary across nurses and care workers of different ages and levels of qualification or experience. Recognising this diversity is key: understanding how to attract, recruit and retain staff needs to discriminate and offer solutions that address this diversity. This important area of practice does not lend itself to a 'one-approach-fits-all' solution. This commentary provides a brief overview of known workforce challenges for the care home sector and argues for studies that use empirical evidence to test different theories of what might work for different staff, how and why, and in different circumstances.

Information sharing challenges in end-of-life care: a qualitative study of patient, family and professional perspectives on the potential of an Electronic Palliative Care Co-ordination System.

OBJECTIVES: To explore current challenges in interdisciplinary management of end-of-life care in the community and the potential of an Electronic Palliative Care Co-ordination System (EPaCCS) to facilitate the delivery of care that meets patient preferences. DESIGN: Qualitative study using interviews and focus groups. SETTING: Health and Social Care Services in the North of England. PARTICIPANTS: 71 participants, 62 health and social care professionals, 9 patients and family members. RESULTS: Four key themes were identified: information sharing challenges; information sharing systems; perceived benefits of an EPaCCS and barriers to use and requirements for an EPaCCS. Challenges in sharing information were a source of frustration for health and social care professionals as well as patients, and were suggested to result in inappropriate hospital admissions. Current systems were perceived by participants to not work well-paper advance care planning (ACP) documentation was often unavailable or inaccessible, meaning it could not be used to inform decision-making at the point of care. Participants acknowledged the benefits of an EPaCCS to facilitate information sharing; however, they also raised concerns about confidentiality, and availability of the increased time and resources required to access and maintain such a system. CONCLUSIONS: EPaCCS offer a potential solution to information sharing challenges in end-of-life care. However, our findings suggest that there are issues in the initiation and documentation of end-of-life discussions that must be addressed through investment in training in order to ensure that there is sufficient information regarding ACP to populate the system. There is a need for further qualitative research evaluating use of an EPaCCS, which explores benefits and challenges, uptake and reasons for disparities in use to better understand the potential utility and implications of such systems.

Exploring and understanding the scope and value of the Parkinson's nurse in the UK (The USP Project): a realist economic evaluation protocol.

INTRODUCTION: There are multiple configurations of specialist nurses working in the field of Parkinson's. Parkinson's Nurse Specialists (PNSs) are recognised as playing a pivotal role; however, there is little published evidence to demonstrate their effectiveness. Further evidence is needed to establish which aspects of the PNSs provide the greatest benefit to people with Parkinson's and their families, and the cost-effectiveness of different models of care. METHODS AND ANALYSIS: Realist approaches explain how and why programmes work (or not) through striving to answer the question: what works, for whom and under what circumstances. This research uses a realist evaluation and aims to integrate an economic analysis within the realist framework. We refer to this as 'realist economic evaluation'. It comprises four phases: (1) developing resource-sensitive initial programme theories (IPTs) using surveys to gain a better understanding of the role and impact (costs and benefits) of the PNSs; (2) testing the IPTs through qualitative interviews and quantitative data analysis; (3) evaluating the cost and resource use implications alongside the benefits associated with the role of the PNSs and (4) iteratively refining the IPTs throughout the project. The IPTs will draw on both quantitative and qualitative data. The result of the study will be a series of refined programme theories, which will explain how specialist nurses work in the field of Parkinson's in the UK, what impact they have on people with Parkinson's and their families and carers, and at what cost. ETHICS AND DISSEMINATION: Northumbria University, the Health Research Authority and Health and Care Research Wales have approved this study. Key findings will be disseminated throughout the duration of the project online and through social media, and via annual and regional Parkinson's meetings and the Parkinson's UK Excellence Network. Academic dissemination will occur through publication and conference presentations.

Impact of emergency care centralisation on mortality and efficiency: a retrospective service evaluation.

OBJECTIVE: Evidence favours centralisation of emergency care for specific conditions, but it remains unclear whether broader implementation improves outcomes and efficiency. Routine healthcare data examined consolidation of three district general hospitals with mixed medical admission units (MAU) into a single high-volume site directing patients from the ED to specialty wards with consultant presence from 08:00 to 20:00. METHODS: Consecutive unscheduled adult index admissions from matching postcode areas were identified retrospectively in Hospital Episode Statistics over a 3-year period: precentralisation baseline (from 16 June 2014 to 15 June 2015; n=18 586), year 1 postcentralisation (from 16 June 2015 to 15 June 2016; n=16 126) and year 2 postcentralisation (from 16 June 2016 to 15 June 2017; n=17 727). Logistic regression including key demographic covariates compared baseline with year 1 and year 2 probabilities of mortality and daily discharge until day 60 after admission and readmission within 60 days of discharge. RESULTS: Relative to baseline, admission postcentralisation was associated with favourable OR (95% CI) for day 60 mortality (year 1: 0.95 (0.88 to 1.02), p=0.18; year 2: 0.94 (0.91 to 0.97), p<0.01), mainly among patients aged 80+ years (year 1: 0.88 (0.79 to 0.97); year 2: 0.91 (0.87 to 0.96)). The probability of being discharged alive on any day since admission increased (year 1: 1.07 (1.04 to 1.10), p<0.01; year 2: 1.04 (1.02 to 1.05), p<0.01) and the risk of readmission decreased (year 1: 0.90 (0.87 to 0.94), p<0.01; year 2: 0.92 (0.90 to 0.94), p<0.01). CONCLUSION: A centralised site providing early specialist care was associated with improved short-term outcomes and efficiency relative to lower volume ED admitting to MAU, particularly for older patients.

Implementing world class commissioning competencies.

BACKGROUND: The world class commissioning (WCC) programme was introduced in the English NHS in 2007 to develop primary care trust (PCT) commissioning of health services. There has been limited evaluation of health commissioning initiatives over the years and in particular little is known about how commissioners interpret and implement initiatives and guidance intended to strengthen commissioning. This research explores the development and implementation of WCC and draws implications for future commissioning arrangements. METHODS: This research draws on interviews with key informants (n = 6) and a literature review to analyse the aims of, and stimulus for, WCC. In-depth interviews (n = 38) were conducted in three PCTs in the north of England in 2009 to analyse the interpretation and implementation of WCC. RESULTS: The aims and rationale of WCC, in particular, the specification of commissioning skills and the aspirations to improve health outcomes, were largely welcomed and supported by interviewees. However, the implementation of WCC posed a number of challenges, including: availability of resources and knowledge; lack of a supportive organizational culture and networks; and the dominance of central government control. CONCLUSIONS: The findings have implications for emerging clinical commissioning groups (CCGs) in the English NHS. Specifically, the research highlights the need for a system-wide approach to improving commissioning, including appropriately aligned policy and objectives underpinned by a co-ordinated and supportive organizational culture.

Priority setting in healthcare: towards guidelines for the program budgeting and marginal analysis framework.

Economists' approaches to priority setting focus on the principles of opportunity cost, marginal analysis and choice under scarcity. These approaches are based on the premise that it is possible to design a rational priority setting system that will produce legitimate changes in resource allocation. However, beyond issuing guidance at the national level, economic approaches to priority setting have had only a moderate impact in practice. In particular, local health service organizations - such as health authorities, health maintenance organizations, hospitals and healthcare trusts - have had difficulty implementing evidence from economic appraisals. Yet, in the context of making decisions between competing claims on scarce health service resources, economic tools and thinking have much to offer. The purpose of this article is to describe and discuss ten evidence-based guidelines for the successful design and implementation of a program budgeting and marginal analysis (PBMA) priority setting exercise. PBMA is a framework that explicitly recognizes the need to balance pragmatic and ethical considerations with economic rationality when making resource allocation decisions. While the ten guidelines are drawn from the PBMA framework, they may be generalized across a range of economic approaches to priority setting.

Overcoming barriers to priority setting using interdisciplinary methods.

Ten years ago, Holm's highly influential paper "Goodbye to the simple solutions: the second phase of priority setting" was published [Holm S. Goodbye to the simple solutions: the second phase of priority setting in health care. British Medical Journal 1998;317:1000-7]. Whilst attending the 2nd International Conference on Priorities in Health Care in London, Holm argued that the search for a rational set of decision-making rules was no longer adequate. Instead, the priority setting process itself was now thought to be more complex. Ten years later, the Conference returns to the UK for the first time, and it is timely to describe some new tools intended to assist both researchers and decision-makers seeking to develop both rational and fair and legitimate priority setting processes. In this paper we argue that to do so, researchers and decision-makers need to adopt an interdisciplinary and collaborative approach to priority setting. We focus on program budgeting and marginal analysis (PBMA) and bring together three hitherto separate interdisciplinary strands of the PBMA literature. Our aim is to assist researchers and decision-makers seeking to effectively develop and implement PBMA in practice. Specifically, we focus on the use of multi-criteria decision analysis, participatory action research, and accountability for reasonableness, drawn from the disciplines of decision analysis, sociology, and ethics respectively.

Commissioning NHS dentistry in England: issues for decision-makers managing the new contract with finite resources.

OBJECTIVES: To explore the views of dental decision-makers in Primary Care Organisations with regard to the management of NHS dental services, and to gauge participants' awareness of economics-based approaches including programme budgeting and marginal analysis, with which to potentially structure commissioning decisions. METHODS: Recorded semi-structured interviews were conducted with 18 NHS dental decision-makers (mixed clinical and finance backgrounds) predominantly across Primary Care Trusts in England. Data were analysed using qualitative methods and the constant comparative approach. RESULTS: Participants were generally involved with contracting rather than commissioning new dental services at the time of interview. It was unclear how oral health needs assessments would guide future resource shifts and how commissioners would ensure the efficient use of finite resources. Whilst many participants thought that economic approaches would assist their commissioning decisions, few participants were aware of programme budgeting and marginal analysis as an alternative economics-based approach. CONCLUSIONS: An assessment of the extent to which finite resources actually maximise the oral health of local populations is timely. Pragmatic economic approaches such as programme budgeting and marginal analysis may offer a framework to guide decision-makers through commissioning and the stages which lie beyond oral health needs assessments.

Managing to manage healthcare resources in the English NHS? What can health economics teach? What can health economics learn?

OBJECTIVES: To provide a 'thick description' of how decision-makers understand and manage healthcare prioritisation decisions, and to explore the potential for using economic frameworks in the context of the NHS in England. METHODS: Interviews were conducted with 22 key decision-makers from six Primary Care Trusts (PCTs) in northern England. A constant comparative approach was used to identify broad themes and sub-themes. RESULTS: Six broad themes emerged from the analysis. In summary, decision-makers recognised the concepts of resources scarcity, competing claims, and the need for choices and trade-offs to be made. Decision-makers even went on to identify a common set of principles that ought to guide commissioning decisions. However, the process of commissioning was dominated by political, historical and clinical methods of commissioning which, failed to recognise these concepts in practice, and departed from the principles. As a result, the commissioning process was viewed as not being systematic or transparent and, therefore, seen as underperforming. CONCLUSIONS: Health economists need to acknowledge the importance of contextual factors and the realities of priority setting. Our research suggests that the emphasis should be on integrating principles of economics into a management process rather than expecting decision-makers to apply the output of ever more seemingly 'technically sound' health economic methods which cannot reflect the dominating and driving complexities of the commissioning process.

Resource allocation in orthopaedics: economic evaluation to priority setting.

In 2000 the World Health Organization launched the "Bone and Joint Decade" campaign in part to promote cost-effective treatments. This will impact the organization, delivery, and funding of health care as the population ages. However, it is well recognized that resources in health care are limited and it is essential the resources available are used to best effect. Thus, there has been greater emphasis in the orthopaedic literature on the use of economics. Still, there is little discussion of whether and how the results of these economic methods can be further used to aid resource allocation decisions. We discuss the suitability of economic methods for priority setting in orthopaedic surgery, arguing economic evaluation alone is not sufficient for addressing resource allocation decisions. We also describe an alternative approach to priority setting that has been steadily gaining prominence within health economics--program budgeting and marginal analysis--and use a working example from the United Kingdom National Health Service to illustrate its application within orthopaedic surgery.

Où sont les chercheurs? Speaking at cross-purposes or across boundaries?

Knowledge transfer and exchange (KTE) relates to both the translation and transfer of information, as well as the exchange of information, between researchers and decision-makers. Despite recent advances, KTE efforts may be compromised on two fronts: first, the existing reward structure for university-based researchers may not be compatible with applied research; and second, there appears to be a lack of research capacity in healthcare organizations. In this short paper, we contest the first of these points, suggesting that applied research can and should be published in high-index journals, and thus the tenure and promotions process does not need reform. Regarding the second point, we suggest that partnerships be formed across healthcare organizations, universities, government agencies and research funders to support the positioning of PhD-trained researchers directly in healthcare delivery organizations. In our view, it is here, once organizational boundaries are crossed, that significant progress will be made in completing the health policy and health research cycles.

Preferences for access to the GP: a discrete choice experiment.

BACKGROUND: Access to primary care services is one of the key components of the NHS Plan which states that patients should be able to see a health professional within 24 hours and a GP within 48 hours. However, it is not clear how patients value speed of access in comparison with other aspects of primary care. AIM: To investigate patient preferences when making an routine appointment for a GP, and to describe the trade-offs and relationships between speed of access, choice of time and choice of doctor in different patient groups. DESIGN OF STUDY: Discrete choice experiment. SETTING: Adults consulting a GP in six general practices in Sunderland. METHOD: Choice sets based on three attributes (time to appointment, choice of time, choice of doctor) were presented in a self-completion questionnaire. RESULTS: We obtained 6985 observations from 1153 patients. We found that the waiting time to make an appointment was only important if the appointment is for a child or when attending for a new health problem. Other responders would trade-off a shorter waiting time and be willing to wait in order to either see their own choice of doctor or attend an appointment at their own choice of time. For responders who work, choice of time is six times more important than a shorter waiting time and they are willing to wait up to 1 day extra for this. Those with a long-standing illness value seeing their own GP more than seven times as much as having a shorter waiting time for an appointment and will wait an extra 1 day for an appointment with the GP of their choice, women will wait an extra 2 days, and older patients an extra 2.5 days. CONCLUSION: Speed of access is of limited importance to patients accessing their GP, and for many is outweighed by choice of GP or convenience of appointment.