A modified action framework to develop and evaluate academic-policy engagement interventions.

BACKGROUND: There has been a proliferation of frameworks with a common goal of bridging the gap between evidence, policy, and practice, but few aim to specifically guide evaluations of academic-policy engagement. We present the modification of an action framework for the purpose of selecting, developing and evaluating interventions for academic-policy engagement. METHODS: We build on the conceptual work of an existing framework known as SPIRIT (Supporting Policy In Health with Research: an Intervention Trial), developed for the evaluation of strategies intended to increase the use of research in health policy. Our aim was to modify SPIRIT, (i) to be applicable beyond health policy contexts, for example encompassing social, environmental, and economic policy impacts and (ii) to address broader dynamics of academic-policy engagement. We used an iterative approach through literature reviews and consultation with multiple stakeholders from Higher Education Institutions (HEIs) and policy professionals working at different levels of government and across geographical contexts in England, alongside our evaluation activities in the Capabilities in Academic Policy Engagement (CAPE) programme. RESULTS: Our modifications expand upon Redman et al.'s original framework, for example adding a domain of 'Impacts and Sustainability' to capture continued activities required in the achievement of desirable outcomes. The modified framework fulfils the criteria for a useful action framework, having a clear purpose, being informed by existing understandings, being capable of guiding targeted interventions, and providing a structure to build further knowledge. CONCLUSION: The modified SPIRIT framework is designed to be meaningful and accessible for people working across varied contexts in the evidence-policy ecosystem. It has potential applications in how academic-policy engagement interventions might be developed, evaluated, facilitated and improved, to ultimately support the use of evidence in decision-making.

Factors influencing the implementation of early discharge hospital at home and admission avoidance hospital at home: a qualitative evidence synthesis.

BACKGROUND: Worldwide there is an increasing demand for Hospital at Home as an alternative to hospital admission. Although there is a growing evidence base on the effectiveness and cost-effectiveness of Hospital at Home, health service managers, health professionals and policy makers require evidence on how to implement and sustain these services on a wider scale. OBJECTIVES: (1) To identify, appraise and synthesise qualitative research evidence on the factors that influence the implementation of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home, from the perspective of multiple stakeholders, including policy makers, health service managers, health professionals, patients and patients' caregivers. (2) To explore how our synthesis findings relate to, and help to explain, the findings of the Cochrane intervention reviews of Admission Avoidance Hospital at Home and Early Discharge Hospital at Home services. SEARCH METHODS: We searched MEDLINE, CINAHL, Global Index Medicus and Scopus until 17 November 2022. We also applied reference checking and citation searching to identify additional studies. We searched for studies in any language. SELECTION CRITERIA: We included qualitative studies and mixed-methods studies with qualitative data collection and analysis methods examining the implementation of new or existing Hospital at Home services from the perspective of different stakeholders. DATA COLLECTION AND ANALYSIS: Two authors independently selected the studies, extracted study characteristics and intervention components, assessed the methodological limitations using the Critical Appraisal Skills Checklist (CASP) and assessed the confidence in the findings using GRADE-CERQual (Confidence in the Evidence from Reviews of Qualitative research). We applied thematic synthesis to synthesise the data across studies and identify factors that may influence the implementation of Hospital at Home. MAIN RESULTS: From 7535 records identified from database searches and one identified from citation tracking, we included 52 qualitative studies exploring the implementation of Hospital at Home services (31 Early Discharge, 16 Admission Avoidance, 5 combined services), across 13 countries and from the perspectives of 662 service-level staff (clinicians, managers), eight systems-level staff (commissioners, insurers), 900 patients and 417 caregivers. Overall, we judged 40 studies as having minor methodological concerns and we judged 12 studies as having major concerns. Main concerns included data collection methods (e.g. not reporting a topic guide), data analysis methods (e.g. insufficient data to support findings) and not reporting ethical approval. Following synthesis, we identified 12 findings graded as high (n = 10) and moderate (n = 2) confidence and classified them into four themes: (1) development of stakeholder relationships and systems prior to implementation, (2) processes, resources and skills required for safe and effective implementation, (3) acceptability and caregiver impacts, and (4) sustainability of services. AUTHORS' CONCLUSIONS: Implementing Admission Avoidance and Early Discharge Hospital at Home services requires early development of policies, stakeholder engagement, efficient admission processes, effective communication and a skilled workforce to safely and effectively implement person-centred Hospital at Home, achieve acceptance by staff who refer patients to these services and ensure sustainability. Future research should focus on lower-income country and rural settings, and the perspectives of systems-level stakeholders, and explore the potential negative impact on caregivers, especially for Admission Avoidance Hospital at Home, as this service may become increasingly utilised to manage rising visits to emergency departments.

Developing a Scale of Care Work-Related Quality of Life (CWRQoL) for Long-Term Care Workers in England.

BACKGROUND: Long-term care (LTC) workers are subjected to structural and inherent difficult conditions that are likely to impact their quality of life at work; however, no agreed scale measures it. This study aims to develop a scale to measure the work-related quality of life among LTC workers in England (CWRQoL). The study establishes the domains/sub-domains of CWRQoL, investigates the tool's utility and collates information on existing supporting strategies for CWRQoL. METHODS: We adopt a mixed-methods approach employing inductive/deductive processes at three stages: (1) a scoping review of the literature; (2) interviews and focus groups with frontline LTC workers, managers and LTC stakeholders; and (3) a content validity consensus survey. RESULTS: CWRQoL is composed of seven domains (and 23 sub-domains). Additional domains to those in the literature include financial wellbeing, sufficient time for building relations, managing grief and emotions associated with client death and end of life care. Stakeholders identified several benefits and challenges related to the CWRQoL tool's utility. COVID-19 significantly impacted LTC workers' mental wellbeing and spillover between work and home. CONCLUSIONS: The study highlighted the complex nature of CWRQoL and provided a solid ground for developing and validating a CWRQoL scale.

The work of older people and their informal caregivers in managing an acute health event in a hospital at home or hospital inpatient setting.

BACKGROUND: There is limited understanding of the contribution made by older people and their caregivers to acute healthcare in the home and how this compares to hospital inpatient healthcare. OBJECTIVES: To explore the work of older people and caregivers at the time of an acute health event, the interface with professionals in a hospital and hospital at home (HAH) and how their experiences relate to the principles underpinning comprehensive geriatric assessment (CGA). DESIGN: A qualitative interview study within a UK multi-site participant randomised trial of geriatrician-led admission avoidance HAH, compared with hospital inpatient care. METHODS: We conducted semi-structured interviews with 34 older people (15 had received HAH and 19 hospital care) alone or alongside caregivers (29 caregivers; 12 HAH, 17 hospital care), in three sites that recruited participants to a randomised trial, during 2017-2018. We used normalisation process theory to guide our analysis and interpretation of the data. RESULTS: Patients and caregivers described efforts to understand changes in health, interpret assessments and mitigate a lack of involvement in decisions. Practical work included managing risks, mobilising resources to meet health-related needs, and integrating the acute episode into longer-term strategies. Personal, relational and environmental factors facilitated or challenged adaptive capacity and ability to manage. CONCLUSIONS: Patients and caregivers contributed to acute healthcare in both locations, often in parallel to healthcare providers. Our findings highlight an opportunity for CGA-guided services at the interface of acute and chronic condition management to facilitate personal, social and service strategies extending beyond an acute episode of healthcare.

Supporting self-management after traumatic brain injury: Codesign and evaluation of a new intervention across a trauma pathway.

BACKGROUND: Supported self-management (SSM) is a recognized approach for people with long-term conditions but, despite the prevalence of unmet needs, little is known about its role for people with traumatic brain injury (TBI). OBJECTIVES: To codesign an SSM intervention with people with TBI and evaluate feasibility of implementation through multidisciplinary staff across a trauma pathway. SETTING AND PARTICIPANTS: People who had previously been admitted to a Major Trauma Centre following TBI and family members participated in a series of codesign activities. Staff attended SSM workshops and used the intervention with patients in acute and rehabilitation settings. METHODS: We used Normalization Process Theory constructs to guide and interpret implementation. Knowledge, beliefs and confidence of staff in SSM were assessed through pre- and post-training questionnaires, and staff, patients' and families' experiences were explored through semi-structured interviews. Qualitative data were analysed thematically, and clinical measures were mapped against a matched sample. RESULTS: Codesigned resources were created and used within an SSM approach for which 110 staff participated in training. Evaluation demonstrated significant differences in staff SSM confidence and skills, following training. Qualitative evaluation revealed adoption by staff, and patients' and families' experiences of using the resources. Challenges included reaching staff across complex pathways to achieve collective implementation. CONCLUSION: This is the first project to demonstrate feasibility of SSM for people after TBI starting in an acute trauma setting. Through an open approach to codesign with a marginalized group, the SSM resources were valued by them and held meaning and relevance for staff.

A protocol for the process evaluation of a multi-centre randomised trial to compare the effectiveness of geriatrician-led admission avoidance hospital at home versus inpatient admission.

BACKGROUND: Attempts to design services to support the delivery of healthcare closer to home have taken various forms as countries respond to an increase in hospital admission rates for older people, who are at risk of hospital-acquired morbidity, prolonged lengths of stay and readmission. Evidence to support the development of these services is limited. We are conducting a process evaluation, alongside a UK multi-site randomised trial, to understand the contexts and practices of implementing geriatrician-led admission avoidance hospital at home services and to explore ways that the intervention might be effective, under what conditions, for whom, and how it differs from inpatient care. METHODS: We are interviewing patients and their caregivers, from sites that are purposively sampled from participating National Health Service (NHS) trusts across the UK. We are also visiting sites to observe local processes and discuss the establishment and running of services with a range of multidisciplinary staff, managers, commissioners, primary care and social services representatives. We aim to interview approximately 36 patients and their caregivers with experience of hospital at home or inpatient services; 12 at each of three sites. We will use a content analysis approach to explore data across participants, services and sites. DISCUSSION: This process evaluation will enable evaluation of implementation processes prior to knowing trial outcomes. We encompass domains of reach, delivery, change, context and response to the intervention by patients, their carers, health professionals and the health system. TRIAL REGISTRATION: ISRCTN60477865 . Registered on 10 March 2014. Trial sponsor: University of Oxford. Version 3.1, registered on 14 June 2016.

"She doesn't want to go to hospital. That's one thing she hates": Collective performativity in avoidable nursing home to hospital transfers.

Older people who live with a combination of conditions experience fluctuations over time, which others may interpret as a need for medical attention. For some nursing home residents, this results in transitions in and out of hospital. Such transfers may be arranged without expectation of improved quality of life, can be associated with significant morbidity and mortality, and may preclude end-of-life preferences. Factors affecting avoidable hospitalization for nursing home residents are not well understood. I aim to explore potential drivers, moving beyond deficit explanations relating to funding, training, and resources. I use a framework of analysis that firstly considers medicalization of frailty, as a state of vulnerability that provides focus for others' action. I then draw on Judith Butler's theory of performativity, to explore nursing homes as sites of identity work for staff, residents and families. I consider ways subjectivities can be effected through reiterative practice that is compelled by normative conventions. Trouble may arise when citational practice of health care staff, and performative acquiescence of residents and families, culminates in an inevitability of hospitalization when navigating grey areas of assumed clinical risk. Principles of coproduction could present a disruptive opening, to rework power asymmetries, and move toward aspirations for residents and their relatives to be at the centre of decisions about care.

Starting early: integration of self-management support into an acute stroke service.

Self-management support following stroke is rare, despite emerging evidence for impact on patient outcomes. The promotion of a common approach to self-management support across a stroke pathway requires collaboration between professionals. To date, the feasibility of self-management support in acute stroke settings has not been evaluated. The Bridges stroke self-management package (SMP) is based on self-efficacy principles. It is delivered by professionals and supported by a patient-held workbook. The aim of this project was to introduce the Bridges stroke SMP to the multidisciplinary staff of a London hyperacute and acute stroke unit. The 'Plan Do Study Act' (PDSA) cycle guided iterative stages of project development, with normalisation process theory helping to embed the intervention into existing ways of working. Questionnaires explored attitudes, beliefs and experiences of the staff who were integrating self-management support into ways of working in the acute stroke setting. Self-management support training was delivered to a total of 46 multidisciplinary stroke staff. Of the staff who attended the follow-up training, 66% had implemented Bridges self-management support with patients since initial training, and 100% felt their practice had changed. Questionnaire findings demonstrated that staff attitudes and beliefs had changed following training, particularly regarding ownership and type of rehabilitation goals set, and prioritisation of self-management support within acute stroke care. Staff initiated an audit of washing and dressing practices pre- and post-training. This was designed to evaluate the number of occasions when techniques were used by staff to facilitate patients' independence and self-management. They found that the number of occasions featuring optimum practice went from 54% at baseline to 63% at three months post-training. This project demonstrated the feasibility of integrating self-management support into an acute stroke setting. Further work is required to evaluate sustainability of the Bridges stroke SMP, to understand the barriers and opportunities involved in engaging all professional groups in integrated self-management support in acute stroke settings, and to assess patient reported outcomes.

Written medical discharge communication from an acute stroke service: a project to improve content through development of a structured stroke-specific template.

Specific guidelines for the content of discharge summaries from acute stroke services do not currently exist. The aims of this project were to assess the strengths and weaknesses of stroke discharge communication from Imperial College Healthcare NHS Trust, to develop a structured template to guide completion, and to re-audit discharge communication following its implementation. The audit compared local performance against record standards from the Academy of Medical Royal Colleges (1), which was augmented by criteria generated from the British Association of Stroke Physicians (BASP) Stroke Service Standards (2). Discharge information was examined within the Trust's Electronic Discharge Communication (EDC) system to determine the recording of selected items for consecutively discharged patients from the hyperacute and acute stroke units. The audit was repeated following implementation of a newly developed stroke-specific discharge summary template. Fifty-one EDC summaries were examined at baseline (July 2012) and 30 summaries at re-audit (January 2013). The criteria which showed low adherence initially and which showed the most significant improvement following the introduction of the template were the guidance on blood pressure and lipids targets (increased from 2% and 0% respectively at baseline, to 93% post intervention), and the driving and flying advice (from 3% to 79%). Documentation was also seen to improve for measures of physical and cognitive function, discharge arrangements, and follow up plans. This audit cycle has demonstrated improvement in the consistency of content within written discharge communication following the introduction of a structured stroke-specific template adhering to combined criteria from identified standards.

The effects of low doses of delta-9 tetrahydrocannabinol on reinforcement processing in the risky decision-making of young healthy adults.

Research suggests that risky decision-making is sensitive to neuromodulatory influences acting upon corticolimbic circuitry. However, while other evidence attests to effects of delta-9 tetrahydrocannabinol (THC) on the activity of reward pathways, relatively little is known about the possible involvement of cannabinoid activity in risky choice. In this experiment, we examined the effects of a single sublingual 5 mg dose of THC on a test of risky decision-making (requiring choices between simultaneously presented gambles differing in their magnitude of gains, magnitude of losses and the probability with which these outcomes were delivered). Tests of non-normative decision-making involving risk-aversion when deciding between gains and risk-seeking choices when deciding between losses were also included. In all, 15 healthy adults were administered 5 mg THC and placebo in a double-blind, placebo-controlled, within-subject, cross-over design. THC had three principal effects relative to placebo: (i) THC reduced choice of gambles with variable gains and losses, but increased choice of gambles with zero-expected value; (ii) THC reduced participants' attention towards losses when the probability of winning was low (and the probability of losing was high); and (iii) THC speeded participants' responses to gambles with large compared to small potential gains. These results suggest that THC mediates specific motivational processes and the processing of reinforcement cues during risky choice, perhaps reflecting altered CB1 receptor or catecholamine activity within corticolimbic pathways.

Low doses of delta-9 tetrahydrocannabinol (THC) have divergent effects on short-term spatial memory in young, healthy adults.

Evidence suggests that manipulating spatial information within working memory depends upon a circuitry organized around the prefrontal cortex (PFC) and the activity of the catecholamine systems. Other evidence attests to the effects of Delta-9 tetrahydrocannabinol (THC) on short-term spatial memory function, most probably involving CB(1) receptor activity within hippocampal circuitries. At the current time, there have been no systematic studies of the effects of THC on spatial working memory in human subjects using tasks known to depend upon frontotemporal neural circuitries. We examined the effects of a single sublingual 5 mg dose of THC on a test of spatial working memory (requiring active manipulation of remembered spatial information for the management of future behavior) and a test of spatial span (requiring only the reproduction of sequences of previously presented spatial cues). In all, 19 healthy adults were administered 5 mg THC and placebo in a double-blind, placebo-controlled, within-subject, crossover design. Male participants performed more accurately than female participants. THC significantly enhanced spatial working memory performance of female participants. By contrast, male and female participants produced more intrusion errors during performance of the Spatial Span task. These results suggest that THC has relatively complex effects on spatial memory in human subjects, perhaps reflecting altered CB(1) receptor activity within frontotemporal circuits or altered activity of mesocortical dopaminergic pathways in PFC areas associated with spatial memory.

Do cannabis-based medicinal extracts have general or specific effects on symptoms in multiple sclerosis? A double-blind, randomized, placebo-controlled study on 160 patients.

The objective was to determine whether a cannabis-based medicinal extract (CBME) benefits a range of symptoms due to multiple sclerosis (MS). A parallel group, double-blind, randomized, placebo-controlled study was undertaken in three centres, recruiting 160 outpatients with MS experiencing significant problems from at least one of the following: spasticity, spasms, bladder problems, tremor or pain. The interventions were oromucosal sprays of matched placebo, or whole plant CBME containing equal amounts of delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) at a dose of 2.5-120 mg of each daily, in divided doses. The primary outcome measure was a Visual Analogue Scale (VAS) score for each patient's most troublesome symptom. Additional measures included VAS scores of other symptoms, and measures of disability, cognition, mood, sleep and fatigue. Following CBME the primary symptom score reduced from mean (SE) 74.36 (11.1) to 48.89 (22.0) following CBME and from 74.31 (12.5) to 54.79 (26.3) following placebo [ns]. Spasticity VAS scores were significantly reduced by CBME (Sativex) in comparison with placebo (P =0.001). There were no significant adverse effects on cognition or mood and intoxication was generally mild.

A preliminary controlled study to determine whether whole-plant cannabis extracts can improve intractable neurogenic symptoms.

OBJECTIVES: To determine whether plant-derived cannabis medicinal extracts (CME) can alleviate neurogenic symptoms unresponsive to standard treatment, and to quantify adverse effects. DESIGN: A consecutive series of double-blind, randomized, placebo-controlled single-patient cross-over trials with two-week treatment periods. SETTING: Patients attended as outpatients, but took the CME at home. SUBJECTS: Twenty-four patients with multiple sclerosis (18), spinal cord injury (4), brachial plexus damage (1), and limb amputation due to neurofibromatosis (1). INTERVENTION: Whole-plant extracts of delta-9-tetrahydrocannabinol (THC), cannabidiol (CBD), 1:1 CBD:THC, or matched placebo were self-administered by sublingual spray at doses determined by titration against symptom relief or unwanted effects within the range of 2.5-120 mg/24 hours. Measures used: Patients recorded symptom, well-being and intoxication scores on a daily basis using visual analogue scales. At the end of each two-week period an observer rated severity and frequency of symptoms on numerical rating scales, administered standard measures of disability (Barthel Index), mood and cognition, and recorded adverse events. RESULTS: Pain relief associated with both THC and CBD was significantly superior to placebo. Impaired bladder control, muscle spasms and spasticity were improved by CME in some patients with these symptoms. Three patients had transient hypotension and intoxication with rapid initial dosing of THC-containing CME. CONCLUSIONS: Cannabis medicinal extracts can improve neurogenic symptoms unresponsive to standard treatments. Unwanted effects are predictable and generally well tolerated. Larger scale studies are warranted to confirm these findings.