Evidence for models of diagnostic service provision in the community: literature mapping exercise and focused rapid reviews

Background Current NHS policy favours the expansion of diagnostic testing services in community and primary care settings. Objectives Our objectives were to identify current models of community diagnostic services in the UK and internationally and to assess the evidence for quality, safety and clinical effectiveness of such services. We were also interested in whether or not there is any evidence to support a broader range of diagnostic tests being provided in the community. Review methods We performed an initial broad literature mapping exercise to assess the quantity and nature of the published research evidence. The results were used to inform selection of three areas for investigation in more detail. We chose to perform focused reviews on logistics of diagnostic modalities in primary care (because the relevant issues differ widely between different types of test); diagnostic ultrasound (a key diagnostic technology affected by developments in equipment); and a diagnostic pathway (assessment of breathlessness) typically delivered wholly or partly in primary care/community settings. Databases and other sources searched, and search dates, were decided individually for each review. Quantitative and qualitative systematic reviews and primary studies of any design were eligible for inclusion. Results We identified seven main models of service that are delivered in primary care/community settings and in most cases with the possible involvement of community/primary care staff. Not all of these models are relevant to all types of diagnostic test. Overall, the evidence base for community- and primary care-based diagnostic services was limited, with very few controlled studies comparing different models of service. We found evidence from different settings that these services can reduce referrals to secondary care and allow more patients to be managed in primary care, but the quality of the research was generally poor. Evidence on the quality (including diagnostic accuracy and appropriateness of test ordering) and safety of such services was mixed. Conclusions In the absence of clear evidence of superior clinical effectiveness and cost-effectiveness, the expansion of community-based services appears to be driven by other factors. These include policies to encourage moving services out of hospitals; the promise of reduced waiting times for diagnosis; the availability of a wider range of suitable tests and/or cheaper, more user-friendly equipment; and the ability of commercial providers to bid for NHS contracts. However, service development also faces a number of barriers, including issues related to staffing, training, governance and quality control. Limitations We have not attempted to cover all types of diagnostic technology in equal depth. Time and staff resources constrained our ability to carry out review processes in duplicate. Research in this field is limited by the difficulty of obtaining, from publicly available sources, up-to-date information about what models of service are commissioned, where and from which providers. Future work There is a need for research to compare the outcomes of different service models using robust study designs. Comparisons of ‘true’ community-based services with secondary care-based open-access services and rapid access clinics would be particularly valuable. There are specific needs for economic evaluations and for studies that incorporate effects on the wider health system. There appears to be no easy way of identifying what services are being commissioned from whom and keeping up with local evaluations of new services, suggesting a need to improve the availability of information in this area. Funding The National Institute for Health Research Health Services and Delivery Research programme

Factors Influencing Customer Satisfaction towards E-shopping in Malaysia

Online shopping or e-shopping has changed the world of business and quite a few people have decided to work with these features. What their primary concerns precisely and the responses from the globalisation are the competency of incorporation while doing their businesses. E-shopping has also increased substantially in Malaysia in recent years. The rapid increase in the e-commerce industry in Malaysia has created the demand to emphasize on how to increase customer satisfaction while operating in the e-retailing environment. It is very important that customers are satisfied with the website, or else, they would not return. Therefore, a crucial fact to look into is that companies must ensure that their customers are satisfied with their purchases that are really essential from the ecommerce’s point of view. With is in mind, this study aimed at investigating customer satisfaction towards e-shopping in Malaysia. A total of 400 questionnaires were distributed among students randomly selected from various public and private universities located within Klang valley area. Total 369 questionnaires were returned, out of which 341 questionnaires were found usable for further analysis. Finally, SEM was employed to test the hypotheses. This study found that customer satisfaction towards e-shopping in Malaysia is to a great extent influenced by ease of use, trust, design of the website, online security and e-service quality. Finally, recommendations and future study direction is provided. Keywords: E-shopping, Customer satisfaction, Trust, Online security, E-service quality, Malaysia

International Consensus Statement on Allergy and Rhinology: Allergic Rhinitis.

BACKGROUND: Critical examination of the quality and validity of available allergic rhinitis (AR) literature is necessary to improve understanding and to appropriately translate this knowledge to clinical care of the AR patient. To evaluate the existing AR literature, international multidisciplinary experts with an interest in AR have produced the International Consensus statement on Allergy and Rhinology: Allergic Rhinitis (ICAR:AR). METHODS: Using previously described methodology, specific topics were developed relating to AR. Each topic was assigned a literature review, evidence-based review (EBR), or evidence-based review with recommendations (EBRR) format as dictated by available evidence and purpose within the ICAR:AR document. Following iterative reviews of each topic, the ICAR:AR document was synthesized and reviewed by all authors for consensus. RESULTS: The ICAR:AR document addresses over 100 individual topics related to AR, including diagnosis, pathophysiology, epidemiology, disease burden, risk factors for the development of AR, allergy testing modalities, treatment, and other conditions/comorbidities associated with AR. CONCLUSION: This critical review of the AR literature has identified several strengths; providers can be confident that treatment decisions are supported by rigorous studies. However, there are also substantial gaps in the AR literature. These knowledge gaps should be viewed as opportunities for improvement, as often the things that we teach and the medicine that we practice are not based on the best quality evidence. This document aims to highlight the strengths and weaknesses of the AR literature to identify areas for future AR research and improved understanding

Joining the dots

SEED Foundation (Social Environmental Enterprise + Design), established by Brass in 2007, was invited to present a paper to the House of Lords Science and Technology sub-committee following a response to a call for evidence. At the time, the design approach to sustainability still focused predominantly on products and different ways of reducing their environmental impact. Jonathan Chapman had recently published Emotionally Durable Design, presenting a means to extend the life of products, and Cradle-to-Cradle explored the design of products for infinite cycles. SEED, in contrast, spearheaded a drive to address the underlying issue of consumption and hypothesised that designers should address systems rather than products to effect positive social and environmental change. The paper set out a new agenda for design in light of the government’s waste plans. Reflecting SEED’s manifesto, it highlighted the need for cross-disciplinary working, and opportunities to develop design-led entrepreneurial solutions to existing waste problems. Furthermore, it stressed the importance of embedding these principles in design education through schools, universities and continuous professional development programmes. It explored the relevance of various design approaches to waste, suggesting that reducing the amount of waste being generated, e.g. through a service approach, could be more effective than designing better systems for waste management. It built on leading service design thinking (Engine/Live|Work) highlighting the value and relevance of service design methodologies (e.g. co-creation, mapping) to the sustainability agenda, and cited relevant case studies (Ford, Electrolux, Interface Flor) where focusing on service rather than product led to the implementation of new business models. Design methods such as visualisation, prototyping and the staging of real-world scenarios were suggested as vital in the waste agenda to achieve the critical engagement described by the Sustainable Development Commission’s paper, I Will if You Will: Towards Sustainable Consumption, between business, government and people