From Programme Theory to Logic Models for Multispecialty Community Providers: A Realist Evidence Synthesis

Background: The NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets. Objectives: To use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly. Design: Realist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way. Data sources: Systematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions. Results: The IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs. Limitations: The studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed. Conclusions: Multidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

BackgroundThe NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets.ObjectivesTo use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly.DesignRealist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way.Data sourcesSystematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions.ResultsThe IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs.LimitationsThe studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed.ConclusionsMultidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience.Study registrationThis study is registered as PROSPERO CRD42016038900.FundingThe National Institute for Health Research (NIHR) Health Services and Delivery Research programme and supported by the NIHR Collaboration for Leadership in Applied Health Research and Care South West Peninsula

From programme theory to logic models for multispecialty community providers: a realist evidence synthesis

Background: The NHS policy of constructing multispecialty community providers (MCPs) rests on a complex set of assumptions about how health systems can replace hospital use with enhanced primary care for people with complex, chronic or multiple health problems, while contributing savings to health-care budgets. Objectives: To use policy-makers’ assumptions to elicit an initial programme theory (IPT) of how MCPs can achieve their outcomes and to compare this with published secondary evidence and revise the programme theory accordingly. Design: Realist synthesis with a three-stage method: (1) for policy documents, elicit the IPT underlying the MCP policy, (2) review and synthesise secondary evidence relevant to those assumptions and (3) compare the programme theory with the secondary evidence and, when necessary, reformulate the programme theory in a more evidence-based way. Data sources: Systematic searches and data extraction using (1) the Health Management Information Consortium (HMIC) database for policy statements and (2) topically appropriate databases, including MEDLINE, MEDLINE In-Process & Other Non-Indexed Citations, PsycINFO, the Cumulative Index to Nursing and Allied Health Literature (CINAHL) and Applied Social Sciences Index and Abstracts (ASSIA). A total of 1319 titles and abstracts were reviewed in two rounds and 116 were selected for full-text data extraction. We extracted data using a formal data extraction tool and synthesised them using a framework reflecting the main policy assumptions. Results: The IPT of MCPs contained 28 interconnected context–mechanism–outcome relationships. Few policy statements specified what contexts the policy mechanisms required. We found strong evidence supporting the IPT assumptions concerning organisational culture, interorganisational network management, multidisciplinary teams (MDTs), the uses and effects of health information technology (HIT) in MCP-like settings, planned referral networks, care planning for individual patients and the diversion of patients from inpatient to primary care. The evidence was weaker, or mixed (supporting some of the constituent assumptions but not others), concerning voluntary sector involvement, the effects of preventative care on hospital admissions and patient experience, planned referral networks and demand management systems. The evidence about the effects of referral reductions on costs was equivocal. We found no studies confirming that the development of preventative care would reduce demands on inpatient services. The IPT had overlooked certain mechanisms relevant to MCPs, mostly concerning MDTs and the uses of HITs. Limitations: The studies reviewed were limited to Organisation for Economic Co-operation and Development countries and, because of the large amount of published material, the period 2014–16, assuming that later studies, especially systematic reviews, already include important earlier findings. No empirical studies of MCPs yet existed. Conclusions: Multidisciplinary teams are a central mechanism by which MCPs (and equivalent networks and organisations) work, provided that the teams include the relevant professions (hence, organisations) and, for care planning, individual patients. Further primary research would be required to test elements of the revised logic model, in particular about (1) how MDTs and enhanced general practice compare and interact, or can be combined, in managing referral networks and (2) under what circumstances diverting patients from in-patient to primary care reduces NHS costs and improves the quality of patient experience

Mobilising Clinical Practice Data to Improve Multidisciplinary Oncology Care

As cancer incidence grows, healthcare services are increasingly pressured to provide timely, efficient, evidence-based care. The use of quality indicators are essential to identify and address variations in care delivery and patient outcomes. This thesis aims to inform best-practice quality measurement, feedback, and improvement utilising routinely collected data in cancer care. A systematic review of electronic medical record enabled measurement feedback systems found 12 of 14 studies reported mostly positive outcomes, but were of low-quality and lacking implementation context to replicate findings. A qualitative study identified significant consensus among key informant interviews on factors influencing success of data use and measurement feedback systems. A common theme between the review and interviews was the importance of clinical relevance and engagement. The findings were applied to a case study in colorectal cancer (CRC), including a systematic review and modified Delphi to identify clinically relevant quality indicators and a quantitative study to test the feasibility of the identified indicators against a population-based linked dataset of clinical practice data. The review identified 93 indicators in the literature and 56 CRC professionals prioritised 26 of those indicators. The feasibility study found that only six of the clinically prioritised indicators were feasible using available data in NSW. Feasible indicators were predominantly surgical, whereas indicators related to imaging, (neo)adjuvant therapy, and supportive care were lacking required data. As the use of data and value-based care continues to grow, this thesis provides direction for future data driven quality measurement for clinically meaningful quality improvement. System-wide coordination and standardised data capture, management, and operable exchange is required to transform data and quality indicators into actionable information to improve care

Exploring the use of routine healthcare data through process mining to inform the management of musculoskeletal diseases

Healthcare informatics can help address some of the challenges faced by both healthcare providers and patients. The medical domain is characterised by inherently complex and intricate issues, data can often be of poor quality and novel techniques are required. Process mining is a discipline that uses techniques to extract insights from event data, generated during the execution of processes. It has had good results in various branches of medical science but applications to musculoskeletal diseases remain largely unexplored. This research commenced with a review of the healthcare and technical literature and applied a variety of process mining techniques in order to investigate approaches to the healthcare plans of patients with musculoskeletal conditions. The analysis involved three datasets from: 1) a private hospital in Boston, US, where data was used to create disease trajectory models. Results suggest the method may be of interest to healthcare researchers, as it enables a more rapid modelling and visualisation; 2) a mobile healthcare application for patients receiving physiotherapy in Sheffield, UK, where data was used to identify possible indicators for health outcomes. After evaluation of the results, it was found that the indicators identified may be down to chance; and 3) the population of Wales to explore knee pain surgery pathways. Results suggest that process mining is an effective technique. This work demonstrates how routine healthcare data can be analysed using process mining techniques to provide insights that may benefit patients suffering with musculoskeletal conditions. This thesis explores how strict criteria for analysis can be performed. The work is intended to expand the breadth of process mining methods available to the data science community and has contributed by making recommendations for service utilisation within physiotherapy at Sheffield Hospital and helped to define a roadmap for a leading healthcare software company

Healthcare Access

Adequate healthcare access not only requires the availability of comprehensive healthcare facilities but also affordability and knowledge of the availability of these services. As an extended responsibility, healthcare providers can create mechanisms to facilitate subjective decision-making in accessing the right kind of healthcare services as well various options to support financial needs to bear healthcare-related expenses while seeking health and fulfilling the healthcare needs of the population. This volume brings together experiences and opinions from global leaders to develop affordable, sustainable, and uniformly available options to access healthcare services