Using patient-reported measures to drive change in healthcare: the experience of the digital, continuous and systematic PREMs observatory in Italy

BACKGROUND: The use of Patient Reported Experience Measures (PREMs) has great potential in healthcare service improvement, but a limited use. This paper presents an empirical case of PREMs innovation in Italy, to foster patient data use up to the ward level, by keeping strengths and addressing weaknesses of previous PREMs survey experiences. The paper reports key lessons learned in this ongoing experience of action research, directly involving practitioners. METHODS: The aim of this paper is to present the results of an ongoing action research, encompassing the innovation of PREMs collection, reporting and use, currently adopted by 21 hospitals of two Italian regions. The continuous and systematic PREMs collection has been implemented between 2017 and 2019 and includes: a continuous web-based administration, using web-services; an augmented and positive questionnaire matching standard closed-ended questions with narrative sections; the inclusion and benchmarking of patient data within a shared performance evaluation system; public disclosure of aggregated anonymized data; a multi-level and real-time web-platform for reporting PREMs to professionals. The action research was carried out with practitioners in a real-life and complex context. The authors used multiple data sources and methods: observations, feedback of practitioners, collected during several workshops and meetings, and analysis of preliminary data on the survey implementation. RESULTS: A continuous and systematic PREMs observatory was developed and adopted in two Italian regions. PREMs participation and response rates tend to increase over time, reaching stable percentages after the first months. Narrative feedback provide a 'positive narration' of episodes and behaviours that made the difference to patients and can inform quality improvement actions. Real-time reporting of quantitative and qualitative data is enabling a gratifying process of service improvement and people management at all the hospitals' levels. CONCLUSIONS: The PREMs presented in this paper has been recognized by healthcare professionals and managers as a strategic and positive tool for improving an actual use of PREMs at system and ward levels, by measuring and highlighting positive deviances, such as compassionate behaviours

A design ideation method for novice designers

Design ideation is a core stage in the design process that begins with a design brief and results in a range of design concepts from which solutions can be selected. The success of design ideation relies upon designers’ creativity and ingenuity. In current practice, design ideation tends to be an ad hoc process which combines the designer’s experience with techniques such as sketching, brainstorming, and mock-up to develop creative solutions in response to the brief. There are notable differences in ideation performance between novice and expert designers in that experts tend to follow a more systematic process, and have more experience and knowledge of previous designs to draw on. Design ideation is more challenging for novice designers who have limited experience on which to draw and no systematic process to follow. This thesis provides a method that enhances the design ideation performance of novice designers by providing a systematic design ideation process for them to follow, and a database and associated visualisation method that gives them access to previous designs. The method was assessed through empirical evaluation experiments conducted with 101 students in the UK and South Korea. This confirmed that the method improves novice designers’ generation of creative solution concepts in response to a design brief. The research makes four contributions. The method, Knowledge-Enabled Design Ideation Method (KEDIM), provides a systematic design ideation process that includes three steps. The first step draws on a Database of Design Cases (DOS) that is supported by a database schema. DOS is a part of the research contribution that provides a structure to capture case data. DOS was validated through population with 540 design cases, and through use in the second stage of KEDIM, Perceptual Mapping Generation Software (PMGS). The core contribution of PMGS is its visualisation method that brings together selected design cases from the database and presents them in a way that enhances novice designers’ abilities to draw analogies. The final contribution is Systematic Brainstorming (SBI), where these analogies are developed through a set of specific ideation themes alongside solution concepts. KEDIM, through these three tools, improves the effectiveness of novice designers ideation by increasing the number of solution concepts generated when compared with students not using KEDIM responding to the same brief

The STRESS Method for Boundary-point Performance Analysis of End-to-end Multicast Timer-Suppression Mechanisms

Evaluation of Internet protocols usually uses random scenarios or scenarios based on designers' intuition. Such approach may be useful for average-case analysis but does not cover boundary-point (worst or best-case) scenarios. To synthesize boundary-point scenarios a more systematic approach is needed.In this paper, we present a method for automatic synthesis of worst and best case scenarios for protocol boundary-point evaluation. Our method uses a fault-oriented test generation (FOTG) algorithm for searching the protocol and system state space to synthesize these scenarios. The algorithm is based on a global finite state machine (FSM) model. We extend the algorithm with timing semantics to handle end-to-end delays and address performance criteria. We introduce the notion of a virtual LAN to represent delays of the underlying multicast distribution tree. The algorithms used in our method utilize implicit backward search using branch and bound techniques and start from given target events. This aims to reduce the search complexity drastically. As a case study, we use our method to evaluate variants of the timer suppression mechanism, used in various multicast protocols, with respect to two performance criteria: overhead of response messages and response time. Simulation results for reliable multicast protocols show that our method provides a scalable way for synthesizing worst-case scenarios automatically. Results obtained using stress scenarios differ dramatically from those obtained through average-case analyses. We hope for our method to serve as a model for applying systematic scenario generation to other multicast protocols.Comment: 24 pages, 10 figures, IEEE/ACM Transactions on Networking (ToN) [To appear

Eltrombopag for the treatment of chronic idiopathic (immune) thrombocytopenic purpura : A Single Technology Appraisal

Evidence Review Group (ERG) final report for the National Institute for Health and Clinical ExcellencePublisher PD

Options for basing Dietary Reference Intakes (DRIs) on chronic disease endpoints: report from a joint US-/Canadian-sponsored working group.

Dietary Reference Intakes (DRIs) are used in Canada and the United States in planning and assessing diets of apparently healthy individuals and population groups. The approaches used to establish DRIs on the basis of classical nutrient deficiencies and/or toxicities have worked well. However, it has proved to be more challenging to base DRI values on chronic disease endpoints; deviations from the traditional framework were often required, and in some cases, DRI values were not established for intakes that affected chronic disease outcomes despite evidence that supported a relation. The increasing proportions of elderly citizens, the growing prevalence of chronic diseases, and the persistently high prevalence of overweight and obesity, which predispose to chronic disease, highlight the importance of understanding the impact of nutrition on chronic disease prevention and control. A multidisciplinary working group sponsored by the Canadian and US government DRI steering committees met from November 2014 to April 2016 to identify options for addressing key scientific challenges encountered in the use of chronic disease endpoints to establish reference values. The working group focused on 3 key questions: 1) What are the important evidentiary challenges for selecting and using chronic disease endpoints in future DRI reviews, 2) what intake-response models can future DRI committees consider when using chronic disease endpoints, and 3) what are the arguments for and against continuing to include chronic disease endpoints in future DRI reviews? This report outlines the range of options identified by the working group for answering these key questions, as well as the strengths and weaknesses of each option

Characterizing Service Level Objectives for Cloud Services: Motivation of Short-Term Cache Allocation Performance Modeling

Service level objectives (SLOs) stipulate performance goals for cloud applications, microservices, and infrastructure. SLOs are widely used, in part, because system managers can tailor goals to their products, companies, and workloads. Systems research intended to support strong SLOs should target realistic performance goals used by system managers in the field. Evaluations conducted with uncommon SLO goals may not translate to real systems. Some textbooks discuss the structure of SLOs but (1) they only sketch SLO goals and (2) they use outdated examples. We mined real SLOs published on the web, extracted their goals and characterized them. Many web documents discuss SLOs loosely but few provide details and reflect real settings. Systematic literature review (SLR) prunes results and reduces bias by (1) modeling expected SLO structure and (2) detecting and removing outliers. We collected 75 SLOs where response time, query percentile and reporting period were specified. We used these SLOs to confirm and refute common perceptions. For example, we found few SLOs with response time guarantees below 10 ms for 90% or more queries. This reality bolsters perceptions that single digit SLOs face fundamental research challenges.This work was funded by NSF Grants 1749501 and 1350941.No embargoAcademic Major: Computer Science and EngineeringAcademic Major: Financ

Transport Coefficients from Large Deviation Functions

We describe a method for computing transport coefficients from the direct evaluation of large deviation function. This method is general, relying on only equilibrium fluctuations, and is statistically efficient, employing trajectory based importance sampling. Equilibrium fluctuations of molecular currents are characterized by their large deviation functions, which is a scaled cumulant generating function analogous to the free energy. A diffusion Monte Carlo algorithm is used to evaluate the large deviation functions, from which arbitrary transport coefficients are derivable. We find significant statistical improvement over traditional Green-Kubo based calculations. The systematic and statistical errors of this method are analyzed in the context of specific transport coefficient calculations, including the shear viscosity, interfacial friction coefficient, and thermal conductivity.Comment: 11 pages, 5 figure

Evaluation of the NHS R & D implementation methods programme

Chapter 1: Background and introduction • Concern with research implementation was a major factor behind the creation of the NHS R&D Programme in 1991. In 1994 an Advisory Group was established to identify research priorities in this field. The Implementation Methods Programme (IMP) flowed from this and its Commissioning Group funded 36 projects. Funding for the IMP was capped before the second round of commissioning. The Commissioning Group was disbanded and eventually responsibility for the programme passed to the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO) which, when most projects had finished, asked the Health Economics Research Group (HERG) to conduct an evaluation. This was intended to cover: the quality of outputs; lessons to be learnt about the communication strategy and the commissioning process; and the benefits or payback from the projects. As agreed, the evaluation also addresses the questions of whether there should be a synthesis of the findings from the IMP and any further assessment of payback. Chapter 2: Methods • We adopted a wide range of quantitative and qualitative methods in the evaluation. They included: documentary analysis; interviews with key actors; questionnaires to the funded lead researchers; questionnaires to potential users; and desk analysis. Chapter 3: The outputs from the programme • As in previous assessments of research programmes, we first examined the outputs in terms of knowledge production and various items related to capacity to conduct further research. Although there was a high response rate to the questionnaire to lead researchers (30/36), missing responses mean that the data given below are incomplete. In the case of publications, however, we also made some use of data previously gathered by the programme office. • We attempted to identify publications that were in some way a specific product of IMP funding. About half (59) of the publications from the IMP projects are articles in peer reviewed journals. The journal used most frequently for publication, the BMJ, is also the one with the highest journal impact factor score of those publishing articles specifically from the programme. The recent publication datesof many articles reduces the value of citation analysis. Nevertheless, one article, Coulter et al, 1999, has already been cited on 53 occasions. Important publications, including No Magic Bullets (Oxman et al, 1995), are also associated with preliminary work undertaken for the IMP to assist priority setting. • Fifteen projects, with grants of over £1.3 million, have been awarded to IMP researchers by other funders for follow-on studies connected in some way to the IMP. We also collected details about some non-IMP researchers who are building on the IMP projects. • Research training provided in at least nine of the funded IMP projects is associated with higher/research degrees, including three MDs and four PhDs, that have been awarded or are being completed. Chapter 4: Disseminating and using the research findings • Limited thought had been given by the Implementation Methods Programme to dissemination strategies, but many of the individual researchers were active here. In response to the questionnaires, lead researchers reported making 92 presentations to academic audiences and 104 to practitioner/service groups. Some lead researchers showed that their effective dissemination led to utilisation of the findings. • The Commissioning Group gave some thought to the likely use that could be made of individual research projects, but there was limited systematic analysis of how the findings as a whole would be taken forward. Achieving impact is difficult in this complex field and less than a third of lead researchers claimed to have done so, but about half thought impact could be expected. Based mainly on reports from lead researchers, we give a brief account of how the findings from six projects are being utilised. • We sent electronic questionnaires to groups of potential users of selected projects but this produced a very low response rate. Our postal survey to Heads of Midwifery/researchers in perinatal care produced a higher response of 44%. Amongst those who did respond, there is quite a high level of knowledge about some of the programme’s projects and some level of existing and potential utilisation. We suggest, however, that in some cases there are difficulties in identifying how far the respondent’s focus is on the findings from the original research projects, and it how far it is on the impact of the IMP study that is about ways of influencing the uptake of such findings. Comments from several respondents showed strong support for the cutting edge nature of some of the research. Others, however, also indicated why findings might not be utilised by some practitioners. Several respondents advocated greater dissemination of the IMP. Chapter 5: Comparing applications with outputs • We attempted to compare the scores given to project applications with those given to projects based on their outputs. This exercise faced various problems. The final reports from all completed projects had in theory already been reviewed and given scores for their quality and relevance. In practice, not all final reports received scores. We added a refinement by giving further scores that incorporated the additional information we gathered about both publications and any uptake of the research findings. • Various limitations meant that we conducted this analysis on just 19 of the 36 projects. Nevertheless, the wide range of scores given to the outputs from projects indicates that some were much more successful than others. Our rather limited evidence suggests that there is some correlation between the scores for applications and those for outputs but it is small, which could be related to the difficulties encountered during commissioning. Chapter 6: Lessons learnt about the commissioning process • Those who established the IMP were aware that it was a different type of research field from those previously addressed within the NHS R&D Programme, but one regarded nonetheless as important. Within the NHS R&D Programme at that time a standard clinical RCT approach was strongly favoured. There was also, as ever, a need for quick results. • In developing an understanding of implementation the Advisory Group (AG) conducted cutting edge analysis, consulted widely and drew on a wide range of disciplines. Our interviewees generally took the view that the AG worked well in setting priorities and went as far as it could at the time, especially given the time constraints. • Based on our field work and analysis we identified a series of lessons that might inform future exercises. More attention was required to ensure that all relevant background disciplines were adequately taken into account in setting priorities and commissioning research. Some of these processes needed to be given more time than was available. Consultation needed to be organised in a sufficiently selective way to be of maximum benefit in such a complex area. A time-limited programme was not the most appropriate way to cover a field such as this. • In relation to the commissioning of the projects, we identified issues about the composition of commissioning groups and how people from different backgrounds (researchers, practitioners, managers and patient representatives) should best be involved. • In this new field the Commissioning Group (CG) had to work closely with applicants to develop some of the research applications. This raised issues about how, and when, this process should be handled. • Despite its own rationale, and for a variety of reasons, including the disbanding of the CG, the Implementation Methods Programme never developed an implementation or communication strategy for its own findings. • The general conclusion of those who had been involved with the IMP was that it worked as well as it could at the time, and that various important projects were commissioned. But it was only a start. Chapter 7: Should a synthesis of the findings from the programme and further payback analysis be undertaken? • From interviews and questionnaires we identified widespread, but not total, agreement that there should be some type of synthesis of the findings from the IMP. There is more debate about the form such a synthesis should take. There is some support for a more limited type of stock taking, but also wider backing for the inclusion of many different elements. These could include: a conceptual map of the field of research implementation; an exploration of how the findings from the IMP fit into the context of research implementation today; and an assessment of how far work is still needed in those areas where no projects were funded. One possible suggestion that might incorporate much of this thinking is for the establishment of a group or commission of leading researchers in the field. Their investigation could incorporate all these elements and attempt to show how the issues could be advanced. • We suggest that further work on assessing the payback from the IMP is probably not worthwhile unless it is undertaken as part of a wide-ranging synthesis. Chapter 8: Conclusions, lessons and recommendations • We conclude that the IMP was seen by many of those involved as a new and exciting field. Looking back, they were generally positive about what was started through the IMP. It commissioned a series of projects that produced some important, rigorous, and cutting edge research, at least some of which is making an impact. But this is a complex area in which traditional clinical research, health services research and the social sciences all have a role to play. A unique set of difficulties, as well as opportunities, was faced by those responsible for taking the programme forward. The intellectual challenges of constructing a programme to cover such a vast area with diverse and sometimes conflicting conceptual and methodological perspectives, were compounded by practical problems. These included the capping of the programme’s funding and the premature winding up of the Commissioning Group. As a result, this complex programme, which arguably needed better support than its more clinically orientated predecessors, did not receive it at some stages. Those involved in the programme had a considerable task – the difficulties of which were not completely appreciated at the time. They are clearer in retrospect and feed into the lessons and recommendations presented here, but it is recognised that a programme such as the SDO is already adopting some of the steps. • In relation to research commissioning and communication strategies for research programmes in general, we suggest it could be helpful if protocols were drawn up to cover certain potential difficulties. These include the remit and role of the various stakeholders represented on commissioning groups and the extent to which commissioning groups should be expected to support applicants with their proposals. Perhaps the key general lesson from this evaluation is the need for research programmes to have a proper communication strategy. This should target dissemination at relevant audiences and stress the desirability for contact to be made with potential users as early as possible in the process of devising a project. • Our other recommendations are more specifically relevant when the SDO Programme is considering an area such as implementation methods research. It would be desirable for more time to be made available for preparatory work than was allowed for the IMP and also scope provided for the programme to be able to re-visit issues and learn from early results. It is difficult to incorporate all the analysis that is required if a programme is operating in a time-limited way. • Our conclusion that research implementation is a crucial area for the NHS R&D Programme leads to the recommendation that more R&D activity is needed in this field in order to assist delivery of some key NHS agenda items. As a preliminary step, there is certainly scope for a type of stock taking of the findings from the IMP. On balance there seems also to be an argument for conducting a synthesis of work in the implementation field that goes beyond a mere collation of findings from the specific projects funded. If undertaken, it should fundamentally examine the current NHS needs for research on implementation and how they could be addressed in the light of the findings from the IMP and elsewhere. • Finally, we recommend that more attention should be given to the timing of evaluations such as this and that a phased approach should be adopted. Furthermore, researchers should be informed at the outset of their project about the likely requirements that might be placed upon them in terms of responding to requests for information by those conducting an evaluation.National Co-ordinating Centre for NHS Service Delivery and Organisation R&D (NCCSDO