Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

BACKGROUND: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. METHODS: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. FINDINGS: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96-1·28). INTERPRETATION: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. FUNDING: National Institute for Health Research Health Services and Delivery Research Programme

Effectiveness of a national quality improvement programme to improve survival after emergency abdominal surgery (EPOCH): a stepped-wedge cluster-randomised trial

Background: Emergency abdominal surgery is associated with poor patient outcomes. We studied the effectiveness of a national quality improvement (QI) programme to implement a care pathway to improve survival for these patients. Methods: We did a stepped-wedge cluster-randomised trial of patients aged 40 years or older undergoing emergency open major abdominal surgery. Eligible UK National Health Service (NHS) hospitals (those that had an emergency general surgical service, a substantial volume of emergency abdominal surgery cases, and contributed data to the National Emergency Laparotomy Audit) were organised into 15 geographical clusters and commenced the QI programme in a random order, based on a computer-generated random sequence, over an 85-week period with one geographical cluster commencing the intervention every 5 weeks from the second to the 16th time period. Patients were masked to the study group, but it was not possible to mask hospital staff or investigators. The primary outcome measure was mortality within 90 days of surgery. Analyses were done on an intention-to-treat basis. This study is registered with the ISRCTN registry, number ISRCTN80682973. Findings: Treatment took place between March 3, 2014, and Oct 19, 2015. 22 754 patients were assessed for elegibility. Of 15 873 eligible patients from 93 NHS hospitals, primary outcome data were analysed for 8482 patients in the usual care group and 7374 in the QI group. Eight patients in the usual care group and nine patients in the QI group were not included in the analysis because of missing primary outcome data. The primary outcome of 90-day mortality occurred in 1210 (16%) patients in the QI group compared with 1393 (16%) patients in the usual care group (HR 1·11, 0·96–1·28). Interpretation: No survival benefit was observed from this QI programme to implement a care pathway for patients undergoing emergency abdominal surgery. Future QI programmes should ensure that teams have both the time and resources needed to improve patient care. Funding: National Institute for Health Research Health Services and Delivery Research Programme

Reconstituting community: Social justice, social order and the politics of community

18 page(s

Lacan's gap: sexual identity and the problem of "connectedness"

Feminists have been attracted to Lacan's linguistic reading of Freud because it seems to offer a theory of subjectivity and sexual identity which has no anatomical limitations. This paper draws out the problematic nature of this project, arguing that the attempt to circumvent the necessity for paternal authority, or the imposition of "the law of the father", is doomed to fail because no alternative social bonds can be gleaned from his work. This is because Lacan does not go far enough in his linguistic re-interpretation of Freud. He does not, and cannot, take his linguistic reading into the pre-oedipal stage itself, where alternative forms of sociality might be found, because he remains contained within an individualistic model of psychic development. A communicative, interactive framework is required, capable of locating the agency of the (m)other and the significance of her potentially critical and reflective efforts to "read" the cries of the child

The politics of women's time

This article draws on phenomenological perspectives of time to develop a temporal perspective on mothering. It argues that feminist politics, whether organised around women's "sameness" or "difference" to men, has tended to re-inforce dominant conceptions of time as an already formulated category that can be divided up into natural or social components. This way of conceiving tune obscures the need for time to be constituted as a socially meaningful category through maternal subjectivity. The phenomenological perspective developed highlights the reflexive nature of this process of engendering time, focusing on the way in which the child's developing sense of self in relation to others is shaped by a process of mutual recognition made possible by maternal reflexivity. It then considers the possible consequences of transforming the temporal structures of the workplace to gain greater "workplace flexibility," on these temporal processes of mothering, and the implications for feminist politics

Clustering noisy data in a reduced dimension space via multivariate regression trees

Cluster analysis is sensitive to noise variables intrinsically contained within high dimensional data sets. As the size of data sets increases, clustering techniques robust to noise variables must be identified. This investigation gauges the capabilities of recent clustering algorithms applied to two real data sets increasingly perturbed by superfluous noise variables. The recent techniques include mixture models of factor analysers and auto-associative multivariate regression trees. Statistical techniques are integrated to create two approaches useful for clustering noisy data: multivariate regression trees with principal component scores and multivariate regression trees with factor scores. The tree techniques generate the superior clustering results

Choices and life chances : feminism and the politics of generational change

The perception that young women are disengaged from feminist politics has provoked a great deal of tension between feminist generations. Recent feminist research into generational change has largely avoided this tension by focusing on the shifting meanings of feminism and the discrepancy between young women's reluctance to identify as "feminists" and their general acceptance of feminist attitudes toward gender issues. Nevertheless, in an era when gender equity goals seem to be if not slipping backwards then lacking urgency, young women are less likely to identify with a collective feminist politics than are older women. Underpinned by the findings of a major study of the attitudes toward work, family, and retirement of three generations of Australian women, this paper develops an approach that helps explain this reluctance. Drawing on the work of Karl Mannheim, the paper suggests that the cultural currents shaping the consciousness of different generations of women impact significantly on gender identity. The implications of this cultural shift are considered in the context of feminist politics and the contemporary "culture wars.

Transforming retirement: re-thinking models of retirement to accommodate the experiences of women

Like other governments in the Western world, the Australian government is re-thinking its retirement policy in response to the ageing of the population. A ‘transitional’ model is being encouraged, which has the aim of extending the working life into the retirement period. This article unpacks the meaning of a transitional phase to women in different family and work situations. Drawing on a larger, Australian Research Council funded project, examining the shift in attitudes towards work and retirement in three generations of Australian women, three different models of retirement are developed which enable women's diverse pathways into retirement to be identified and compared, and policy options considered for enhancing women's transition to retirement. The models also highlight the different effects of workplace flexibility on different groups of women, exposing the economic vulnerability of single mothers

Couples' experiences of postnatal depression: a framing analysis of cultural identity, gender and communication

Difficulties in communication have been associated with fathers’ perceived lack of support for mothers suffering postnatal depression (PND). This paper investigates why the communication of the experience of PND is so difficult and considers how these difficulties might be linked, in part, to the diagnostic process. The study explores, through in-depth interviews, how six Australian couples talked about the new mothers’ experience of mild to moderate PND. Framing analysis revealed discrepancies in the couples’ explanations of the mothers’ PND. The application of the concept of ‘framing’ has come to the study of mental health by way of Goffman's work on how experience becomes organised. Goffman used the technique of ‘frame analysis’ to identify and describe the taken-for-granted sociocultural elements that give meaning to a situation. This study identified that mothers and fathers used different frames, with mothers understanding their postnatal experience primarily from within an ‘identity’ frame and fathers understanding the mothers’ experience primarily through a ‘psychological’ or ‘physical hardship’ frame. Implications for health service providers are considered

Auto-associative multivariate regression trees for cluster analysis

Multivariate Regression Trees, an intuitive and simple regression technique, intrinsically produce homogenous subsets of data. These characteristics imply that Multivariate Regression Trees have the potential to be utilised as an easily interpretable clustering method. The suitability of Multivariate Regression Trees as a clustering technique is investigated with two real datasets containing only explanatory variables. The preliminary results show that Multivariate Regression Trees as a clustering algorithm produce clusters of similar quality to the well-known K-means technique, and more recent approaches to Cluster Analysis including Mixture Models of Factor Analysers and Plaid Models. The study also evaluates the suitability of various criteria used to describe cluster solutions