Limitations of Internet searching for understanding the commissioning and delivery of health services: findings from a systematic review of diagnostic ultrasound services

Background Diagnostic ultrasound services are commonly provided by direct access to hospital-based facilities for GPs. Services may also be delivered in primary care or community settings, for example by appropriately trained GPs or mobile services. As part of a larger project, we used an Internet and grey literature search to identify current providers and models of service in the UK NHS (primarily England). Methods Internet searches were performed using the Google search engine. We also searched OpenGrey (European grey literature database) and the website of the National Institute for Health Research (NIHR) Diagnostic Evidence Co-Operative (DEC) Oxford, which specialises in diagnostic tests suitable for use in primary care. The first 100 results from Google searches were examined. Websites of companies providing diagnostic ultrasound services in NHS community settings and of ‘NHS community diagnostic centres’ (providing diagnostic ultrasound alongside other tests) were searched for evaluations or fuller descriptions of the services and any information on governance, accreditation and similar issues. Results We identified details of 22 companies providing diagnostic ultrasound services, one of which appeared to be an exclusively private service. Details available on the company websites were highly variable. Commonly reported features included time standards for appointments and report delivery and patient satisfaction ratings. Links to the NHS were emphasised by most of the companies. It appeared that many staff worked part-time for the companies and the remainder of the time for NHS organisations. Services were generally commissioned through the ‘any qualified provider’ (AQP) system. All the services appeared to follow the model of a mobile service operating through GP surgeries and other community sites. Services were staffed by radiographers (and healthcare assistants) with access to consultant radiologists as required. We also identified websites for four ‘community diagnostic centres’ and five ‘primary care centres’ (diagnostic services integrated with GP surgeries). We did not identify any listings of what types of services are being commissioned and by whom or any reports of evaluations of services. Conclusion Community-based services run by non-NHS providers with links to the NHS for governance and quality control are common. However, our findings should be regarded as a snapshot rather than a comprehensive list. At present it appears difficult to compile information about service delivery and evaluation from Internet sources. There is an urgent need for more comprehensive information to support commissioning decisions and inform the public

What evidence is there for the identification and management of frail older people in the emergency department? A systematic mapping review

Abstract Background Emergency departments (EDs) are facing unprecedented levels of demand. One of the causes of this increased demand is the ageing population. Older people represent a particular challenge to the ED as those older people who are frail will require management that considers their frailty alongside their presenting complaint. How to identify these older people as frail and how best to manage them in the ED is a major challenge for the health service to address. Objectives To systematically map interventions to identify frail and high-risk older people in the ED and interventions to manage older people in the ED and to map the outcomes of these interventions and examine whether or not there is any evidence of the impact of these interventions on patient and health service outcomes. Design A systematic mapping review. Setting Evidence from developed countries on interventions delivered in the ED. Participants Frail and high-risk older people and general populations of older people (aged > 65 years). Interventions Interventions to identify older people who are frail or who are at high risk of adverse outcomes and to manage (frail) older people within the ED. Main outcome measures Patient outcomes (direct and indirect) and health service outcomes. Data sources Evidence from 103 peer-reviewed articles and conference abstracts and 17 systematic reviews published from 2005 to 2016. Review methods A review protocol was drawn up and a systematic database search was undertaken for the years 2005–2016 (using MEDLINE, EMBASE, The Cochrane Library, Web of Science, Cumulative Index to Nursing and Allied Health Literature, Health Management Information Consortium and PROSPERO). Studies were included according to predefined criteria. Following data extraction, evidence was classified into interventions relating to the identification of frail/high-risk older people in the ED and interventions relating to their management. A narrative synthesis of interventions/outcomes relating to these categories was undertaken. A quality assessment of individual studies was not undertaken; instead, an assessment of the overall evidence base in this area was made. Results Of the 90 included studies, 32 focused on a frail/high-risk population and 60 focused on an older population. These studies reported on interventions to identify (n = 57) and manage (n = 53) older people. The interventions to identify frail and at-risk older people, on admission and at discharge, utilised a number of different tools. There was extensive evidence on these question-based tools, but the evidence was inconclusive and contradictory. Service delivery innovations comprised changes to staffing, infrastructure and care delivery. There was a general trend towards improved outcomes in admissions avoidance, reduced ED reattendance and improved discharge outcomes. Limitations This review was a systematic mapping review. Some of the methods adopted differed from those used in a standard systematic review. Mapping the evidence base has led to the inclusion of a wide variety of evidence (in terms of study type and reporting quality). No recommendations on the effectiveness of specific interventions have been made as this was outside the scope of the review. Conclusions A substantial body of evidence on interventions for frail and high-risk older people was identified and mapped. Future work Future work in this area needs to determine why interventions work and whether or not they are feasible for the NHS and acceptable to patients. Study registration This study is registered as PROSPERO CRD42016043260. Funding The National Institute for Health Research Health Services and Delivery Research programme

The lack of variability of the iron line in MCG-6-30-15: general relativistic effects

The spectrum and variability of the Seyfert galaxy MCG-6-30-15 can be decomposed into two apparently disconnected components: a highly variable power law and an almost constant component which contains a broad and strong iron line. We explore a possible explanation of the puzzling lack of variability of the iron line, by assuming that the variations of the power law component are due to changes in the height of the primary source in the near vicinity of a rotating black hole. Due to the bending of light in the strong field of the central black hole, the apparent brightness of the power-law component can vary by about a factor 4 according to its position, while the total iron line flux variability is less than 20 percent. This behaviour is obtained if the primary source is located within 3-4 gravitational radii ($r_{\rm g}$) from the rotation axis with a variable height of between $\sim$ 3 and 8 $r_{\rm g}$. These results revive the possibility that future X-ray observations of MCG-6-30-15 can map out the strong gravity regime of accreting black holes.Comment: accepted for publication in MNRAS Letter

Understanding new models of integrated care in developed countries: a systematic review

Background The NHS has been challenged to adopt new integrated models of service delivery that are tailored to local populations. Evidence from the international literature is needed to support the development and implementation of these new models of care. Objectives The study aimed to carry out a systematic review of international evidence to enhance understanding of the mechanisms whereby new models of service delivery have an impact on health-care outcomes. Design The study combined rigorous and systematic methods for identification of literature, together with innovative methods for synthesis and presentation of findings. Setting Any setting. Participants Patients receiving a health-care service and/or staff delivering services. Interventions Changes to service delivery that increase integration and co-ordination of health and health-related services. Main outcome measures Outcomes related to the delivery of services, including the views and perceptions of patients/service users and staff. Study design Empirical work of a quantitative or qualitative design. Data sources We searched electronic databases (between October 2016 and March 2017) for research published from 2006 onwards in databases including MEDLINE, EMBASE, PsycINFO, Cumulative Index to Nursing and Allied Health Literature, Science Citation Index, Social Science Citation Index and The Cochrane Library. We also searched relevant websites, screened reference lists and citation searched on a previous review. Review methods The identified evidence was synthesised in three ways. First, data from included studies were used to develop an evidence-based logic model, and a narrative summary reports the elements of the pathway. Second, we examined the strength of evidence underpinning reported outcomes and impacts using a comparative four-item rating system. Third, we developed an applicability framework to further scrutinise and characterise the evidence. Results We included 267 studies in the review. The findings detail the complex pathway from new models to impacts, with evidence regarding elements of new models of integrated care, targets for change, process change, influencing factors, service-level outcomes and system-wide impacts. A number of positive outcomes were reported in the literature, with stronger evidence of perceived increased patient satisfaction and improved quality of care and access to care. There was stronger UK-only evidence of reduced outpatient appointments and waiting times. Evidence was inconsistent regarding other outcomes and system-wide impacts such as levels of activity and costs. There was an indication that new models have particular potential with patients who have complex needs. Limitations Defining new models of integrated care is challenging, and there is the potential that our study excluded potentially relevant literature. The review was extensive, with diverse study populations and interventions that precluded the statistical summary of effectiveness. Conclusions There is stronger evidence that new models of integrated care may enhance patient satisfaction and perceived quality and increase access; however, the evidence regarding other outcomes is unclear. The study recommends factors to be considered during the implementation of new models. Future work Links between elements of new models and outcomes require further study, together with research in a wider variety of populations. Study registration This study is registered as PROSPERO CRD37725. Funding The National Institute for Health Research Health Services and Delivery Research programme

The Sun's position in the sky

We express the position of the Sun in the sky as a function of time and the observer's geographic coordinates. Our method is based on applying rotation matrices to vectors describing points on the celestial sphere. We also derive direct expressions, as functions of date of the year and geographic latitude, for the duration of daylight, the maximum and minimum altitudes of the Sun, and the cardinal directions to sunrise and sunset. We discuss how to account for the eccentricity of the earth's orbit, the precessions of the equinoxes and the perihelion, the size of the solar disk, and atmospheric refraction. We illustrate these results by computing the dates of "Manhattanhenge" (when sunset aligns with the east-west streets on the main traffic grid for Manhattan, in New York City), by plotting the altitude of the Sun over representative cities as a function of time, and by showing plots ("analemmas") for the position of the Sun in the sky at a given hour of the day.Comment: 19 pages, 16 figures. v3: Replaced to match published version and to re-package Mathematica notebook as an ancillary fil

Towards greater understanding of implementation during systematic reviews of complex healthcare interventions: the framework for implementation transferability applicability reporting (FITAR)

Background: There have been calls for greater consideration of applicability and transferability in systematic reviews, to improve their usefulness in informing policy and practice. Understanding how evidence is, or is not applicable and transferable to varying local situations and contexts, is a key challenge for systematic review synthesis in healthcare. Assessing applicability and transferability in systematic reviews is reported to be difficult, particularly in reviews of complex interventions. There is a need for exploration of factors perceived to be important by policy-makers, and for further guidance on which items should be reported. In this paper we focus on the process of development of a framework that can be used by systematic reviewers to identify and report data across studies relating to applicability and transferability. Methods: The framework was developed by scrutinising existing literature on applicability and transferability, examining data during a systematic review of highly complex changes to health service delivery, and was informed by stakeholder engagement. The items of the framework were thus grounded in both data identified during a real review, and stakeholder input. The paper describes examples of data identified using the framework during a review of integrated care interventions, and outlines how it informed analysis and reporting of the review findings. Results: The Framework for Implementation Transferability Applicability Reporting (FITAR) comprises 44 items which can be used to structure analysis and reporting across studies during systematic reviews of complex interventions. The framework prompts detailed consideration of contextual data during extraction and reporting, within areas of: patient type and populations; type of organisations and systems; financial and commissioning processes; systems leadership elements; features of services; features of the workforce; and finally elements of the interventions/initiatives. Conclusions: Use of the framework during our review of complex healthcare interventions helped the review team to surface contextual data, which may not be commonly extracted, analysed and reported. Further exploration and evaluation of systems for identifying and reporting these factors during reviews is required

Blood glucose self-monitoring in type 2 diabetes: a randomised controlled trial

OBJECTIVES: To determine whether self-monitoring of blood glucose (SMBG), either alone or with additional instruction in incorporating the results into self-care, is more effective than usual care in improving glycaemic control in non-insulin-treated diabetes. DESIGN: An open, parallel group randomised controlled trial. SETTING: 24 general practices in Oxfordshire and 24 in South Yorkshire, UK. PARTICIPANTS: Patients with non-insulin-treated type 2 diabetes, aged > or = 25 years and with glycosylated haemoglobin (HbA1c) > or = 6.2%. INTERVENTIONS: A total of 453 patients were individually randomised to one of: (1) standardised usual care with 3-monthly HbA1c (control, n = 152); (2) blood glucose self-testing with patient training focused on clinician interpretation of results in addition to usual care (less intensive self-monitoring, n = 150); (3) SMBG with additional training of patients in interpretation and application of the results to enhance motivation and maintain adherence to a healthy lifestyle (more intensive self-monitoring, n = 151). MAIN OUTCOME MEASURES: The primary outcome was HBA1c at 12 months, and an intention-to-treat analysis, including all patients, was undertaken. Blood pressure, lipids, episodes of hypoglycaemia and quality of life, measured with the EuroQol 5 dimensions (EQ-5D), were secondary measures. An economic analysis was also carried out, and questionnaires were used to measure well-being, beliefs about use of SMBG and self-reports of medication taking, dietary and physical activities, and health-care resource use. RESULTS: The differences in 12-month HbA1c between the three groups (adjusted for baseline HbA1c) were not statistically significant (p = 0.12). The difference in unadjusted mean change in HbA1c from baseline to 12 months between the control and less intensive self-monitoring groups was -0.14% [95% confidence interval (CI) -0.35 to 0.07] and between the control and more intensive self-monitoring groups was -0.17% (95% CI -0.37 to 0.03). There was no evidence of a significantly different impact of self-monitoring on glycaemic control when comparing subgroups of patients defined by duration of diabetes, therapy, diabetes-related complications and EQ-5D score. The economic analysis suggested that SMBG resulted in extra health-care costs and was unlikely to be cost-effective if used routinely. There appeared to be an initial negative impact of SMBG on quality of life measured on the EQ-5D, and the potential additional lifetime gains in quality-adjusted life-years, resulting from the lower levels of risk factors achieved at the end of trial follow-up, were outweighed by these initial impacts for both SMBG groups compared with control. Some patients felt that SMBG was helpful, and there was evidence that those using more intensive self-monitoring perceived diabetes as having more serious consequences. Patients using SMBG were often not clear about the relationship between their behaviour and the test results. CONCLUSIONS: While the data do not exclude the possibility of a clinically important benefit for specific subgroups of patients in initiating good glycaemic control, SMBG by non-insulin-treated patients, with or without instruction in incorporating findings into self-care, did not lead to a significant improvement in glycaemic control compared with usual care monitored by HbA1c levels. There was no convincing evidence to support a recommendation for routine self-monitoring of all patients and no evidence of improved glycaemic control in predefined subgroups of patients

The role of informal carers in the diagnostic process of heart failure:a secondary qualitative analysis

Abstract Background Heart failure (HF) is a common clinical syndrome, particularly in older people, and symptoms can develop gradually. The aim of this study was to explore the role of informal carers in the HF diagnostic process. Methods Secondary analysis of qualitative interviews with 16 participants with a new diagnosis of HF. Original interviews were conducted in the participant’s home, with carers present in some cases. Interview transcripts were re-analysed using the Framework Method for themes pertaining to informal carers and how they were involved in the diagnostic process. Results Informal carers often noticed symptoms, such as breathlessness, before participants. In some cases, carers colluded with participants in normalising symptoms but over time, when symptoms failed to resolve or got worse, they encouraged participants to seek medical help. Adult children of participants commonly initiated help-seeking behaviour. During the diagnostic process, carers coordinated participants’ healthcare through advocacy and organisation. Carers were keen to be informed about the diagnosis, but both participants and carers struggled to understand some aspects of the term ‘heart failure’. Conclusions Carers play a crucial role in HF diagnosis, particularly in initiating contact with healthcare services, and should be empowered to encourage people with HF symptoms to seek medical help. Improving public awareness of HF could mean informal carers are more likely to notice symptoms. The important role of carers in supporting the patient’s route to diagnosis should be incorporated into future care pathways and explored in further research