Randomised trials in the South African Medical Journal, 1948- 1997

Objective. To describe randomised controlled trials (RCTs) published in the South African Medical Journal (SAMJ) over a 50-year period from 1948 to 1997 with regard to number, topic and quality.Methods. We hand searched all issues of the SAMJ published during the study period to identify all published RCTs.Outcome measures. Number, topic and quality of RCTs published from 1948 to 1997.Results. Eight hundred and fifty-eight clinical trials were published during the period reviewed. Eighty-four per cent of RCTs were published as full articles. During the 1980s the number of RCTs published increased rapidly,  with a peak of 35 in 1985, but then declined to only 5 in 1997. The majority (92%) of RCTs were conducted in a hospital setting. A varied range of subjects was covered, with gastroenterology taking the lead and no trials in public health. The sample size in more than 50% of RCTs was smaller than 50 patients. Fifty-one per cent (435 trials) used random allocation and 49% (423) quasi-random methods of allocation. Concealment of treatment allocation was judged to be adequate in 46% of studies (N == 200), blinding of observers assessing outcomes was adequate in 28% (123), and all the allocated test subjects were included in the primary analysis in 28% (123). The follow-up period was more than 1 year in 4% (17) and less than 6 days in 16% (71).Conclusions. Compared with other international journals the SAMJ is highly regarded in terms of the number of trials published. There are, however, a number of deficiencies in the quality of the trials

Educating the future workforce: building the evidence about interprofessional learning

This paper addresses the theme of interprofessional education for health and social care professionals as it effects on the development of the work force. The drivers for change in the UK, typified by the Bristol Royal Infirmary and Victoria Climbié inquiries and the response to this in the form of Department of Health policy, are discussed. The need for rapid development of the evidence base around this subject is evident form literature reviews of the impact of interprofessional education. Directions for future research and investment in this area are proposed including the need for a stronger theoretical base and for longitudinal studies over extended periods of time in order to examine short, medium and long term outcomes in relation to health care practice

Developing, delivering and documenting rehabilitation in a multi-centre randomised controlled surgical trial: experiences from the ProFHER trial

OBJECTIVES: A rigorous approach to developing, delivering and documenting rehabilitation within randomised controlled trials of surgical interventions is required to underpin the generation of reliable and usable evidence. This article describes the key processes used to ensure provision of good quality and comparable rehabilitation to all participants of a multi-centre randomised controlled trial comparing surgery with conservative treatment of proximal humeral fractures in adults. METHODS: These processes included the development of a patient information leaflet on self-care during sling immobilisation, the development of a basic treatment physiotherapy protocol that received input and endorsement by specialist physiotherapists providing patient care, and establishing an expectation for the provision of home exercises. Specially designed forms were also developed to facilitate reliable reporting of the physiotherapy care that patients received. RESULTS: All three initiatives were successfully implemented, alongside the measures to optimise the documentation of physiotherapy. Thus, all participating sites that recruited patients provided the sling immobilisation leaflet, all adhered to the physiotherapy protocol and all provided home exercises. There was exemplary completion of the physiotherapy forms that often reflected a complex patient care pathway. These data demonstrated equal and high access to and implementation of physiotherapy between groups, including the performance of home exercises. CONCLUSION: In order to increase the validity and relevance of the evidence from trials of surgical interventions and meet international reporting standards, careful attention to study design, conduct and reporting of the intrinsic rehabilitation components is required. The involvement of rehabilitation specialists is crucial to achieving this. Cite this article: Bone Joint Res 2014;3:335–40

The benefits of interprofessional education 10 years on.

Interprofessional education (IPE) was first conceived in 1973 by a World Health Organization (WHO) expert group in Geneva. WHO member states were then charged with implementing medical education IPE pilot projects and from then to today there has a been a rapid proliferation in the number of publications on the subject. IPE has generated research into its use, conferences specific to IPE, organisations dedicated to it and policy championing it. The authors question whether there has been any major shift in the silos in which different professions might be working. The authors published an article on the benefits of IPE ( Illingworth and Chelvanayagam, 2007 ). Ten years have now passed and many changes have been implemented and experienced in health and social care and therefore a review of the literature is required. Also, it is 7 years since the publication of WHO's report outlining the role of IPE in the preparation of health professionals ( WHO, 2010 ) and, increasingly, UK Government policy champions collaborative and integrated working. The conclusions from the 2007 article acknowledged the development of IPE; however, it highlighted the need for empirical evidence to demonstrate the effectiveness of IPE in service user and carer outcomes. This article will explore whether IPE has achieved the benefits discussed in the previous article and what developments have occurred since it was published

Development of a minimization instrument for allocation of a hospital-level performance improvement intervention to reduce waiting times in Ontario emergency departments

<p>Abstract</p> <p>Background</p> <p>Rigorous evaluation of an intervention requires that its allocation be unbiased with respect to confounders; this is especially difficult in complex, system-wide healthcare interventions. We developed a short survey instrument to identify factors for a minimization algorithm for the allocation of a hospital-level intervention to reduce emergency department (ED) waiting times in Ontario, Canada.</p> <p>Methods</p> <p>Potential confounders influencing the intervention's success were identified by literature review, and grouped by healthcare setting specific change stages. An international multi-disciplinary (clinical, administrative, decision maker, management) panel evaluated these factors in a two-stage modified-delphi and nominal group process based on four domains: change readiness, evidence base, face validity, and clarity of definition.</p> <p>Results</p> <p>An original set of 33 factors were identified from the literature. The panel reduced the list to 12 in the first round survey. In the second survey, experts scored each factor according to the four domains; summary scores and consensus discussion resulted in the final selection and measurement of four hospital-level factors to be used in the minimization algorithm: improved patient flow as a hospital's leadership priority; physicians' receptiveness to organizational change; efficiency of bed management; and physician incentives supporting the change goal.</p> <p>Conclusion</p> <p>We developed a simple tool designed to gather data from senior hospital administrators on factors likely to affect the success of a hospital patient flow improvement intervention. A minimization algorithm will ensure balanced allocation of the intervention with respect to these factors in study hospitals.</p

Task shifting and integration of HIV care into primary care in South Africa: The development and content of the streamlining tasks and roles to expand treatment and care for HIV (STRETCH) intervention

Background: Task shifting and the integration of human immunodeficiency virus (HIV) care into primary care services have been identified as possible strategies for improving access to antiretroviral treatment (ART). This paper describes the development and content of an intervention involving these two strategies, as part of the Streamlining Tasks and Roles to Expand Treatment and Care for HIV (STRETCH) pragmatic randomised controlled trial. Methods: Developing the intervention: The intervention was developed following discussions with senior management, clinicians, and clinic staff. These discussions revealed that the establishment of separate antiretroviral treatment services for HIV had resulted in problems in accessing care due to the large number of patients at ART clinics. The intervention developed therefore combined the shifting from doctors to nurses of prescriptions of antiretrovirals (ARVs) for uncomplicated patients and the stepwise integration of HIV care into primary care services. Results: Components of the intervention: The intervention consisted of regulatory changes, training, and guidelines to support nurse ART prescription, local management teams, an implementation toolkit, and a flexible, phased introduction. Nurse supervisors were equipped to train intervention clinic nurses in ART prescription using outreach education and an integrated primary care guideline. Management teams were set up and a STRETCH coordinator was appointed to oversee the implementation process. Discussion: Three important processes were used in developing and implementing this intervention: active participation of clinic staff and local and provincial management, educational outreach to train nurses in intervention sites, and an external facilitator to support all stages of the intervention rollout

Theorising interprofessional pedagogic evaluation: framework for evaluating the impact of interprofessional CPD on practice change

This paper outlines the development of a conceptual framework to guide the evaluation of the impact of the pedagogy employed in continuing professional development for professionals in education, health and social care. The work is developed as part of the Centre for Excellence in Teaching and Learning: Interprofessional Learning across the Public Sector (CETL: IPPS) at the University of Southampton. The paper briefly outlines the field for pedagogic research and comments on the underpinning theories that have so far been used to guide research into interprofessional learning (IPL). It maps out the development of interprofessional CPD in its specific context as part of the CETL: IPPS with its links to a local authority undergoing service reorganisation and the role of the continuing professional development (CPD) in effecting change. It then brings together a theoretical framework with the potential toexplore, explain and evaluate the essential features of the model of pedagogy used in interprofessional CPD, in which professionals from education have for the first time been included alongside those from health and social care. The framework draws upon elements of situated learning theory, Activity Theory and Dreier’s work (2002, 1999) on trajectories of participation, particularly Personal Action Potency. By combining the resulting analytic framework with an adapted version of an established evaluation model, a theoretically-driven, practicable evaluation matrix is developed. The matrix has potential use in evaluating the impact of pedagogic input on practice change. The paper models a process for developing a conceptual framework to steer pedagogic evaluation. Such a process and the resulting matrix may be of use to other researchers who are similarly developing pedagogic evaluation

Evaluation of an emergency department lean process improvement program to reduce length of stay

Study objective In recent years, lean principles have been applied to improve wait times in the emergency department (ED). In 2009, an ED process improvement program based on lean methods was introduced in Ontario as part of a broad strategy to reduce ED length of stay and improve patient flow. This study seeks to determine the effect of this program on ED wait times and quality of care. Methods We conducted a retrospective cohort study of all ED visits at program and control sites during 3 program waves from April 1, 2007, to June 30, 2011, in Ontario, Canada. Time series analyses of outcomes before and after the program and difference-in-differences analyses comparing changes in program sites with control sites were conducted. Results In before-after models among program sites alone, 90th percentile ED length of stay did not change in wave 1 (–14 minutes [95% confidence interval {CI} –47 to 20]) but decreased after wave 2 (–87 [95% CI –108 to –66]) and wave 3 (–33 [95% CI –50 to –17]); median ED length of stay decreased after wave 1 (–18 [95% CI –24 to –12]), wave 2 (–23 [95% CI –27 to –19]), and wave 3 (–15 [95% CI –18 to –12]). In all waves, decreases were observed in time to physician assessment, left-without-being-seen rates, and 72-hour ED revisit rates. In the difference-in-difference models, in which changes in program sites were compared with controls, the program was associated with no change in 90th percentile ED length of stay in wave 2 (17 [95% CI –0.2 to 33]) and increases in wave 1 (23 [95% CI 0.9 to 45]) and wave 3 (31 [95% CI 10 to 51]), modest reductions in median ED length of stay in waves 2 and 3 alone, and a decrease in time to physician assessment in wave 3 alone. Conclusion Although the program reduced ED waiting times, it appeared that its benefits were diminished or disappeared when compared with that of control sites, which were exposed to system-wide initiatives such as public reporting and pay for performance. This study suggests that further evaluation of the effectiveness of lean methods in the ED is warranted before widespread implementation