Evidence based policy making and the 'art' of commissioning - How English healthcare commissioners access and use information and academic research in 'real life' decision-making: An empirical qualitative study

© 2015 Wye et al. Background: Policymakers such as English healthcare commissioners are encouraged to adopt 'evidence-based policy-making', with 'evidence' defined by researchers as academic research. To learn how academic research can influence policy, researchers need to know more about commissioning, commissioners' information seeking behaviour and the role of research in their decisions. Methods: In case studies of four commissioning organisations, we interviewed 52 people including clinical and managerial commissioners, observed 14 commissioning meetings and collected documentation e.g. meeting minutes and reports. Using constant comparison, data were coded, summarised and analysed to facilitate cross case comparison. Results: The 'art of commissioning' entails juggling competing agendas, priorities, power relationships, demands and personal inclinations to build a persuasive, compelling case. Policymakers sought information to identify options, navigate ways through, justify decisions and convince others to approve and/or follow the suggested course. 'Evidence-based policy-making' usually meant pragmatic selection of 'evidence' such as best practice guidance, clinicians' and users' views of services and innovations from elsewhere. Inconclusive or negative research was unhelpful in developing policymaking plans and did not inform disinvestment decisions. Information was exchanged through conversations and stories, which were fast, flexible and suited the rapidly changing world of policymaking. Local data often trumped national or research-based evidence. Local evaluations were more useful than academic research. Discussion: Commissioners are highly pragmatic and will only use information that helps them create a compelling case for action. Therefore, researchers need to start producing more useful information. Conclusions: To influence policymakers' decisions, researchers need to 1) learn more about local policymakers' priorities 2) develop relationships of mutual benefit 3) use verbal instead of writtencommunication 4) work with intermediaries such as public health consultants and 5) co-produce local evaluations

The impact of NHS based primary care complementary therapy services on health outcomes and NHS costs: a review of service audits and evaluations

<p>Abstract</p> <p>Background</p> <p>The aim of this study was to review evaluations and audits of primary care complementary therapy services to determine the impact of these services on improving health outcomes and reducing NHS costs. Our intention is to help service users, service providers, clinicians and NHS commissioners make informed decisions about the potential of NHS based complementary therapy services.</p> <p>Methods</p> <p>We searched for published and unpublished studies of NHS based primary care complementary therapy services located in England and Wales from November 2003 to April 2008. We identified the type of information included in each document and extracted comparable data on health outcomes and NHS costs (e.g. prescriptions and GP consultations).</p> <p>Results</p> <p>Twenty-one documents for 14 services met our inclusion criteria. Overall, the quality of the studies was poor, so few conclusions can be made. One controlled and eleven uncontrolled studies using SF36 or MYMOP indicated that primary care complementary therapy services had moderate to strong impact on health status scores. Data on the impact of primary care complementary therapy services on NHS costs were scarcer and inconclusive. One controlled study of a medical osteopathy service found that service users did not decrease their use of NHS resources.</p> <p>Conclusion</p> <p>To improve the quality of evaluations, we urge those evaluating complementary therapy services to use standardised health outcome tools, calculate confidence intervals and collect NHS cost data from GP medical records. Further discussion is needed on ways to standardise the collection and reporting of NHS cost data in primary care complementary therapy services evaluations.</p

Uptake of smoking cessation aids by smokers with a mental illness

Psychiatric inpatient settings represent an opportunity to initiate the provision of tobacco cessation care to smokers with a mental illness. This study describes the use of evidence-based smoking cessation aids proactively and universally offered to a population of psychiatric inpatients upon discharge, and explores factors associated with their uptake. Data derived from the conduct of a randomised controlled trial were analysed in terms of the proportion of participants (N = 378) that utilised cessation aids including project delivered telephone smoking cessation counselling and nicotine replacement therapy (NRT), and Quitline support. Factors associated with uptake of cessation aids were explored using multivariable logistic regression analyses. A large proportion of smokers utilised project delivered cessation counselling calls (89 %) and NRT (79 %), while 11 % used the Quitline. The majority accepted more than seven project delivered telephone cessation counselling calls (52 %), and reported NRT use during more than half of their accepted calls (70 %). Older age, higher nicotine dependence, irregular smoking and seeing oneself as a non-smoker were associated with uptake of behavioural cessation aids. Higher nicotine dependence was similarly associated with use of pharmacological aids, as was NRT use whilst an inpatient. Most smokers with a mental illness took up a proactive offer of aids to support their stopping smoking. Consideration by service providers of factors associated with uptake may increase further the proportion of such smokers who use evidence-based cessation aids and consequently quit smoking successfully

Towards improving diagnosis of memory loss in general practice:TIMeLi diagnostic test accuracy study protocol

Background People with cognitive problems, and their families, report distress and uncertainty whilst undergoing evaluation for dementia and perceive that traditional diagnostic evaluation in secondary care is insufficiently patient centred. The James Lind Alliance has prioritised research to investigate the role of primary care in supporting a more effective diagnostic pathway, and the topic is also of interest to health commissioners. However, there are very few studies that investigate the accuracy of diagnostic tests for dementia in primary care. Methods We will conduct a prospective diagnostic test accuracy study to evaluate the accuracy of a range of simple tests for diagnosing all-cause-dementia in symptomatic people aged over 70 years who have consulted with their general practitioner (GP). We will invite eligible people to attend a research clinic where they will undergo a range of index tests that a GP could perform in the surgery and also be assessed by a specialist in memory disorders at the same appointment. Participating GPs will request neuroimaging and blood tests and otherwise manage patients in line with their usual clinical practice. The reference standard will be the consensus judgement of three experts (neurologist, psychiatrist and geriatrician) based on information from the specialist assessment, GP records and investigations, but not including items in the index test battery. The target condition will be all-cause dementia but we will also investigate diagnostic accuracy for sub-types where possible. We will use qualitative interviews with patients and focus groups with clinicians to help us understand the acceptability and feasibility of diagnosing dementia in primary care using the tests that we are investigating. Discussion Our results will help clinicians decide on which tests to perform in someone where there is concern about possible dementia and inform commissioning of diagnostic pathways

Macrophage-epithelial crosstalk during alveolar epithelial repair following pathogen-induced pulmonary inflammation

Bacterial invasion of the alveolar air space is followed by the fast, tightly regulated immune response facilitating a successful pathogen clearance. Upon pathogen recognition activated resident alveolar macrophages (AMf;) early release pro-inflammatory cytokines, stimulating neighbouring alveolar cells to produce chemokines which in turn mediate the infiltration of neutrophils, exudate macrophages and lymphocytes. The following inflammatory reaction and the pathogen itself leave a damaged alveolar barrier associated with pulmonary oedema and impaired gas exchange. Consequently, epithelial repair processes are initiated to restore the normal lung homeostasis. During the later phase of infection AMf; have been shown to acquire an anti-inflammatory phenotype thereby enhancing alveolar repair processes. However, the potential of early activated, pro-inflammatory AMf to influence epithelial repair remains largely elusive. Therefore, in the present thesis it was investigated whether activated AMf contribute to alveolar epithelial repair upon LPS challenge in vitro and in vivo, as well as in K. pneumoniae pneumonia, and the molecular interaction pathways involved were analysed. The cross-talk between resident alveolar macrophages and alveolar epithelial cells during alveolar repair was assessed in an in vitro co-culture system and an in vivo model of LPS-induced acute lung injury. Gene expression and protein analysis showed that LPS-activated alveolar macrophages stimulated alveolar epithelial cells (AEC) to express growth factors, particularly GM-CSF upon co-culture. Antibody neutralization experiments revealed epithelial GM-CSF expression to be macrophage TNF-alpha dependent. GM-CSF elicited proliferative signalling in alveolar epithelial cells via autocrine activation of the transcription factor STAT 5 and Cyclin D1 expression. Notably, macrophage TNF-alphab induced epithelial proliferation in wild-type but not in GM-CSF-deficient alveolar epithelial cells as shown by [3H]-thymidine incorporation and cell counting. Matrigel:collagen AEC culture preserving the type II phenotype in vitro supported the concept that the proliferative response to GM-CSF is related to the type II AEC phenotype. Moreover, intra-alveolar TNF-alpha neutralization impaired alveolar epithelial type II cell proliferation in LPS-injured mice in vivo, as investigated by flow cytometric Ki67 and immunofluorescence staining of lung sections. Additionally, GM-CSF-deficient mice displayed reduced AEC II proliferation and sustained alveolar barrier dysfunction upon LPS treatment compared to wild-type and SPC-GM mice (overexpressing GM-CSF in AEC II in a GM-CSF-deficient background). Similarly, K. pneumoniae lung infection confirmed the findings in the LPS-model and resulted in early release of macrophage TNF-alpha and epithelial GM-CSF, as well as subsequent TNF-alpha-dependent AEC II proliferation during alveolar repair events. Collectively, these findings indicate that TNF-alpha released from activated resident alveolar macrophages induces epithelial GM-CSF expression, which in turn initiates alveolar epithelial type II cell proliferation and thus contributes to restore alveolar barrier function.Die bakterielle Infektion des Alveolarraumes ist regelhaft von einer schnellen, streng koordinierten Immunantwort gefolgt, deren Ziel die rasche Elimination des Erregers ist. Nach der Erkennung des Erregers über spezielle Pathogen-Rezeptoren setzen Alveolarmakrophagen (AMf;) pro-inflammatorische Zytokine frei und stimulieren benachbarte Parenchymzellen zur Produktion von Chemokinen, welche letztendlich die Chemotaxis neutrophiler Granulozyten, von Exudatmakrophagen und Lymphozyten vermitteln. Diese Immunreaktion, aber auch die Infektion selbst, führen zu einer Destruktion der alveolären Barriere mit konsekutivem alveolärem Ödem und eingeschränktem Gasaustausch. In der Folge werden alveoläre Reparaturprozesse in Gang gesetzt, um die Organfunktion wieder herzustellen. Alveolarmakrophagen aquirieren in der Spätphase der Entzündung einen anti-inflammatorischen Phänotyp und können solche Reparaturprozesse in Gang setzen. Jedoch war das Reparaturpotenzial früh aktivierter, pro-inflammatorischer Alveolarmakrophagen bis dato ungeklärt. In der vorliegenden Arbeit wurde deshalb untersucht, ob früh-inflammatorisch aktivierte residente Alveolarmakrophagen zur alveolarepithelialen Reparatur nach LPS-Applikation in vitro und in vivo und im Klebsiella-Pneumonie-Modell beitragen und welche die zugrunde liegenden molekularen Mechanismen sind. Es wurden die Mediatoren des Cross-talk zwischen Alveolarmakrophagen und Alveolarepithel in der alveolarepithelialen Reparatur in einem in vitro Ko-Kulturmodell und im Mausmodell der LPS-induzierten Acute Lung Injury ermittelt. Genexpressions- und Proteinanalysen zeigten hierbei, dass LPS-aktivierte Alveolarmakrophagen in der Ko-Kultur Alveolarepithelzellen zur Freisetzung epithelialer Wachstumsfaktoren, insbesondere von GM-CSF, stimulieren. Neutralisationsexperimente zeigten, dass die epitheliale GM-CSF Expression abhängig war von Makrophagen-sezerniertem TNF-alpha. GM-CSF induzierte autokrin eine STAT5-Cyclin D1-vermittelte proliferative Signalkaskade in Alveolarepithelzellen. Interessanterweise konnte mittels [3H]-Thymidin-Einbau und Zellzählung gezeigt werden, dass TNF-alpha eine epitheliale Proliferation in Wildtyp-, nicht jedoch in GM-CSF-defizienten Alveolarepithelzellen induziert. Ähnliche Experimente mit Alveolarepithelzellen, die auf einer Matrigel:Collagen-Matrix kultiviert wurden und dabei einen Phänotyp II (AEC II) behielten, zeigten, dass diese GM-CSF-vermittelte Proliferationsantwort an den Phänotyp II gekoppelt war. Darüberhinaus konnte im LPS-Mausmodell gezeigt werden, dass die intraalveoläre Neutralisation von TNF-alpha die Proliferation von Typ II Alveolarepithelzellen in vivo, gemessen anhand der Ki-67 Expression im FACS und in der Immunfluoreszenz, deutlich reduzierte. Zusätzlich zeigten GM-CSF-defiziente Mäuse eine eingeschränkte Alveolarepithelzellproliferation und eine deutlich prolongierte Dysfunktion der alveolären Barriere nach intratrachealer LPS-Gabe verglichen mit Wildtyp- oder SPC-GM-Mäusen (mit Überexpression von GM-CSF im Alveolarepithel, generiert in GM-CSF-defizienten Mäusen). Im Klebsiella-Pneumoniemodell konnten diese Mechanismen bestätigt werden. Zusammenfassend konnte gezeigt werden, dass TNF-alpha, welches von LPS-aktivierten residenten Alveolarmakrophagen freigesetzt wird, eine alveolarepitheliale GM-CSF-Expression induziert. GM-CSF wiederum initiiert über eine autokrine Signalkaskade die Proliferation von Typ II Alveolarepithelzellen und trägt somit wesentlich zur Erneuerung und Funktionalität der alveolarepithelialen Barriere bei

Total smoking bans in psychiatric inpatient services: a survey of perceived benefits, barriers and support among staff

Background: The introduction of total smoking bans represents an important step in addressing the smoking and physical health of people with mental illness. Despite evidence indicating the importance of staff support in the successful implementation of smoking bans, limited research has examined levels of staff support prior to the implementation of a ban in psychiatric settings, or factors that are associated with such support. This study aimed to examine the views of psychiatric inpatient hospital staff regarding the perceived benefits of and barriers to implementation of a successful total smoking ban in mental health services. Secondly, to examine the level of support among clinical and non-clinical staff for a total smoking ban. Thirdly, to examine the association between the benefits and barriers perceived by clinicians and their support for a total smoking ban in their unit. Methods: Cross-sectional survey of both clinical and non-clinical staff in a large inpatient psychiatric hospital immediately prior to the implementation of a total smoking ban. Results: Of the 300 staff, 183 (61%) responded. Seventy-three (41%) of total respondents were clinical staff, and 110 (92%) were non-clinical staff. More than two-thirds of staff agreed that a smoking ban would improve their work environment and conditions, help staff to stop smoking and improve patients' physical health. The most prevalent clinician perceived barriers to a successful total smoking ban related to fear of patient aggression (89%) and patient non-compliance (72%). Two thirds (67%) of all staff indicated support for a total smoking ban in mental health facilities generally, and a majority (54%) of clinical staff expressed support for a ban within their unit. Clinical staff who believed a smoking ban would help patients to stop smoking were more likely to support a smoking ban in their unit. Conclusions: There is a clear need to more effectively communicate to staff the evidence that consistently applied smoking bans do not increase patient aggression. There is also a need to communicate the benefits of smoking bans in aiding the delivery of smoking cessation care, and the benefits of both smoking bans and such care in aiding patients to stop smoking

Response Parameters for SMS Text Message Assessments Among Pregnant and General Smokers Participating in SMS Cessation Trials.

INTRODUCTION: Despite a substantial increase in use of SMS text messages for collecting smoking-related data, there is limited knowledge on the parameters of response. This study assessed response rates, response speed, impact of reminders and predictors of response to text message assessments among smokers. METHODS: Data were from two SMS cessation intervention trials using clinical samples of pregnant (n = 198) and general smokers (n = 293) sent text message assessments during 3-month cessation programs. Response rates were calculated using data from the host web-server. Changes in response over time, impact of reminders and potential demographic (age, gender, ethnicity, parity, and deprivation) and smoking (nicotine dependence, determination to quit, prenatal smoking history, smoking status at follow-up) predictors of response were analyzed. RESULTS: Mean response rates were 61.9% (pregnant) and 67.8% (general) with aggregated median response times of 0.35 (pregnant) and 0.64 (general) hours. Response rate reduced over time (P = .003) for general smokers only. Text message reminders had a significant effect on response (Ps < .001), with observed mean increases of 13.8% (pregnant) and 17.7% (general). Age (odds ratio [OR] = 0.95, 95% confidence interval [CI] 0.90-1.00) and deprivation (OR = 0.98, 95% CI 0.96-1.00) weakly predicted response among pregnant smokers and nonsmoking status at 4 weeks follow-up (OR = 8.63, 95% CI 3.03-24.58) predicted response among general smokers. CONCLUSIONS: Text message assessments within trial-based cessation programs yield rapid responses from a sizable proportion of smokers, which can be increased using text reminders. While few sources of nonresponse bias were identified for general smokers, older and more deprived pregnant women were less likely to respond. IMPLICATIONS: This study demonstrates that most pregnant and general smokers enrolled in a cessation trial will respond to a small number of questions about their smoking sent by text message, mostly within 1 hour of being sent the assessment text message. For those who do not initially respond, our findings suggest that 24- and 48-hour text message reminders are likely to increase response a small but meaningful amount. However, older age and higher deprivation among pregnant smokers and relapse among general smokers is likely to reduce the chance of response.The MiQuit feasibility trial was funded by Cancer Research UK (CR-UK) grant number C1345/A5809. The iQuit in Practice trial was funded by the National Institute for Health Research (NIHR) School for Primary Care Research (SPCR).This is the final version of the article. It first appeared from Oxford University Press via http://dx.doi.org/10.1093/ntr/ntv26

The effect of hydrogen dilution on the structure of a-C : H

Two a-C:H samples were prepared using a fast-atom deposition system from acetylene and an acetylene/hydrogen gas mixture. Their structure was investigated using neutron and x-ny diffraction and infrared spectroscopy measurements. Compositional analysis shows that a 1:1 C2H2:H-2 mixture results in a change from a-C-77:H-23 to a-C-79:H-21, i.e. has a very small effect on the composition. The diffraction data also show that the addition of hydrogen to the precursor gas has no significant effect on the average bond distances and angles but shows a small change in the H-C-H and C-C-H correlations between the two samples. However, the infrared data show that there are significant changes in the bonding of hydrogen within the sample-changes which do not affect the average network structure. We observe a decrease in the amount of sp(3) CH2 and CH3 groups, and an increase in the fraction of sp(2) and sp(3) CH groups, with the formation of a second sp(2) CH bonding environment in the hydrogen-diluted sample. Therefore, in addition to providing useful structural information on these a-C:H samples, this set of experiments illustrates very well the complementary nature of the data from diffraction and spectroscopic techniques