Health Care User Perspectives on Constructing, Contextualizing, and Co-Producing "Quality of Care"

Most of the research on health care user “quality of care” perspectives seeks discrete and measurable indicators to advance quality improvement (QI) goals. This lacks sufficiently grounded query about the meaning of “quality of care” for health users, and how context influences their ideas and experiences. We studied this between 2010 and 2011, repeatedly interviewing and shadowing 45 individuals in three of New York’s hospital-based outpatient HIV care settings during routine visits. We found participants using common terminology, but across the cohort meaning varied and employed personal narratives. Participants conveyed the impact of historic and current experiences of stigma and discrimination on limiting access to care, and showed its destabilizing effects on quality constructs. Participants also felt they contributed to their health care settings’ delivery of quality care. From our findings, we discuss the applicability and implications of “co-production” to conceptualize health care as jointly delivered by typical “givers” and “receivers” of care

Temporal variations in quality of acute stroke care and outcomes in London hyperacute stroke units: a mixed-methods study

This is the final version. Available from the NIHR Journals Library via the DOI in this recordBackground Seven-day working in hospitals is a current priority of international health research and policy. Previous research has shown variability in delivering evidence-based clinical interventions across different times of the day and week. We aimed to identify factors influencing such variations in London hyperacute stroke units. Objectives To investigate variations in quality of acute stroke care and outcomes by day and time of admission in London hyperacute stroke units, and to identify factors influencing such variations. Design This was a prospective cohort study using anonymised patient-level data from the Sentinel Stroke National Audit Programme. Factors influencing variations in care and outcomes were studied through interview and observation data. Setting The setting was acute stroke services in London hyperacute stroke units. Participants A total of 7094 patients with a primary diagnosis of stroke took part. We interviewed hyperacute stroke unit staff (n = 76), including doctors, nurses, therapists and administrators, and 31 patients and carers. We also conducted non-participant observations of delivery of care at different times of the day and week (n = 45, ≈102 hours). Intervention Hub-and-spoke model for care of suspected acute stroke patients in London with performance standards was designed to deliver uniform access to high-quality hyperacute stroke unit care across the week. Main outcome measures Indicators of quality of acute stroke care, mortality at 3 days after admission, disability at the end of the inpatient spell and length of stay. Data sources Sentinel Stroke National Audit Programme data for all patients in London hyperacute stroke units with a primary diagnosis of stroke between 1 January and 31 December 2014, and nurse staffing data for all eight London hyperacute stroke units for the same period. Results We found no variation in quality of care by day and time of admission across the week in terms of stroke nursing assessment, brain scanning and thrombolysis in London hyperacute stroke units, nor in 3-day mortality nor disability at hospital discharge. Other quality-of-care measures significantly varied by day and time of admission. Quality of care was better if the nurse in charge was at a higher band and/or there were more nurses on duty. Staff deliver ‘front-door’ interventions consistently by taking on additional responsibilities out of hours, creating continuities between day and night, building trusting relationships and prioritising ‘front-door’ interventions. Limitations We were unable to measure long-term outcomes as our request to the Sentinel Stroke National Audit Programme, the Healthcare Quality Improvement Partnership and NHS Digital for Sentinel Stroke National Audit Programme data linked with patient mortality status was not fulfilled. Conclusions Organisational factors influence 24 hours a day, 7 days a week (24/7), provision of stroke care, creating temporal patterns of provision reflected in patient outcomes, including mortality, length of stay and functional independence. Future work Further research would help to explore 24/7 stroke systems in other contexts. We need a clearer understanding of variations by looking at absolute time intervals, rather than achievement of targets. Research is needed with longer-term mortality and modified Rankin Scale data, and a more meaningful range of outcomes.National Institute for Health Research (NIHR

UCL qualitative health research symposium 2015: enriching qualitative inquiry in health

The field of health research appears increasingly open to qualitative approaches. We celebrate the rise in qualitative and mixed methods publications and the marked presence of qualitative researchers in academic centres of health research. However, we note enduring tensions between the conceptual and methodological approaches of qualitative research and those of a quantitative paradigm, generally more familiar to health practitioners, policymakers and often other researchers. In some instances, qualitatively-oriented investigations continue to conflict with the expectations within health research to provide concrete and timely findings and recommendations. These concerns foreground questions to be explored around the applicability, value, contribution, legitimacy and limitations of qualitative inquiry within the prevailing research culture. In recognition of these questions, we curated a day long symposium around abstracts submitted in response to an open, internationally disseminated call, framed to create a productive space for the critical examination of the current state of qualitative health research, and the exploration of ways to enable its enrichment. We organised the papers, posters, keynote address and panel discussion into three themes. The first, Problematising the research landscape, reflects on particular issues arising when we 'do' qualitative research. The second, Re-approaching familiar frameworks, explores the application of epistemological traditions of the social sciences to understand health, and to consider what underpins how we frame and treat such topics. The third, Imagination at work-enriching the potential, attends to the prospects of bringing new approaches into research, sometimes borrowed from other fields. The symposium facilitated engagement with current research and reflections on connecting methodological advances with theoretical traditions amidst challenges of carrying out applied health research. A perceived need exists for qualitative researchers to concertedly promote and enrich our contributions without homogenising or obscuring what our approach has to offer. This could be achieved through the continued development of a common platform for qualitative research that facilitates collaborations and fosters interdisciplinary education and training. This symposium represents critical steps towards these aims, to be further developed through the convening of future events

The frequency of osteogenic activities and the pattern of intermittence between periods of physical activity and sedentary behaviour affects bone mineral content: the cross-sectional NHANES study

BACKGROUND: Sedentary behaviours, defined as non exercising seated activities, have been shown to have deleterious effects on health. It has been hypothesised that too much sitting time can have a detrimental effect on bone health in youth. The aim of this study is to test this hypothesis by exploring the association between objectively measured volume and patterns of time spent in sedentary behaviours, time spent in specific screen-based sedentary pursuits and bone mineral content (BMC) accrual in youth. METHODS: NHANES 2005–2006 cycle data includes BMC of the femoral and spinal region via dual-energy X-ray absorptiometry (DEXA), assessment of physical activity and sedentary behaviour patterns through accelerometry, self reported time spent in screen based pursuits (watching TV and using a computer), and frequency of vigorous playtime and strengthening activities. Multiple regression analysis, stratified by gender was performed on N = 671 males and N = 677 females aged from 8 to 22 years. RESULTS: Time spent in screen-based sedentary behaviours is negatively associated with femoral BMC (males and females) and spinal BMC (females only) after correction for time spent in moderate and vigorous activity. Regression coefficients indicate that an additional hour per day of screen-based sitting corresponds to a difference of −0.77 g femoral BMC in females [95% CI: -1.31 to −0.22] and of −0.45 g femoral BMC in males [95% CI: -0.83 to −0.06]. This association is attenuated when self-reported engagement in regular (average 5 times per week) strengthening exercise (for males) and vigorous playing (for both males and females) is taken into account. Total sitting time and non screen-based sitting do not appear to have a negative association with BMC, whereas screen based sedentary time does. Patterns of intermittence between periods of sitting and moderate to vigorous activity appears to be positively associated with bone health when activity is clustered in time and inter-spaced with long continuous bouts of sitting. CONCLUSIONS: Some specific sedentary pursuits (screen-based) are negatively associated with bone health in youth. This association is specific to gender and anatomical area. This relationship between screen-based time and bone health is independent of the total amount of physical activity measured objectively, but not independent of self-reported frequency of strengthening and vigorous play activities. The data clearly suggests that the frequency, rather than the volume, of osteogenic activities is important in counteracting the effect of sedentary behaviour on bone health. The pattern of intermittence between sedentary periods and activity also plays a role in bone accrual, with clustered short bouts of activity interspaced with long periods of sedentary behaviours appearing to be more beneficial than activities more evenly spread in time

The Distributional Effect of Events on Rural and Urban Households in China

International tourism is considered an effective means of economic development. However, the effects of tourism are not evenly distributed between rural and urban households in China. In the wake of significant socioeconomic events, the uneven distribution of the economic effects has huge welfare implications for Chinese households. This study is the first attempt to evaluate the distributional effect of two large, recent, sequential events on China’s rural and urban households. It adopts an innovative approach that combines an econometric model and a two-household computable general equilibrium model. The results show that in terms of welfare, urban households were more adversely affected by the events than rural households. To mitigate the loss of welfare, measures should be taken to continually promote China as a destination and attract tourists after such events occur. Meanwhile, training and education should be made more accessible to rural households to increase their job opportunities

Spontaneous recanalization of a completely occluded saphenous vein graft two months following acute myocardial infarction with persistent one year patency

Acute myocardial infarction resulting from saphenous vein graft occlusion occurs not infrequently in patients who have undergone coronary artery bypass graft surgery. In this case report, we present a novel case of spontaneous recanalization of a thrombotic graft occlusion in a patient who presented with a subacute myocardial infarction. The patient was treated medically with aspirin as the only anti-platelet agent. Interestingly, he presented 2 months later with new onset angina. Coronary angiography demonstrated complete resolution of thrombus but a severe focal stenosis in the distal anastomoses. Following drug eluting stent placement, a favorable clinical course has ensued and patency confirmed on follow up angiography at 1 year

The Feasibility and Impact of Delivering a Mind-Body Intervention in a Virtual World

Introduction: Mind-body medical approaches may ameliorate chronic disease. Stress reduction is particularly helpful, but face-to-face delivery systems cannot reach all those who might benefit. An online, 3-dimensional virtual world may be able to support the rich interpersonal interactions required of this approach. In this pilot study, we explore the feasibility of translating a face-to-face stress reduction program into an online virtual setting and estimate the effect size of the intervention. Methods and Findings: Domain experts in virtual world technology joined with mind body practitioners to translate an existing 8 week relaxation response-based resiliency program into an 8-week virtual world-based program in Second Life™ (SL). Twenty-four healthy volunteers with at least one month's experience in SL completed the program. Each subject filled out the Perceived Stress Scale (PSS) and the Symptom Checklist 90- Revised (SCL-90-R) before and after taking part. Participants took part in one of 3 groups of about 10 subjects. The participants found the program to be helpful and enjoyable. Many reported that the virtual environment was an excellent substitute for the preferred face-to-face approach. On quantitative measures, there was a general trend toward decreased perceived stress, (15.7 to 15.0), symptoms of depression, (57.6 to 57.0) and anxiety (56.8 to 54.8). There was a significant decrease of 2.8 points on the SCL-90-R Global Severity Index (p<0.05). Conclusions: This pilot project showed that it is feasible to deliver a typical mind-body medical intervention through a virtual environment and that it is well received. Moreover, the small reduction in psychological distress suggests further research is warranted. Based on the data collected for this project, a randomized trial with less than 50 subjects would be appropriately powered if perceived stress is the primary outcome