Impact on maternity professionals of novel approaches to clinical audit feedback

We compared three approaches to feedback of clinical audit findings relating to miscarriage in 15 Scottish maternity services (printed report alone; report plus Action Planning Letter; report plus face-to-face Facilitated Action Planning). We surveyed clinicians to measure Theory of Planned Behaviour constructs (in the context of two audit criteria) before and after feedback (n=253) and assessed perceptions of the audit through in-depth interviews (n=17). Pre-feedback, clinicians had positive attitudes and strong subjective norms and intentions to comply, although perceived behavioural control was lower. Generally, positive attitudes, subjective norms and intentions increased after feedback but for one of the two criteria (providing a 7-day miscarriage service), perceived behavioural control decreased. No changes over time reached statistical significance and analysis of covariance (adjusting for pre-feedback scores) showed no consistent relationships between method of feedback and post-feedback construct scores. Interviews revealed positive perceptions of audit but frustration at lack of capacity to implement changes. While interventions which increased intensity of feedback proved feasible and acceptable to clinicians, we were unable to demonstrate that they increased intention to comply with audit criteria.This study was funded by NHS Quality Improvement Scotland

The curious case of an internal pilot in a multicentre randomised trial-time for a rethink?

Acknowledgements The authors would like to acknowledge helpful discussions on this topic held with various colleagues in connection with a variety of projects. Funding No funding was received for this work.Peer reviewedPublisher PD

Quality of life in the five years after intensive care : a cohort study

Peer reviewedPublisher PD

The Accuracy of Accredited Glaucoma Optometrists in the Diagnosis and Treatment Recommendation for Glaucoma

Background/aims: To compare the diagnostic performance of accredited glaucoma optometrists (AGO) for both the diagnosis of, and decision to treat glaucoma with that of routine hospital eye care against a reference standard of expert opinion, i.e. consultant ophthalmologist with a special interest in glaucoma. Methods: A directly comparative, masked, performance study was performed in Grampian, Scotland. 165 people were invited to participate and, of those, 100 (61%) were examined. People suspected of having glaucoma underwent a full ophthalmic assessment both in a newly established, community optometry led, glaucoma management scheme and in a consultant led hospital eye service within a month. Results: The agreement between the AGO and the consultant ophthalmologist in the diagnosis of glaucoma was substantial (89%, kappa = 0.703, SE=0.083). The agreement regarding the need for treatment was also substantial (88%, kappa = 0.716, SE =0.076). The agreement between the trainee ophthalmologists and the consultant ophthalmologist in the diagnosis of glaucoma and treatment recommendation were moderate (83%, kappa = 0.541, SE = 0.098, SE = 0.98; and 81%, kappa = 0.553, SE = 0.90, respectively). The diagnostic accuracy of the optometrists in detecting glaucoma in this population was high for specificity (0.93 [95% CI 0.85 to 0.97]) but lower for sensitivity at 0.76 (95% CI 0.57 to 0.89). The performance was similar when accuracy was assessed for treatment recommendation (sensitivity, 0.73[95% CI 0.57 to 0.85]; specificity 0.96[95% CI 0.88 to 0.99]). The differences in sensitivity and specificity between AGO and junior ophthalmologist was not statistically significant.Conclusions: Community optometrists trained in glaucoma provided satisfactory decisions regarding diagnosis and initiation of treatment for glaucoma. With such additional training in glaucoma optometrists are at least as accurate as junior ophthalmologists but some cases of glaucoma missed.Chief Scientist Office of the Scottish Executive Health Departmen

Identifying active ingredients in complex behavioural interventions for obese adults with obesity-related co-morbidities or additional risk factors for co-morbidities : a systematic review

Peer reviewedPostprin

Effects of weight loss interventions for adults who are obese on mortality, cardiovascular disease and cancer : a systematic review and meta-analysis

We thank Associate Professor Andrew Grey for helping to resolve discrepancies in data extraction and interpretation for cardiovascular events and cancer events. We thank trialists from 16 studies for clarifying or providing additional information for this review [Andrews 2011, Aveyard 2016, Bennett 2012, de Vos 2014, Finnish Diabetes Prevention Study 2009, Goodwin 2014, Green 2015, Horie 2016, Hunt (FFIT) 2014, Katula 2013, Li (Da Qing) 2014, Logue 2005, Ma 2013, O’Neil 2016, Rejeski (CLIP) 2011, Uusitupa 1993] and also others who provided information, but their trials were later found not to fulfil our inclusion criteria. Funding: The Health Services Research Unit is funded by the Chief Scientist Office of the Scottish Government Health and Social Care Directorate.Peer reviewedPublisher PD

The effect of superabsorbent polymers on mechanical characteristics and cracking susceptibility of alkali-activated mortars containing ground granulated blast-furnace slag and copper Slag

In an attempt to increase sustainability of construction materials, both ground granulated blast-furnace slag (GGBS) and, less popular, copper slag (CS) can be used in alkali-activated composites. However, such composites are often more susceptible to cracking, triggered by the self-desiccation processes. The addition of superabsorbent polymers (SAP) may enable internal curing of concrete and prevent excessive cracking. Thus, this paper aims to evaluate the effectiveness of SAP as an internal curing agent for alkali-activated slag mortars containing GGBS and CS. The samples were activated by sodium silicate using 6.5% Na2O by mass of precursor. The evaluation was based on the analysis of mechanical properties, autogenous shrinkage, and water absorption capacity of two types of SAPs. Depending on the type of polymer, a higher alkali concentration in SAP solutions speeds up early age reactions up to 7 days. After this period, SAP collapses and reactions follow at the same pace as the reference sample. In the presence of CS, SAP with higher absorption and smaller particles well-distributed in the mix leads to a higher extension of reactions, observed in higher values of autogenous shrinkage (AS). This results in increased compressive strength of GGBS-CS mortars, achieving values 8.8% greater than the reference sample (without SAP) at 6 months. Although its leads to higher cracking susceptibility, SAP can improve mechanical properties and promote new applications for sustainable material containing copper slag

Perspectives on financial incentives to health service providers for increasing breast feeding and smoking quit rates during pregnancy: a mixed methods study

Objective: To explore the acceptability, mechanisms and consequences of provider incentives for smoking cessation and breast feeding as part of the Benefits of Incentives for Breastfeeding and Smoking cessation in pregnancy (BIBS) study. Design: Cross-sectional survey and qualitative interviews. Setting: Scotland and North West England. Participants: Early years professionals: 497 survey respondents included 156 doctors; 197 health visitors/maternity staff; 144 other health staff. Qualitative interviews or focus groups were conducted with 68 pregnant/postnatal women/family members; 32 service providers; 22 experts/decision-makers; 63 conference attendees. Methods: Early years professionals were surveyed via email about the acceptability of payments to local health services for reaching smoking cessation in pregnancy and breastfeeding targets. Agreement was measured on a 5-point scale using multivariable ordered logit models. A framework approach was used to analyse free-text survey responses and qualitative data. Results: Health professional net agreement for provider incentives for smoking cessation targets was 52.9% (263/497); net disagreement was 28.6% (142/497). Health visitors/maternity staff were more likely than doctors to agree: OR 2.35 (95% CI 1.51 to 3.64; p<0.001). Net agreement for provider incentives for breastfeeding targets was 44.1% (219/497) and net disagreement was 38.6% (192/497). Agreement was more likely for women (compared with men): OR 1.81 (1.09 to 3.00; p=0.023) and health visitors/maternity staff (compared with doctors): OR 2.54 (95% CI 1.65 to 3.91; p<0.001). Key emergent themes were 'moral tensions around acceptability', 'need for incentives', 'goals', 'collective or divisive action' and 'monitoring and proof'. While provider incentives can focus action and resources, tensions around the impact on relationships raised concerns. Pressure, burden of proof, gaming, box-ticking bureaucracies and health inequalities were counterbalances to potential benefits. Conclusions: Provider incentives are favoured by non-medical staff. Solutions which increase trust and collaboration towards shared goals, without negatively impacting on relationships or increasing bureaucracy are required

Efficacy and safety of using mesh or grafts in surgery for anterior and/or posterior vaginal wall prolapse: systematic review and meta-analysis.

Background The efficacy and safety of mesh/graft in surgery for anterior or posterior pelvic organ prolapse is uncertain. Objectives To systematically review the efficacy and safety of mesh/graft for anterior or posterior vaginal wall prolapse surgery. Search strategy Electronic databases and conference proceedings were searched, experts and manufacturers contacted and reference lists of retrieved papers scanned. Selection criteria Randomised controlled trials (RCTs), non-randomised comparative studies, registries, case series involving at least 50 women, and RCTs published as conference abstracts from 2005 onwards. Data collection and analysis One reviewer screened titles/abstracts, undertook data extraction, and assessed study quality. Data analysis was conducted for three subgroups: anterior, posterior, and anterior and/or posterior repair (not reported separately). Results Forty-nine studies involving 4569 women treated with mesh/graft were included. Study quality was generally high. Median follow up was 13 months (range 1 to 51). In anterior repair, there was short-term evidence that mesh/graft (any type) significantly reduced objective prolapse recurrence rates compared with no mesh/graft (relative risk 0.48, 95% CI 0.32-0.72). Non-absorbable synthetic mesh had a significantly lower objective prolapse recurrence rate (8.8%, 48/548) than absorbable synthetic mesh (23.1%, 63/273) and biological graft (17.9%, 186/1041), but a higher erosion rate (10.2%, 68/666) than synthetic mesh (0.7%, 1/147) and biological graft (6.0%, 35/581). There was insufficient information to compare any of the other outcomes regardless of prolapse type. Conclusion Evidence for most outcomes was too sparse to provide meaningful conclusions. Rigorous long-term RCTs are required to determine the comparative efficacy of using mesh/graft.The National Institute for Health and Clinical Excellence Interventional Procedures Programme