A realistic evaluation : the case of protocol-based care

Background 'Protocol based care' was envisioned by policy makers as a mechanism for delivering on the service improvement agenda in England. Realistic evaluation is an increasingly popular approach, but few published examples exist, particularly in implementation research. To fill this gap, within this paper we describe the application of a realistic evaluation approach to the study of protocol-based care, whilst sharing findings of relevance about standardising care through the use of protocols, guidelines, and pathways. Methods Situated between positivism and relativism, realistic evaluation is concerned with the identification of underlying causal mechanisms, how they work, and under what conditions. Fundamentally it focuses attention on finding out what works, for whom, how, and in what circumstances. Results In this research, we were interested in understanding the relationships between the type and nature of particular approaches to protocol-based care (mechanisms), within different clinical settings (context), and what impacts this resulted in (outcomes). An evidence review using the principles of realist synthesis resulted in a number of propositions, i.e., context, mechanism, and outcome threads (CMOs). These propositions were then 'tested' through multiple case studies, using multiple methods including non-participant observation, interviews, and document analysis through an iterative analysis process. The initial propositions (conjectured CMOs) only partially corresponded to the findings that emerged during analysis. From the iterative analysis process of scrutinising mechanisms, context, and outcomes we were able to draw out some theoretically generalisable features about what works, for whom, how, and what circumstances in relation to the use of standardised care approaches (refined CMOs). Conclusions As one of the first studies to apply realistic evaluation in implementation research, it was a good fit, particularly given the growing emphasis on understanding how context influences evidence-based practice. The strengths and limitations of the approach are considered, including how to operationalise it and some of the challenges. This approach provided a useful interpretive framework with which to make sense of the multiple factors that were simultaneously at play and being observed through various data sources, and for developing explanatory theory about using standardised care approaches in practice

Migraine: treatments, comorbidities, and quality of life, in the USA

This study sought to characterize the experience of stress, treatment patterns, and medical and disability profile in the migraineur population to better understand how the experience of migraines impacts the social and psychological functioning of this group. A 30-minute self-report survey was presented via a migraine-specific website with data collection occurring between May 15 and June 15, 2012. Recruitment for the study was done through online advertisements. In total, 2,907 individuals began the survey and 2,735 met the inclusion criteria for the study. The sample was predominantly female (92.8%). Migraine-associated stress was correlated with length of time since first onset of symptoms (P \u3c 0.01) and number of symptoms per month (P \u3c 0.01). Disorders related to stress, such as depression (P \u3c 0.01) and anxiety (P \u3c 0.01), were also positively correlated with the measured stress resulting from migraines. Migraine-associated stress must be understood as a multidimensional experience with broader impacts of stress on an individual correlating much more highly with negative mental and physical health profiles. Stress resulting from frequent migraine headaches may contribute to the development of medical and psychological comorbidities and may be a part of a cyclical relationship wherein stress is both a cause and effect of the social and medical impairments brought about by migraine

A case study evaluation of implementation of a care pathway to support normal birth in one English birth centre: anticipated benefits and unintended consequences

Background: The policy drive for the UK National Health Service (NHS) has focused on the need for high quality services informed by evidence of best practice. The introduction of care pathways and protocols to standardise care and support implementation of evidence into practice has taken place across the NHS with limited evaluation of their impact. A multi-site case study evaluation was undertaken to assess the impact of use of care pathways and protocols on clinicians, service users and service delivery. One of the five sites was a midwifery-led Birth Centre, where an adapted version of the All Wales Clinical Pathway for Normal Birth had been implemented. Methods: The overarching framework was realistic evaluation. A case study design enabled the capture of data on use of the pathway in the clinical setting, use of multiple methods of data collection and opportunity to study and understand the experiences of clinicians and service users whose care was informed by the pathway. Women attending the Birth Centre were recruited at their 36 week antenatal visit. Episodes of care during labour were observed, following which the woman and the midwife who cared for her were interviewed about use of the pathway. Interviews were also held with other key stakeholders from the study site. Qualitative data were content analysed. Results: Observations were undertaken of four women during labour. Eighteen interviews were conducted with clinicians and women, including the women whose care was observed and the midwives who cared for them, senior midwifery managers and obstetricians. The implementation of the pathway resulted in a number of anticipated benefits, including increased midwifery confidence in skills to support normal birth and promotion of team working. There were also unintended consequences, including concerns about a lack of documentation of labour care and negative impact on working relationships with obstetric and other midwifery colleagues. Women were unaware their care was informed by a care pathway. Conclusion: Care pathways are complex interventions which generate a number of consequences for practice. Those considering introduction of pathways need to ensure all relevant stakeholders are engaged with this and develop robust evaluation strategies to accompany implementation

Final report of the Pearling Industry Review Committee to the Hon. Julian Grill, Western Australian Minister for Fisheries and Hon. John Kerin, M.P. Federal Minister for Primary Industries and Energy.

In October 1987 an Interim Report was issued to enable the present licence holders, the Licensed Pearl Producers\u27 Association and other who had expressed an interest to the Committee, to consider the interim recommendations and , if necessary, make written comment to the Committee. The Committee considered the comments it received. It now presents its Final Report to the Western Australian Minister for Fisheries, the Hon. Julian Grill and the Federal Minister for Primary Industries and Energy, the Hon. John Kerin. The Committee is recommending that the industry be quota controlled with entry by transfer only. The present licence holders plus new applicants yet to be determined are recommended as the companies to comprise those engaged in the industry. The Committee is also recommending that the north west coast be divided into two sectors - one south of Port Hedland, the other north of Port Hedland to the Northern Territory border. the Northern Sector would be zoned to (a) ensure that the very important Eighty Mile Beach area is protected against overfishing and (b) to allow a number of present licence holders to increase their overall catch by fishing in the areas north of Broome

Bayesian optimization of the PC algorithm for learning Gaussian Bayesian networks

The PC algorithm is a popular method for learning the structure of Gaussian Bayesian networks. It carries out statistical tests to determine absent edges in the network. It is hence governed by two parameters: (i) The type of test, and (ii) its significance level. These parameters are usually set to values recommended by an expert. Nevertheless, such an approach can suffer from human bias, leading to suboptimal reconstruction results. In this paper we consider a more principled approach for choosing these parameters in an automatic way. For this we optimize a reconstruction score evaluated on a set of different Gaussian Bayesian networks. This objective is expensive to evaluate and lacks a closed-form expression, which means that Bayesian optimization (BO) is a natural choice. BO methods use a model to guide the search and are hence able to exploit smoothness properties of the objective surface. We show that the parameters found by a BO method outperform those found by a random search strategy and the expert recommendation. Importantly, we have found that an often overlooked statistical test provides the best over-all reconstruction results

Chemical reactivity of hydrogen, nitrogen and oxygen atoms at temperatures below 100 deg K Fifth semiannual technical report

Chemical reactivity of hydrogen, nitrogen, and oxygen atoms at temperatures below 100 deg

The implausibility of ‘usual care’ in an open system: sedation and weaning practices in Paediatric Intensive Care Units (PICUs) in the United Kingdom (UK)

Background: The power of the randomised controlled trial depends upon its capacity to operate in a closed system whereby the intervention is the only causal force acting upon the experimental group and absent in the control group, permitting a valid assessment of intervention efficacy. Conversely, clinical arenas are open systems where factors relating to context, resources, interpretation and actions of individuals will affect implementation and effectiveness of interventions. Consequently, the comparator (usual care) can be difficult to define and variable in multi-centre trials. Hence outcomes cannot be understood without considering usual care and factors that may affect implementation and impact on the intervention. Methods: Using a fieldwork approach, we describe PICU context, ‘usual’ practice in sedation and weaning from mechanical ventilation, and factors affecting implementation prior to designing a trial involving a sedation and ventilation weaning intervention. We collected data from 23 UK PICUs between June and November 2014 using observation, individual and multi-disciplinary group interviews with staff. Results: Pain and sedation practices were broadly similar in terms of drug usage and assessment tools. Sedation protocols linking assessment to appropriate titration of sedatives and sedation holds were rarely used (9 % and 4 % of PICUs respectively). Ventilator weaning was primarily a medical-led process with 39 % of PICUs engaging senior nurses in the process: weaning protocols were rarely used (9 % of PICUs). Weaning methods were variably based on clinician preference. No formal criteria or use of spontaneous breathing trials were used to test weaning readiness. Seventeen PICUs (74 %) had prior engagement in multi-centre trials, but limited research nurse availability. Barriers to previous trial implementation were intervention complexity, lack of belief in the evidence and inadequate training. Facilitating factors were senior staff buy-in and dedicated research nurse provision. Conclusions: We examined and identified contextual and organisational factors that may impact on the implementation of our intervention. We found usual practice relating to sedation, analgesia and ventilator weaning broadly similar, yet distinctively different from our proposed intervention, providing assurance in our ability to evaluate intervention effects. The data will enable us to develop an implementation plan; considering these factors we can more fully understand their impact on study outcomes

Electron-impact excitation of X 1Sigma_g⁺(v[double-prime]=0) to the a[double-prime] 1Sigma_g⁺, b 1Piu, c3 1Piu, o3 1Piu, b[prime] 1Sigma_u⁺, c₄^[prime] 1Sigma_u⁺, G 3Piu, and F 3Piu states of molecular nitrogen

Measurements of differential cross sections (DCSs) for electron-impact excitation of the a[double-prime] 1Sigmag+, b 1Piu, c3 1Piu, o3 1Piu, b[prime] 1Sigmau+, c4[prime] 1Sigmau+, G 3Piu, and F 3Piu states in N2 from the X 1Sigmag+(v[double-prime]=0) ground level are presented. The DCSs were obtained from energy-loss spectra in the region of 12 to 13.82 eV measured at incident energies of 17.5, 20, 30, 50, and 100 eV and for scattering angles ranging from 2° to 130°. The analysis of the spectra follows a different algorithm from that employed in a previous study of N2 for the valence states [Khakoo et al. Phys. Rev. A 71, 062703 (2005)], since the 1Piu and 1Sigmau+ states form strongly interacting Rydberg-valence series. The results are compared with existing data

Two-dimensional dynamic stall as simulated in a varying freestream

A low speed wind tunnel equipped with a axial gust generator to simulate the aerodynamic environment of a helicopter rotor was used to study the dynamic stall of a pitching blade in an effort to ascertain to what extent harmonic velocity perturbations in the freestream affect dynamic stall. The aerodynamic moment on a two dimensional, pitching blade model in both constant and pulsating airstream was measured. An operational analog computer was used to perform on-line data reduction and plots of moment versus angle of attack and work done by the moment were obtained. The data taken in the varying freestream were then compared to constant freestream data and to the results of two analytical methods. These comparisons show that the velocity perturbations have a significant effect on the pitching moment which can not be consistently predicted by the analytical methods, but had no drastic effect on the blade stability

The move beyond edutainment: have we learnt our lessons from the entertainment industry?

Serious games (SGs) have been used in the education of students and professionals for decades, but still have not reached their full potential, despite the large consensus they have gained recently. The entertainment game industry is a rapidly developing phenomenon, with a high market potential, enabled and enhanced by technological innovation. The question examined in this paper is: Did serious game designers learn from Entertainment Game (EG) designers in building a successful game? This paper presents three case study examples of games that have good learning outcomes to explore this question. This paper discusses the salient aspects and the differences between the examples and suggests how SGs could learn more from successful EGs