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

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

Decentralised Learning MACs for Collision-free Access in WLANs

By combining the features of CSMA and TDMA, fully decentralised WLAN MAC schemes have recently been proposed that converge to collision-free schedules. In this paper we describe a MAC with optimal long-run throughput that is almost decentralised. We then design two \changed{schemes} that are practically realisable, decentralised approximations of this optimal scheme and operate with different amounts of sensing information. We achieve this by (1) introducing learning algorithms that can substantially speed up convergence to collision free operation; (2) developing a decentralised schedule length adaptation scheme that provides long-run fair (uniform) access to the medium while maintaining collision-free access for arbitrary numbers of stations

COMPARISON OF MEN'S AND WOMEIU'S 100 M FREESTYLE PERFORMANCES AT THE 1996 PARALYMPIC GAMES

Swimming competition for persons with a loco-motor disability is organised according to a functional classification system. One manner of checking the validity of this system is to compare the race results of men and women, in this case for the 100 m freestyle at the 1996 Paralympic Games. Men swam faster than women and had longer stroke lengths but no differences in stroke rate. Starting and turning ability did not differ. Women finished faster. In general the pattern of differences between Olympic and Paralympic swimmers and among classes was similar in men and women, supporting the validity of the functional classification system used for freestyle

SPECTRAL PROCEDURES ENHANCE THE ANALYSIS OF THREE AGRICULTURAL TIME SERIES

Many agricultural and environmental variables are influenced by cyclic processes that occur naturally. Consequently their time series often have cyclic behavior. This study develops time series models for three different phenomena: (1) a 60 year-long state annual average crop yield record, (2) a four year-long daily stream flow record with values aggregated to weekly averages, and (3) a half-hour long wind speed record sampled at 10 hertz with values aggregated to 0.5 min averages. Trend tests, simple high pass filtering, and spectral analysis on original and detrended and residual data series are used to guide model development. Next, as a means to provide insight for researchers, nonlinear regression procedures are used to develop models in the time domain. The models considered may have a large scale trend, low to high frequency cycles, and, if need be, an autoregressive (AR) error structure. Selected models for all three sets included a trend component. The model for yield has a linear trend in time and includes two high frequency cycles of 2.3 and 2.5 years. The model for stream flow has a complicated trend consisting of splined polynomials in the square root of time. Cycles include an annual and approximately 8, 6, and 3 month periods. Also an AR1 error structure is added. Results suggest the wind speed can be modeled as a superposition of damped and undamped oscillations. A zero order fractional Bessel function models the trend, here a damped oscillation with a period of 10.5 min. Smaller scale regular cycles of 6.6, 3.3 and 2.2 min are added along with an AR1 error structure. The use of time series methods instead of the inverse transform on selected frequencies allows for simultaneous estimation of all components. Moreover it opens the door to the use of a much broader class of functions to model the trend, to the use of other kinds of periodic functions to model the cycles, and to the incorporation of structure in the error term. This approach may provide useful insight and a methodological approach for several ongoing and some future studies at the National Soil Tilth Laboratory

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

Evidence for nodal superconductivity in LaFePO

In several iron-arsenide superconductors there is strong evidence for a fully gapped superconducting state consistent with either a conventional s-wave symmetry or an unusual $s_\pm$ state where there the gap changes sign between the electron and hole Fermi surface sheets. Here we report measurements of the penetration depth $\lambda(T)$ in very clean samples of the related iron-phosphide superconductor, LaFePO, at temperatures down to $\sim$ 100 mK. We find that $\lambda(T)$ varies almost perfectly linearly with $T$ strongly suggesting the presence of gap nodes in this compound. Taken together with other data, this suggests the gap function may not be generic to all pnictide superconductors

Seasonal Training-Load Quantification in Elite English Premier League Soccer Players

Purpose: To quantify the seasonal training load completed by professional soccer players of the English Premier League. Methods: Thirty players were sampled (using GPS, heart rate, and rating of perceived exertion [RPE]) during the daily training sessions of the 2011–12 preseason and in-season period. Preseason data were analyzed across 6 × 1-wk microcycles. In-season data were analyzed across 6 × 6-wk mesocycle blocks and 3 × 1-wk microcycles at start, midpoint, and end-time points. Data were also analyzed with respect to number of days before a match. Results: Typical daily training load (ie, total distance, high-speed distance, percent maximal heart rate [%HRmax], RPE load) did not differ during each week of the preseason phase. However, daily total distance covered was 1304 (95% CI 434–2174) m greater in the 1st mesocycle than in the 6th. %HRmax values were also greater (3.3%, 1.3–5.4%) in the 3rd mesocycle than in the first. Furthermore, training load was lower on the day before match (MD-1) than 2 (MD-2) to 5 (MD-5) d before a match, although no difference was apparent between these latter time points. Conclusions: The authors provide the 1st report of seasonal training load in elite soccer players and observed that periodization of training load was typically confined to MD-1 (regardless of mesocycle), whereas no differences were apparent during MD-2 to MD-5. Future studies should evaluate whether this loading and periodization are facilitative of optimal training adaptations and match-day performance

Use of Otolith Strontium:Calcium Ratios for Hindcasting Larval Cod Gadus Morhua Distributions Relative to Water Masses on Georges Bank

The concentration ratios of strontium to calcium in laboratory-reared larval cod otoliths are shown to be related to the water temperature (T) at the time of otolith precipitation. This relationship is curvilinear, and is best described by a simple exponential equation of the form (Sr/Ca x 1000 = a exp(-T/b). We show that when Sr/Ca elemental analyses are related to the daily growth increments in the larval otoliths, relative temperature histories of individual field-caught larvae can be reconstructed from the egg stage to the time of capture. We present preliminary examples of how such reconstructed temperature histories of Atlantic cod Gadus morhua larvae, collected on Georges Bank during April and May 1993, may be interpreted in relation to the broad-scale larval distributions and the hydrography of the Bank