A Critical Analysis of Evidence-Based Practice in Healthcare: The Case of Asthma Action Plans

Evidence-based practice is an integral part of multi-disciplinary healthcare, but its routine clinical implementation remains a challenge internationally. Written asthma action plans are an example of sub-optimal evidence-based practice because, despite being recommended, these plans are under-issued by health professionals and under-used by patients/carers. This thesis is a critical analysis of the generation and implementation of evidence in this area and provides fresh insight into this specific theory/practice gap. This submission brings together, in five published papers, a body of work conducted by the candidate. Findings report that known barriers to action plan use (such as a lack of practitioner time) are symptomatic of deeper and more complex underlying factors. In particular, over-reliance on knowledge derived from randomised controlled trials and their systematic review, as the primary and sole source of evidence for healthcare practice, hindered the implementation of these plans. A lack of evidence reflecting the personal experience of using these plans in the real world, rather than in trial settings, contributed to a mismatch between what patients/carers want from asthma action plans and what they are currently being provided with by professionals. This submission illustrates the benefits of utilising a broader range of knowledge as a basis for clinical practice. The presented papers report how new and innovative research methodologies (including meta-ethnography and cross-study synthesis) can be used to synthesise individual studies reporting the personal experiences of patients and professionals and how such findings can then be used to better understand why interventions can be implemented in trial settings rather than everyday practice. Whilst these emerging approaches have great potential to contribute to evidence-based practice by, for example, strengthening the ‘weight’ of experiential knowledge, there are methodological challenges which, whilst acknowledged, have yet to be fully addressed

Best Practice Statements: Report of the Impact Evaluation Study

This evaluation investigated the dissemination, support and impact of the first five Best Practice Statements developed and launched by the Nursing and Midwifery Practice Development Unit (NMPDU), NHSScotland, in June 2002. The evaluation, funded by the NMPDU, was undertaken between March and August 2003. This investigation focused on the implementation and use of the Best Practice Statements from the perspective of nurses and midwives working in Scotland

Clinical and Biological Aspects of Disseminated Tumor Cells and Dormancy in Breast Cancer

Progress in detection and treatment have drastically improved survival for early breast cancer patients. However, distant recurrence causes high mortality and is typically considered incurable. Cancer dissemination occurs via circulating tumor cells (CTCs) and up to 75% of breast cancer patients could harbor micrometastatses at time of diagnosis, while metastatic recurrence often occurs years to decades after treatment. During clinical latency, disseminated tumor cells (DTCs) can enter a state of cell cycle arrest or dormancy at distant sites, and are likely shielded from immune detection and treatment. While this is a challenge, it can also be seen as an outstanding opportunity to target dormant DTCs on time, before their transformation into lethal macrometastatic lesions. Here, we review and discuss progress made in our understanding of DTC and dormancy biology in breast cancer. Strides in our mechanistic insights of these features has led to the identification of possible targeting strategies, yet, their integration into clinical trial design is still uncertain. Incorporating minimally invasive liquid biopsies and rationally designed adjuvant therapies, targeting both proliferating and dormant tumor cells, may help to address current challenges and improve precision cancer care

What constitutes effective problematic substance use treatment from the perspective of people who are homeless? A systematic review and meta-ethnography

Background: People experiencing homelessness have higher rates of problematic substance use but difficulty engaging with treatment services. There is limited evidence regarding how problematic substance use treatment should be delivered for these individuals. Previous qualitative research has explored perceptions of effective treatment by people who are homeless, but these individual studies need synthesised to generate further practice-relevant insights from the perspective of this group.Methods: Meta-ethnography was conducted to synthesise research reporting views on substance use treatment by people experiencing homelessness. Studies were identified through systematic searching of electronic databases (CINAHL; Criminal Justice Abstracts; Health Source; MEDLINE; PsycINFO; SocINDEX; Scopus; and Web of Science) and websites and were quality appraised. Original participant quotes and author interpretations were extracted and coded thematically. Concepts identified were compared to determine similarities and differences between studies. Findings were translated (reciprocally and refutationally) across studies, enabling development of an original over-arching line-of-argument and conceptual model.Results: Twenty-three papers published since 2002 in three countries, involving 462 participants, were synthesised. Findings broadly related, through personal descriptions of, and views on, the particular intervention components considered effective to people experiencing homelessness. Participants of all types of interventions had a preference for harm reduction-oriented services. Participants considered treatment effective when it provided: a facilitative service environment; compassionate and non-judgemental support; time; choices; and opportunities to (re)learn how to live. Interventions that were of longer duration and offered stability to service users were valued, especially by women. From the line-of-argument synthesis a new model was developed highlighting critical components of effective substance use treatment from the service user’s perspective, including a service context of good relationships, with person-centred care and an understanding of the complexity of people’s lives.Conclusion: This is the first meta-ethnography to examine the components of effective problematic substance use treatment from the perspective of those experiencing homelessness. Critical components of effective problematic substance use treatment are highlighted. The way in which services and treatment are delivered is more important than the type of treatment provided. Substance use interventions should address these components, including prioritising good relationships between staff and those using services, person-centred approaches, and a genuine understanding of individuals’ complex lives

Treatment non-adherence in pediatric long-term medical conditions: systematic review and synthesis of qualitative studies of caregivers’ views.

Background: Non-adherence to prescribed treatments is the primary cause of treatment failure in pediatric long-termconditions. Greater understanding of parents and caregivers’ reasons for non-adherence can help to address thisproblem and improve outcomes for children with long-term conditions.Methods: We carried out a systematic review and thematic synthesis of qualitative studies. Medline, Embase,Cinahl and PsycInfo were searched for relevant studies published in English and German between 1996 and 2011.Papers were included if they contained qualitative data, for example from interviews or focus groups, reporting theviews of parents and caregivers of children with a range of long-term conditions on their treatment adherence.Papers were quality assessed and analysed using thematic synthesis.Results: Nineteen papers were included reporting 17 studies with caregivers from 423 households in five countries.Long-term conditions included; asthma, cystic fibrosis, HIV, diabetes and juvenile arthritis. Across all conditions caregiverswere making on-going attempts to balance competing concerns about the treatment (such as perceived effectivenessor fear of side effects) with the condition itself (for instance perceived long-term threat to child). Although the barriersto implementing treatment regimens varied across the different conditions (including complexity and time-consumingnature of treatments, un-palatability and side-effects of medications), it was clear that caregivers worked hard toovercome these day-to-day challenges and to deal with child resistance to treatments. Yet, carers reported that stricttreatment adherence, which is expected by health professionals, could threaten their priorities around preserving familyrelationships and providing a ‘normal life’ for their child and any siblings.Conclusions: Treatment adherence in long-term pediatric conditions is a complex issue which needs to be seen in thecontext of caregivers balancing the everyday needs of the child within everyday family life. Health professionals maybe able to help caregivers respond positively to the challenge of treatment adherence for long-term conditions bysimplifying treatment regimens to minimise impact on family life and being aware of difficulties around child resistanceand supportive of strategies to attempt to overcome this. Caregivers would also welcome help with communicatingwith children about treatment goals

Healing of surgical site after total hip and knee replacements show similar telethermographic patterns

BACKGROUND: Isolated reports indicate the efficacy of infrared thermography for monitoring wound healing and septic complications, but no long-term analysis has ever been performed on this, and there are no data on the telethermographic patterns of surgical site healing after uncomplicated total hip prosthesis and after knee prosthesis. MATERIALS AND METHODS: In this prospective, observational, nonrandomized cohort study, two groups with forty consecutive patients each, who were operated on respectively for total hip and for total knee replacements, underwent telethermographic examination of the operated and contralateral joints prior to and at fixed intervals for up to 1\ua0year after uncomplicated surgery. A digital, portable telethermocamera and dedicated software were used for data acquisition and processing. RESULTS: No thermographic difference was observed preoperatively between the affected side and the contralateral side in both groups. After the intervention, a steep increase in the temperature of the operated joint was recorded after total hip replacement and after knee replacement, with a peak mean differential temperature measured three days postoperatively between the operated and unoperated joint of 3.1\ua0\ub1\ua00.8\ub0C after total hip replacement, and 3.4\ua0\ub1\ua00.7\ub0C after total knee replacement. Thereafter, the mean differential temperature declined slowly to 0.7\ua0\ub1\ua01.1\ub0C and to 0.5\ua0\ub1\ua01.3\ub0C at 60\ua0days, and to 0.0\ua0\ub1\ua01.0\ub0C and -0.1\ua0\ub1\ua01.1\ub0C 90\ua0days post-operatively, respectively. No further changes were observed for up to 1\ua0year after surgery. Results were similar when comparing the average telethermographic values of an elliptical area where the main axis corresponded to the surgical wound. CONCLUSIONS: The surgical sites after uncomplicated total hip or total knee replacement show similar telethermographic patterns for up to 1\ua0year from surgery, and can easily be monitored using a portable, digital, telethermocamera

Improving antibiotic use in hospitals: development of a digital antibiotic review tracking toolkit (DARTT) using the behaviour change wheel

Objective To develop a theory-informed behaviour change intervention to promote appropriate hospital antibiotic use, guided by the Medical Research Council’s complex interventions framework. MethodsA phased approach was used, including triangulation of data from meta-ethnography and two qualitative studies. Central to intervention design was the generation of a robust theoretical basis using the Behaviour Change Wheel to identify relevant determinants of behaviour change and intervention components. Intervention content was guided by APEASE (Acceptability, Practicability, Effectiveness, Affordability, Side-effects, Equity) criteria and coded using a Behaviour Change Technique Taxonomy. Stakeholders were involved throughout.ResultsFrom numerous modifiable prescribing behaviours identified, active ‘antibiotic time-out’ was selected as the target behaviour to help clinicians safely initiate antibiotic reassessment. Prescribers` capability, opportunity, and motivation were potential drivers for changing this behaviour. The design process resulted in the selection of 25 behaviour change techniques subsequently translated into intervention content. Integral to this work was the development and refinement of a Digital Antibiotic Review Tracking Toolkit. ConclusionThis novel work demonstrates how the Behaviour Change Wheel can be used with the Medical Research Council framework to develop a theory-based behaviour change intervention targeting barriers to timely hospital antibiotic reassessment. Future research will evaluate the Antibiotic Toolkit’s feasibility and effectiveness

A methodological systematic review of what’s wrong with meta-ethnography reporting.

Background: Syntheses of qualitative studies can inform health policy, services and our understanding of patient experience. Meta-ethnography is a systematic seven-phase interpretive qualitative synthesis approach well-suited to producing new theories and conceptual models. However, there are concerns about the quality of meta-ethnography reporting, particularly the analysis and synthesis processes. Our aim was to investigate the application and reporting of methods in recent meta-ethnography journal papers, focusing on the analysis and synthesis process and output.Methods: Methodological systematic review of health-related meta-ethnography journal papers published from 2012–2013. We searched six electronic databases, Google Scholar and Zetoc for papers using key terms including ‘meta-ethnography.’ Two authors independently screened papers by title and abstract with 100% agreement. We identified 32 relevant papers. Three authors independently extracted data and all authors analysed the application and reporting of methods using content analysis.Results: Meta-ethnography was applied in diverse ways, sometimes inappropriately. In 13% of papers the approach did not suit the research aim. In 66% of papers reviewers did not follow the principles of meta-ethnography. The analytical and synthesis processes were poorly reported overall. In only 31% of papers reviewers clearly described how they analysed conceptual data from primary studies (phase 5, ‘translation’ of studies) and in only one paper (3%) reviewers explicitly described how they conducted the analytic synthesis process (phase 6). In 38% of papers we could not ascertain if reviewers had achieved any new interpretation of primary studies. In over 30% of papers seminal methodological texts which could have informed methods were not cited.Conclusions: We believe this is the first in-depth methodological systematic review of meta-ethnography conduct and reporting. Meta-ethnography is an evolving approach. Current reporting of methods, analysis and synthesis lacks clarity and comprehensiveness. This is a major barrier to use of meta-ethnography findings that could contribute significantly to the evidence base because it makes judging their rigour and credibility difficult. To realise the high potential value of meta-ethnography for enhancing health care and understanding patient experience requires reporting that clearly conveys the methodology, analysis and findings. Tailored meta-ethnography reporting guidelines, developed through expert consensus, could improve reporting

Understanding the complexities of antibiotic prescribing behaviour in acute hospitals: a systematic review and meta-ethnography

Background: Antimicrobial resistance poses a serious global public health threat. Hospital misuse of antibiotics hascontributed to this problem and evidence-based interventions are urgently needed to change inappropriateprescribing practices. This paper reports the first theoretical stage of a longer-term project to improve antibioticprescribing in hospitals through design of an effective behaviour-change intervention.Methods: Qualitative synthesis using meta-ethnography of primary studies reporting doctors’ views andexperiences of antibiotic prescribing in hospitals for example, their barriers to appropriate prescribing. Twentyelectronic databases were systematically searched over a 10-year period and potential studies screened againsteligibility criteria. Included studies were quality-appraised. Original participant quotes and author interpretationswere extracted and coded thematically into NVivo. All study processes were conducted by two reviewers workingindependently with findings discussed with the wider team and key stakeholders. Studies were related by findingsinto clusters and translated reciprocally and refutationally to develop a new line-of-argument synthesis andconceptual model. Findings are reported using eMERGe guidance.Results: Fifteen papers (13 studies) conducted between 2007 and 2017 reporting the experiences of 336 doctors ofvarying seniority working in acute hospitals across seven countries, were synthesised. Study findings related in fourways which collectively represented multiple challenges to appropriate antibiotic medical prescribing in hospitals:loss of ownership of prescribing decisions, tension between individual care and public health concerns, evidence-based practice versus bedside medicine, and diverse priorities between different clinical teams. The resulting newline-of-argument and conceptual model reflected how these challenges operated on both micro- and macro-level,highlighting key areas for improving current prescribing practice, such as creating feedback mechanisms,normalising input from other specialties and reducing variation in responsibility for antibiotic decisions