Between analysis and transformation: technology, methodology and evaluation on the SPLICE project

This paper concerns the ways in which technological change may entail methodological development in e-learning research. The focus of our argument centres on the subject of evaluation in e-learning and how technology can contribute to consensus-building on the value of project outcomes, and the identification of mechanisms behind those outcomes. We argue that a critical approach to the methodology of evaluation which harnesses technology in this way is vital to agile and effective policy and strategy-making in institutions as the challenges of transformation in a rapidly changing educational and technological environment are grappled with. With its focus on mechanisms and multiple stakeholder perspectives, we identify Pawson and Tilley’s ‘Realistic Evaluation’ as an appropriate methodological approach for this purpose, and we report on its use within a JISC-funded project on social software, SPLICE (Social Practices, Learning and Interoperability in Connected Environments). The project created new tools to assist the identification of mechanisms responsible for change to personal and institutional technological practice. These tools included collaborative mind-mapping and focused questioning, and tools for the animated modelling of complex mechanisms. By using these tools, large numbers of project stakeholders could engage in a process where they were encouraged to articulate and share their theories and ideas as to why project outcomes occurred. Using the technology, this process led towards the identification and agreement of common mechanisms which had explanatory power for all stakeholders. In conclusion, we argue that SPLICE has shown the potential of technologically-mediated Realistic Evaluation. Given the technologies we now have, a methodology based on the mass cumulation of stakeholder theories and ideas about mechanisms is feasible. Furthermore, the summative outcomes of such a process are rich in explanatory and predictive power, and therefore useful to the immediate and strategic problems of the sector. Finally, we argue that as well as generating better explanations for phenomena, the evaluation process can itself become transformative for stakeholders

The Epidemiology of Multimorbidity in Primary Care

Background: Multimorbidity places a substantial burden on patients and the healthcare system but few contemporary data are available. Aim: To describe the epidemiology of multimorbidity in adults in England and quantify associations between multimorbidity and health service utilisation. Design: Retrospective cohort study Setting: A random sample of 403,985 adult patients (≥18 years) in England who were registered with a general practice on 1 January 2012 and included in the Clinical Practice Research Datalink. Methods: We defined multimorbidity as having two or more of 36 long-term conditions recorded in patients’ medical records and quantified associations between multimorbidity and health service utilisation (GP consultations, prescriptions, and hospitalisations) over four years. Results: 27.2% of patients were multimorbid. The most prevalent conditions were hypertension (18.2%), depression or anxiety (10.3%), and chronic pain (10.1%). Prevalence of multimorbidity was higher in females than males (30% vs. 24.4% respectively) and among those with lower socioeconomic status (33.8% in the most deprived quintile vs. 24.2% in the least deprived quintile). Physical-mental comorbidity contributed a much greater proportion of overall morbidity in both younger patients and those patients with lower socioeconomic status. Multimorbidity was strongly associated with health service utilisation. Multimorbid patients accounted for 53% of GP consultations, 79% of prescriptions, and 56% percent of hospital admissions. Conclusion: Multimorbidity is common, socially patterned, and associated with increased health service utilisation. These findings support the need to improve the quality and efficiency of health services providing care to multimorbid patients at the practice and national-level.This study received no specific funding. Kirsty Rhodes was supported by the UK Medical Research Council (grant number: U105260558)

Opportunities for shared decision-making about major surgery with high-risk patients: a multi-method qualitative study

Background: Little is known about the opportunities for shared decision-making when older high-risk patients are offered major surgery. This study examines how, when, and why clinicians and patients can share decision-making about major surgery. Methods: This was a multi-method qualitative study, combining video recordings of preoperative consultations, interviews, and focus groups (33 patients, 19 relatives, 36 clinicians), with observations and documentary analysis in clinics in five hospitals in the UK undertaking major orthopaedic, colorectal, and/or cardiac surgery. Results: Three opportunities for shared decision-making about major surgery were identified. Resolution-focused consultations (cardiac/colorectal) resulted in a single agreed preferred option related to a potentially life-threatening problem, with limited opportunities for shared decision-making. Evaluative and deliberative consultations offered more opportunity. The former focused on assessing the likelihood of benefits of surgery for a presenting problem that was not a threat to life for the patient (e.g., orthopaedic consultations) and the latter (largely colorectal) involved discussion of a range of options while also considering significant comorbidities and patient preferences. The extent to which opportunities for shared decision-making were available, and taken up by surgeons, was influenced by the nature of the presenting problem, clinical pathway, and patient trajectory. Conclusions: Decisions about major surgery were not always shared between patients and doctors. The nature of the presenting problem, comorbidities, clinical pathways, and patient trajectories all informed the type of consultation and opportunities for sharing decision-making. Our findings have implications for clinicians, with shared decision-making about major surgery most feasible when the focus is on life-enhancing treatment

Characteristics, service use and mortality of clusters of multimorbid patients in England: a population-based study

Abstract: Background: Multimorbidity is associated with mortality and service use, with specific types of multimorbidity having differential effects. Additionally, multimorbidity is often negatively associated with participation in research cohorts. Therefore, we set out to identify clusters of multimorbidity patients and how they are differentially associated with mortality and service use across age groups in a population-representative sample. Methods: Linked primary and secondary care electronic health records contributed by 382 general practices in England to the Clinical Practice Research Datalink (CPRD) were used. The study included a representative set of multimorbid adults (18 years old or more, N = 113,211) with two or more long-term conditions (a total of 38 conditions were included). A random set of 80% of the multimorbid patients (N = 90,571) were stratified by age groups and clustered using latent class analysis. Consistency between obtained multimorbidity phenotypes, classification quality and associations with demographic characteristics and primary outcomes (GP consultations, hospitalisations, regular medications and mortality) was validated in the remaining 20% of multimorbid patients (N = 22,640). Results: We identified 20 patient clusters across four age strata. The clusters with the highest mortality comprised psychoactive substance and alcohol misuse (aged 18–64); coronary heart disease, depression and pain (aged 65–84); and coronary heart disease, heart failure and atrial fibrillation (aged 85+). The clusters with the highest service use coincided with those with the highest mortality for people aged over 65. For people aged 18–64, the cluster with the highest service use comprised depression, anxiety and pain. The majority of 85+-year-old multimorbid patients belonged to the cluster with the lowest service use and mortality for that age range. Pain featured in 13 clusters. Conclusions: This work has highlighted patterns of multimorbidity that have implications for health services. These include the importance of psychoactive substance and alcohol misuse in people under the age of 65, of co-morbid depression and coronary heart disease in people aged 65–84 and of cardiovascular disease in people aged 85+

The meaning of materiality: reconsidering the materiality of Gramscian IR

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Fluid Optimisation in Emergency Laparotomy (FLO-ELA) Trial: study protocol for a multi-centre randomised trial of cardiac output-guided fluid therapy compared to usual care in patients undergoing major emergency gastrointestinal surgery

INTRODUCTION: Postoperative morbidity and mortality in patients undergoing major emergency gastrointestinal surgery are a major burden on healthcare systems. Optimal management of perioperative intravenous fluids may reduce mortality rates and improve outcomes from surgery. Previous small trials of cardiac-output guided haemodynamic therapy algorithms in patients undergoing gastrointestinal surgery have suggested this intervention results in reduced complications and a modest reduction in mortality. However, this existing evidence is based mainly on elective (planned) surgery, with little evaluation in the emergency setting. There are fundamental clinical and pathophysiological differences between the planned and emergency surgical setting which may influence the effects of this intervention. A large definitive trial in emergency surgery is needed to confirm or refute the potential benefits observed in elective surgery and to inform widespread clinical practice. METHODS: The FLO-ELA trial is a multi-centre, parallel-group, open, randomised controlled trial. 3138 patients aged 50 and over undergoing major emergency gastrointestinal surgery will be randomly allocated in a 1:1 ratio using minimisation to minimally invasive cardiac output monitoring to guide protocolised administration of intra-venous fluid, or usual care without cardiac output monitoring. The trial intervention will be carried out during surgery and for up to 6 h postoperatively. The trial is funded through an efficient design call by the National Institute for Health and Care Research Health Technology Assessment (NIHR HTA) programme and uses existing routinely collected datasets for the majority of data collection. The primary outcome is the number of days alive and out of hospital within 90 days of randomisation. Participants and those delivering the intervention will not be blinded to treatment allocation. Participant recruitment started in September 2017 with a 1-year internal pilot phase and is ongoing at the time of publication. DISCUSSION: This will be the largest contemporary randomised trial examining the effectiveness of perioperative cardiac output-guided haemodynamic therapy in patients undergoing major emergency gastrointestinal surgery. The multi-centre design and broad inclusion criteria support the external validity of the trial. Although the clinical teams delivering the trial interventions will not be blinded, significant trial outcome measures are objective and not subject to detection bias. TRIAL REGISTRATION: ISRCTN 14729158. Registered on 02 May 2017

Potential unique causes of burnout for chiropractic professionals

Objective The objective of this narrative review is to discuss the potential for burnout in chiropractic practitioners. This discussion is grounded in the job demands-resource model, the conservation of resources model, the unique profession-specific stressors experienced by chiropractors, and information from similar health care professions. Methods A search using both the indexed (PubMed and PsychLit) and nonindexed psychosocial literature was used. Other resources included the Cochrane Library, articles from governing bodies of the chiropractic profession, trade magazines, and research conferences and symposium proceedings. Articles were analyzed following the grounded theory principles: open coding and memos for conceptual labeling, axial coding and memos for category building, and selective coding for model building. Results Potential stressors unique to doctors of chiropractic include factors associated with physical workload, role stress, and mental and emotional demands. Conclusions There are unique chiropractic-specific occupational characteristics that possibly contribute to burnout in the chiropractic professionals. These findings emphasize the need for assessing and measuring burnout and attrition within the chiropractic profession

Buber, educational technology, and the expansion of dialogic space

Buber’s distinction between the ‘I-It’ mode and the ‘I-Thou’ mode is seminal for dialogic education. While Buber introduces the idea of dialogic space, an idea which has proved useful for the analysis of dialogic education with technology, his account fails to engage adequately with the role of technology. This paper offers an introduction to the significance of the I-It/I-Thou duality of technology in relation to opening dialogic space. This is followed by a short schematic history of educational technology which reveals the role technology plays, not only in opening dialogic space, but also in expanding dialogic space. The expansion of dialogic space is an expansion of what it means to be ‘us’ as dialogic engagement facilitates the incorporation, into our shared sense of identity, of aspects of reality that are initially experienced as alien or ‘other’. Augmenting Buber with an alternative understanding of dialogic space enables us to see how dialogue mediated by technology, as well as dialogue with monologised fragments of technology (robots), can, through education, lead to an expansion of what it means to be human