A clinical informaticist to support primary care decision making

Objectives—To develop and evaluate an information service in which a "clinical informaticist" (a GP with training in evidence-based medicine) provided evidence-based answers to questions posed by GPs and nurse practitioners. Design—Descriptive pilot study with systematic recording of the process involved in searching for and critically appraising literature. Evaluation by questionnaire and semi-structured interview. Setting—General practice. Participants—34 clinicians from two London primary care groups (Fulham and Hammersmith). Main outcome measures—Number and origin of questions; process and time involved in producing summaries; satisfaction with the service. Results—All 100 clinicians in two primary care groups were approached. Thirty four agreed to participate, of whom 22 asked 60 questions over 10 months. Participants were highly satisfied with the summaries they received. For one third of questions the clinicians stated they would change practice in the index patient, and for 55% the participants stated they would change practice in other patients. Answering questions thoroughly was time consuming (median 130 minutes). The median turnaround time was 9 days; 82% of questions were answered within the timeframe specified by the questioner. Without the informaticist, one third of questions would not have been pursued. Conclusion—The clinical informaticist service increased access to evidence for busy clinicians. Satisfaction was high among users and clinicians stated that changes in practice would occur. However, uptake of the service was lower than expected (22% of those offered the service). Further research is needed into how this method of increasing access to evidence compares with other strategies, and whether it results in improved health outcomes for patients

A meta-narrative review of electronic patient records

This session comprises four papers that consider how systematic review methods may be developed in order to make the best use of complex evidence in education and health. The methods and approaches reflected upon in these papers are not drawn from a single research tradition, but share a common goal of broadening the methodological scope of systematic reviews and better understanding the utilisation of knowledge produced in this way. The first paper (Henry Potts) reports an ongoing review using a meta-narrative approach to make sense of the diverse sources of knowledge regarding electronic patient records. The review method has stressed the importance of understanding knowledge from within the research tradition in which it was produced; it is argued that this has important implications for the way that evidence is utilised in the policy making process. The second paper (Geoff Wong) reflects upon the experience of using an explicit realist approach in the synthesis of the evidence in Internet based learning. This realist synthesis offers a method of making sense of the highly heterogeneous and context dependent evidence which exists in this field thus enabling greater insights into what makes such educational interventions ‘work’. The third paper (Rod Sheaff) reports a review of the predominantly qualitative research literature on organisational structures and their impacts upon policy outcomes in health systems. A scoping study found 14389 relevant papers of which 1568 were selected for review. These studies were very variable in the amount and quality of the qualitative data, hence 'evidence', which they reported. The paper describes an attempt to adapt realist methods so as to synthesise such bodies of research in ways which take account of this variation in the strength of qualitative evidence. The fourth paper (Mark Pearson) draws upon the work of Donald Campbell and colleagues in order to gain a fuller understanding of how systematic reviews are utilised in the policy making process. It is argued that interpretive approaches to understanding policy making (such as rhetorical analysis) need to be tempered with a more nuanced understanding of research validity. The case is made that interpretive approaches not only can, but should, be melded with research validity to increase understanding of the policy making process

Living with polypharmacy: a narrative interview study with older Pakistanis in East London.

BACKGROUND: Polypharmacy is a growing and major public health issue. It can be burdensome and risky for patients and costly to healthcare systems. Older adults and those from ethnic minority backgrounds are disproportionately affected by polypharmacy. This study focuses on medication practices among Urdu-speaking Pakistani patients, a significant ethnic group in the UK. Most existing research on medication practices within South-Asian communities centres on adherence, leaving the social and moral dimensions of polypharmacy unpacked. Understanding how British Pakistani patients understand and manage polypharmacy in the context of their daily lives is crucial to avoiding harmful polypharmacy. METHODS: In-depth narrative interviews were conducted with 15 first-generation Pakistani patients using the Biographical Narrative Interview Method. Participants were recruited from GP practices in East London. All participants were prescribed ten or more regular medications (a pragmatic marker of 'higher risk' polypharmacy) and were aged over 50. Interviews were conducted with a bilingual researcher at home and were designed to elicit narratives of patients' experiences of polypharmacy in the context of their biographies and daily lives. RESULTS: Polypharmacy is enacted through networks of interpersonal and socio-material relationships. The doctor-patient relationship and the family network held particular significance to study participants. In addition, participants described emotional bonds between themselves and their medicines, identifying them as 'forces for good'-substances which allowed them to maintain their health through the intercession of God. Meanings attributed to medicines and enacted through these social, emotional, and spiritual relationships contributed to emerging and sustaining polypharmacy. CONCLUSIONS: Patients make sense of and manage treatments in culturally specific ways. Developing an understanding of how medication practices in different communities are enacted is important for informing meaningful and effective conversations with patients about their medicines. Our findings contribute to enabling the integration of culturally sensitive approaches to prescribing

Caring for the patient, caring for the record: an ethnographic study of 'back office' work in upholding quality of care in general practice

© 2015 Swinglehurst and Greenhalgh; licensee BioMed Central. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly credited. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.Additional file 1: Box 1. Field notes on summarising (Clover Surgery). Box 2. Extract of document prepared for GPs by summarisers at Clover Surgery. Box 3. Fieldnotes on coding incoming post, Clover (original notes edited for brevity).This work was funded by a research grant from the UK Medical Research Council (Healthcare Electronic Records in Organisations 07/133) and a National Institute of Health Research doctoral fellowship award for DS (RDA/03/07/076). The funders were not involved in the selection or analysis of data nor did they make any contribution to the content of the final manuscript

Computer templates in chronic disease management: ethnographic case study in general practice

This work was funded by a research grant from the UK Medical Research Council (Healthcare Electronic Records in Organisations, 07/133) and a National Institute for Health Research Doctoral Fellowship Award (RDA/03/07/076) for D

'Cosmetic boob jobs' or evidence-based breast surgery: an interpretive policy analysis of the rationing of 'low value' treatments in the English National Health Service

BACKGROUND: In England the National Health Service (NHS) is not allowed to impose 'blanket bans' on treatments, but local commissioners produce lists of 'low value' procedures that they will normally not fund. Breast surgery is one example. However, evidence suggests that some breast surgery is clinically effective, with significant health gain. National guidelines indicate the circumstances under which breast surgery should be made available on the NHS, but there is widespread variation in their implementation.The purpose of this study was to explore the work practices of 'individual funding request' (IFR) panels, as they considered 'one-off' funding requests for breast surgery; examine how the notion of 'value' is dialogically constructed, and how decisions about who is deserving of NHS funding and who is not are accomplished in practice. METHODS: We undertook ethnographic exploration of three IFR panels. We extracted all (22) breast surgery cases considered by these panels from our data set and progressively focused on three case discussions, one from each panel, covering the three main breast procedures.We undertook a microanalysis of the talk and texts arising from these cases, within a conceptual framework of interpretive policy analysis. RESULTS: Through an exploration of the symbolic artefacts (language, objects and acts) that are significant carriers of policy meaning, we identified the ways in which IFR panels create their own 'interpretive communities', within which deliberations about the funding of breast surgery are differently framed, and local decisions come to be justified. In particular, we demonstrated how each decision was contingent on [a] the evaluative accent given to certain words, [b] the work that documentary objects achieve in foregrounding particular concerns, and [c] the act of categorising. Meaning was constructed dialogically through local interaction and broader socio-cultural discourses about breasts and 'cosmetic' surgery. CONCLUSION: Despite the appeal of calls to tackle 'unwarranted variation' in access to low priority treatments by ensuring uniformity of local guidelines and policies, our findings suggest that ultimately, given the contingent nature of practice, this is likely to remain an illusory policy goal. Our findings challenge the scientistic thinking underpinning mainstream health policy discourse

'Timely' diagnosis of dementia: what does it mean? A narrative analysis of GPs' accounts

This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors