Bringing Anglo-governmentality into public management scholarship : the case of evidence-based medicine in UK health care

The field of public administration and management exhibits a limited number of favored themes and theories, including influential New Public Management and Network Governance accounts of contemporary government. Can additional social science–based perspectives enrich its theoretical base, in particular, analyzing a long-term shift to indirect governance evident in the field? We suggest that a variant of Foucauldian analysis is helpful, namely “Anglo-governmentality.” Having reviewed the literatures, we apply this Anglo-governmentality perspective to two case studies of “post hierarchical” UK health care settings: first, the National Institute for Health and Clinical Excellence (NICE), responsible for producing evidence-based guidelines nationally, and the second, a local network tasked with enacting such guidelines into practice. Compared with the Network Governance narrative, the Anglo-governmentality perspective distinctively highlights (a) a power–knowledge nexus giving strong technical advice; (b) pervasive grey sciences, which produce such evidence-based guidelines; (c) the “subjectification” of local governing agents, herein analyzed using Foucauldian concepts of the “technology of the self” and “pastoral power”; and (d) the continuing indirect steering role of the advanced neoliberal health care State. We add to Anglo-governmentality literature by highlighting hybrid “grey sciences,” which include clinical elements and energetic self-directed clinical–managerial hybrids as local governing agents. These findings suggest that the State and segments of the medical profession form a loose ensemble and that professionals retain scope for colonizing these new arenas. We finally suggest that Anglo-governmentality theory warrants further exploration within knowledge-based public organizations

Conservative interventions for urinary incontinence in women: an overview of Cochrane systematic reviews

This is the protocol for a review and there is no abstract. The objectives are as follows:  To synthesise Cochrane reviews of conservative interventions, as described above, for the prevention or treatment of female urinary incontinence.Output Type: Protoco

Getting research findings into practice : when to act on the evidence.

There is increasing interest in providing evidence based health care—that is, care in which healthcare professionals, provider managers, those who commission health care, the public, and policymakers consistently consider research evidence when making decisions. Purchasers, for example, should be able to influence the organisation and delivery of care (such as for cancer and stroke services) and the type and content of services (such as using chiropractic for back pain or dilatation and curettage and drug treatment for menorrhagia). Policymakers should ensure that policies on treatment reflect and are consistent with research evidence, and that the incentive structure within the health system promotes cost effective practice. They must also ensure that there is an adequate infrastructure for monitoring changes in practice and for producing, gathering, summarising, and disseminating evidence. Clinicians determine the day to day care patients receive in healthcare systems, and user groups (for example, patients, their families, and their representatives) are also beginning to play an important role in influencing healthcare decisions

Interventions for behaviour change and self-management in stroke secondary prevention: protocol for an overview of reviews

Abstract Background Stroke secondary prevention guidelines recommend medication prescription and adherence, active education and behavioural counselling regarding lifestyle risk factors. To impact on recurrent vascular events, positive behaviour/s must be adopted and sustained as a lifestyle choice, requiring theoretically informed behaviour change and self-management interventions. A growing number of systematic reviews have addressed complex interventions in stroke secondary prevention. Differing terminology, inclusion criteria and overlap of studies between reviews makes the mechanism/s that affect positive change difficult to identify or replicate clinically. Adopting a two-phase approach, this overview will firstly comprehensively summarise systematic reviews in this area and secondly identify and synthesise primary studies in these reviews which provide person-centred, theoretically informed interventions for stroke secondary prevention. Methods An overview of reviews will be conducted using a systematic search strategy across the Cochrane Database of Systematic Reviews, PubMed and Epistomonikas. Inclusion criteria: systematic reviews where the population comprises individuals post-stroke or TIA and where data relating to person-centred risk reduction are synthesised for evidence of efficacy when compared to standard care or no intervention. Primary outcomes of interest include mortality, recurrent stroke and other cardiovascular events. In phase 1, two reviewers will independently (1) assess the eligibility of identified reviews for inclusion; (2) rate the quality of included reviews using the ROBIS tool; (3) identify unique primary studies and overlap between reviews; (4) summarise the published evidence supporting person-centred behavioural change and self-management interventions in stroke secondary prevention and (5) identify evidence gaps in this field. In phase 2, two independent reviewers will (1) examine person-centred, primary studies in each review using the Template for Intervention Description and Replication (TIDieR checklist), itemising, where present, theoretical frameworks underpinning interventions; (2) group studies employing theoretically informed interventions by the intervention delivered and by the outcomes reported (3) apply GRADE quality of evidence for each intervention by outcome/s identified from theoretically informed primary studies. Disagreement between reviewers at each process stage will be discussed and a third reviewer consulted. Discussion This overview will comprehensively bring together the best available evidence supporting person-centred, stroke secondary prevention strategies in an accessible format, identifying current knowledge gaps

From the Trenches: A Cross-Sectional Study Applying the GRADE Tool in Systematic Reviews of Healthcare Interventions

Background: GRADE was developed to address shortcomings of tools to rate the quality of a body of evidence. While much has been published about GRADE, there are few empirical and systematic evaluations. Objective: To assess GRADE for systematic reviews (SRs) in terms of inter-rater agreement and identify areas of uncertainty. Design: Cross-sectional, descriptive study. Methods: We applied GRADE to three SRs (n = 48, 66, and 75 studies, respectively) with 29 comparisons and 12 outcomes overall. Two reviewers graded evidence independently for outcomes deemed clinically important a priori. Inter-rater reliability was assessed using kappas for four main domains (risk of bias, consistency, directness, and precision) and overall quality of evidence. Results: For the first review, reliability was: k = 0.41 for risk of bias; 0.84 consistency; 0.18 precision; and 0.44 overall quality. Kappa could not be calculated for directness as one rater assessed all items as direct; assessors agreed in 41 % of cases. For the second review reliability was: 0.37 consistency and 0.19 precision. Kappa could not be assessed for other items; assessors agreed in 33 % of cases for risk of bias; 100 % directness; and 58 % overall quality. For the third review, reliability was: 0.06 risk of bias; 0.79 consistency; 0.21 precision; and 0.18 overall quality. Assessors agreed in 100 % of cases for directness. Precision created the most uncertainty due to difficulties in identifying ‘‘optimal’ ’ information size and ‘‘clinica

Responsiveness and construct validity of a symptom scale for acute otitis media

BACKGROUND:: Because resolution of symptoms is a primary goal of antimicrobial therapy in children with acute otitis media (AOM), measurement of symptoms in studies of antimicrobial effectiveness in such children is important. We have developed a scale for measuring symptoms of AOM in young children (AOM-SOS), and we present data on its construct validity and responsiveness. METHODS:: We followed children 3 months to 3 years of age with AOM, who were receiving antimicrobial treatment, using the AOM-SOS scale. The scale was administered at the enrollment visit, as a twice-a-day diary measure, and at the follow-up visit (days 5-7). To evaluate construct validity, we examined the correlation, at entry, between AOM-SOS scores and scores on other measures of pain and functional status. To evaluate the scale's responsiveness, we examined the change in scale scores from entry to follow-up. We also examined the levels of agreement between the scale scores and overall assessments of the children by parents. RESULTS:: We enrolled 70 children (mean age 12.5 months) of whom 57 returned for follow-up. The magnitude of the correlations between the AOM-SOS scale scores and other measures of pain and functional status ranged from 0.56 to 0.84. The responsiveness of the AOM-SOS, as measured by the standardized response mean was 1.20. CONCLUSIONS:: These data support the validity and responsiveness of the AOM-SOS; the scale seems to measure effectively both pain and overall functional status in young children with AOM. Changes in score over the first few days of illness were substantial and generally matched the assessments both of parents and of clinicians. The AOM-SOS promises to be useful as an outcome measure in clinical studies of AOM

Cautionary tales in the interpretation of clinical studies involving older persons

The care of patients 65 years or older presents a challenge for evidence-based medicine. Such patients are underrepresented in clinical trials, are more vulnerable to treatment-induced harm, and often are unable to fully participate in treatment decisions. We outline several cautionary themes in the interpretation of clinical studies of therapeutic interventions involving older persons as they apply to processes of everyday clinical decision making. In particular, we focus on issues of study design and quality of evidence, choice of outcome measures, missing outcome data, assessment of potential harm, quantifying treatment effects in individual patients (and adjusting these for effect modifiers and reduced life expectancy), eliciting patient values and preferences, prioritizing therapeutic goals and selection of treatments, and assisting patients in adhering to agreed therapeutic regimens. ©2010 American Medical Association. All rights reserved

Assessing and presenting summaries of evidence in Cochrane Reviews

Cochrane Reviews are intended to help providers, practitioners and patients make informed decisions about health care. The goal of the Cochrane Applicability and Recommendation Methods Group (ARMG) is to develop approaches, strategies and guidance that facilitate the uptake of information from Cochrane Reviews and their use by a wide audience with specific focus on developers of recommendations and on healthcare decision makers. This paper is part of a series highlighting developments in systematic review methodology in the 20 years since the establishment of The Cochrane Collaboration, and its aim is to present current work and highlight future developments in assessing and presenting summaries of evidence, with special focus on Summary of Findings (SoF) tables and Plain Language Summaries. A SoF table provides a concise and transparent summary of the key findings of a review in a tabular format. Several studies have shown that SoF tables improve accessibility and understanding of Cochrane Reviews. The ARMG and GRADE Working Group are working on further development of the SoF tables, for example by evaluating the degree of acceptable flexibility beyond standard presentation of SoF tables, developing SoF tables for diagnostic test accuracy reviews and interactive SoF tables (iSoF). The plain language summary (PLS) is the other main building block for dissemination of review results to end-users. The PLS aims to summarize the results of a review in such a way that health care consumers can readily understand them. Current efforts include the development of a standardized language to describe statistical results, based on effect size and quality of supporting evidence. Producing high quality PLS and SoF tables and making them compatible and linked would make it easier to produce dissemination products targeting different audiences (for example, providers, health policy makers, guideline developers). Current issues of debate include optimal presentation formats of SoF tables, the training required to produce SoF tables, and the extent to which the authors of Cochrane Reviews should provide explicit guidance to target audiences of patients, clinicians and policy-makers

Digitalis for treatment of heart failure in patients in sinus rhythm

<b>Background</b><p></p> Digitalis glycosides have been in clinical use for the treatment of heart failure (HF) for longer than 200 years. In recent years, several trials have been conducted to address concerns about their efficacy and toxicity.<p></p> <b>Objectives</b><p></p> To examine the effectiveness of digitalis glycosides in treating HF in patients with normal sinus rhythm. To examine the effects of digitalis in patients taking diuretics and angiotensin-converting enzyme inhibitors; in patients with varying severity and duration of disease; in patients with prior exposure to digitalis versus no prior exposure; and in patients with "HF due to systolic dysfunction" versus "HF with preserved ejection fraction."<p></p> <b>Search methods</b><p></p> Searches on the following databases were updated in May 2013: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Dissertation Abstracts. Annual meeting abstracts of the American Heart Association, the American College of Cardiology, and the European Society of Cardiology were searched from 1996 to March 2013. In addition, reference lists provided by the pharmaceutical industry (GlaxoSmithKline and Covis Pharma) were searched.<p></p> <b>Selection criteria</b><p></p> Included were randomized placebo-controlled trials of 20 or more adult participants of either sex with symptomatic HF who were studied for seven weeks or longer. Excluded were trials in which the prevalence of atrial fibrillation was 2% or greater, or in which any arrhythmia that might compromise cardiac function or any potentially reversible cause of HF such as acute ischemic heart disease or myocarditis was present.<p></p> <b>Data collection and analysis</b><p></p> Articles selected from the searches described above were evaluated in a joint effort of the review authors. The staff of the Cochrane Heart Group ran searches on the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE.<p></p> <b>Main results</b><p></p> No new studies were identified in the updated searches. Thirteen studies (7896 participants) are included, and major endpoints of mortality, hospitalization, and clinical status, based respectively on 8, 4, and 12 of these selected studies, were recorded and analyzed. The data show no evidence of a difference in mortality between treatment and control groups, whereas digitalis therapy is associated with lower rates of both hospitalization and clinical deterioration. The largest study, in which most participants were taking angiotensin-converting enzyme inhibitors, showed a significant rise in “other cardiac” deaths, possibly due to arrhythmias. However collectively, these findings were based on studies done before beta-blockers, as well as angiotensin receptor blockers and aldosterone antagonists, became widely used to treat HF.<p></p> <b>Authors' conclusions</b><p></p> The literature indicates that digitalis may have a useful role in the treatment of patients with HF who are in normal sinus rhythm. New trials are needed to elucidate the importance of the dosage of digitalis and its usefulness in the era of beta-blockers and other agents shown to be effective in treating HF.<p></p&gt