Guro Huby

The case study approach

The case study approach allows in-depth, multi-faceted explorations of complex issues in their real-life settings. The value of the case study approach is well recognised in the fields of business, law and policy, but somewhat less so in health services research. Based on our experiences of conducting several health-related case studies, we reflect on the different types of case study design, the specific research questions this approach can help answer, the data sources that tend to be used, and the particular advantages and disadvantages of employing this methodological approach. The paper concludes with key pointers to aid those designing and appraising proposals for conducting case study research, and a checklist to help readers assess the quality of case study reports.

From trial data to practical knowledge: qualitative study of how general practitioners have accessed and used evidence about statin drugs in their management of hypercholesterolaemia

Abstract Objectives To explore how general practitioners have accessed and evaluated evidence from trials on the use of statin lipid lowering drugs and incorporated this evidence into their practice. To draw out the practical implications of this study for strategies to integrate clinical evidence into general medical practice. DesignQualitative analysis of semistructured interviews. SettingGeneral practices in Lothian. Subjects24 general practitioners selected to obtain a heterogeneous sample. Results Respondents were generally aware of the evidence relating to the use of statins in secondary prevention of coronary heart disease, but they were less clear about the evidence in primary prevention. The benefits of statins in secondary prevention were clearer to them andthe social and economic issues less complex than was the case for use in primary prevention. Respondents rarely said they appraised the methods and content of trials, rather they judged the trustworthiness of the source of trial evidence and interpreted it within the context of the economic and social factors which impinge on their practice. Moreover, trial data become relevant for routinepractice only when underpinned by a consensus on these issues. Conclusion Strategies to promote incorporation of evidence from clinical trials into everyday practice are likely to be effective if they tap into and build on the process of local consensus building. Strategies such as teaching critical appraisal skills and guideline development may have little effect if they are separated from this process.

Increased Hospital-Based Physical Rehabilitation and Information Provision After Intensive Care Unit Discharge: The RECOVER Randomized Clinical Trial

IMPORTANCE Critical illness results in disability and reduced health-related quality of life (HRQOL), but the optimum timing and components of rehabilitation are uncertain. OBJECTIVE To evaluate the effect of increasing physical and nutritional rehabilitation plus information delivered during the post-intensive care unit (ICU) acute hospital stay by dedicated rehabilitation assistants on subsequent mobility, HRQOL, and prevalent disabilities. DESIGN, SETTING, AND PARTICIPANTS A parallel group, randomized clinical trial with blinded outcome assessment at 2 hospitals in Edinburgh, Scotland, of 240 patients discharged from the ICU between December 1, 2010, and January 31, 2013, who required at least 48 hours of mechanical ventilation. Analysis for the primary outcome and other 3-month outcomes was performed between June and August 2013; for the 6- and 12-month outcomes and the health economic evaluation, between March and April 2014. INTERVENTIONS During the post-ICU hospital stay, both groups received physiotherapy and dietetic, occupational, and speech/language therapy, but patients in the intervention group received rehabilitation that typically increased the frequency of mobility and exercise therapies 2- to 3-fold, increased dietetic assessment and treatment, used individualized goal setting, and provided greater illness-specific information. Intervention group therapy was coordinated and delivered by a dedicated rehabilitation practitioner. MAIN OUTCOMES AND MEASURES The Rivermead Mobility Index (RMI) (range 0-15) at 3 months; higher scores indicate greater mobility. Secondary outcomes included HRQOL, psychological outcomes, self-reported symptoms, patient experience, and cost-effectiveness during a 12-month follow-up (completed in February 2014). RESULTS Median RMI at randomization was 3 (interquartile range [IQR], 1-6) and at 3 months was 13 (IQR, 10-14) for the intervention and usual care groups (mean difference, -0.2 [95% CI, -1.3 to 0.9; P = .71]). The HRQOL scores were unchanged by the intervention (mean difference in the Physical Component Summary score, -0.1 [95% CI, -3.3 to 3.1; P = .96]; and in the Mental Component Summary score, 0.2 [95% CI, -3.4 to 3.8; P = .91]). No differences were found for self-reported symptoms of fatigue, pain, appetite, joint stiffness, or breathlessness. Levels of anxiety, depression, and posttraumatic stress were similar, as were hand grip strength and the timed Up & Go test. No differences were found at the 6- or 12-month follow-up for any outcome measures. However, patients in the intervention group reported greater satisfaction with physiotherapy, nutritional support, coordination of care, and information provision. CONCLUSIONS AND RELEVANCE Post-ICU hospital-based rehabilitation, including increased physical and nutritional therapy plus information provision, did not improve physical recovery or HRQOL, but improved patient satisfaction with many aspects of recovery. TRIAL REGISTRATION isrctn.com Identifier: ISRCTN09412438.

Reconciling the perspective of practitioner and service user: findings from The Aphasia in Scotland study

BACKGROUND It is widely accepted that service users should be actively involved in new service developments, but there remain issues about how best to consult with them and how to reconcile their views with those of service providers. AIMS This paper uses data from The Aphasia in Scotland study, set up by NHS Quality Improvement Scotland to identify the direction of the development of services for people with aphasia in Scotland. It examines the views both of those who provide and of those who receive those services. METHODS & PROCEDURES The study integrated findings from a questionnaire to all speech and language therapists treating people with aphasia across Scotland with findings from focus groups with service users and aphasia practitioners. OUTCOMES & RESULTS Three themes were identified: (1) public and professional awareness of the impact of aphasia on the individual and their family; (2) current service provision and gaps in services; and (3) directions for the future development of services and barriers to change. Although the impact of aphasia is well recognized amongst most professionals (that is, not just speech and language therapists), considerable concern was expressed about the level of knowledge amongst professionals who do not specialize in stroke care and about public awareness of aphasia. Service providers indicated a shift in the model of service delivery of which the service users were largely unaware. Although the majority of speech and language therapists spend most of their time providing one-to-one therapy, and this is valued by service users, there is undoubtedly an emerging shift towards a focus on broader social function and the inclusion of the person with aphasia in supportive social networks. This creates tensions because of the existing pressure for individualized models of delivery. Concern was expressed by practitioners, although not echoed by patients, about the transition from the acute sector to primary care. Practitioners also expressed concern about the introduction of more recent services like NHS 24 and e-health initiatives, which rely on means of communication that may be particularly challenging for people with aphasia. CONCLUSIONS & IMPLICATIONS The findings from this study indicate that although there are clearly common perspectives, the views of people with aphasia about services do not necessarily coincide with those of service providers. This is an important consideration when initiating consultation and highlights the need for clarity on the part of practitioners in identifying the aims and objectives of their services as far as people with aphasia are concerned.

Is multidisciplinary teamwork the key? A qualitative study of the development of respiratory services in the UK

Summary Objectives Using frameworks, such as the long-term conditions pyramid of healthcare, primary care organizations (PCOs) in England and Wales are exploring ways of developing services for people with long-term respiratory disease. We aimed to explore the current and planned respiratory services and the roles of people responsible for change. Setting A purposive sample of 30 PCOs in England and Wales. Design Semi-structured telephone interviews with the person responsible for driving the reconfiguration of respiratory services. Recorded interviews were transcribed and coded, and themes identified. The association of the composition of the team driving change with the breadth of services provided was explored using a matrix. Results All but two of the PCOs described clinical services developed to address the needs of people with respiratory conditions, usually with a focus on preventing admissions for chronic obstructive pulmonary disease (COPD). Although the majority identified the need to develop a strategic approach to service development and to meet educational needs of primary care professionals, relatively few described clearly developed plans for addressing these issues. Involvement of clinicians from both primary and secondary care was associated with a broad multifaceted approach to service development. Teamwork was often challenging, but could prove rewarding for participants and could result in a fruitful alignment of objectives. The imminent merger of PCOs and overriding financial constraints resulted in a ‘fluid’ context which challenged successful implementation of plans. Conclusions While the majority of PCOs are developing clinical services for people with complex needs (principally in order to reduce admissions), relatively few are addressing the broader strategic issues and providing for local educational needs. The presence of multidisciplinary teams, which integrated primary and secondary care clinicians with PCO management, was associated with more comprehensive service provision addressing the needs of all respiratory patients. Future research needs to provide insight into the structures, processes and inter-professional relationships that facilitate development of clinical, educational and policy initiatives which aim to enhance local delivery of respiratory care.

A randomised controlled trial evaluating a rehabilitation complex intervention for patients following intensive care discharge: the RECOVER study

Introduction Patients who survive an intensive care unit admission frequently suffer physical and psychological morbidity for many months after discharge. Current rehabilitation pathways are often fragmented and little is known about the optimum method of promoting recovery. Many patients suffer reduced quality of life. Methods and analysis The authors plan a multicentre randomised parallel group complex intervention trial with concealment of group allocation from outcome assessors. Patients who required more than 48 h of mechanical ventilation and are deemed fit for intensive care unit discharge will be eligible. Patients with primary neurological diagnoses will be excluded. Participants will be randomised into one of the two groups: the intervention group will receive standard ward-based care delivered by the NHS service with additional treatment by a specifically trained generic rehabilitation assistant during ward stay and via telephone contact after hospital discharge and the control group will receive standard ward-based care delivered by the current NHS service. The intervention group will also receive additional information about their critical illness and access to a critical care physician. The total duration of the intervention will be from randomisation to 3 months postrandomisation. The total duration of follow-up will be 12 months from randomisation for both groups. The primary outcome will be the Rivermead Mobility Index at 3 months. Secondary outcomes will include measures of physical and psychological morbidity and function, quality of life and survival over a 12-month period. A health economic evaluation will also be undertaken. Groups will be compared in relation to primary and secondary outcomes; quantitative analyses will be supplemented by focus groups with patients, carers and healthcare workers. Ethics and dissemination Consent will be obtained from patients and relatives according to patient capacity. Data will be analysed according to a predefined analysis plan. Trial registration The trial is registered as ISRCTN09412438 and funded by the Chief Scientist Office, Scotland.

Mind the gap between policy imperatives and service provision: a qualitative study of the process of respiratory service development in England and Wales

BackgroundHealthcare systems globally are reconfiguring to address the needs of people with long-term conditions such as respiratory disease. Primary Care Organisations (PCOs) in England and Wales are charged with the task of developing cost-effective patient-centred local models of care. We aimed to investigate how PCOs in England and Wales are reconfiguring their workforce to develop respiratory services, and the background factors influencing service redesign.MethodsSemi-structured qualitative telephone interviews with the person(s) responsible for driving respiratory service reconfiguration in a purposive sample of 30 PCOs. Interviews were recorded, transcribed, coded and thematically analysed.ResultsWe interviewed representatives of 30 PCOs with diverse demographic profiles planning a range of models of care. Although the primary driver was consistently identified as the need to respond to a central policy to shift the delivery of care for people with long-term conditions into the community whilst achieving financial balance, the design and implementation of services were subject to a broad range of local, and at times serendipitous, influences. The focus was almost exclusively on the complex needs of patients at the top of the long-term conditions (LTC) pyramid, with the aim of reducing admissions. Whilst some PCOs seemed able to develop innovative care despite uncertainty and financial restrictions, most highlighted many barriers to progress, describing initiatives suddenly shelved for lack of money, progress impeded by reluctant clinicians, plans thwarted by conflicting policies and a PCO workforce demoralised by job insecurity.ConclusionFor many of our interviewees there was a large gap between central policy rhetoric driving workforce change, and the practical reality of implementing change within PCOs when faced with the challenges of limited resources, diverse professional attitudes and an uncertain organisational context. Research should concentrate on understanding these complex dynamics in order to inform the policymakers, commissioners, health service managers and professionals.

What Comes Around Goes Around: On the Language and Practice of ‘Integration’ in Health and Social Care in Scotland

Rhetoric and reality lead separate lives when it comes to integrating health and social services in Scotland, and it is making planning and implementation difficult for practitioners of integration. This paper is a collaboration between a practitioner and two academics who teach, research and write about integration. It explores the views of other integration practitioners about the policy, language and nature of integration, and the issues practitioners are currently grappling with, especially how the policy language of ‘integration’ fails to connect with integration in practice. It appears that ‘integration’ has less to do with broad policy aspirations and principles of service (re)organisation, than with the specific aims, objectives and outcomes of individual projects delivered in very specific circumstances. Acknowledging the localisation of integration, and allowing the time for productive problem solving which can generate a new language, ought to be essential elements of integration.

Contributions Of Ethnography To The Study Of Public Services Management

Abstract Ethnography in the study of public service organizations is gaining acceptance, but the practice of ethnography is changing in line with epistemological concerns and new organizational realities. We outline a move away from ethnography as participant observation of micro process in spatially bounded settings. Work in contemporary organizations is embedded in relationships that cross boundaries, and relationships are not just between people, but also between people and human artefacts such as IT systems. ‘Multi-sited’ ethnography is an approach to understand and manage ‘the organization’ as connections, disruptions and fluid boundaries. Implications for ethnographys contributions to multi-disciplinary organizational research are suggested.

The incidence of cases of aphasia following first stroke referred to speech and language therapy services in Scotland

Background: Key to the provision of appropriate services is an understanding of the number of cases in a given population. This study examined the incidence of aphasia following first ever stroke. It was part of a larger study, the Aphasia in Scotland Study, which examined the provision of services for people with aphasia in Scotland. Aims: The present study examines the incidence of aphasia referred to speech and language therapy services in people who have experienced their first ever stroke. The specific questions addressed were: What is the incidence of aphasia following first ever stroke? What is the percentage of aphasia following first ever stroke? What are the crude figures for aphasia following first ever stroke by age? What are the crude figures for aphasia following first ever stroke by gender? What are the crude figures for aphasia following first ever stroke by severity? Methods & Procedures: All 14 health boards in Scotland were approached but only 3, NHS Borders, Orkney, and Shetland, were able to provide the level of information required. Respondents were asked to provide information about the age and gender and level of communication need of referred cases over a given year. Outcomes & Results: Results suggested that the incidence of aphasia following first ever stroke was found to be 54, 57, and 77.5 per 100,000, for NHS Borders, Orkney, and Shetland respectively. This is slightly higher than in other comparable studies. The percentage of new cases of aphasia following a first ever stroke across NHS Borders, Orkney, and Shetland was 19, 22, and 34% respectively. The variability across the three sites is probably a function of the potential effect of small changes in the relatively low numbers. The majority of cases were, unsurprisingly, over 65 years of age but a substantial minority—17% (Shetland), 26% (Borders) and 36% (Orkney)—were below 65 years of age. One third of new cases resulted in severe aphasia. Although the proportions of men and women with aphasia were similar, women tended to be older at the point at which they experienced their first stroke. Conclusions: The results are discussed in terms the practicalities of this sort of data collection exercise and the implications of the results for service delivery. There is a need for comparable local data collection exercises tied in to current epidemiological studies.