Julie Peconi

What are the highest priorities for research in emergency prehospital care

The recent UK Department of Health publication “ Taking Healthcare to the Patient: Transforming NHS Ambulance Services ”1 recommended that the Department of Health should commission a programme of work to build the evidence base for the delivery of emergency and unscheduled prehospital care. As a starting point, the Department of Health commissioned the 999 EMS Research Forum to review the evidence base for the delivery of emergency prehospital care; to identify gaps in the evidence base; and to prioritise topics for future research. The 999 EMS Research Forum is a partnership of academics, clinicians and prehospital care practitioners and managers formed in 1999, whose aim is to encourage, promote and disseminate research and evidence-based policy and practice in 999 health care. Prioritisation of research topics is a key part of the process of commissioning of research, although methods may differ.2 3 The desirability of including a wide range of stakeholders in a structured approach has been stressed, in order to achieve a credible result that may be more likely to produce research that informs policy and practice.4–6 This emergency prehospital care research prioritisation exercise included …

Qualitative research within trials: developing a standard operating procedure for a clinical trials unit

BackgroundQualitative research methods are increasingly used within clinical trials to address broader research questions than can be addressed by quantitative methods alone. These methods enable health professionals, service users, and other stakeholders to contribute their views and experiences to evaluation of healthcare treatments, interventions, or policies, and influence the design of trials. Qualitative data often contribute information that is better able to reform policy or influence design.MethodsHealth services researchers, including trialists, clinicians, and qualitative researchers, worked collaboratively to develop a comprehensive portfolio of standard operating procedures (SOPs) for the West Wales Organisation for Rigorous Trials in Health (WWORTH), a clinical trials unit (CTU) at Swansea University, which has recently achieved registration with the UK Clinical Research Collaboration (UKCRC). Although the UKCRC requires a total of 25 SOPs from registered CTUs, WWORTH chose to add an additional qualitative-methods SOP (QM-SOP).ResultsThe qualitative methods SOP (QM-SOP) defines good practice in designing and implementing qualitative components of trials, while allowing flexibility of approach and method. Its basic principles are that: qualitative researchers should be contributors from the start of trials with qualitative potential; the qualitative component should have clear aims; and the main study publication should report on the qualitative component.ConclusionsWe recommend that CTUs consider developing a QM-SOP to enhance the conduct of quantitative trials by adding qualitative data and analysis. We judge that this improves the value of quantitative trials, and contributes to the future development of multi-method trials.

Equity and service innovation: the implementation of a bibliotherapy scheme in Wales

OBJECTIVE Book Prescription Wales (BPW) is a pilot bibiliotherapy scheme launched in July 2005 as a primary care treatment option for people with mild to moderate mental health problems. In an innovative model, patients are prescribed self-help books from a list, to borrow from local libraries. Our objective was to evaluate its implementation, focusing on the issue of equity of service delivery. METHODS Data were gathered from Welsh Assembly Government concerning project set-up and borrowing rates. Mailed questionnaires were completed by 21/22 (95.4%) Local Health Boards and 44/64 (68.8%) Community Mental Health Teams. In addition, 327 out of 497 (66%) primary care practices were surveyed by telephone, 20 prescribers took part in in-depth telephone interviews and three focus groups were conducted with library staff. RESULTS From July 2005-March 2006, books were borrowed 15,236 times. There was a 10-fold variation in borrowing rates across local authorities (1.07 to 10.18 loans/1000 people). The priority which Local Health Board staff reported giving to the scheme varied. Uptake among prescribers was mixed: in 35% of general practices (n = 116) no-one participated. Prescribers reported different ways of using the bibliotherapy scheme. Library staff reported issues of patchy uptake. CONCLUSION Variation in usage of bibliotherapy raises questions about equity; it is unlikely to reflect the distribution of people who could potentially benefit. Factors influencing variation existed all along the implementation chain. It is not always possibly to separate demand-side and supply-side factors when considering equity and service innovation in health care.

Paramedic Assessment of Older Adults After Falls, Including Community Care Referral Pathway: Cluster Randomized Trial

Study objective: We aim to determine clinical and cost‐effectiveness of a paramedic protocol for the care of older people who fall. Methods: We undertook a cluster randomized trial in 3 UK ambulance services between March 2011 and June 2012. We included patients aged 65 years or older after an emergency call for a fall, attended by paramedics based at trial stations. Intervention paramedics could refer the patient to a community‐based falls service instead of transporting the patient to the emergency department. Control paramedics provided care as usual. The primary outcome was subsequent emergency contacts or death. Results: One hundred five paramedics based at 14 intervention stations attended 3,073 eligible patients; 110 paramedics based at 11 control stations attended 2,841 eligible patients. We analyzed primary outcomes for 2,391 intervention and 2,264 control patients. One third of patients made further emergency contacts or died within 1 month, and two thirds within 6 months, with no difference between groups. Subsequent 999 call rates within 6 months were lower in the intervention arm (0.0125 versus 0.0172; adjusted difference –0.0045; 95% confidence interval –0.0073 to –0.0017). Intervention paramedics referred 8% of patients (204/2,420) to falls services and left fewer patients at the scene without any ongoing care. Intervention patients reported higher satisfaction with interpersonal aspects of care. There were no other differences between groups. Mean intervention cost was

Involving older people in a multi-centre randomised trial of a complex intervention in pre-hospital emergency care: implementation of a collaborative model

23 per patient, with no difference in overall resource use between groups at 1 or 6 months. Conclusion: A clinical protocol for paramedics reduced emergency ambulance calls for patients attended for a fall safely and at modest cost.

Evaluating the effectiveness of different approaches to home support for people in later stage dementia:A protocol for an observational study

BackgroundHealth services research is expected to involve service users as active partners in the research process, but few examples report how this has been achieved in practice in trials. We implemented a model to involve service users in a multi-centre randomised controlled trial in pre-hospital emergency care. We used the generic Standard Operating Procedure (SOP) from our Clinical Trials Unit (CTU) as the basis for creating a model to fit the context and population of the SAFER 2 trial.MethodsIn our model, we planned to involve service users at all stages in the trial through decision-making forums at 3 levels: 1) strategic; 2) site (e.g. Wales; London; East Midlands); 3) local. We linked with charities and community groups to recruit people with experience of our study population. We collected notes of meetings alongside other documentary evidence such as attendance records and study documentation to track how we implemented our model.ResultsWe involved service users at strategic, site and local level. We also added additional strategic level forums (Task and Finish Groups and Writing Days) where we included service users. Service user involvement varied in frequency and type across meetings, research stages and locations but stabilised and increased as the trial progressed.ConclusionInvolving service users in the SAFER 2 trial showed how it is feasible and achievable for patients, carers and potential patients sharing the demographic characteristics of our study population to collaborate in a multi-centre trial at the level which suited their health, location, skills and expertise. A standard model of involvement can be tailored by adopting a flexible approach to take account of the context and complexities of a multi-site trial.Trial registrationCurrent Controlled Trials ISRCTN60481756. Registered: 13 March 2009

Qualitative research within trials

BACKGROUND Dementia is a major health problem with a growing number of people affected by the condition, both directly and indirectly through caring for someone with dementia. Many live at home but little is known about the range and intensity of the support they receive. Previous studies have mainly reported on discrete services within a single geographical area. This paper presents a protocol for study of different services across several sites in England. The aim is to explore the presence, effects, and cost-effectiveness of approaches to home support for people in later stage dementia and their carers. METHODS This is a prospective observational study employing mixed methods. At least 300 participants (people with dementia and their carers) from geographical areas with demonstrably different ranges of services available for people with dementia will be selected. Within each area, participants will be recruited from a range of services. Participants will be interviewed on two occasions and data will be collected on their characteristics and circumstances, quality of life, carer health and burden, and informal and formal support for the person with dementia. The structured interviews will also collect qualitative data to explore the perceptions of older people and carers. CONCLUSIONS This national study will explore the components of appropriate and effective home support for people with late stage dementia and their carers. It aims to inform commissioners and service providers across health and social care.

Advice given by NHS Direct in Wales: do deprived patients get more urgent decisions? Study of routine data

BackgroundQualitative research methods are increasingly used within clinical trials to address broader research questions than can be addressed by quantitative methods alone. These methods enable health professionals, service users, and other stakeholders to contribute their views and experiences to evaluation of healthcare treatments, interventions, or policies, and influence the design of trials. Qualitative data often contribute information that is better able to reform policy or influence design.MethodsHealth services researchers, including trialists, clinicians, and qualitative researchers, worked collaboratively to develop a comprehensive portfolio of standard operating procedures (SOPs) for the West Wales Organisation for Rigorous Trials in Health (WWORTH), a clinical trials unit (CTU) at Swansea University, which has recently achieved registration with the UK Clinical Research Collaboration (UKCRC). Although the UKCRC requires a total of 25 SOPs from registered CTUs, WWORTH chose to add an additional qualitative-methods SOP (QM-SOP).ResultsThe qualitative methods SOP (QM-SOP) defines good practice in designing and implementing qualitative components of trials, while allowing flexibility of approach and method. Its basic principles are that: qualitative researchers should be contributors from the start of trials with qualitative potential; the qualitative component should have clear aims; and the main study publication should report on the qualitative component.ConclusionsWe recommend that CTUs consider developing a QM-SOP to enhance the conduct of quantitative trials by adding qualitative data and analysis. We judge that this improves the value of quantitative trials, and contributes to the future development of multi-method trials.

Telenursing in the UK: A Brief Profile of National Health Service Direct

Background In the UK, National Health Service Direct Wales (NHSDW) uses computerised decision support software to advise patients on appropriate care. However, the effect of deprivation on the advice given is not known. We aimed to estimate the effect of deprivation on advice given by nurses in NHSDW adjusting for confounding variables. Methods We included 400 000 calls to NHSDW between January 2002 and June 2004. We used logistic regression to model the effect of deprivation on advice given by nurses in response to calls seeking advice or information. We analysed two outcomes: receiving advice to phone 999 emergency care rather than to seek other care and receiving advice to seek care face to face rather than self-care. Results After adjustment for covariates, an increase in deprivation from one-fifth of the distribution to the next fifth increased by 13% the probability that those calling for advice rather than information received advice to phone 999 (OR 1.127; 95% CI from 1.113 to 1.143). Deprivation increased the corresponding probability of being advised to seek care face to face rather than self-care by 5% (OR 1.049; 95% CI from 1.041 to 1.058) within advice calls and by 3% (OR 1.034; 95% CI from 1.022 to 1.047) within information calls. Conclusions Deprivation increased the chance of receiving more urgent advice, particularly advice to call 999. While our dataset may underestimate the ‘need’ of deprived patients, it yields no evidence of major inequity in advice given to these patients.

Real nursing? The development of telenursing

The responsibility for health and well-being in the United Kingdom (UK) falls to the National Health Service (NHS). The NHS was established in 1948 to promote “the establishment of a comprehensive health service designed to secure improvement in the physical and mental health of the people of England and Wales and the prevention, diagnosis and treatment of illness” (NHS Act, 1946). The service varies from health-care provision in other Western countries, in that responsibility falls to the government in power.37 As a result of changes in political administration and alongside changes in health, an aging population and advances in technology, over the past 60 years the NHS has experienced many adaptations, not only in the manner of delivery of health-care services, but also in the structure and organization of these services.