Melanie Rimmer

Using logic model methods in systematic review synthesis: describing complex pathways in referral management interventions

BackgroundThere is increasing interest in innovative methods to carry out systematic reviews of complex interventions. Theory-based approaches, such as logic models, have been suggested as a means of providing additional insights beyond that obtained via conventional review methods.MethodsThis paper reports the use of an innovative method which combines systematic review processes with logic model techniques to synthesise a broad range of literature. The potential value of the model produced was explored with stakeholders.ResultsThe review identified 295 papers that met the inclusion criteria. The papers consisted of 141 intervention studies and 154 non-intervention quantitative and qualitative articles. A logic model was systematically built from these studies. The model outlines interventions, short term outcomes, moderating and mediating factors and long term demand management outcomes and impacts. Interventions were grouped into typologies of practitioner education, process change, system change, and patient intervention. Short-term outcomes identified that may result from these interventions were changed physician or patient knowledge, beliefs or attitudes and also interventions related to changed doctor-patient interaction. A range of factors which may influence whether these outcomes lead to long term change were detailed. Demand management outcomes and intended impacts included content of referral, rate of referral, and doctor or patient satisfaction.ConclusionsThe logic model details evidence and assumptions underpinning the complex pathway from interventions to demand management impact. The method offers a useful addition to systematic review methodologies.Trial registration numberPROSPERO registration number: CRD42013004037.

Academic careers: what do early career researchers think?

ARE YOUNG RESEARCHERS GETTING A FAIR DEAL? Early career researchers (ECRs) are often anecdotally described as facing major challenges. These challenges reportedly include lack of job security, too few opportunities to carve out their own interests, fighting to survive in competitive institutions and being perceived as resources rather than as people. These issues have attracted increasing attention in scientific circles and now also in the media. In response to these concerns, the SSM ECR Subcommittee conducted an ECR members’ survey in early 2015 to obtain views on a range of issues. We had 65 responses (response rate 50.7%) of whom approximately three-quarters were female, and a third were based in London. Responses clustered around three main themes: job instability, limited opportunities to develop an academic career and lack of mentoring.

An evaluation tool for Age-Friendly and Dementia Friendly Communities

Purpose The purpose of this paper is to report how an evaluation tool originally developed for Age-Friendly Cities was pilot-tested in the context of the Dementia Friendly Community (DFC) initiative of the city of Sheffield/UK. It presents finding and outputs on which other communities with dementia friendly agendas can draw. Design/methodology/approach The original evaluation tool was adapted to a focus on dementia friendliness. Data collection involved scoping conversations, documentary analysis, interviews and group discussions. Following evidence appraisal, Sheffield’s approach to dementia friendliness was assessed. A local steering group was central to the study. Findings The evidence indicates areas of strength in Sheffield’s approach to dementia friendliness: involvement of older people; service provision; collaboration; monitoring and evaluation. Scope for improvement was identified around resource allocation, and use of existing guidance on dementia friendliness. Recommendations for policy and practice include enhancing pooling of resources, more detailed recording of resources allocated to dementia-related activity, and collection of evidence on how people affected by dementia have shaped the city’s DFC initiative. Key research outputs are an adaptable logic model and an emerging evaluation framework for DFCs. Research limitations/implications The study was a short pilot with limited resources. Its findings and outputs must be considered preliminary. Originality/value The findings and outputs provide a basis for further research. The study has suggested key components of an evaluation framework for DFCs. It is informing ongoing work to develop such a framework.

23 Patient and staff perspectives on the reasons for increasing emergency department attendances

Background/objectives An NHS England review recognised that demand for Urgent and Emergency Care is unsustainable. Health practitioners and policy makers are interested in understanding the reasons why patients with low acuity problems attend the Emergency Department (ED). This should, in turn, assist the development of interventions to reduce demand. We aimed to gain an understanding about the reasons for rising ED demand and to identify possible solutions. Methods A self-report patient survey was administered to non-ambulance patients at 9 EDs across Yorkshire and Humber (Y and H) asking participants: reasons for attending the ED; awareness of alternative services; and perceptions of the suitability of other services to manage their health problem. Survey data was analysed descriptively and compared with two similar studies conducted in 1997 and 2006. Semi-structured interviews were conducted with ED and Urgent Care staff (Consultants, Doctors, Nurses, Managers, General Practitioner) working in 9 EDs across Y and H. The interview topic guide was structured around: description of patients attending EDs and impact on demand; and current/future initiatives to deal with rising demand. The interviews were transcribed verbatim and analysed thematically using Framework Analysis. Results 481 surveys were completed. Increasing numbers of patients reported that a health professional advised them to attend the ED (31% in 1997 vs 50% in 2016). Awareness of alternative urgent care services had increased since 2006 but the perceived appropriateness of these services had decreased or stayed the same. Interviews were carried out with 25 ED and urgent care staff. Reasons for attendance at the ED were divided into patient-level reasons (e.g., people are more demanding of the healthcare system; poor health literacy) and structural-level reasons (e.g., difficulties accessing primary care; alternative healthcare services directing patients to the ED inappropriately). Our participants described a wide range of interventions divided into patient-level interventions (e.g., increasing patient education) and system-level interventions (e.g., streaming patients into appropriate services), but there was no clear consensus with regards to which interventions had had the greatest impact. Conclusion We found evidence of a rise in patients being referred to the ED by other healthcare services. This may be a reflection of the wider healthcare system under strain, thereby causing overspill into EDs. Future research is needed to design and test interventions that can lead to improvements in the system that are acceptable to patients, do not lead to increased demand, are cost-effective and lead to more sustainable working environments.

8 Different approaches needed to manage ED demand among different age-groups

Background/objectives A variety of interventions have been proposed to manage rising demand for Emergency and Urgent Care, described by an NHS England review as unsustainable in the long term. However it is unlikely that any suggested approach will be equally suitable for the diverse population of ED users. We aimed to understand the patterns of demand amongst different types of patients attending ED. We also sought to understand the intended and unintended effects of demand management initiatives. Our study combined insights from routine data, a survey of ED patients, and qualitative interviews with ED staff. This paper describes the results of our analysis of the interviews. Methods We conducted semi-structured interviews with 25 ED and Urgent Care Centre staff across 7 hospital sites in Yorkshire and Humber between 25 April and 11 July 2016. The interview topic guide asked about 4 broad areas; job role, description of patients and their impact on demand, description of inappropriate attendance, and current/future initiatives to deal with rising demand. Interviews were transcribed verbatim and analysed using framework analysis. We analysed the results to identify groups of patients with different patterns of use of ED services. We also explored ED staff experiences of demand management initiatives, and their suggestions for future initiatives. Results Although we did not ask specifically about patients’ age, our analysis revealed that ED staff categorised attenders as children and young people, working age people, and older people. These groups had different reasons for attendance, different routes to the ED, different rate of non-urgent attendance, and different issues driving demand. Staff also described variation in the time taken to treat patients of different ages, with the oldest and youngest patients described as requiring the most time. There was no consensus amongst staff about the effectiveness of initiatives for managing demand. A strikingly wide variety of initiatives were mentioned including patient education, co-location of other services with ED (‘ED hubs’), and extending community-based services. Conclusion ED staff attribute distinctly different patterns of ED attendance to patients of different age groups, including reasons for attending ED, the route to the ED, and the rate of non-urgent attendance. Given this variation, proposed demand management interventions are likely to impact differently on different age groups, and one solution is unlikely to be optimal for all ages. Therefore a number of different approaches will be needed to manage ED demand among different age groups.

Age-related references in national public health, technology appraisal and clinical guidelines and guidance: documentary analysis.

Abstract Background older people may be less likely to receive interventions than younger people. Age bias in national guidance may influence entire public health and health care systems. We examined how English National Institute for Health & Care Excellence (NICE) guidance and guidelines consider age. Methods we undertook a documentary analysis of NICE public health (n = 33) and clinical (n = 114) guidelines and technology appraisals (n = 212). We systematically searched for age-related terms, and conducted thematic analysis of the paragraphs in which these occurred (‘age-extracts’). Quantitative analysis explored frequency of age-extracts between and within document types. Illustrative quotes were used to elaborate and explain quantitative findings. Results 2,314 age-extracts were identified within three themes: age documented as an a-priori consideration at scope-setting (518 age-extracts, 22.4%); documentation of differential effectiveness, cost-effectiveness or other outcomes by age (937 age-extracts, 40.5%); and documentation of age-specific recommendations (859 age-extracts, 37.1%). Public health guidelines considered age most comprehensively. There were clear examples of older-age being considered in both evidence searching and in making recommendations, suggesting that this can be achieved within current processes. Conclusions we found inconsistencies in how age is considered in NICE guidance and guidelines. More effort may be required to ensure age is consistently considered. Future NICE committees should search for and document evidence of age-related differences in receipt of interventions. Where evidence relating to effectiveness and cost-effectiveness in older populations is available, more explicit age-related recommendations should be made. Where there is a lack of evidence, it should be stated what new research is needed.