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Preventing premature death is the aim of coroners’ Prevention of Future Deaths reports. But is this system really helping us to prevent such harms? Oxford medical student, Ali Anis, examined deaths involving cardiovascular disease and anticoagulants for his Final Honours Scheme (FHS) research, to assess the state of play, now published in BJGP Open.
Healthcare decision-makers' perspectives on evaluating conflict management training in paediatric healthcare: a utilisation-focused qualitative study.
BackgroundConflict is prevalent across healthcare settings but is especially common in paediatrics, where high emotional stakes and parental expectations often intensify disagreements. Conflict can lead to negative outcomes for hospitals, staff and patients. Effective conflict management training can mitigate these impacts, but evaluating such training programmes remains challenging due to a lack of standardised tools and best practices.MethodsThis qualitative study aimed to explore healthcare decision-makers' perspectives on what key areas should be evaluated in conflict management training programmes in paediatric healthcare settings, employing Patton's utilisation-focused evaluation approach. Semi-structured interviews were conducted with 13 healthcare decision-makers and key stakeholders from various healthcare and charitable organisations. Interviews were analysed using reflexive thematic analysis by Braun and Clarke to identify key themes for evaluation.ResultsFour primary themes were generated regarding the key areas that healthcare decision-makers believe should be evaluated in conflict management training. These were experience of training sessions, staff competency and well-being, patient/family experiences of conflict and impact on staff time and on clinical resources. Interviewees identified that the evaluation of training sessions should focus on participant engagement and satisfaction. Codes relating to staff competency and well-being included the acquisition and long-term retention of conflict management skills. Codes relating to patient/family experience focused on the quality of communication and support during conflicts. The theme of resource utilisation included codes relating to the time and cost implications of conflict.ConclusionThe study identified essential evaluation areas that align with and expand on Kirkpatrick's framework, suggesting the need for both qualitative and quantitative data and long-term follow-up. Tailoring evaluation frameworks to specific programme contexts can enhance their relevance and utility, contributing to improved conflict management in both paediatric and wider healthcare settings.
Prevalence and patterns of testing for anaemia in primary care in England.
Background Despite epidemiological data on anaemia being available on a global scale, its prevalence in the United Kingdom is not well described. Aim To investigate anaemia prevalence and testing patterns for haemoglobin and other blood parameters. Design and Setting A population-based cohort study using data drawn from the Clinical Practice Research Datalink Aurum database in 2019. Method We extracted demographic data for each person who was registered at their current practice during 2019, including linked data on Index of Multiple Deprivation. We calculated anaemia prevalence in 2019 based on World Health Organization specified age and gender thresholds for haemoglobin. We classified anaemia based on mean corpuscular volume and ferritin. We followed up people with anaemia for up to one year to investigate longitudinal testing patterns for haemoglobin. Results The cohort contained 14 million people. Anaemia prevalence in 2019 was 4.1% (5.1 % females and 3.1% males). Prevalence was higher in people aged >65 years, Black and Asian ethnicities, and people living in areas with higher social deprivation. Only half of people with anaemia and a mean corpuscular volume of ≤100 fL had an accompanying ferritin value recorded. About half of people with anaemia had a follow-up haemoglobin test within one-year, most of which still indicated anaemia. Conclusion Anaemia is prevalent in the UK with large disparities between levels of demographic variables. Investigation and follow-up of anaemia is suboptimal in many patients. Health interventions aimed at improving anaemia investigation and treatment are needed, particularly in these at-risk groups.
A review of methods for the analysis of diagnostic tests performed in sequence.
BACKGROUND: Many clinical pathways for the diagnosis of disease are based on diagnostic tests that are performed in sequence. The performance of the full diagnostic sequence is dictated by the diagnostic performance of each test in the sequence as well as the conditional dependence between them, given true disease status. Resulting estimates of performance, such as the sensitivity and specificity of the test sequence, are key parameters in health-economic evaluations. We conducted a methodological review of statistical methods for assessing the performance of diagnostic tests performed in sequence, with the aim of guiding data analysts towards classes of methods that may be suitable given the design and objectives of the testing sequence. METHODS: We searched PubMed, Scopus and Web of Science for relevant papers describing methodology for analysing sequences of diagnostic tests. Papers were classified by the characteristics of the method used, and these were used to group methods into themes. We illustrate some of the methods using data from a cohort study of repeat faecal immunochemical testing for colorectal cancer in symptomatic patients, to highlight the importance of allowing for conditional dependence in test sequences and adjustment for an imperfect reference standard. RESULTS: Five overall themes were identified, detailing methods for combining multiple tests in sequence, estimating conditional dependence, analysing sequences of diagnostic tests used for risk assessment, analysing test sequences in conjunction with an imperfect or incomplete reference standard, and meta-analysis of test sequences. CONCLUSIONS: This methodological review can be used to help researchers identify suitable analytic methods for studies that use diagnostic tests performed in sequence.
Enhancing the trustworthiness of pain research: A call to action.
The personal, social and economic burden of chronic pain is enormous. Tremendous research efforts are being directed toward understanding, preventing, and managing chronic pain. Yet patients with chronic pain, clinicians and the public are sometimes poorly served by an evidence architecture that contains multiple structural weaknesses. These include incomplete research governance, a lack of diversity and inclusivity, inadequate stakeholder engagement, poor methodological rigour and incomplete reporting, a lack of data accessibility and transparency, and a failure to communicate findings with appropriate balance. These issues span pre-clinical research, clinical trials and systematic reviews and impact the development of clinical guidance and practice. Research misconduct and inauthentic data present a further critical risk. Combined, they increase uncertainty in this highly challenging area of study and practice, drive the provision of low value care, increase costs and impede the discovery of more effective solutions. In this focus article, we explore how we can increase trust in pain science, by examining critical challenges using contemporary examples, and describe a novel integrated conceptual framework for enhancing the trustworthiness of pain science. We end with a call for collective action to address this critical issue. Perspective: Multiple challenges can adversely impact the trustworthiness of pain research and health research more broadly. We present ENTRUST-PE, a novel, integrated framework for more trustworthy pain research with recommendations for all stakeholders in the research ecosystem, and make a call to action to the pain research community.
Oro-faecal transmission of SARS-CoV-2: A systematic review of studies employing viral culture from gastrointestinal and other potential oro-faecal sources and evidence for transmission to humans
The extent to which the oro-faecal route contributes to the transmission of SARS-CoV-2 is not established. We systematically reviewed the evidence on the presence of infectious SARS-CoV-2 in faeces and other gastrointestinal sources by examining studies that used viral culture to investigate the presence of replication-competent virus in these samples. We conducted searches in the WHO COVID-19 Database, LitCovid, medRxiv, and Google Scholar for SARS-CoV-2 using keywords and associated synonyms, with a search date up to 28 November 2023. We included 13 studies involving 229 COVID-19 subjects-providing 308 faecal or rectal swab SARS-CoV2 reverse transcription-polymerase chain reaction (RT-PCR)-positive samples tested with viral culture. The methods used for viral culture across the studies were heterogeneous. Three studies (two cohorts and one case series) reported observing replication-competent SARS-CoV-2 confirmed by quantitative RT-PCR (qPCR) and whole-genome sequencing, and qPCR including appropriate cycle threshold changes. Overall, six (1.9%) of 308 faecal samples subjected to cell culture showed replication-competent virus. One study found replication-competent samples from one immunocompromised patient. No studies were identified demonstrating direct evidence of oro-faecal transmission to humans. Our review found a relatively low frequency of replication-competent SARS-CoV-2 in faecal and other gastrointestinal sources. Although it is biologically plausible, more research is needed using standardized cell culture methods, control groups, adequate follow-up, and robust epidemiologic methods, including whether secondary infections occurred, to determine the role of the oro-faecal route in the transmission of SARS-CoV-2.
Effect of the National Enhanced Service for weight management on the content of annual review consultations for patients living with obesity and hypertension and/or diabetes
Guidelines specify that clinicians should support patients living with obesity by referring to weight management programmes (WMPs), but clinicians do so infrequently. To provide additional support to patients living with obesity and weight-related conditions, the UK government instated the National Enhanced Service (NES) for weight management in England, including a reimbursement to general practices for referring eligible patients to WMPs. To assess the impact of the NES on conversations regarding weight and relevant behavioural risk factors in primary care consultations we recruited 11 medical practices in England where the NES was operating and six comparator practices from Scotland and Wales where the NES was not implemented. Clinicians audio-recorded annual review appointments of patients living with obesity and hypertension and/or diabetes. The content of these consultations was synthesised using quantitative content analysis. Consultations with 92 patients were analysed: 58 in England and 34 in Scotland and Wales. No difference was found between the NES sites (England) and non-NES sites (Scotland and Wales) in the proportion of referrals made to WMPs. Clinicians in England weighed patients and took other body measurements more often, mentioned body mass index more often, and had more detailed discussions about patients' diets, but there was no evidence that they differed in their discussion of WMPs or other modifiable risk factors. We found no strong evidence that the NES affected how clinicians addressed weight management or related behavioural risk factors within annual review consultations for patients living with obesity and hypertension and/or diabetes.
The need for translational bioethics within perinatal healthcare and policy making: A COVID-19 case study
The COVID-19 pandemic highlighted many issues that can occur due to lack of translation between the spheres of bioethics and clinical practice. In this paper, we examine how mothers and newborn infants were inappropriately separated during the initial stages of the pandemic due to inconsistent application of ethical principles in determining policy. One of the significant challenges that translational bioethics face is the complexity regarding its implementation into the health service environment. As outlined in the literature, it may be postulated that responsibility for translating bioethics from philosophical concepts into practice is the duty of those training in philosophical theory and reasoning. However, the use of bioethics in informing clinical practice is not just the case of needing a translator but rather requires an interpreter in the widest sense: professionals attuned to both bioethics and clinical practice, who can communicate with both groups effectively. A two-way dialogue needs to be more cohesively established to ensure clinical practice is guided by ethical principles and to focus academic debate towards the pragmatic issues that require ethical exploration. Utilising the translational bioethics model described by Bærøe and applying it to our perinatal COVID case study, we examine how an integrated translational bioethics approach could have prevented the harm and disruption to mother–infant dyads during the initial phase of the pandemic in 2020.
Validity and timeliness of cancer diagnosis data collected during a prospective cohort study and reported by the English and Welsh cancer registries: a retrospective, comparative analysis
Background: Cancer places a high burden on society and health-care systems. Cancer research requires high-quality data, which is resource-intensive to obtain. Using administrative datasets such as cancer registries could improve the efficiency of cancer studies if data were valid and timely. We aimed to compare the validity and timeliness of diagnostic cancer data on-site during the SYMPLIFY study to that obtained from the cancer registries of England and Wales. Methods: Cancer data were collected from 5461 participants across 44 hospital sites during a prospective observational study in England and Wales, SYMPLIFY (ISRCTN10226380). Linked cancer data were obtained from Digital Health and Care Wales (DHCW), the Welsh Cancer Intelligence and Surveillance Unit (WCISU), and the English National Cancer Registration Dataset (NCRD) and Rapid Cancer Registration Dataset (RCRD), regularly between April, 2022, and September, 2023. The primary objectives of the study were to evaluate the validity (via assessment of the proportion of completed data fields and concordance with SYMPLIFY sites), and timeliness of the data in all datasets, for all cancers diagnosed within 9 months of study enrolment. Data fields investigated were cancer site via International Classification of Disease, 10th Revision (ICD-10) code; cancer morphology via International Classification of Diseases for Oncology, 3rd Edition (ICD-O-3) morphology histology code and broad morphological grouping; overall stage; and TNM classification. Findings: For data collected between April, 2022, and September, 2023, completeness at the last data cut available for each dataset ranged from 84% to 100% for ICD-O-3 morphology, from 43% to 100% for overall stage, and from 74% to 83% for TNM stage. The concordance between SYMPLIFY data and NCRD was 96% (95% CI 92–98) for ICD-10, 60% (53–66) for ICD-O-3 morphology, 83% (78–88) for ICD-O-3 broad morphology groupings, 73% (67–78) for stage, and 51% (44–59) for TNM; and with WCISU was 89% (95% CI 81–94) for ICD-10, 63% (53–73) for ICD-O-3 morphology, 80% (70–87) for ICD-O-3 broad morphology groupings, 83% (74–90) for overall stage, and 49% (38–61) for TNM stage. Concordance between SYMPLIFY and RCRD was 95% (95% CI 92–98) for ICD-10, 67% (60–74) for ICD-O-3 morphology, 85% (79–90) for ICD-O-3 broad morphology groupings, and 73% (65–80) for overall stage; and between SYMPLIFY and DHCW was 96% (91–99) for ICD-10, 74% (64–83) for ICD-O-3 morphology, 84% (75–91) for ICD-O-3 broad morphology groupings, and 87% (74–95) for stage. The SYMPLIFY dataset reached completion at 12 months post-enrolment in November, 2022, compared with 13 months for NCRD in December, 2023. RCRD and DHCW reached completion at 13 months and 15 months post-enrolment, in December, 2022, and February, 2023, respectively. Interpretation: We report similar completeness of data fields, concordance, and timeliness between on-site and centrally collected cancer outcomes data. Our findings suggest that central registry data can help alleviate the resource burden in clinical trials and improve cancer research. Cancer registries might need additional resources to provide data for registry-based trials at scale. Funding: GRAIL Bio UK.
Building common understanding: seeking consensus and defining social prescribing across contexts - a collective commentary on a Delphi study
Social prescribing has become a global phenomenon. A Delphi study was recently conducted with 48 social prescribing experts from 26 countries to establish global agreement on the definition of social prescribing. We reflect on the use and utility of the outputs of this work, and where we go from here.
Risk of repeat self-harm among individuals presenting to healthcare services: development and validation of a clinical risk assessment model (OxSET)
BACKGROUND: A self-harm episode is a major risk factor for repeat self-harm. Existing tools to assess and predict repeat self-harm have major methodological limitations, and few are externally validated. OBJECTIVE: To develop and validate a risk assessment model of repeat self-harm up to 6 months after an episode of non-fatal self-harm that resulted in an emergency visit to hospital or specialised care. METHODS: Using Swedish national registers, we identified 53 172 people aged≥10 years who self-harmed during 2008-2012. We allocated 37 523 individuals to development (2820 or 7.5% repeat self-harm incidents within 6 months) and 15 649 to geographic validation (1373 repeat episodes) samples, based on region of residence. In a temporal validation of people who self-harmed during 2018-2019, we identified 25 036 individuals (2886 repeat episodes). We fitted a multivariable accelerated failure time model to predict risk of repeat self-harm. FINDINGS: In the external validations (n=40 685), rates of repeat self-harm were 8.8%-11.5% over 6 months. The final model retained 17 factors. Calibration and discrimination were similar in both validation samples, with observed-to-expected ratio=1.15 (95% CI=1.09 to 1.21) and c-statistic=0.72 (95% CI=0.70 to 0.73) in the geographical validation. At 6 months and a 10% risk cut-off, sensitivity was 51.5% (95% CI=48.8% to 54.2%) and specificity was 80.7% (95% CI=80.1% to 81.4%) in geographic validation; corresponding values were 56.9% (95% CI=55.1% to 58.7%) and 76.0% (95% CI=75.5% to 76.6%) in temporal validation. Discrimination was slightly worse at the 1-month prediction horizon (c-statistics of 0.66-0.68). CONCLUSIONS: Using mostly routinely collected data, simple risk assessment models and tools can provide acceptable levels of accuracy for repeat of self-harm. CLINICAL IMPLICATIONS: This risk model (OXford SElf-harm repeat tool) may assist clinical decision-making.