Professor Graham Law, who recently joined the university and CaHRU as Professor in Medical Statitics, delivered the latest of CaHRU/LIH’s Implementation Science and Research Methods seminar series – on Causal Models and the use of Directed Acyclic Graphs. Professor Law set out the epidemiological context for the seminar. Epidemiology is the study of disease. The scientific methods used within epidemiology aim to discover the determinants of disease. The state of having the disease is the outcome. Causal models seek to examine the factors that contribute to this outcome. Causation is not usually dealt with by statistics. Instead, statistics concerns itself more with associations and relationships between variables.
A Directed Acyclic Graph (DAG) comprises variables (nodes) and arrows between nodes (directed edges) such that the graph is acyclic, i.e., it not being possible to start at any node, follow the directed edges in the arrowhead direction, and end up back at the same node. In seeking to represent causation, DAGs typically display a series of factors, mediators and outcomes. Having explained this, Graham split the audience into two groups and challenged them to create their own DAGs to display all the possible factors involved in whether sunlight causes lymphoma. The interactive nature of the seminar engaged the audience. The fun nature of the concluding task made a potentially complicated subject easier for the audience to understand and apply.
The latest CaHRU Implementation Science and Research Methods seminar was presented by Dr Murray Smith on 25th October 2016, on the topic of statistical modelling of time series data. Dr Smith, research fellow at the Community and Health Research Unit (CaHRU), is an econometrician with a wide range of experience and research interests in micro-econometric modelling, health informatics, health economic modelling, mathematical statistics and computer algebra. Murray has previously worked as an Associate Professor in the Department of Econometrics and Business Statistics at the University of Sydney, Australia, and as an Associate Professor at the School of Pharmacy, University of Nottingham before coming to the University of Lincoln. His research has focuses on the quality of use of pharmaceutical medicines in chronic disease, with analyses that utilise prescribing data drawn from a large database of general practice patient records.
He introduced his topic by defining (and giving examples) of data, and related these to how researchers can statistically model time series data in different ways. Murray described four fundamental components of times series including: time (Tt); Cycle (Ct); Seasonal (St) and Irregular (It). He also gave examples of Time Series Analysis Curves such as survival data, Engle’s AutoRegressive Conditional Heteroscedasticity (ARCH) and segmented regression. He showed how modelling time series data can be useful for quality improvement research, as this can facilitate the measurement of outcomes or impact over time and extrapolate or estimate future values or outcomes. A time series method (using segmented regression) is being used in a paper currently being prepared by Dr Murray Smith and Professor Niro Siriwardena for publication.
Dr Smith concluded his interesting presentation by recommending three key books for further reading on Statistical Modelling of Time Series Data: Time Series Analysis by Jame D Hamilton, Time Series Analysis: Forecasting and Control by George E. P. Box et al. and Introduction to Time Series and Forecasting by Peter J. Brockwell & Richard A. Davis. He made the session so interesting that participants asked for further presentations on time series analysis. For his next seminar, Murray will focus more on use of the method for current research at CaHRU to enable more researchers to apply this method to their research.
Members of the Scaling up PINCER project team (PINCER is a pharmacist-led information technology intervention for reducing clinically important errors in medication management in general practice), Prof Niro Siriwardena, Janice Wiseman, Dr Sarah Rodgers, Chris Rye and Despina Laparidou, recently attended (on June 29th) the Scaling-Up Improvement Programme Mid-point Event in London. The event was organised by the Health Foundation, the main funder for the six participating projects. The focus of the meeting was on evaluation and sustainability of improvement.
The day was designed to be as interactive as possible and teams were asked to bring materials with them, such as information, pictures, posters, leaflets, data, etc., to put up on a pin board, with the purpose of giving a visual story of their project for other teams to view during and between sessions. This created a wonderful opportunity for teams to learn about each other’s projects and discuss issues (such as successes and challenges) around their progress.
A number of interesting talks were presented around evaluating and sustaining scaling-up improvements, such as the sessions facilitated by Tom Ling/Bryn Garrod (RAND Europe) and Kathy Elliott (NCAT) respectively. One of the most stimulating and thought-provoking sessions, “Influencing for sustainability”, asked delegates to split into two large groups and have one person from each project team ‘make a case’ for their project, facilitated by Carl Smith (Frontline) and Jamie Ripman (Practive). At the end of each brief presentation, the rest of the delegates provided feedback on their performance and suggestions on how to improve their style and adjust the context of the presentation to better fit the target audience’s agenda.
At the end of the day, Sally Williams (Frontline) and Valentina Karas (the Health Foundation) brought the event to its close by reflecting on the day and discussing future actions.
The first of this year’s series of CaHRU/LIH (Community and Health Research Unit/Lincoln Institute for Health) improvement science and research methods seminars was given by Prof Siriwardena on mixed methods on 16 February 2016. Improvement and implementation science benefits from the use of mixed research designs which combine quantitative and qualitative methods to show not only what happened but also why and how this might have occurred. Mixed methods approaches are a subset of multiple methods which involve more than one type of qualitative or quantitative method.
The seminar covered principles such as definitions, theoretical approaches (such as pragmatism and transformation), basic and advanced (including case study) designs and approaches to data integration and transformation. This was then applied to examples of mixed methods designs used by CaHRU in a previous programme of research: the Ambulance Services Cardiovascular Quality Initiative (ASCQI). ASCQI was a national project, led by CaHRU and East Midlands Ambulance Service NHS Trust, designed to improve care for people presenting to ambulance services with heart attack or stroke using a large-scale quality improvement collaborative (QIC), evaluated using a multiple case-study design.
ASCQI involved gathering quantitative and qualitative data to describe what effect the QIC had, and how improvements, if they did occur, were brought about. Integration of data was carried out using techniques such annotated control charts showing time series data together with what was implemented, pattern matching comparing what services did and whether improvements occurred (doi: 10.1186/1748-5908-9-17), and comparison of quantitative and qualitative data from an online questionnaire (doi: 10.1111/jep.12438). Attendees were finally asked to consider a mixed methods question and think about research designs which they might use to answer it.
Thank you to all those staff and students who attended. Details of future seminars will be posted on the CaHRU and the LIH sites shortly.
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Professor Niro Siriwardena and the CaHRU team have been awarded a major grant from the Health Foundation under their Scaling Up Improvement programme. The project is led by Lincolnshire Community Health Services NHS Trust supported by the University of Lincoln, University of Nottingham, the East Midlands Academic Health Science Network and 17 of the region’s Clinical Commissioning Groups.
The aim of the study is to spread an intervention called PINCER (pharmacist-led information technology intervention for reducing clinically important errors in medication management) across East Midlands general practices and then more widely across the United Kingdom using a quality improvement collaborative, a model which CaHRU have used in previous projects.
The project will provide participating GP practices access to computer software that automatically reviews prescriptions together with expert support from a pharmacist who will work with practice staff to review prescriptions and drugs monitoring. This will reduce the risk of drug errors and failure to monitor, particularly in those people with more than one long term condition on a combination of drugs. Pharmacists and GPs will share learning as part of the project.