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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Dr Stephanie Armstrong joined CaHRU this month to work on the Wellcome Trust funded ‘Network exploring Ethics in Ambulance Trials (NEAT)’ project. She says, “I come to Community and Health Research Unit from a rather diverse background having begun my academic life in the field of Zoology. I completed a PhD in Zoology from Trinity College, Dublin in 2006, where my work focussed on the nutrition and behaviour of large captive herbivores and in particular zebra.
In 2004 I joined Sparsholt College, Hampshire as a lecturer in the Equine Studies section and worked my way up to Head of Department for Animal Management Higher Education. This career path however, took me away from hands on research and, after working for Sparsholt College for 7 years, I realised that I needed a change of direction. With that in mind I undertook an MSc in Forensic Anthropology at the University of Lincoln, reigniting my passion for research. I also hold degrees in Equine Studies and Herbal Medicine.
As a result I have extensive experience in a wide range of research both quantitative and qualitative ranging from novel animal behaviour studies to in-depth systematic reviews. My research interests lie within the areas of ethics and human rights.” The NEAT project is CaHRU’s first Wellcome Trust grant, led by Prof Siriwardena in collaboration with Dr Adele Langlois from the School of Social and Political Sciences.
Researchers from CaHRU with colleagues from the School of Health and Related Research (ScHARR) at the University of Sheffield have published a new study: “Reassurance as a key outcome valued by emergency ambulance service users: a qualitative interview study” in the journal Health Expectations. The study’s lead author was Fiona Togher, PhD student and Graduate Research Assistant in CaHRU. She was supported in the work by Alicia O’Cathain, Professor of Health Services Research at the University of Sheffield, Viet-Hai Phung, Research Assistant in CaHRU, Janette Turner, Research Fellow at the University of Sheffield and Professor Niro Siriwardena, director of CaHRU. The study is part of a five year NIHR Programme for Applied Health Research, Prehospital Outcomes for Evidence Based Evaluation (PhOEBE).
The authors aimed to investigate the aspects of emergency ambulance care that were most valued by users of the service. Fiona and Viet-Hai interviewed people (patients and carers) that had used the ambulance service for a range of different conditions such as diabetes, suspected stroke, breathing difficulties and falls. The participants had also received various types of ambulance service response i.e. ‘hear and treat’ in which the participants received enhanced clinical assessment and advice over the telephone only, ‘see and treat’ in which the participants were treated on-scene by appropriately skilled clinicians without the need for hospital admission and the more familiar, ‘see and convey’ in which the participants received pre-hospital assessment and treatment before transportation to acute care.
The authors found that regardless of their specific clinical problem people valued similar aspects of their emergency ambulance service experience. Participants had often been extremely anxious about their health, and they most valued the reassurance they felt from receiving appropriate advice, treatment and care from ambulance service staff. It was found that the ability of the emergency ambulance service to allay the high levels of fear and anxiety felt by users is crucial to the delivery of a high quality service.
The qualitative interview data collected from this research is now being re-analysed as part of Fiona’s doctoral studies to develop a Patient Reported Experience Measure (PREM) for use in UK ambulance services.
Novel treatments for stroke are increasingly being tested and delivered in the ultra-acute period during initial presentation to ambulance services. In the first feasibility trial of nitroglycerin (glyceryl trinitrate) in ultra-acute stroke (RIGHT) there were early indications of improvements in outcomes and disability at three months. The research team was led by Prof Philip Bath and his team at Nottingham University, together with Sandeep Ankolekar, Prof Niro Siriwardena from CaHRU and researchers at East Midlands Ambulance Service NHS Trust.
Suggestions for improvement included a simple diagnostic tool for stroke, use of assent and proxy consent on behalf of patients (as in the trial), and simpler trial processes.Recruitment became easier with each new randomisation attempt. Paramedics in the study were motivated to participate in research. Treatment of acute stroke in the out-of-hospital environment was feasible, but important barriers needed to be addressed.
In a world where genetic tests for coronary heart disease (CHD) are becoming increasingly commercially available, how do patients make sense of the results particularly when considered alongside the results from routine cardiovascular risk assessments undertaken by their general practitioner? This was the subject of a qualitative study with Dr Jo Middlemass, research fellow at CaHRU, as lead author: ‘Introducing genetic testing for cardiovascular disease in primary care: a qualitative study’. The authors interviewed 29 patients from 12 practices in Nottingham, who had received a routine cardiovascular risk assessment, followed by genetic testing to assess their CHD risk, to assess their understanding and response to both tests.
The results showed that genetic testing procedures were acceptable for patients. However, there was limited recall of the results for either the genetic test or the conventional cardiovascular disease (CVD) assessment undertaken in the practice. There was also some confusion on how to interpret the results, for example was being ‘above average risk’ better than being ‘average’? In addition there were sometimes contradictory findings in terms of being ‘above average genetic risk’ but ‘average’ conventional CVD risk and vice versa. Patients dealt with these conflicting findings in different ways. Some thought that healthy behaviour had mitigated their increased genetic risk while others were falsely reassured when their genetic risk was ‘average’ but their conventional risk was ‘above average’.
Patients often said that their main motivation to have genetic test for CHD was because they had a perceived family history of CHD and wanted to be able to share the genetic predisposition results with their adult children. However, despite this, very few did actually discuss the results with their offspring. The findings indicate that health professionals should discuss patient’s perceptions about the results of CHD risk assessments (both conventional and genetic) in order to facilitate greater awareness and understanding and to maximise any potential for behaviour change.
For the full article see Br J Gen Pract 2014; DOI: 10.3399/bjgp14X679714. Authors: Jo B Middlemass, Momina F Yazdani, Joe Kai, Penelope J Standen and Nadeem Qureshi.