The latest in the CAHRU/LIH research methods seminars was given by Dr Paul Leighton on 24 October 2017 on the subject of ‘Realist evaluation in health services research’. Paul Leighton is a senior research fellow at the University of Nottingham, deputy director of the NIHR Research Design Service for the East Midlands and an expert in health services research, qualitative methods and process evaluation. The presentation covered the philosophy of critical realism and how this related to realist methods, described a practical example of a realist evaluation and finished with concluding thoughts and comment on the method.
Critical realism was described as a philosophical approach developed by Roy Bhaskar that adopts an ontological position of being in which: the actual world is independent of the human mind and the mind is capable of perceiving the empirical world, but unable to directly perceive unseen forces in the real world. Gravity and social class were cited as examples of unseen forces in the real world.
“Realist” or “realistic evaluation” was described as a form of primary research methodology derived from critical realist philosophy, by Ray Pawson and Nick Tilley, which acknowledges the potential for unseen forces and accepts that interventions will not always work or work in the same way because of local contextual factors will influence how an intervention works and the impact it has. Realistic evaluation was summed up as “What works, for whom, in what circumstances?”
The process of realistic evaluation involves developing a programme theory, which theorises what should happen and how it might happen. This so-called mid-range theory is tested using qualitative and/or quantitative methods to explore the context, mechanisms (often hidden) and outcomes (C+M=O), revised iteratively and tested again, leading to a refined mid-range theory.
This was illustrated using the Falls in Care Homes (FinCH) study and summarised by concluding that interventions will not work all the time in all settings, but will work differently in different contexts.
[su_document url=”https://communityandhealth.dev.lincoln.ac.uk/files/2017/11/lincoln-realist-oct17.pdf” responsive=”no”]Multi-morbidity, goal-oriented care, the community and equity[/su_document]
A. N. Siriwardena
This year’s British Sleep Society (BSS) conference, held in Brighton at the Hilton Metropole, featured an invited presentation from Prof Niro Siriwardena, director of CaHRU, entitled ‘Tribulations and trials in primary care insomnia’.
After a welcome to the conference by Professor Mary Morell, President of the BSS, the opening keynote was given by Professor Franco Cappuccio, from the University of Warwick on the topic of ‘Healthy sleep’. This was followed by the opening session of the conference on ‘Sleep and health’ chaired by Professor Graham Law, secretary of the BSS and a member of CaHRU. This session included three presentations. The first was on ‘Sleep and chronic pain: moving from association to causation?’ give by Dr John McBeth, Reader at the University of Manchester. He described the bidirectional relationship between chronic pain and sleep, with pain giving rise to insomnia and sleep disturbance exacerbating or even causing pain. Studies had shown that treating insomnia in people with chronic pain, for example due to fibromyalgia led to improvements in wellbeing and quality of life but no improvement in pain.
Prof Siriwardena next talked about how he had initially developed an interest in the problem of insomnia through initial research into use of sleeping tablets by general practitioners. ‘Tribulations and trials in primary care insomnia’ went on to describe the studies that showed that hypnotic drugs like benzodiazepines and z-drugs though often prescribed for insomnia did more harm than good, and that primary care trials of cognitive behavioural therapy for insomnia (CBT-I) showed positive effects. He went on to describe the work on the Resources for Effective Sleep Treatment (REST) project, a quality improvement project which successfully implemented CBT-I in general practice which led to reduced hypnotic prescribing in those practices. Because of the low uptake of CBT-I in primary care, there was increasing evidence that online or self-help CBT-I was effective with similar effect sizes to face-to-face individual or group therapy. Finally he presented the evidence on short behavioural therapies such as sleep restriction therapy including a forthcoming HTA funded trial led by Oxford University’s Simon Kyle and involving the Universities of Manchester (Peter Bower) and Lincoln (Niro Siriwardena).
The final talk in the session was Dr Eleanor Scott, Senior Lecturer at Leeds University and Consultant Diabetologist at Leeds Teaching Hospitals, who spoke on Sleep and metabolic health, describing the relationship between insomnia and diabetes, obesity and cardiovascular disease. This was followed by Dr Jason Rihel,of University College London discussing his work on sleep in zebrafish and Dr Claire Sexton of Oxford University on her work on sleep related to dementia. Brighton was an excellent setting for a well-attended BSS conference.
By Niro Siriwardena
Three members of the CaHRU team, Professor Niro Siriwardena, Dr Stephanie Armstrong and Greg Whitley (paramedic and doctoral student) led an interactive exploration of the latest research and innovation in ambulance care in a session entitled ‘Innovations in ambulance service care: ‘bangs, brains and hearts’ as part of the Lincoln Get Hold of Technology and Science (LiGHTS) Expo on 29 September 2017.
The seminar was presented twice to around 40 members of the public in all aged 7 to 60+ years. It explored the kind of care we can expect currently from ambulance services. The team explained how today’s ambulance service is about far more than transporting people to hospital. Prof Siriwardena discussed how ambulance services should be measured using an animation from the Prehospital Outcomes for Evidence Based Evaluation (PhOEBE) programme. Steph Armstrong discussed ‘Why do ambulance research and how difficult is it?’ exploring the difficulties of randomising patients and gaining consent in this setting. Prof Siriwardena then spoke about the use of GTN (also known as nitroglycerine, a component of dynamite) for stroke in the RIGHT2 trial and Greg Whitley, paramedic on the AIRWAYS2 trial explained the different airways device being tested in the study.
The seminar continued with a hands-on exercise involving cardio-pulmonary resuscitation, looking at airway devices and listening to heart sounds with a stethoscope. There was also plenty of audience participation with questions, answers and prizes! Prof Siriwardena and Dr Stephanie Armstrong gave an interview to Melvyn Prior at BBC Radio Lincolnshire as part of the event.
Two key articles on development and prioritization of new ambulance performance measures were published this autumn 2017 in Health Expectations. The studies come from, Prehospital Outcomes for Evidence Based Evaluation (PhOEBE), funded by a five year National Institute for Health Research Programme Grant for Applied Health Research led by Professor Niro Siriwardena from CaHRU and Janette Turner of the Centre for Urgent and Emergency care research (CURE).
The first article, ‘Prioritizing novel and existing ambulance performance measures through expert and lay consensus: a three-stage multimethod consensus study‘ involved a multistakeholder consensus event, modified Delphi study, and patient and public consensus workshop, which together identified a shortlist of ambulance outcome and performance measures important to ambulance clinicians and service providers, service users, commissioners and academics.
The final set of measures included change in pain score, accuracy of call identification, average response time, proportion of patients with a serious condition who survived to 7 days post-admission, death (within 3 days) from a low risk condition, proportion of patients transported to the Emergency Department who were discharged without treatment or investigation, and the proportion of those with specific conditions treated according to current guidelines.
The public consensus workshop, ‘A coproduced patient and public event: An approach to developing and prioritizing ambulance performance measures‘, was effective for obtaining public feedback on which ambulance performance measures were most highly favoured by lay participants. These measures have been developed to be used in future by ambulance services or commissioners to benchmark care quality between services or regions or to measure performance over time.
By Prof Niro Siriwardena
East Midlands Academic Health Science Network hosted the latest East Midlands Quality Improvement Network meeting at Trent Vineyard, Nottingham on 17 May 2017 to over 150 delegates. The network has grown from the East Midlands Quality Improvement, Research and Education (ENQuIRE) Network set up as part of the HEI Challenge project between 2015 and 2016, led by the University of Lincoln. There were over 150 attendees at the event chaired by Dr Cheryl Crocker.
There were key notes from Richard Taunt, founder of Kaleidoscope Health & Care on ‘Bridging the disconnect between research and practice’ and Paul O’Neill, director of the East Midlands Leadership Academy on ‘Leading for quality improvement’. This was followed by an inspirational talk from Emma Wiggs, four time gold medallist Paralympian on ‘Improving mindset – improving quality’.
Professor Siriwardena, director of CaHRU then co-led, with Prof Bryn Baxendale of Nottingham University Hospitals NHS Trust, a workshop session on Measurement of Quality Improvement. There were also workshops on human factors, safety and evaluation of QI projects.
The afternoon was devoted to a series of talks on Q, clinical audit and patient involvement in safety. The day ended with a discussion on next steps for the network.