Surgery (Austin & Northern Health) - Research Publications
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ItemNo Preview AvailableEstablishing a perioperative medicine for older people undergoing surgery service for general surgical patients at a district general hospital.(Elsevier BV, 2021-11)INTRODUCTION: There is growing recognition of the need for perioperative medicine services for older surgical patients. Comprehensive geriatric assessment and optimisation methodology has been successfully used to improve perioperative outcomes at tertiary centres. This paper describes translation of an established model of geriatrician-led perioperative care to a district general hospital (DGH) setting. METHODS: A mixed methods quality improvement programme was used and included stakeholder co-design, identification of core components, definition of mechanisms for change, and measurement of impact through qualitative and quantitative approaches. RESULTS: Within 18 months, a substantive perioperative service for older people was established at a DGH, funded by the surgical directorate. Key outcomes included reduction in length of stay and 30-day readmission and positive staff and patient experience. DISCUSSION: This study is in keeping with improvement science literature demonstrating the importance of a mixed-methods approach in translating an evidenced-based intervention into another setting, maintaining fidelity and replicating results.
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ItemNo Preview AvailableA critical review of measures of childhood vaccine confidence.(Elsevier BV, 2021-08)The World Health Organization and global partners sought to identify existing measures of confidence in childhood vaccines, as part of a broader effort to measure the range of behavioural and social drivers of vaccination. We identified 14 confidence measures applicable to childhood vaccination in general, all published between 2010 and 2019. The measures examined 1-5 constructs and included a mean of 12 items. Validation studies commonly examined factor structure, internal consistency reliability, and criterion-related validity. Fewer studies examined convergent and discriminant validity, test-retest reliability, or used cognitive interviewing. Most measures were developed and validated only in high-income countries. These findings highlight the need for a childhood vaccine confidence measure validated for use in diverse global contexts.
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ItemNo Preview AvailableA user-centered approach to developing a new tool measuring the behavioural and social drivers of vaccination.(Elsevier BV, 2021-10-08)BACKGROUND: Children around the world remain under-vaccinated for many reasons. To develop effective vaccine delivery programmes and monitor intervention impact, vaccine programme implementers need to understand reasons for under-vaccination within their local context. The World Health Organization (WHO) Working Group on the Behavioural and Social Drivers of Vaccination (BeSD) is developing standardised tools for assessing childhood vaccine acceptance and uptake that can be used across regions and countries. The tools will include: (1) a validated survey; (2) qualitative interview guides; and (3) corresponding user guidance. We report a user-centred needs assessment of key end-users of the BeSD tools. METHODS: Twenty qualitative interviews (Apr-Aug 2019) with purposively sampled vaccine programme managers, partners and stakeholders from UNICEF and WHO country and regional offices. The interviews assessed current systems, practices and challenges in data utilisation and reflections on how the BeSD tools might be optimised. Framework analysis was used to code the interviews. RESULTS: Regarding current practices, participants described a variety of settings, data systems, and frequencies of vaccination attitude measurement. They reported that the majority of data used is quantitative, and there is appetite for increased use of qualitative data. Capacity for conducting studies on social/behavioural drivers of vaccination was high in some jurisdictions and needed in others. Issues include barriers to collecting such data and variability in sources. Reflecting on the tools, participants described the need to explore the attitudes and practices of healthcare workers in addition to parents and caregivers. Participants were supportive of the proposed mixed-methods structure of the tools and training in their usage, and highlighted the need for balance between tool standardisation and flexibility to adapt locally. CONCLUSIONS: A user-centred approach in developing the BeSD tools has given valuable direction to their design, bringing the use of behavioural and social data to the heart of programme planning.
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ItemImplementation, Adoption, and Perceptions of Telemental Health During the COVID-19 Pandemic: Systematic Review.(JMIR Publications Inc., 2021-12-09)BACKGROUND: Early in 2020, mental health services had to rapidly shift from face-to-face models of care to delivering the majority of treatments remotely (by video or phone call or occasionally messaging) due to the COVID-19 pandemic. This resulted in several challenges for staff and patients, but also in benefits such as convenience or increased access for people with impaired mobility or in rural areas. There is a need to understand the extent and impacts of telemental health implementation, and barriers and facilitators to its effective and acceptable use. This is relevant both to future emergency adoption of telemental health and to debates on its future use in routine mental health care. OBJECTIVE: To investigate the adoption and impacts of telemental health approaches during the COVID-19 pandemic, and facilitators and barriers to optimal implementation. METHODS: Four databases (PubMed, PsycINFO, CINAHL, and Web of Science) were searched for primary research relating to remote working, mental health care, and the COVID-19 pandemic. Preprint servers were also searched. Results of studies were synthesized using framework synthesis. RESULTS: A total of 77 papers met our inclusion criteria. In most studies, the majority of contacts could be transferred to a remote form during the pandemic, and good acceptability to service users and clinicians tended to be reported, at least where the alternative to remote contacts was interrupting care. However, a range of impediments to dealing optimal care by this means were also identified. CONCLUSIONS: Implementation of telemental health allowed some continuing support to the majority of service users during the COVID-19 pandemic and has value in an emergency situation. However, not all service users can be reached by this means, and better evidence is now needed on long-term impacts on therapeutic relationships and quality of care, and on impacts on groups at risk of digital exclusion and how to mitigate these. TRIAL REGISTRATION: PROSPERO International prospective register of systematic reviews CRD42021211025; https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42021211025.
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ItemPreventing unnecessary referrals into specialist mental health services: an interrupted time-series evaluation of a new primary care-linked mental health service(Emerald, 2021-11-30)Purpose Many patients referred by their GP for an assessment by secondary mental health services are unlikely to ever meet eligibility thresholds for specialist treatment and support. A new service was developed to support people in primary care. “the authors evaluate” whether the phased introduction of the Lambeth Living Well Network (LWN) Hub to a population in south London led to: a reduction in the overall volume of patients referred from primary care for a secondary mental health care assessment; and an increase in the proportion of patients referred who met specialist service eligibility criteria, as indicated by the likelihood of being accepted in secondary care. Design/methodology/approach The evaluation applied a quasi-experimental interrupted time series design using electronic patient records data for a National Health Service (NHS) provider of secondary mental health services in south London. Findings Scale-up of the Hub to the whole of the population of Lambeth led to an average of 98 fewer secondary care assessments per month (95% CI −118 to −78) compared to an average of 203 assessments per month estimated in the absence of the Hub; and an absolute incremental increase in the probability of acceptance for specialist intervention of 0.20 (95% CI; 0.14 to 0.27) above an average probability of acceptance of 0.57 in the absence of the Hub. Research limitations/implications Mental health outcomes for people using the service and system wide-service impacts were not evaluated preventing a more holistic evaluation of the effectiveness and cost-effectiveness of the LWN Hub. Practical implications Providing general practitioners with access to service infrastructure designed to help people whose needs cannot be managed within specialist mental health services can prevent unnecessary referrals into secondary care assessment teams. Social implications Reducing unnecessary referrals through provision of a primary-care linked mental health service will reduce delay in access to professional support that can address specific mental-health related needs that could not be offered within the secondary care services and could prevent the escalation of problems. Originality/value The authors use NHS data to facilitate the novel application of a quasi-experimental methodology to deliver new evidence on whether an innovative primary care linked mental health service was effective in delivering on one of its key aims.
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ItemNational implementation of a pragmatic quality improvement skills curriculum for urology residents in the UK: Application and results of 'theory-of-change' methodology.(Elsevier BV, 2021-02)BACKGROUND: There is global momentum to establish scalable Quality Improvement (QI) skills training curricula. We report development of an implementation plan for national scale-up of the 'Education in Quality Improvement' program (EQUIP) in UK urology residencies. MATERIALS & METHODS: Theory-of-Change (ToC) methodology was used, which engaged EQUIP stakeholders in developing a single-page implementation 'Logic Model' in 4 study phases (2 stakeholder workshops (N = 20); 10 stakeholder interviews). The framework method was used for analysis. RESULTS: Core elements of the EQUIP Logic Model include: (i) QI curriculum integration into national surgical curricula; (ii) resident-led, modular, team-based QI projects; (iii) development of a national web-platform as QI projects library; (iv) a train-the-trainers module to develop attendings as QI mentors; and (v) knowledge transfer activities (e.g., peer-reviewed publications of residents' QI projects). CONCLUSIONS: ToC methodology was useful in developing a stakeholder-driven, actionable implementation plan for the national scale-up of EQUIP in the UK.
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ItemThe cancer multidisciplinary team meeting: in need of change? History, challenges and future perspectives.(Wiley, 2021-09)Two decades since their inception, multidisciplinary teams (MDTs) are widely regarded as the 'gold standard' of cancer care delivery. Benefits of MDT working include improved patient outcomes, adherence to guidelines, and even economic benefits. Benefits to MDT members have also been demonstrated. An increasing body of evidence supports the use of MDTs and provides guidance on best practise. The system of MDTs in cancer care has come under increasing pressure of late, due to the increasing incidence of cancer, the popularity of MDT working, and financial pressures. This pressure has resulted in recommendations by national bodies to implement streamlining to reduce workload and improve efficiency. In the present review we examine the historical evidence for MDT working, and the scientific developments that dictate best practise. We also explore how streamlining can be safely and effectively undertaken. Finally, we discuss the future of MDT working including the integration of artificial intelligence and decision support systems and propose a new model for improving patient centredness.
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ItemA Smartphone App Designed to Empower Patients to Contribute Toward Safer Surgical Care: Qualitative Evaluation of Diverse Public and Patient Perceptions Using Focus Groups.(JMIR Publications Inc., 2021-04-08)BACKGROUND: MySurgery is a smartphone app designed to empower patients and their caregivers to contribute toward safer surgical care by following practical advice to help reduce susceptibility to errors and complications. OBJECTIVE: The aim of this study is to evaluate service users' perceptions of MySurgery, including its perceived acceptability, the potential barriers and facilitators to accessing and using its content, and ideas about how to facilitate its effective implementation. The secondary aim is to analyze how the intended use of the app might differ for diverse patients, including seldom-heard groups. METHODS: We implemented a diversity approach to recruit participants from a range of backgrounds with previous experience of surgery. We aimed to achieve representation from seldom-heard groups, including those from a Black, Asian, and minority ethnic (BAME) background; those with a disability; and those from the lesbian, gay, bisexual, transgender, queer (LGBT+) community. A total of 3 focus groups were conducted across a 2-month period, during which a semistructured protocol was followed to elicit a rich discussion around the app. The focus groups were audio recorded, and thematic analysis was carried out. RESULTS: In total, 22 individuals participated in the focus groups. A total of 50% (n=11) of the participants were from a BAME background, 59% (n=13) had a disability, and 36% (n=8) were from the LGBT+ community. There was a strong degree of support for the MySurgery app. The majority of participants agreed that it was acceptable and appropriate in terms of content and usability, and that it would help to educate patients about how to become involved in improving safety. The checklist-like format was popular. There was rich discussion around the accessibility and inclusivity of MySurgery. Specific user groups were identified who might face barriers in accessing the app or acting on its advice, such as those with visual impairments or learning difficulties and those who preferred to take a more passive role (eg, some individuals because of their cultural background or personality type). The app could be improved by signposting further specialty-specific information and incorporating a calendar and notes section. With regard to implementation, it was agreed that use of the app should be signposted before the preoperative appointment and that training and education should be provided for clinicians to increase awareness and buy-in. Communication about the app should clarify its scientific basis in plain English and should stress that its use is optional. CONCLUSIONS: MySurgery was endorsed as a powerful tool for enhancing patient empowerment and facilitating the direct involvement of patients and their caregivers in maintaining patient safety. The diversity approach allowed for a better understanding of the needs of different population groups and highlighted opportunities for increasing accessibility and involvement in the app.
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ItemAdaptation of the World Health Organization Electronic Mental Health Gap Action Programme Intervention Guide App for Mobile Devices in Nepal and Nigeria: Protocol for a Feasibility Cluster Randomized Controlled Trial.(JMIR Publications Inc., 2021-06-15)BACKGROUND: There is a growing global need for scalable approaches to training and supervising primary care workers (PCWs) to deliver mental health services. Over the past decade, the World Health Organization Mental Health Gap Action Programme Intervention Guide (mhGAP-IG) and associated training and implementation guidance have been disseminated to more than 100 countries. On the basis of the opportunities provided by mobile technology, an updated electronic Mental Health Gap Action Programme Intervention Guide (e-mhGAP-IG) is now being developed along with a clinical dashboard and guidance for the use of mobile technology in supervision. OBJECTIVE: This study aims to assess the feasibility, acceptability, adoption, and other implementation parameters of the e-mhGAP-IG for diagnosis and management of depression in 2 lower-middle-income countries (Nepal and Nigeria) and to conduct a feasibility cluster randomized controlled trial (cRCT) to evaluate trial procedures for a subsequent fully powered trial comparing the clinical effectiveness and cost-effectiveness of the e-mhGAP-IG and remote supervision with standard mhGAP-IG implementation. METHODS: A feasibility cRCT will be conducted in Nepal and Nigeria to evaluate the feasibility of the e-mhGAP-IG for use in depression diagnosis and treatment. In each country, an estimated 20 primary health clinics (PHCs) in Nepal and 6 PHCs in Nigeria will be randomized to have their staff trained in e-mhGAP-IG or the paper version of mhGAP-IG v2.0. The PHC will be the unit of clustering. All PCWs within a facility will receive the same training (e-mhGAP-IG vs paper mhGAP-IG). Approximately 2-5 PCWs, depending on staffing, will be recruited per clinic (estimated 20 health workers per arm in Nepal and 15 per arm in Nigeria). The primary outcomes of interest will be the feasibility and acceptability of training, supervision, and care delivery using the e-mhGAP-IG. Secondary implementation outcomes include the adoption of the e-mhGAP-IG and feasibility of trial procedures. The secondary intervention outcome-and the primary outcome for a subsequent fully powered trial-will be the accurate identification of depression by PCWs. Detection rates before and after training will be compared in each arm. RESULTS: To date, qualitative formative work has been conducted at both sites to prepare for the pilot feasibility cRCT, and the e-mhGAP-IG and remote supervision guidelines have been developed. CONCLUSIONS: The incorporation of mobile digital technology has the potential to improve the scalability of mental health services in primary care and enhance the quality and accuracy of care. TRIAL REGISTRATION: ClinicalTrials.gov NCT04522453; https://clinicaltrials.gov/ct2/show/NCT04522453. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/24115.
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ItemMortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study(ELSEVIER SCIENCE INC, 2021-07-24)BACKGROUND: Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. METHODS: We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung's disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. FINDINGS: We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung's disease) from 264 hospitals (89 in high-income countries, 166 in middle-income countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36-39) and median bodyweight at presentation was 2·8 kg (2·3-3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in low-income countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88-4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59-2·79], p<0·0001), sepsis at presentation (1·20 [1·04-1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4-5 vs ASA 1-2, 1·82 [1·40-2·35], p<0·0001; ASA 3 vs ASA 1-2, 1·58, [1·30-1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02-1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41-2·71], p=0·0001; parenteral nutrition 1·35, [1·05-1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47-0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50-0·86], p=0·0024) or percutaneous central line (0·69 [0·48-1·00], p=0·049) were associated with lower mortality. INTERPRETATION: Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between low-income, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030. FUNDING: Wellcome Trust.