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Conference paperModi HN, Leff DR, Singh H, et al., 2016,
Temporal Demands Increase Workload and Degrade Surgical Performance
, International Surgical Congress of the Association of Surgeons of Great Britain and Ireland, Publisher: Wiley, Pages: 52-53, ISSN: 1365-2168 -
Journal articleVamos EP, Pape UJ, Curcin V, et al., 2016,
Effectiveness of the influenza vaccine in preventing admission to hospital and death in people with type 2 diabetes.
, Canadian Medical Association Journal, ISSN: 0008-4409BACKGROUND: The health burden caused by seasonal influenza is substantial. We sought to examine the effectiveness of influenza vaccination against admission to hospital for acute cardiovascular and respiratory conditions and all-cause death in people with type 2 diabetes. METHODS: We conducted a retrospective cohort study using primary and secondary care data from the Clinical Practice Research Datalink in England, over a 7-year period between 2003/04 and 2009/10. We enrolled 124 503 adults with type 2 diabetes. Outcome measures included admission to hospital for acute myocardial infarction (MI), stroke, heart failure or pneumonia/influenza, and death. We fitted Poisson regression models for influenza and off-season periods to estimate incidence rate ratios (IRR) for cohorts who had and had not received the vaccine. We used estimates for the summer, when influenza activity is low, to adjust for residual confounding. RESULTS: Study participants contributed to 623 591 person-years of observation during the 7-year study period. Vaccine recipients were older and had more comorbid conditions compared with nonrecipients. After we adjusted for covariates and residual confounding, vaccination was associated with significantly lower admission rates for stroke (IRR 0.70, 95% confidence interval [CI] 0.53-0.91), heart failure (IRR 0.78, 95% CI 0.65-0.92) and pneumonia or influenza (IRR 0.85, 95% CI 0.74-0.99), as well as all-cause death (IRR 0.76, 95% CI 0.65-0.83), and a nonsignificant change for acute MI (IRR 0.81, 95% CI 0.62-1.04) during the influenza seasons. INTERPRETATION: In this cohort of patients with type 2 diabetes, influenza vaccination was associated with reductions in rates of admission to hospital for specific cardiovascular events. Efforts should be focused on improvements in vaccine uptake in this important target group as part of comprehensive secondary prevention.
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Journal articleHarris MJ, Weisberger E, Silver D, et al., 2016,
That’s not how the learning works - the paradox of Reverse Innovation: a qualitative study
, Globalization and Health, Vol: 12, ISSN: 1744-8603BackgroundThere are significant differences in the meaning and use of the term ‘Reverse Innovation’ between industry circles, where the term originated, and health policy circles where the term has gained traction. It is often conflated with other popularized terms such as Frugal Innovation, Co-development and Trickle-up Innovation. Compared to its use in the industrial sector, this conceptualization of Reverse Innovation describes a more complex, fragmented process, and one with no particular institution in charge. It follows that the way in which the term ‘Reverse Innovation’, specifically, is understood and used in the healthcare space is worthy of examination.MethodsBetween September and December 2014, we conducted eleven in-depth face-to-face or telephone interviews with key informants from innovation, health and social policy circles, experts in international comparative policy research and leaders in the Reverse Innovation space in the United States. Interviews were open-ended with guiding probes into the barriers and enablers to Reverse Innovation in the US context, specifically also informants' experience and understanding of the term Reverse Innovation. Interviews were recorded, transcribed and analyzed thematically using the process of constant comparison.ResultsWe describe three main themes derived from the interviews. First, ‘Reverse Innovation,’ the term, has marketing currency to convince policy-makers that may be wary of learning from or adopting innovations from unexpected sources, in this case Low-Income Countries. Second, the term can have the opposite effect - by connoting frugality, or innovation arising from necessity as opposed to good leadership, the proposed innovation may be associated with poor quality, undermining potential translation into other contexts. Finally, the term ‘Reverse Innovation’ is a paradox – it breaks down preconceptions of the directionality of knowledge and learning
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Journal articleCowling T, Harris M, Majeed F, 2016,
Extended opening hours and patient experience of general practice in England: multilevel regression analysis of a national patient survey
, BMJ Quality & Safety, Vol: 26, Pages: 360-371, ISSN: 2044-5423Background The UK government plans to extend the opening hours of general practices in England. The ‘extended hours access scheme’ pays practices for providing appointments outside core times (08:00 to 18.30, Monday to Friday) for at least 30 min per 1000 registered patients each week.Objective To determine the association between extended hours access scheme participation and patient experience.Methods Retrospective analysis of a national cross-sectional survey completed by questionnaire (General Practice Patient Survey 2013–2014); 903 357 survey respondents aged ≥18 years old and registered to 8005 general practices formed the study population. Outcome measures were satisfaction with opening hours, experience of making an appointment and overall experience (on five-level interval scales from 0 to 100). Mean differences between scheme participation groups were estimated using multilevel random-effects regression, propensity score matching and instrumental variable analysis.Results Most patients were very (37.2%) or fairly satisfied (42.7%) with the opening hours of their general practices; results were similar for experience of making an appointment and overall experience. Most general practices participated in the extended hours access scheme (73.9%). Mean differences in outcome measures between scheme participants and non-participants were positive but small across estimation methods (mean differences ≤1.79). For example, scheme participation was associated with a 1.25 (95% CI 0.96 to 1.55) increase in satisfaction with opening hours using multilevel regression; this association was slightly greater when patients could not take time off work to see a general practitioner (2.08, 95% CI 1.53 to 2.63).Conclusions Participation in the extended hours access scheme has a limited association with three patient experience measures. This questions expected impacts of current plans to extend opening hours on patient experience.
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Journal articleFlott KM, Graham C, Darzi A, et al., 2016,
Can we use patient-reported feedback to drive change? The challenges of using patient-reported feedback and how they might be addressed
, BMJ Quality & Safety, Vol: 26, Pages: 502-507, ISSN: 2044-5423 -
Journal articleRao A, Suliman A, Vuik S, et al., 2016,
Outcomes of dementia: systematic review and meta-analysis of hospital administrative database studies
, Archives of Gerontology and Geriatrics, Vol: 66, Pages: 198-204, ISSN: 1872-6976INTRODUCTION: Aim of the study was to compare various outcomes of dementia patients with elderly patients without dementia by conducting a systematic review of previous population-based studies. METHODS: The relevant studies were retrieved from search of electronic databases. RESULTS: The pooled data from included 11 studies consisted of outcomes of 1,044,131 dementia patients compared to 9,639,027 elderly patients without dementia. Meta-analysis showed that the mortality in dementia patients was 15.3% as compared to 8.7% in non-dementia cases (RR 1.70, CI 95%, 1.27-2.28, p 0.0004). However, there was significant heterogeneity between the studies (p<0.00001). Dementia patients had significantly increased overall readmission rate (OR 1.18; 95% CI, 1.08-1.29, p<0.001). They had higher complication rates for urinary tract infections (RR 2.88; 95% CI, 2.45-3.40, p<0.0001), pressure ulcers (RR 184; 95% CI, 1.31-1.46, p<0.0001), pneumonia (RR 1.66; 95% CI, 1.36-2.02, p<0.0001), delirium (RR 3.10; 95% CI, 2.31-4.15, p<0.0001), and, dehydration and electrolyte imbalance (RR 1.87; 95% CI, 1.55-2.25, p<0.0001). Dementia patients had more acute cardiac events (HR 1.16; 95% CI, 1.06-1.28, p 0.002), while fewer revascularization procedures (HR 0.12; 95% CI, 0.08-0.20, p<0.001). Patients with dementia had lesser use of ITU (reduction by 7.5%; 95% CI, 6.9-8.1), ventilation (reduction by 5.4%; 95% CI, 5.0-5.9), and dialysis (reduction by 0.5%; 95% CI, 0.4-0.8). DISCUSSION: Compared to older adult population, patients with dementia had poorer outcome. Despite higher mortality rate and readmission rate, they underwent fewer interventions and procedures.
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Journal articleVuik SI, Mayer EK, Darzi A, 2016,
Patient segmentation analysis offers significant benefits for integrated care and support
, Health Affairs, Vol: 35, Pages: 769-775, ISSN: 0278-2715Integrated care aims to organize care around the patient instead of the provider. It is therefore crucial to understand differences across patients and their needs. Segmentation analysis that uses big data can help divide a patient population into distinct groups, which can then be targeted with care models and intervention programs tailored to their needs. In this article we explore the potential applications of patient segmentation in integrated care. We propose a framework for population strategies in integrated care—whole populations, subpopulations, and high-risk populations—and show how patient segmentation can support these strategies. Through international case examples, we illustrate practical considerations such as choosing a segmentation logic, accessing data, and tailoring care models. Important issues for policy makers to consider are trade-offs between simplicity and precision, trade-offs between customized and off-the-shelf solutions, and the availability of linked data sets. We conclude that segmentation can provide many benefits to integrated care, and we encourage policy makers to support its use.
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Journal articleMajeed F, Hansell A, Saxena S, et al., 2016,
How would a decision to leave the European Union affect medical research and health in the United Kingdom?
, Journal of the Royal Society of Medicine, Vol: 109, Pages: 216-218, ISSN: 1758-1095 -
Journal articleMarcus HJ, Payne CJ, Hughes-Hallett A, et al., 2016,
REGULATORY APPROVAL OF NEW MEDICAL DEVICES: A CROSS SECTIONAL STUDY
, British Medical Journal, Vol: 353, ISSN: 1756-1833Objective To investigate the regulatory approval of new medical devices.Design Cross sectional study of new medical devices reported in the biomedical literature.Data sources PubMed was searched between 1 January 2000 and 31 December 2004 to identify clinical studies of new medical devices. The search was carried out during this period to allow time for regulatory approval.Eligibility criteria for study selection Articles were included if they reported a clinical study of a new medical device and there was no evidence of a previous clinical study in the literature. We defined a medical device according to the US Food and Drug Administration as an “instrument, apparatus, implement, machine, contrivance, implant, in vitro reagent, or other similar or related article.”Main outcome measures Type of device, target specialty, and involvement of academia or of industry for each clinical study. The FDA medical databases were then searched for clearance or approval relevant to the device.Results 5574 titles and abstracts were screened, 493 full text articles assessed for eligibility, and 218 clinical studies of new medical devices included. In all, 99/218 (45%) of the devices described in clinical studies ultimately received regulatory clearance or approval. These included 510(k) clearance for devices determined to be “substantially equivalent” to another legally marketed device (78/99; 79%), premarket approval for high risk devices (17/99; 17%), and others (4/99; 4%). Of these, 43 devices (43/99; 43%) were actually cleared or approved before a clinical study was published.Conclusions We identified a multitude of new medical devices in clinical studies, almost half of which received regulatory clearance or approval. The 510(k) pathway was most commonly used, and clearance often preceded the first published clinical study.
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Journal articleVlaev I, King D, Dolan P, et al., 2016,
The Theory and Practice of "Nudging": Changing Health Behaviors
, Public Administration Review, Vol: 76, Pages: 550-561, ISSN: 1540-6210 -
Journal articleFlott K, Callahan R, Darzi A, et al., 2016,
A Patient-Centered Framework for Evaluating Digital Maturity of Health Services: A Systematic Review
, Journal of Medical Internet Research, Vol: 18, ISSN: 1439-4456Background: Digital maturity is the extent to which digital technologies are used as enablers to deliver a high-quality health service. Extensive literature exists about how to assess the components of digital maturity, but it has not been used to design a comprehensive framework for evaluation. Consequently, the measurement systems that do exist are limited to evaluating digital programs within one service or care setting, meaning that digital maturity evaluation is not accounting for the needs of patients across their care pathways.Objective: The objective of our study was to identify the best methods and metrics for evaluating digital maturity and to create a novel, evidence-based tool for evaluating digital maturity across patient care pathways.Methods: We systematically reviewed the literature to find the best methods and metrics for evaluating digital maturity. We searched the PubMed database for all papers relevant to digital maturity evaluation. Papers were selected if they provided insight into how to appraise digital systems within the health service and if they indicated the factors that constitute or facilitate digital maturity. Papers were analyzed to identify methodology for evaluating digital maturity and indicators of digitally mature systems. We then used the resulting information about methodology to design an evaluation framework. Following that, the indicators of digital maturity were extracted and grouped into increasing levels of maturity and operationalized as metrics within the evaluation framework.Results: We identified 28 papers as relevant to evaluating digital maturity, from which we derived 5 themes. The first theme concerned general evaluation methodology for constructing the framework (7 papers). The following 4 themes were the increasing levels of digital maturity: resources and ability (6 papers), usage (7 papers), interoperability (3 papers), and impact (5 papers). The framework includes metrics for each of these levels at each stag
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Journal articleGardner B, Phillips A, Judah GD, 2016,
Habitual instigation and habitual execution: definition, measurement, and effects on behaviour frequency
, British Journal of Health Psychology, Vol: 21, Pages: 613-630, ISSN: 1359-107XObjectives‘Habit’ is a process whereby situational cues generate behaviour automatically, via activation of learned cue–behaviour associations. This article presents a conceptual and empirical rationale for distinguishing between two manifestations of habit in health behaviour, triggering selection and initiation of an action (‘habitual instigation’), or automating progression through subactions required to complete action (‘habitual execution’). We propose that habitual instigation accounts for habit–action relationships, and is the manifestation captured by the Self-Report Habit Index (SRHI), the dominant measure in health psychology.DesignConceptual analysis and prospective survey.MethodsStudent participants (N = 229) completed measures of intentions, the original, non-specific SRHI, an instigation-specific SRHI variant, an execution-specific variant, and, 1 week later, behaviour, in three health domains (flossing, snacking, and breakfast consumption). Effects of habitual instigation and execution on behaviour were modelled using regression analyses, with simple slope analysis to test habit–intention interactions. Relationships between instigation, execution, and non-specific SRHI variants were assessed via correlations and factor analyses.ResultsThe instigation-SRHI was uniformly more predictive of behaviour frequency than the execution-SRHI and corresponded more closely with the original SRHI in correlation and factor analyses.ConclusionsFurther, experimental work is needed to separate the impact of the two habit manifestations more rigorously. Nonetheless, findings qualify calls for habit-based interventions by suggesting that behaviour maintenance may be better served by habitual instigation and that disrupting habitual behaviour may depend on overriding habits of instigation. Greater precision of measurement may help to minimize confusion between habitual instigation and execution.
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Journal articleJudah G, Vlaev I, Gunn L, et al., 2016,
Incentives in Diabetic Eye Assessment by Screening (IDEAS): study protocol of a three-arm randomized controlled trial using financial incentives to increase screening uptake in London.
, BMC Ophthalmology, Vol: 16, ISSN: 1471-2415BACKGROUND: Diabetes is an increasing public health problem in the UK and globally. Diabetic retinopathy is a microvascular complication of diabetes, and is one of the leading causes of blindness in the UK working age population. The diabetic eye screening programme in England aims to invite all people with diabetes aged 12 or over for retinal photography to screen for the presence of diabetic retinopathy. However, attendance rates are only 81 %, leaving many people at risk of preventable sight loss. METHODS: This is a three arm randomized controlled trial to investigate the impact of different types of financial incentives (based on principles from behavioral economics) on increasing attendance at diabetic eye screening appointments in London. Eligible participants will be aged 16 or over, and are those who have been invited to screening appointments annually, but who have not attended, or telephoned to rearrange an appointment, within the last 24 months. Eligible participants will be randomized to one of three conditions: 1. Control condition (usual invitation letter) 2. Fixed incentive condition (usual invitation letter, including a voucher for £10 if they attend their appointment) 3. Probabilistic incentive condition (invitation letter, including a voucher for a 1 in 100 chance of winning £1000 if they attend their appointment). Participants will be sent invitation letters, and the primary outcome will be whether or not they attend their appointment. One thousand participants will be included in total, randomized with a ratio of 1.4:1:1. In order to test whether the incentive scheme has a differential impact on patients from different demographic or socio-economic groups, information will be recorded on age, gender, distance from screening center, socio-economic status and length of time since they were last screened. A cost-effectiveness analysis will also be performed. DISCUSSION: This study will be the first trial of financial incentives
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Journal articleHarris M, Bhatti Y, Darzi A, 2016,
Does the Country of Origin Matter in Health Care Innovation Diffusion?
, Journal of the American Medical Association, Vol: 315, Pages: 1103-1104, ISSN: 0002-9955 -
ReportMayer E, Flott K, Callahan RP, et al., 2016,
National Reporting and Learning System Research and Development
This report presents the findings of the NRLS Researchand Development Programme conducted by thePatient Safety Translational Research Centre (PSTRC)and the Centre for Health Policy (CHP) at ImperialCollege London.It sets out the current state of affairs regardingpatient safety incident reporting in the NHS, andspecifies where the most pressing areas of concerns are,including thorough descriptions of the various incidentreporting systems used in the NHS today. Furthermore itidentifies areas for improvement in the overall landscapeof incident reporting, and suggests how systems like theNRLS can capitalise on developments in technology.The main body of the report is then devoted toexplaining the findings from the research programme. Theresearch was divided into four domains, and the reportdetails the new findings discovered about each of them:1. Purpose of incident reporting in healthcare2. User experience with reporting systems3. Data quality and analysis4. Effective feedback for learningBuilding on these findings, the report moves on to describehow they can be applied to the next generation ofincident reporting. Specifically, it focuses on a prototypefor a new incident reporting system that incorporates theimprovement ideas generated by the research.Finally, the report concludes with a description ofan evidence-based framework for evaluating incidentreporting systems and an ‘Achievement Toolkit’ often recommendations for improvements to incidentreporting systems.
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Journal articleSteedman MR, Kampmann B, Schillings E, et al., 2016,
Strategies to boost maternal immunization to achieve further gains in improved maternal and newborn health
, Health Affairs, Vol: 35, Pages: 309-316, ISSN: 0278-2715Despite the indisputable successes of the United Nations Millennium Development Goals, which include goals on improving maternal health and reducing child mortality, millions of mothers and newborns still die tragically and unnecessarily each year. Many of these deaths result from vaccine-preventable diseases, since obstacles such as cost and accessibility have hampered efforts to deliver efficacious vaccines to those most in need. Additionally, many vaccines given to mothers and children under age five are not suitable for newborns, since their maturing immune systems do not respond optimally during the first few months of life. Maternal immunization—the process by which a pregnant woman’s immune system is fortified against a particular disease and the protection is then transferred to her unborn child—has emerged as a strategy to prevent many unnecessary maternal and newborn deaths. We review vaccines that are already used for maternal immunization, analyze vaccines under development that could be used for maternal immunization strategies in the future, and recommend that policy makers use maternal immunization for improved maternal and newborn health.
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Journal articleHarris MJ, Macinko J, Jimenez G, et al., 2015,
Does a research article’s country of origin affect perception of its quality and relevance? A national trial of US public health researchers.
, BMJ Open, Vol: 5, ISSN: 2044-6055Objectives The source of research may influence one's interpretation of it in either negative or positive ways, however, there are no robust experiments to determine how source impacts on one's judgment of the research article. We determine the impact of source on respondents’ assessment of the quality and relevance of selected research abstracts.Design Web-based survey design using four healthcare research abstracts previously published and included in Cochrane Reviews.Setting All Council on the Education of Public Health-accredited Schools and Programmes of Public Health in the USA.Participants 899 core faculty members (full, associate and assistant professors)Intervention Each of the four abstracts appeared with a high-income source half of the time, and low-income source half of the time. Participants each reviewed the same four abstracts, but were randomly allocated to receive two abstracts with high-income source, and two abstracts with low-income source, allowing for within-abstract comparison of quality and relevancePrimary outcome measures Within-abstract comparison of participants’ rating scores on two measures—strength of the evidence, and likelihood of referral to a peer (1–10 rating scale). OR was calculated using a generalised ordered logit model adjusting for sociodemographic covariates.Results Participants who received high income country source abstracts were equal in all known characteristics to the participants who received the abstracts with low income country sources. For one of the four abstracts (a randomised, controlled trial of a pharmaceutical intervention), likelihood of referral to a peer was greater if the source was a high income country (OR 1.28, 1.02 to 1.62, p<0.05).Conclusions All things being equal, in one of the four abstracts, the respondents were influenced by a high-income source in their rating of research abstracts. More research may be needed to explore how the origin of a research article may lead
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Journal articleParston G, McQueen J, Patel H, et al., 2015,
The Science And Art Of Delivery: Accelerating The Diffusion Of Health Care Innovation
, Health Affairs, Vol: 34, Pages: 2160-2166, ISSN: 0278-2715There is a widely acknowledged time lag in health care between an invention or innovation and its widespread use across a health system. Much is known about the factors that can aid the uptake of innovations within discrete organizations. Less is known about what needs to be done to enable innovations to transform large systems of health care. This article describes the results of in-depth case studies aimed at assessing the role of key agents and agencies that facilitate the rapid adoption of innovations. The case studies—from Argentina, England, Nepal, Singapore, Sweden, the United States, and Zambia—represent widely varying health systems and economies. The implications of the findings for policy makers are discussed in terms of key factors within a phased approach for creating a climate for change, engaging and enabling the whole organization, and implementing and sustaining change. Purposeful and directed change management is needed to drive system transformation.
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Journal articleCowling TE, Richards EC, Gunning E, et al., 2015,
Online data on opening hours of general practices in England: a comparison with telephone survey data
, British Journal of General Practice, ISSN: 1478-5242 -
Journal articleHarris MJ, Weisberger E, Silver D, et al., 2015,
‘They hear “Africa” and they think that there can’t be any good services’ – perceived context in cross-national learning: a qualitative study of the barriers to Reverse Innovation.
, Globalization and Health, Vol: 11, ISSN: 1744-8603BackgroundCountry-of-origin of a product can negatively influence its rating, particularly if the product is from a low-income country. It follows that how non-traditional sources of innovation, such as low-income countries, are perceived is likely to be an important part of a diffusion process, particularly given the strong social and cognitive boundaries associated with the healthcare professions.MethodsBetween September and December 2014, we conducted eleven in-depth face-to-face or telephone interviews with key informants from innovation, health and social policy circles, experts in international comparative policy research and leaders in Reverse Innovation in the United States. Interviews were open-ended with guiding probes into the barriers and enablers to Reverse Innovation in the US context, specifically also to understand whether, in their experience translating or attempting to translate innovations from low-income contexts into the US, the source of the innovation matters in the adopter context. Interviews were recorded, transcribed and analyzed thematically using the process of constant comparison.ResultsOur findings show that innovations from low-income countries tend to be discounted early on because of prior assumptions about the potential for these contexts to offer solutions to healthcare problems in the US. Judgments are made about the similarity of low-income contexts with the US, even though this is based oftentimes on flimsy perceptions only. Mixing levels of analysis, local and national, leads to country-level stereotyping and missed opportunities to learn from low-income countries.ConclusionsOur research highlights that prior expectations, invoked by the Low-income country cue, are interfering with a transparent and objective learning process. There may be merit in adopting some techniques from the cognitive psychology and marketing literatures to understand better the relative importance of source in healthcare research and innovation diffusi
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