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We lead multidisciplinary applied research and training to rethink the way health care is delivered in general practice and across the community.
Sodium valproate in pregnancy: What are the risks and should we use a shared decision-making approach?
Background: Despite significant teratogenic risks, sodium valproate is still widely prescribed in many countries to women of childbearing age, as a mood stabiliser in bipolar disorder and also in epilepsy. The UK has recently banned valproate use in women who are not in a pregnancy prevention programme. Whilst this ruling reflects prevailing clinical practice, it also highlights an ongoing debate about when (if ever) a woman who is or could become pregnant should be allowed to choose to take valproate. Main body: We review the benefits and harms of drugs available for bipolar disorder and epilepsy in women of childbearing age, with a particular focus on teratogenic risk. We speculate on hypothetical rare situations in which potential benefits of valproate may outweigh potential harms in such women. We also review the literature on shared decision-making - on which there is now a NICE guideline and numerous evidence-based decision tools. Drawing on previous work by experts in shared decision-making, we offer a list of 'frequently asked questions' and a matrix of options to support conversations with women about continuing or discontinuing the drug in (or in anticipation of) pregnancy. We also consider whether shared decision-making is an appropriate paradigm when considering whether to continue a teratogenic drug. Conclusion: We conclude that because valproate in pregnancy remains the subject of such debate, there is scope for further research - not only into the relative efficacy and safety of alternatives to it - but also into the dynamics of communication and shared decision-making in this situation.
HiddenWork and the challenges of scalability and sustainability in ambulatory assisted living
Assisted living technologies may help people live independently while also-potentially-reducing health and care costs. But they are notoriously difficult to implement at scale and many devices are abandoned following initial adoption.We report findings from a study of global positioning system (GPS) tracking devices intended to support the independent living of people with cognitive impairment. Our aims were threefold: to understand (through ethnography) such individuals' lived experience of GPS tracking; to facilitate (through action research) the customization and adaptation of technologies and care services to provide effective, ongoing support; and to explore the possibilities for a co-production methodology that would enable people with cognitive impairment and their families to work with professionals and technical designers to shape these devices and services to meet their particular needs in a sustainable way.We found that the articulation work needed for maintaining the GPS technology in "working order" was extensive and ongoing. This articulation work does not merely supplement formal procedures, a lot of it is needed to get round them, but it is also often invisible and thus its importance goes largely unrecognized. If GPS technologies are to be implemented at scale and sustainably, methods must be found to capitalize on the skills and tacit knowledge held within the care network (professional and lay) to resolve problems, improve device design, devise new service solutions, and foster organizational learning. 2018
Costs, and cost-outcome of school feeding programmes and feeding programmes for young children. Evidence and recommendations
Our objectives for this study were to provide updated, realistic data on the costs and cost-outcomes of school feeding in Low and Middle Income Countries. We also aimed to identify factors that may influence effectiveness and therefore, cost effectiveness of the interventions. To do this, we combined data on effect sizes for physical and psychosocial outcomes from two Cochrane systematic reviews with new data on the costs of school feeding. We simulated the costs of preschool feeding based on the school feeding costs. We found that he average for low- and middle-income countries combined was US$72, with large variations across countries. We also found a wide variation in costs for different outcomes. We suggest several ways in which effectiveness may be improved and cost-per outcome lowered for both programmes.
Twice-told tales? How public inquiry could inform N of 1 case study research
This chapter considers the usefulness and validity of public inquiries as a source of data and preliminary interpretation for case study research. Using two contrasting examples - the Bristol Inquiry into excess deaths in a children's cardiac surgery unit and the Woolf Inquiry into a breakdown of governance at the London School of Economics (LSE) - I show how academics can draw fruitfully on, and develop further analysis from, the raw datasets, published summaries and formal judgements of public inquiries. Academic analysis of public inquiries can take two broad forms, corresponding to the two main approaches to individual case study defined by Stake: instrumental (selecting the public inquiry on the basis of predefined theoretical features and using the material to develop and test theoretical propositions) and intrinsic (selecting the public inquiry on the basis of the particular topic addressed and using the material to explore questions about what was going on and why). The advantages of a public inquiry as a data source for case study research typically include a clear and uncontested focus of inquiry; the breadth and richness of the dataset collected; the exceptional level of support available for the tasks of transcribing, indexing, collating, summarising and so on; and the expert interpretations and insights of the inquiry's chair (with which the researcher may or may not agree). A significant disadvantage is that whilst the dataset collected for a public inquiry is typically 'rich', it has usually been collected under far from ideal research conditions. Hence, while public inquiries provide a potentially rich resource for researchers, those who seek to use public inquiry data for research must justify their choice on both ethical and scientific grounds.
Uncertainty and clinical method
Trisha Greenhalgh reviews the literature on clinical uncertainty by describing the visits with four of her primary care patients. She presents a four-part taxonomy of uncertainty illustrated in the context of these patients' visits. Uncertainty about the evidence – the ‘voice of medicine’ dimension of the visit – relates to the completeness, accuracy, relevance of research-based evidence, and balance between potential benefits and harms. Uncertainty about the patient's story – the ‘voice of the lifeworld’ dimension – raises questions about how to explore the contexts and complexities of patients’ lives. Uncertainty about what best to do for the particular patient raises questions about using clinical judgment (the summation of knowledge, skill, and practical wisdom) to address each patient's unique set of issues. Uncertainties embodied in risks to quality and safety arising when care becomes a collaborative endeavour with its mix of human-human, technology-human, and technology-technology interactions add to the substrate for the clinical method.
Technology-Enhanced Consultations in Diabetes, Cancer, and Heart Failure: Protocol for the Qualitative Analysis of Remote Consultations (QuARC) Project.
BACKGROUND: Remote videoconsulting is promoted by policy makers as a way of delivering health care efficiently to an aging population with rising rates of chronic illness. As a radically new service model, it brings operational and interactional challenges in using digital technologies. In-depth research on this dynamic is needed before remote consultations are introduced more widely. OBJECTIVE: The objective of this study will be to identify and analyze the communication strategies through which remote consultations are accomplished and to guide patients and clinicians to improve the communicative quality of remote consultations. METHODS: In previous research, we collected and analyzed two separate datasets of remote consultations in a National Institute for Health Research-funded study of clinics in East London using Skype and a Wellcome Trust-funded study of specialist community heart failure teams in Oxford using Skype or FaceTime. The Qualitative Analysis of Remote Consultations (QuARC) study will combine datasets and undertake detailed interactional microanalysis of up to 40 remote consultations undertaken by senior and junior doctors and nurse specialists, including consultations with adults with diabetes, women who have diabetes during pregnancy, people consulting for postoperative cancer surgery and community-based patients having routine heart failure reviews along with up to 25 comparable face-to-face consultations. Drawing on established techniques (eg, conversation analysis), analysis will examine the contextual features in remote consultations (eg, restricted visual field) combined with close analysis of different modes of communication (eg, speech, gesture, and gaze). RESULTS: Our findings will address the current gap in knowledge about how technology shapes the fine detail of communication in remote consultations. Alongside academic outputs, findings will inform the coproduction of information and guidance about communication strategies to support successful remote consultations. CONCLUSIONS: Identifying the communication strategies through which remote consultations are accomplished and producing guidance for patients and clinicians about how to use this kind of technology successfully in consultations is an important and timely goal because roll out of remote consultations is planned across the National Health Service. REGISTERED REPORT IDENTIFIER: RR1-10.2196/10913.
Rethinking bias and truth in evidence-based health care
In modern philosophy, the concept of truth has been problematized from different angles, yet in evidence-based health care (EBHC), it continues to operate hidden and almost undisputed through the linked concept of “bias.” To prevent unwarranted relativism and make better inferences in clinical practice, clinicians may benefit from a closer analysis of existing assumptions about truth, validity, and reality. In this paper, we give a brief overview of several important theories of truth, notably the ideal limit theorem (which assumes an ultimate and absolute truth towards which scientific inquiry progresses), the dominant way truth is conceptualized in the discourse and practice of EBHC. We draw on Belgian philosopher Isabelle Stengers' work to demonstrate that bias means one thing if one assumes a world of hard facts “out there,” waiting to be collected. It means something different if one takes a critical view of the knowledge-power complex in research trials. Bias appears to have both an unproductive aspect and a productive aspect as argued by Stengers and others: Facts are not absolute but result from an interest, or interesse: a bias towards a certain line of questioning that cannot be eliminated. The duality that Stengers' view invokes draws attention to and challenges the assumptions underlying the ideal limit theory of truth in several ways. Most importantly, it casts doubt on the ideal limit theory as it applies to the single case scenario of the clinical encounter, the cornerstone of EBHC. To the extent that the goal of EBHC is to support inferencing in the clinical encounter, then the ideal limit as the sole concept of truth appears to be conceptually insufficient. We contend that EBHC could usefully incorporate a more pluralist understanding of truth and bias and provide an example how this would work out in a clinical scenario.
How are health-related behaviours influenced by a diagnosis of pre-diabetes? A meta-narrative review
Background: Several countries, including England, have recently introduced lifestyle-focused diabetes prevention programmes. These aim to reduce the risk of individuals with pre-diabetes developing type 2 diabetes. We sought to summarise research on how socio-cultural influences and risk perception affect people's behaviour (such as engagement in lifestyle interventions) after being told that they have pre-diabetes. Methods: Using the RAMESES standards for meta-narrative systematic reviews, we identified studies from database searches and citation-tracking. Studies were grouped according to underlying theorisations of pre-diabetes. Following a descriptive analysis, the studies were synthesised with reference to Cockerham's health lifestyle theory. Results: In total, 961 titles were scanned, 110 abstracts assessed and 35 full papers reviewed. Of 15 studies included in the final analysis, 11 were based on individual interviews, focus groups or ethnography and five on structured questionnaires or surveys. Three meta-narratives emerged. The first, which we called biomedical, characterised pre-diabetes as the first stage in a recognised pathophysiological illness trajectory and sought to intervene with lifestyle changes to prevent its progression. The second, which we called psychological, focused on the theory-informed study of the knowledge, attitudes and behaviours in people with pre-diabetes. These studies found that participants generally had an accurate perception of their risk of developing diabetes, but this knowledge did not directly lead to behavioural change. Some psychological studies incorporated wider social factors in their theoretical models and sought to address these through action at the individual level. The third meta-narrative we termed social realist. These studies conceptualised pre-diabetes as the product of social determinants of health and they applied sociological theories to explore the interplay between individual agency and societal influences, such as the socio-cultural context and material and economic circumstances. They recommended measures to address these structural influences on lifestyle choices. Conclusions: The study of pre-diabetes to date has involved at least three research disciplines (biomedicine, psychology and sociology), which up to now have operated largely independently of one another. Behavioural science and sociology are increasing our understanding of how personal, social, cultural and economic aspects influence health-related behaviours. An interdisciplinary approach with theoretically informed multi-level studies could potentially improve the success of diabetes prevention strategies.