Objective To describe where papers come from in a systematic review of complex evidence. Method Audit of how the 495 primary sources for the review were originally identified. Results Only 30% of sources were obtained from the protocol denned at the outset of the study (that is, from the database and hand searches). Fifty one per cent were identified by \"snowballing\" (such as pursuing references of references), and 24% by personal knowledge or personal contacts. Conclusion Systematic reviews of complex evidence cannot rely solely on protocol-driven search strategies.
\n \n\n \n \nEven when good scientific data are available, people's interpretation of risks and benefits will differ.
\n \n\n \n \nObjectives: To describe and evaluate two different models of a clinical informaticist service. Design A case study approach, using various qualitative methods to illuminate the complexity of the project groups' experiences. Setting UK primary health care. Interventions: Two informaticist projects to provide evidence based answers to questions arising in clinical practice and thereby support high quality clinical decision making by practitioners. Results: The projects took contrasting and complementary approaches to establishing the service. One was based in an academic department of primary health care. The service was academically highly rigorous, remained true to its original proposal, included a prominent research component, and involved relatively little personal contact with practitioners. This group achieved the aim of providing general information and detailed guidance to others intending to set up a similar service. The other group was based in a service general practice and took a much more pragmatic, flexible, and facilitative approach. They achieved the aim of a credible, acceptable, and sustainable service that engaged local practitioners beyond the innovators and enthusiasts and secured continued funding. Conclusion An informaticist service should be judged on at least two aspects of quality - an academic dimension (the technical quality of the evidence based answers) and a service dimension (the facilitation of questioning behaviour and implementation). This study suggests that, while the former may be best achieved within an academic environment, the latter requires a developmental approach in which pragmatic service considerations are addressed.
\n \n\n \n \nObjective: To explore the introduction of a centrally stored, shared electronic patient record (the summary care record (SCR)) in England and draw wider lessons about the implementation of large scale information technology projects in health care. Design: Multi-site, mixed method case study applying utilisation focused evaluation. Setting: Four early adopter sites for the SCR in England - three in urban areas of relative socioeconomic deprivation and the fourth in a relatively affluent rural area. Data sources and analysis: Data included 250 staff interviews, 1500 hours of ethnographic observation, interviews and focus groups with 170 patients and carers, 2500 pages of correspondence and documentary evidence, and incorporation of relevant surveys and statistics produced by others. These were analysed by using a thematic approach drawing on (and extending) a theoretical model of complex change developed in a previous systematic review. Main findings: The mixed fortunes of the SCR programme in its first year were largely explained by eight interacting influences. The first was the SCR's material properties (especially technical immaturity and lack of interoperability) and attributes (especially the extent to which potential adopters believed the benefits outweighed the risks). The second was adopters' concerns (especially about workload and the ethicality of sharing \"confidential\" information on an implied consent model). The third influence was interpersonal influence (for example, opinion leaders, champions, facilitators), and the fourth was organisational antecedents for innovation (for example, past experience with information technology projects, leadership and management capacity, effective data capture systems, slack resources). The fifth was organisational readiness for the SCR (for example, innovation-system fit, tension forchange, power balances between supporters and opponents, baseline data quality). The sixth was the implementation process (including the nature of the change model and the extent to which new routines associated with the SCR aligned with existing organisational routines). The seventh influence was the nature and quality of links between different parts of the system, and the final one was the wider environment (especially the political context of the programme). Conclusion: Shared electronic records are not plug-in technologies. They are complex innovations that must be accepted by individual patients and staff and also embedded in organisational and inter-organisational routines. This process is heavily influenced at the microlevel by the material properties of the technology, individuals' attitudes and concerns, and interpersonal influence; at the meso-level by organisational antecedents, readiness, and operational aspects of implementation; and at the macro-level by institutional and socio-political forces. A case study approach and multi-level theoretical analysis can illuminate how contextual factors shape, enable, and constrain new, technology supported models of patient care.
\n \n\n \n \nIn this investigation contrast threshold measurements are compared with supra-threshold perception for a group of human amblyopes. The results indicate that human amblyopia involves, in some cases, not only loss of sensitivity but spatial distortion. Thus a new group of amblyopes can now be identified in which only distortion occurs. These results have important physiological implications for both the normal and abnormal visual systems. Neurophysiologists investigating visual loss from deprivation should assess whether similar distortions occur in animals. This question may hold the answer to whether the present animal models are relevant to the human condition. \u00a9 1978 Springer-Verlag.
\n \n\n \n \nThis paper reports a study of the prescribing and dispensing of drugs in India. The drugs supplied to 2400 patients by the public and private medical sectors and by private pharmacies (over the counter dispensing) were recorded, and were analysed with respect to the patient's presenting complaint and diagnosis. The main findings discussed in this paper are: 1. 1. Large numbers of drugs are prescribed by doctors in the private sector. Combination preparations containing 'hidden' classes of drug are often given. Anti-infectives are widely and often inappropriately used. 2. 2. Potentially dangerous drugs are sold over the counter and prescribed for trivial or bizzare indications. Drugs which have been withdrawn as dangerous in the West remain popular first line drugs in India. 3. 3. Food supplements and tonics of dubious nutritional and pharmacological value make up a high proportion of the total drugs bill. It is concluded that a rational drugs policy and/or an essential drugs list will be useless unless accompanied by intensive efforts to improve the education and updating of doctors and pharmacists and to reduce the commercial pressures on doctors to prescribe unnecessary drugs. \u00a9 1987.
\n \n\n \n \nIn 2005 we published draft guidelines for reporting studies of quality improvement interventions as the initial step in a consensus process for development of a more definitive version. The current article contains the revised version, which we refer to as SQUIRE (Standards for QUality Improvement Reporting Excellence). We describe the consensus process, which included informal feedback, formal written commentaries, input from publication guideline developers, review of the literature on the epistemology of improvement and on methods for evaluating complex social programs, and a meeting of stakeholders for critical review of the guidelines' content and wording, followed by commentary on sequential versions from an expert consultant group. Finally, we examine major differences between SQUIRE and the initial draft, and consider limitations of and unresolved questions about SQUIRE; we also describe ancillary supporting documents and alternative versions under development, and plans for dissemination, testing, and further development of SQUIRE.
\n \n\n \n \nContext: Large-scale, whole-systems interventions in health care require imaginative approaches to evaluation that go beyond assessing progress against predefined goals and milestones. This project evaluated a major change effort in inner London, funded by a charitable donation of approximately $21 million, which spanned four large health care organizations, covered three services (stroke, kidney, and sexual health), and sought to \" modernize\" these services with a view to making health care more efficient, effective, and patient centered. Methods: This organizational case study draws on the principles of realist evaluation, a largely qualitative approach that is centrally concerned with testing and refining program theories by exploring the complex and dynamic interaction among context, mechanism, and outcome. This approach used multiple data sources and methods in a pragmatic and reflexive manner to build a picture of the case and follow its fortunes over the three-year study period. The methods included ethnographic observation, semistructured interviews, and scrutiny of documents and other contemporaneous materials. As well as providing ongoing formative feedback to the change teams in specific areas of activity, we undertook a more abstract, interpretive analysis, which explored the context-mechanism-outcome relationship using the guiding question \"what works, for whom, under what circumstances?\" Findings: In this example of large-scale service transformation, numerous projects and subprojects emerged, fed into one another, and evolved over time. Six broad mechanisms appeared to be driving the efforts of change agents: integrating services across providers, finding and using evidence, involving service users in the modernization effort, supporting self-care, developing the workforce, and extending the range of services. Within each of these mechanisms, different teams chose widely differing approaches and met with differing success. The realist analysis of the fortunes of different subprojects identified aspects of context and mechanism that accounted for observed outcomes (both intended and unintended). Conclusions: This study was one of the first applications of realist evaluation to a large-scale change effort in health care. Even when an ambitious change program shifts from its original goals and meets unforeseen challenges (indeed, precisely because the program morphs and adapts over time), realist evaluation can draw useful lessons about how particular preconditions make particular outcomes more likely, even though it cannot produce predictive guidance or a simple recipe for success. Noting recent calls by others for the greater use of realist evaluation in health care, this article considers some of the challenges and limitations of this method in the light of this experience and suggests that its use will require some fundamental changes in the worldview of some health services researchers. \u00a9 2009 Milbank Memorial Fund.
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