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NIHR CLAHRC West Midlands News Blog header
This work is funded by the National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) West Midlands. 
The views expressed are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health
National Institute for Health Research logo
Welcome to the latest issue of your NIHR CLAHRC West Midlands News Blog.
Richard Lilford as the Statue of Liberty
In this issue we present the first of two articles on the scientific method in service delivery / quality improvement research. Here we tackle the subject of objectivity, while complexity will be tackled in the next issue. In this News Blog we also look at improving availability of donor human milk for premature babies in LMICs; reducing the risk of ovarian cancer; integrated care; the McMaster PLUS database for clinical studies; and the use of the WHO surgical checklist. 

We also profile Sam Watson
bring you the latest newsevents, and our CLAHRC WM Quiz. Finally, we have details of our latest publications.

We hope that you find these posts of interest, and we welcome any comments. You can find previous issues of our News Blog here.
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Director & Co-Directors' Blog

Objectivity in Service Delivery Research

The CLAHRC WM Director gave two recent talks about methodology and causal modelling in the evaluation of service delivery / quality improvement initiatives.

In both he received push back from a section of the audience. The remarks could be divided into two categories:
  1. Objectivity may be useful in physics and biomedical research, but cannot be usefully applied to service delivery research.
  2. Service delivery is too complex to be evaluated by standard scientific tools and the CLAHRC WM Director just doesn’t get it.
So, in this blog I shall tackle the question of objectivity, leaving the issue of complexity for a forthcoming post.

Concerning objectivity, I am a Bayesian and therefore need no convincing that science cannot be shorn of subjectivity. After all, the posterior probability is a function, not just of the data, but the ‘prior’. And the prior is subjective since it is constructed mentally (except in rare cases, such as genetics when it can be calculated from Mendel’s laws). Therefore, I regard subjectivity as an ineluctable part of science. But that does not follow that objectivity must be extirpated from health service evaluations. The fact that science cannot be totally objective does not mean that it is all subjective, any more than the fact that it being partly subjective excludes a role for objectivity. No, in forming a subjective view of the world (for example, in calibrating a parameter of interest to a decision-maker) the observations that are made should be as objective as we can make them. Why should they be objective? The answer is simple – to reduce the risk of error. Why is there a risk of error? Again the answer is simple – the human mind is prone to cognitive illusions. We favour observations that fit our preconceptions,[1] as discussed in a previous post. We anchor our minds on more recent experience or evidence encountered early in a chain of evidence. We are poorly calibrated over probability estimates, especially contingent probabilities.[2] The list of cognitive biases to which the human mind is prone is extensive and has been the subject of considerable research – try Daniel Kahneman’s “Thinking Fast and Slow”, for a summary.[3] It flies in the face of accumulated evidence to reify ‘lived experience’ at the expense of gathering objective evidence in the search for scientific understanding.

It should be understood that neither subjectivism nor objectivism need to ‘win’ – they are both in play. This idea that subjectivity is inherent in science, but objectivity has an important part to play, is clearly counter-intuitive to many people. So it may help to think metaphorically, and regard science as a journey, and objectivity as sign-posts along the way. The journey has to start with a question originating in human creativity and imagination – clearly a subjective process. But creativity yields theories to test and parameters to estimate. It is in collecting and making the initial analysis of such data that objectivity should be sought. The degree to which objectivity can be achieved will, of course, vary from one situation to another. In some cases, the observer can distance herself, as when a statistician is blinded to the intervention and control group in estimating an effectiveness parameter from RCT data. In other cases such separation is not possible, as when an ethnographer makes field notes. But objectivity is still the aim, just as a (good) teacher strives for objectivity in marking a piece of work. Once the analysis is complete, then meaning must be ascribed, guidelines formulated, etc. Here personal and social factors interact, as Bandura so elegantly describes in social cognitive theory,[4] and Bruno Latour equally elegantly explicates in the specific context of scientific understanding.[5] It is failure to appreciate that science is not just one thing that seems to cause people to trip up in understanding the interplay between subjectivity and objectivity in scientific achievement. To further help explain this concept I provide the following mind-line:

Conception of the idea - creativity and imagination; to Design  study; to Collect data; to Analyse data; to Interpret data; to Determine action.

Lastly, I encounter the objection that this is as may be in physics or life sciences, but does not apply to the social sciences. That’s cobblers – if there were no general statements we could make about personal and collective behaviour, then there would be no such thing as psychology or sociology. People who argue that human volition vitiates scientific inference confuse heterogeneity (it is hard, maybe impossible, to predict how an individual will behave) from a general tendency (women will accept a lower return than men in the ultimatum game; demand for health care is elastic on price). For a sure-footed philosophical account of this issue of objectivism and subjectivism in scientific reasoning I recommend John Searle.[6]


-- Richard Lilford, CLAHRC WM Director

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CLAHRC International

The Payback from Improving Availability of
Donor Human Milk for Premature Babies

CLAHRC WM is collaborating with the African Population Health Research Centre (APHRC) in the evaluation of donor milk banks in slums (informal settlements) in Kenya. The initiative is led by PATH,[1] which has had considerable success in establishing an altruistic donor service in South Africa. The donor milk is donated to hospital wards caring for premature infants.

There is excellent evidence that donor human milk is superior to 'formula' in babies whose mothers are unable to express breast milk. As a result of passive immunity, and also because it has nutritional properties that formula is not able to replicate, donor human milk reduces the risk of neonatal infection.[2] In particular, it reduces the dangerous condition of necrotising enterocolitis (NEC).[3][4] NEC can be fatal and may also require surgery that may have permanent consequences – particularly the ‘short bowel syndrome’. The decreased infection risk resulting from use of donor milk is associated with a measurable decrease in mean length of stay.[5]

One concern is that the mothers of infants who receive donor milk may be less likely to initiate breast feeding at a later date for psychological or physiological reasons. The evidence does not bear out this concern and, if anything, these mothers, perhaps inspired by the altruism of the donors, are more likely to breastfeed.[6][7] If so, this may be expected to augment the benefits of donor milk and also reduce the mother’s risk of developing breast cancer later in life.[8]

The benefits do not seem to end there. There is observational evidence, recently reinforced by a substantial study from Brazil,[9] that cognitive ability in later life is improved by human milk. There is a dose-response effect and the results remain after extensive statistical adjustment for confounders. There is also some experimental (RCT) evidence for a beneficial effect on IQ.[10] Improved IQ is correlated with earning power [11] and, we must assume, payback to society.[12]

To summarise the benefits of breastfeeding we offer the following Influence Diagram (Causal Pathway: Model):

A health economic analysis of promotion of breastfeeding for older children (not premature infants specifically) found that the intervention ‘dominated’ – reduced short-term benefits (less infection) and the contingent cost savings (reduced hospital stays) meant that interventions to promote breastfeeding are cost-saving, not just beneficial for health.[12][13]

There have been two studies of the cost-effectiveness of a donor milk service for premature babies. Both found that the service was cost-effective. The first study was based on a hypothetical baby who was very premature (28 weeks gestational age), rather than an observed mean intervention effect observed at the group level.[14] The calculated benefits might therefore be exaggerated. The second study was based on only 175 propensity scored low birth weight infants.[5] The risk of sepsis decreased with increasing dose of human milk, and total costs obtained from the hospital billing system were lower in proportion to the amount of human milk consumed. However, most infants received some human milk, so the infants could not be divided into a control and intervention population, and the above correlation between outcome and volume of donor milk consumed may have been confounded by factors that determine both access to human milk and sepsis, notwithstanding propensity scoring. Both the above studies were American.

Working with colleagues above, we propose a comprehensive health economic model that takes account of long-term outcomes and that can be populated with country-specific data. The base-case model will be populated with evidence from systematic reviews,[12][13] and we propose to use Bayesian techniques to 'down weight' observational evidence using the Turner and Spiegelhalter method.[15]

-- Richard Lilford, CLAHRC WM Director
-- Celia Taylor, Senior Lecturer

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References
 
CLAHRC WM Quiz
CLAHRC WM Quiz

What is the literal translation of the word Kwashiorkor, the severe wasting disease that occurs in areas of famine or poor food supply?
 
Email CLAHRC WM your answer.
 
Answer to our previous quiz: A declaration that committed countries to providing basic education for all its citizens was recently adopted in Arusha, Tanzania. Read moreCongratulations to Jo Sartori who was first to answer.
Director's Choice - From the Journals

Biology Never Ceases to Surprise:
Preventing Cancer of the Ovary by Tubal Ligation 

One might have thought that ovarian cancer can be prevented by removing the ovaries – say at the time of hysterectomy – and that obstructing or removing the fallopian tubes would not, by itself, reduce the risk of ovarian cancer. These hypotheses are based on the plausible assumption that cancer arises in the ovaries, just as breast cancer arises in the breast. However, it now appears that ovarian cancer may arise in the fallopian tubes, at least in a substantial proportion of cases. A Swedish record linkage study shows that fallopian tube ligation is associated with a 30% reduction in the incidence of ovarian cancer.[1] Confounding by high fertility do I hear you say? Apparently not as parity has been adjusted for. Caused by preventing access of carcinogens ascending the reproductive tract? Probably not, since removal of the fallopian tube provides even stronger protection against ovarian cancer, than does ligation which leaves the ovarian end of the tube in situ. Implausible hypothesis reminiscent of transubstantiation? No, cells with the appearance of ovarian cancer have been harvested from fallopian tubes, and the molecular signature of many ovarian cancers suggests a fallopian tube provenance.

-- Richard Lilford, CLAHRC WM Director

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Reference

 
Integrated Care

A recent BMJ paper [1] from Stephen Shortell and collaborators from the King’s Fund discusses the design of models of care to improve integration between hospital and community, and between health and social care – an old chestnut. They have a taxonomy of integrated care models that I represent like this:
 

Model 1 seems to locate responsibility for integration mostly with community providers, while model 2b evokes a structural solution in which hospital and community providers work in an organisation straddling hospital and community. The article comes down in favour of model 2b and gives successful examples from America (where quality has improved at reduced cost).[2][3][4][5] The article emphasises the importance of integrated computer care records, almost saying this is a necessary ingredient.

On this latter point, the CLAHRC WM Director begs to differ – as argued in a previous post, a patient-held paper record has considerable advantages over attempted ‘all singing and all dancing’ IT systems. He does agree, however, with the idea of an integrated record (not necessarily computer-based), the authors' emphasis on ‘clinical integration’, and the need to win the hearts and minds of service providers.[6] CLAHRC WM is involved with two grant applications to help develop the tacit skills needed to care for patients with multiple morbidities, and different needs and preferences, across multiple types of care provider in different locations.


-- Richard Lilford, CLAHRC WM Director

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References

 
Calling All Systematic Reviewers

The CLAHRC WM Director is provoked by the ever increasing – indeed, exponentially increasing – number of articles returned by standard literature searches. At this rate, screening all the articles identified by a typical search will be all but impossible within two decades. Some form of systematisation is necessary.

A start has been made in clinical research through the creation of the McMaster Premium LiteratUre Service (PLUS) database of pre-appraised clinical studies. PLUS is generated by manually reviewing 120 clinical journals for high-quality articles using a reproducible selection process. A paper comparing PLUS with 89 recent Cochrane reviews,[1] found that while PLUS contained fewer articles, restricting searches to PLUS did not change the conclusions of any of the Cochrane reviews included in the sample.

The PLUS database is a start, but it:

  1. still relies on manual review;
  2. is confined to clinical research.
A method is urgently required to:
  1. improve coding of topic and study type;
  2. automate compilation of bibliographies;
  3. cover health and social care as a whole.

Literature retrieval processes will be radically different in two decades – they will have to be.
 
-- Richard Lilford, CLAHRC WM Director

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Reference
 
Use of WHO Surgical Checklist

We thank Mary Dixon-Woods for drawing our attention to an interesting article on the use of the fabled WHO surgical checklist.[1] Interesting because the topic is important and because the authors used a step wedge, cluster, experimental design as they introduced the intervention across different surgical specialities in two Norwegian hospitals. Step wedge designs need to avoid pitfalls of all cluster studies related to interaction between intervention and willingness to be recruited. The neat way out of this conundrum is to use routinely collected data and enter everyone in the cluster. That was done here. It is important to control for systematically later time periods in the intervention 'cells' of the step wedge and, again, the authors did so. So what did they find in this procedurally satisfactory study? A large and statistically significant intervention effect was observed. This is in keeping with many, but not all, previous studies of the conventional checklist.

My problem lies in the underlying hypothesis; as a previous surgeon I find the theoretical basis for the checklist unconvincing. In other words I start from a sceptical prior that is reluctantly being pulled towards a more optimistic estimate. Also, I fret over publication bias in the social science/service delivery literature, as discussed in a previous post. All the same a sceptic like me cannot ignore these positive results. So how may the checklist work and yield benefits that seem counter-intuitive initially? Firstly, the word "checklist" may be a misnomer. It may just be a convenient focus around which to engender a positive and professional personal and team approach. This could explain why it sometimes works and sometimes does not. The idea here would be that it can't work when: 1) attitudes are totally hostile, or 2) practice is already very good so there is little headroom for improvement. In that case it would be like any behavioural intervention – it will work among those who are receptive to improvement, but not yet improved. It is also possible that use of the checklist, even in a tokenistic way, will be effective in the very long term. Here I rely on the theory of cognitive dissonance.[2] People who start with ritualistic tokens of compliance are inclined to either stop complying or move their attitudes towards their outward actions. Comments welcome.

-- Richard Lilford, CLAHRC WM Director

News

New CLAHRC WM Co-Director

CLAHRC WM are pleased to announce that Prof Christian Mallen, Professor of General Practice at Keele University, and member of Theme 4, Chronic Diseases, has agreed to become our third Co-Director, representing our colleagues working at the extremely successful primary care department at Keele University. This move will provide closer alignment and strengthen our links to our three major HEI collaborators, and aligns to the AHSN geography of a hub and spoke model.
 

PhD Opportunity

Funding for a PhD is available at the University of Birmingham to study the use of electronic patient records to investigate detection and management of chronic disease, with the aim to identify opportunities for improvement. Click here for more information. 

To inquire about this studentship please contact Prof Tom Marshall. The closing data for applications is Friday 26 June 2015.

 

Senior Investigator Funding

The NIHR have recently launched the 9th round of funding for Senior Investigators. NIHR Senior Investigators are fundamental to the NIHR Faculty and include some of the country's foremost researchers who are making the most outstanding contribution to clinical and applied health and social care research. Leading researchers funded by the NIHR or the Department of Health's Policy Research Programme (and who are employed by an NHS Trust, university, or charity based in England) are encouraged to apply. All Senior Investigators are awarded a £15,000 benefit a year to support their research work. Please click here for more information.

If any member of CLAHRC WM is planning to, or would like to apply then please let us know. The deadline for proposals is Tuesday 28 July 2015.

 

NIHR eNewsletter – Faculty World

The NIHR have recently published their latest e-Newsletter, Faculty World, focussing on Allied Health Professionals working in the NIHR. Please click here to view online.
 

APHRC wins 2015 UN Population Award

Congratulations to the African Population and Health Research Center (APHRC) for winning the 2015 United Nations Population Award for improving the health of women and children in Africa, and training a new generation of African health researchers. 

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Selected Replies

Re: Healthcare in a Parallel World

An interesting alternative reality to consider, thanks Tom! Though many of these components already exist within the field of Health Psychology (or behavioural medicine). Health Psychologists don't often propose education as the 'most important intervention' as it implies primarily information provision and increasing knowledge and skills,  which we know are rarely sufficient to change patient behaviour (as lack of knowledge is rarely the main reason for failing to follow health advice). However, I acknowledge that by 'education' you may mean something broader, incorporating psychological methods (e.g. increasing self-efficacy, decreasing anxiety) and what we would term, 'behaviour change techniques'. In Health Psychology we are already working on developing and refining these interventions, including the materials, communication technologies, virtual learning communities, and 'gamification' approaches mentioned above. Interventions are often developed in collaboration with NHS services, Public Health teams, and patient groups, but the challenge for our discipline is to increase our visibility and authority within the health system as a whole. Perhaps in the future we may reach a point where the parallel world envisioned in your post becomes somewhat real, co-existing with the pathophysiological approach. To do so, Health Psychologists must influence health care policy and practice, which will require greater collaboration with health service researchers (including CLAHRCs), clinicians and policy-makers.

-- Dr Elaine Cameron


That’s all well and good. But if skills and knowledge haven’t produced a lowered A1c, nothing’s been accomplished. The tests are the ultimate measure of progress.

Fortunately, I’ve been lucky with my doctors and even though I can keep my A1c well under 6, they still let me order tests when I think I need them and let me have my test strips! (yay!)

-- Dan Hunter


Re: Assessing Publication Bias in Social Sciences

Richard, an important issue. In my early research days we used to discuss a 'Journal of nil results'. Nil results are important to minimise repetition of similar research - hence funding issues, and by demonstrating that a long-held belief is not justified by the evidence. Of course there will be situation where a treatment works in one situation but not another and that is a research topic in its own right?

-- Andrew Entwistle


Re: An Argument to Give Family Physicians / GPs a Larger Role in Hospital Care

I can confirm that my GP does already take this dual role. Dr Mulligan of Alrewas Surgery works as a general physician. On a recent trip to Burton Hospital A&E department with my daughter I saw him also attending A&E clinic which seemed to me to be a suitable place for a GP to attend as much the same as GP you will receive a wide range of patients for primary care. Maybe all GPs should assist in A&E departments? I can’t say too much about my GPs background but he does originate from New Zealand so I wonder if his medical training has been different to UK setting – over to Dr Celia Taylor on this point...

-- Nathalie Maillard

 Events

25 Jun 2015, 8:30am-4:30pm
Safer Care Conference 2015

Birmingham City University

The second Safer Care Conference is an opportunity for health professionals to share ideas and develop skills in research practice that could be translated into impactful improvements in the quality and safety of care. There will be a number of sessions, including Measurement for Improvement: Views from the Frontline; and Making the Invisible Visible, along with a variety of skills development workshops. For more information and to book, please click here.

 
1-2 Jul 2015
HSRN Symposium

Nottingham Conference Centre

The Health Services Research Network (HSRN) are holding their annual symposium on 1-2 July 2015 at the Nottingham Conference Centre, where the leading edge of health services research will be presented in a multidisciplinary programme. More information can be found online.

 
8-10 Jul 2015
44th Annual Conference of the Society for Academic Primary Care. Evidence and Innovation in Primary Care.
University of Oxford

This regular meeting is the UK’s largest and most well-established primary care conference, held in partnership with the University of Oxford’s Nuffield Department of Primary Care Health Sciences. It typically attracts around 350 GPs and researchers to discuss the latest research and education to advance primary care. Presentation abstracts can still be submitted until 10:00am, 23rd February. Further details can be found online.

 
20 Jul 2015, 3pm-4pm
Patient Safety Seminar

Warwick Business School

Professor Charles Vincent (Professor of Psychology at University of Oxford) will be giving a seminar on patient safety at the Warwick Business School. Prof. Vincent is a trained clinical psychologist whose work focuses on conducting research on the causes of harm to patients, the consequences for patients and staff, and methods of improving the safety of healthcare. His current work covers three broad areas:
  1. developing methods of studying and improving patient safety
  2. developing ways to measure and monitor safety in healthcare organisations
  3. how regulation in healthcare contributes to safety and how it can potentially stifle safety improvement.
Please click here for further details and to register.
 
 
Personality of the Issue

Sam Watson

Dr Sam Watson

Dr Sam Watson is a Research Fellow in Health Economics working on CLAHRC Theme 6, HiSLAC, ePrescribing, and other projects at the University of Warwick.

Sam obtained his BSc in Natural Sciences from the University of Bath in 2010, where he focussed on pharmacology and statistics. An MRC/ESRC/NIHR studentship to undertake a Masters in Health Economics at City University, London led him to transition from natural to social sciences. In 2011, Sam began a PhD in Health Economics at the University of Warwick, examining how the structure and function of neonatal units and broader economic conditions affect the health of newborns. Following this, Sam joined the CAHRD team as a Research Fellow in 2014.

He is currently involved in a number of projects including studying the effects of consultant presence in hospitals at the weekend (HiSLAC) and the impact of electronic prescribing systems. Sam is also working on projects looking at using observational evidence in decision making and analysis,  methodological issues in biomedical research, and causal modelling and evidence synthesis.
 

Sam's passion is rock-climbing and he loves to frighten the vertiginous CLAHRC WM Director with photos of himself climbing seemingly unscalable peaks.

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Erratum

In the CLAHRC International section of the 2nd May 2014 issue (Of International Trends, Hypotheses and Instrumental Variables), the sentence referring to reference 14 was misleading and has been corrected. Many thanks to Dr Hugo Delile for bringing this to our attention.
"with some even attributing the downfall of Rome to the ubiquitous use of lead pipes in the Empire, though a recent paper concluded the likely concentration of lead would be unlikely to represent a major health risk.[14]"

Publications

Flach C, French P, Dunn G, Fowler D, Gumley AI, Birchwood M, Stewart SL, Morrison AP. Components of therapy as mechanisms of change in cognitive therapy for people at risk of psychosis: analysis of the EDIE-2 trial. Br J Psychiatry. 2015. [ePub].

Grove A, Clarke A, Currie G. The barriers and facilitators to the implementation of clinical guidance in elective orthopaedic surgery: a qualitative study. Implement Sci. 2015; 10: 81.

Madigan CD, Jolly K, Roalfe A, Lewis AL, Webber L, Aveyard P, Daley AJ. Study protocol: the effectiveness and cost effectiveness of a brief behavioural intervention to promote regular self-weighing to prevent weight regain after weight loss: randomised controlled trial (The LIMIT Study). BMC Public Health. 2015; 15: 530.

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