Variation In Provision Research Articles

Exploring the evidence base for Tier 3 weight management interventions for adults: a systematic review.

Specialist weight management services provide a treatment option for severe obesity. The objective of the study is to review the characteristics, impact and practice implications of specialist weight management services for adults in the UK. Systematic review: EMBASE, MEDLINE and PsycINFO were searched from January 2005 to March 2016 with supplementary searches. Adults with a body mass index of ≥40 kg m-2 , or ≥35 kg m-2 with comorbidity or ≥30 kg m-2 with type 2 diabetes and any study of multicomponent interventions, in any UK or Ireland setting, delivered by a specialist multidisciplinary team are the inclusion criteria. Fourteen studies in a variety of settings were included: 1 randomized controlled trial, 3 controlled and 10 observational studies. Mean baseline body mass index and age ranged from 40 to 54 kg m-2 and from 40 to 58 years. The studies were heterogeneous making comparisons of service characteristics difficult. Multidisciplinary team composition and eligibility criteria varied; dropout rates were high (43-62%). Statistically significant reduction in mean body mass index over time ranged from -1.4 to -3.1 kg m-2 and mean weight changes ranged from -2.2 to -12.4 kg. Completers achieving at least 5% reduction of initial body weight ranged from 32 to 51%. There was evidence for improved outcomes in diabetics. Specialist weight management services can demonstrate clinically significant weight loss and have an important role in supporting adults to manage severe and often complex forms of obesity. This review highlights important variations in provision and strongly indicates the need for further research into effective approaches to support severely obese adults.

DEVELOPING A PROGRAMME THEORY OF HEALTH CARE IN UK CARE HOMES—REVIEWS, SURVEYS, AND INTERVIEWS

AbstractWe aimed to develop a programme theory of health care delivery to UK care homes. A review of 15 surveys of care home health services completed since 2008 found working relationships lacking in structure and purpose and wide variation in provision of healthcare services. 58 stakeholder interviews with health and social care managers, providers, commissioners and regulators identified 3 overlapping approaches to health care in care homes: investment in relational working to foster continuity; provision of age-appropriate clinical services; and governance arrangements using incentives. A realist literature review identified important contextual factors as: care home readiness to work with health care staff; availability of structured assessment and care plans; involvement of health care staff to support learning; organisational endorsement of collaborative working; financial remuneration; and staff incentives. These findings acted as the focus of case studies in phase 2 of the study.

Trends and regional variations in provision of contraception methods in a commercially insured population in the United States based on nationally proposed measures

ObjectivesThree measures to assess the provision of effective contraception methods among reproductive-aged women have recently been endorsed for national public reporting. Based on these measures, this study examined real-world trends and regional variations of contraceptive provision in a commercially insured population in the United States. Study designWomen 15–44years old with continuous enrollment in each year from 2005 to 2014 were identified from a commercial claims database. In accordance with the proposed measures, percentages of women (a) provided most effective or moderately effective (MEME) methods of contraception and (b) provided a long-acting reversible contraceptive (LARC) method were calculated in two populations: women at risk for unintended pregnancy and women who had a live birth within 3 and 60days of delivery. ResultsDuring the 10-year period, the percentages of women at risk for unintended pregnancy provided MEME contraceptive methods increased among 15–20-year-olds (24.5%–35.9%) and 21–44-year-olds (26.2%–31.5%), and those provided a LARC method also increased among 15–20-year-olds (0.1%–2.4%) and 21–44-year-olds (0.8%–3.9%). Provision of LARC methods increased most in the North Central and West among both age groups of women. Provision of MEME contraceptives and LARC methods to women who had a live birth within 60days postpartum also increased across age groups and regions. ConclusionsThis assessment indicates an overall trend of increasing provision of MEME contraceptive methods in the commercial sector, albeit with age group and regional variations. If implemented, these proposed measures may have impacts on health plan contraceptive access policy.

The application of network-based GIS tools to investigate spatial variations in the provision of sporting facilities

ABSTRACTMethods whereby access to facilities can be captured in order to support national policies geared towards promoting sports participation and help plan the provision of local facilities are urgently needed. Objective measures derived from the use of Geographical Information Systems can be used to gain an understanding of spatial variations in the location and quality of sporting infrastructure. The aim of this study is to draw on a recreational database for Wales to demonstrate the benefits of ‘enhanced two-step floating catchment area’ techniques for gaining a wider understanding of variations in potential demand for sport facilities in the light of available supply. A practical demonstration showing how such tools can be used to examine variations in provision in relation to potential demand arising from targeted demographic groups is illustrated using the case study of spatial access to lawn bowling greens, an increasingly popular leisure pursuit in Wales.

The Impact of the Current Expected Credit Loss Standard (CECL) on the Timing and Comparability of Reserves

The new forward-looking credit loss provisioning standard, CECL, is intended to promote proactive provisioning as loan loss reserves can be conditioned on expectations of the economic cycle. We study the degree to which one modeling decision?expectations about the path of future house prices ? affects the size and timing of provisions for first-lien residential mortgage portfolios. While we find that provisions are generally less pro-cyclical compared to the current incurred loss standard, CECL may complicate the comparability of provisions across banks and time. Market participants will need to disentangle the degree to which variation in provisions across firms is driven by underlying risk versus differences in modeling assumptions.

Documenting patterns of breast reconstruction in Australia: The national picture

IntroductionDifferences in national health data collection systems preclude accurate assessments of how much breast reconstruction (BR) is performed in Australia. This paper aims to quantitatively document and visually map the national prevalence and distribution of BR, using the best available evidence. Materials and methodsQuantitative analysis and spatial mapping of hospital-level data on BR prevalence in all six Australian states and two mainland territories. Data was extracted on 3786 women, under the care of members of Breast Surgeons of Australia and New Zealand Incorporated, who had mastectomy for breast malignancy with or without post-mastectomy BR in 2013. ResultsAnalysis revealed a national BR rate of 18.3%. Statistically significant differences in BR uptake (p < .0001) were found between jurisdictions [χ2 (df = 7) = 284.29], with BR more likely in younger women [χ2 (df = 14) = 395.62] and in private hospitals (χ2 = 63.99) and less likely in remote areas [χ2 (df = 4) = 66.49]. ConclusionAnalysis of this substantial subset of Australian women requiring mastectomy for breast cancer has demonstrated significant variation in provision or uptake of BR across four important variables. As BR has been shown to provide long-term survivorship benefits for the growing number of women living longer following mastectomy for breast cancer, there is an urgent need to ensure BR is accessible and affordable for all women who choose this option.

Exploring access to end of life care for ethnic minorities with end stage kidney disease through recruitment in action research.

BackgroundVariation in provision of palliative care in kidney services and practitioner concerns to provide equitable access led to the development of this study which focussed on the perspectives of South Asian patients and their care providers. As people with a South Asian background experience a higher risk of Type 2 Diabetes (T2DM) and end stage kidney failure (ESKF) compared to the majority population but wait longer for a transplant, there is a need for end of life care to be accessible for this group of patients. Furthermore because non English speakers and people at end of life are often excluded from research there is a dearth of research evidence with which to inform service improvement. This paper aims to explore issues relating to the process of recruitment of patients for a research project which contribute to our understanding of access to end of life care for ethnic minority patients in the kidney setting.MethodsThe study employed an action research methodology with interviews and focus groups to capture and reflect on the process of engaging with South Asian patients about end of life care. Researchers and kidney care clinicians on four NHS sites in the UK recruited South Asian patients with ESKF who were requiring end of life care to take part in individual interviews; and other clinicians who provided care to South Asian kidney patients at end of life to take part in focus groups exploring end of life care issues. In action research planning, action and evaluation are interlinked and data were analysed with emergent themes fed back to care providers through the research cycle. Reflections on the process of patient recruitment generated focus group discussions about access which were analysed thematically and reported here.ResultsSixteen patients were recruited to interview and 45 different care providers took part in 14 focus groups across the sites. The process of recruiting patients to interview and subsequent focus group data highlighted some of the key issues concerning access to end of life care. These were: the identification of patients approaching end of life; and their awareness of end of life care; language barriers and informal carers’ roles in mediating communication; and contrasting cultures in end of life kidney care.ConclusionsReflection on the process of recruitment in this action research study provided insight into the complex scenario of end of life in kidney care. Some of the emerging issues such as the difficulty identifying patients are likely to be common across all patient groups, whilst others concerning language barriers and third party communication are more specific to ethnic minorities. A focus on South Asian ethnicity contributes to better understanding of patient perspectives and generic concepts as well as access to end of life kidney care for this group of patients in the UK. Action research was a useful methodology for achieving this and for informing future research to include informal carers and other ethnic groups.

Improving Interprofessional and Coproductive Outcomes of Care for Patients with Chronic Obstructive Pulmonary Disease

In the U.S., suboptimal care quality for patients with chronic obstructive pulmonary disease (COPD) is reflected by high rates of emergency department visits and hospital readmissions, as well as excessive...

Improving Quality of Acute Asthma Care in US Hospitals: Changes Between 1999-2000 and 2012-2013

Little is known about the longitudinal change in the quality of acute asthma care for hospitalized children and adults in the United States. We investigated whether the concordance of inpatient asthma care with the national guidelines improved over time, identified hospital characteristics predictive of guideline concordance, and determined whether guideline-concordant care is associated with a shorter hospital length of stay (LOS). This study was an analysis of data from two multicenter chart review studies of hospitalized patients aged 2 to 54 years with acute asthma during two time periods: 1999-2000 and 2012-2013. Outcomes were guideline concordance at the patient and hospital levels, and association of patient composite concordance with hospital LOS. The analytic cohort for the comparison of guideline concordance comprised 1,634 patients: 834 patients from 1999-2000 vs800 patients from 2012-2013. Over these 15 years, inpatient asthma care became more concordant at the hospital-level, with the mean composite score increasing from 74 to 82 (P< .001). However, during 2012-2013, wide variability in guideline concordance of acute asthma care remained across hospitals, with the greatest variation in provision of individualized written action plan at discharge (SD, 36). Guideline concordance was significantly lower in Midwestern and Southern hospitals compared with Northeastern hospitals. After adjusting for severity, patients who received care perfectly concordant with the guidelines had significantly shorter hospital LOS (-14%[95%CI, -23 to -4]; P= .009). Between 1999 and 2013, the guideline concordance of acute asthma care for hospitalized patients improved. However, interhospital variability remains substantial. Greater concordance with evidence-based guidelines was associated with a shorter hospital LOS.

Drug allergy: diagnosis and management of drug allergy in adults, children and young people; a look at NICE guidance

When any patient uses a medicine, it has the ability to cause a noxious and unintended response known as an ‘adverse drug reaction’ (ADR). A drug allergy is defined as an ADR with specific clinical features compatible with an immunological mechanism that re-occurs on re-exposure to that offending drug. Sometimes, it can be a challenge to decide from the clinical history alone as to whether a drug reaction is allergic or not without the need for further investigations. In September 2014, the National Institute for Health and Care Excellence (NICE) published a guideline entitled ‘Drug allergy: diagnosis and management of drug allergy in adults, children and young people’.1 This was developed due to variation in provision of care for people with a suspected drug allergy and to optimise best practice advice on the diagnosis, documentation and communication of drug allergy. Our focus here will be on the recommendations for children and young people. The British Society for Allergy and Clinical Immunology (BSACI) guidelines for the management of drug allergy were published in 20082 with an update which can be found in box 1. The European Association of Allergy and Clinical Immunology (EAACI) also published an international consensus of drug allergy in February 2014.3 Both of these look at the management of drug allergy within the secondary-care and tertiary-care setting, including details on specialist investigations, in contrast to the NICE guideline, which is aimed at all health professionals who review and manage children including in primary care. Differences between these guidelines are demonstrated in table 1. View this table: Table 1 Comparison of guidelines Box 1 ### Resources

The provision of total hip replacement for displaced intracapsular hip fractures.

The National Institute for Health and Care Excellence (NICE) currently recommends the use of total hip replacement (THR) for displaced intracapsular hip fractures in patients who meet certain mobility, cognitive and health criteria. A multicentre prospective audit was conducted within a defined geographic region to assess current practice and variation in provision of THR for displaced intracapsular hip fractures. A total of 879 patients with hip fractures, admitted to 8 acute trauma units, were included in this study. Of 462 patients with displaced intracapsular hip fractures, 169 fulfilled the NICE criteria for THR. THR was performed for only 49 of (29%) the eligible patients. There was significant variation in THR provision between the eight units (0% to 50% THR usage, p<0.001). There were statistically significant differences in age, ASA (American Society of Anesthesiologists) grade, abbreviated mental test score and walking ability prior to the injury between patients who underwent fixation, THR or hemiarthroplasty (all p≤0.05). There was a significantly increased chance of not undergoing THR if a patient was older than 77 years (median age for the THR eligible cohort; relative risk [RR]: 7.9, 95% confidence interval [CI]: 2.8-22.0, p<0.001). There was also a trend for this with patients who were ASA grade 3 compared with ASA grade 1 or 2 (RR: 2.7, 95% CI: 1.0-7.3, p=0.06). The surgeons gave multifactorial reasons for not performing THR in eligible patients. There is significant variation in the provision of THR for eligible hip fracture patients, which is influenced by both patient demographics and the unit to which a patient is admitted.

Medical marijuana laws and adolescent marijuana use in the USA from 1991 to 2014: results from annual, repeated cross-sectional surveys

Adolescent use of marijuana is associated with adverse later effects, so the identification of factors underlying adolescent use is of substantial public health importance. The relationship between US state laws that permit marijuana for medical purposes and adolescent marijuana use has been controversial. Such laws could convey a message about marijuana acceptability that increases its use soon after passage, even if implementation is delayed or the law narrowly restricts its use. We used 24 years of national data from the USA to examine the relationship between state medical marijuana laws and adolescent use of marijuana. Using a multistage, random-sampling design with replacement, the Monitoring the Future study conducts annual national surveys of 8th, 10th, and 12th-grade students (modal ages 13-14, 15-16, and 17-18 years, respectively), in around 400 schools per year. Students complete self-administered questionnaires that include questions on marijuana use. We analysed data from 1 098 270 adolescents surveyed between 1991 and 2014. The primary outcome of this analysis was any marijuana use in the previous 30 days. We used multilevel regression modelling with adolescents nested within states to examine two questions. The first was whether marijuana use was higher overall in states that ever passed a medical marijuana law up to 2014. The second was whether the risk of marijuana use changed after passage of medical marijuana laws. Control covariates included individual, school, and state-level characteristics. Marijuana use was more prevalent in states that passed a medical marijuana law any time up to 2014 than in other states (adjusted prevalence 15·87% vs 13·27%; adjusted odds ratio [OR] 1·27, 95% CI 1·07-1·51; p=0·0057). However, the risk of marijuana use in states before passing medical marijuana laws did not differ significantly from the risk after medical marijuana laws were passed (adjusted prevalence 16·25% vs 15·45%; adjusted OR 0·92, 95% CI 0·82-1·04; p=0·185). Results were generally robust across sensitivity analyses, including redefining marijuana use as any use in the previous year or frequency of use, and reanalysing medical marijuana laws for delayed effects or for variation in provisions for dispensaries. Our findings, consistent with previous evidence, suggest that passage of state medical marijuana laws does not increase adolescent use of marijuana. However, overall, adolescent use is higher in states that ever passed such a law than in other states. State-level risk factors other than medical marijuana laws could contribute to both marijuana use and the passage of medical marijuana laws, and such factors warrant investigation. US National Institute on Drug Abuse, Columbia University Mailman School of Public Health, New York State Psychiatric Institute.

Provision of NHS generalist and specialist services to care homes in England: review of surveys.

The number of beds in care homes (with and without nurses) in the United Kingdom is three times greater than the number of beds in National Health Service (NHS) hospitals. Care homes are predominantly owned by a range of commercial, not-for-profit or charitable providers and their residents have high levels of disability, frailty and co-morbidity. NHS support for care home residents is very variable, and it is unclear what models of clinical support work and are cost-effective. To critically evaluate how the NHS works with care homes. A review of surveys of NHS services provided to care homes that had been completed since 2008. It included published national surveys, local surveys commissioned by Primary Care organisations, studies from charities and academic centres, grey literature identified across the nine government regions, and information from care home, primary care and other research networks. Data extraction captured forms of NHS service provision for care homes in England in terms of frequency, location, focus and purpose. Five surveys focused primarily on general practitioner services, and 10 on specialist services to care home. Working relationships between the NHS and care homes lack structure and purpose and have generally evolved locally. There are wide variations in provision of both generalist and specialist healthcare services to care homes. Larger care home chains may take a systematic approach to both organising access to NHS generalist and specialist services, and to supplementing gaps with in-house provision. Access to dental care for care home residents appears to be particularly deficient. Historical differences in innovation and provision of NHS services, the complexities of collaborating across different sectors (private and public, health and social care, general and mental health), and variable levels of organisation of care homes, all lead to persistent and embedded inequity in the distribution of NHS resources to this population. Clinical commissioners seeking to improve the quality of care of care home residents need to consider how best to provide fair access to health care for older people living in a care home, and to establish a specification for service delivery to this vulnerable population.

Accessibility to sport facilities in Wales: A GIS-based analysis of socio-economic variations in provision

Previous studies concerned with investigating the relationship between levels of physical activity and aspects of the built environment have often led to inconsistent and mixed findings concerning associations between the availability of recreational or sport facilities and area socio-economic status. Further complications may arise when analysis is conducted separately for access to either publicly available or private facilities or where alternative methodological approaches to measuring accessibility are adopted. This paper provides a review of such research before exploring the potential use of methods for examining variations in accessibility based on enhanced floating catchment area (FCA) models which are increasingly being advocated in medical geography applications. Using bespoke tools developed within a commercial GIS package, which are being made publicly available by the authors, and a national database of sport facilities, variations in accessibility are investigated in relation to a widely used measure of deprivation in the UK. Findings from this analysis suggest that whilst those living in deprived areas of Wales have greater potential access to publicly available sporting opportunities, associations with privately owned facilities are reversed for some distance thresholds and at different spatial scales. The paper concludes by drawing attention to the implications of such findings given current financial pressures on local government and other sport and leisure providers and highlights how spatial analytical techniques can be used to monitor such trends.

Value coalitions and policy change: The impact of gendered patterns of work, religion and partisanship on childcare policy across German states

Since the 2002 Barcelona summit, Germany has been seen as a regional leader in achieving European states’ shared commitment to increase state-funded childcare. Yet Germany’s childcare success has not been homogeneous across its Länder; rather, it has shown remarkable subnational variation, with considerable differences in spending, policy design and coverage. Using panel data analysis and historical narratives, this article provides a theory for variation in provision of state-financed childcare for children under three years of age. We argue that competing visions of childcare at the subnational level – driven by the demands of differing numbers of women in the workforce and religious beliefs, and channelled by local government partisanship – have served as powerful constraints on convergence. Left partisanship and increased participation of women in the labour force are associated with higher provision of childcare for those aged under three, while larger Catholic populations are correlated with less extensive state-funded childcare.

The delivery of chemotherapy at home: an evidence synthesis

BackgroundRecent policy and guidance has focused on chemotherapy services being offered closer to home, but the clinical and economic implications of this are uncertain.ObjectivesTo compare the impact of delivering intravenous chemotherapy in different settings on a range of outcomes, including quality of life, safety and costs.DesignMultimethods approach: systematic review of clinical effectiveness, qualitative and cost-effectiveness studies; description of the patient pathway and brief survey of current provision; and development of a decision model to explore aspects of cost-effectiveness.SettingProvision of intravenous chemotherapy.ParticipantsChemotherapy patients.InterventionsSetting in which chemotherapy was administered (home, community or outpatient).Outcome measuresSafety, quality of life, preference, satisfaction, opinions/experiences, social functioning, clinical outcomes, costs and resource/organisational issues.Data sourcesSixteen electronic databases (including MEDLINE, EMBASE and The Cochrane Library) were searched from inception to October 2013 for published and unpublished studies.Review methodsTwo reviewers independently screened potentially relevant studies, extracted data and quality assessed the included studies. Study validity was evaluated using appropriate quality assessment tools. Clinical effectiveness and cost-effectiveness studies were summarised narratively, and qualitative studies were synthesised using meta-ethnography.ResultsOf the 67 eligible studies, 25 were comparative, with nine including a concurrent economic evaluation. Although some of the 10 randomised trials were designed to minimise avoidable biases, slow recruitment rates and non-participation of eligible patients for setting-related reasons meant that trial sample sizes were small and populations were inherently biased to favour the home or community settings. There was little evidence to suggest differences between settings in terms of quality of life, clinical outcomes, psychological outcomes or adverse events. All nine economic evaluations were judged as having low or uncertain quality, providing limited evidence to draw overall conclusions. Most were cost–consequence analyses, presenting cost outcomes alongside trial results but deriving no summary measure of benefit. Poor resource use reporting and use of different perspectives across settings made results difficult to compare. Seventeen qualitative studies (450 participants) were judged as moderate to good quality, although all compared new or proposed services with existing outpatient facilities and biased samples were used. The three main lines of argument were barriers to service provision, satisfaction with chemotherapy and making compromises to maintain normality. Most patients made explicit trade-offs between the time and energy required for outpatient chemotherapy, which reduced quality of life, and an increased sense of safety. A patient pathway was described, informed by expert advice and a brief survey of NHS and private providers, which identified wide variation in the ways in which home and community chemotherapy was delivered. Considering limitations of the available data and variation in provision, cost-effectiveness modelling results were not robust and were viewed as exploratory only; the results were highly unstable.ConclusionsPrimary studies comparing settings for administering intravenous chemotherapy appear difficult to conduct. Consequently, few robust conclusions can be made about the clinical effectiveness and cost-effectiveness. Qualitative studies indicate that the patient time and energy required for outpatient chemotherapy reduces quality of life. A nested randomised controlled trial within a larger observational cohort of patients is proposed to enhance recruitment and improve generalisability of results. Future economic evaluations require detailed patient characteristic, resource use, cost and quality-of-life data, although their results are likely to have limited generalisability.Study registrationThis study is registered as PROSPERO CRD42013004851.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Guidance and Counseling in Aotearoa, New Zealand, Secondary Schools: Revisiting the Issues

The changes in education policies in Aotearoa, New Zealand, since the 1980s have significantly affected guidance and counseling in secondary schools, leading to variations in provision and effectiveness. Issues being faced by school guidance counselors were identified in “Guidance and Counselling in New Zealand Secondary Schools: Exploring the Issues,” which represented a call for an external government authority who understood guidance and counseling and their value in schools to create national guidelines and standards for this work (Crowe, 2006). This 2014 article revisits the issues and reports on the findings and recommendations of a 2013 evaluation of guidance and counseling in Aotearoa, New Zealand secondary schools. The government requested the evaluation in response to the need to provide good guidance and counseling for young people at risk of developing mental health issues. The results and recommendations from the evaluation have highlighted the issues being faced by guidance counselors, other guidance staff, and their schools. The effectiveness of guidance and counseling in schools in Aotearoa, New Zealand will depend upon the implementation of the recommendations made in the report to the Ministry of Education, and, in particular, the review of the guidance staffing formula and the establishment of guidelines/expectations for schools/wharekura regarding the provision of guidance and counseling.

Collective Bargaining Agreement Provisions in the Wake of Ohio Teacher Evaluation System Legislation

Guided by Honig and Hatch’s conceptualization of bridging and buffering, we analyzed the first teacher collective bargaining agreements negotiated after the enactment of the Ohio Teacher Evaluation System to understand how state law has shaped provisions for teacher evaluation, compensation, reductions in force (RIF), transfers, and contract renewal. We found surprising variation in provisions across districts. Most notable was how districts defined comparable evaluations in making RIF decisions. Bridging districts provided the greatest protections for the most accomplished teachers, regardless of seniority. In contrast, buffering districts have RIF provisions based on seniority.

Variation inprovision and outcome of emergency appendicectomy in paediatric specialist centres

Acute appendicitis is the most common indication for emergency abdominal surgery in children and adolescents. The incidence increases with increasing age with an annual rate of 1–6 per 10,000 children from birth to 4 years of age to 19–28 per 10,000 children up to 14 years. 1 boys are more commonly affected than girls with a lifetime risk of 9% and 7% respectively. in england, almost 7,000 appendicectomies are performed on children aged 14 years and under annually. 2

Variation inprovision and outcome of emergency appendicectomy in paediatric specialist centres

Variation inprovision and outcome of emergency appendicectomy in paediatric specialist centres