Effects of a demand-led evidence briefing service on the uptake and use of research evidence by commissioners of health services: protocol for a controlled before and after study

Background: Clinical Commissioning Groups (CCGs) are mandated to use research evidence effectively to ensure optimum use of resources by the National Health Service (NHS), both in accelerating innovation and in stopping the use of less effective practices and models of service delivery. We intend to evaluate whether access to a demand-led evidence service improves uptake and use of research evidence by NHS commissioners compared with less intensive and less targeted alternatives. 

Methods/design: This is a controlled before and after study involving CCGs in the North of England. Participating CCGs will receive one of three interventions to support the use of research evidence in their decision-making:1) consulting plus responsive push of tailored evidence; 2) consulting plus an unsolicited push of non-tailored evidence; or 3) standard service unsolicited push of non-tailored evidence. Our primary outcome will be changed at 12 months from baseline of a CCGs ability to acquire, assess, adapt and apply research evidence to support decision-making. Secondary outcomes will measure individual clinical leads and managers’ intentions to use research evidence in decision making. Documentary evidence of the use of the outputs of the service will be sought. A process evaluation will evaluate the nature and success of the interactions both within the sites and between commissioners and researchers delivering the service. 

Discussion: The proposed research will generate new knowledge of direct relevance and value to the NHS. The findings will help to clarify which elements of the service are of value in promoting the use of research evidence.Those involved in NHS commissioning will be able to use the results to inform how best to build the infrastructure they need to acquire, assess, adapt and apply research evidence to support decision-making and to fulfil their statutory duties under the Health and Social Care Act.

Rapid detection of health-care-associated bloodstream infection in critical care using multipathogen real-time polymerase chain reaction technology: a diagnostic accuracy study and systematic review

Background: There is growing interest in the potential utility of real-time polymerase chain reaction (PCR) in diagnosing bloodstream infection by detecting pathogen deoxyribonucleic acid (DNA) in blood samples within a few hours. SeptiFast (Roche Diagnostics GmBH, Mannheim, Germany) is a multipathogen probe-based system targeting ribosomal DNA sequences of bacteria and fungi. It detects and identifies the commonest pathogens causing bloodstream infection. As background to this study, we report a systematic review of Phase III diagnostic accuracy studies of SeptiFast, which reveals uncertainty about its likely clinical utility based on widespread evidence of deficiencies in study design and reporting with a high risk of bias. 

Objective: Determine the accuracy of SeptiFast real-time PCR for the detection of health-care-associated bloodstream infection, against standard microbiological culture. 

Design: Prospective multicentre Phase III clinical diagnostic accuracy study using the standards for the reporting of diagnostic accuracy studies criteria. 

Setting: Critical care departments within NHS hospitals in the north-west of England. 

Participants: Adult patients requiring blood culture (BC) when developing new signs of systemic inflammation. 

Main outcome measures: SeptiFast real-time PCR results at species/genus level compared with microbiological culture in association with independent adjudication of infection. Metrics of diagnostic accuracy were derived including sensitivity, specificity, likelihood ratios and predictive values, with their 95% confidence intervals (CIs). Latent class analysis was used to explore the diagnostic performance of culture as a reference standard. 

Results: Of 1006 new patient episodes of systemic inflammation in 853 patients, 922 (92%) met the inclusion criteria and provided sufficient information for analysis. Index test assay failure occurred on 69 (7%) occasions. Adult patients had been exposed to a median of 8 days (interquartile range 4–16 days) of hospital care, had high levels of organ support activities and recent antibiotic exposure. SeptiFast real-time PCR, when compared with culture-proven bloodstream infection at species/genus level, had better specificity (85.8%, 95% CI 83.3% to 88.1%) than sensitivity (50%, 95% CI 39.1% to 60.8%). When compared with pooled diagnostic metrics derived from our systematic review, our clinical study revealed lower test accuracy of SeptiFast real-time PCR, mainly as a result of low diagnostic sensitivity. There was a low prevalence of BC-proven pathogens in these patients (9.2%, 95% CI 7.4% to 11.2%) such that the post-test probabilities of both a positive (26.3%, 95% CI 19.8% to 33.7%) and a negative SeptiFast test (5.6%, 95% CI 4.1% to 7.4%) indicate the potential limitations of this technology in the diagnosis of bloodstream infection. However, latent class analysis indicates that BC has a low sensitivity, questioning its relevance as a reference test in this setting. Using this analysis approach, the sensitivity of the SeptiFast test was low but also appeared significantly better than BC. Blood samples identified as positive by either culture or SeptiFast real-time PCR were associated with a high probability (> 95%) of infection, indicating higher diagnostic rule-in utility than was apparent using conventional analyses of diagnostic accuracy. 

Conclusion: SeptiFast real-time PCR on blood samples may have rapid rule-in utility for the diagnosis of health-care-associated bloodstream infection but the lack of sensitivity is a significant limiting factor. Innovations aimed at improved diagnostic sensitivity of real-time PCR in this setting are urgently required. Future work recommendations include technology developments to improve the efficiency of pathogen DNA extraction and the capacity to detect a much broader range of pathogens and drug resistance genes and the application of new statistical approaches able to more reliably assess test performance in situation where the reference standard (e.g. blood culture in the setting of high antimicrobial use) is prone to error.

‘Plugging the Gap’: Shared Education and the promotion of community relations through schools in Northern Ireland

Although there is no consensus amongst educationalists as to the role schools play as drivers of hostilities in divided societies, there is broad agreement that they can facilitate more positive intergroup relations. In Northern Ireland the promotion of school based inter-group contact has been offered as a means through which this can happen. Until 2007, the approach was twofold, reflected on the one hand in short-term contact opportunities for pupils in predominantly Catholic and Protestant schools, and on the other, in support for integrated schools which educate Catholics and Protestants together. In 2007 the Shared Education Programme was introduced to ‘bridge the gap’ between short-term opportunities for contact, and ‘full immersion’ integrated schools. Informed by contact theory, shared education offers curriculum based interaction between pupils attending all school types, aimed at promoting the type of contact likely to reduce negative social attitudes and ultimately contribute to social harmony. In this paper, we examine the impact of shared education thus far. Our analysis suggests that whilst shared education is generally effective in promoting positive assessments of other group members, there is a danger that programme impact may be inhibited by the foregrounding of educational over reconciliation priorities. Appreciating that the downplaying reconciliation objectives may have been necessary when the programme was established in order to maximize recruitment to it, we argue that if the full potential of shared education is to be realized, moving forward, it is important for schools to engage with issues of group differences.

Electrochemical promotion of a Pt catalyst supported on La 0.6Sr 0.4Co 0.2Fe 0.8O 3 - δ hollow fibre membranes

The use of wireless electrochemical promotion of catalysis (EPOC) of a Pt catalyst supported on a mixed ionic electronic conducting hollow fibre membranes is investigated. This reactor configuration offers high surface areas per unit volume and is ideally suited for scaled-up applications. The MIEC membrane used is the La _0.6Sr _0.4Co _0.2Fe _0.8O ₃ perovskite (LSCF) with a Pt catalyst film deposited on the outer surface of the LSCF membrane. Experimental results showed that after initial catalyst deactivation (in the absence of an oxygen chemical potential difference across the membrane) the catalytic rate can be enhanced by using an oxygen sweep and wireless EPOC can be used for the in situ regeneration of a deactivated catalyst. © 2012 Elsevier B.V.

In situ catalyst activity control in a novel membrane reactor-Reaction driven wireless electrochemical promotion of catalysis

A dual chamber membrane reactor was used in order to study the effect of macroscopically applied oxygen chemical potential differences to a platinum catalyst supported on a mixed oxygen ion and electronic conducting membrane. It is believed that the oxygen chemical potential difference imposed by the use of an oxygen sweep in one of the reactor chambers causes the back-spillover of oxygen species from the support onto the catalyst surface, resulting in the modification of the catalytic activity. The use of different sweep gases, such as ethylene and hydrogen was investigated as the means to reverse the rate modification by removing the spilt over species from the catalyst surface and returning the system to its initial state. Oxygen sweep in general had a positive effect on the reaction rate with rate increases up to 20% measured. Experimental results showed that hydrogen is a more potent sweep gas than ethylene in terms of the ability to reverse rate modification. A 10% rate loss was observed when using an ethylene sweep as compared with an almost 60% rate decrease when hydrogen was used as the sweep gas. © 2009 Elsevier Ltd. All rights reserved.

Electrochemical promotion of a platinum catalyst supported on the high-temperature proton conductor La0.99Sr0.01NbO4-δ

The recently discovered, high-temperature proton conductor, La_0.99Sr_0.01NbO_4-δ, was used as a support for the electrochemical promotion of a platinum catalyst. Ethylene oxidation was used as a probe reaction in the temperature range 350-450 °C. Moderate non-Faradaic rate modification, attributable to a protonic promoting species, occurred under negative polarisation; some permanent promotion was also observed. In oxidative atmospheres, both the p_O2 of the reaction mixture and the temperature influenced the type and magnitude of the observed rate modification. Rate-enhancement values of up to ρ = 1.4 and Faradaic-efficiency values approaching Λ = -100 were obtained. Promotion was observed under positive polarisation and relatively dry, oxygen-rich atmospheres suggesting that some oxygen ion conductivity may occur under these conditions. Impedance spectroscopy performed in atmospheres of 4 kPa O₂/N₂ and of 5 kPa H₂/N₂ under dry and slightly humidified (0.3 kPa H₂O) conditions indicated that the electrical resistivity is heavily dominated by the grain-boundary response in the temperature range of the EPOC studies; much lower grain-boundary impedances in the wetter conditions are likely to be attributable to proton transport. © 2009 Elsevier B.V. All rights reserved.

Comparative studies between classic and wireless electrochemical promotion of a Pt catalyst for ethylene oxidation

A comparative study between a classic and a wireless electrochemical promotion experiment was undertaken as a tool towards the better understanding of both systems. The catalytic modification of a platinum catalyst for ethylene oxidation was studied. The catalyst was supported on yttria-stabilised-zirconia (YSZ), a known pure oxide ion conductor, for the classic experiment and La _0.6Sr_0.4Co_0.2Fe_0.8O _3-δ-a mixed oxide ion electronic conductor-was used for the wireless experiment. The two systems showed certain similarities in terms of the reaction classification (in both cases electrophobic behaviour was observed) and the promotion mechanism. Significant difference was observed in the time scales and the reversibility of the induced rate modification. © 2008 Springer Science+Business Media B.V.

Electrochemical promotion of catalysis controlled by chemical potential difference across a mixed ionic-electronic conducting ceramic membrane - An example of wireless NEMCA

A La_0.6Sr_0.4Co_0.2F_0.8O₃ mixed ionic electronic conducting (MIEC) membrane was used in a dual chamber reactor for the promotion of the catalytic activity of a platinum catalyst for ethylene oxidation. By controlling the oxygen chemical potential difference across the membrane, a driving force for oxygen ions to migrate across the membrane and backspillover onto the catalyst surface is established. The reaction is then promoted by the formation of a double layer of oxide anions on the catalyst surface. Thelectronic conductivity of the membrane material eliminates the need for an external circuit to pump the promoting oxide ion species through the membrane and onto the catalyst surface. This renders this "wireless" system simpler and more amenable for large-scale practical application. Preliminary experiments show that the reaction rate of ethylene oxidation can indeed be promoted by almost one order of magnitude upon exposure to an oxygen atmosphere on the sweep side of the membrane reactor, and thus inducing an oxygen chemical potential difference across the membrane, as compared to the rate under an inert sweep gas. Moreover, the rate does not return to its initial unpromoted value upon cessation of the oxygen flow on the sweep side, but remains permanently promoted. A number of comparisons are drawn between the classical electrochemical promotion that utilises an external circuit and the "wireless" system that utilises chemical potential differences. In addition a 'surface oxygen capture' model is proposed to explain the permanent promotion of the catalyst activity. © 2007 Springer Science+Business Media, LLC.

Electrochemical promotion of a metal catalyst supported on a mixed-ionic conductor

It has been found that the catalytic activity and selectivity of a metal film deposited on a solid electrolyte could be enhanced dramatically and in a reversible way by applying an electrical current or potential between the metal catalyst and the counter electrode (also deposited on the electrolyte). This phenomenon is know as NEMCA [S. Bebelis, C.G. Vayenas, Journal of Catalysis, 118 (1989) 125-146.] or electrochemical promotion (EP) [J. Prichard, Nature, 343 (1990) 592.] of catalysis. Yttria-doped barium zirconate, BaZr_0.9Y_0.1O_{3 - α} (BZY), a known proton conductor, has been used in this study. It has been reported that proton conducting perovskites can, under the appropriate conditions, act also as oxide ion conductors. In mixed conducting systems the mechanism of conduction depends upon the gas atmosphere that to which the material is exposed. Therefore, the use of a mixed ionic (oxide ion and proton) conducting membrane as a support for a platinum catalyst may facilitate the tuning of the promotional behaviour of the catalyst by allowing the control of the conduction mechanism of the electrolyte. The conductivity of BZY under different atmospheres was measured and the presence of oxide ion conduction under the appropriate conditions was confirmed. Moreover, kinetic experiments on ethylene oxidation corroborated the findings from the conductivity measurements showing that the use of a mixed ionic conductor allows for the tuning of the reaction rate. © 2006 Elsevier B.V. All rights reserved.

Electrochemical promotion of catalysis using solid-state proton-conducting membranes

A solid-state electrochemical reactor with ceramic proton-conducting membrane has been used to study the effect of electrochemically induced hydrogen spillover on the catalytic activity of platinum during ethylene oxidation. Suitable proton-conducting electrolyte membranes (Gd-doped BaPrO ₃ (BPG) and Y-doped BaZrO₃ (BZY)) were fabricated. These materials were chosen because of their protonic conductivity in the operational temperature region of the reaction (400-700 °C). The BZY-based electrochemical cell was used to investigate the open-circuit voltage (OCV) dependence on H₂ partial pressure with comparison being made to the theoretical OCV as predicted by the Nernst equation. Furthermore, the BZY pellets were used to study the effect of proton transfer of the catalytic activity of platinum during ethylene oxidation. The reaction was found to exhibit electrochemical promotion at 400 °C and to be electrophilic in nature, i.e. proton addition to the platinum surface resulted in an increase in reaction rate. At higher temperatures, the rate was not affected, within experimental error, by proton addition or removal. Under similar conditions, AC impedance showed that there was a large overall cell resistance at 400 °C with significantly decreased resistance at higher temperatures. It is possible that there could be a relationship between large cell resistances and the onset of electrochemical promotion in this system but there is, as yet, no conclusive evidence for this. © 2003 Elsevier B.V. All rights reserved.