Failure of a numerical quality assessment scale to identify potential risk of bias in a systematic review: a comparison study

BACKGROUND: Assessing methodological quality of primary studies is an essential component of systematic reviews. Following a systematic review which used a domain based system [United States Preventative Services Task Force (USPSTF)] to assess methodological quality, a commonly used numerical rating scale (Downs and Black) was also used to evaluate the included studies and comparisons were made between quality ratings assigned using the two different methods. Both tools were used to assess the 20 randomized and quasi-randomized controlled trials examining an exercise intervention for chronic musculoskeletal pain which were included in the review. Inter-rater reliability and levels of agreement were determined using intraclass correlation coefficients (ICC). Influence of quality on pooled effect size was examined by calculating the between group standardized mean difference (SMD).

RESULTS: Inter-rater reliability indicated at least substantial levels of agreement for the USPSTF system (ICC 0.85; 95% CI 0.66, 0.94) and Downs and Black scale (ICC 0.94; 95% CI 0.84, 0.97). Overall level of agreement between tools (ICC 0.80; 95% CI 0.57, 0.92) was also good. However, the USPSTF system identified a number of studies (n = 3/20) as "poor" due to potential risks of bias. Analysis revealed substantially greater pooled effect sizes in these studies (SMD -2.51; 95% CI -4.21, -0.82) compared to those rated as "fair" (SMD -0.45; 95% CI -0.65, -0.25) or "good" (SMD -0.38; 95% CI -0.69, -0.08).

CONCLUSIONS: In this example, use of a numerical rating scale failed to identify studies at increased risk of bias, and could have potentially led to imprecise estimates of treatment effect. Although based on a small number of included studies within an existing systematic review, we found the domain based system provided a more structured framework by which qualitative decisions concerning overall quality could be made, and was useful for detecting potential sources of bias in the available evidence.

Disabled women’s experiences of accessing and utilising maternity services when they are affected by domestic abuse: a critical incident technique study

Background: Women and their babies are entitled to equal access to high quality maternity care. However, when women fit into two or more categories of vulnerability they can face multiple, compound barriers to accessing and utilising services. Disabled women are up to three times more likely to experience domestic abuse than non-disabled women. Domestic abuse may compromise health service access and utilisation and disabled people in general have suboptimal access to healthcare services. Despite this, little is known about the compounding effects of disability and domestic abuse on women’s access to maternity care.

Methods: The aim of the study was to identify how women approach maternity care services, their expectations of services and whether they are able to get the type of care that they need and want. We conducted a qualitative, Critical Incident Technique study in Scotland. Theoretically we drew on Andersen’s model of healthcare use. The model was congruent with our interest in women’s intended/actual use of maternity services and the facilitators and barriers
impacting their access to care. Data were generated during 2013 using one-to-one interviews.

Results: Five women took part and collectively reported 45 critical incidents relating to accessing and utilising maternity services. Mapped to the underpinning theoretical framework, our findings show how the four domains of attitudes; knowledge; social norms; and perceived control are important factors shaping maternity care experiences.

Conclusions: Positive staff attitude and empowering women to have control over their own care is crucial in influencing women’s access to and utilisation of maternity healthcare services. Moreover these are cyclical, with the consequences and outcomes of healthcare use becoming part of the enabling or disabling factors affecting future healthcare decisions.Further consideration needs to be given to the development of strategies to access and recruit women in these circumstances. This will provide an opportunity for under-represented and silenced voices to be heard.

The use of patient experience survey data by out-of-hours primary care services: a qualitative interview study

Background English National Quality Requirements mandate out-of-hours primary care services to routinely audit patient experience, but do not state how it should be done.

Objectives We explored how providers collect patient feedback data and use it to inform service provision. We also explored staff views on the utility of out-of-hours questions from the English General Practice Patient Survey (GPPS).

Methods A qualitative study was conducted with 31 staff (comprising service managers, general practitioners and administrators) from 11 out-of-hours primary care providers in England, UK. Staff responsible for patient experience audits within their service were sampled and data collected via face-to-face semistructured interviews.

Results Although most providers regularly audited their patients’ experiences by using patient surveys, many participants expressed a strong preference for additional qualitative feedback. Staff provided examples of small changes to service delivery resulting from patient feedback, but service-wide changes were not instigated. Perceptions that patients lacked sufficient understanding of the urgent care system in which out-of-hours primary care services operate were common and a barrier to using feedback to enable change. Participants recognised the value of using patient experience feedback to benchmark services, but perceived weaknesses in the out-of-hours items from the GPPS led them to question the validity of using these data for benchmarking in its current form.

Conclusions The lack of clarity around how out-of-hours providers should audit patient experience hinders the utility of the National Quality Requirements. Although surveys were common, patient feedback data had only a limited role in service change. Data derived from the GPPS may be used to benchmark service providers, but refinement of the out-of-hours items is needed.

Contribution of biobanks to care services

Approaches to the management of patients with cancer have been revolutionised by the ability to examine tumours at a genetic and molecular level and tailor treatments accordingly. Underpinning this work is the need for large numbers of high-quality human biospecimens for use in translational research studies to identify new biomarkers for the prediction, diagnosis and treatment of cancer. Biobanking has subsequently emerged as a dedicated activity to provide the infrastructure required for the standardised collection, storage and distribution of high quality human biospecimens for research purposes. This article provides an overview of the role of biobanks and the vital contribution they make to the delivery of cancer care for patients now and in the future

People with intellectual disabilities: promoting quality end of life care

Background: Internationally concerns have been highlighted about the quality of palliative care that people with intellectual disability receive. It has also been evidenced that people with intellectual disabilities are seldom referred to hospice and palliative care services. 

Aims: This study aimed to explore the experience of health and social care professionals in providing palliative care to people with intellectual disabilities. 

Methods An exploratory, qualitative design was used. A purposive sample of thirty health and social care professionals, working in intellectual disability and palliative care services, who had provided end-of-life care to adults with intellectual disabilities, were recruited to the study following informed consent. They were asked to reflect on a case scenario of a person with intellectual disability to whom they had provided end of life care. A semi-structured interview technique, with open questions and prompts, was used to explore their experiences and insights. The narrative from the case scenarios were content analysed using a recognised framework. 

Results: Three themes emerged from the data within the case scenarios: Identifying end of life care needs, meeting support needs and empowerment in partnership. Examples of good practice and issues in practice were apparent. 

Conclusion/ Discussion: This study contributes to the developing international evidence base to enhance end of life care for people with intellectual disabilities and provides further insights into this area of practice. Funder: HSC Research and Development Doctoral Fellowship Scheme

SWOT analysis of a pediatric rehabilitation programme : a participatory evaluation fostering quality improvement

Purpose. To present the results of a strengths, weaknesses, opportunities and threats (SWOT) analysis used as part of a process aimed at reorganising services provided within a pediatric rehabilitation programme (PRP) in Quebec, Canada and to report the perceptions of the planning committee members regarding the usefulness of the SWOT in this process. Method. Thirty-six service providers working in the PRP completed a SWOT questionnaire and reported what they felt worked and what did not work in the existing model of care. Their responses were used by a planning committee over a 12- month period to assist in the development of a new service delivery model. Committee members shared their thoughts about the usefulness of the SWOT. Results. Current programme strengths included favourable organisational climate and interdisciplinary work whereas weaknesses included lack of psychosocial support to families and long waiting times for children. Opportunities included working with community partners, whereas fear of losing professional autonomy with the new service model was a threat. The SWOT results helped the planning committee redefine the programme goals and make decisions to improve service coordination. SWOT analysis was deemed as a very useful tool to help guide service reorganisation. Conclusions. SWOT analysis appears to be an interesting evaluation tool to promote awareness among service providers regarding the current functioning of a rehabilitation programme. It fosters their active participation in the reorganisation of a new service delivery model for pediatric rehabilitation.

Development of a Parent Version of the Manchester-Minneapolis Quality of Life Survey for use by Parents and Crers of UK Children: MMQL-UK (PF).

Background Although it is now widely endorsed that children should as far as possible rate their own health related quality of life (HRQL), there are situations where proxy information on child HRQL may be useful, especially where a child is too ill or young to provide their own HRQL assessment. There is limited availability of generic HRQL scales that have a parallel child and parent version and that are reliable, valid, brief, comprehensible and suitable for use in UK populations. The aims of this study were therefore to develop and validate a parent version of the anglicised Manchester-Minneapolis Quality of Life child form (MMQL-UK (CF)) and to determine the level of association between the child and parent versions of this form. Methods This study was undertaken concurrently with the anglicisation and validation of the MMQL, a measure of HRQL developed for use with children in North America. At that time, no parent version existed, so the MMQL form for children (MMQL-UK (CF)) was used as the basis for the development of the MMQL-UK parent form (PF). The sample included a control group of healthy children and their parents and five exemplar groups; children diagnosed with asthma, diabetes or inflammatory bowel disease and their parents, children in remission from cancer and their parents and children in public care and their carers. Consistency of the MMQL-UK (PF) components were assessed by calculating Cronbach's alpha. Validation of the parent questionnaire was undertaken by comparing MMQL-UK (PF) component scores with comparable components on the proxy PedsQL™ quality of life scales, comparing MMQL-UK (PF) component scores between parents of healthy and chronic disease children and by comparison of component scores from children and their parents or carers. Reproducibility and responsiveness were assessed by retesting parents by follow-up questionnaires. Results A total of 874 children (completing MMQL-UK (CF)) and 572 parents or carers (completing MMQL-UK (PF)) took part in the study. The internal consistency of all the MMQL-UK (PF) components exceeding the accepted criterion of 0.70 and the construct validity was good with moderate correlations being evident between comparable components of the MMQL-UK (PF) and the proxy PedsQL™. Discriminant validity was demonstrated with significant differences being identified between parents of healthy children and those with chronic conditions. Intra-class correlations exceeded 0.65 for all MMQL-UK (PF) components demonstrating good reproducibility. Weak to moderate levels of responsiveness were demonstrated for all but social functioning. The MMQL-UK (PF) showed moderate parent-child correlation with the MMQL-UK (CF) for all components. The best correlations were seen for those components measuring the same construct (Pearson's r ranged from 0.31 to 0.61, p < 0.01 for equivalent components). Conclusion The MMQL-UK (PF) showed moderate to good correlations with the MMQL-UK (CF) component scores. The MMQL-UK (PF) will be of use when comparing child and parent/carer perception of the impact of a child's condition on their HRQL or where the child is too ill or young to provide their own report.

A generic model for integration of Quality, Environment and Safety Management Systems

Purpose – The purpose of this paper is to propose a generic model of Integrated Management System of Quality, Environment and Safety (IMS-QES) that can be adapted and progressively to assimilate various Management Systems, of which highlights: ISO 9001 for Quality; ISO 14001 for Environment; OHSAS 18001 for Occupational Health and Safety. Design/methodology/approach – The model was designed in the real environment of a Portuguese Organization and 160 employees were surveyed. The rate response was equal to 86 percent. The conceived model was implemented in a first phase for the integration of Quality, Environment and Safety Management Systems. Findings – Among the main findings of the survey the paper highlights: the elimination of conflicts between individual systems with resources optimization; creation of added value to the business by eliminating several types of wastes; the integrated management of sustainability components in a global market; the improvement of partnerships with suppliers of goods and services; reducing the number of internal and external audits. Originality/value – This case study is one of the first Portuguese empirical researches about IMS-QES and the paper believes that it can be useful in the creation of a Portuguese guideline for integration, namely the Quality Management Systems; Environmental Management Systems and Occupational Health and Safety Management Systems among others.

The Interactions between clients and providers of services related to marketing activities

The purpose of this paper is to analyze the business interactions involved in the purchase of services related to marketing activities. We build on the literature about business services classifications and the interaction between clients and providers of business services. An empirical study is conducted by means of a survey questionnaire. Data were collected from a sample of 80 buying firms of services related to marketing activities who agreed to cooperate and represent medium and large Portuguese’s firms. The results show that the buying of services related to marketing activities involves both the client and the provider in the interaction process. This paper contributes to understanding the interaction process of buying services related to marketing activities in terms of the parties involved, product/service exchange, financial and information exchange. Providers of services related to marketing activities can expect stable and preferred relationships if they can offer a good price and quality of service, meet the agreed deadlines and respond quickly to client orders. On the client’s side, the relevance, the characteristics and the wide diversity of services related to marketing activities requires a good understanding and management of the interaction portfolio with providers.

Smart Grid Market Using Joint Energy and Ancillary Services Bids

The power systems operation in the smart grid context increases significantly the complexity of their management. New approaches for ancillary services procurement are essential to ensure the operation of electric power systems with appropriate levels of stability, safety, quality, equity and competitiveness. These approaches should include market mechanisms which allow the participation of small and medium distributed energy resources players in a competitive market environment. In this paper, an energy and ancillary services joint market model used by an aggregator is proposed, considering bids of several types of distributed energy resources. In order to improve economic efficiency in the market, ancillary services cascading market mechanism is also considered in the model. The proposed model is included in MASCEM – a multi-agent system electricity market simulator. A case study considering a distribution network with high penetration of distributed energy resources is presented.

A Clinical Support System Based on Quality of Life Estimation

Quality of life is a concept influenced by social, economic, psychological, spiritual or medical state factors. More specifically, the perceived quality of an individual's daily life is an assessment of their well-being or lack of it. In this context, information technologies may help on the management of services for healthcare of chronic patients such as estimating the patient quality of life and helping the medical staff to take appropriate measures to increase each patient quality of life. This paper describes a Quality of Life estimation system developed using information technologies and the application of data mining algorithms to access the information of clinical data of patients with cancer from Otorhinolaryngology and Head and Neck services of an oncology institution. The system was evaluated with a sample composed of 3013 patients. The results achieved show that there are variables that may be significant predictors for the Quality of Life of the patient: years of smoking (p value 0.049) and size of the tumor (p value < 0.001). In order to assign the variables to the classification of the quality of life the best accuracy was obtained by applying the John Platt's sequential minimal optimization algorithm for training a support vector classifier. In conclusion data mining techniques allow having access to patients additional information helping the physicians to be able to know the quality of life and produce a well-informed clinical decision.

Evaluation of outpatient child-adolescent mental health services (CAMHS) in Attica-Greece

ABSTRACT: Background: Childhood is a critical time for social and emotional development, educational progress and mental health prevention. Mental health for children and adolescents is defined by the achievement of expected developmental, cognitive, social and emotional skills. The development of child-adolescent mental health services (CAMHS) is a necessity for each country, not only as a prevention measure for the wellbeing of people, but also as an investment to the future of countries. Qualitative evaluation of services is the only way to ensure whether services function under quality standards and increase the possibility of better outcomes for their patients. This study examines the greek outpatient CAMHS against the British Standards of National Institute of Excellence for community CAMHS. The Standards assessed refer to the areas of Assessment, Care and Intervention. Objectives: The main objectives of the study are 1) to evaluate Greek outpatient CAMHS in the Attica region 2) to promote the evaluation process for mental health services in Greece. Methods: Due to the fact that Greek services are based on the British model, the tool used was the British self-review questionnaire of Quality Network for Community CAMHS(QNCC).The tool was translated, adapted and posted to services. Twelve out of twenty outpatient CAMHS of Attica (including Athens) responded. Data was collected and performed by the Statistical Package for Social Sciences SPSS. Results: The study resulted that the CAMHS examined, meet moderately the British Standards of 1) Referral and Access, 2) Assessment & Care planning, 3) Care & Intervention. Two out of twelve services examined, meet the standards of "Assessment and Care" in a higher percentage between 75% and 100%. Conclusions: The paper describes a satisfactory function of CAMHS in Attica prefecture taking into consideration the extremely difficult political situation of Greece at the time of the research. Strong and weak domains are identified. Also the translation and adaptation of British tools promote the evaluation process and quality assurance of Greek CAMHS.

Implementation progress of mental health services in Rwanda: Bugesera district case

RESUMO: O Ministério da Saúde do Governo do Ruanda identifica a saúde mental como uma área de prioridade estratégica para a intervenção em resposta à alta carga dos transtornos mentais no Ruanda. Ao longo dos últimos 20 anos após o genocídio, o sector público reconstruiu sua Resposta Nacional de Saúde Mental com base no acesso equitativo aos cuidados, através do desenvolvimento de uma Política Nacional de Saúde Mental e novas estruturas de saúde mental. A política de Saúde Mental do Ruanda, revista em 2010, prima pela descentralização e integração dos serviços de saúde mental em todas as estruturas nacionais do sistema de saúde e ao nível da comunidade. O presente estudo de caso tem como objetivo avaliar a situação do sistema de saúde mental de um distrito típico de uma área rural no Ruanda, e sugerir melhorias, incluindo algumas estratégias para monitoras as mudanças. Os resultados do estudo permitirão ao Ruanda reforçar a sua capacidade para implementar o Plano Nacional de Saúde Mental ao nível dos distritos. O relatório também será útil para monitorar o progresso da implementação de serviços de saúde mental nos distritos, incluindo a prestação de serviços de base comunitária e a participação dos usuários, suas famílias e outros interessados na promoção, prevenção, assistência e reabilitação em saúde mental. Este estudo também procurou avaliar o progresso da implementação dos cuidados de saúde mental a nível descentralizado, com vista a compreender as implicações em termos de recursos desses processos. Foi realizada uma análise situacional num local do distrito, baseado em entrevistas com as principais partes interessadas responsáveis, usando o Instrumento de Avaliação de Sistemas de Saúde Mental da Organização Mundial da Saúde (WHO-AIMS). Os resultados sugerem que os recursos humanos para a saúde mental e serviços de base comunitária de saúde mental no distrito continuam a ser extremamente limitados. Os profissionais de saúde mental são adicionalmente limitados na sua capacidade para oferecer intervenções de emergência a pacientes psiquiátricos e garantir a continuidade do tratamento farmacológico a pacientes com condições crônicas. Para planejar efetivamente, de acordo com as necessidades da comunidade, sugerimos que o sistema de saúde mental deve envolver também os representantes das famílias e dos usuários no processo de planificação de modo a melhorar a sua contribuição no processo de implementação das atividades de saúde mental. Este estudo de caso do Distrito de Bugesera oferece a primeira análise de nível distrital dos serviços de saúde mental no Ruanda, e pode servir como uma mais-valia para a melhoria do sistema de saúde mental, incluindo a advocacia para a melhoria da qualidade dos cuidados de saúde mental a este nível, aumentando o financiamento para a implementação de serviços clínicos de saúde mental e os recursos humanos disponíveis para a prestação de cuidados de saúde mental, principalmente a nível dos cuidados primários.--------------------- ABSTRACT: To deal with the high burden of mental health disorders resulting from consequences of the 1994 genocide against Tutsis, the Rwanda Ministry of Health (MoH) considers mental health as a priority intervention. For the last 20 years, Ministry of Health focused on rebuilding a national and equity-oriented mental health program responding to the population needs in mental health. Mental health services are now decentralized and integrated in the national health system, from the community level up to the referral level. This study assessed the situation of mental health services in one rural district in Rwanda. It was aimed at assessing the progress of implementation of mental health care at the decentralized level, focusing on resource implications and processes. This study is based on interviews conducted with key stakeholders, using the World Health Organization's Assessment Instrument for Mental Health Systems (WHO-AIMS). Findings show that human resources for mental health care and community-based mental health services of the assessed district remain extremely limited. Mental health professionals face limitation regarding the ability to provide emergency management of psychiatric patients and to ensure continuity of psychopharmacological treatment of patients with chronic conditions. To improve the implementation process of mental health interventions and activities, a planning process based on community needs and the involvement of representatives of families and users in planning process should be considered. The Bugesera case study on the situation of mental health services can serve as a baseline for improvement of the mental health program in Rwanda, in terms of quality care services, infrastructure and equipment, human and financial resources.

Families of the traumatically brian-injured : a case study approach to perceptions of quality of service, degree of satisfaction, and family needs /

The purpose of this qualitative research study was to foster an understanding of the rehabilitation counselling practice offamilies of the brain-injured. Specifically, the study explores the perceptions of stakeholders in regards to the degree of satisfaction with the quality of service received. Questionnaires were administered, and semi-structured, openended interviews were conducted, with six participating families (n=8). Preliminary data were collected via two instruments: (i) the Family Participant Questionnaire, consisting of participants' sample characteristics, information pertaining to the history of the family, details of the injury, and information relating to the type, use, and need offamily services utilized; and (ii) the Community Integration Questionnaire, a measurement of the degree of social displacementllevel of community integration of the injured family member. Utilizing the procedural steps outlined by Colaizzi's (1978) method of protocol analysis, recommendations for a future program based on related and current family needs are discussed in detail. Substantiating and supporting information are offered to rehabilitation practitioners, educational planners, and policymakers alike, concerning the degree of satisfaction with rehabilitative service, and the means of improving upon the overall quality of health care to families of the brain-injured. Implications for clinical practice and research are also raised for discussion.