End-of-life care pathways for improving outcomes in caring for the dying (Review)

Background This is an updated version of a Cochrane review first published in Issue 1, 2010 of The Cochrane Library. In many clinical areas, integrated care pathways are utilised as structured multidisciplinary care plans that detail essential steps in caring for patients with specific clinical problems. In particular, care pathways for the dying have been developed as a model to improve care of patients who are in the last days of life. The care pathways were designed with an aim of ensuring that the most appropriate management occurs at the most appropriate time and that it is provided by the most appropriate health professional. There have been sustained concerns about the safety of implementing end-of-life care pathways, particularly in the UK. Therefore, there is a significant need for clinicians and policy makers to be informed about the effects of end-of-life care pathways with a systematic review. Objectives To assess the effects of end-of-life care pathways, compared with usual care (no pathway) or with care guided by another end-of-life care pathway across all healthcare settings (e.g. hospitals, residential aged care facilities, community). In particular, we aimed to assess the effects on symptom severity and quality of life of people who are dying; those related to the care such as families, carers and health professionals; or a combination of these. Search Methods We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (Issue 6, 2013), MEDLINE, EMBASE, PsycINFO, CINAHL, review articles and reference lists of relevant articles.We conducted the original search in September 2009, and the updated search in June 2013. Selection Criteria All randomised controlled trials (RCTs), quasi-randomised trial or high-quality controlled before-and-after studies comparing use versus non-use of an end-of-life care pathway in caring for the dying. Data Collection and Analysis Two review authors assessed the results of the searches against the predetermined criteria for inclusion. Main Results The original review identified 920 titles. The updated search found 2042 potentially relevant titles (including the original 920), but no additional studies met criteria for inclusion in the review update. Authors’ Conclusions With sustained concerns about the safety of the pathway implementation and the lack of available evidence on important patient and relative outcomes, recommendations for the use of end-of-life pathways in caring for the dying cannot be made. Since the last version of this review, no new studies met criteria for inclusion in the review update. With recently documented concerns related to the potential adverse effects associated with Liverpool Care Pathway (the most commonly used end-of-life care pathway), we do not recommend decision making based on indirect or low-quality evidence. All health services using end-of-life care pathways are encouraged to have their use of the pathway, to date, independently audited. Any subsequent use should be based on carefully documented evaluations. Large RCTs or other well-designed controlled studies are urgently required for the evaluation of the use of end-of-life care pathways in caring for dying people in various clinical settings. In future studies, outcome measures should include benefits or harms concerning the outcomes of interest in this review in relation to patients, families, carers and health professionals.

Review: "Context : A framework for its Influence on Evaluation Practice (New Directions for Evaluation No. 135)" edited by Rog, D. J.; Fitzpatrick, J. L. and Conner, R. F.

This book offers a framework for the influence of context on evaluation practice and is applied to three case studies: environmental context; indigenous context and political context; and finishes with a process for implementation.

Kaleidoscope : Reframing learning and teaching evaluation through a shared stakeholder lens

Sector wide interest in Reframe: QUT’s Evaluation Framework continues with a number of institutions requesting finer details as QUT embeds the new approach to evaluation across the university in 2013. This interest, both nationally and internationally has warranted QUT’s collegial response to draw upon its experiences from developing Reframe into distilling and offering Kaleidoscope back to the sector. The word Reframe is a relevant reference for QUT’s specific re-evaluation, reframing and adoption of a new approach to evaluation; whereas Kaleidoscope reflects the unique lens through which any other institution will need to view their own cultural specificity and local context through an extensive user-led stakeholder engagement approach when introducing new approaches to learning and teaching evaluation. Kaleidoscope’s objectives are for QUT to develop its research-based stakeholder approach to distil the successful experience exhibited in the Reframe Project into a transferable set of guidelines for use by other tertiary institutions across the sector. These guidelines will assist others to design, develop, and deploy, their own culturally specific widespread organisational change informed by stakeholder engagement and organisational buy-in. It is intended that these guidelines will promote, support and enable other tertiary institutions to embark on their own evaluation projects and maximise impact. Kaleidoscope offers an institutional case study of widespread organisational change underpinned by Reframe’s (i) evidence-based methodology; (ii) research including published environmental scan, literature review (Alderman, et al., 2012), development of a conceptual model (Alderman, et al., in press 2013), project management principles (Alderman & Melanie, 2012) and national conference peer reviews; and (iii) year-long strategic project with national outreach to collaboratively engage the development of a draft set of National Guidelines. Kaleidoscope’s aims are to inform Higher Education evaluation policy development through national stakeholder engagement, the finalisation of proposed National Guidelines. In correlation with the conference paper, the authors will present a Draft Guidelines and Framework ready for external peer review by evaluation practitioners from the Higher Education sector, as part of Kaleidoscope’s dissemination strategy (Hinton & Gannaway, 2011) applying illuminative evaluation theory (Parlett & Hamilton, 1976), through conference workshops and ongoing discussions (Shapiro, et al., 1983; Jacobs, 2000). The initial National Guidelines will be distilled from the Reframe: QUT’s Evaluation Framework’s Policy, Protocols, and incorporated Business Rules. It is intended that the outcomes of Kaleidoscope are owned by and reflect sectoral engagement, including iterative evaluation through multiple avenues of dissemination and collaboration including the Higher Education sector. The dissemination strategy with the inclusion of Illuminative Evaluation methodology provides an inclusive opportunity for other institutions and stakeholders across the Higher Education sector to give voice through the information-gathering component of evaluating the draft Guidelines, providing a comprehensive understanding of the complex realities experienced across the Higher Education sector, and thereby ‘illuminating’ both the shared and unique lenses and contexts. This process will enable any final guidelines developed to have broader applicability, greater acceptance, enhanced sustainability and additional relevance benefiting the Higher Education sector, and the adoption and adaption by any single institution for their local contexts.

REFRAME: a new approach to evaluation in higher education

Evaluation practices in the higher education sector have been criticised for having unclear purpose and principles; ignoring the complexity and changing nature of learning and teaching and the environments in which they occur; relying almost exclusively on student ratings of teachers working in classroom settings; lacking reliability and validity; using data for inappropriate purposes; and focusing on accountability and marketing rather than the improvement of learning and teaching. In response to similar criticism from stakeholders, in 2011 Queensland University of Technology began a project, entitled REFRAME, to review its approach to evaluation, particularly the student survey system it had been using for the past five years. This presentation will outline the scholarly, evidence based methodology used to undertake institution-wide change, meet the needs of stakeholders suitable to the cultural needs of the institution. It is believed that this approach is broadly applicable to other institutions contemplating change with regard to evaluation of learning and teaching.

Kaleidoscope : illuminating learning and teaching evaluation for a shared stakeholder lens

Within the Australian higher education sector, institutions are required to evaluate teaching, units and courses to assure the quality of the student learning experience, however with hardly any regulatory parameters guiding institutions, and with disparate practices, there are few opportunities to benchmakr across institutions or the sector. QUT has received interest and requests from national and international universities on accessing Reframe: QUT's Evaluation Framework.

Evaluation of the alkaline comet assay and urinary 3-methyladenine excretion for monitoring DNA damage in melanoma patients treated with dacarbazine and tamoxifen

Purpose: To develop, using dacarbazine as a model, reliable techniques for measuring DNA damage and repair as pharmacodynamic endpoints for patients receiving chemotherapy. Methods: A group of 39 patients with malignant melanoma were treated with dacarbazine 1 g/m2 i.v. every 21 days. Tamoxifen 20 mg daily was commenced 24 h after the first infusion and continued until 3 weeks after the last cycle of chemotherapy. DNA strand breaks formed during dacarbazine-induced DNA damage and repair were measured in individual cells by the alkaline comet assay. DNA methyl adducts were quantified by measuring urinary 3-methyladenine (3-MeA) excretion using immunoaffinity ELISA. Venous blood was taken on cycles 1 and 2 for separation of peripheral blood lymphocytes (PBLs) for measurement of DNA strand breaks. Results: Wide interpatient variation in PBL DNA strand breaks occurred following chemotherapy, with a peak at 4 h (median 26.6 h, interquartile range 14.75- 40.5 h) and incomplete repair by 24 h. Similarly, there was a range of 3-MeA excretion with peak levels 4-10 h after chemotherapy (median 33 nmol/h, interquartile range 20.448.65 nmol/h). Peak 3-MeA excretion was positively correlated with DNA strand breaks at 4 h (Spearman's correlation coefficient, r = 0.39, P = 0.036) and 24 h (r = 0.46, P = 0.01). Drug-induced emesis correlated with PBL DNA strand breaks (Mann Whitney U-test, P = 0.03) but not with peak 3-MeA excretion. Conclusions: DNA damage and repair following cytotoxic chemotherapy can be measured in vivo by the alkaline comet assay and by urinary 3-MeA excretion in patients receiving chemotherapy.

An evaluation of dog-assisted therapy for residents of aged care facilities with dementia.

Although some research suggests that dog-assisted therapy may be beneficial for people with dementia living in residential aged care facilities, the intervention has not been adequately investigated. To address this shortcoming, we conducted a randomized controlled trial of dog-assisted therapy versus a human-therapist-only intervention for this population. Fifty-five residents with mild to moderate dementia living in three Australian residential aged care facilities completed an 11-week trial of the interventions. Allocation to the intervention was random and participants completed validated measures of mood, psychosocial functioning, and quality of life (QOL), both prior to and following the intervention. No adverse events were associated with the dog-assisted intervention, and following it participants who had worse baseline depression scores demonstrated significantly improved depression scores relative to participants in the human-therapist-only intervention. Participants in the dogassisted intervention also showed significant improvements on a measure of QOL in one facility compared with those in the human-therapist-only group (although worse in another facility that had been affected by an outbreak of gastroenteritis). This study provides some evidence that dog-assisted therapy may be beneficial for some residents of aged care facilities with dementia.

Advance transit oriented development typology : case study in Brisbane, Australia

Internationally, transit oriented development (TOD) is characterised by moderate to high density development with diverse land use patterns and well connected street networks centred around high frequency transit stops (bus and rail). Although different TOD typologies have been developed in different contexts, they are based on subjective evaluation criteria derived from the context in which they are built and typically lack a validation measure. Arguably there exist sets of TOD characteristics that perform better in certain contexts, and being able to optimise TOD effectiveness would facilitate planning and supporting policy development. This research utilises data from census collection districts (CCDs) in Brisbane with different sets of TOD attributes measured across six objectively quantified built environmental indicators: net employment density, net residential density, land use diversity, intersection density, cul-de-sac density, and public transport accessibility. Using these measures, a Two Step Cluster Analysis was conducted to identify natural groupings of the CCDs with similar profiles, resulting in four unique TOD clusters: (a) residential TODs, (b) activity centre TODs, (c) potential TODs, and; (d) TOD non-suitability. The typologies are validated by estimating a multinomial logistic regression model in order to understand the mode choice behaviour of 10,013 individuals living in these areas. Results indicate that in comparison to people living in areas classified as residential TODs, people who reside in non-TOD clusters were significantly less likely to use public transport (PT) (1.4 times), and active transport (4 times) compared to the car. People living in areas classified as potential TODs were 1.3 times less likely to use PT, and 2.5 times less likely to use active transport compared to using the car. Only a little difference in mode choice behaviour was evident between people living in areas classified as residential TODs and activity centre TODs. The results suggest that: (a) two types of TODs may be suitable for classification and effect mode choice in Brisbane; (b) TOD typology should be developed based on their TOD profile and performance matrices; (c) both bus stop and train station based TODs are suitable for development in Brisbane.

A brief staff dementia education program : implementation and evaluation

Brief dementia education training programs appear to be effective in improving knowledge about dementia and self-confidence in interacting with patients with dementia. It is recommended that brief dementia training sessions be provided on a regular, on-going basis, particularly in view of frequent staff changes in the acute hospital environment.

An evaluation of tumor oxygenation and gene expression in patients with early stage non-small cell lung cancers

Background: To directly assess tumor oxygenation in resectable non - small cell lung cancers (NSCLC) and to correlate tumor pO2 and the selected gene and protein expression to treatment outcomes. Methods: Twenty patients with resectable NSCLC were enrolled. Intraoperative measurements of normal lung and tumor pO2 were done with the Eppendorf polarographic electrode. All patients had plasma osteopontin measurements by ELISA. Carbonic anhydrase-IX (CA IX) staining of tumor sections was done in the majority of patients (n = 16), as was gene expression profiling (n = 12) using cDNA microarrays. Tumor pO2 was correlated with CA IX staining, osteopontin levels, and treatment outcomes. Results: The median tumor pO2 ranged from 0.7 to 46 mm Hg (median, 16.6) and was lower than normal lung pO2 in all but one patient. Because both variables were affected by the completeness of lung deflation during measurement, we used the ratio of tumor/normal lung (T/L) pO2 as a reflection of tumor oxygenation. The median T/L pO 2 was 0.13. T/L pO2 correlated significantly with plasma osteopontin levels (r = 0.53, P = 0.02) and CA IX expression (P = 0.006). Gene expression profiling showed that high CD44 expression was a predictor for relapse, which was confirmed by tissue staining of CD44 variant 6 protein. Other variables associated with the risk of relapse were T stage (P = 0.02), T/L pO2 (P = 0.04), and osteopontin levels (P = 0.001). Conclusions: Tumor hypoxia exists in resectable NSCLC and is associated with elevated expression of osteopontin and CA IX. Tumor hypoxia and elevated osteopontin levels and CD44 expression correlated with poor prognosis. A larger study is needed to confirm the prognostic significance of these factors. © 2006 American Association for Cancer Research.

INFORMAS (International Network for Food and Obesity/non-communicable diseases Research, Monitoring and Action Support) : overview and key principles

Non-communicable diseases (NCDs) dominate disease burdens globally and poor nutrition increasingly contributes to this global burden. Comprehensive monitoring of food environments, and evaluation of the impact of public and private sector policies on food environments is needed to strengthen accountability systems to reduce NCDs. The International Network for Food and Obesity/NCDs Research, Monitoring and Action Support (INFORMAS) is a global network of public-interest organizations and researchers that aims to monitor, benchmark and support public and private sector actions to create healthy food environments and reduce obesity, NCDs and their related inequalities. The INFORMAS framework includes two ‘process’ modules, that monitor the policies and actions of the public and private sectors, seven ‘impact’ modules that monitor the key characteristics of food environments and three ‘outcome’ modules that monitor dietary quality, risk factors and NCD morbidity and mortality. Monitoring frameworks and indicators have been developed for 10 modules to provide consistency, but allowing for stepwise approaches (‘minimal’, ‘expanded’, ‘optimal’) to data collection and analysis. INFORMAS data will enable benchmarking of food environments between countries, and monitoring of progress over time within countries. Through monitoring and benchmarking, INFORMAS will strengthen the accountability systems needed to help reduce the burden of obesity, NCDs and their related inequalities.

Evaluation of canine bone marrow-derived mesenchymal stem cells after long-term cryopreservation

Autologous bone marrow-derived mesenchymal stem cell (BMSCs)-based therapies show great potential in regenerative medicine. However, long-term storage and preservation of BMSCs for clinical use is still a great clinical challenge. The present study aimed to analyze the effect of long-term cryopreservation on the regenerative ability of BMSCs. After cryopreservation of BMSCs from beagle dogs for three years, cell viability, and quantitative analysis of alkaline phosphatase (ALP) activity, surface adherence, and mineralized nodule formation were analyzed. BMSCs in cell-scaffold complex were then implanted into nude mice. There was no significant difference in cell viability and ALP activity between osteogenic differentiation and non-osteogenic differentiation of BMSCs, and BMSCs in cell-scaffold complex retained osteogenic differentiation ability in vivo. These results indicate that long-term cryopreserved BMSCs maintain their have capacity to contribute to regeneration.

Learner-focused evaluation cycles : facilitating learning using feedforward, concurrent and feedback evaluation

There is a growing trend to offer students learning opportunities that are flexible, innovative and engaging. As educators embrace student-centred agile teaching and learning methodologies, which require continuous reflection and adaptation, the need to evaluate students’ learning in a timely manner has become more pressing. Conventional evaluation surveys currently dominate the evaluation landscape internationally, despite recognition that they are insufficient to effectively evaluate curriculum and teaching quality. Surveys often: (1) fail to address the issues for which educators need feedback, (2) constrain student voice, (3) have low response rates and (4) occur too late to benefit current students. Consequently, this paper explores principles of effective feedback to propose a framework for learner-focused evaluation. We apply a three-stage control model, involving feedforward, concurrent and feedback evaluation, to investigate the intersection of assessment and evaluation in agile learning environments. We conclude that learner-focused evaluation cycles can be used to guide action so that evaluation is not undertaken simply for the benefit of future offerings, but rather to benefit current students by allowing ‘real-time’ learning activities to be adapted in the moment. As a result, students become co-producers of learning and evaluation becomes a meaningful, responsive dialogue between students and their instructors.

Monitoring foods and beverages provided and sold in public sector settings

This paper outlines a step-wise framework for monitoring foods and beverages provided or sold in publicly funded institutions. The focus is on foods in schools, but the framework can also be applied to foods provided or sold in other publicly funded institutions. Data collection and evaluation within this monitoring framework will consist of two components. In component I, information on existing food or nutrition policies and/or programmes within settings would be compiled. Currently, nutrition standards and voluntary guidelines associated with such policies/programmes vary widely globally. This paper, which provides a comprehensive review of such standards and guidelines, will facilitate institutional learnings for those jurisdictions that have not yet established them or are undergoing review of existing ones. In component II, the quality of foods provided or sold in public sector settings is evaluated relative to existing national or sub-national nutrition standards or voluntary guidelines. Where there are no (or only poor) standards or guidelines available, the nutritional quality of foods can be evaluated relative to standards of a similar jurisdiction or other appropriate standards. Measurement indicators are proposed (within ‘minimal’, ‘expanded’ and ‘optimal’ approaches) that can be used to monitor progress over time in meeting policy objectives, and facilitate comparisons between countries.

Design, implementation and multisite evaluation of a system suitability protocol for the quantitative assessment of instrument performance in liquid chromatography-multiple reaction monitoring-MS (LC-MRM-MS)

Multiple reaction monitoring (MRM) mass spectrometry coupled with stable isotope dilution (SID) and liquid chromatography (LC) is increasingly used in biological and clinical studies for precise and reproducible quantification of peptides and proteins in complex sample matrices. Robust LC-SID-MRM-MS-based assays that can be replicated across laboratories and ultimately in clinical laboratory settings require standardized protocols to demonstrate that the analysis platforms are performing adequately. We developed a system suitability protocol (SSP), which employs a predigested mixture of six proteins, to facilitate performance evaluation of LC-SID-MRM-MS instrument platforms, configured with nanoflow-LC systems interfaced to triple quadrupole mass spectrometers. The SSP was designed for use with low multiplex analyses as well as high multiplex approaches when software-driven scheduling of data acquisition is required. Performance was assessed by monitoring of a range of chromatographic and mass spectrometric metrics including peak width, chromatographic resolution, peak capacity, and the variability in peak area and analyte retention time (RT) stability. The SSP, which was evaluated in 11 laboratories on a total of 15 different instruments, enabled early diagnoses of LC and MS anomalies that indicated suboptimal LC-MRM-MS performance. The observed range in variation of each of the metrics scrutinized serves to define the criteria for optimized LC-SID-MRM-MS platforms for routine use, with pass/fail criteria for system suitability performance measures defined as peak area coefficient of variation <0.15, peak width coefficient of variation <0.15, standard deviation of RT <0.15 min (9 s), and the RT drift <0.5min (30 s). The deleterious effect of a marginally performing LC-SID-MRM-MS system on the limit of quantification (LOQ) in targeted quantitative assays illustrates the use and need for a SSP to establish robust and reliable system performance. Use of a SSP helps to ensure that analyte quantification measurements can be replicated with good precision within and across multiple laboratories and should facilitate more widespread use of MRM-MS technology by the basic biomedical and clinical laboratory research communities.