A systematic review of the approaches to multi-level learning in the general practice context, using a realist synthesis approach: BEME Guide No. 55

Abstract Background An upstream approach to palliative care in the last 12 months of life delivered by primary care practices is often referred to as Primary Palliative Care (PPC). Implementing case management functions can support delivery of PPC and help patients and their families navigate health, social and fiscal environments that become more complex at end-of-life. A realist synthesis was conducted to understand how multi-level contexts affect case management functions related to initiating end-of-life conversations, assessing patient and caregiver needs, and patient/family centred planning in primary care practices to improve outcomes. The synthesis also explored how these functions aligned with critical community resources identified by patients/families dealing with end-of-life. Methods A realist synthesis is theory driven and iterative, involving the investigation of proposed program theories of how particular contexts catalyze mechanisms (program resources and individual reactions to resources) to generate improved outcomes. To assess whether program theories were supported and plausible, two librarian-assisted and several researcher-initiated purposive searches of the literature were conducted, then extracted data were analyzed and synthesized. To assess relevancy, health system partners and family advisors informed the review process. Results Twenty-eight articles were identified as being relevant and evidence was consolidated into two final program theories: 1) Making end-of-life discussions comfortable, and 2) Creating plans that reflect needs and values. Theories were explored in depth to assess the effect of multi-level contexts on primary care practices implementing tools or frameworks, strategies for improving end-of-life communications, or facilitators that could improve advance care planning by primary care practitioners. Conclusions Primary care practitioners’ use of tools to assess patients/families’ needs facilitated discussions and planning for end-of-life issues without specifically discussing death. Also, receiving training on how to better communicate increased practitioner confidence for initiating end-of-life discussions. Practitioner attitudes toward death and prior education or training in end-of-life care affected their ability to initiate end-of-life conversations and plan with patients/families. Recognizing and seizing opportunities when patients are aware of the need to plan for their end-of-life care, such as in contexts when patients experience transitions can increase readiness for end-of-life discussions and planning. Ultimately conversations and planning can improve patients/families’ outcomes.

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Conditions under Which Trickle-Down Effects Occur: A Realist Synthesis Approach

Sustainability ◽

10.3390/su13010069 ◽

2020 ◽

Vol 13 (1) ◽

pp. 69

Author(s):

Luke R. Potwarka ◽

Pamela Wicker

Keyword(s):

Role Models ◽

Public Funding ◽

Realist Synthesis ◽

Policy Makers ◽

Sport Policy ◽

What Works ◽

Sport Events ◽

Synthesis Approach ◽

Elite Sports ◽

Trickle Down

Policy makers often legitimize bids for major sport events and public funding of elite sports by trickle-down effects, suggesting that hosting events, sporting success, and athlete role models inspire the population to participate themselves in sport and physical activity. According to previous review articles, empirical evidence of trickle-down effects are mixed, with several studies citing marginal or no effect. The purpose of this study is to apply a realist synthesis approach to evaluate under which conditions trickle-down effects occur (i.e., what works for whom under which circumstances?). Using rapid evidence assessment methodology, 58 empirical articles were identified in the search process and critically analyzed through the lens of realist synthesis evaluation. The analysis identified six conditions under which trickle-down effects have occurred: Event leveraging initiatives, capacity of community sport to cater for new participants, live spectating experiences, consumption possibilities on television or other media, and communities housing event venues. The findings have implications for the sustainability of sport policy decisions and public finance, as the likelihood of trickle-down effects increases with integrated planning and sustainable spending related to the above six conditions.

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An evaluation of service user experience, clinical outcomes and service use associated with urgent care services that utilise telephone-based digital triage: a systematic review protocol

Systematic Reviews ◽

10.1186/s13643-021-01576-x ◽

2021 ◽

Vol 10 (1) ◽

Author(s):

Vanashree Sexton ◽

Jeremy Dale ◽

Helen Atherton

Keyword(s):

Systematic Review ◽

Mixed Methods ◽

Clinical Outcomes ◽

User Experience ◽

Service User ◽

Service Use ◽

Urgent Care ◽

Narrative Synthesis ◽

Service User Experience ◽

Synthesis Approach

Abstract Background Telephone-based digital triage is widely used by services that provide urgent care. This involves a call handler or clinician using a digital triage tool to generate algorithm-based care advice, based on a patient’s symptoms. Advice typically takes the form of signposting within defined levels of urgency to specific services or self-care advice. Despite wide adoption, there is limited evaluation of its impact on service user experience, service use and clinical outcomes; no previous systematic reviews have focussed on services that utilise digital triage, and its impact on these outcome areas within urgent care. This review aims to address this need, particularly now that telephone-based digital triage is well established in healthcare delivery. Methods Studies assessing the impact of telephone-based digital triage on service user experience, health care service use and clinical outcomes will be identified through searches conducted in Medline, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Web of Science and Scopus. Search terms using words relating to digital triage and urgent care settings (excluding in-hours general practice) will be used. The review will include all original study types including qualitative, quantitative and mixed methods studies; studies published in the last 20 years and studies published in English. Quality assessment of studies will be conducted using the Mixed Methods Appraisal Tool (MMAT); a narrative synthesis approach will be used to analyse and summarise findings. Discussion This is the first systematic review to evaluate service user experience, service use and clinical outcomes related to the use of telephone-based digital triage in urgent care settings. It will evaluate evidence from studies of wide-ranging designs. The narrative synthesis approach will enable the integration of findings to provide new insights on service delivery. Models of urgent care continue to evolve rapidly, with the emergence of self-triage tools and national help lines. Findings from this review will be presented in a practical format that can feed into the design of digital triage tools, future service design and healthcare policy. Systematic review registration This systematic review is registered on the international database of prospectively registered systematic reviews in health and social care (PROSPERO 2020 CRD42020178500).

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Chest pain in general practice: a systematic review of prediction rules

BMJ Open ◽

10.1136/bmjopen-2018-027081 ◽

2019 ◽

Vol 9 (2) ◽

pp. e027081 ◽

Cited By ~ 2

Author(s):

Ralf E Harskamp ◽

Simone C Laeven ◽

Jelle CL Himmelreich ◽

Wim A M Lucassen ◽

Henk C P M van Weert

Keyword(s):

Systematic Review ◽

General Practice ◽

Chest Pain ◽

Coronary Disease ◽

Clinical Decision ◽

Clinical Judgement ◽

Predictive Values ◽

Heart Score ◽

Coronary Syndrome ◽

Rule Out

ObjectiveTo identify and assess the performance of clinical decision rules (CDR) for chest pain in general practice.DesignSystematic review of diagnostic studies.Data sourcesMedline/Pubmed, Embase/Ovid, CINAHL/EBSCO and Google Scholar up to October 2018.Study selectionStudies that assessed CDRs for intermittent-type chest pain and for rule out of acute coronary syndrome (ACS) applicable in general practice, thus not relying on advanced laboratory, computer or diagnostic testing.Review methodsReviewers identified studies, extracted data and assessed the quality of the evidence (using Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2)), independently and in duplicate.ResultsEight studies comprising five CDRs met the inclusion criteria. Three CDRs are designed for rule out of coronary disease in intermittent-type chest pain (Gencer rule, Marburg Heart Score, INTERCHEST), and two for rule out of ACS (Grijseels rule, Bruins Slot rule). Studies that examined the Marburg Heart Score had the highest methodological quality with consistent sensitivity (86%–91%), specificity (61%–81%) and positive (23%–35%) and negative (97%–98%) predictive values (PPV and NPV). The diagnostic performance of Gencer (PPV: 20%–34%, NPV: 95%–99%) and INTERCHEST (PPV: 35%–43%, NPV: 96%–98%) appear comparable, but requires further validation. The Marburg Heart Score was more sensitive in detecting coronary disease than the clinical judgement of the general practitioner. The performance of CDRs that focused on rule out of ACS were: Grijseels rule (sensitivity: 91%, specificity: 37%, PPV: 57%, NPV: 82%) and Bruins Slot (sensitivity: 97%, specificity: 10%, PPV: 23%, NPV: 92%). Compared with clinical judgement, the Bruins Slot rule appeared to be safer than clinical judgement alone, but the study was limited in sample size.ConclusionsIn general practice, there is currently no clinical decision aid that can safely rule out ACS. For intermittent chest pain, several rules exist, of which the Marburg Heart Score has been most extensively tested and appears to outperform clinical judgement alone.

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Patient information leaflets to reduce antibiotic use and reconsultation rates in general practice: a systematic review

BMJ Open ◽

10.1136/bmjopen-2015-007612 ◽

2015 ◽

Vol 5 (6) ◽

pp. e007612-e007612 ◽

Cited By ~ 31

Author(s):

E. G. P. M. de Bont ◽

M. Alink ◽

F. C. J. Falkenberg ◽

G.-J. Dinant ◽

J. W. L. Cals

Keyword(s):

Systematic Review ◽

General Practice ◽

Patient Information ◽

Antibiotic Use ◽

Patient Information Leaflets ◽

Information Leaflets

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A systematic review of the literature on patient priorities for general practice care. Part 1: Description of the research domain

Social Science & Medicine ◽

10.1016/s0277-9536(98)00222-6 ◽

1998 ◽

Vol 47 (10) ◽

pp. 1573-1588 ◽

Cited By ~ 186

Author(s):

Michel Wensing ◽

Hans Peter Jung ◽

Jan Mainz ◽

Frede Olesen ◽

Richard Grol

Keyword(s):

Systematic Review ◽

General Practice ◽

Review Of The Literature ◽

Research Domain ◽

General Practice Care ◽

Practice Care

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P109. Bridging the cervicothoracic junction during multi-level posterior cervical decompression and fusion -A systematic review and meta-analysis

The Spine Journal ◽

10.1016/j.spinee.2021.05.317 ◽

2021 ◽

Vol 21 (9) ◽

pp. S193

Author(s):

Eeric Truumees ◽

Devender Singh ◽

Heather Livingston ◽

Darlene Ennis ◽

Ashley Duncan ◽

...

Keyword(s):

Systematic Review ◽

Meta Analysis ◽

Cervicothoracic Junction ◽

Multi Level

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Business model framework applications in health care: A systematic review

Health Services Management Research ◽

10.1177/0951484817726918 ◽

2017 ◽

Vol 30 (4) ◽

pp. 219-226 ◽

Cited By ~ 2

Author(s):

Jens Jacob Fredriksson ◽

Pamela Mazzocato ◽

Rafiq Muhammed ◽

Carl Savage

Keyword(s):

Systematic Review ◽

Health Care ◽

Business Model ◽

Health Care Organizations ◽

Model Description ◽

Model Framework ◽

Triple Aim ◽

Financial Assessment ◽

Constituent Elements ◽

Synthesis Approach

It has proven to be a challenge for health care organizations to achieve the Triple Aim. In the business literature, business model frameworks have been used to understand how organizations are aligned to achieve their goals. We conducted a systematic literature review with an explanatory synthesis approach to understand how business model frameworks have been applied in health care. We found a large increase in applications of business model frameworks during the last decade. E-health was the most common context of application. We identified six applications of business model frameworks: business model description, financial assessment, classification based on pre-defined typologies, business model analysis, development, and evaluation. Our synthesis suggests that the choice of business model framework and constituent elements should be informed by the intent and context of application. We see a need for harmonization in the choice of elements in order to increase generalizability, simplify application, and help organizations realize the Triple Aim.

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