Understanding the impact of delegated home visiting services accessed via general practice by community-dwelling patients: a realist review protocol

IntroductionIn western countries, early visiting services (EVS) have been proposed as a recent intervention to reduce both general practitioner workload and hospital admissions among housebound individuals experiencing a healthcare need within the community. EVS involves the delegation of the patient home visits to other staff groups such as paramedics or nursing staff. However, the principles of organising this care are unknown and it remains unclear how different contexts, such as patient conditions and the processes of organising EVS influence care outcomes. A review has been designed to understand how EVS are enacted and, specifically, who benefits, why, how and when in order to provide further insight into the design and delivery of EVS.Methods and analysisThe purpose of this review is to produce findings that provide explanations of how and why EVS contexts influence their associated outcomes. Evidence on EVS will be consolidated through realist review—a theory-driven approach to evidence synthesis. A realist approach is needed as EVS is a complex intervention. What EVS achieve is likely to vary for different individuals and contexts. We expect to synthesise a range of relevant data such as qualitative, quantitative and mixed-method research in the following stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesising and refining the programme theory.Ethics and disseminationA formal ethics review is not required as this study is secondary research. Findings will be disseminated in a peer-reviewed journal, at national and international conferences and to relevant professional associations.PROSPERO registration numberCRD42018096518.

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Protocol for the impact of paramedics in NHS primary care: application of realist approaches to improve understanding and support intelligent policy and future workforce planning

British Paramedic Journal ◽

10.29045/14784726.2019.12.4.3.35 ◽

2019 ◽

Vol 4 (3) ◽

pp. 35-42 ◽

Cited By ~ 1

Author(s):

Georgette Eaton ◽

Veronika Williams ◽

Geoff Wong ◽

Nia Roberts ◽

Kamal R. Mahtani

Keyword(s):

Primary Care ◽

Life Support ◽

Evidence Synthesis ◽

Workforce Planning ◽

Advanced Life Support ◽

Realist Review ◽

Professional Associations ◽

Realist Evaluation ◽

Programme Theory ◽

The Impact

Introduction: In the United Kingdom, changing demands on ambulance services has caused a change in what is expected of a paramedic. As well as advanced life support, paramedics now need to be skilled in managing a range of urgent case presentations, with emphasis on treat-at-scene. The change in the scope of work paramedics can undertake has established their role within primary care. However, as paramedics transition to roles within primary care, their knowledge and skillset will undoubtedly need to change. The current opportunities for paramedics’ employment in primary care require careful evaluation. In order to contribute to patients’ and the NHS’ primary care agenda, evidence must be generated to show how and why these changes would work, for whom, in what context and to what extent.Methods and analysis: The purpose of this research is to produce findings that will improve our understanding of the ways in which (i.e. how, why and in what contexts) paramedics impact on the primary care workforce. A theory-driven approach to evidence-synthesis will be conducted in a realist review, to produce a programme theory. This programme theory will be tested using empirical data collected through a realist evaluation. Survey and interview data will be collected from paramedics working in primary care, general practitioners and patients to assess under which contexts, and by which mechanisms, paramedics are working in primary care, and thus test the programme theory. Based on the findings, we will be able to highlight the role of paramedics in primary care, as well as how they operate and under what conditions.Ethics and dissemination: Formal ethics review is not required for the review, as it is secondary research, but will be sought for the evaluation. Findings will be disseminated in a peer-reviewed journal, at national and international conferences and to relevant professional associations.

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Understanding how and why audits work: protocol for a realist review of audit programmes to improve hospital care

BMJ Open ◽

10.1136/bmjopen-2016-015121 ◽

2017 ◽

Vol 7 (6) ◽

pp. e015121 ◽

Cited By ~ 3

Author(s):

Lisanne Hut-Mossel ◽

Gera Welker ◽

Kees Ahaus ◽

Rijk Gans

Keyword(s):

Hospital Care ◽

Evidence Synthesis ◽

Realist Review ◽

Local Context ◽

Quality Improvements ◽

Programme Theory ◽

Meta Review ◽

Ethical Approval ◽

Registration Number ◽

Improve Hospital

IntroductionMany types of audits are commonly used in hospital care to promote quality improvements. However, the evidence on the effectiveness of audits is mixed. The objectives of this proposed realist review are (1) to understand how and why audits might, or might not, work in terms of delivering the intended outcome of improved quality of hospital care and (2) to examine under what circumstances audits could potentially be effective. This protocol will provide the rationale for using a realist review approach and outline the method.Methods and analysisThis review will be conducted using an iterative four-stage approach. The first and second steps have already been executed. The first step was to develop an initial programme theory based on the literature that explains how audits are supposed to work. Second, a systematic literature search was conducted using relevant databases. Third, data will be extracted and coded for concepts relating to context, outcomes and their interrelatedness. Finally, the data will be synthesised in a five-step process: (1) organising the extracted data into evidence tables, (2) theming, (3) formulating chains of inference from the identified themes, (4) linking the chains of inference and formulating CMO configurations and (5) refining the initial programme theory. The reporting of the review will follow the ‘Realist and Meta-Review Evidence Synthesis: Evolving Standards’ (RAMESES) publication standards.Ethics and disseminationThis review does not require formal ethical approval. A better understanding of how and why these audits work, and how context impacts their effectiveness, will inform stakeholders in deciding how to tailor and implement audits within their local context. We will use a range of dissemination strategies to ensure that findings from this realist review are broadly disseminated to academic and non-academic audiences.PROSPERO registration numberCRD42016039882.

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Caregiver-mediated interventions to support self-regulation among infants and young children (0–5 years): a protocol for a realist review

BMJ Open ◽

10.1136/bmjopen-2020-046078 ◽

2021 ◽

Vol 11 (6) ◽

pp. e046078

Author(s):

Amy Finlay-Jones ◽

Jetro Emanel Ang ◽

Elaine Bennett ◽

Jenny Downs ◽

Sally Kendall ◽

...

Keyword(s):

School Readiness ◽

Working Group ◽

Protective Factor ◽

Evidence Synthesis ◽

Grey Literature ◽

Self Regulation ◽

Realist Review ◽

Programme Theory ◽

Review Team ◽

The Impact

IntroductionSelf-regulation is a modifiable protective factor for lifespan mental and physical health outcomes. Early caregiver-mediated interventions to promote infant and child regulatory outcomes prevent long-term developmental, emotional and behavioural difficulties and improve outcomes such as school readiness, educational achievement and economic success. To harness the population health promise of these programmes, there is a need for more nuanced understanding of the impact of these interventions. The aim of this realist review is to understand how, why, under which circumstances and for whom, early caregiver-mediated interventions improve infant and child self-regulation. The research questions guiding this review were based on consultation with families and community organisations that provide early childhood and family services.Methods and analysisRealist reviews take a theory-driven and iterative approach to evidence synthesis, structured around continuous refinement of a programme theory. Programme theories specify context-mechanism-outcome configurations to explain what works, for whom, under which circumstances and how. Our initial programme theory is based on prior work in this field and will be refined through the review process. A working group, comprising service users, community organisation representatives, representatives from specific populations, clinicians and review team members will guide the evidence synthesis and interpretation, as well as the development and dissemination of recommendations based on the findings of the review. The review will involve searching: (i) electronic databases, (ii) connected papers, articles and citations and (iii) grey literature. Decisions to include evidence will be guided by judgements about their contribution to the programme theory and will be made by the research team, with input from the working group. Evidence synthesis will be reported using the Realist and MEta-narrative Evidence Synthesis: Evolving Standards guidelines.Ethics and disseminationEthical approval is not required as this is a review. Findings will be disseminated to our working group and through peer-reviewed publications and conference presentations.Review registration numberThe protocol is registered with Open Science Framework https://osf.io/5ce2z/registrations.

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A realist review of community engagement with health research

Wellcome Open Research ◽

10.12688/wellcomeopenres.15298.1 ◽

2019 ◽

Vol 4 ◽

pp. 87 ◽

Cited By ~ 3

Author(s):

Bipin Adhikari ◽

Robin Vincent ◽

Geoff Wong ◽

Claire Duddy ◽

Emma Richardson ◽

...

Keyword(s):

Global Health ◽

Community Engagement ◽

Health Research ◽

Evidence Synthesis ◽

Realist Review ◽

Evidence Base ◽

Programme Theory ◽

Middle Income ◽

Middle Income Countries ◽

Registration Number

Introduction: Community engagement is increasingly recognized as a critical aspect of global health. Recent years have seen an expansion of community engagement activities linked to health research, but debates and inconsistencies remain about the aims of different types of engagement, mechanisms underpinning their implementation and impact, and influential contextual factors. Greater commitment to and consistency around community engagement by health research programs, implementers and funders requires a more coherent evidence base. This realist review is designed to improve our understanding of how and why community engagement contributes to intended and unintended outcomes (including research and ethical outcomes) in different contexts. Given the breadth and diversity of the literature on community engagement in health research, the review will initially focus on malaria research in low- and middle-income countries (LMICs) and draw on wider global health literature where needed. Methods and analysis: Community engagement in practice is often a complex set of interventions. We will conduct a realist review – a theory driven approach to evidence synthesis – to provide explanations for how and why community engagement with health research produces the pattern of outcomes observed across different contexts of application. We will consolidate evidence from a range of documents, including qualitative, quantitative and mixed method studies. The review will follow several stages: devising an initial programme theory, searching evidence, selecting appropriate documents, extracting data, synthesizing and refining the programme theory, and reiteration of these steps as needed. Ethics and dissemination: A formal ethics review is not required for this literature review. Findings will be disseminated in a peer reviewed journal, through national and international conferences, and through a set of short briefings tailored for audiences with an interest in community engagement. Outputs and presentations will be informed by and feed into our network of community engagement experts. PROSPERO registration number: CRD42019125687

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A realist review of community engagement with health research

Wellcome Open Research ◽

10.12688/wellcomeopenres.15298.2 ◽

2019 ◽

Vol 4 ◽

pp. 87 ◽

Cited By ~ 1

Author(s):

Bipin Adhikari ◽

Robin Vincent ◽

Geoff Wong ◽

Claire Duddy ◽

Emma Richardson ◽

...

Keyword(s):

Global Health ◽

Community Engagement ◽

Health Research ◽

Evidence Synthesis ◽

Realist Review ◽

Evidence Base ◽

Programme Theory ◽

Middle Income ◽

Middle Income Countries ◽

Registration Number

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Conversations about FGM in primary care: a realist review on how, why and under what circumstances FGM is discussed in general practice consultations

BMJ Open ◽

10.1136/bmjopen-2020-039809 ◽

2021 ◽

Vol 11 (3) ◽

pp. e039809

Author(s):

Sharon Dixon ◽

Claire Duddy ◽

Gabrielle Harrison ◽

Chrysanthi Papoutsi ◽

Sue Ziebland ◽

...

Keyword(s):

Primary Care ◽

Grey Literature ◽

Relevant Literature ◽

Theory Development ◽

Realist Review ◽

Primary Outcome Measure ◽

Mandatory Reporting ◽

Programme Theory ◽

Genital Mutilation ◽

The Impact

ObjectivesLittle is known about the management of female genital mutilation (FGM) in primary care. There have been significant recent statutory changes relevant to general practitioners (GPs) in England, including a mandatory reporting duty. We undertook a realist synthesis to explore what influences how and when GPs discuss FGM with their patients.SettingPrimary care in England.Data sourcesRealist literature synthesis searching 10 databases with terms: GPs, primary care, obstetrics, gynaecology, midwifery and FGM (UK and worldwide). Citation chasing was used, and relevant grey literature was included, including searching FGM advocacy organisation websites for relevant data. Other potentially relevant literature fields were searched for evidence to inform programme theory development. We included all study designs and papers that presented evidence about factors potentially relevant to considering how, why and in what circumstances GPs feel able to discuss FGM with their patients.Primary outcome measureThis realist review developed programme theory, tested against existing evidence, on what influences GPs actions and reactions to FGM in primary care consultations and where, when and why these influences are activated.Results124 documents were included in the synthesis. Our analysis found that GPs need knowledge and training to help them support their patients with FGM, including who may be affected, what needs they may have and how to talk sensitively about FGM. Access to specialist services and guidance may help them with this role. Reporting requirements may complicate these conversations.ConclusionsThere is a pressing need to develop (and evaluate) training to help GPs meet FGM-affected communities’ health needs and to promote the accessibility of primary care. Education and resources should be developed in partnership with community members. The impact of the mandatory reporting requirement and the Enhanced Dataset on healthcare interactions in primary care warrants evaluation.PROSPERO registration numberCRD42018091996.

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Impact of an integrated community-based model of care for older people with complex conditions on hospital emergency presentations and admissions: a step-wedged cluster randomized trial

BMC Health Services Research ◽

10.1186/s12913-021-06668-x ◽

2021 ◽

Vol 21 (1) ◽

Author(s):

Jennifer Mann ◽

Fintan Thompson ◽

Robyn McDermott ◽

A. Esterman ◽

Edward Strivens

Keyword(s):

Older People ◽

Older Persons ◽

Hospital Admissions ◽

Community Dwelling ◽

Trial Registration ◽

Significant Finding ◽

Complex Needs ◽

Primary Practice ◽

The Impact ◽

Open Arch

Abstract Background Health systems must reorient towards preventative and co-ordinated care to reduce hospital demand and achieve positive and fiscally responsible outcomes for older persons with complex needs. Integrated care models can improve outcomes by aligning primary practice with the specialist health and social services required to manage complex needs. This paper describes the impact of a community-facing program that integrates care at the primary-secondary interface on the rate of Emergency Department (ED) presentation and hospital admissions among older people with complex needs. Methods The Older Persons Enablement and Rehabilitation for Complex Health Conditions (OPEN ARCH) study is a multicentre randomised controlled trial with a stepped wedge cluster design. General practitioners (GPs; n = 14) in primary practice within the Cairns region are considered ‘clusters’ each comprising a mixed number of participants. 80 community-dwelling persons over 70 years of age if non-Indigenous and over 50 years of age if Indigenous were included at baseline with no new participants added during the study. Clusters were randomly assigned to one of three steps that represent the time at which they would commence the OPEN ARCH intervention, and the subsequent intervention duration (3, 6, or 9 months). Each participant was its own control. GPs and participants were not blinded. The primary outcomes were ED presentations and hospital admissions. Data were collected from Queensland Health Casemix data and analysed with multilevel mixed-effects Poisson regression modelling to estimate the effectiveness of the OPEN ARCH intervention. Data were analysed at the cluster and participant levels. Results Five clusters were randomised to steps 1 and 2, and 4 clusters randomised to step 3. All clusters (n = 14) completed the trial accounting for 80 participants. An effect size of 9% in service use (95% CI) was expected. The OPEN ARCH intervention was found to not make a statistically significant difference to ED presentations or admissions. However, a stabilising of ED presentations and a trend toward lower hospitalisation rates over time was observed. Conclusions While this study detected no statistically significant change in ED presentations or hospital admissions, a plateauing of ED presentation and admission rates is a clinically significant finding for older persons with complex needs. Multi-sectoral integrated programs of care require an adequate preparation period and sufficient duration of intervention for effectiveness to be measured. Trial registration The OPEN ARCH study received ethical approval from the Far North Queensland Human Research Ethics Committee, HREC/17/QCH/104–1174 and is registered on the Australian and New Zealand Trials Registry, ACTRN12617000198325p.

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Understanding how to enhance efficacy and effectiveness of feedback via e-portfolio: a realist synthesis protocol

BMJ Open ◽

10.1136/bmjopen-2019-029173 ◽

2019 ◽

Vol 9 (5) ◽

pp. e029173 ◽

Cited By ~ 1

Author(s):

Mojca Babovič ◽

Ren-Huei Fu ◽

Lynn V Monrouxe

Keyword(s):

Course Design ◽

Evidence Synthesis ◽

Educational Practice ◽

Realist Synthesis ◽

Programme Theory ◽

Clinical Supervisors ◽

Context Sensitive ◽

Ethical Approval ◽

Registration Number ◽

Synthesis Report

IntroductionThe validity of feedback as one of the defining components for electronic portfolios (e-portfolios) to be effective and efficacious has yet to be demonstrated. While the literature has shown individual beneficial features of e-portfolios and feedback per se, evidence of feedback as mediated through technology directly resulting in improved educational practice is scarce. The explanation of how feedback via e-portfolio improves educational practice is particularly vague.Methods and analysisThe aim of this research is to unpack how and why feedback via e-portfolio is likely to flourish or wither in its path. Given the complexity of intervention, we will apply a theory-driven approach for evidence synthesis called realist synthesis. Informed by realist philosophy of science, it seems the most appropriate method because it explores observed outcomes (O) in terms of causal relationship between relevant contexts (C) and generating mechanisms (M). Initial programme theory will be developed through literature scoping. Later on it will be tested against purposively gathered evidence (through database and journal search), which simultaneously will be evaluated for rigour and relevance (whether method used are trustworthy and whether data contributes to theory building). We strive to (1) uncover ‘context sensitive’ mechanisms that generate feedback via e–portfolio to be (in) effective and (2) define in what circumstances is this mostly likely to occur.Ethics and disseminationThe synthesis report will be written according to the RAMESES guidelines and its findings will be published in peer reviewed articles and presented at relevant conferences. The aim is to inform: (1) policy and decision makers for future-course design; (2) medical educators/clinical supervisors and learners for improved educational use. No formal ethical approval is required.PROSPERO registration number120863.

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Remediating doctors’ performance to restore patient safety: a realist review protocol

BMJ Open ◽

10.1136/bmjopen-2018-025943 ◽

2018 ◽

Vol 8 (10) ◽

pp. e025943 ◽

Cited By ~ 2

Author(s):

Tristan Price ◽

Nicola Brennan ◽

Jennifer Cleland ◽

Linda Prescott-Clements ◽

Amanda Wanner ◽

...

Keyword(s):

Patient Safety ◽

Evidence Synthesis ◽

Grey Literature ◽

Realist Review ◽

Evidence Base ◽

Stakeholder Group ◽

Programme Theory ◽

Dissemination Strategy ◽

Knowledge To Action ◽

Patient Representatives

IntroductionUnderperformance by doctors poses a risk to patient safety. Remediation is an intervention designed to remedy underperformance and return a doctor to safe practice. Remediation is widely used across healthcare systems globally, and has clear implications for both patient safety and doctor retention. Yet, there is a poor evidence base to inform remediation programmes. In particular, there is a lack of understanding as to why and how a remedial intervention may work to change a doctor’s practice. The aim of this research is to identify why, how, in what contexts, for whom and to what extent remediation programmes for practising doctors work to support patient safety.Methods and analysisRealist review is an approach to evidence synthesis that seeks to develop programme theories about how an intervention works to produce its effects. The initial search strategy will involve: database and grey literature searching, citation searching and contacting authors. The evidence search will be extended as the review progresses and becomes more focused on the development of specific aspects of the programme theory. The development of the programme theory will involve input from a stakeholder group consisting of professional experts in the remediation process and patient representatives. Evidence synthesis will use a realist logic of analysis to interrogate data in order to develop and refine the initial programme theory into a more definitive realist programme theory of how remediation works. The study will follow and be reported according to Realist And Meta-narrative Evidence Syntheses—Evolving Standards (RAMESES).Ethics and disseminationEthical approval is not required. Our dissemination strategy will include input from our stakeholder group. Customised outputs will be developed using the knowledge-to-action cycle framework, and will be targeted to: policy-makers; education providers and regulators, the National Health Service, doctors and academics.PROSPERO registration numberCRD42018088779.

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Untangling the inter-relatedness within integrated care programmes for community-dwelling frail older people: a rapid realist review

BMJ Open ◽

10.1136/bmjopen-2020-043280 ◽

2021 ◽

Vol 11 (4) ◽

pp. e043280

Author(s):

Anam Ahmed ◽

Maria E T C van den Muijsenbergh ◽

Janne C Mewes ◽

Walter P Wodchis ◽

Hubertus J M Vrijhoef

Keyword(s):

Older People ◽

Integrated Care ◽

Informal Caregivers ◽

Realist Review ◽

Community Dwelling ◽

Care Process ◽

Multidisciplinary Teams ◽

Frail Older People ◽

Programme Theory ◽

Rapid Realist Review

ObjectiveTo identify the relationships between the context in which integrated care programmes (ICPs) for community-dwelling frail older people are applied, the mechanisms by which the programmes do (not) work and the outcomes resulting from this interaction by establishing a programme theory.DesignRapid realist review.Inclusion criteriaReviews and meta-analyses (January 2013–January 2019) and non-peer-reviewed literature (January 2013–December 2019) reporting on integrated care for community-dwelling frail older people (≥60 years).AnalysisSelection and appraisal of documents was based on relevance and rigour according to the Realist And Meta-narrative Evidence Syntheses: Evolving Standards criteria. Data on context, mechanisms, programme activities and outcomes were extracted. Factors were categorised into the five strategies of the WHO framework of integrated people-centred health services (IPCHS).Results27 papers were included. The following programme theory was developed: it is essential to establish multidisciplinary teams of competent healthcare providers (HCPs) providing person-centred care, closely working together and communicating effectively with other stakeholders. Older people and informal caregivers should be involved in the care process. Financial support, efficient use of information technology and organisational alignment are also essential. ICPs demonstrate positive effects on the functionality of older people, satisfaction of older people, informal caregivers and HCPs, and a delayed placement in a nursing home. Heterogeneous effects were found for hospital-related outcomes, quality of life, healthcare costs and use of healthcare services. The two most prevalent WHO-IPCHS strategies as part of ICPs are ‘creating an enabling environment’, followed by ‘strengthening governance and accountability’.ConclusionCurrently, most ICPs do not address all WHO-IPCHS strategies. In order to optimise ICPs for frail older people the interaction between context items, mechanisms, programme activities and the outcomes should be taken into account from different perspectives (system, organisation, service delivery, HCP and patient).

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