Development and validation of a patient-reported measure of compassion in healthcare: the Sinclair Compassion Questionnaire (SCQ)

ObjectivesCompassion is a key indicator of quality care that is reportedly eroding from patients’ care experience. While the need to assess compassion is recognised, valid and reliable measures are lacking. This study developed and validated a clinically informed, psychometrically rigorous, patient-reported compassion measure.DesignData were collected from participants living with life-limiting illnesses over two study phases across four care settings (acute care, hospice, long term care (LTC) and homecare). In phase 1, data were analysed through exploratory factor analysis (EFA), with the final items analysed via confirmatory factor analysis (CFA) in phase 2. The Schwartz Center Compassionate Care Scale (SCCCS), the revised Edmonton Symptom Assessment Scale (ESAS-r) and Picker Patient Experience Questionnaire (PPEQ) were also administered in phase 2 to assess convergent and divergent validity.Setting and participants633 participants were recruited over two study phases. In the EFA phase, a 54-item version of the measure was administered to 303 participants, with 330 participants being administered the final 15-item measure in the CFA phase.ResultsBoth EFA and CFA confirmed compassion as a single factor construct with factor loadings for the 15-item measure ranging from 0.76 to 0.86, with excellent test–retest reliability (intraclass correlation coefficient range: 0.74–0.89) and excellent internal reliability (Cronbach’s alpha of 0.96). The measure was positively correlated with the SCCCS (r=0.75, p<0.001) and PPEQ (r=0.60, p<0.001). Participants reporting higher experiences of compassion had significantly greater well-being and lower depression on the ESAS-r. Patients in acute care and hospice reported significantly greater experiences of compassion than LTC residents.ConclusionsThere is strong initial psychometric evidence for the Sinclair Compassion Questionnaire (SCQ) as a valid and reliable patient-reported compassion measure. The SCQ provides healthcare providers, settings and administrators the means to routinely measure patients experiences of compassion, while providing researchers a robust measure to conduct high-quality research.

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Psychometric evaluation of a Canadian version of the Seattle Angina Questionnaire (SAQ-CAN)

Health and Quality of Life Outcomes ◽

10.1186/s12955-020-01627-2 ◽

2020 ◽

Vol 18 (1) ◽

Author(s):

Oluwaseyi A. Lawal ◽

◽

Oluwagbohunmi Awosoga ◽

Maria J. Santana ◽

Matthew T. James ◽

...

Keyword(s):

Factor Analysis ◽

Heart Disease ◽

Cardiac Catheterization ◽

Stable Angina ◽

Intraclass Correlation ◽

Factorial Structure ◽

Seattle Angina Questionnaire ◽

Internal Reliability ◽

Patient Reported ◽

Confirmatory Factor

Abstract Background The Seattle Angina Questionnaire (SAQ) is a widely-used patient-reported outcomes measure in patients with heart disease. This study assesses the validity and reliability of the SAQ in a Canadian cohort of individuals with stable angina. Methods and results Data are from the Alberta Provincial Project for Outcome Assessment in Coronary Heart Disease (APPROACH) registry, a population-based registry of patients who received cardiac catheterization in Alberta, Canada. The cohort consists of 4052 patients undergoing cardiac catheterization for stable angina and completed the SAQ within 2 weeks. Exploratory factor analysis and confirmatory factor analysis (CFA) were used to assess the factorial structure of the SAQ. Internal and test–retest reliabilities of a new measure (i.e., SAQ-CAN) was measured using Cronbach α and intraclass correlation coefficient, respectively. CFA model fit was assessed using the root mean square error of approximation (RMSEA) and comparative fit index (CFI). Construct validity of the SAQ-CAN was assessed in relation to Hospital Anxiety and Depression Scales (HADS), Euro Quality of life 5 dimension (EQ5D), and original SAQ. Of the 4052 patients included in this analysis, 3281 (80.97%) were younger than 75 years old, while 3239 (79.94%) were male. Both exploratory and confirmatory factor analyses revealed a four-factorial structure consisting of 16 items that provided a better fit to the data (RMSEA = 0.049 [90% CI = (0.047, 0.052)]; CFI = 0.975). The 16-item SAQ demonstrated good to excellent internal reliability (Cronbach’s α range from 0.77 to 0.90), moderate to strong correlation with the Original SAQ and EQ5D but negligible correlations with HADS. Conclusion The SAQ-CAN has acceptable psychometric properties that are comparable to the original SAQ. We recommend its use for assessing coronary health outcomes in Canadian patients with Coronary Artery Disease.

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Cognitive appraisals of dissociation in psychosis: a new brief measure

Behavioural and Cognitive Psychotherapy ◽

10.1017/s1352465820000958 ◽

2020 ◽

pp. 1-13

Author(s):

Emma Černis ◽

Jessica C. Bird ◽

Andrew Molodynski ◽

Anke Ehlers ◽

Daniel Freeman

Keyword(s):

Factor Analysis ◽

Convergent Validity ◽

Intraclass Correlation ◽

Cognitive Appraisals ◽

Test Reliability ◽

Psychotic Symptoms ◽

Psychotic Experiences ◽

Internal Reliability ◽

Dissociative Experiences ◽

Additional Variance

Abstract Background: Catastrophic cognitive appraisals, similar to those in anxiety disorders, are implicated in depersonalisation, a form of dissociation. No scales exist to measure appraisals of dissociative experiences. Dissociation is common in psychosis. Misinterpretations of dissociative experiences may maintain psychotic symptoms. Therefore, assessing appraisals in this context may be valuable. Aims: The primary aim was to develop a measure of key appraisals of dissociation in psychosis. Secondary aims were to test the relationship between appraisals and psychotic experiences (paranoia and hallucinations), and determine whether appraisals explain additional variance in psychotic symptoms above dissociative symptoms. Method: Fifty items were generated from transcripts of interviews with patients. The measure was developed and psychometrically validated via factor analysis of data from 9902 general population participants and 1026 patients with psychosis. Convergent validity, test–re-test reliability, and internal reliability were assessed. Regression analyses tested relationships with psychotic symptoms. Results: A 13-item single-factor measure was developed. Factor analysis indicated good model fit [χ2(65) = 247.173, comparative fit index (CFI) = 0.960, root mean square error of approximation (RMSEA) = 0.052]. The scale had good convergent validity with a rumination (non-clinical: r = 0.71; clinical: r = 0.73) and dissociation measure (r = 0.81; r = 0.80), high internal consistency (α = 0.93; α = 0.93), and excellent 1-week test–re-test reliability [intraclass correlation (ICC) = 0.90]. It explained variance in psychotic symptoms (paranoia: 36.4%; hallucinations: 35.0%), including additional variance compared with dissociation alone (paranoia: 5.3%; hallucinations: 2.3%). Conclusions: The Cognitive Appraisals of Dissociation in Psychosis (CAD-P) measure is a psychometrically robust scale identifying appraisals of dissociative experiences in psychosis and is associated with the presence of psychotic experiences. It is likely to prove useful for clinical assessment and research.

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Physical Activity Health Literacy in Iranian Older Adults: Development and Psychometric Testing

Journal of Aging and Physical Activity ◽

10.1123/japa.2021-0221 ◽

2021 ◽

pp. 1-9

Author(s):

Moeini Babak ◽

Barati Majid ◽

Heidarimoghadam Rashid ◽

Tapak Leili ◽

Parsamajd Shahryar

Keyword(s):

Physical Activity ◽

Older Adults ◽

Factor Analysis ◽

Health Literacy ◽

Phase 1 ◽

Intraclass Correlation ◽

Psychometric Testing ◽

Validity And Reliability ◽

Confirmatory Factor ◽

Two Phases

Inadequate health literacy decreases physical activity. This study aimed to develop and examine psychometrics of physical activity health literacy in Iranian older adults. This methodological work was conducted in two phases. Phase 1 consisted of extensive studies review and qualitative study to extract and design the items. The psychometrics were measured in Phase 2 included content, faceconstruct validities, reliability, and stability. The collected data were analyzed in SPSS (version 25.0) and AMOS (version 24.0). The results of the exploratory factor analysis showed four factors— information evaluation, reading skill, perception, and decision making—and used information that explained 70.08% of the variance. The model’s fitness was supported by confirmatory factor analysis. Internal consistency based on Cronbach’s alpha was .89 with composite reliability >0.85. Stability was confirmed through the test–retest method and intraclass correlation coefficient (.89–1). Psychometrics of physical activity health literacy in Iranian older adults supported validity and reliability of the tool.

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MP08: A novel measure to capture transactional stress in paramedic services

CJEM ◽

10.1017/cem.2018.162 ◽

2018 ◽

Vol 20 (S1) ◽

pp. S43-S43

Author(s):

M. Davis ◽

E. A. Donnelly ◽

P. Bradford ◽

C. Hedges ◽

D. Socha ◽

...

Keyword(s):

Factor Analysis ◽

Critical Incident ◽

Convergent Validity ◽

Online Survey ◽

Health And Safety ◽

Well Being ◽

Stress Reactions ◽

Oblique Rotation ◽

Internal Reliability ◽

Confirmatory Factor

Introduction: In the past few years, there has been an increase in awareness of the challenge of managing work related stress in EMS. Extant research has liked different types of chronic and critical incident stress to stress reactions like posttraumatic stress. However, there is no tool to capture the transactional stresses which are associated with the day to day provision of service (e.g., dealing with offload delays or mandatory overtime) and interacting with allied professions (e.g., emergency department staff) or allied agencies (e.g., law enforcement). The purpose of this study was to develop and validate a measure which captured transactional stresses in paramedics Methods: An online survey was conducted with ten Canadian Paramedic Services with a 40.5% response rate (n= 717). Factor analysis was used to identify variation in responses related to the latent factor of transactional stress. The scale was validated using both exploratory and confirmatory factor analyses. Results: The sample of transactional stress questions was split to allow for multiple analyses (EFA n=360/ CFA n=357). In the exploratory factor analysis, principal axis factoring with an oblique rotation revealed a two-factor, twelve item solution, (KMO=.832, x2=1440.19, df=66, p<.001). Confirmatory factor analysis also endorsed a two factor, 12 item solution, (x2 =130.39, df=51, p<.001, CFI=.95, TLI= .93, RMSEA= .07, SRMR= .06). Results supported two groups of six-item factors that captured transactional stress in the provision of service. The factors, clearly aligned with transactional stress issues internal to the ambulance and transactional stress relationships external to the ambulance. Both subscales demonstrated good internal reliability (= .843/ =.768) and were correlated (p.01) with a convergent validity measure. Conclusion: This study successfully validated a two-factor scale which captures stress associated with the day to day provision of EMS and the interaction with allied professions. The development of this measure of transactional stresses further expands the potential that paramedics, Paramedic Services, employers, and prehospital physicians may understand the dynamics that influence provider health and safety. As a result, there may be greater opportunities to intervene holistically to improve paramedic health and well-being.

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Psychometric Properties of the Czech Version of the Falls Efficacy Scale-International in Patients with Early-Stage Dementia

Dementia and Geriatric Cognitive Disorders Extra ◽

10.1159/000501676 ◽

2019 ◽

Vol 9 (2) ◽

pp. 319-329 ◽

Cited By ~ 2

Author(s):

Helena Kisvetrová ◽

David Školoudík ◽

Roman Herzig ◽

Kateřina Langová ◽

Petra Kurková ◽

...

Keyword(s):

Factor Analysis ◽

Fear Of Falling ◽

Early Stage ◽

Intraclass Correlation ◽

Geriatric Depression Scale ◽

Depression Scale ◽

Reliability And Validity ◽

Internal Reliability ◽

Good Reliability ◽

People With Dementia

Introduction: A fear of falling marks an important psychological factor connected with a reduction in the life space of people with dementia. The Czech version of the Falls Efficacy Scale-International (FES-I) has not been validated in patients with early-stage dementia. Methods: The tests were administered to 282 patients with early-stage dementia. The test battery included the following: the FES-I, the Short Physical Performance Battery, the Geriatric Depression Scale, the Bristol Activity Daily Living Scale, and the Quality of Life-Alzheimer’s Disease Scale. Internal reliability (Cronbach’s α and intraclass correlation [ICC]), Pearson’s and Spearman’s correlations, exploratory factor analysis, and a t test for independent samples were used for statistical analyses. Results: The Czech version of the FES-I had excellent internal and test-retest reliability (Cronbach’s α = 0.98, ICC = 0.90; 95% CI 0.82–0.94). Factor analysis suggested 2 relevant factors. A significantly higher FES-I score was associated with patients with early-stage dementia who were older (p = 0.003) or female (p = 0.001), lived alone (p = 0.0001), spent >8 h a day alone (p = 0.032), used mobility aids (p < 0.0001), or had severe hearing (p = 0.004) or vision impairment (p < 0.0001) or a lower education (r = –0.16, p = 0.007). Conclusion: The Czech version of the FES-I had very good reliability and validity and may be useful in future cross-cultural comparisons in research among patients with early-stage dementia.

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Effects of Trial Duration on Intrasession Reliability of Single Leg Balance Testing on Stable and Unstable Surfaces

Journal of Sport Rehabilitation ◽

10.1123/jsr.2016-0205 ◽

2017 ◽

Vol 26 (6) ◽

Cited By ~ 2

Author(s):

Bryan L. Riemann ◽

Kelsey Piersol ◽

George J. Davies

Keyword(s):

Center Of Pressure ◽

Phase 1 ◽

Intraclass Correlation ◽

Correlation Coefficients ◽

Phase 2 ◽

Single Trial ◽

Trial Duration ◽

Phase 3 ◽

Intraclass Correlation Coefficients ◽

Balance Testing

Context: Single leg balance testing is a commonly used tool in sports medicine; however, there has been no consensus on trial duration needed to obtain reliable measures. Objective: This investigation sought to determine the minimum trial duration required to obtain the highest intrasession single and average trial reliability for single leg balance testing on stable and unstable surfaces using dominant and nondominant limbs. Design: Intrasession reliability.Setting:Biomechanics laboratory. Participants: 70 healthy (35 men, 35 women), physically active young adults aged 22.8 ± 2.8 y divided into 3 subgroups (n = 10, 30, 30) across a 3-phase study. Methods:3 phases of single leg balance testing were performed. For phase 1, the duration of time each participant could maintain posture on each limb/surface were computed. Phase 2 considered performance for 6 cumulative time intervals (5s, 10s, 15s, 20s, 25s, 30s). Phase 3 served to solidify results of phase 2 by computing reliability of 15s trials. Main outcome measures: Overall stability index of the center of pressure and platform tilt. Results: Intraclass correlation coefficients for phase 2 ranged from .74 (5s interval for nondominant limb on unstable surface) to .94 (20s interval for nondominant limb on stable surface). Phase 3 intraclass correlation coefficients ranged from .66 to .78 for single trial and .85 to .92 for 3 trial average with coefficients of variation ranging from 23.9% to 40.4% for single trial and 13.8% to 23.0% for 3 trial average. Conclusions:These results ultimately suggest 15s as the optimal trial duration to provide reliable measures while reducing compensatory event occurrence.

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The Role of Coping Strategies in Maintaining Well-Being During the COVID-19 Outbreak in South Korea

Social Psychological and Personality Science ◽

10.1177/1948550621990595 ◽

2021 ◽

pp. 194855062199059

Author(s):

Joo Hyun Kim ◽

Yerin Shim ◽

Incheol Choi ◽

Eunsoo Choi

Keyword(s):

South Korea ◽

Coping Strategies ◽

Growth Models ◽

Phase 1 ◽

Well Being ◽

Rate Of Change ◽

Phase 2 ◽

Behavioral Strategies ◽

The Individual

The COVID-19 pandemic continues to pose an unprecedented challenge for the world as people strive to cope with this significant threat to their well-being. This intensive longitudinal study of the first 94 days of the COVID-19 outbreak in South Korea (Phase 1: initial outbreak, Phase 2: intense social distancing) examined individuals’ changes in well-being, in relation to their use of coping strategies and fear of infection. A sample of 10,464 South Koreans participated in surveys during Phase 1 and Phase 2, resulting in 35,846 observations. Multilevel growth models revealed a decrease in well-being while different coping strategies moderated the individual rate of change in well-being. Although preventive measures were associated with a greater decrease in well-being, cognitive appraisal and behavioral strategies predicted stable well-being during the pandemic. Coping strategies further mediated the association between fear of infection and deterioration of well-being.

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ZUMA-8: A phase 1/2 multicenter study evaluating KTE-X19 in patients (pts) with relapsed/refractory (R/R) chronic lymphocytic leukemia (CLL).

Journal of Clinical Oncology ◽

10.1200/jco.2019.37.15_suppl.tps7566 ◽

2019 ◽

Vol 37 (15_suppl) ◽

pp. TPS7566-TPS7566 ◽

Cited By ~ 1

Author(s):

Ian Flinn ◽

Michael Marris ◽

William G. Wierda ◽

Steven Coutre ◽

John M. Pagel ◽

...

Keyword(s):

High Risk ◽

Multicenter Study ◽

Residual Disease ◽

Phase 1 ◽

Objective Response ◽

Progression Free Survival ◽

Lymphocytic Leukemia ◽

Phase 2 ◽

T Cell Therapy ◽

Patient Reported

TPS7566 Background: Despite treatment advances, CLL is largely incurable. First-line targeted therapy with ibrutinib mostly produces durable remissions, but high-risk disease or many prior therapies increases relapse risk (Ghia P, et al. Haematologica. 2014). Relapse after ibrutinib is associated with a poor outcome (Maddocks KJ, et al. JAMA Oncol. 2015). Allogeneic stem cell transplantation potentially offers long-term remissions but has a high risk of morbidity/mortality (Shustik C, et al. Ann Hematol. 2017). Autologous T cells expressing a CD19-specific chimeric antigen receptor (CAR) with a CD28 costimulatory domain may be efficacious against CLL (Kochenderfer JN, et al. Blood. 2012). KTE-X19 is an autologous anti-CD19 CAR T cell therapy under investigation for R/R hematologic malignancies and may offer longer durable remissions with manageable safety in pts with R/R CLL. ZUMA-8 is a Phase 1/2 multicenter study for pts with R/R CLL. Methods: Adult pts must have R/R CLL with ≥ 2 prior treatment regimens, disease progression on ibrutinib, ECOG 0-1, and adequate organ function. Phase 1 will enroll 12-18 pts to assess dose-limiting toxicities (DLTs) with a 6 + 3 dose escalation/de-escalation design; 30 more pts may be enrolled to further assess safety. Phase 2 will enroll ≈60 pts to evaluate efficacy and safety. Pts will undergo leukapheresis followed by optional bridging therapy. Cyclophosphamide (500 mg/m2) and fludarabine (30 mg/m2) conditioning chemotherapy will be given on Days -5, -4 and -3. KTE-X19 will be given on Day 0 at 0.5, 1 or 2 × 106 KTE-X19 cells/kg. The primary endpoint is incidence of DLTs for Phase 1 and independent review committee-assessed objective response rate (ORR) per iwCLL 2018 criteria for Phase 2. Secondary endpoints include complete remission (CR) rate, investigator-assessed ORR, minimal residual disease (MRD) negativity rate, MRD-negative CR rate, duration of response, progression-free survival, overall survival, safety, and patient-reported outcomes (Phase 2). Serum cytokine and blood KTE-X19 cell levels over time and level of anti-KTE-X19 antibodies are exploratory endpoints. Accrual is ongoing. Clinical trial information: NCT03624036.

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The Biomechanics and Optimization of the Needle-Syringe System for Injecting Triamcinolone Acetonide into Keloids

Journal of Medical Engineering ◽

10.1155/2016/5162394 ◽

2016 ◽

Vol 2016 ◽

pp. 1-8 ◽

Cited By ~ 13

Author(s):

Anthony Vo ◽

Marc Doumit ◽

Gloria Rockwell

Keyword(s):

Triamcinolone Acetonide ◽

Correlation Coefficient ◽

Tap Water ◽

Phase 1 ◽

Intraclass Correlation ◽

Maximum Force ◽

Phase 2 ◽

Injection Speed ◽

Injection Force ◽

Physical Challenge

Purpose. Injecting triamcinolone acetonide (TA) into a keloid is physically challenging due to the density of keloids. The purpose was to investigate the effects of various syringe and needle combinations on the injection force to determine the most ergonomic combination. Materials and Methods. A load cell was used to generate and measure the injection force. Phase 1: the injection force of 5 common syringes was measured by injecting water into air. The syringe that required the lowest injection force was evaluated with various needle gauges (25, 27, and 30 G) and lengths (16, 25, and 38 mm) by injecting TA (40 mg/mL) into air. The needle-syringe combination with the lowest injection force (CLIF) was deemed the most ergonomic combination. Phase 2: comparisons between the CLIF and a standard combination (SC) were performed by injecting TA into air and tap water into a keloid specimen. Intraclass Correlation Coefficient (ICC) and independent t-test were used. Results. Increasing the syringe caliber, injection speed, and needle gauge and length significantly increased the injection force (p value < 0.001). The SC required a maximum force of 40.0 N to inject water into keloid, compared to 25.0 N for the CLIF. Injecting TA into keloid using the SC would require an injection force that was 103.5% of the maximum force female thumbs could exert compared to 64.8% for the CLIF. ICC values were greater than 0.4. Conclusions. The 1 mL polycarbonate syringe with a 25 G, 16 mm needle (CLIF) was the most ergonomic combination. The SC required a substantial injection force, which may represent a physical challenge for female thumbs.

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An evaluation of foundation doctor training: a mixed-methods study of the impact on workforce well-being and patient care [the Evaluating the Impact of Doctors in Training (EDiT) study]

Health Services and Delivery Research ◽

10.3310/hsdr01150 ◽

2013 ◽

Vol 1 (15) ◽

pp. 1-208 ◽

Cited By ~ 3

Author(s):

S Mason ◽

C O’Keeffe ◽

A Carter ◽

R O’Hara ◽

C Stride

Keyword(s):

Health Care ◽

Quality Of Care ◽

Longitudinal Study ◽

Phase 1 ◽

Well Being ◽

Junior Doctors ◽

Phase 2 ◽

Adequate Quality ◽

The Impact

BackgroundA major reform of junior doctor training was undertaken in 2004–5, with the introduction of foundation training (FT) to address perceived problems with work structure, conditions and training opportunities for postgraduate doctors. The well-being and motivation of junior doctors within the context of this change to training (and other changes such as restrictions in working hours of junior doctors and increasing demand for health care) and the consequent impact upon the quality of care provided is not well understood.ObjectivesThis study aimed to evaluate the well-being of foundation year 2 (F2) doctors in training. Phase 1 describes the aims of delivering foundation training with a focus on the role of training in supporting the well-being of F2 doctors and assesses how FT is implemented on a regional basis, particularly in emergency medicine (EM). Phase 2 identifies how F2 doctor well-being and motivation are influenced over F2 and specifically in relation to EM placements and quality of care provided to patients.MethodsPhase 1 used semistructured interviews and focus groups with postgraduate deanery leads, training leads (TLs) and F2 doctors to explore the strategic aims and implementation of FT, focusing on the specialty of EM. Phase 2 was a 12-month online longitudinal study of F2 doctors measuring levels of and changes in well-being and motivation. In a range of specialties, one of which was EM, data from measures of well-being, motivation, intention to quit, confidence and competence and job-related characteristics (e.g. work demands, task feedback, role clarity) were collected at four time points. In addition, we examined F2 doctor well-being in relation to quality of care by reviewing clinical records (criterion-based and holistic reviews) during the emergency department (ED) placement relating to head injury and chronic obstructive pulmonary disease (COPD).ResultsPhase 1 of the study found that variation exists in how successfully FT is implemented locally; F2 lacks a clearly defined end point; there is a minimal focus on the well-being of F2 doctors (only on the few already shown to be ‘in difficulty’); the ED presented a challenging but worthwhile learning environment requiring a significant amount of support from senior ED staff; and disagreement existed about the performance and confidence levels of F2 doctors. A total of 30 EDs in nine postgraduate medical deaneries participated in phase 2 with 217 foundation doctors completing the longitudinal study. F2 doctors reported significantly increased confidence in managing common acute conditions and undertaking practical procedures over their second foundation year, with the biggest increase in confidence and competence associated with their ED placement. F2 doctors had levels of job satisfaction and anxiety/depression that were comparable to or better than those of other NHS workers, and adequate quality and safety of care are being provided for head injury and COPD.ConclusionsThere are ongoing challenges in delivering high-quality FT at the local level, especially in time-pressured specialties such as EM. There are also challenges in how FT detects and manages doctors who are struggling with their work. The survey was the first to document the well-being of foundation doctors over the course of their second year, and average scores compared well with those of other doctors and health-care workers. F2 doctors are benefiting from the training provided as we found improvements in perceived confidence and competence over the year, with the ED placement being of most value to F2 doctors in this respect. Although adequate quality of care was demonstrated, we found no significant relationships between well-being of foundation doctors and the quality of care they provided to patients, suggesting the need for further work in this area.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

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