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Biomedical subjects

Richard Lilford

Publications and source records attributed to Richard Lilford.

11 recordsLinked to original sources
PubMed2006

Cross sectional study of performance indicators for English Primary Care Trusts: testing construct validity and identifying explanatory variables.

BACKGROUND: The performance of Primary Care Trusts in England is assessed and published using a number of different performance indicators. Our study has two broad purposes. Firstly, to find out whether pairs of indicators that purport to measure similar aspects of quality are correlated (as would be expected if they are both valid measures of the same construct). Secondly, we wanted to find out whether broad (global) indicators correlated with any particular features of Primary Care Trusts, such as expenditure per capita. METHODS: Cross sectional quantitative analysis using data from six 2004/05 PCT performance indicators for 303 English Primary Care Trusts from four sources in the public domain: Star Rating, aggregated Quality and Outcomes Framework scores, Dr Foster mortality index, Dr Foster equity index (heart by-pass and hip replacements), NHS Litigation Authority Risk Management standards and Patient Satisfaction scores from the Star Ratings. Forward stepwise multiple regression analysis to determine the effect of Primary Care Trust characteristics on performance. RESULTS: Star Rating and Quality and Outcomes Framework total, both summary measures of global quality, were not correlated with each other (F = 0.66, p = 0.57). There were however positive correlations between Quality and Outcomes Framework total and patient satisfaction (r = 0.61, p < 0.001) and between screening/'additional services' indicators on the Star Ratings and Quality and Outcomes Framework (F = 24, p < 0.001). There was no correlation between different measures of access to services. Likewise we found no relationship between either Star Rating or Litigation Authority Standards and hospital mortality (F = 0.61, p = 0.61; F = 0.31, p = 0.73). CONCLUSION: Performance assessment in healthcare remains on the Government's agenda, with new core and developmental standards set to replace the Star Ratings in 2006. Yet the results of this analysis provide little evidence that the current indicators have sufficient construct validity to measure the underlying concept of quality, except when the specific area of screening is considered.

Catchment Area, Health↗
PubMed2006

Admissions processes for five year medical courses at English schools: review.

OBJECTIVE: To describe the current methods used by English medical schools to identify prospective medical students for admission to the five year degree course. DESIGN: Review study including documentary analysis and interviews with admissions tutors. SETTING: All schools (n = 22) participating in the national expansion of medical schools programme in England. RESULTS: Though there is some commonality across schools with regard to the criteria used to select future students (academic ability coupled with a "well rounded" personality demonstrated by motivation for medicine, extracurricular interests, and experience of team working and leadership skills) the processes used vary substantially. Some schools do not interview; some shortlist for interview only on predicted academic performance while those that shortlist on a wider range of non-academic criteria use various techniques and tools to do so. Some schools use information presented in the candidate's personal statement and referee's report while others ignore this because of concerns over bias. A few schools seek additional information from supplementary questionnaires filled in by the candidates. Once students are shortlisted, interviews vary in terms of length, panel composition, structure, content, and scoring methods. CONCLUSION: The stated criteria for admission to medical school show commonality. Universities differ greatly, however, in how they apply these criteria and in the methods used to select students. Different approaches to admissions should be developed and tested.

Education, Medical, Undergraduate↗
PubMed2005

Measurement of beliefs about effectiveness of laparoscopic uterosacral nerve ablation.

To explore gynaecologists' 'prior' beliefs on effectiveness of laparoscopic uterosacral nerve ablation (LUNA), a structured survey was used to gather information on the distribution of their prior beliefs regarding the effects of LUNA on pelvic pain, both numerically [on a 10-point visual analogue scale] and by responses to a questionnaire. None of the 25 gynaecologists responding to the questionnaire stated that LUNA would increase pain, while two of the 25 gave numerical answers suggesting they believed that the intervention would worsen the pain. The most widely held 'prior belief', reflected in both questionnaire and numerical responses, was that LUNA would have a small beneficial effect on pain.

Attitude of Health Personnel↗
PubMed2004

Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma.

The history of monitoring the outcomes of health care by external agencies can be traced to ancient times. However, the danger, now as then, is that in the search for improvement, comparative measures of mortality and morbidity are often overinterpreted, resulting in judgments about the underlying quality of care. Such judgments can translate into performance management strategies in the form of capricious sanctions (such as star ratings) and unjustified rewards (such as special freedoms or financial allocations). The resulting risk of stigmatising an entire institution injects huge tensions into health-care organisations and can divert attention from genuine improvement towards superficial improvement or even gaming behaviour (ie, manipulating the system). These dangers apply particularly to measures of outcome and throughput. We argue that comparative outcome data (league tables) should not be used by external agents to make judgments about quality of hospital care. Although they might provide a reasonable measure of quality in some high-risk surgical situations, they have little validity in acute medical settings. Their use to support a system of reward and punishment is unfair and, unsurprisingly, often resisted by clinicians and managers. We argue further that although outcome data are useful for research and monitoring trends within an organisation, those who wish to improve care for patients and not penalise doctors and managers, should concentrate on direct measurement of adherence to clinical and managerial standards.

Critical Care↗
PubMed2004

The eVALuate study: two parallel randomised trials, one comparing laparoscopic with abdominal hysterectomy, the other comparing laparoscopic with vaginal hysterectomy.

OBJECTIVE: To compare the effects of laparoscopic hysterectomy and abdominal hysterectomy in the abdominal trial, and laparoscopic hysterectomy and vaginal hysterectomy in the vaginal trial. DESIGN: Two parallel, multicentre, randomised trials. SETTING: 28 UK centres and two South African centres. PARTICIPANTS: 1380 women were recruited; 1346 had surgery; 937 were followed up at one year. Primary outcome Rate of major complications. RESULTS: In the abdominal trial laparoscopic hysterectomy was associated with a higher rate of major complications than abdominal hysterectomy (11.1% v 6.2%, P = 0.02; difference 4.9%, 95% confidence interval 0.9% to 9.1%) and the number needed to treat to harm was 20. Laparoscopic hysterectomy also took longer to perform (84 minutes v 50 minutes) but was less painful (visual analogue scale 3.51 v 3.88, P = 0.01) and resulted in a shorter stay in hospital after the operation (3 days v 4 days). Six weeks after the operation, laparoscopic hysterectomy was associated with less pain and better quality of life than abdominal hysterectomy (SF-12, body image scale, and sexual activity questionnaires). In the vaginal trial we found no evidence of a difference in major complication rates between laparoscopic hysterectomy and vaginal hysterectomy (9.8% v 9.5%, P = 0.92; difference 0.3%, -5.2% to 5.8%), and the number needed to treat to harm was 333. We found no evidence of other differences between laparoscopic hysterectomy and vaginal hysterectomy except that laparoscopic hysterectomy took longer to perform (72 minutes v 39 minutes) and was associated with a higher rate of detecting unexpected pathology (16.4% v 4.8%, P = < 0.01). However, this trial was underpowered. CONCLUSIONS: Laparoscopic hysterectomy was associated with a significantly higher rate of major complications than abdominal hysterectomy. It also took longer to perform but was associated with less pain, quicker recovery, and better short term quality of life. The trial comparing vaginal hysterectomy with laparoscopic hysterectomy was underpowered and is inconclusive on the rate of major complications; however, vaginal hysterectomy took less time.

Adult↗
PubMed2004

Lay conceptions of the ethical and scientific justifications for random allocation in clinical trials.

Randomised controlled trials (RCTs) play a central role in modern medical advance, and they require participants who understand and accept the procedures involved. Published evidence suggests that RCT participants often fail to understand that treatments are allocated at random and that clinicians are in equipoise about which treatment is best. We examine background assumptions that members of the public might draw upon if invited to take part in a RCT. Four studies (N=82; 67; 67; 128), in the UK, identified whether members of the public (i). accept that an individual clinician might be genuinely unsure which of two treatments was better; (ii). judge that when there is uncertainty it is acceptable to suggest deciding at random; (iii). recognise scientific benefits of random allocation to treatment conditions in a trial. Around half the participants were loathe to accept that a clinician could be completely uncertain, and this was no different whether the context was one of individual treatment or research. Most participants found it unacceptable to suggest allocating treatment at random, though there was weak evidence that a research context may reduce the unacceptability. Participants did not judge that more certain knowledge would be gained about which treatment was best when treatments were allocated at random rather than by patient/doctor choice: scientific benefits of randomisation were apparently not recognised. Judgements were no different in non-medical contexts. Results suggest a large mismatch between the assumptions underlying the trial design, and the assumptions that lay participants can bring to bear when they try to make sense of descriptive information about randomisation and equipoise. Previous attempts to improve understanding by improving the clarity or salience of trial information, or of making explicit the research context, while helpful, may need to be supplemented with accessible explanations for random allocation.

Adult↗
PubMed2003

Action research: a way of researching or a way of managing?

Scrutinising recent systematic reviews both on action research and on the management of change in organisations, we have made two observations which, we believe, clarify a rather amorphous literature. First, by comparing formal descriptions of each, action research cannot be clearly distinguished from many other change methodologies. This applies particularly to total quality management (TQM). Both action research and TQM are cyclical activities involving examination of existing processes, change, monitoring the apparent effects of the change and further change. Both emphasise active participation of stakeholders. The examples used to illustrate action research would serve equally well as examples of TQM and vice versa. Second, the methods used in action research are neither specific to action research nor are they of any particular kind. It therefore follows that action research, in so far as it purports to describe a unique or discrete form of research rather than a change process, is a misnomer. Based on these observations, we make two suggestions. Organisational change should be described in terms of the steps actually taken to effect change rather than in 'terms of art' which, like the various brands of post-Freudian psychotherapy, obscure what they have in common rather than illuminate substantive differences. And the research embedded in any cyclical managerial process can have two broad (non-exclusive) aims: to help local service managers to take the next step or to assist managers in other places and in future years to make decisions. These can be described as limited (formative) and general (summative) aims. Whether, or to what extent, a research finding is generalisable across place and time is a matter of judgement and turns on the form of the research and on its context; it is completely independent of whether or not the research was carried out within a cycle of managerial action currently described by terms such as action research or TQM.

Decision Support Systems, Management↗
PubMed1999

Pharmacological adjuvants during infertility surgery: a systematic review of evidence derived from randomized controlled trials.

The aim of this study was to evaluate systematically the role of pharmacological agents used as adjuvants during infertility surgery to prevent or reduce postoperative adhesion formation and improve pregnancy rates. Meta-analyses were performed of the ten randomized controlled trials identified that evaluated the use of pharmacological adjuvants at infertility surgery. The administration of steroids, dextran 70, noxytioline, heparin, or promethazine have all been investigated for their adjuvant role in preventing adhesion formation during pelvic surgery for infertility. Outcome measures were taken as: pregnancy rates after infertility surgery; number of patients with absent, improved or deteriorated adhesions at second look laparoscopy (dichotomous outcomes); and changes in adhesion score from initial surgery to second look laparoscopy (ordinal outcome). None of the pharmacological adjuncts investigated in a randomized controlled fashion was shown to improve postoperative pregnancy rates. There was some evidence that steroids reduced the incidence or severity of postoperative adhesion formation; there was little evidence to support the use of dextran. The routine use of pharmacological adjuncts during infertility surgery cannot be recommended on the basis of the available evidence derived from randomized controlled trials. Dextran appears to offer no advantage. The evidence with regard to steroids is far from conclusive but tentatively indicates that they may be beneficial.

Journal Article↗