The development of the Primary Care Clusters Multidimensional Assessment (PCCMA): A mixed-methods study.

A strong primary care (PC) system is essential for an efficient and high-quality healthcare service. Many countries have adopted a model of PC that encourages different healthcare providers to work together, at scale, in multidisciplinary/multiagency teams (PC clusters). The aim of the present work was to develop a quantitative instrument for the systematic and comprehensive assessment of PC clusters. This was a non-experimental, mixed-methods study grouping four work packages (WP), and involving PC cluster leads and a wide range of key stakeholders from across Wales. Interviews with 22 PC cluster leads (34 %) investigated the clusters' functioning (WP1). A systematic review identified relevant PC assessment frameworks and instruments (WP2). An expert group reviewed the evidence and drafted the new assessment tool, further evaluated and amended in two stakeholder workshops (WP3). Thirty-eight cluster leads (62 %) completed the newly developed online assessment (WP4). The final instrument consisted of 53 indicators, across 11 systemic dimensions of PC and produced a comprehensive assessment of the functioning of PC clusters in Wales. This rigorous early development of an innovative instrument to evaluate PC at a scaled-up (cluster) level (particularly in the format of a 360-degree assessment) can inform healthcare policy decisions regarding the expansion and ongoing adjustment of the model in response to local needs and challenges.

Pragmatic methods for reviewing exceptionally large bodies of evidence: systematic mapping review and overview of systematic reviews using lung cancer survival as an exemplar.

INTRODUCTION: Lung cancer (LC) is the most common cause of cancer death in the world and associated with significant economic burden. We conducted a review of published literature to identify prognostic factors associated with LC survival and determine which may be modifiable and could be targeted to improve outcomes. METHODS: The exceptionally large volume of LC prognostic research required a new staged approach to reviewing the literature. This comprised an initial mapping review of existing reviews or meta-analyses, based on titles and abstracts, followed by an overview of systematic reviews evaluating factors that independently contribute to lung cancer survival. The overview of reviews was based on full text papers and incorporated a more in-depth assessment of reviews evaluating modifiable factors. RESULTS: A large volume of published systematic reviews and meta-analyses were identified, but very few focused on modifiable factors for LC survival. Several modifiable factors were identified, which are potential candidates for targeted interventions aiming to improve cancer outcomes. The mapping review included 398 reviews, of which 207 investigated the independent effect of prognostic factors on lung cancer survival. The most frequently evaluated factors were novel biomarkers (86 biomarkers in 138 reviews). Only 15 modifiable factors were investigated in 20 reviews. Those associated with significant survival improvement included normal BMI/less weight loss, good performance status, not smoking/quitting after diagnosis, good pre-treatment quality of life, small gross volume tumour, early-stage tumour, lung resection undertaken by a thoracic/cardiothoracic surgeon, care being discussed by a multidisciplinary team, and timeliness of care. CONCLUSIONS: The study utilised a novel approach for reviewing an extensive and complicated body of research evidence. It enabled us to address a broad research question and focus on a specific area of priority. The staged approach ensured the review remained relevant to the stakeholders throughout, whilst maintaining the use of objective and transparent methods. It also provided important information on the needs of future research. However, it required extensive planning, management, and ongoing reviewer training.

Patient perspectives on delays in diagnosis and treatment of cancer: a qualitative analysis of free-text data.

BACKGROUND: Earlier cancer diagnosis is crucial in improving cancer survival. The International Cancer Benchmarking Partnership Module 4 (ICBP4) is a quantitative survey study that explores the reasons for delays in diagnosis and treatment of breast, colorectal, lung, and ovarian cancer. To further understand the associated diagnostic processes, it is also important to explore the patient perspectives expressed in the free-text comments. AIM: To use the free-text data provided by patients completing the ICBP4 survey to augment the understanding of patients' perspectives of their diagnostic journey. DESIGN AND SETTING: Qualitative analysis of the free-text data collected in Wales between October 2013 and December 2014 as part of the ICBP4 survey. Newly-diagnosed patients with either breast, ovarian, colorectal, or lung cancer were identified from registry data and then invited by their GPs to participate in the survey. METHOD: A thematic framework was used to analyse the free-text comments provided at the end of the ICBP4 survey. Of the 905 patients who returned a questionnaire, 530 included comments. RESULTS: The free-text data provided information about patients' perspectives of the diagnostic journey. Analysis identified factors that acted as either barriers or facilitators at different stages of the diagnostic process. Some factors, such as screening, doctor-patient familiarity, and private treatment, acted as both barriers and facilitators depending on the context. CONCLUSION: Factors identified in this study help to explain how existing models of cancer diagnosis (for example, the Pathways to Treatment Model) work in practice. It is important that clinicians are aware of how these factors may interact with individual clinical cases and either facilitate, or act as a barrier to, subsequent cancer diagnosis. Understanding and implementing this knowledge into clinical practice may result in quicker cancer diagnoses.

Anomalous experiences and the contents of persecutory delusions during acute psychotic episodes.

Criteria for judging the presence of persecutory delusions, and theoretical distinctions between different kinds of persecutory delusions, depend on the identification of the contents of such delusions. The first aim of this study was to assess whether contents can be assessed reliably. It has been suggested that anomalous experiences are involved in the formation and maintenance of delusions. The second aim of this study was to assess whether independent judges could agree when persecutory delusions depend on such experiences. Twenty-two inpatients suffering from acute psychotic episodes were recruited. Two independent raters categorized the contents of their delusions in terms of the timing, agent, intention, motivation, type, and severity of harm using information from a variety of sources. Agreement between the raters was adequate for all content areas and for judgments of associations with anomalous experiences. Using ideas of reference as evidence for the persecution was associated with believing that the harm is already very severe, that multiple types of harm are occurring, and that worse persecution is imminent. Theoretical explanations need to be elaborated to account for the variety of contents that can be identified reliably. Associations with anomalous experiences might guide such elaborations.