Looking beyond the forest: Using harvest plots, gap analysis, and expert consultations to assess effectiveness, engage stakeholders, and inform policy.

We describe a combination of methods for assessing the effectiveness of complex interventions, especially where substantial heterogeneity with regard to the population, intervention, comparison, outcomes, and study design of interest is expected. We applied these methods in a recent systematic review of the effectiveness of reinforced home-based palliative care (rHBPC) interventions, which included home-based care with an additional and explicit component of lay caregiver support. We first summarized the identified evidence, deemed inappropriate for statistical pooling, graphically by creating harvest plots. Although very useful as a tool for summary and presentation of overall effectiveness, such graphical summary approaches may obscure relevant differences between studies. Thus, we then used a gap analysis and conducted expert consultations to look beyond the aggregate level at how the identified evidence of effectiveness may be explained. The goal of these supplemental methods was to step outside of the conventional systematic review and explore this heterogeneity from a broader perspective, based on the experience of palliative care researchers and practitioners. The gap analysis and expert consultations provided valuable input into possible underlying explanations in the evidence, which could be helpful in the further adaptation and testing of existing rHBPC interventions or the development and evaluation of new ones. We feel that such a combination of methods could prove accessible, understandable, and useful in informing decisions and could thus help increase the relevance of systematic reviews to the decision-making process.

Why is it so difficult to integrate ethics in Health Technology Assessment (HTA)? The epistemological viewpoint.

Ethics has been identified as a key element in Health Technology Assessment (HTA) since its conception. However, ethical issues are still not frequently addressed explicitly in HTA. Several valuable reasons have been identified. The basis of the article is the claim that ethics is often not part of HTA for "epistemological reasons". Hence, the main aim of the contribution is to explore in more details and emphasize them by using the fact/value dichotomy. Our conclusion is that current HTA configuration is predominantly based on the comparison among objective and empirically testable "facts", whilst ethics is not empirically testable. In this sense, there is a sort of "epistemological gap", which can explain why it is so difficult to integrate ethics in HTA. We suggest that the epistemological differences among the various domains of HTA are addressed more explicitly.

'You do know he's had a stroke, don't you?' Preparation for family care-giving--the neglected dimension.

Countries throughout the developed world have introduced a policy of community care for older people to reduce costs to the state and maintain quality of life. In reality community care is largely family care and recognition of the need to support family carers is being promoted through the notion of partnership with professional carers. Such a partnership calls for a more complete understanding of how carers' needs change over time and how professional support can be most effective. Support is particularly important at the start of care-giving in order that carers can exercise free choice and be adequately prepared for their role. This paper provides an overview an ongoing longitudinal study and reports specifically on the findings of data from a preliminary study in which a convenience sample of seven experienced carers of stroke survivors who attended a stroke and carers club were interviewed in their own homes. Based on initial data from a longitudinal study of stroke victims, this paper outlines four themes: 'What's it all about', 'Going it alone', 'Up to the job' and 'What about me?' These themes highlight the difficulties carers experience in the immediate aftermath of stroke.

Frequency response of spine extensors during rapid isometric contractions: effects of muscle length and tension.

During muscle contraction, electrical activity necessarily precedes force output, yet models that utilize processed electromyograms sometimes predict force as preceding EMG under rapid ballistic loading conditions. The purpose of this study was to define the frequency response transfer function of the upper and lower erector spinae musculature, at different lengths and tensions, using rectified, low pass filtered EMG. This would enable accurate estimates of force from the processed electromyogram, specifically during impulsive contractions. Abdominal and erector spinae EMG were measured in synchrony with impulsive low back moments in five men. EMG signals were rectified and low pass filtered repeatedly with cut-off frequencies from 1 to 3 Hz at 0.5 Hz increments in order to quantify the frequency response. It was found that EMG signals processed through a simple, Butterworth low pass filter could not produce the measured force output without an additional time shift. These shifts were quantified by cross-correlating EMG and force with increments of 1 ms. In order to define the transfer function of EMG to force, optimal cut-off frequencies were selected two ways: quantitatively by searching for maximum cross correlations coefficients, and qualitatively. Results indicated that the frequency response of both the upper and lower erector spinae can be modelled with a cut-off frequency between 2 and 2.5 Hz and that these values are not significantly modulated by changes in muscle length or tension.

Community-based leg ulcer clinics: organisation and cost-effectiveness.

To establish the cost effectiveness of community leg ulcer clinics using four-layer compression bandaging and the care provided by district nurses, a randomised controlled trial was set up in eight community-based research clinics in four trusts, funded by Trent Regional Health Authority. The main outcomes monitored were the amount of time needed to complete ulcer healing, patient health status, and recurrence. Satisfaction with care, use of services and personal costs were also monitored.

Cost effectiveness of community leg ulcer clinics: randomised controlled trial.

OBJECTIVES: To establish the relative cost effectiveness of community leg ulcer clinics that use four layer compression bandaging versus usual care provided by district nurses. DESIGN: Randomised controlled trial with 1 year of follow up. SETTING: Eight community based research clinics in four trusts in Trent. SUBJECTS: 233 patients with venous leg ulcers allocated at random to intervention (120) or control (113) group. INTERVENTIONS: Weekly treatment with four layer bandaging in a leg ulcer clinic (clinic group) or usual care at home by the district nursing service (control group). MAIN OUTCOME MEASURES: Time to complete ulcer healing, patient health status, and recurrence of ulcers. Satisfaction with care, use of services, and personal costs were also monitored. RESULTS: The ulcers of patients in the clinic group tended to heal sooner than those in the control group over the whole 12 month follow up (log rank P=0.03). At 12 weeks, 34% of patients in the clinic group were healed compared with 24% in the control. The crude initial healing rate of ulcers in intervention compared with control patients was 1.45 (95% confidence interval 1.04 to 2. 03). No significant differences were found between the groups in health status. Mean total NHS costs were 878.06 pounds per year for the clinic group and 859.34 pounds for the control (P=0.89). CONCLUSIONS: Community based leg ulcer clinics with trained nurses using four layer bandaging is more effective than traditional home based treatment. This benefit is achieved at a small additional cost and could be delivered at reduced cost if certain service configurations were used.

Using photoplethysmography as part of nursing assessment.

A review of the literature on the use of photoplethysmography as an assessment tool to identify the presence of venous insufficiency.

Preparation for family care-giving: stroke as a paradigm case.

This article considers the nurse's role in assisting family (informal) carers who adopt their role suddenly, following an acute health crisis. Carers of stroke survivors are used as a 'paradigm' case to highlight the challenges faced by family members at the time of hospital discharge. The needs of family members who suddenly adopt a caring role are poorly understood, but greater awareness is needed as the Carers (Recognition and Services) Act (1995) provides statutory recognition of the rights of such individuals to an assessment of their needs, emphasizing the importance of carers making an informed choice based on a willingness and ability to adopt a care-giving role. Evidence suggests that new family carers are currently poorly prepared to take on their role, lacking the information and skills needed to provide good care. Nurses have a major role to play in preparing carers, but currently lack a systematic approach to assessment and intervention. Further empirical work is required to establish more clearly the needs of new carers and to develop and evaluate appropriate intervention strategies to address their needs.