Economic evaluations performed alongside randomized implementation trials in clinical settings: a systematic review.

BACKGROUND: Economic evaluations alongside implementation trials compare the outcomes and costs of competing implementation strategies to identify the most efficient strategies. The aims of this systematic review were to investigate how economic evaluations are performed in randomized implementation trials in clinical settings and to assess the quality of these evaluations. METHODS: A systematic literature review was conducted on 23 March 2023 to identify studies that reported on economic evaluations embedded in randomized implementation trials in clinical settings. A systematic search was applied across seven databases, and references of relevant reviews were screened for additional studies. The Drummond Checklist was used to assess the quality and risk of bias of included economic evaluations. Study characteristics and quality assessments were tabulated and described. RESULTS: Of the 6,550 studies screened for eligibility, 10 met the inclusion criteria. Included studies were published between 1990 and 2022 and from North America, the United Kingdom, Europe, and Africa. Most studies were conducted in the primary and out-patient care setting. Implementation costs included materials, staffing, and training, and the most common approach to collecting implementation costs was obtaining expense and budget reports. Included studies scored medium to high in terms of economic methodological quality. CONCLUSIONS: Economic evidence is particularly useful for healthcare funders and service providers to inform the prioritization of implementation efforts in the context of limited resources and competing demands. The relatively small number of studies identified may be due to lack of guidance on how to conduct economic evaluations alongside implementation trials and the lack of standardized terminology used to describe implementation strategies in clinical research. We discuss these methodological gaps and present recommendations for embedding economic evaluations in implementation trials. First, reporting implementation strategies used in clinical trials and aligning these strategies with implementation outcomes and costs are an important advancement in clinical research. Second, economic evaluations of implementation trials should follow guidelines for standard clinical trial economic evaluations and adopt an appropriate costing and data collection approach. Third, hybrid trial designs are recommended to generate evidence for effective and cost-effective implementation strategies alongside clinical effectiveness and cost-effectiveness. TRIAL REGISTRATION: The review was prospectively registered with PROSPERO (CRD42023410186).

Можно ли предотвратить или отсрочить появление диабета 2-го типа и связанных с ним осложнений у людей с промежуточной гипергликемией? Резюме

В Европейском регионе ВОЗ диабетом страдает каждый одиннадцатый взрослый. Это один из основных факторов риска развития сердечно-сосудистых заболеваний, почечной недостаточности, потери зрения и повреждения нервов. Промежуточная гипергликемия — это состояние, при котором уровни глюкозы в крови выше нормального диапазона, но ниже пороговых значений, характерных для диабета. Она связана с повышенным риском развития диабета 2-го типа, ожирения, сердечно-сосудистых заболеваний и смертности. В настоящем обзоре изучается влияние лечебных мероприятий на состояние здоровья людей с промежуточной гипергликемией. Результаты рандомизированных контролируемых испытаний показывают, что риск развития диабета 2-го типа у людей с промежуточной гипергликемией можно снизить при помощи ведения здорового образа жизни и принятия (некоторых) фармакологических препаратов. В результате анализа большинства имеющихся фактических данных не обнаружено различий в уровне смертности или других важных показателях здоровья при проведении фармакологических вмешательств или изменении образа жизни. Хотя, возможно, что периоды наблюдения были недостаточно продолжительными, чтобы заметить положительную динамику в показателях здоровья. Имеющиеся в настоящее время фактические данные свидетельствуют о том, что риск развития диабета 2-го типа можно снизить за счет проведения лечебных мероприятий на стадии промежуточной гипергликемии, однако неизвестно, как влияют эти мероприятия на показатели здоровья в долгосрочной перспективе.

Can type 2 diabetes and its associated complications be prevented or delayed in people with intermediate hyperglycaemia? Summary

Diabetes affects one in 11 adults in the WHO European Region. It is a key risk factor for cardiovascular diseases, kidney failure, vision loss and nerve damage. Intermediate hyperglycaemia is a state in which blood glucose levels are above the normal range but below the threshold for diabetes. It is associated with an increased risk for type 2 diabetes, obesity, cardiovascular diseases and mortality. This review assessed the effects of interventions for people with intermediate hyperglycaemia. Results from randomized controlled trials indicate that the risk of developing type 2 diabetes in people with intermediate hyperglycaemia is reduced by lifestyle and (some) pharmacological interventions. Most of the available evidence did not find a difference in mortality or other serious health outcomes for either pharmacological or lifestyle interventions. However, the follow-up periods may have been too short for health outcomes to have emerged. The current evidence suggests that the risk of developing type 2 diabetes is reduced through intervention at the point of in

Can type 2 diabetes and its associated complications be prevented or delayed in people with intermediate hyperglycaemia?

Diabetes affects one in 11 adults in the WHO European Region. It is a key risk factor for cardiovascular diseases, kidney failure, vision loss and nerve damage. Intermediate hyperglycaemia is a state in which blood glucose levels are above the normal range but below the threshold for diabetes. It is associated with an increased risk for type 2 diabetes, obesity, cardiovascular diseases and mortality. This review assessed the effects of interventions for people with intermediate hyperglycaemia. Results from randomized controlled trials indicate that the risk of developing type 2 diabetes in people with intermediate hyperglycaemia is reduced by lifestyle and (some) pharmacological interventions. Most of the available evidence did not find a difference in mortality or other serious health outcomes for either pharmacological or lifestyle interventions. However, the follow-up periods may have been too short for health outcomes to have emerged. The current evidence suggests that the risk of developing type 2 diabetes is reduced through intervention at the point of intermediate hyperglycaemia, but that the effects of these interventions on long-term health outcomes are unclear.

Как влияет на показатели здоровья проведение популяционного скрининга бессимптомных взрослых на сахарный диабет 2-го типа или промежуточную гипергликемию? Резюме

Диабет – это одно из самых распространенных хронических заболеваний в мире. Он приводит к болезням сердца, проблемам со зрением и почками, а также к преждевременной смертности. Промежуточная гипергликемия (ПГ) – состояние, при котором уровни глюкозы в крови выше нормального диапазона, но ниже пороговых значений, характерных для диабета, – связана с повышенным риском развития сахарного диабета 2-го типа (СД2), ожирения, сердечно-сосудистых заболеваний и смертности. В настоящем обзоре дается оценка того, может ли проведение популяционного скрининга на СД2 и ПГ повлиять на показатели здоровья. Результаты единственного недостаточно статистически мощного исследования с высокой вероятностью систематических ошибок показали отсутствие доказательств пользы проведения популяционного скрининга на СД2 для снижения показателей заболеваемости или смертности. Ни в одном исследовании не сравнивались показатели здоровья в случаях, когда лечение проводилось после обнаружения болезни в результате скрининга, и в случаях, когда лечение не проводилось совсем или проводилось после появления симптомов. В одном исследовании с низкой статистической мощностью не было обнаружено существенной разницы в показателях здоровья пациентов, одна группа которых прошла более интенсивное лечение после обнаружения болезни в результате скрининга, а другая – менее интенсивное. Таким образом, в настоящее время отсутствуют доказательства того, что скрининг на СД2 или ПГ содействует снижению показателей заболеваемости или смертности.

What is the effect of population-level screening of asymptomatic adults for type 2 diabetes mellitus or intermediate hyperglycaemia on health outcomes: summary

Diabetes mellitus is one of the world's fastest growing chronic conditions. It is associated with heart disease, eye and kidney problems, and premature death. Intermediate hyperglycaemia, a state in which blood glucose levels are above the normal range but below the threshold for diabetes, is associated with an increased risk for type 2 diabetes (T2DM), obesity, cardiovascular diseases and mortality. The review assessed whether population-level screening for intermediate hyperglycaemia and T2DM can improve health outcomes. A single, underpowered, biased study found no benefit of population-level screening for T2DM to reduce morbidity or mortality. No studies reported whether treatment after screen detection improved health outcomes compared with either no treatment or treatment after later symptomatic detection. One underpowered study found no significant difference in health outcomes between more- and less-intensive treatment after screen detection. In summary, there is currently no evidence that screening for T2DM or IHG reduces morbidity or mortality.

What is the effect of population-level screening of asymptomatic adults for type 2 diabetes mellitus or intermediate hyperglycaemia on health outcomes

Diabetes mellitus is one of the world's fastest growing chronic conditions. It is associated with heart disease, eye and kidney problems, and premature death. Intermediate hyperglycaemia, a state in which blood glucose levels are above the normal range but below the threshold for diabetes, is associated with an increased risk for type 2 diabetes (T2DM), obesity, cardiovascular diseases and mortality. The review assessed whether population-level screening for intermediate hyperglycaemia and T2DM can improve health outcomes. A single, underpowered, biased study found no benefit of population-level screening for T2DM to reduce morbidity or mortality. No studies reported whether treatment after screen detection improved health outcomes compared with either no treatment or treatment after later symptomatic detection. One underpowered study found no significant difference in health outcomes between more- and less-intensive treatment after screen detection. In summary, there is currently no evidence that screening for T2DM or IHG reduces morbidity or mortality.

What is the best way to evaluate social prescribing? A qualitative feasibility assessment for a national impact evaluation study in England.

OBJECTIVES: Despite significant investment in social prescribing in England over the last decade, we still do not know if it works, or how models of social prescribing fit within wider health and care policy and practice. This study explores current service delivery structures and assesses the feasibility of a national evaluation of the link worker model. METHODS: Semi-structured interviews were conducted between May and September 2020, with 25 key informants from across social prescribing services in England. Participants included link workers, voluntary, community and social enterprise staff, and those involved in policy and decision-making for social prescribing services. Interview and workshop transcripts were analysed thematically, adopting a framework approach. RESULTS: We found differences in how services are provided, including by individual link workers, and between organisations and regions. Standards, referral pathways, reporting, and monitoring structures differ or are lacking in voluntary services as compared to clinical services. People can self-refer to a link worker or be referred by a third party, but the lack of standardised processes generated confusion in both public and professional perceptions of the link worker model. We identified challenges in determining the appropriate outcomes and outcome measures needed to assess the impact of the link worker model. CONCLUSIONS: The current varied service delivery structures in England poses major challenges for a national impact evaluation. Any future rigorous evaluation needs to be underpinned with national standardised outcomes and process measures which promote uniform data collection.

Clinical effectiveness of pharmacological interventions for managing chronic migraine in adults: a systematic review and network meta-analysis.

BACKGROUND: Chronic migraine can be a profoundly disabling disorder that may be treated with preventive medications. However, uncertainty remains as to which preventive medication is the most effective. We present a network meta-analysis to determine the effectiveness and rank of preventive drugs for chronic migraine in adults. METHODS: We identified, reviewed, and extracted data from randomised controlled trials (RCTs) of preventive drugs for chronic migraine with at least 200 participants. Data were analysed using network meta-analysis. FINDINGS: We included 12 RCTs of six medications (Eptinezumab, Erenumab, Fremanezumab, Galcanezumab, Onabotulinumtoxin A, and Topiramate) compared to placebo or each other. All drugs effectively reduced monthly headache and migraine days compared with placebo. The most effective drug for monthly headache days was Eptinezumab 300mg, with a mean difference of -2.46 days, 95% Credible Interval (CrI): -3.23 to -1.69. On the Surface Under the Cumulative Ranking Area (SUCRA) analysis, the probability that Eptinezumab 300mg was ranked highest was 0.82. For monthly migraine days, the most effective medication was Fremanezumab-monthly, with a mean difference: -2.77 days, 95% CrI: -3.36 to -2.17, and 0.98 probability of being ranked the highest. All included drugs, except Topiramate, improved headache-related quality of life. No eligible studies were identified for the other common preventive oral medications such as Amitriptyline, Candesartan, and Propranolol. The main reasons were that the studies did not define chronic migraine, were undertaken before the definition of chronic migraine, or were too small. INTERPRETATION: All six medications were more effective than the placebo on monthly headache and migraine days. The absolute differences in the number of headache/migraine days are, at best, modest. No evidence was found to determine the relative effectiveness of the six included drugs with other oral preventive medications. REGISTRATION: PROSPERO (number CRD42021265990).

In which context and for whom can interventions improve leadership of surgical trainees, surgeons and surgical teams and why: a realist review protocol.

Background: Improving effective leadership of individuals, groups, and healthcare organisations is essential for improving surgical performance and indirectly improving health outcomes for patients. Numerous systematic reviews have been conducted which seek to determine the effectiveness of specific leadership interventions across a range of disciplines and healthcare outcomes. The purpose of this realist review is to systematically synthesise the literature which examines in which context and for whom leadership interventions improve leadership of surgeons, surgical teams, and trainees. Methods: Several approaches will be used to iteratively search the scientific and grey literature to identify relevant evidence. Selected articles will inform the development of a programme theory that seeks to explain in which context and for whom interventions can improve leadership of surgical trainees, surgeons, and surgical teams. Next, empirical studies will be searched systematically in order to test and, where necessary, refine the theory. Once theoretical saturation has been achieved, recommendations for advancing leadership in surgery will be developed. Stakeholder and patient and public consultations will contribute to the development of the programme theory. The review will be written up according to the Realist And Meta-narrative Evidence Synthesis: Evolving Standards publication standards. No ethical review will be required for the conduct of this realist review. Discussion: The knowledge gained from this review will provide evidence-based guidance for those planning or designing leadership interventions in surgery. The recommendations will help policymakers, educationalists, healthcare providers, and those delivering or planning leadership development programmes across the surgical disciplines to design interventions that are acceptable to the surgical community and successful in improving surgical leadership.PROSPERO registration: CRD42021230709.

How do leadership development activities need to be designed in order to improve the leadership of surgeons, surgical teams and surgical trainees? Leadership is seen to be an important skill for those working in healthcare. Healthcare systems therefore, invest a lot of money into the development of the leadership of surgeons, surgical teams, and surgical trainees. Leadership development activities include leadership courses and programmes, mentoring and coaching, feedback activities, and simulation training. To date there is no agreement on what makes leadership development activities effective or not. We also do not know whether they work for certain people or professionals more than others. It is important to find out what interventions are best, in order to spend money on leadership development effectively. This protocol describes our plan to develop a theory explaining in which context and for whom leadership development activities work and why. We will develop the theory based on the existing literature and through discussions with experts in the field. To make the results more reliable, we will search databases systematically and the different stages of the review will be checked by two people. Results will feed into further research where we collect 'real world' data on leadership development activities that take place in the National Health Service (NHS) and whether they work and why. Our study will also provide guidance for those who are planning or designing leadership development activities for surgeons, surgical teams and surgical trainees.

Advancing leadership in surgery: a realist review of interventions and strategies to promote evidence-based leadership in healthcare.

BACKGROUND: Healthcare systems invest in leadership development of surgeons, surgical trainees, and teams. However, there is no agreement on how interventions should be designed, or what components they must contain to be successful. The objective of this realist review was to generate a programme theory explaining in which context and for whom surgical leadership interventions work and why. METHODS: Five databases were systematically searched, and articles screened against inclusion considering their relevance. Context-mechanism-outcome configurations (CMOCs) and fragments of CMOCs were identified. Gaps in the CMOCs were filled through deliberation with the research team and stakeholder feedback. We identified patterns between CMOCs and causal relationships to create a programme theory. RESULTS: Thirty-three studies were included and 19 CMOCs were developed. Findings suggests that interventions for surgeons and surgical teams improve leadership if timely feedback is delivered on multiple occasions and by trusted and respected people. Negative feedback is best provided privately. Feedback from senior-to-junior or peer-to-peer should be delivered directly, whereas feedback from junior-to-senior is preferred when delivered anonymously. Leadership interventions were shown to be most effective for those with awareness of the importance of leadership, those with confidence in their technical surgical skills, and those with identified leadership deficits. For interventions to improve leadership in surgery, they need to be delivered in an intimate learning environment, consider implementing a speak-up culture, provide a variety of interactive learning activities, show a genuine investment in the intervention, and be customised to the needs of surgeons. Leadership of surgical teams can be best developed by enabling surgical teams to train together. CONCLUSIONS: The programme theory provides evidence-based guidance for those who are designing, developing and implementing leadership interventions in surgery. Adopting the recommendations will help to ensure interventions are acceptable to the surgical community and successful in improving surgical leadership. TRIAL REGISTRATION: The review protocol is registered with PROSPERO (CRD42021230709).

Surgical implementation gap: an interrupted time series analysis with interviews examining the impact of surgical trials on surgical practice in England.

OBJECTIVES: Landmark studies published near the turn of the 21st century found an implementation gap concerning the effect of evidenced-based findings on clinical practice. The current study examines the uptake of six trials that produced actionable findings to describe the effects of evidence on practice and the reasons for those effects. DESIGN: A sequential, explanatory mixed methods study was conducted. First, a quantitative study assessed whether actionable findings from large, publicly funded elective surgical trials influenced practice. Subsequently, qualitative interviews were conducted to explain the quantitative findings. SETTING: Changes in NHS-funded practice were tracked across hospitals in England. Interviews were conducted online. DATA AND PARTICIPANTS: The six surgical trials were funded and published by England's National Institute for Health Research's Health Technology Assessment programme between 2006 and 2015. Quantitative time series analyses used data about the frequencies or proportions of relevant surgical procedures conducted in England between 2001 and 2020. Subsequently, qualitative interviews were conducted with 25 participants including study authors, surgeons and other healthcare staff in the supply chain. Transcripts were coded to identify major temporal events and Consolidated Framework for Implementation Research (CFIR) domains/constructs that could influence implementation. Findings were synthesised by clinical area. RESULTS: The quantitative analyses reveal that practice changed in accordance with findings for three trials. In one trial (percutaneous vs nasogastric tube feed after stroke), the change took a decade to occur. In another (patella resurfacing), change anticipated the trial findings. In the third (abdominal aortic aneurysm repair), changes tracked the evolving evidence base. In the remaining trials (two about varicose veins and one about gastric reflux), practice did not change in line with findings. For varicose veins, the results were superseded by a further trial. For gastric reflux, surgical referrals declined as medical treatment increased. The exploratory qualitative analysis informed by CFIR found that evidence from sources apart from the trial in question was mentioned as a reason for non-adoption in the three trials where evidence did not affect practice and in the trial where uptake was delayed. There were no other consistent patterns in the qualitative data. CONCLUSION: While practice does not always change in the direction indicated by clinical trials, our results suggest that individuals, official committees and professional societies do assimilate trial evidence. Decision-makers seem to respond to the totality of evidence such that there are often plausible reasons for not adopting the evidence of any one trial in isolation.

Investigating informed choice in screening programmes: a mixed methods analysis.

BACKGROUND: Screening programmes aim to identify individuals at higher risk of developing a disease or condition. While globally, there is agreement that people who attend screening should be fully informed, there is no consensus about how this should be achieved. We conducted a mixed methods study across eight different countries to understand how countries address informed choice across two screening programmes: breast cancer and fetal trisomy anomaly screening. METHODS: Fourteen senior level employees from organisations who produce and deliver decision aids to assist informed choice were interviewed, and their decision aids (n = 15) were evaluated using documentary analysis. RESULTS: We discovered that attempts to achieve informed choice via decision aids generate two key tensions (i) between improving informed choice and increasing uptake and (ii) between improving informed choice and comprehensibility of the information presented. Comprehensibility is fundamentally at tension with an aim of being fully informed. These tensions emerged in both the interviews and documentary analysis. CONCLUSION: We conclude that organisations need to decide whether their overarching aim is ensuring high levels of uptake or maximising informed choice to participate in screening programmes. Consideration must then be given to all levels of development and distribution of information produced to reflect each organisation's aim. The comprehensibility of the DA must also be considered, as this may be reduced when informed choice is prioritised.

Is the assumption of waning of treatment effect applied consistently across NICE technology appraisals? A case-study focusing on disease-modifying therapies for treatment of multiple sclerosis.

OBJECTIVES: Whether the effects of therapies may wane over time is a matter of debate, especially when considering their long-term cost-effectiveness. Here, we examined how the assumption of the waning of treatment effect was applied across the National Institute for Health and Care Excellence (NICE) appraisals for disease-modifying therapies (DMTs) used in multiple sclerosis. METHODS: We undertook a document analysis following a search of the NICE website. The inclusion criteria of the study were as follows: all publicly available documents related to completed appraisals for DMTs (period: January 2000 to July 2021). The exclusion criteria of the study were as follows: all documents that did not meet the inclusion criteria, especially pertaining to drugs used in other disease areas. We extracted information about the waning of treatment effect assumption as considered by companies, assessment groups, and appraisal committees, and we analyzed trends over time. RESULTS: We reviewed fifteen appraisals that reported guidance on sixteen DMTs. Irrespective of the drugs' mechanism of action or their pharmaceutical nature, there was substantial variation in the modalities when the assumption of waning was implemented. We noted the recent preference to use all-cause discontinuation as a proxy. This heterogeneity did not appear to affect acceptance of the DMTs (all but one were recommended for use across the National Health System (NHS)). CONCLUSIONS: Modeling the long-term effect of therapies is challenging, especially given the limited follow-up duration of related trials. This generates recurrent debates on the presence of waning of treatment efficacy and heterogeneity across appraisals. More refined recommendations obtained by consensus among stakeholders could help to achieve greater consistency in decision making.

The Effectiveness of Interventions for the Prevention or Treatment of Paternal Perinatal Anxiety: A Systematic Review.

Background: The worldwide prevalence of paternal perinatal anxiety (PPA) ranges between 3.4% and 25.0% antenatally, and 2.4% and 51.0% postnatally. Experiencing PPA can adversely impact the individual, partners, and infants. Research concerning PPA is lagging and fragmented compared to research for new mothers. Objectives: To establish the effectiveness of prevention or treatment interventions for PPA in adults identifying as male. Data sources: We completed searches of Medline, EMBASE, PsycINFO and Web of Science from inception to 2 December 2021, as well as hand searches of references from relevant papers. Search selection and data extraction: Randomised controlled trials delivering prevention or treatment interventions and reporting anxiety outcomes for new/expectant fathers in the perinatal mental health period were included. Our review follows the PRISMA reporting guidelines. One reviewer independently screened 5170 titles/abstracts; second reviewers screened 50%. Two reviewers independently screened full text, extracted data, and conducted risk of bias assessments. Synthesis: Cochrane's collaboration tool 2 was used to assess quality. Primarily results are synthesised narratively, a post-hoc sub-group analysis was completed on four studies using the same outcome measure. Main results: Twelve of the 5170 studies fulfilled the inclusion criteria. Studies used psychoeducational or practical skills interventions. Interventions mostly involved couple-dyads and three studies assessed PPA as a primary outcome. Included interventions were prevention-based; no treatment interventions were found. Father-only interventions consistently reported a significant reduction of PPA. Conclusions: Systematic searching yielded no treatment interventions, highlighting a substantial gap in the evidence base. Within a limited and heterogenous sample, no studies targeted diagnosed PPA. Evidence suggested father-focused interventions may be effective in preventing PPA, regardless of the intervention delivery mode or intervention content. However, consistency between study design and options within the field are lacking compared to interventions available for mothers.

Perioperative oxygen therapy: a protocol for an overview of systematic reviews and meta-analyses.

BACKGROUND: Oxygen is routinely given to patients during and after surgery. Perioperative oxygen administration has been proposed as a potential strategy to prevent and treat hypoxaemia and reduce complications, such as surgical site infections, pulmonary complications and mortality. However, uncertainty exists as to which strategies in terms of amount, delivery devices and timing are clinically effective. The aim of this overview of systematic reviews and meta-analyses is to answer the research question, 'For which types of surgery, at which stages of care, in which sub-groups of patients and delivered under what conditions are different types of perioperative oxygen therapy clinically effective?'. METHODS: We will search key electronic databases (MEDLINE, EMBASE, the Cochrane Database of Systematic Reviews, CENTRAL, Epistemonikos, PROSPERO, the INAHTA International HTA Database and DARE archives) for systematic reviews and randomised controlled trials comparing perioperative oxygen strategies. Each review will be mapped according to type of surgery, surgical pathway timepoints and clinical comparison. The highest quality reviews with the most comprehensive and up-to-date coverage of relevant literature will be chosen as anchoring reviews. Standardised data will be extracted from each chosen review, including definition of oxygen therapy, summaries of interventions and comparators, patient population, surgical characteristics and assessment of overall certainty of evidence. For clinical outcomes and adverse events, the overall pooled findings and results of subgroup and sensitivity analyses (where available) will be extracted. Trial-level data will be extracted for surgical site infections, mortality, and potential trial-level effect modifiers such as risk of bias, outcome definition and type of surgery to facilitate quantitative data analysis. This analysis will adopt a multiple indication review approach with panoramic meta-analysis using review-level data and meta-regression using trial-level data. An evidence map will be produced to summarise our findings and highlight any research gaps. DISCUSSION: There is a need to provide a panoramic overview of systematic reviews and meta-analyses describing peri-operative oxygen practice to both inform clinical practice and identify areas of ongoing uncertainty, where further research may be required. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42021272361.

Paragons, Mavericks and Innovators-A typology of orthopaedic surgeons' professional identities. A comparative case study of evidence-based practice.

Clinical guidelines, as vehicles for evidence-based practice (EBP) attempt to standardize health-care practice, reduce variation and increase quality. However, their use for surgery has been contested, and often resisted. This article examines professional responses to EBP in hip replacement surgery using data from case study observations and interviews in three English orthopaedic departments. A professional identity perspective is adopted to explain how standardization through EBP, represents an empirical phenomenon around which surgeons enact their identities as Paragons, Mavericks or Innovators, to enhance legitimacy and stratify themselves in their response to EBP. Attention is drawn to variation between Paragon surgeons working in university (teaching) hospitals and Maverick and Innovator types located in general hospitals, and the ways this interacts with adoption of EBP. The typology shows how practice variation is related to surgeons' tendencies to align to characteristic types, with distinct social processes, power and prestige, and which are in turn influenced by organizational context. The dynamics of EBP and professional identity continues to limit attempts to standardize surgical practice. The typology contributes to the understanding of failures to follow EBP, as associated with the identities individuals create and negotiate, and with identity narratives used to legitimize differing responses to EBP.

Public health intelligence challenges for local public health authorities responding to disease outbreaks: a mixed-methods systematic review protocol.

Background: Information management capacity is crucial for controlling risks from health emergencies. But little is known about how sub-national public health bodies overcome public health intelligence challenges when responding to disease outbreaks. This paper describes a protocol for a mixed-methods systematic review to fill this knowledge gap. In addition to describing the evidence base and characterising public health intelligence responses, it will explore reported facilitators and barriers to response. Methods: Research on sub-national Public Health Intelligence disease outbreak responses will be synthesised. The review will be limited to articles published in English, during or after 2019. Key electronic databases will be searched for peer-reviewed, primary research studies. Two reviewers will independently screen articles for relevance. Articles that refer to a public health intelligence response to a propagated disease outbreak by a sub-national Public Health Authority will be included. Quality assessment of included articles will be undertaken using published tools. Data integration will be by the Pillar Integration Process (PIP). Discussion: This review will describe and synthesise the recent literature on sub-national Public Health Authorities' responses to propagated disease outbreaks. The systematic design will limit bias and the inclusion of data from quantitative, qualitative and mixed-methods studies will ensure relevant evidence is considered regardless of the methodology used to produce it. The review is part of a larger research project which aims to explore the role of sub-national public health intelligence during the COVID-19 pandemic and investigate how public health intelligence preparedness could be improved in the future. This could provide information to support the development of training, preparedness indicators and/or ways of implementing directives. PROSPERO registration: CRD42022308042 (08/02/2022).

What are the information challenges for local public health services responding to an outbreak of disease? Useful information is vital for planning public health activities. This means good information management is very important during an outbreak of disease. But little is known about how local public health bodies overcome challenges in this area. Examples of challenges could include not receiving sufficient data and/or not having enough staff to analyse it. This paper describes planned research based on a review of the literature. We want to know how local public health bodies have collected, analysed and provided useful information during disease outbreaks and what makes it easier or harder for them to do this. To make the results more reliable, the review will take a structured approach. Two people will work on some stages to check each other's work. We will search databases of research articles to find any kind of study that describes information challenges for local public health organisations during a disease outbreak. Specific criteria will be used to judge which studies to include. To be included, studies must be about a disease that spreads from person-to-person, and they must have been published in or after 2019. Included studies will be summarised. Results will feed into further research on how local public health bodies could be better prepared for disease outbreaks in the future.