This article summarizes an extensive literature review addressing the question, How can we spread and sustain innovations in health service delivery and organization? It considers both content (defining and measuring the diffusion of innovation in organizations) and process (reviewing the literature in a systematic and reproducible way). This article discusses (1) a parsimonious and evidence-based model for considering the diffusion of innovations in health service organizations, (2) clear knowledge gaps where further research should be focused, and (3) a robust and transferable methodology for systematically reviewing health service policy and management. Both the model and the method should be tested more widely in a range of contexts.

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Diffusion of Innovations in Service Organizations: Systematic Review and Recommendations

OBJECTIVE — To systematically review the incidence of posttransplantation diabetes (PTD), risk factors for its development, prognostic implications, and optimal management. RESEARCH DESIGN AND METHODS — We searched databases (MEDLINE, EMBASE, the Cochrane Library, and others) from inception to September 2000, reviewed bibliographies in reports retrieved, contacted transplantation experts, and reviewed specialty journals. Two reviewers independently determined report inclusion (original studies, in all languages, of PTD in adults with no history of diabetes before transplantation), assessed study methods, and extracted data using a standardized form. Meta-regression was used to explain between-study differences in incidence. RESULTS — Nineteen studies with 3,611 patients were included. The 12-month cumulative incidence of PTD is lower (10% in most studies) than it was 3 decades ago. The type of immunosuppression explained 74% of the variability in incidence (P 0.0004). Risk factors were patient age, nonwhite ethnicity, glucocorticoid treatment for rejection, and immunosuppression with high-dose cyclosporine and tacrolimus. PTD was associated with decreased graft and patient survival in earlier studies; later studies showed improved outcomes. Randomized trials of treatment regimens have not been conducted. CONCLUSIONS — Physicians should consider modification of immunosuppressive regimens to decrease the risk of PTD in high-risk transplant recipients. Randomized trials are needed to evaluate the use of oral glucose-lowering agents in transplant recipients, paying particular attention to interactions with immunosuppressive drugs. Diabetes Care 25:583–592, 2002

A systematic review of the literature

Imprecise definition of key terms in the “public participation” domain have hindered the conduct of good research and militated against the development and implementation of effective participation practices. In this article, we define key concepts in the domain: public communication, public consultation, and public participation. These concepts are differentiated according to the nature and flow of information between exercise sponsors and participants. According to such an information flow perspective, an exercise’s effectiveness may be ascertained by the efficiency with which full, relevant information is elicited from all appropriate sources, transferred to (and processed by) all appropriate recipients, and combined(when required) to give an aggregate/consensual response. Key variables that may theoretically affect effectiveness—and on which engagement mechanisms differ—are identified and used to develop a typology of mechanisms. The resultant typology reveals four communication, six consultation, and...

http://ccvq.org/documents/vie-du-quartier/st-ls-gz/etudes/Rowe&Frewer(2005).pdf

A typology of public engagement mechanisms

The view is widely held that experimental methods (randomised controlled trials) are the “gold standard” for evaluation and that observational methods (cohort and case control studies) have little or no value. This ignores the limitations of randomised trials, which may prove unnecessary, inappropriate, impossible, or inadequate. Many of the problems of conducting randomised trials could often, in theory, be overcome, but the practical implications for researchers and funding bodies mean that this is often not possible. The false conflict between those who advocate randomised trials in all situations and those who believe observational data provide sufficient evidence needs to be replaced with mutual recognition of the complementary roles of the two approaches. Researchers should be united in their quest for scientific rigour in evaluation, regardless of the method used.

Despite the essential role of observational methods in shedding light on the effectiveness of many aspects of health care, some scientists believe such methods have little or even nothing to contribute. In his summing up at a major conference held in 1993, the eminent medical epidemiologist Richard Doll concluded that observational methods “provide no useful means of assessing the value of a therapy.”1 The widely held view that experimental methods (randomised controlled trials) are the “gold standard” for evaluation has led to the denigration of non-experimental methods, to the extent that research funding bodies and journal editors automatically reject them. I suggest that such attitudes limit our potential to evaluate health care and hence to improve the scientific basis of how to treat individuals and how to organise services.

My main contention is that those who are opposed to the use of observational methods have assumed that they represent an alternative to experimentation rather than a set of complementary approaches. This in turn stems from a misguided notion that everything …

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Why we need observational studies to evaluate the effectiveness of health care

Objective: To determine whether nurse practitioners can provide care at first point of contact equivalent to doctors in a primary care setting. Design: Systematic review of randomised controlled trials and prospective observational studies. Data sources: Cochrane controlled trials register, specialist register of trials maintained by Cochrane Effective Practice and Organisation of Care Group, Medline, Embase, CINAHL, science citation index, database of abstracts of reviews of effectiveness, national research register, hand searches, and published bibliographies. Included studies: Randomised controlled trials and prospective observational studies comparing nurse practitioners and doctors providing care at first point of contact for patients with undifferentiated health problems in a primary care setting and providing data on one or more of the following outcomes: patient satisfaction, health status, costs, and process of care. Results: 11 trials and 23 observational studies met all the inclusion criteria. Patients were more satisfied with care by a nurse practitioner (standardised mean difference 0.27, 95% confidence interval 0.07 to 0.47). No differences in health status were found. Nurse practitioners had longer consultations (weighted mean difference 3.67 minutes, 2.05 to 5.29) and made more investigations (odds ratio 1.22, 1.02 to 1.46) than did doctors. No differences were found in prescriptions, return consultations, or referrals. Quality of care was in some ways better for nurse practitioner consultations. Conclusion: Increasing availability of nurse practitioners in primary care is likely to lead to high levels of patient satisfaction and high quality care. What is already known on this topic Nurse practitioners have existed in North America for many years An increasing number of such nurses are being employed in the United Kingdom in general practice, emergency departments, and other primary care settings Reviews suggest that nurse practitioners are equivalent to doctors on most variables studied, but the relevance of this in the context of the NHS is unclear What this study adds Patients are more satisfied with care from a nurse practitioner than from a doctor, with no difference in health outcomes Nurse practitioners provide longer consultations and carry out more investigations than doctors Most recent research has related to patients requesting same day appointments for minor illness, which is only a limited part of a doctor9s role

https://www.bmj.com/content/bmj/324/7341/819.full.pdf

Systematic review of whether nurse practitioners working in primary care can provide equivalent care to doctors

Rightly ambitious, but can the NHS deliver?

https://www.bmj.com/content/bmj/364/bmj.l84.full.pdf

The NHS long term plan

News p 317 

This is probably as good as it gets: a significant injection of money for the NHS sustained over five years1 coupled with a comprehensive national plan for the NHS, announced last week.2 The plan is true to the NHS's founding principles and has been drawn up by all the NHS's major stakeholders—who have signed up to help make it a reality.2 The plan is impressive in scope and clearly reflects messages coming from staff and the public in the recent public consultation exercise3—from “bring back matron,” to improving hospital food, to reducing micro-management of the service from Whitehall. It is a plan for the medium, not the short, term.

Four headlines stand out: capacity; standards and targets; delivery; partnership. Years of lower growth in expenditure compared with other European countries have left the NHS looking worthy but relatively clapped out. The single most important part of the NHS plan is the cash injection to boost capacity: 7500 more consultants; 2000 more general practitioners, 20 000 more nurses; 7000 more beds (particularly to boost intermediate care), investment in NHS facilities—the list goes on. To anyone who has worked in frontline care, this is manna (leaving aside for the moment questions of how and when). The disappointment for many was …

https://www.bmj.com/content/bmj/321/7257/315.full.pdf

The NHS plan.

The NHS needs to be clear about the aims and how to achieve them 

The government is promoting public involvement in health care as part of new NHS policy.1 2 Proposals include allowing the public to elect members of the governing boards of foundation trusts3 and primary care trusts' obligations to engage with the public.4 However, clarity and consensus are lacking about what public involvement means in health care, why it is desirable, and whether current policies will meet the desired objectives. We examine the latest polices and their potential effects.

Public involvement and other allied terms are used to mean a variety of activities or objectives. In this article we use public involvement to refer to the involvement of members of the public in strategic decisions about health services and policy at local or national level—for instance, about the configuration of services or setting priorities. Public involvement is different from patient involvement, which refers to the involvement of individual patients, together with health professionals, in making decisions about their own health care. Clearly, a spectrum of possible involvement of patients and the public exists between these two extremes. For example, user involvement may refer to a group of patients helping to shape a particular service. Arnstein defined another spectrum of public involvement, ranging from professionals giving information to the public to a genuine hand over of power and decision making to the public.5

Advocates of increased public involvement argue that public services are paid for by the people and therefore should be shaped more extensively by them, preferably by a fully representative sample.6 One assumption made is that greater public involvement will lead to more democratic decision making and, in turn, better accountability, but, as we discuss below, neither is necessarily the case. A …

https://www.bmj.com/content/bmj/328/7432/159.full.pdf

Public involvement in health care

Background The aim of the study was to assess the reproducibility of clinical coding in two National Health Service hospitals within North West Thames region Methods A retrospective audit was carried out, of clinical coding in hospital episode statistics, involving comparison of the codes assigned by local staff with those assigned by members of an external team unaware of the locally assigned codes Where local and external coders disagreed, the records were reviewed for a third time by a further independent coder The subjects were a random sample of 1607 non-maternity, non-psychiatric admissions occurring between 1991 and 1993, stratified for year and type of disease (asthma, diabetes, appendicitis, fractured femur and 'general' - a random selection of any diagnoses) The main outcome measures were the levels of exact agreement between local and external teams over codes for main diagnosis and procedure, and the level of approximate agreement (over the first three characters of the ICD-9 code for diagnosis and the letter and first two digits of the OPCS-4 code for procedure) For disagreements, the outcome measure was the level of agreement between the 'third' coder and the local and external coders Results For the main diagnosis in the 'general' group at

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Assessment of the reproducibility of clinical coding in routinely collected hospital activity data : a study in two hospitals

Recent organisational changes to the NHS are bound to affect the care of patients with chronic diseases. But will they help or hinder?

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Jennifer Dixon

Papers

The NHS long term plan

The NHS plan.

Public involvement in health care

Assessment of the reproducibility of clinical coding in routinely collected hospital activity data : a study in two hospitals

Rethinking management of chronic diseases.