Monthly Archives: December 2016

Is Social Media a Reliable Way to Assess Research Output?

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Valeria Scotti, Annalisa De Silvestri, Luigia Scudeller, Paola Abele, Funda Topuz and Moreno Curti have published a paper titled ‘Novel bibliometric scores for evaluating research quality and output: a correlation study with established indexes‘ in the International Journal of Biological Markers under a creative commons license.

Traditionally the impact of research has been evaluated using the impact factor of the journal in which the research is published and also the h-index.

The researchers in this Italian study wanted to see if the Altmetrics score, a measure of social media interest in a research article correlated with one of the more traditional measures.

The primary question was answered by looking at departments within their hospital. The researchers looked at the research output of each department, summed the Altmetrics scores and the impact factors of the Journals and used these as data points. The researchers then assessed the correlation using the Spearman’s Rho, which is a measure of the relationship between two variables.

They found that the sum of the impact factors was highly correlated with sum of the Altmetrics scores (‘Spearman’s rho 0.88; p<0.0001’).

The researchers also looked at individual social media components of the Altmetrics score and found some similarly interesting results although this is a secondary analysis.

The researchers have provided evidence of the utility of the Almetrics score in a clinical setting.

On a slightly separate note, Altmetrics.com recently published the top 100 Altmetrics scores for 2016 and it contains a very interesting set of research publications.

Index: There are indices for the TAWOP site here and here

Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link.

TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link.

Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk.

Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Whatever Happened to the 7 Pillars of Clinical Governance?

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Picture by Rama distributed under a Creative Commons SA 2.0 License

Clinical governance is a process by which the quality of clinical practice can be assessed and improved. There are of course other definitions but the crux of clinical governance is that we look at a systematic process to improve what we do. Clinical governance sometimes gets confused with corporate governance but the two are distinct.

Many years ago, the seven pillars of clinical governance were espoused without question. From my perspective they have been an invaluable tool in supporting improvements in clinical practice. In some senses I would view clinical governance as the ‘engine of clinical practice’.

There is only one problem. The seven pillars of clinical practice have almost disappeared without a trace. As if they never existed. I looked online recently thinking it would be a straightforward matter to find the source material for the ‘7 pillars’. There were traces of the ‘7 pillars’ in online revision sites as well as tangential references in policy documents but the source material was not immediately forthcoming.

A clinical governance article by Scally and Donaldson has been quite influential but a cursory examination reveals no reference specifically to the ‘7 pillars’.

In the end, it was the internet equivalent of archaeology that came to the rescue. There are various archives which store parts of the internet in case it is lost or changes with the passage of time. Here is what I found.

clinicalgovernancearchives

I began to recollect events. There was an NHS Clinical Governance Support Team. Then it disbanded.

cgstclosure

The documentation states that the functions will be taken over by the Strategic Health Authorities (SHA). Like the CGST, the SHA’s are now historical structures.

Looking through the archived documentation, it is clear that the seven pillars went through one more iteration before the closure of the CGST. They had now become an umbrella encompassing ten strands.

cgumbrella

So there we have it. Policy became myth and myth became legend.

Although the story doesn’t quite end there…….

There is a much older reference to the seven pillars of clinical governance in a relatively obscure article by the remarkable Professor Avedis Donabedian. I hope I am not overstating the case when I refer to Donabedian as a ‘healthcare genius’ with a profound knowledge of healthcare systems and a philosopher-like approach to the fundamental healthcare questions. I would venture that there are very few people that would fully understand Donabedian’s considerable body of work that he developed on moving to America. To paraphrase…

Would the Real Clinical Governance Please Step Forward?

The article from 1993 is titled ‘Quality in Healthcare: Whose responsibility is it?’ in the journal ‘American College of Medical Quality’ and is freely accessible here.

Donabedian refers to two elements in healthcare – (1) healthcare science and technology and (2) The application of the healthcare science and technology.

From the interaction between these two elements, he identifies seven attributes.

(1) Efficacy

(2) Effectiveness

(3) Efficiency

(4) Optimality

(5) Acceptability

(6) Legitimacy

(7) Equity

While some of the terms may not be so obvious in their contextual meaning, Donabedian clarifies these terms with definitions. For instance:-

Acceptability: ‘Conformity to the wishes, desires and expectations of patients and responsible members of their families‘.

The quote above offers a firm foundation for the construct of patient and public involvement. Donabedian developed the concept of pillars in earlier works in the 80’s.

Clinical governance moves forwards in a more decentralised way in the UK. There are heavyweight organisations involved for instance in research that push forwards aspects of the clinical governance agenda.

However I am reminded of the Antikythera mechanism. This was a device found on the seafloor by the island of Antikythera by divers after 2000 years. The device has a possible link to Archimedes. The point is that when it was lost, so too was the knowledge associated with it. The Antikythera mechanism has features including a differential gear mechanism which were to be ‘rediscovered’ some 2000 years later.

The moral of the story is that great works with the potential to benefit society can be lost and forgotten about without a concerted effort to carry them forwards in some way.

I’m left puzzled by the various gaps in the narrative.

  • How did we get from Donabedian to the NHS 7 pillars of clinical governance?
  • How was the work of the CGST taken forwards?
  • Is there comparative evidence for national versus decentralised Clinical Governance systems?

Whatever the answers to these questions, there is one more quote from Donabedian about clinical governance and the wisdom he developed over a lifetime of work.

Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love

Index: There are indices for the TAWOP site here and here

Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link.

TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link.

Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk.

Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Involving Patients in Pharmaceutical Development (Updated 1.1.17)

Attorney Neela Carlton gives an interesting TEDx talk about involving patients in pharmaceutical development. The talk is in the context of the American healthcare system although the principles are generalisable. Here in the UK, patient and public involvement in research has developed over time (the UK Health Research Authority discusses patient and public involvement in more detail here). In the UK, INVOLVE is part of the National Institute for Health Research ‘to support active public involvement in NHS, public health and social care research’.

Patient and public involvement has long been a feature of ‘clinical governance’ originally as one of the ‘7 Pillars of Clinical Governance’ and later under the ‘umbrella‘ of themes and components. The talk above therefore fits into this wider but often understated discussion about clinical governance.

Index: There are indices for the TAWOP site here and here

Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link.

TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link.

Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk.

Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Conflicts of Interest: *For potential conflicts of interest please see the About section.

Risk Factors for Delirium After Orthopaedic Surgery

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Picture created by Bruce Blaus under a Creative Commons 4.0 License

Li-Hong Wang, Dong-Juan Xu, Xian-Jiao Wei, Hao-Teng Chang and Guo-Hong Xu have published a paper titled ‘Electrolyte disorders and aging: risk factors for delirium in patients undergoing orthopedic surgeries’ under a Creative Commons 4.0 license.

The researchers note that

In different hospital units, the incidence of delirium varied from 10% in emergency departments … to 70% in intensive care units

  • The researchers undertook a retrospective study of casenotes including people who had received a DSM-IV diagnosis from an attending Psychiatrist and comparing them with a control group without Delirium. The study took place in Dongyang, China.
  • The exclusion criteria were Dementia, mental illness, use of psychiatric medication, severe hearing or visual impairment, emergency or bilateral surgery and stroke.
  • The researchers utilised a range of outcome measures including electrolytes, haemoglobin and albumin. They compared the Delirium and non-Delirium groups with the student t-test, univariate and multivariate logistic regression.
  • Age and electrolyte disturbances were the factors which were correlated with an increased risk of Delirium post-operatively.
  • The odds ratio for Delirium post-operatively compared to those under the age of 70,  was 6.328 for those aged 70-79 (95% CI 1.350-29.667) and for those aged 80 or over it was 26.371 (95% CI 5.415-128.416). The upper limit of 128 for the odds ratio in the latter group should be noted.
  • The odds ratio for Delirium in those with electrolytes compared with those without was 2.376 (95% CI 1.157-4.879). Electrolyte disturbances were hypocalcaemia and hyponatraemia with the exception of 2 cases of hypernatraemia.

The researchers have identified three main risk factors for post-operative delirium with 4 orthopaedic operations – age, hypocalcaemia and hyponatraemia. Hyponatraemia and age as risk factors are particularly well described in the literature and this study reinforces these findings. Hypocalcaemia has also been described as a risk factor (e.g. this study).The researchers have identified the limitations in the study but provided useful data in terms of the odds ratios for comparison with other studies.

Index: There are indices for the TAWOP site here and here

Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link.

TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link.

Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk.

Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Conflicts of Interest: *For potential conflicts of interest please see the About section.

How Many Databases Are Needed for a Systematic Review or Meta-analysis?

reviewbysvklimkin

Researchers Adjunct Professor Lisa Hartling, Robin Featherstone, Megan Nuspl, Kassi Shave, Dr Donna M. Dryden and Ben Vandermeer have published a freely accessible paper ‘The contribution of databases to the results of systematic reviews: a cross-sectional study’ under a Creative Commons 4.0 license in BMC Medical Research Methodology. The research team was interested in how many databases should be utilised for a comprehensive literature review.

One of the hallmarks of a well-conducted SR is a thorough, objective and reproducible search of a range of sources to identify as many relevant studies as possible, to minimize bias and assist in achieving reliable estimates of effects

They reference current guidelines:-

Methodological standards for the conduct of new Cochrane interventions require searches of CENTRAL, Medline and Embase, and reviewers are encouraged to consider subject specific databases (e.g. CINAHL for nursing related topics, or PsycINFO for psychological interventions) and regional databases (e.g. LILACS)

and identify an important gap on the evidence behind the review process itself

One important gap is the modest amount of empirical evidence demonstrating the impact on results and conclusions from different approaches to searching………While methodological guidance for SRs encourages comprehensive searching, there are diminishing returns with each additional database searched ….and the impact of searching each additional database in terms of the final results and conclusions is not known‘.

The research team looked to answer this question by identifying relevant databases and examining published meta-analyses to see if changing the databases accessed would impact on the results:-

To determine our set of databases for investigation we sampled 50 reviews conducted by three Cochrane review groups (ARI, DPLP and Airways) and developed a preliminary list of 108 information sources……The remaining information sources were reviewed by our research librarian (RF) and a second author (DMD). We selected the ten databases as those most likely to be searched in SRs of healthcare interventions‘.

Three research areas were selected by the researchers:-

The researchers focused on 3 key subject areas for meta-analyses – Acute Respiratory Infections (ARI; n = 57), Infectious Diseases (ID; n = 38), and Development, Psychosocial and Learning Problems (DPLP; n = 34)

The researchers found that there were three combinations of databases (Medline + Embase for ARI, Medline + Psychinfo for DPLP and Medline, Embase and BIOSIS for ID) that identified most of the papers in meta-analyses and that exclusion of the other databases did not on the whole significantly change the results:-

For ID, yield was highest for Medline (92 %), Embase (81 %), and BIOSIS (67 %). Restricting meta-analyses to trials that appeared in Medline + BIOSIS yielded fewest changes with 1 meta-analysis changing in statistical significance. Point estimates changed in 8 of 31 meta-analyses; change less than 20 % in all cases. For DPLP, identification of relevant studies was highest for Medline (75 %) and Embase (62 %). Restricting meta-analyses to trials that appeared in Medline + PsycINFO resulted in only one change in significance. Point estimates changed for 13 of 33 meta-analyses; less than 20 % in 9 cases

The researchers have challenged an intuitive assertion that comprehensive literature reviews should include as many database sources as possible. Given the trade-off between resources and comprehensive searches, this is a valuable addition to the literature and it will be interesting to see how this impacts on future guidelines for meta-analyses and systematic reviews.

Index: There are indices for the TAWOP site here and here

Twitter: You can follow ‘The Amazing World of Psychiatry’ Twitter by clicking on this link.

TAWOP Channel: You can follow the TAWOP Channel on YouTube by clicking on this link.

Responses: If you have any comments, you can leave them below or alternatively e-mail justinmarley17@yahoo.co.uk.

Disclaimer: The comments made here represent the opinions of the author and do not represent the profession or any body/organisation. The comments made here are not meant as a source of medical advice and those seeking medical advice are advised to consult with their own doctor. The author is not responsible for the contents of any external sites that are linked to in this blog.

Conflicts of Interest: *For potential conflicts of interest please see the About section.