The Leeds University Maternity Audit Project

ENhancinG vAGinal dElivery in Greece through educational and behavioral interventions among maternity care providers regarding labor management: the ENGAGE stepped-wedge randomized prospective trial protocol

BACKGROUND

There is an emerging need to systematically investigate the causes for the increased cesarean section rates in Greece and undertake interventions so as to substantially reduce its rates. To this end, the ability of the participating Greek obstetricians to follow evidence-based guidelines and respond to other educational and behavioral interventions while managing labor will be explored, along with barriers and enablers. Herein discussed is the protocol of a stepped-wedge designed intervention trial in Greek maternity units with the aforementioned goals in mind, named ENGAGE (ENhancinG vAGinal dElivery in Greece).

METHODS

Twenty-two selected maternity units in Greece will participate in a multicenter stepped-wedge randomized prospective trial involving 20,000 to 25,000 births, with two of them entering the intervention period of the study each month (stepped randomization). The maternity care units entering the study will apply the suggested interventions for a period of 8-18 months depending on the time they enter the intervention stage of the study. There will also be an initial phase of the study lasting from 8 to 18 months including observation and recording of the routine practice (cesarean section, vaginal birth, and maternal and perinatal morbidity and mortality) in the participating units. The second phase, the intervention period, will include such interventions as the application of the HSOG (the Hellenic Society of Obstetrics and Gynecology) Guidelines on labor management, training on the correct interpretation of cardiotocography, and dealing with emergencies in vaginal deliveries, while the steering committee members will be available to discuss and implement organizational and behavioral changes, answer questions, clarify relevant issues, and provide practical instructions to the participating healthcare professionals during regular visits or video conferences. Furthermore, during the study, the results will be available for the participating units in order for them to monitor their own performance while also receiving feedback regarding their rates. Τhe final 2-month phase of the study will be devoted to completing follow-up questionnaires with data concerning maternal and neonatal morbidities that occurred after the completion of the intervention period. The total duration of the study is estimated at 28 months. The primary outcome assessed will be the cesarean section rate change and the secondary outcomes will be maternal and neonatal morbidity and mortality.

DISCUSSION

The study is expected to yield new information on the effects, advantages, possibilities, and challenges of consistent clinical engagement and implementation of behavioral, educational, and organizational interventions described in detail in the protocol on cesarean section practice in Greece. The results may lead to new insights into means of improving the quality of maternal and neonatal care, particularly since this represents a shared effort to reduce the high cesarean section rates in Greece and, moreover, points the way to their reduction in other countries.

TRIAL REGISTRATION

NCT04504500 (ClinicalTrials.gov). The trial was prospectively registered. Ethics Reference No: 320/23.6.2020, Bioethics and Conduct Committee, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.

Factors influencing appropriate use of interventions for management of women experiencing preterm birth: A mixed-methods systematic review and narrative synthesis

BACKGROUND

Preterm birth-related complications are the leading cause of death in newborns and children under 5. Health outcomes of preterm newborns can be improved with appropriate use of antenatal corticosteroids (ACSs) to promote fetal lung maturity, tocolytics to delay birth, magnesium sulphate for fetal neuroprotection, and antibiotics for preterm prelabour rupture of membranes. However, there are wide disparities in the rate and consistency in the use of these interventions across settings, which may underlie the differential health outcomes among preterm newborns. We aimed to assess factors (barriers and facilitators) affecting the appropriate use of ACS, tocolytics, magnesium sulphate, and antibiotics to improve preterm birth management.

METHODS AND FINDINGS

We conducted a mixed-methods systematic review including primary qualitative, quantitative, and mixed-methods studies. We searched MEDLINE, EMBASE, CINAHL, Global Health, and grey literature from inception to 16 May 2022. Eligible studies explored perspectives of women, partners, or community members who experienced preterm birth or were at risk of preterm birth and/or received any of the 4 interventions, health workers providing maternity and newborn care, and other stakeholders involved in maternal care (e.g., facility managers, policymakers). We used an iterative narrative synthesis approach to analysis, assessed methodological limitations using the Mixed Methods Appraisal Tool, and assessed confidence in each qualitative review finding using the GRADE-CERQual approach. Behaviour change models (Theoretical Domains Framework; Capability, Opportunity, and Motivation (COM-B)) were used to map barriers and facilitators affecting appropriate use of these interventions. We included 46 studies from 32 countries, describing factors affecting use of ACS (32/46 studies), tocolytics (13/46 studies), magnesium sulphate (9/46 studies), and antibiotics (5/46 studies). We identified a range of barriers influencing appropriate use of the 4 interventions globally, which include the following: inaccurate gestational age assessment, inconsistent guidelines, varied knowledge, perceived risks and benefits, perceived uncertainties and constraints in administration, confusion around prescribing and administering authority, and inadequate stock, human resources, and labour and newborn care. Women reported hesitancy in accepting interventions, as they typically learned about them during emergencies. Most included studies were from high-income countries (37/46 studies), which may affect the transferability of these findings to low- or middle-income settings.

CONCLUSIONS

In this study, we identified critical factors affecting implementation of 4 interventions to improve preterm birth management globally. Policymakers and implementers can consider these barriers and facilitators when formulating policies and planning implementation or scale-up of these interventions. Study findings can inform clinical preterm birth guidelines and implementation to ensure that barriers are addressed, and enablers are reinforced to ensure these interventions are widely available and appropriately used globally.

Women's, partners' and healthcare providers' views and experiences of assisted vaginal birth: a systematic mixed methods review

BACKGROUND

When certain complications arise during the second stage of labour, assisted vaginal delivery (AVD), a vaginal birth with forceps or vacuum extractor, can effectively improve outcomes by ending prolonged labour or by ensuring rapid birth in response to maternal or fetal compromise. In recent decades, the use of AVD has decreased in many settings in favour of caesarean section (CS). This review aimed to improve understanding of experiences, barriers and facilitators for AVD use.

METHODS

Systematic searches of eight databases using predefined search terms to identify studies reporting views and experiences of maternity service users, their partners, health care providers, policymakers, and funders in relation to AVD. Relevant studies were assessed for methodological quality. Qualitative findings were synthesised using a meta-ethnographic approach. Confidence in review findings was assessed using GRADE CERQual. Findings from quantitative studies were synthesised narratively and assessed using an adaptation of CERQual. Qualitative and quantitative review findings were triangulated using a convergence coding matrix.

RESULTS

Forty-two studies (published 1985-2019) were included: six qualitative, one mixed-method and 35 quantitative. Thirty-five were from high-income countries, and seven from LMIC settings. Confidence in the findings was moderate or low. Spontaneous vaginal birth was most likely to be associated with positive short and long-term outcomes, and emergency CS least likely. Views and experiences of AVD tended to fall somewhere between these two extremes. Where indicated, AVD can be an effective, acceptable alternative to caesarean section. There was agreement or partial agreement across qualitative studies and surveys that the experience of AVD is impacted by the unexpected nature of events and, particularly in high-income settings, unmet expectations. Positive relationships, good communication, involvement in decision-making, and (believing in) the reason for intervention were important mediators of birth experience. Professional attitudes and skills (development) were simultaneously barriers and facilitators of AVD in quantitative studies.

CONCLUSIONS

Information, positive interaction and communication with providers and respectful care are facilitators for acceptance of AVD. Barriers include lack of training and skills for decision-making and use of instruments.

Clinical trials registries are underused in the pregnancy and childbirth literature: a systematic review of the top 20 journals

Background

Systematic reviews and meta-analyses that do not include unpublished data in their analyses may be prone to publication bias, which in some cases has been shown to have deleterious consequences on determining the efficacy of interventions.

Methods

We retrieved systematic reviews and meta-analyses published in the past 8 years (January 1, 2007–December 31, 2015) from the top 20 journals in the Pregnancy and Childbirth literature, as rated by Google Scholar’s h5-index. A meta-epidemiologic analysis was performed to determine the frequency with which authors searched clinical trials registries for unpublished data.

Results

A PubMed search retrieved 372 citations, 297 of which were deemed to be either a systematic review or a meta-analysis and were included for analysis. Twelve (4 %) of these searched at least one WHO-approved clinical trials registry or clinicaltrials.gov.

Conclusion

Systematic reviews and meta-analyses published in pregnancy and childbirth journals do not routinely report searches of clinical trials registries. Including these registries in systematic reviews may be a promising avenue to limit publication bias if registry searches locate unpublished trial data that could be used in the systematic review.

A prospective audit of the adherence to a new magnesium sulphate guideline for the neuroprotection of infants born less than 30 weeks' gestation

Antenatal magnesium sulphate reduces the risk of cerebral palsy in babies born <30 weeks' gestation. A guideline for its use in women at imminent risk of preterm birth was implemented at National Women's Health, Auckland City Hospital in 2012. This prospective audit assessed adherence to the guideline in women delivering at <30 weeks in the first year after its implementation. Magnesium sulphate was safely administered to 58 of 71 (82%) eligible women and 58 of 61 (95%) of women where it was clinically appropriate and practically achievable.

Evidence-based organization and patient safety strategies in European hospitals

OBJECTIVE

To explore how European hospitals have implemented patient safety strategies (PSS) and evidence-based organization of care pathway (EBOP) recommendations and examine the extent to which implementation varies between countries and hospitals.

DESIGN

Mixed-method multilevel cross-sectional design in seven countries as part of the European Union-funded project 'Deepening our Understanding of Quality improvement in Europe' (DUQuE).

SETTING AND PARTICIPANTS

Seventy-four acute care hospitals with 292 departments managing acute myocardial infarction (AMI), hip fracture, stroke, and obstetric deliveries. Main outcome measure Five multi-item composite measures-one generic measure for PSS and four pathway-specific measures for EBOP.

RESULTS

Potassium chloride had only been removed from general medication stocks in 9.4-30.5% of different pathways wards and patients were adequately identified with wristband in 43.0-59.7%. Although 86.3% of areas treating AMI patients had immediate access to a specialist physician, only 56.0% had arrangements for patients to receive thrombolysis within 30 min of arrival at the hospital. A substantial amount of the total variance observed was due to between-hospital differences in the same country for PSS (65.9%). In EBOP, between-country differences play also an important role (10.1% in AMI to 57.1% in hip fracture).

CONCLUSIONS

There were substantial gaps between evidence and practice of PSS and EBOP in a sample of European hospitals and variations due to country differences are more important in EBOP than in PSS, but less important than within-country variations. Agencies supporting the implementation of PSS and EBOP should closely re-examine the effectiveness of their current strategies.

Clinical audit: a useful tool for reducing severe postpartum haemorrhages?

OBJECTIVE

Reducing the rate of severe postpartum haemorrhage (PPH) is a major challenge in obstetrics today. One potentially effective tool for improving the quality of care is the clinical audit, that is, peer evaluation and comparison of actual practices against explicit criteria. Our objective was to assess the impact of regular criteria-based audits on the prevalence of severe PPH.

DESIGN

Quasi-experimental before-and-after survey.

SETTING

Two French maternity units in the Rhône-Alpes region, with different organization of care.

PARTICIPANTS

All staff of both units.

INTERVENTION

Quarterly clinical audit meetings at which a team of reviewers analysed all cases of severe PPH and provided feedback on quality of care and where all staff actively participated.

MAIN OUTCOME MEASURES

The primary outcome was the prevalence of severe PPH. Secondary outcomes included the global quality of care for women with severe PPH, including the performance rate for each recommended procedure. Differences in these variables between 2005 and 2008 were tested.

RESULTS

The prevalence of severe PPH declined significantly in both units, from 1.52 to 0.96% of deliveries in the level III hospital (P = 0.048) and from 2.08 to 0.57% in the level II hospital (P < 0.001). From 2005 to 2008, the proportion of deliveries with severe PPH that was managed consistently with the guidelines increased for all of its main components, in both units.

CONCLUSION

Regular clinical audits of cases severe PPH were associated with a persistent reduction in the prevalence of severe PPH.

Patient safety: a literature review to inform an evaluation of a maternity service

This literature review summarises the history of patient safety initiatives in health-care systems around the world. The need to improve patient safety is commonly called for following interrogation of data captured as a measure of patient safety including audit, clinical indicator reporting and evaluation methods. Many such reports exist for maternity services. Recommendations for improvement identified after review may be taken up, but there is little in the literature that demonstrates how clinicians consider such recommendations, implement improvement strategies and assess their impact. The authors of this paper concur with other authors who call for more research in this regard.

Who needs what from a national health research system: lessons from reforms to the English Department of Health's R&D system

Health research systems consist of diverse groups who have some role in health research, but the boundaries around such a system are not clear-cut. To explore what various stakeholders need we reviewed the literature including that on the history of English health R&D reforms, and we also applied some relevant conceptual frameworks.We first describe the needs and capabilities of the main groups of stakeholders in health research systems, and explain key features of policymaking systems within which these stakeholders operate in the UK. The five groups are policymakers (and health care managers), health professionals, patients and the general public, industry, and researchers. As individuals and as organisations they have a range of needs from the health research system, but should also develop specific capabilities in order to contribute effectively to the system and benefit from it.Second, we discuss key phases of reform in the development of the English health research system over four decades - especially that of the English Department of Health's R&D system - and identify how far legitimate demands of key stakeholder interests were addressed.Third, in drawing lessons we highlight points emerging from contemporary reports, but also attempt to identify issues through application of relevant conceptual frameworks. The main lessons are: the importance of comprehensively addressing the diverse needs of various interacting institutions and stakeholders; the desirability of developing facilitating mechanisms at interfaces between the health research system and its various stakeholders; and the importance of additional money in being able to expand the scope of the health research system whilst maintaining support for basic science.We conclude that the latest health R&D strategy in England builds on recent progress and tackles acknowledged weaknesses. The strategy goes a considerable way to identifying and more effectively meeting the needs of key groups such as medical academics, patients and industry, and has been remarkably successful in increasing the funding for health research. There are still areas that might benefit from further recognition and resourcing, but the lessons identified, and progress made by the reforms are relevant for the design and coordination of national health research systems beyond England.

Setting up An Acute Stroke Service

The administration of intravenous thrombolytic therapy to appropriate patients and the provision of care in a dedicated stroke unit setting form the pillars of evidence-based acute stroke care. Yet, the availability of these interventions remains variable around the world. Many challenges exist for physicians attempting to set up an acute stroke service for the first time. Based upon their experience in three countries, the authors propose 12 key steps in setting up a successful acute stroke service: identify the building blocks understand local funding mechanisms forge partnerships engage senior managers obtain training be inclusive adapt to local surroundings maintain a clinical focus be incremental capitalise on the enthusiasm of others lead from the front; and provide feedback.

The authors then examine some of the specific barriers that may be encountered and offer three historical examples of evidence-based interventions that were slow to be adopted. An acute stroke service is evidence-based and cost effective, yet the ability of patients to access such a service is variable, even in the developed world. By considering 12 common-sense steps, physicians and managers can maximise their chances of setting up a sustainable and successful acute stroke service.

Lessons from the evaluation of the UK's NHS R&D implementation methods programme

Background

Concern about the effective use of research was a major factor behind the creation of the NHS R&D Programme in 1991. In 1994, an advisory group was established to identify research priorities in research implementation. The Implementation Methods Programme (IMP) flowed from this, and its commissioning group funded 36 projects. In 2000 responsibility for the programme passed to the National Co-ordinating Centre for NHS Service Delivery and Organisation R&D, which asked the Health Economics Research Group (HERG), Brunel University, to conduct an evaluation in 2002. By then most projects had been completed. This evaluation was intended to cover: the quality of outputs, lessons to be learnt about the communication strategy and the commissioning process, and the benefits from the projects.

Methods

We adopted a wide range of quantitative and qualitative methods. They included: documentary analysis, interviews with key actors, questionnaires to the funded lead researchers, questionnaires to potential users, and desk analysis.

Results

Quantitative assessment of outputs and dissemination revealed that the IMP funded useful research projects, some of which had considerable impact against the various categories in the HERG payback model, such as publications, further research, research training, impact on health policy, and clinical practice.

Qualitative findings from interviews with advisory and commissioning group members indicated that when the IMP was established, implementation research was a relatively unexplored field. This was reflected in the understanding brought to their roles by members of the advisory and commissioning groups, in the way priorities for research were chosen and developed, and in how the research projects were commissioned. The ideological and methodological debates associated with these decisions have continued among those working in this field. The need for an effective communication strategy for the programme as a whole was particularly important. However, such a strategy was never developed, making it difficult to establish the general influence of the IMP as a programme.

Conclusion

Our findings about the impact of the work funded, and the difficulties faced by those developing the IMP, have implications for the development of strategic programmes of research in general, as well as for the development of more effective research in this field.

Cluster randomised trial of an active, multifaceted educational intervention based on the WHO Reproductive Health Library to improve obstetric practices

OBJECTIVE

We conducted a trial to evaluate the effect of an active, multifaceted educational strategy to promote the use of the WHO Reproductive Health Library (RHL) on obstetric practices.

DESIGN

Cluster randomised trial. The trial was assigned the International Standardised Randomised Controlled Trial Number ISRCTN14055385.

SETTINGS

Twenty-two hospitals in Mexico City and 18 in the Northeast region of Thailand.

METHODS

The intervention consisted primarily of three interactive workshops using RHL over a period of 6 months. The focus of the workshops was to provide access to knowledge and enable its use. A computer and support for using both the computer and RHL were provided at each hospital. The control hospitals did not receive any intervention.

MAIN OUTCOME MEASURES

The main outcome measures were changes in ten selected clinical practices as recommended in RHL starting approximately four to six months after the third workshop. Clinical practice data were collected at each hospital from 1000 consecutively delivered women or for a 6-month period whichever was reached sooner.

RESULTS

The active, multifaceted educational intervention we employed did not affect the ten targeted practices in a consistent and substantive way. Iron/folate supplementation, uterotonic use after birth and breastfeeding on demand were already frequently practiced, and we were unable to measure external cephalic version. Of the remaining six practices, selective, as opposed to routine episiotomy policy increased in the intervention group (difference in adjusted mean rate = 5.3%; 95% CI -0.1 to 10.7%) in Thailand, and there was a trend towards an increased use of antibiotics at caesarean section in Mexico (difference in adjusted mean rate = 19.0%; 95% CI: -8.0 to 46.0%). There were no differences in the use of labour companionship, magnesium sulphate use for eclampsia, corticosteroids for women delivering before 34 weeks and vacuum extraction. RHL awareness (24.8-65.5% in Mexico and 33.9-83.3% in Thailand) and use (4.8-34.9% in Mexico and 15.5-76.4% in Thailand) increased substantially after the intervention in both countries.

CONCLUSION

The multifaceted, active strategy to provide health workers with the knowledge and skills to use RHL to improve their practice led to increased access to and use of RHL, however, no consistent or substantive changes in clinical practices were detected within 4-6 months after the third workshop.

Cochrane reviews in pregnancy: the role of perinatal randomized trials and systematic reviews in establishing evidence

Evidence from randomized trials and systematic reviews provides the highest level of evidence from which to make clinical decisions. There are over 340 Cochrane reviews and protocols in pregnancy and childbirth; these provide the best single source of evidence for care of pregnant women and their babies, and highlight further research priorities. The challenges to health professionals are to ensure that the Cochrane reviews are prepared, kept up to date, and used in clinical care, and where relevant reliable evidence is not available to ensure that high-quality randomized trials are promptly conducted.

Evidence-informed obstetric practice during normal birth in China: trends and influences in four hospitals

Background

A variety of international organizations, professional groups and individuals are promoting evidence-informed obstetric care in China. We measured change in obstetric practice during vaginal delivery that could be attributed to the diffusion of evidence-based messages, and explored influences on practice change.

Methods

Sample surveys of women at postnatal discharge in three government hospitals in Shanghai and one in neighbouring Jiangsu province carried out in 1999, repeated in 2003, and compared. Main outcome measures were changes in obstetric practice and influences on provider behaviour. "Routine practice" was defined as more than 65% of vaginal births. Semi-structured interviews with doctors explored influences on practice.

Results

In 1999, episiotomy was routine at all four hospitals; pubic shaving, rectal examination (to monitor labour) and electronic fetal heart monitoring were routine at three hospitals; and enema on admission was common at one hospital. In 2003, episiotomy rates remained high at all hospitals, and actually significantly increased at one; pubic shaving was less common at one hospital; one hospital stopped rectal examination for monitoring labour, and the one hospital where enemas were common stopped this practice. Mobility during labour increased in three hospitals. Continuous support was variable between hospitals at baseline and showed no change with the 2003 survey.

Provider behaviour was mainly influenced by international best practice standards promoted by hospital directors, and national legislation about clinical practice.

Conclusion

Obstetric practice became more evidence-informed in this selected group of hospitals in China. Change was not directly related to the promotion of evidence-based practice in the region. Hospital directors and national legislation seem to be particularly important influences on provider behaviour at the hospital level.

Assessing the benefits of health research: lessons from research into the use of antenatal corticosteroids for the prevention of neonatal respiratory distress syndrome

Do the benefits from health research justify the resources devoted to it? Addressing this should not only meet increasing accountability demands, but could also enhance understanding of research utilisation and how best to organise health research systems to increase the benefits. The process from basic research to eventual application and patient benefit is usually complex. The use of antenatal corticosteroids when preterm delivery is expected has featured large in the debates about research utilisation and provides an insight into these complexities. Based on an analysis of previous modelling of research utilisation and payback assessment, a framework is developed in which the existing literature on the use of corticosteroids, combined with new material developed by the authors, can be reviewed and synthesised. The move from animal studies to human trials was undertaken by the same individual. Some early clinical application of the findings occurred concurrently with a series of further trials. Nevertheless, the implementation of these findings stalled rather than accelerated as is predicted by some models. The eventual systematic review of the trials played a part in the development of the Cochrane Collaboration and increased the impact on practice. Further implementation approaches were used in various countries, including clinical guidelines, a National Institutes of Health Consensus Conference, and various implementation projects within the UK. This paper shows how an assessment of the benefits from this stream of research and utilisation projects can be constructed. It concludes that the application of a model for assessing payback can help to demonstrate the benefits from the research in this field and enhance our understanding of research utilisation.

Towards improved neonatal outcome: future strategies

The role of the obstetrician is to help predict and prevent maternal/fetal infection/inflammation related to neonatal mortality and morbidity. Predictive studies have mainly focused on the high-risk phenotype. Currently, there is a scientific drive to analyse the genetic susceptibility of preterm birth (PTB). Studies of the combination of environmental and lifestyle risk factors with the known genotype may result in a better understanding of the causation of PTB. Predictive technical markers such as fibronectin, cervical length measurement and home uterine activity remain largely unproven. Current antenatal care has not achieved primary prevention of PTB. Tocolytics and antibiotics constitute the two key elements of secondary prevention. Tocolytics have a minimal benefit but should not be used to prolong an infected preterm pregnancy. The use of antibiotics in preterm premature rupture of membranes can prolong the pregnancy with a decrease in neonatal morbidity. Anti-inflammatory cytokines, cytokine inhibitors and soluble cytokine receptors are promising treatment options that could modulate the intra-amniotic inflammatory process.

A randomised controlled trial of a tailored multifaceted strategy to promote implementation of a clinical guideline on induced abortion care

OBJECTIVE

To evaluate the effectiveness and efficiency of a tailored multifaceted strategy, delivered by a national clinical effectiveness programme, to implement a guideline on induced abortion.

DESIGN

Cluster randomised controlled trial.

SETTING AND PARTICIPANTS

All 26 hospital gynaecology units in Scotland providing induced abortion care.

INTERVENTION

Following the identification of barriers to guideline implementation, intervention units received a package comprising audit and feedback, unit educational meetings, dissemination of structured case records and promotion of a patient information booklet. Control units received printed guideline summaries alone.

MAIN OUTCOME MEASURES

Compliance with five key guideline recommendations (primary outcomes) and compliance with other recommendations, patient satisfaction and costs of the implementation strategy (secondary outcomes).

RESULTS

No effect was observed for any key recommendation: appointment with a gynaecologist within five days of referral (odds ratio 0.89; 95% confidence interval 0.50 to 1.58); ascertainment of cervical cytology history (0.93; 0.36 to 2.40); antibiotic prophylaxis or screening for lower genital tract infection (1.70; 0.71 to 5.99); use of misoprostol as an alternative to gemeprost (1.00; 0.27 to 1.77); and offer of contraceptive supplies at discharge (1.11; 0.48 to 2.53). Median pre-intervention compliance was near optimal for antibiotic prophylaxis and misoprostol use. No intervention benefit was observed for any secondary outcome. The intervention costs an average of pound 2607 per gynaecology unit.

CONCLUSIONS

The tailored multifaceted strategy was ineffective. This was possibly attributable to high pre-intervention compliance and the limited impact of the strategy on factors outside the perceived control of clinical staff.

Health technology assessment in England and Wales

In this study, we describe the current state of the Health Technology Assessment (HTA) system in England and Wales. This system rests on a distinction between assessment and appraisal and has three main strands: researcher-led HTA, the research and development program, and the HTA-NICE (National Institute for Clinical Excellence) process. We outline the pressures for HTA and how it has evolved in the British National Health Service. We discuss how HTA priorities are chosen, how HTA information is collected and assessed, how HTA evidence is used, and we make some observations about its impact. In our discussion, we consider some limitations of the HTA system, its possible divergence from evidence-based health care, its centralization, and some of the key challenges for managing HTA-driven policy. But we remain hopeful that HTA can contribute to better and more explicit decision-making within England and Wales.

Use and misuse of process and outcome data in managing performance of acute medical care: avoiding institutional stigma

The history of monitoring the outcomes of health care by external agencies can be traced to ancient times. However, the danger, now as then, is that in the search for improvement, comparative measures of mortality and morbidity are often overinterpreted, resulting in judgments about the underlying quality of care. Such judgments can translate into performance management strategies in the form of capricious sanctions (such as star ratings) and unjustified rewards (such as special freedoms or financial allocations). The resulting risk of stigmatising an entire institution injects huge tensions into health-care organisations and can divert attention from genuine improvement towards superficial improvement or even gaming behaviour (ie, manipulating the system). These dangers apply particularly to measures of outcome and throughput. We argue that comparative outcome data (league tables) should not be used by external agents to make judgments about quality of hospital care. Although they might provide a reasonable measure of quality in some high-risk surgical situations, they have little validity in acute medical settings. Their use to support a system of reward and punishment is unfair and, unsurprisingly, often resisted by clinicians and managers. We argue further that although outcome data are useful for research and monitoring trends within an organisation, those who wish to improve care for patients and not penalise doctors and managers, should concentrate on direct measurement of adherence to clinical and managerial standards.

The measurement of active errors: methodological issues

The value of research in any topic area turns on its validity. Patient safety research has revealed--or, at least, given renewed urgency to--a raft of methodological issues. The meaning and thus the value of empirical research in this field is contingent on getting the methodology right. The need for good methods for the measurement of error is necessary whenever an inference is intended and, since inferences lie at the heart of research and management, there is a huge need to understand better how to make measurements that are meaningful, precise, and accurate. In this paper we consider issues relating to the measurement of error and the need for more research.

Trials in surgery

Background

Trials in surgery pose some special problems. This paper examines these with reference to 10 years of methodological research sponsored by the UK National Health Service Research and Development programme.

Methods

Solutions to common problems encountered in surgical studies were considered, such as issues of blinding, dependence of results on technical skill and continued evolution of technology.

Results

Numerous methodological developments are described, including the tracker trial concept in which trial design can be adapted to take account of technical developments and interim results. The governance of trials, solutions to ethical conundra and the rising importance of databases are also discussed.

Conclusion

Like surgery itself, the methodological toolkit for evaluation of surgical procedures continues to evolve. The rules of statistical and scientific probity provide plenty of scope for imaginative design solutions for surgical trials.