RAND Europe

This study aimed to review the literature describing and quantifying time lags in the health research translation process. Papers were included in the review if they quantified time lags in the development of health interventions. The study identified 23 papers. Few were comparable as different studies use different measures, of different things, at different time points. We concluded that the current state of knowledge of time lags is of limited use to those responsible for R&D and knowledge transfer who face difficulties in knowing what they should or can do to reduce time lags. This effectively 'blindfolds' investment decisions and risks wasting effort. The study concludes that understanding lags first requires agreeing models, definitions and measures, which can be applied in practice. A second task would be to develop a process by which to gather these data.

This paper provides a consolidated overview of public and healthcare professionals' attitudes towards vaccination in Europe by bringing together for the first time evidence across various vaccines, countries and populations. The paper relies on an extensive review of empirical literature published in English after 2009, as well as an analysis of unpublished market research data from member companies of Vaccines Europe. Our synthesis suggests that hesitant attitudes to vaccination are prevalent and may be increasing since the influenza pandemic of 2009. We define hesitancy as an expression of concern or doubt about the value or safety of vaccination. This means that hesitant attitudes are not confined only to those who refuse vaccination or those who encourage others to refuse vaccination. For many people, vaccination attitudes are shaped not just by healthcare professionals but also by an array of other information sources, including online and social media sources. We find that healthcare professionals report increasing challenges to building a trustful relationship with patients, through which they might otherwise allay concerns and reassure hesitant patients. We also find a range of reasons for vaccination attitudes, only some of which can be characterised as being related to lack of awareness or misinformation. Reasons that relate to issues of mistrust are cited more commonly in the literature than reasons that relate to information deficit. The importance of trust in the institutions involved with vaccination is discussed in terms of implications for researchers and policy-makers; we suggest that rebuilding this trust is a multi-stakeholder problem requiring a co-ordinated strategy.

\n\t\t\t\t\tReflection and the promotion of reflective practice have become popular features of the design of educational programmes. This has often led to learning being more effectively facilitated. However, alongisde these positive initiatives have grown more disturbing developments under the general heading of reflection. They have involved both misconceptions of the nature of reflection which have led to instrumental or rule-following approaches to reflective activities, and the application of reflective strategies in ways which have sought inappropriate levels of disclosure from participants or involved otherwise unethical practices. The article examines the question: what constitutes the effective use of reflective activities? It argues that reflection needs to be flexibly deployed, that it is highly context-specific and that the social and cultural context in which reflection takes place has a powerful influence over what kinds of reflection it is possible to foster and the ways in which this might be done. The article concludes by exploring conditions in which reflective activities might appropriately be used in professional education\n\t\t\t\t

BACKGROUND: Governments can intervene to change health-related behaviours using various measures but are sensitive to public attitudes towards such interventions. This review describes public attitudes towards a range of policy interventions aimed at changing tobacco and alcohol use, diet, and physical activity, and the extent to which these attitudes vary with characteristics of (a) the targeted behaviour (b) the intervention and (c) the respondents. METHODS: We searched electronic databases and conducted a narrative synthesis of empirical studies that reported public attitudes in Europe, North America, Australia and New Zealand towards interventions relating to tobacco, alcohol, diet and physical activity. Two hundred studies met the inclusion criteria. RESULTS: Over half the studies (105/200, 53%) were conducted in North America, with the most common interventions relating to tobacco control (110/200, 55%), followed by alcohol (42/200, 21%), diet-related interventions (18/200, 9%), interventions targeting both diet and physical activity (18/200, 9%), and physical activity alone (3/200, 2%). Most studies used survey-based methods (160/200, 80%), and only ten used experimental designs. Acceptability varied as a function of: (a) the targeted behaviour, with more support observed for smoking-related interventions; (b) the type of intervention, with less intrusive interventions, those already implemented, and those targeting children and young people attracting most support; and (c) the characteristics of respondents, with support being highest in those not engaging in the targeted behaviour, and with women and older respondents being more likely to endorse more restrictive measures. CONCLUSIONS: Public acceptability of government interventions to change behaviour is greatest for the least intrusive interventions, which are often the least effective, and for interventions targeting the behaviour of others, rather than the respondent him or herself. Experimental studies are needed to assess how the presentation of the problem and the benefits of intervention might increase acceptability for those interventions which are more effective but currently less acceptable.

The Centers for Disease Control and Prevention (CDC) in the United States has declared insufficient sleep a "public health problem." Indeed, according to a recent CDC study, more than a third of American adults are not getting enough sleep on a regular basis. However, insufficient sleep is not exclusively a US problem, and equally concerns other industrialised countries such as the United Kingdom, Japan, Germany, or Canada. According to some evidence, the proportion of people sleeping less than the recommended hours of sleep is rising and associated with lifestyle factors related to a modern 24/7 society, such as psychosocial stress, alcohol consumption, smoking, lack of physical activity and excessive electronic media use, among others. This is alarming as insufficient sleep has been found to be associated with a range of negative health and social outcomes, including success at school and in the labour market. Over the last few decades, for example, there has been growing evidence suggesting a strong association between short sleep duration and elevated mortality risks. Given the potential adverse effects of insufficient sleep on health, well-being and productivity, the consequences of sleep-deprivation have far-reaching economic consequences. Hence, in order to raise awareness of the scale of insufficient sleep as a public-health issue, comparative quantitative figures need to be provided for policy- and decision-makers, as well as recommendations and potential solutions that can help tackling the problem.

Mental disorders are common worldwide, yet the quality of care for these disorders has not increased to the same extent as that for physical conditions. In this paper, we present a framework for promoting quality measurement as a tool for improving quality of mental health care. We identify key barriers to this effort, including lack of standardized information technology-based data sources, limited scientific evidence for mental health quality measures, lack of provider training and support, and cultural barriers to integrating mental health care within general health environments. We describe several innovations that are underway worldwide which can mitigate these barriers. Based on these experiences, we offer several recommendations for improving quality of mental health care. Health care payers and providers will need a portfolio of validated measures of patient-centered outcomes across a spectrum of conditions. Common data elements will have to be developed and embedded within existing electronic health records and other information technology tools. Mental health outcomes will need to be assessed more routinely, and measurement-based care should become part of the overall culture of the mental health care system. Health care systems will need a valid way to stratify quality measures, in order to address potential gaps among subpopulations and identify groups in most need of quality improvement. Much more attention should be devoted to workforce training in and capacity for quality improvement. The field of mental health quality improvement is a team sport, requiring coordination across different providers, involvement of consumer advocates, and leveraging of resources and incentives from health care payers and systems.

OBJECTIVE: The aim of this study was to develop a measure of social care outcome, an equivalent to the quality-adjusted life year (QALY) in health, which could be used in a range of circumstances. DESIGN: The project drew on previous and parallel work developing the Adult Social Care Outcome Toolkit and the national Adult Social Care Survey. We developed and tested an instrument designed to reflect service users' social care-related quality of life (SCRQoL) and tested it with 30 service users from a variety of user groups and 300 older home care service users. In parallel, we explored discrete choice experiment (DCE) and best-worst scaling (BWS) approaches to preference elicitation with 300 members of the general population, and cognitively tested these with service users. We also cognitively tested a computer-aided time trade-off (TTO) exercise using SCRQoL attributes with members of the general population. In the second phase, using the finalised instruments, BWS interviews were conducted with 500 members of the general population, TTO interviews with a follow-up sample of 126 of these respondents, and BWS interviews with 458 people using equipment services. MAIN OUTCOME MEASURES: The final measure had eight domains: personal cleanliness and comfort, accommodation cleanliness and comfort, food and drink, safety, social participation and involvement, occupation, control over daily life and dignity. In addition to measuring current SCRQoL, the instrument includes questions used to establish service users' views of their 'expected' SCRQoL in the absence of services. The difference between a person's current and 'expected' SCRQoL provides an indicator of service impact. RESULTS: There was good evidence for the validity of the descriptive system and the validity of the current, expected and SCRQoL gain scales. The DCE and BWS approaches yielded similar results and, once introductions made clear, were understood by service users. BWS was used for the main stages, as it had technical and cognitive advantages. The computer-aided approach to TTO worked well, and respondents found questions acceptable and understandable. There were no substantive differences in the preferences of service users and the general population. The key domain was control over daily life, with the lowest and highest levels strongly estimated in all models. After allowing for observable heterogeneity, service users' preferences appeared to be more closely associated with their own SCRQoL than with those of the general population. The consistency of the results with the results of a previous study allowed the final model to be based on the preferences of 1000 members of the general population. A formula based on the relationship between TTO and BWS values was estimated for a social care QALY, with '0' equivalent to 'being dead' and '1' being the 'ideal' SCRQoL state. Members of the population experienced significantly higher SCRQoL than service users. CONCLUSIONS: Although further work is needed, particularly to develop an equivalent measure for informal carers and to explore the links with health QALYs, the measure has considerable potential. A number of methodological advances were achieved, including the first application of TTO in a social care context and use of BWS to establish service user preferences. FUNDING: The National Institute for Health Research Health Technology Assessment programme.

BACKGROUND: The time taken, or 'time lags', between biomedical/health research and its translation into health improvements is receiving growing attention. Reducing time lags should increase rates of return to such research. However, ways to measure time lags are under-developed, with little attention on where time lags arise within overall timelines. The process marker model has been proposed as a better way forward than the current focus on an increasingly complex series of translation 'gaps'. Starting from that model, we aimed to develop better methods to measure and understand time lags and develop ways to identify policy options and produce recommendations for future studies. METHODS: Following reviews of the literature on time lags and of relevant policy documents, we developed a new approach to conduct case studies of time lags. We built on the process marker model, including developing a matrix with a series of overlapping tracks to allow us to present and measure elements within any overall time lag. We identified a reduced number of key markers or calibration points and tested our new approach in seven case studies of research leading to interventions in cardiovascular disease and mental health. Finally, we analysed the data to address our study's key aims. RESULTS: The literature review illustrated the lack of agreement on starting points for measuring time lags. We mapped points from policy documents onto our matrix and thus highlighted key areas of concern, for example around delays before new therapies become widely available. Our seven completed case studies demonstrate we have made considerable progress in developing methods to measure and understand time lags. The matrix of overlapping tracks of activity in the research and implementation processes facilitated analysis of time lags along each track, and at the cross-over points where the next track started. We identified some factors that speed up translation through the actions of companies, researchers, funders, policymakers, and regulators. Recommendations for further work are built on progress made, limitations identified and revised terminology. CONCLUSIONS: Our advances identify complexities, provide a firm basis for further methodological work along and between tracks, and begin to indicate potential ways of reducing lags.

Background: Randomized trials of therapies that primarily lowered triglycerides have not consistently shown reductions in cardiovascular events. Methods: We performed a systematic review and trial-level meta-regression analysis of 3 classes of lipid-lowering therapies that reduce triglycerides to a greater extent than they do low-density lipoprotein cholesterol (LDL-C): fibrates, niacin, and marine-derived omega-3 fatty acids. Key inclusion criteria were a randomized controlled trial that reported major vascular events. We also incorporated data from a previous meta-regression of 25 statin trials. The main outcome measure was the risk ratio (RR) for major vascular events associated with absolute reductions in lipid parameters. Results: A total of 197 270 participants from 24 trials of nonstatin therapy with 25 218 major vascular events and 177 088 participants from 25 trials of statin therapy with 20 962 major vascular events were included, for a total of 374 358 patients and 46 180 major cardiovascular events. Starting with non–high-density lipoprotein cholesterol, a surrogate for very-low-density lipoproteins and low-density lipoproteins, the RR per 1-mmol/L reduction in non–high-density lipoprotein cholesterol was 0.79 (95% CI, 0.76–0.82; P <0.0001; 0.78 per 40 mg/dL). In a multivariable meta-regression model that included terms for both LDL-C and triglyceride (surrogates for low-density lipoproteins and very-low-density lipoproteins, respectively), the RR was 0.80 (95% CI, 0.76–0.85; P <0.0001) per 1-mmol/L (0.79 per 40 mg/dL) reduction in LDL-C and 0.84 (95% CI, 0.75–0.94; P =0.0026) per 1-mmol/L (0.92 per 40 mg/dL) reduction in triglycerides. REDUCE-IT (Reduction of Cardiovascular Events With Icosapent Ethyl–Intervention Trial) was a significant outlier and strongly influential trial in the meta-regression. When removed, the RRs became 0.79 (95% CI, 0.76–0.83; P <0.0001) per 1-mmol/L (0.78 per 40 mg/dL) reduction in LDL-C and 0.91 (95% CI, 0.81–1.006; P =0.06) per 1-mmol/L (0.96 per 40 mg/dL) reduction in triglycerides. In regard to omega-3 dose, each 1 g/d eicosapentaenoic acid administered was associated with a 7% relative risk reduction in major vascular events (RR, 0.93 [95% CI, 0.91–0.95]; P <0.0001), whereas there was no significant association between the dose of docosahexaenoic acid and the relative risk reduction in major vascular events (RR 0.96 [95% CI, 0.89–1.03]). Conclusions: In randomized controlled trials, triglyceride lowering is associated with a lower risk of major vascular events, even after adjustment for LDL-C lowering, although the effect is less than that for LDL-C and attenuated when REDUCE-IT is excluded. Furthermore, the benefits of marine-derived omega-3 fatty acids, particularly high-dose eicosapentaenoic acid, appear to exceed their lipid-lowering effects.

Car ownership models found in the academic literature (with a focus on the recent literature and on models developed for transport planning) are classified into a number of model types. The different model types are compared on a number of criteria: inclusion of demand and supply side of the car market, level of aggregation, dynamic or static model, long‐ or short‐run forecasts, theoretical background, inclusion of car use, data requirements, treatment of business cars, car‐type segmentation, inclusion of income, of fixed and/or variable car cost, of car quality aspects, of licence holding, of sociodemographic variables and of attitudinal variables, and treatment of scrappage.

A bile salt hydrolase (BSH) was isolated from Bifidobacterium longum SBT2928, purified, and characterized. Furthermore, we describe for the first time cloning and analysis of the gene encoding BSH (bsh) in a member of the genus Bifidobacterium. The enzyme has a native molecular weight of 125,000 to 130,000 and a subunit molecular weight of 35,024, as determined from the deduced amino acid sequence, indicating that the enzyme is a tetramer. The pH optimum of B. longum BSH is between 5 and 7, and the temperature optimum is 40 degrees C. The enzyme is strongly inhibited by thiol enzyme inhibitors, indicating that a Cys residue is likely to be involved in the catalytic reaction. The BSH of B. longum can hydrolyze all six major human bile salts and at least two animal bile salts. A slight preference for glycine-conjugated bile acids was detected based on both the specificity and the K(m) values. The nucleotide sequence of bsh was determined and used for homology studies, transcript analysis, and construction and analysis of various mutants. The levels of homology with BSH of other bacteria and with penicillin V acylase (PVA) of Bacillus sphaericus were high. On the basis of the similarity of BSH and PVA, whose crystal structure has been elucidated, BSH can be classified as an N-terminal nucleophile hydrolase with Cys as the N-terminal amino acid. This classification was confirmed by the fact that a Cys1Ala exchange by site-directed mutagenesis resulted in an inactive protein. Reverse transcription-PCR experiments revealed that bsh is part of an operon containing at least two genes, bsh and glnE (GlnE is glutamine synthetase adenylyltransferase). Two UV-induced BSH-negative mutants and one spontaneous BSH-negative mutant were isolated from B. longum SBT2928 cultures and characterized. These mutants had point mutations that inactivated bsh by premature termination, frameshift, or amino acid exchange.

OBJECTIVE: To review and characterize existing health care efficiency measures in order to facilitate a common understanding about the adequacy of these methods. DATA SOURCES: Review of the MedLine and EconLit databases for articles published from 1990 to 2008, as well as search of the "gray" literature for additional measures developed by private organizations. STUDY DESIGN: We performed a systematic review for existing efficiency measures. We classified the efficiency measures by perspective, outputs, inputs, methods used, and reporting of scientific soundness. PRINCIPAL FINDINGS: We identified 265 measures in the peer-reviewed literature and eight measures in the gray literature, with little overlap between the two sets of measures. Almost all of the measures did not explicitly consider the quality of care. Thus, if quality varies substantially across groups, which is likely in some cases, the measures reflect only the costs of care, not efficiency. Evidence on the measures' scientific soundness was mostly lacking: evidence on reliability or validity was reported for six measures (2.3 percent) and sensitivity analyses were reported for 67 measures (25.3 percent). CONCLUSIONS: Efficiency measures have been subjected to few rigorous evaluations of reliability and validity, and methods of accounting for quality of care in efficiency measurement are not well developed at this time. Use of these measures without greater understanding of these issues is likely to engender resistance from providers and could lead to unintended consequences.

We propose the pooled estimator of kappa, an efficient estimator when summarizing the interrater agreement for qualitative data with many items but few subjects. We evaluate this estimator through a simulation of proposed and alternative (average kappa) estimators and subsequently apply our method to calculate pooled and average kappas over 2,176 rated items from six semistructured interviews with sponsors of the CAHPS. The proposed pooled kappa estimator efficiently summarizes interrater agreement by domain. It is more widely applicable and makes better use of scarce subjects than simply averaging item-level kappas.

SUMMARY: The scorecard summarises key indicators of the burden of osteoporosis and its management in each of the member states of the European Union. The resulting scorecard elements were then assembled on a single sheet to provide a unique overview of osteoporosis in Europe. INTRODUCTION: The scorecard for osteoporosis in Europe (SCOPE) is an independent project that seeks to raise awareness of osteoporosis care in Europe. The aim of this project was to develop a scorecard and background documents to draw attention to gaps and inequalities in the provision of primary and secondary prevention of fractures due to osteoporosis. METHODS: The SCOPE panel reviewed the information available on osteoporosis and the resulting fractures for each of the 27 countries of the European Union (EU27). The information researched covered four domains: background information (e.g. the burden of osteoporosis and fractures), policy framework, service provision and service uptake e.g. the proportion of men and women at high risk that do not receive treatment (the treatment gap). RESULTS: There was a marked difference in fracture risk among the EU27. Of concern was the marked heterogeneity in the policy framework, service provision and service uptake for osteoporotic fracture that bore little relation to the fracture burden. For example, despite the wide availability of treatments to prevent fractures, in the majority of the EU27, only a minority of patients at high risk receive treatment for osteoporosis even after their first fracture. The elements of each domain in each country were scored and coded using a traffic light system (red, orange, green) and used to synthesise a scorecard. The resulting scorecard elements were then assembled on a single sheet to provide a unique overview of osteoporosis in Europe. CONCLUSIONS: The scorecard will enable healthcare professionals and policy makers to assess their country's general approach to the disease and provide indicators to inform future provision of healthcare.

Police use of force is at the forefront of public awareness in many countries. Body-worn videos (BWVs) have been proposed as a new way of reducing police use of force, as well as assaults against officers. To date, only a handful of peer-reviewed randomised trials have looked at the effectiveness of BWVs, primarily focusing on use of force and complaints. We sought to replicate these studies, adding assaults against police officers as an additional outcome. Using a prospective meta-analysis of multi-site, multi-national randomised controlled trials from 10 discrete tests with a total population of +2 million, and 2.2 million police officer-hours, we assess the effect of BWVs on the rates of (i) police use of force and (ii) assaults against officers. Averaged over 10 trials, BWVs had no effect on police use of force ( d = 0.021; SE = 0.056; 95% CI: –0.089–0.130), but led to an increased rate of assaults against officers wearing cameras (d = 0.176; SE = 0.058; 95% CI: 0.061–0.290). As there is evidence that cameras may increase the risk of assaults against officers, more attention should be paid to how these devices are implemented. Likewise, since other public-facing organisations are considering equipping their staff with BWVs (e.g. firefighters, private security, traffic wardens), the findings on risks associated with BWVs are transferrable to those occupations as well.

BACKGROUND: In 2008, the English Department of Health appointed 16 'Integrated Care Pilots' which used a range of approaches to provide better integrated care. We report qualitative analyses from a three-year multi-method evaluation to identify barriers and facilitators to successful integration of care. THEORY AND METHODS: Data were analysed from transcripts of 213 in-depth staff interviews, and from semi-structured questionnaires (the 'Living Document') completed by staff in pilot sites at six points over a two-year period. Emerging findings were therefore built from 'bottom up' and grounded in the data. However, we were then interested in how these findings compared and contrasted with more generic analyses. Therefore after our analyses were complete we then systematically compared and contrasted the findings with the analysis of barriers and facilitators to quality improvement identified in a systematic review by Kaplan et al. (2010) and the analysis of more micro-level shapers of behaviour found in Normalisation Process Theory (May et al. 2007). Neither of these approaches claims to be full blown theories but both claim to provide mid-range theoretical arguments which may be used to structure existing data and which can be undercut or reinforced by new data. RESULTS AND DISCUSSION: Many barriers and facilitators to integrating care are those of any large-scale organisational change. These include issues relating to leadership, organisational culture, information technology, physician involvement, and availability of resources. However, activities which appear particularly important for delivering integrated care include personal relationships between leaders in different organisations, the scale of planned activities, governance and finance arrangements, support for staff in new roles, and organisational and staff stability. We illustrate our analyses with a 'routemap' which identifies questions that providers may wish to consider when planning interventions to improve the integration of care.

BACKGROUND: Public involvement in health-care policy has been advocated as a means to enhance health system responsiveness, yet evidence for its impact has been difficult to ascertain. OBJECTIVES: To review the peer-reviewed empirical evidence on outcomes of public involvement in health-care policy. METHODS: We systematically searched PsychINFO and PubMed from November 2000 to April 2010 for empirical studies that reported on original research only; studies in languages other than English, German or French were excluded. Data were extracted using a standardized evidence table with a priori determined headings. MAIN RESULTS: Nineteen studies were identified as eligible for inclusion in our review. We found that sound empirical evidence of the outcomes of public involvement activities in health care remains underdeveloped. The concept and the indicators used to examine and determine outcomes remain poorly specified and inconsistent, as does the reporting of the evidence. There was some evidence for the developmental role of public involvement, such as enhancing awareness, understanding and competencies among lay participants. Evidence for instrumental benefits of public involvement initiatives was less well documented. CONCLUSIONS: Despite the growing body of work on public involvement in health-care policy, evidence of its impact remains scarce; thus, firm conclusions about involvement activities that are appropriate and effective for policy development are difficult to draw. However, focus on outcomes risks missing the normative argument that involving the public in the health-care policy process may be seen to be of intrinsic value.

The logsum is a measure of consumer surplus in the context of logit choice models. In spite of the very frequent use of logit models in transport, project assessment is only rarely done using logsums. Instead in project evaluation or appraisal, changes in transport costs and time (borrowing values of time from some source) are commonly used to get the traveller benefits. The paper contains a review of the theoretical and applied literature on the use of logsums as a measure of consumer surplus change in project appraisal and evaluation. It then goes on to describe a case study with the Dutch National Model System for transport in which the logsum method and the commonly used value of time method are compared for a specific project (high speed trains that would connect the four main cities in the Randstad: Amsterdam, The Hague, Rotterdam and Utrecht).

This study aimed to establish what is known about the mental health of researchers based on the existing literature. There is limited published evidence on the prevalence of specific mental health conditions among researchers. The majority of the identified literature on prevalence relates to work-related stress among academic staff and postgraduate students in university settings. Survey data indicate that the majority of university staff find their job stressful. Levels of burnout appear higher among university staff than in general working populations and are comparable to "high-risk" groups such as healthcare workers. The proportions of both university staff and postgraduate students with a risk of having or developing a mental health problem, based on self-reported evidence, were generally higher than for other working populations. Large proportions (>40 per cent) of postgraduate students report symptoms of depression, emotion or stress-related problems, or high levels of stress. Factors including increased job autonomy, involvement in decision making and supportive management were linked to greater job satisfaction among academics, as was the amount of time spent on research. Opportunities for professional development were also associated with reduced stress. UK higher education (HE) and research staff report worse wellbeing, as compared to staff in other sectors, in most aspects of work that can affect workers' stress levels. The evidence around the effectiveness of interventions to support the mental health of researchers specifically is thin. Few interventions are described in the literature and even fewer of those have been evaluated.

Open innovation has gained increased attention as a potential paradigm for improving innovation performance. This paper addresses crowdsourcing, an under-researched type of open innovation that is often enabled by the web. We focus on a type of crowdsourcing where financial rewards exist, where a crowd is tasked with solving problems which solution seekers anticipate to be empirically provable, but where the source of solutions is uncertain and addressing the challenge in-house perceived to be too high-risk. There is a growing recourse to crowdsourcing, but we really know little about its effectiveness, best practices, challenges and implications. We consider the shift to more open innovation trajectories over time, define crowdsourcing as an open innovation model, and clarify how crowdsourcing differs from other types of ‘open’ innovation (e.g. outsourcing and open-source). We explore who is crowdsourcing and how, looking at the potential diversity and core features and variables implicated in crowdsourcing models.